Factors related to medical students’ and doctors’ attitudes towards older patients: A systematic review

Background:Studies have sought to identify the possible determinants of medical students’ and doctors’ attitudes towards older patients by examining relationships with a variety of factors: demographic; educational/training; exposure to older people; personality/cognitive; and job/career factors. This review collates and synthesises these findings. Methods: An electronic search of ten databases was performed (ABI/Inform, ASSIA, British Nursing Index, CINAHL, Informa Health, Medline, PsycINFO, Science Direct, Scopus, and Web of Science) through to 7 February 2017. Results: The main search identified 2332 articles; 37 studies met the eligibility criteria set. All included studies analysed self-reported attitudes based on correlational analyses or difference testing, therefore causation could not be determined. However, self-reported positive attitudes towards older patients were related to: (i) intrinsic motivation for studying medicine; (ii) increased preference for working with older patients; and (iii) good previous relationships with older people. Additionally, more positive attitudes were also reported in those with higher knowledge scores but these may relate to the use of a knowledge assessment which is an indirect measure of attitudes (i.e. Palmore’s Facts on Aging Quizzes). Four out of the five high quality studies included in this review reported more positive attitudes in females compared to males. Conclusion:This paper identifies factors associated with medical students’ and doctors’ positive attitudes towards older patients. Future research could bring greater clarity to the relationship between knowledge and attitudes by using a knowledge measure which is distinct from attitudes and also measures knowledge that is relevant to clinical care

Reflecting on the methodological challenge of recruiting older care home residents to podiatry research

IntroductionSuccessful randomisd controlled trials (RCTs) require successful participant recruitment; poor recruitment leads to poor, under-powered studies, and may waste grant funds. Recruitment of older care home residents to RCTs is challenging. This is problematic for podiatry, because older people within care home settings are high users of podiatry services; therefore it is essential that strategies are employed to maximise recruitment to RCTs.We describe the experience of recruiting to a feasibility study of a podiatry intervention to reduce falls in care home residents in the East of Scotland. This was the first phase of a two phase project consisting of the feasibility study to acquire data (recruitment strategy, selection of suitable outcome measures) to inform the conduct of the second phase, an exploratory RCT. Recruitment difficulties became apparent early in the study. Difficulties arose when it came to assessing whether or not potential participants fulfilled certain inclusion criteria:(1) Presence of foot pain (defined as foot pain lasting for at least a day in the last month and a positive response of “some days” or “most/every days” to at least one item on the Manchester Foot Pain and Disability Index (MFPDI))(2) Ability to provide informed consent. The reasons for these difficulties are that (1) we discovered that in the area in which our study was conducted, the majority of care home residents receive basic NHS podiatry care to treat any superficial lesions (i.e. pathological nails and skin callus) thus the prevalence of foot pain resulting from these lesions was lower than we had originally anticipated, and (2) the care homes that we engaged for this phase of the study had residents who were far more dependent and with much higher levels cognitive impairment than we anticipated, making obtaining informed consent difficult. Based on the existing inclusion criteria, it was deemed unlikely that we would meet our recruitment target for the subsequent exploratory randomised controlled trial (n=40).MethodsFollowing discussion with co-applicants we proposed to make two changes in order to improve recruitment, whilst maintaining the scientific integrity of the protocol:(1) We engaged with care homes that cater for less dependent residents in order to improve the likelihood of obtaining informed consent. (2) Since evidence shows that there are several foot and ankle characteristics (toe muscle weakness, hallux valgus, decreased ankle flexibility and strength) that are associated with falls but which do not necessarily cause pain, we widened the inclusion criteria by removing foot pain as a criterion. The recruitment difficulties required a 3 month prolongation of the study duration.ResultsAs a result of tailoring the recruitment strategy early in the feasibility study, we recruited rapidly to the exploratory RCT. We have exceeded our target (n=48).ConclusionsCare home residents represent a convenient population for data collection, but frailty and multiple co-morbidities may make successful recruitment to intervention studies challenging. Whilst the adaptations used in this study may have implications for external validity, this work underlines the importance of testing recruitment strategies at an early stage.Journal supplement-The College of Podiatry Annual Conference 2014: meeting abstract

Finding your feet: The development of a podiatry intervention to reduce falls in care home residents.

