The physician’s role in perioperative management of older patients undergoing surgery

Life-sustaining and life-improving surgical interventions are increasingly available to older, frailer patients, many of whom have multimorbidity. Physicians can help support perioperative multidisciplinary teams with assessment and preoperative optimisation of physiological reserve, comorbidities and associated geriatric syndromes. Similar structured support can be useful in the postoperative period where older patients are at increased risk of delirium, medical complications, increased functional dependency and where discharge planning can prove more difficult than in younger cohorts. Comprehensive geriatric assessment has been shown to improve outcomes and is now embedded in most UK-based services for traumatic hip fracture. Perioperative comprehensive geriatric assessment has been explored in other surgical disciplines and procedures and, where evaluated, has been associated with improved outcomes. The need to support older patients with frailty undergoing surgery exceeds the capacity of specialist geriatricians. Other groups of healthcare professionals need to nurture the core competencies to support this group perioperatively

Does Comprehensive Geriatric Assessment (CGA) have a role in UK care homes?

UK care home residents are frail, dependent and multimorbid. General practitioners (GPs) provide their healthcare but there is evidence that existing provision fails to meet their needs. Comprehensive Geriatric Assessment (CGA) comprises comprehensive multidisciplinary assessment, goal setting and frequent review. This thesis considers a possible role for CGA in UK care homes through three research projects. The Care Home Literature Review (CHoLiR) was a systematic mapping review of randomized controlled trials (RCTs) in care homes. It found no evidence supporting CGA as a whole but described some CGA components supported by RCTs: advanced care planning; interventions to reduce prescribing; staff education around dementia and end-of-life; calcium/vitamin D and alendronate in preventing fractures and osteoporosis; vaccination/neuraminidase inhibitors in preventing influenza; functional incidental and bladder training for incontinence; and risperidone/olanzapine for agitation. The Care Home Outcome Study (CHOS) was a longitudinal cohort study recording dependency, cognition, behaviour, diagnoses, prescribing, nutrition and healthcare resource use in 227 residents across 11 care homes over six months. It reported high levels of dependency, cognitive impairment, malnutrition, multimorbidity and frequent behavioural disturbance. Polypharmacy and prescribing errors were common. Variability between homes and individuals was significant for most baseline and outcome measures. Staff Interviews in Care Homes (STICH) was a qualitative interview study of 32 staff working with care homes including: GPs; care home managers and nurses; NHS community nurses and specialist practitioners. It described care defined by discontinuity and lack-of-anticipation; driven by communication failure, inadequate training and expertise in frail older patients, and arbitrary boundaries between care homes and the NHS which interfered with care. Using the findings of these studies, the author proposes a model of care which is multidisciplinary, guided by comprehensive assessment, reinforced by frequent review and delivered by experts in the care of frail older patients: CGA has a role in UK care homes

Effectiveness of exercise interventions for adults over 65 with moderate-to-severe dementia in community settings: a systematic review

PurposeTo conduct a systematic review of the literature to evaluate the effectiveness of exercise interventions for people with moderate-to-severe dementia in community settings.MethodsEight electronic databases (MEDLINE, Embase, CINAHL, AMED, PsycINFO, PEDro, The Cochrane Library and BNI) were searched from inception to July 2018. Snowball searching identified additional articles not identified initially. Articles were included if they: reported randomised or quasi-randomised controlled trials comparing exercise with usual care or no treatment; and involved people over 65 with moderate-to-severe dementia in community settings. Outcome measures of interest were strength, endurance, mobility, mood and quality of life. Titles and abstracts of all studies were screened by one reviewer. Two reviewers independently screened full text articles for all eligible studies, extracted data and assessed quality and risk of bias.ResultsEight studies with 819 participants were included. Interventions were variable in terms of content, duration and frequency. There was some evidence exercise programmes may improve physical function of people with moderate-to-severe dementia, with significant effects seen for gait speed and endurance, and a trend towards improvement in strength. There was little evidence to suggest exercise programmes improve mood. Most studies were of low quality.ConclusionExercise was associated with improvements in gait speed and endurance for older people with moderate-to-severe dementia living in the community, but the quality of evidence was low. There was no conclusive evidence regarding effect on strength or mood. Findings are limited by the quality of the available evidence

Does Comprehensive Geriatric Assessment (CGA) have a role in UK care homes?

UK care home residents are frail, dependent and multimorbid. General practitioners (GPs) provide their healthcare but there is evidence that existing provision fails to meet their needs. Comprehensive Geriatric Assessment (CGA) comprises comprehensive multidisciplinary assessment, goal setting and frequent review. This thesis considers a possible role for CGA in UK care homes through three research projects. The Care Home Literature Review (CHoLiR) was a systematic mapping review of randomized controlled trials (RCTs) in care homes. It found no evidence supporting CGA as a whole but described some CGA components supported by RCTs: advanced care planning; interventions to reduce prescribing; staff education around dementia and end-of-life; calcium/vitamin D and alendronate in preventing fractures and osteoporosis; vaccination/neuraminidase inhibitors in preventing influenza; functional incidental and bladder training for incontinence; and risperidone/olanzapine for agitation. The Care Home Outcome Study (CHOS) was a longitudinal cohort study recording dependency, cognition, behaviour, diagnoses, prescribing, nutrition and healthcare resource use in 227 residents across 11 care homes over six months. It reported high levels of dependency, cognitive impairment, malnutrition, multimorbidity and frequent behavioural disturbance. Polypharmacy and prescribing errors were common. Variability between homes and individuals was significant for most baseline and outcome measures. Staff Interviews in Care Homes (STICH) was a qualitative interview study of 32 staff working with care homes including: GPs; care home managers and nurses; NHS community nurses and specialist practitioners. It described care defined by discontinuity and lack-of-anticipation; driven by communication failure, inadequate training and expertise in frail older patients, and arbitrary boundaries between care homes and the NHS which interfered with care. Using the findings of these studies, the author proposes a model of care which is multidisciplinary, guided by comprehensive assessment, reinforced by frequent review and delivered by experts in the care of frail older patients: CGA has a role in UK care homes

