Sarcopenia and vascular risk in a healthy elderly UK population (BRAVES study)

Introduction Sarcopenia, the loss of skeletal muscle mass and strength that occurs with advancing age [1] is correlated with functional decline and disability but little is known about its relationship with cardiovascular risk. Bioimpedence analysis (BIA) is a validated technique for measuring muscle mass, convenient for use in large cohort studies. Arterial stiffness (compliance) is an independent predictor of cardiovascular events. Methods The BRAVES study was designed to compare cardiovascular risk between two healthy elderly cohorts in the UK and in Italy. We used data from the UK cohort to investigate the relationship between sarcopenia and vascular compliance. Participants were eligible if aged 65-85 years, lived within the Brighton area and had weight loss of no more than 5% in the last month. All underwent physical exam, BIA assessment of skeletal mass index (SMI) and two measures of arterial compliance. Pulse wave velocity (PWV) was measured between carotid-femoral and carotid-radial arteries and the augmentation index (AIx) derived from carotid and radial arteries. A bivariate correlation was performed. Results Ninety patients (64 female; 26 male) had mean age 73, mean FFM 46.84kg (range 34.7-74.7) and mean SMI 6.77 (range 4.84-10.09). There was a negative relationship between SMI and Radial AIx (R=0.-542, p=0.000) as well as Carotid AIx (R=-0.391, p=0.002) but not PWV. Using multiple regression to control for the effects of age and gender, SMI was independently related to radial AIx (p=.013). Conclusions Skeletal muscle mass index is strongly negatively correlated with augmentation index, a measure of vascular stiffness. This finding suggests that elderly patients with higher muscle mass have a more compliant aorta and hence lower cardiovascular risk. Whether sarcopenia acts as a marker for CV risk or plays an active role in cardiovascular disease progression is not yet established and deserves further investigation

Medical student confidence to care for a dying patient and their family: a systematic review

Background: The General Medical Council expects medical graduates to care for dying patients with skill, clinical judgement and compassion. UK surveys continually demonstrate low confidence and increasing distress amongst junior doctors when providing care to the dying. Aim: This systematic review aims to determine what has been evidenced within worldwide literature regarding medical undergraduate confidence to care for dying patients. Design: A systematic electronic search was undertaken. Data extraction included measurements of baseline confidence, associated assessment tools, and details of applied educational interventions. Pre/post-intervention confidence comparisons were made. Factors influencing confidence levels were explored. The review was prospectively registered via PROSPERO (CRD42019119057). Data sources: MEDLINE, CINAHL, EMBASE, ISI Web of Science, ERIC, PsychINFO, British Education Index and Cochrane Review databases were accessed, with no restrictions on publication year. Eligible studies included the terms ‘medical student’, ‘confidence’, and ‘dying’, alongside appropriate MeSH headings. Study quality was assessed using the Mixed Methods Appraisal Tool. Results: Fifteen eligible studies were included, demonstrating a diversity of assessment tools. Student confidence was low in provision of symptom management, family support, and psycho-spiritual support to dying patients. Eight interventional studies demonstrated increased post-interventional confidence. Lack of undergraduate exposure to dying patients and lack of structure within undergraduate palliative care curricula were cited as factors responsible for low confidence. Conclusion: This review clarifies the objective documentation of medical undergraduate confidence to care for the dying. Identifying where teaching fails to prepare graduates for realities in clinical practice will help inform future undergraduate palliative care curriculum planning

Preferences of nursing and medical students for working with older adults and people with dementia: a systematic review

Background: A current issue in workforce planning is ensuring healthcare professionals are both competent and willing to work with older adults with complex needs. This includes dementia care, which is widely recognised as a priority. Yet research suggests that working with older people is unattractive to undergraduate healthcare students. Methods: The aim of this systematic review and narrative synthesis is to explore the factors related to healthcare (medical and nursing) student preferences' for working with older people and people with dementia. Searches were conducted in five databases: MEDLINE, PsycINFO, CINHAL, BNI, ERIC. Screening, data extraction and quality appraisal were conducted by two independent reviewers. A narrative, data-based convergent synthesis was conducted. Results: One thousand twenty-four papers were screened (139 full texts) and 62 papers were included for a narrative synthesis. Factors were grouped into seven categories; student characteristics, experiences of students, course characteristics, career characteristics, patient characteristics, work characteristics and the theory of planned behaviour. Conclusion: Health educators should review their role in cultivating student interest in working with older adults, with consideration of student preparation and the perceived value of this work. There is a lack of evidence about the career preferences of students in relation to dementia, and this warrants further research

Evaluation of a combined HIV and geriatrics clinic for older people living with HIV: the Silver clinic in Brighton, UK