IntroductionPeople who live in care homes often fall. Foot and ankle muscle weakness, sub-optimal footwear, and common foot problems such as corns and hallux valgus are known and potentially modifiable contributory factors to falls in older people. Conducting a randomised controlled trial in a care home setting to address these issues is challenging and presents a number of uncertainties that need to be addressed prior to undertaking a phase III trial. Therefore, this study used a qualitative approach to assess the feasibility and acceptability of a podiatry falls intervention to care home residents and staff. The data acquired during this qualitative preparatory phase will inform the conduct of a subsequent exploratory randomised controlled trial of a podiatry intervention to reduce falls in care homes.Methods ParticipantsPermanent care home residents with a history of falls, mini mental state examination (MMSE) >9, ability to provide informed consent (n=8); staff (n=5).InterventionResidents, supported by care home staff, participated in a 3-month feasibility-testing phase of an intervention (footwear and orthoses provision, toe and ankle muscle strengthening programme).EvaluationExercise frequency was recorded in logbooks by staff. To assess acceptability and perceptions of feasibility at the conclusion of the 3-month testing period, face to face semi-structured interviews were conducted.Data analysisDescriptive data of exercise frequency were calculated. Analysis of the qualitative data employed a constant-comparative process embedded within the wider framework method to identify emerging themes and concepts to inform the intervention remodelling and development.ResultsFidelity30/57(52.6%) logbooks returned; 11(19.3%) completed in full. Adherence ranged between exercises not having been completed at all in some weeks, to three times per week (optimal) in others.FacilitatorsParticipation in the programme was well received and fitted into care home routines. The exercise component of the intervention was easily carried out and took no longer then 10 minutes to complete. Participants reported that explanation of the aims of the programme at each exercise session was beneficial to adherence. Some residents saw peer support as important; however other residents preferred one-to-one sessions. Footwear and orthoses were well received by the participants.BarriersDiscomfort during exercises, cognitive impairment and illness were barriers reported by residents and staff. A major barrier to adherence was limited access for all staff to training resulting in exercises not being performed when trained staff were not available.ConclusionsA podiatry intervention to reduce falls in care homes is feasible and acceptable. Delivery to residents should be tailored to individual preferences (taking into account goals, targets, and information). Accessing training via DVD or an online resource may improve the reach of the training, facilitating adherence and fidelity. These findings have informed intervention development and modes of delivery for an exploratory randomised controlled trial that is currently underway.Journal supplement - The College of Podiatry Annual Conference 2014: meeting abstract

Podiatry intervention versus usual care to prevent falls in care homes: pilot randomised controlled trial (the PIRFECT study)

BackgroundCommon foot problems are independent risk factors for falls in older people. There is evidence that podiatry can prevent falls in community-dwelling populations. The feasibility of implementing a podiatry intervention and trial in the care home population is unknown. To inform a potential future definitive trial, we performed a pilot randomised controlled trial to assess: (i) the feasibility of a trial of a podiatry intervention to reduce care home falls, and (ii) the potential direction and magnitude of the effect of the intervention in terms of number of falls in care home residents.MethodsInformed by Medical Research Council guidance on developing and evaluating complex interventions, we conducted a single blind, pilot randomised controlled trial in six care homes in the East of Scotland. Participants were randomised to either: (i) a three month podiatry intervention comprising core podiatry care, foot and ankle exercises, orthoses and footwear provision or (ii) usual care. Falls-related outcomes (number of falls, time to first fall) and feasibility-related outcomes (recruitment, retention, adherence, data collection rates) were collected. Secondary outcomes included: generic health status, balance, mobility, falls efficacy, and ankle joint strength.Results474 care home residents were screened. 43 (9.1%) participants were recruited: 23 to the intervention, 20 to control. Nine (21%) participants were lost to follow-up due to declining health or death. It was feasible to deliver the trial elements in the care home setting. 35% of participants completed the exercise programme. 48% reported using the orthoses ‘all or most of the time’. Completion rates of the outcome measures were between 93% and 100%. No adverse events were reported. At the nine month follow-up period, the intervention group per-person fall rate was 0.77 falls vs. 0.83 falls in the control group.ConclusionsA podiatry intervention to reduce falls can be delivered to care home residents within a pilot randomised controlled trial of the intervention. Although not powered to determine effectiveness, these preliminary data provide justification for a larger trial, incorporating a full process evaluation, to determine whether this intervention can significantly reduce falls in this high-risk population.Trial registrationClinicalTrials.gov identifier: NCT02178527; Date of registration: 17 June 2014

