Understanding multiple medication use in people with dementia. A pharmacoepidemiology study of prevalence, intervention and associated harms.

Background: Around 70% of people with dementia live with comorbidities and are subsequently prescribed multiple medications (polypharmacy). Some medicines are considered ‘potentially inappropriate’ when prescribed to older and cognitively impaired adults. Cognitive impairment, dementia and frailty may influence the prevalence and associated effects of polypharmacy and potentially inappropriate medicines (PIMs). Aims: To estimate prevalence trends of polypharmacy and PIMs (antipsychotics, antidepressants, benzodiazepines, anticholinergics and proton pump inhibitors) among people with dementia. To identify associated factors, including the impact of care and medication reviews and to understand the impact of polypharmacy, PIMs and frailty on health in people with cognitive impairment. Methods: Two cohorts were analysed, including primary care electronic medical records (Clinical Practice Research Datalink, 2015-2017) (n=22,448) and the Cognitive Function and Ageing Study (2008-2011) (n=1,154). Results: Polypharmacy and PIMs were prevalent in people with dementia and cognitive impairment. On average, people with dementia were prescribed 8 medications, 30% were prescribed inappropriate PPIs, 17% anticholinergics, 8% antipsychotics, 7% tricyclics and 4% of people with cognitive impairment were prescribed benzodiazepines. Dementia annual reviews and medication reviews were associated with medicines optimisation. Prevalence of PIM was greater in care homes and a medication review in a care home was associated with reduced use of PIMs. Polypharmacy was associated with worse survival. PIMs were not associated with worse survival, with the exception of antipsychotics (adjusted HR=3.24, 95% CI=1.83-5.73). Being cognitively impaired and frail was associated with worse survival overall but frailty was not found to moderate the relationship between polypharmacy, PIMs and survival. Conclusions: Few prescribing guidelines specifically address medicines use in people with cognitive impairment or dementia, despite the prevalence of polypharmacy and PIMs. The number of medicines prescribed should be carefully monitored to reduce harm. Incorporating medication reviews into annual dementia care reviews may optimise prescribing and identify people at increased risk of adverse effects. The findings from this thesis will improve understanding and support the optimisation of medicines for people living with dementia

How do potentially inappropriate medications and polypharmacy affect mortality in frail and non-frail cognitively impaired older adults?:A cohort study

OBJECTIVES: To test whether the use of potentially inappropriate central nervous system acting medications, proton pump inhibitors (PPIs) or polypharmacy are associated with mortality in cognitively impaired older adults and whether frailer people are at greater risk of harm. SETTING: A cohort study nested within the Cognitive Function and Ageing Study II, a population representative cohort study of the older population in Cambridgeshire, Nottingham and Newcastle, UK. PARTICIPANTS: A total of 1154 cognitively impaired participants, aged 65 years or older. EXPOSURES: Any use of antipsychotics, antidepressants, other anticholinergic medication, benzodiazepines or PPIs, polypharmacy (5-9) and hyperpolypharmacy (≥10 reported medications) were ascertained at baseline. Frailty was assessed using the Fried criteria. PRIMARY OUTCOME: Mortality up to 8 years follow-up. HRs associated with potentially inappropriate medication (PIM), frailty and their interaction were estimated adjusting for covariates. RESULTS: Within the sample, 44% were taking one or more PIM. Apart from antipsychotics (adjusted HR=3.24, 95% CI 1.83 to 5.73), use of specific PIM was not associated with greater subsequent mortality. Polypharmacy (HR=1.17, 95% CI 0.95 to 1.45) and hyperpolypharmacy were associated with mortality (HR=1.60, 95% CI 1.16 to 2.22). Being frail (HR=1.90, 95% CI 1.32 to 2.72) or prefrail (HR=1.56, 95% CI 1.10 to 2.20) was associated with increased mortality. There was some evidence that the HR for polypharmacy on mortality was lower among frailer individuals, but the overall polypharmacy by frailty interaction was not statistically significant (p=0.102). CONCLUSIONS: For those with cognitive impairment, greater concern should be afforded to the number of medications than the prescription of specific classes. Frailer individuals may have a lower relative risk of mortality associated with polypharmacy than less frail individuals

