Hypertension treatment for older people-navigating between Scylla and Charybdis.

Hypertension is a common condition in older people, but is often one of many conditions, particularly in frail older people, and so is rarely managed in isolation in the real world-which belies the bulk of the evidence upon which is treatment decisions are often based. In this article, we discuss the issues of ageing, including frailty and dementia, and their impact upon blood pressure management. We examine the evidence base for managing hypertension in older people, and explore some therapeutic ideas that might influence treatment decisions and strategies, including shared decision making

POSC351 Outcome Goals for Older People Living with Frailty and Acute Care Needs: An Interview Study

Conference Abstrac

Outcomes of hospital admissions among frail older people: a 2-year cohort study.

BACKGROUND: 'Frailty crises' are a common cause of hospital admission among older people and there is significant focus on admission avoidance. However, identifying frailty before a crisis occurs is challenging, making it difficult to effectively target community services. Better longer-term outcome data are needed if services are to reflect the needs of the growing population of older people with frailty. AIM: To determine long-term outcomes of older people discharged from hospital following short (<72 hours) and longer hospital admissions compared by frailty status. DESIGN AND SETTING: Two populations aged ≥70 years discharged from hospital units: those following short 'ambulatory' admissions (<72 hours) and those following longer inpatient stays. METHOD: Data for 2-year mortality and hospital use were compared using frailty measures derived from clinical and hospital data. RESULTS: Mortality after 2 years was increased for frail compared with non-frail individuals in both cohorts. Patients in the ambulatory cohort classified as frail had increased mortality (Rockwood hazard ratio 2.3 [95% confidence interval {CI} = 1.5 to 3.4]) and hospital use (Rockwood rate ratio 2.1 [95% CI = 1.7 to 2.6]) compared with those patients classified as non-frail. CONCLUSION: Individuals with frailty who are discharged from hospital experience increased mortality and resource use, even after short 'ambulatory' admissions. This is an easily identifiable group that is at increased risk of poor outcomes. Health and social care systems might wish to examine their current care response for frail older people discharged from hospital. There may be value in a 'secondary prevention' approach to frailty crises targeting individuals who are discharged from hospital

The predictive properties of frailty-rating scales in the acute medical unit.

BACKGROUND: older people are at an increased risk of adverse outcomes following attendance at acute hospitals. Screening tools may help identify those most at risk. The objective of this study was to compare the predictive properties of five frailty-rating scales. METHOD: this was a secondary analysis of a cohort study involving participants aged 70 years and above attending two acute medical units in the East Midlands, UK. Participants were classified at baseline as frail or non-frail using five different frailty-rating scales. The ability of each scale to predict outcomes at 90 days (mortality, readmissions, institutionalisation, functional decline and a composite adverse outcome) was assessed using area under a receiver-operating characteristic curve (AUC). RESULTS: six hundred and sixty-seven participants were studied. Frail participants according to all scales were associated with a significant increased risk of mortality [relative risk (RR) range 1.6-3.1], readmission (RR range 1.1-1.6), functional decline (RR range 1.2-2.1) and the composite adverse outcome (RR range 1.2-1.6). However, the predictive properties of the frailty-rating scales were poor, at best, for all outcomes assessed (AUC ranging from 0.44 to 0.69). CONCLUSION: frailty-rating scales alone are of limited use in risk stratifying older people being discharged from acute medical units

Polypharmacy in older vascular surgery inpatients

Introduction: Polypharmacy is common in older people and is associated with mortality and hospital readmission. The prevalence of polypharmacy in vascular patients is not well described. Methods: Retrospective audit of all patients aged >65 years admitted to a single vascular surgery unit for ≥24 hours during a 10-week study period (20/4/17 – 28/6/17). Data collected included age, gender, admission type, diagnoses, medications and length of stay (LoS). Results: 87 admissions were included. Mean age was 78 [±7.6], 67 [77.0%] patients were male, 63 [72.4%] had unplanned admissions and 40 [46.0%] were admitted with severe limb ischaemia. Median number of medications on admission was 8 [IQR:6-10]. Excessive polypharmacy (defined as ≥10 medications) was present in 27 [31.0%] patients and was not associated with age, gender, admission type or diagnosis (binary logistic regression analysis). Overall, median LoS was 6 days [IQR:3-11.5] and was similar in patients with and without excessive polypharmacy (7 days [IQR:2.5-11.5] vs 6 days [IQR:3-11.25] respectively). 40 [46.0%] patients were discharged on ≥1 more medications than admission; only 9 [10.3%] patients were discharged on ≥1 fewer medications. 33 [37.9%] patients were discharged on more than three high-risk medications, with the only associated patient factor being number of high-risk medications on admission [OR=15.80; 95%CI=3.03-34.80; p<.001] (ordinal logistic regression analysis). Conclusion: Polypharmacy, including prescription of multiple high-risk medications, is highly prevalent amongst older vascular surgery inpatients. Further research is needed to understand the association of polypharmacy on outcomes and determine strategies to reduce the prescribing of unnecessary medications. Take-home message: Polypharmacy is common amongst older vascular surgery inpatients although more research is needed to understand its associations with outcomes from vascular surgery

Why are we misdiagnosing urinary tract infection in older patients? A qualitative inquiry and roadmap for staff behaviour change in the emergency department

Aim: This study sough to determine the psychological and behavioural factors contributing to the incorrect diagnosis of urinary tract infection in older adults and identify potential interventions that can address the incorrect diagnosis of urinary tract infection in older adults? Findings: The findings were that the misdiagnosis of UTI, particularly in older people, is driven by complex, interconnected psychological and behavioural factors, such as lack of knowledge on the role of urine dip testing, bias towards older people, automatic testing, time and resource constraints, pressures from peers and patients and legal pressures. Developing interventions that address the disconnect between knowledge and practice by encompassing both psychological and behavioural factors may improve patient safety and staff satisfaction. Messages: Urine dipstick testing in the ED is often misinterpreted, leading to misdiagnosis which may then impact negatively on patient safety; the reasons this knowledge-practice disconnect exists are multi-factorial, but psychological and behavioural factors play a significant role. Systematic approaches incorporating these factors can potentially improve patient safety, efficiency, costs from unnecessary testing and staff satisfaction

Co-creation of a Patient-Reported Outcome Measure for Older People Living with Frailty Receiving Acute Care (PROM-OPAC)

Older people living with frailty emphasize autonomy and function as acute healthcare outcome goals. Existing Patient-Reported Outcome Measures (PROMs) measure function but do not comprehensively address autonomy. This initial development of a novel autonomy outcome measure used co-creation and cognitive interviews, working toward a PROM for Older People living with frailty receiving Acute Care (“PROM-OPAC”). Novel item question stems and responses considering autonomy were devised with lay research partners. Items were examined for content by lay volunteers, and then selected based on relevance, completeness, and accessibility. Retained items were cognitively tested with patient participants. