Should guidance for the use of antihypertensive medication in older people with frailty be different?

The benefits of antihypertensive treatments have been established in numerous large clinical trials. Although the Hypertension in the Very Elderly Trial (HYVET) confirmed the protective effect of blood pressure medication for healthy, older individuals without dementia over 80 years of age who do not live in a care home [1], the evidence for people who are also frail and/or have comorbidities remains unclear [2]. This is reflected in hypertension guidelines. For example, the guidelines of the European Society of Hypertension and European Society of Cardiology [3] recommend reducing the systolic blood pressure in older people who have a blood pressure of 160 mmHg or above, to between 140 and 150 mmHg with the caveat of those over 80 years of age should be in good physical and mental conditions to do so. The guidelines of the National Institute of Health and Care Excellence (NICE) for Hypertension [4] advise for people under 80 years of age a target blood pressure of 140/90 mmHg and for people over 80 years of age a target blood pressure of 150/90 mmHg. Furthermore, for people over 80 years of age, co-morbidities should be taken into account when deciding on antihypertensive treatment

Classification of athletes with intellectual disabilities : towards the re-inclusion of athletes with intellectual disabilities in the Paralympics

Classification of athletes with intellectual disabilities : towards the re-inclusion of athletes with intellectual disabilities in the Paralympic

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

Promoting physical activity in primary care: a systematic review and meta-analysis

Background: Promoting physical activity is an important part of patient care in primary care and has been investigated in many studies with a wide range of intervention characteristics often including external support. It is unclear, however, if promoting physical activity is effective. Aim: To investigate the effectiveness of behaviour change interventions to promote physical activity in primary care. Design and Setting: This is a systematic review and meta-analysis to evaluate physical activity promotion in a primary care setting. Method: Embase, Medline, PsycInfo and the Joanna Briggs Institute Database were searched for ‘physical activity’, ‘interview’, ‘motivation’, ‘primary care’ and equivalent words to identify randomized controlled trials with physical activity as outcome at patient level. Results: The review identified 23 eligible studies. The quality appraisal showed that most studies reported insufficient details regarding randomization, group allocation, blinding and fidelity of intervention delivery. The included studies reported a wide range of interventions with varying numbers of follow-up visits or phone calls. The overall effect size for interventions with a 6 months follow-up interval was 0.04 (95% CI -0.05 to 0.13), for interventions with a 12 months follow-up interval 0.2 (95% CI 0.04 to 0.36). Only one intervention based on three motivational interviewing sessions achieved a moderate effect. Conclusion: Counselling to promote physical activity in primary care has a limited effect on patients’ behaviour and might not be, on its own, enough to change physical activity behaviour

The association of specific executive functions and falls risk in people with mild cognitive impairment and early-stage dementia

Background/Aims: Impairment in executive function is associated with a heightened risk for falls in people with mild cognitive impairment (MCI) and dementia. The purpose of this study was to determine which aspects of executive function are associated with falls risk. Methods: Forty-two participants with a mean age of 81.6 years and a diagnosis of MCI or mild dementia completed five different executive function tests from the computerised CANTAB test battery and a comprehensive falls risk assessment. Results: A hierarchical regression analysis showed that falls risk was significantly associated with spatial memory abilities and inhibition of a pre-potent response. Conclusion: The concept of executive function may be too general to provide meaningful results in a research or clinical context, which should focus on spatial memory and inhibition of a pre-potent response

Apathy Measures in Older Adults and People with Dementia: A Systematic Review of Measurement Properties Using the COSMIN Methodology

Background: Apathy is highly prevalent in dementia and is also seen in mild cognitive impairment and the general population. Apathy contributes to failure to undertake daily activities and can lead to health problems or crises. It is therefore important to assess apathy. However, there is currently no gold standard measure of apathy. A comprehensive systematic review of the measurement properties of apathy scales is required. Methods: A systematic review was registered with PROSPERO (ID: CRD42018094390). MEDLINE, Embase, PsycINFO, and CINAHL were searched for studies that aimed to develop or assess the validity or reliability of an apathy scale in participants over 65 years, living in the community. A systematic review was conducted in line with the COnsensus-based Standards for the selection of health Measurement INstruments procedure for reviewing patient-reported outcome measures. The studies’ risk of bias was assessed, and all relevant measurement properties were assessed for quality. Results were pooled and rated using a modified Grading of Recommendations Assessment, Development, and Evaluation procedure. Results: Fifty-seven publications regarding 18 measures and 39 variations met the eligibility criteria. The methodological quality of individual studies ranged from inadequate to very good and measurement properties ranged from insufficient to sufficient. Similarly, the overall evidence for measurement properties ranged from very low to high quality. The Apathy Evaluation Scale (AES) and Lille Apathy Rating Scale (LARS) had sufficient content validity, reliability, construct validity, and where applicable, structural validity and internal consistency. Conclusion: Numerous scales are available to assess apathy, with varying psychometric properties. The AES and LARS are recommended for measuring apathy in older adults and people living with dementia. The apathy dimension of the commonly used Neuropsychiatric Inventory should be limited to screening for apathy