Council tenancies and hoarding behaviours: A study with a large social landlord in England

Hoarding behaviours are highly stigmatised and often hidden. People with problematic hoarding behaviours have a higher rate of mental health and other healthcare and social services utilisation. Hoarding is a community health problem, one factor being housing insecurity. Hoarding behaviours represent significant burden to housing providers, impact the community and dealing with it involves multiple community agencies. This study with a city council in England with a large housing stock (over 14,000 properties) in summer 2021 sought to understand the nature, circumstances and extent that hoarding presents. We developed a reporting system and conducted 11 interviews with housing officers in which they described a case to explain their involvement. Our report details the nature of 38 people who hoard. 47% had a known disability or vulnerability, 34% presented a fire and environmental risk, 87% lived alone and 60% were resident in flats. Our qualitative themes are: Working with others, Balancing an enforcement approach, Feeling conflicted, Complex needs of people who hoard and Staff needs. The cases described by the housing officers are combined into six case studies and illustrate the complex, multi-agency circumstances around decision making and risk stratification. Our findings point to housing officers as frontline professionals dealing with a public health and social care issue which is often the manifestation of complex life histories and mental health conditions. We suggest a greater focus on risk stratification and a more holistic approach to hoarding cases to effectively deal with this most complex of community health and social care issues

A report on the introduction of a Financial Inclusion Service at Norwich Foodbank The ‘Making a Difference' project

Background: Food insecurity is when a family or individual struggles to have enough to eat and is associated with uncertainty, worry, anxiety and hunger. Foodbanks provide emergency food provision. This need can be triggered by a change in circumstance or a crisis, or not having long-term sufficient income. Failures in the social security safety net are the most significant driver for hunger in the UK. There is some evidence that an advisory service which runs alongside a foodbank is more effective in reducing emergency provision and the duration and severity of hunger. The ‘Making a Difference’ project at Norwich Foodbank is a pilot scheme aiming to increase financial resilience in their service users. From summer 2022 Norwich Foodbank introduced new advice worker roles, in partnership with Shelter and the British Red Cross, to work alongside an existing Citizen’s Advice worker. All three roles are funded through specialist grant funding streams. The aim of these roles is to pre-empt the need for foodbank use, to triage the financial needs of service users and refer appropriately to reduce repeat visits to the foodbank. The brief: This independent research by University of East Anglia (UEA) aimed to evaluate how effectively these roles are working and to: 1) Understand how well the roles are operating on a practical level (identifying barriers, facilitators and any potential friction points in referrals and partnership working) 2) Whether the service is operating as intended 3) What learning points are there so that the service can be adapted appropriately What we did: From July to October 2022, we interviewed the Foodbank Manager to have a greater understanding of the aims of the ‘Making a difference project’ and four staff and four volunteers. Main findings: Our independent research points to a service that is supporting people with highly complex needs that is provided in a compassionate and person-centered way and cuts across multiple agencies. It aims to holistically provide a service that ‘wraps around’ the person. The volunteers and staff are highly experienced and use their connections to work collaboratively and seamlessly with the individual. This not only efficient but it also reduces the need for distressing stories to be repeated thus helping to reduce shame and stigma and build trust. Sitting in the heart of a community, especially when in community cafés, helps to promote the service and break down barriers. The consequence of this is that the service is reaching ‘seldom heard’ clients who would traditionally not have accessed support, despite their often dire needs. This puts Norwich Foodbank in a unique position as they adapt their service going forward. There was mutual respect and understanding between the volunteers and the advice workers with volunteers integral in building trusting relationships and reducing stigma. They are all proud of the work they do. However, our findings suggest that they are providing a ‘frontline’ service, often listening to distressing life stories. We suggest that there is consideration given to the vicarious trauma that could result from this. Recommendations: We suggest that the findings from this baseline evaluation are used by Norwich Foodbank to help them develop their financial inclusion provision for people who are traditionally excluded but who are accessing them through their emergency Foodbank service in the heart of communities. Staff and volunteers would provide excellent insights into planning a service for the future, beyond providing emergency food aid. To consider the role of providing social prescribing, as Norwich Foodbank is uniquely placed to access people at high risk, with highly complex needs in our seldom heard communities. Working with people with complex needs is emotionally demanding and staff and volunteers may benefit from additional opportunities to share experiences and for support

