Building consensus to enhance research: A study protocol to determine the top issues to improve outcomes of Silver Trauma

Silver trauma research has several obstacles including complexity in determining research priorities and the lack of strong evidence to improve outcomes for injured older adults (especially evidence from the United Kingdom). Therefore, this study aims to identify, investigate, and prioritise the top research priorities to improve outcomes of injured older adults. The study will also highlight the current issues in trauma care for older people and contribute a collaborative and interdisciplinary work among experts who are interested in trauma care for older people.Methods and analysis: This study uses a three-step modified Delphi technique. The process consists of a divergent phase to elicit a broad range of views, a convergent ranking process in the second round (ranking the issues identified in round I), and a consensus meeting in the third round (determining to the top three issues of those met the predetermined consensus threshold in round II). Ethics and dissemination: The ethical approval of this study is currently underway with the University of Leicester, UK. The findings of this study will be published and presented in relevant conferences.

Frailty: time for a new approach to health care?

In The Lancet Healthy Longevity, Joanna Blodgett and colleagues1 provide important evidence that frailty can be observed and measured in younger age groups (ie, in individuals aged ≥20 years), and is perhaps more relevant for predicting health outcomes than age. Except for women aged younger than 35 years, the results show an overall increase in mean frailty levels in all age groups for both men and women, accompanied by stable frailty lethality, from 1999 to 2018 in the USA. This increase poses some serious challenges for population health management. If people are not only failing to delay the onset of frailty in later years, but are also experiencing frailty earlier in life, this trend will result in a big challenge for health systems. [Opening paragraph]<br

What Factors Are Related to Medical Students’ and Doctors’ Attitudes Towards Older Patients?

Background: Studies have sought to determine the possible precursors to medical students’ and doctors’ positive or negative attitudes towards older patients by examining associations with a variety of demographic, educational/training, and job/career factors. A review is now needed to explore the quality of these studies and to synthesize findings. Methods: A systematic review on the worldwide English language literature was conducted. Ten databases were explored (including Medline, PsychInfo and Science Direct) from database inception to December 2015 using a systematic search strategy. Quality was assessed and reported. Results: The search identified 2332 articles; 37 studies met the eligibility criteria. Students’ year in medical school, doctors’ years of practice or seniority, participants’ age and ethnicity did not appear to demonstrate relationships with (positive or negative) attitudes towards older patients. Ten studies reported that female medical students and/or doctors reported significantly more positive attitudes towards older patients than their male counterparts, although 18 studies found no differences. No studies reported more positive attitudes scores for males than females. Interest in working in older patient settings and reporting a high level of intrinsic motivation for choosing medicine as a career were both associated with positive attitudes towards older patients. Eight of 11 studies found more positive attitudes were reported by those who demonstrated higher levels of knowledge about ageing but this apparent relationship is questioned here due to methodological issues identified in the quality assessment stage pertaining to the knowledge measures employed. Reliability and validity of the attitude measures, that were employed, were examined. Conclusions: This article has identified factors associated with medical students’ and doctors’ positive attitudes towards older patients, as well as factors which have been extensively studied but failed to demonstrate meaningful relationships with attitudes. This is the first study to identify that the relationship between attitudes and knowledge about ageing may be a methodological artefact. Future research can build on the relationships identified here and should employ appropriate measures of attitudes with demonstrated reliability and validity