Barefoot vs common footwear:A systematic review of the kinematic, kinetic and muscle activity differences during walking

Habitual footwear use has been reported to influence foot structure with an acute exposure being shown to alter foot position and mechanics. The foot is highly specialised thus these changes in structure/position could influence functionality. This review aims to investigate the effect of footwear on gait, specifically focussing on studies that have assessed kinematics, kinetics and muscle activity between walking barefoot and in common footwear. In line with PRISMA and published guidelines, a literature search was completed across six databases comprising Medline, EMBASE, Scopus, AMED, Cochrane Library and Web of Science. Fifteen of 466 articles met the predetermined inclusion criteria and were included in the review. All articles were assessed for methodological quality using a modified assessment tool based on the STROBE statement for reporting observational studies and the CASP appraisal tool. Walking barefoot enables increased forefoot spreading under load and habitual barefoot walkers have anatomically wider feet. Spatial-temporal differences including, reduced step/stride length and increased cadence, are observed when barefoot. Flatter foot placement, increased knee flexion and a reduced peak vertical ground reaction force at initial contact are also reported. Habitual barefoot walkers exhibit lower peak plantar pressures and pressure impulses, whereas peak plantar pressures are increased in the habitually shod wearer walking barefoot. Footwear particularly affects the kinematics and kinetics of gait acutely and chronically. Little research has been completed in older age populations (50+ years) and thus further research is required to better understand the effect of footwear on walking across the lifespan

Understanding the nature and mechanism of foot pain

Approximately one-quarter of the population are affected by foot pain at any given time. It is often disabling and can impair mood, behaviour, self-care ability and overall quality of life. Currently, the nature and mechanism underlying many types of foot pain is not clearly understood. Here we comprehensively review the literature on foot pain, with specific reference to its definition, prevalence, aetiology and predictors, classification, measurement and impact. We also discuss the complexities of foot pain as a sensory, emotional and psychosocial experience in the context of clinical practice, therapeutic trials and the placebo effect. A deeper understanding of foot pain is needed to identify causal pathways, classify diagnoses, quantify severity, evaluate long term implications and better target clinical intervention

Medial longitudinal arch development of school children : The College of Podiatry Annual Conference 2015: meeting abstracts

Background Foot structure is often classified into flat foot, neutral and high arch type based on the variability of the Medial Longitudinal Arch (MLA). To date, the literature provided contrasting evidence on the age when MLA development stabilises in children. The influence of footwear on MLA development is also unknown. Aim This study aims to (i) clarify whether the MLA is still changing in children from age 7 to 9 years old and (ii) explore the relationship between footwear usage and MLA development, using a longitudinal approach. Methods We evaluated the MLA of 111 healthy school children [age = 6.9 (0.3) years] using three parameters [arch index (AI), midfoot peak pressure (PP) and maximum force (MF: % of body weight)] extracted from dynamic foot loading measurements at baseline, 10-month and 22-month follow-up. Information on the type of footwear worn was collected using survey question. Linear mixed modelling was used to test for differences in the MLA over time. Results Insignificant changes in all MLA parameters were observed over time [AI: P = .15; PP: P = .84; MF: P = .91]. When gender was considered, the AI of boys decreased with age [P = .02]. Boys also displayed a flatter MLA than girls at age 6.9 years [AI: mean difference = 0.02 (0.01, 0.04); P = .02]. At baseline, subjects who wore close-toe shoes displayed the lowest MLA overall [AI/PP/MF: P < .05]. Subjects who used slippers when commencing footwear use experienced higher PP than those who wore sandals [mean difference = 31.60 (1.44, 61.75) kPa; post-hoc P = .04]. Discussion and conclusion Our findings suggested that the MLA of children remained stable from 7 to 9 years old, while gender and the type of footwear worn during childhood may influence MLA development. Clinicians may choose to commence therapy when a child presents with painful flexible flat foot at age 7 years, and may discourage younger children from wearing slippers when they commence using footwear