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

Frailsafe: from conception to national breakthrough collaborative

The number of people aged over 60 years worldwide is projected to rise from 605 million in 2000 to almost 2 billion by 2050, while those over 80 years will quadruple to 395 million. Two-thirds of UK acute hospital admissions are over 65, the highest consultation rate in general practice is in those aged 85-89 and the average age of elective surgical patients is increasing. Adjusting medical systems to meet the demographic imperative has been recognised by the World Health Organisation to be the next global healthcare priority and is a key feature of discussions on policy, health services structures, workforce reconfiguration and frontline care delivery

TRX: A Formally Verified Parser Interpreter

Parsing is an important problem in computer science and yet surprisingly little attention has been devoted to its formal verification. In this paper, we present TRX: a parser interpreter formally developed in the proof assistant Coq, capable of producing formally correct parsers. We are using parsing expression grammars (PEGs), a formalism essentially representing recursive descent parsing, which we consider an attractive alternative to context-free grammars (CFGs). From this formalization we can extract a parser for an arbitrary PEG grammar with the warranty of total correctness, i.e., the resulting parser is terminating and correct with respect to its grammar and the semantics of PEGs; both properties formally proven in Coq.Comment: 26 pages, LMC

Using comprehensive geriatric assessment for quality improvements in healthcare of older people in UK care homes: protocol for realist review within Proactive Healthcare of Older People in Care Homes (PEACH) study

Introduction Care home residents are relatively high users of healthcare resources and may have complex needs. Comprehensive geriatric assessment (CGA) may benefit care home residents and improve efficiency of care delivery. This is an approach to care in which there is a thorough multidisciplinary assessment (physical and mental health, functioning and physical and social environments) and a care plan based on this assessment, usually delivered by a multidisciplinary team. The CGA process is known to improve outcomes for community-dwelling older people and those in receipt of hospital care, but less is known about its efficacy in care home residents. Methods and analysis Realist review was selected as the most appropriate method to explore the complex nature of the care home setting and multidisciplinary delivery of care. The aim of the realist review is to identify and characterise a programme theory that underpins the CGA intervention. The realist review will extract data from research articles which describe the causal mechanisms through which the practice of CGA generates outcomes. The focus of the intervention is care homes, and the outcomes of interest are health-related quality of life and satisfaction with services; for both residents and staff. Further outcomes may include appropriate use of National Health Service services and resources of older care home residents. The review will proceed through three stages: (1) identifying the candidate programme theories that underpin CGA through interviews with key stakeholders, systematic search of the peer-reviewed and non-peer-reviewed evidence, (2) identifying the evidence relevant to CGA in UK care homes and refining the programme theories through refining and iterating the systematic search, lateral searches and seeking further information from study authors and (3) analysis and synthesis of evidence, involving the testing of the programme theories. Ethics and dissemination The PEACH project was identified as service development following submission to the UK Health Research Authority and subsequent review by the University of Nottingham Research Ethics Committee. The study protocols have been reviewed as part of good governance by the Nottinghamshire Healthcare Foundation Trust. We aim to publish this realist review in a peer-reviewed journal with international readership. We will disseminate findings to public and stakeholders using knowledge mobilisation techniques. Stakeholders will include the Quality Improvement Collaboratives within PEACH study. National networks, such as British Society of Gerontology and National Care Association will be approached for wider dissemination

A photo-elicitation study of homeless and marginally housed Veterans’ experiences with patient-centered care

As part of a qualitatively-driven mixed-methods study, this analysis aimed to describe Veterans Affairs (VA) Homeless Patient Aligned Care Team patients’ experiences with patient-centered care. Veterans participated in audio-recorded, semi-structured photo-elicitation interviews about their health and VA health care. Transcripts were analyzed by two coders using template analysis. In 31/36 interviews, 19/20 participants discussed patient-centered care. Veterans noted Picker’s Patient-Centered Care Principles; 1) access to care, 2) respect for patient-centered values, preference and expressed needs, 3) information, communication, and education, and 4) coordination and care integration were most commonly discussed, followed by 5) physical comfort, 6) transition and continuity, 7) emotional support and alleviation of fear/anxiety, and 8) family and friend involvement. They also identified 1) quality care and 2) being present with patient as central to patient-centered care. Improvement suggestions included the patient-provider relationship, VA services, and transportation. Photo-elicitation may be useful in understanding patient preferences, needs, and values to ensure patient-centered care delivery