Preventing falls in older people

Falls are a major cause of injury fear of falling and death affecting 24% of older people annually. Falls have a major impact on hospital services, are an important cause of carer strain and admission to long term care. Multifactorial interventions delivered to fallers are effective in reducing falls rates by 25%. However, no UK studies have evaluated the role of screening older people living in the community and offering those at high risk a falls prevention programme. This work describes two studies – the evaluation of a postal falls risk screening tool, and a randomised controlled trial assessing the benefits of offering a falls prevention programme to those identified as being at high risk. 335 older people were recruited into the screening study, using a modified version of the Falls Risk Assessment Tool. The sensitivity was 79%, specificity 58%, positive predictive value 50% and the negative predictive value 83%. In the RCT, 364 community-dwelling older people at high risk of falls were randomised into a pragmatic, multicentre trial evaluating falls prevention programmes. 181 were allocated to the control group and 183 to the intervention. The primary outcome was the rate of falls; the adjusted IRR was 0.73 (0.51-1.03), p=0.071. There were no significant differences between the groups in terms of the proportion of fallers, recurrent fallers, medically verified falls, injurious falls, time to first fall or time to second fall. Nor were there significant differences in terms of institutionalisation, mortality, basic or extended activities of daily living, or fear of falling. Further work on testing falls prevention interventions for acceptability is required, followed by a further adequately powered RCT to determine the clinical effectiveness of a systematic screening programme and intervention. At present, there is insufficient evidence for health care commissioners to recommend screening and intervention for falls

Preventing falls in older people

Falls are a major cause of injury fear of falling and death affecting 24% of older people annually. Falls have a major impact on hospital services, are an important cause of carer strain and admission to long term care. Multifactorial interventions delivered to fallers are effective in reducing falls rates by 25%. However, no UK studies have evaluated the role of screening older people living in the community and offering those at high risk a falls prevention programme. This work describes two studies – the evaluation of a postal falls risk screening tool, and a randomised controlled trial assessing the benefits of offering a falls prevention programme to those identified as being at high risk. 335 older people were recruited into the screening study, using a modified version of the Falls Risk Assessment Tool. The sensitivity was 79%, specificity 58%, positive predictive value 50% and the negative predictive value 83%. In the RCT, 364 community-dwelling older people at high risk of falls were randomised into a pragmatic, multicentre trial evaluating falls prevention programmes. 181 were allocated to the control group and 183 to the intervention. The primary outcome was the rate of falls; the adjusted IRR was 0.73 (0.51-1.03), p=0.071. There were no significant differences between the groups in terms of the proportion of fallers, recurrent fallers, medically verified falls, injurious falls, time to first fall or time to second fall. Nor were there significant differences in terms of institutionalisation, mortality, basic or extended activities of daily living, or fear of falling. Further work on testing falls prevention interventions for acceptability is required, followed by a further adequately powered RCT to determine the clinical effectiveness of a systematic screening programme and intervention. At present, there is insufficient evidence for health care commissioners to recommend screening and intervention for falls

Visual identifiers for people with dementia in hospitals : a qualitative study to unravel mechanisms of action for improving quality of care

Peer reviewedPublisher PD

Discursive design thinking: the role of explicit knowledge in creative architectural design reasoning

The main hypothesis investigated in this paper is based upon the suggestion that the discursive reasoning in architecture supported by an explicit knowledge of spatial configurations can enhance both design productivity and the intelligibility of design solutions. The study consists of an examination of an architect’s performance while solving intuitively a well-defined problem followed by an analysis of the spatial structure of their design solutions. One group of architects will attempt to solve the design problem logically, rationalizing their design decisions by implementing their explicit knowledge of spatial configurations. The other group will use an implicit form of such knowledge arising from their architectural education to reason about their design acts. An integrated model of protocol analysis combining linkography and macroscopic coding is used to analyze the design processes. The resulting design outcomes will be evaluated quantitatively in terms of their spatial configurations. The analysis appears to show that an explicit knowledge of the rules of spatial configurations, as possessed by the first group of architects can partially enhance their function-driven judgment producing permeable and well-structured spaces. These findings are particularly significant as they imply that an explicit rather than an implicit knowledge of the fundamental rules that make a layout possible can lead to a considerable improvement in both the design process and product. This suggests that by externalizing th

General Practitioners’ views of blood pressure control in people with and without dementia