The Balance and the Mind study: baseline data

OBJECTIVES: The purpose of the study was to establish falls risk factors for people with mild cognitive impairment and mild dementia. METHODS: Survey of 76 people recruited from Memory Clinics (n=56), Falls Services (n=12), Community Geriatricians (n=4), Cognitive Stimulation Therapy groups (n=2), and a Rehabilitation Unit (n=2). The assessments included falls risk, the Falls Efficacy Scale International (FESi), the Montreal Cognitive Assessment (MoCA) as well as neuropsychological tests. RESULTS: Mean age was 80.9 years (SD 6.5, age range: 67-94 years). The sample included 45% men, 98% had a white ethnic background and 48% lived alone. Mean MoCA score was 20.95 (SD 3.6), and 26 people (34%) had between 1 and 24 falls (mean 3.04; SD 4.65). Regarding any fall participants had in the past, 41% sustained an injury, 36% needed medical attention and 32% had been admitted to hospital as a consequence of a fall. The mean FESi score was 27 (SD 10.6) with 59% scoring >23, which is associated with a high fear of falling. The mean Timed Up and Go score was 16.0 seconds with 44% scoring ≥13.5 seconds, which is associated with high risk of falling. The mean Berg Balance score was 46 with 28% scoring ≤40, which is associated with a 100% chance of future falls. All assessments were acceptable to the particpants. CONCLUSIONS: The proportion of falls and falls risk factors was quite high in this population, which reflects findings from similar studies. Specialized falls prevention intervention should take these factors into account

What are the views of adults with an intellectual disability (AWID), carers and healthcare professionals on a community falls management programme for AWID: a qualitative interview study in the UK

Objectives The aim of this study was to refine a draft of the ACTiON FALLS LD programme based on the views of adults with an intellectual disability (AWID), carers and healthcare professionals (HCPs). Design, setting and participants The semistructured interview study included HCP as well as AWID and carers supporting AWID living in the community. Community settings included sheltered living, supported living, AWID living at home with family carers or independently. The interview study explored the first draft of the ACTiON FALLS LD programme as well as the wider falls management for AWID. Interviews with AWID were developed to include a range of approaches (eg, case studies, pictures) to support inclusive participation. Individual interviews were digitally recorded and transcribed. Researcher notes were used during interviews with AWID. All data were analysed using the principles of framework analysis. Results 14 HCP, 8 carers and 13 AWID took part in the interview process. Five key themes were identified: programme components, programme design, programme approach, who would use the programme and programme delivery. Conclusions The views of AWID, HCP and carers showed the need to consider the impact of risk perception, anxiety and fear of falling in the adaption of the ACTiON FALLS programme. The programme needs to be accessible and support the inclusion of AWID in managing falls and ultimately fulfil the requirement for a proactive and educational tool by all.</p

Impact of COVID-19 lockdown on physical exercise among participants receiving the Promoting Activity, Independence and Stability in Early Dementia (PrAISED) intervention: a repeated measure study

BackgroundThe potential decrease in daily physical activity associated with the COVID-19 pandemic lockdowns may have a negative impact on people living with dementia. Given the limited literature around the effects of home confinement in people living with dementia, this study investigated changes in physical exercise levels of participants in the intervention arm of the Promoting Activity, Independence and Stability in Early Dementia (PrAISED) Randomised Controlled Trial during the first COVID-19 national lockdown. It hypothesised that participants would maintain physical exercise levels.MethodsA repeated measure (three time points) study involving 30 participants (mean age = 78.0 years, 15 male and 15 female, 22 (73.0%) living with their primary caregiver), from four regions in England receiving the PrAISED intervention. PrAISED is an individually tailored intervention of physical exercises and functional activities. Trained therapists deliver therapy sessions over a period of 52 weeks. Study participants received therapy sessions via phone or video calling during the COVID-19 lockdown. This study investigated self-reported minutes of physical exercise recorded on study calendars for the months of February (i.e., baseline – pre-lockdown), May (i.e., T1 – during lockdown), and August (i.e., T2 - post-lockdown) 2020. ResultsParticipants reported a statistically significant increase in activity levels between February and May (Wilcoxon Z = -2.013, p = 0.044) and a statistically significant decrease between May and August (Wilcoxon Z = -2.726, p = 0.004). No significant difference was found in the physical activity levels from pre- to post-lockdown (Wilcoxon Z = 0.485, p = 0.620). ConclusionDespite concerns that the restrictions associated with the COVID-19 pandemic might lead to reductions in physical exercise, participants in receipt of the PrAISED intervention increased their amount of physical exercise during lockdown. Our findings support the potential of remote support for people living with dementia to help them maintain physical exercise levels in circumstances where face-to-face service provision is not possible.Trial registration. The PrAISED trial and process evaluation have received ethical approval number 18/YH/0059 from the Bradford/Leeds Ethics Committee. The Clinical Trial Identifier for PrAISED is: ISRCTN15320670 (https://doi.org/10.1186/ISRCTN15320670). Registration was made on 04/09/2018