As life expectancy in people living with HIV (PLWH) has increased, the focus of management has shifted to preventing and treating chronic illnesses, but few services exist for the assessment and management of these individuals. Here, we provide an initial description of a geriatric service for people living with HIV and present data from a service evaluation undertaken in the clinic. We conducted an evaluation of the first 52 patients seen in the clinic between 2016 and 2019. We present patient demographic data, assessment outcomes, diagnoses given, and interventions delivered to those seen in the clinic. The average age of attendees was 67. Primary reasons for referral to the clinic included management of complex comorbidities, polypharmacy, and suspected geriatric syndrome (falls, frailty, poor mobility, or cognitive decline). The median (range) number of comorbidities and comedications (non-antiretrovirals) was 7 (2–19) and 9 (1–15), respectively. All attendees had an undetectable viral load. Geriatric syndromes were observed in 26 (50%) patients reviewed in the clinic, with frailty and mental health disease being the most common syndromes. Interventions offered to patients included combination antiretroviral therapy modification, further health investigations, signposting to rehabilitation or social care services, and in-clinic advice. High levels of acceptability among patients and healthcare professionals were reported. The evaluation suggests that specialist geriatric HIV services might play a role in the management of older people with HIV with geriatric syndromes

Coupling groundwater and riparian vegetation models to assess effects of reservoir releases

Although riparian areas in the arid southwestern United States are critical for maintaining species diversity, their extent and health have been declining since Euro-American settlement. The purpose of this study was to develop a methodology to evaluate the potential for riparian vegetation restoration and groundwater recharge. A numerical groundwater flow model was coupled with a conceptual riparian vegetation model to predict hydrologic conditions favorable to maintaining riparian vegetation downstream of a reservoir. A Geographic Information System(GIS) was used for this one-way coupling. Constant and seasonally varying releases from the dam were simulated using volumes anticipated to be permitted by a regional water supplier. Simulations indicated that seasonally variable releases would produce surface flow 5.4-8.5 km below the dam in a previously dry reach. Using depth to groundwater simulations from the numerical flow model with conceptual models of depths to water necessary for maintenance of riparian vegetation, the GIS analysis predicted a 5- to 6.5-fold increase in the area capable of sustaining riparian vegetation

A qualitative evaluation of the effect of a longitudinal dementia education programme on healthcare student knowledge and attitudes

Background and objectives There is a need to ensure that the future healthcare workforce has the necessary knowledge and skills to deliver high quality compassionate care to the increasing number of people with dementia. Our programme has been set up to address this challenge. In the programme, undergraduate healthcare students (nursing, medical and paramedic) visit a family (person with dementia and their carer) in pairs over a 2-year period. This qualitative study sought to understand the student experience of the programme. Methods Participants were undergraduate healthcare students who were undertaking our programme at two universities. We sampled for variation in the student participants in order to generate a framework for understanding the student experience of the programme. Students were invited to take part in the qualitative study, and written consent was obtained. Interviews and focus group transcripts were analysed using thematic analysis. Results Thirty-nine (nursing, medical and paramedic) student participants took part in individual in-depth qualitative interviews and 38 took part in five focus groups. Four key themes were identified from the analysis; relational learning, insight and understanding, challenging attitudes and enhanced dementia practice. Discussion Student experience of our programme was shown to be positive. The relationship between the students and family was most impactful in supporting student learning, and the subsequent improvement in knowledge, attitudes and practice. Our model of undergraduate dementia education has applicability for other long-term conditions

Barriers and facilitators to HIV testing in people age 50 and above: a systematic review

Background: Effective therapy means HIV-positive individuals can now experience near normal life expectancy. Despite these advances in treatment, about one in six people living with HIV in the UK are unaware of their infection. Although overall number of new HIV diagnoses have decreased, the number of people diagnosed aged 50 and over is increasing. It may be that there are unique factors associated with the decision to test in this group. This systematic review aims to identify patient and clinician related barriers and facilitators to HIV testing in people aged 50 and above. Methods: A systematic electronic search of MEDLINE, Embase, PsychINFO and CINAHL was conducted on 07/04/2016. Search terms included combinations of words describing HIV, old age, and testing. Papers were assessed for eligibility (published since 01/01/1997, describing barriers/facilitators to testing, research in people ≥50 years, written in English). Data from eligible studies were extracted (including study design, sample size and characteristics, analysis and reported barriers/facilitators to testing). Reported barriers/facilitators were grouped into themes and number of times each was reported was noted. Findings: Electronic searches identified 1752 articles, of which 14 primary studies met the inclusion criteria. A further 3 eligible papers were identified from reference and citation searching. Seventeen papers were included in the review. Most of the studies (n=14) were from the US. The main patient-barriers to non-test were low perceived risk and not being offered/encouraged to test by a healthcare professional (HCP) (reported 5 and 3 times respectively). The main clinician-barrier was preconceptions about older people and discomfort discussing sexuality and risk, reported 5 times. Main facilitators of test were being offered/encouraged to test by a HCP, previous interactions with healthcare services and high perceived risk (all reported >5 times). Interpretation: Clinicians’ beliefs that people ≥50 years are not at risk, or will feel uncomfortable discussing risk and sexuality, were among the most commonly cited barriers to test offer. However, being offered or encouraged to test by a healthcare professional was the most commonly cited facilitator to testing. This shows a divide between clinicians’ preconceptions and patient’s expectations, which may impact on testing rates