Introduction: Since 2012, our group has undertaken a programme of research examining the treatment of hypertension in people with dementia. Hypertension is managed by GPs, who are guided by NICE guidelines, which make no mention of different management in people with dementia. We sought to explore the views of GPs on whether they manage hypertension differently in people with dementia. Method: We chose to try using an on-online survey to seek views, with both open and closed questions. We offered vignettes describing 71 and 83 year old women without cognitive impairment or with dementia, and a free text box – comments provided in this box were analysed thematically. Results: Although 427 GPs responded to the questionnaire, this was only 7% of all GPs eligible. Responding GPs were twice as likely not to offer treatment to the patient aged 71 with dementia and a BP above 140/90 (NICE threshold) compared to one without dementia (23.9% vs 11.7%). A similar finding was found when the vignettes involving 83 year old women with and without dementia (using 160/100, the NICE threshold for this age group) where 7.3% would not offer treatment in the woman with dementia compared to 3.3% in those without dementia. The analysis of free text identified four major themes, which were labelled as ‘complex decisions, ‘blood pressure measurement‘, ‘uncertainties around treatment’ and ‘compliance with guidelines’. Discussion: The low response rate in this survey makes the findings potentially unreliable, and other methods of ascertaining GP views, intentions or practices should be considered. Despite this, the findings from this study, in particular the free text comments indicate that the management of hypertension in people with dementia, is likely to be more complex than current guidelines indicate, and we propose that further research and clarification of best practice would be helpful

Preparatory review of studies of withdrawal of anti-hypertensive medication in older people

Introduction: Since 2012 we have undertaken a programme of research into the management of hypertension in people with dementia. As part of this we are studying the feasibility of withdrawing antihypertensive drugs in people with dementia and well-controlled hypertension, with the aim of them remaining normotensive but avoiding some of the burdens and side-effects of antihypertensive medications. We decided to undertake a preliminary examination of the literature to examine the evidence and safety of antihypertensive withdrawal (not restricted to those with dementia) to determine whether this has already been extensively reviewed, to provide an approximate estimate of the likelihood of success of antihypertensive withdrawal, and to prepare for a systematic review of this literature if required and feasible. Method: For this rapid review, we undertook a search for existing reviews and examined the relevant papers identified, and briefly updated the search once we found that the most recent review was in 2008. Results: One appropriate review (from 2008) yielding seven relevant articles, and one further article were identified, giving eight articles which were examined. Seven of the eight were published more than ten years ago. Six of the eight studies had follow-up data for 1 year or longer. Successful long term (1 year or more) withdrawal of antihypertensive medication was reported in 20-52% of patients. Conclusion: Our review indicates that 22-50% of patients whose blood pressures are currently adequately controlled might be able to withdraw medication without return of long term hypertension. The rapid review approach we took may have missed articles of relevance and so we propose that a systematic review of withdrawal is undertaken. Because much of the data will be old, it should seek data not only on the proportions of patients who remained normotensive at long term follow up using the standards of the day, but should seek data on findings relevant to current guidelines. Only data reporting long term follow up (≥ 1 year) should be included. Data referring to old or discontinued medications should be distinguished

New horizons in the implementation and research of comprehensive geriatric assessment: knowing, doing and the “know-do” gap

In this paper we outline the relationship between the need to put existing applied health research knowledge into practice (the “know-do gap”) and the need to improve the evidence base (the “know gap”) with respect to the health care process used for older people with frailty known as comprehensive geriatric assessment (CGA). We explore the reasons for the know-do gap and the principles of how these barriers to implementation might be overcome. We explore how these principles should affect the conduct of applied health research to close the know gap. We propose that impaired flow of knowledge is an important contributory factor in the failure to implement evidence-based practice in comprehensive geriatric assessment; this could be addressed through specific knowledge mobilisation techniques. We describe that implementation failures are also produced by an inadequate evidence base which requires the co-production of research, addressing not only effectiveness but also the feasibility and acceptability of new services, the educational needs of practitioners, the organisational requirements of services, and the contribution made by policy. Only by tackling these issues in concert and appropriate proportion, will the know and know-do gaps for CGA be closed