A qualitative exploration of a Financial Inclusion service in an English foodbank

Aims: Foodbanks provide emergency food provision. This need can be triggered by a change in circumstance or a crisis. Failures in the social security safety net are the most significant driver for hunger in the UK. There is some evidence that an advisory service which runs alongside a foodbank is more effective in reducing emergency provision and the duration and severity of hunger. The ‘Making a Difference’ project at an English foodbank is a pilot scheme aiming to increase financial resilience in their service users. From summer 2022 they introduced new advice worker roles, in partnership with Shelter [Housing advice} and Citizen’s Advice [General, debt and benefits advice], aiming to pre-empt the need for foodbank use, to triage the financial needs of service users and refer appropriately to reduce repeat visits to the foodbank. Methods: This qualitative study involved in-depth interviews with four staff and four volunteers to evaluate barriers, facilitators and potential friction points in referrals and partnership working. Findings: Our data was analysed thematically into four themes: Holistic needs assessment; Reaching seldom heard communities; Empowerment and The needs of staff and volunteers. Two case studies illustrate the complexity of people’s needs. Conclusion: A Financial Inclusion service operating within foodbanks giving housing, debt and benefits advice shows some promise in reaching people in crisis at the point of need. Based within the heart of a community it appears to meet the complex needs of very vulnerable people who may have found mainstream support services inaccessible. This asset-based approach with the foodbank as a trusted provider enabled joined up, compassionate, holistic and person-centred advice quickly cutting across multiple agencies, reaching underserved and socially excluded clients. We suggest that supportive services are needed for volunteers and staff who are vulnerable to vicarious trauma from listening and supporting people in crisis

We care but we’re not carers: perceptions and experiences of social prescribing in a UK national community organisation

Aims: (1) To explore how social prescribing referrals impact experiences of existing members of a voluntary and community-based organisation and (2) to describe the processes and relationships associated with joining community and voluntary organisations. Methods: Online survey and qualitative interviews with members of Men’s Sheds, a global volunteer-led initiative to address loneliness and social isolation in men. 93 self-selecting Shed members (average age 67 years, 93% male) from across England and Scotland took part in the survey about demographics, joining the Shed, and free-text questions about experiences in the Shed. From the survey participants, 21 Shed members were purposively sampled and interviewed to explore the impact of social prescribing and referrals on the Sheds. Results: Participating in the Men’s Shed was often associated with a significant change in personal circumstances, and Sheds provided a unique social support space, particularly valuable for men. Key factors around experiences of social prescribing and referral mechanisms were identified. We developed three themes: the experience of joining a Shed, success factors and risks of social prescribing, and ‘we care but we’re not carers’. Conclusions: The results show that Men’s Sheds are a caring organisation, but their members are not trained as professional carers, and men come to the Shed for their own personal reasons. They are concerned about the potential additional responsibilities associated with formal referrals. They encourage the development of relationships and local-level understanding of the essence of Sheds to enable social prescribing. As models of social prescribing grow nationally and internationally, collaboratively working with voluntary and community organisations to develop a mutually beneficial approach is essential for the effectiveness and sustainability of social prescribing in community health

Investigating inherent functional differences between human cardiac fibroblasts cultured from nondiabetic and Type 2 diabetic donors.

Type 2 diabetes mellitus (T2DM) promotes adverse myocardial remodeling and increased risk of heart failure; effects that can occur independently of hypertension or coronary artery disease. As cardiac fibroblasts (CFs) are key effectors of myocardial remodeling, we investigated whether inherent phenotypic differences exist in CF derived from T2DM donors compared with cells from nondiabetic (ND) donors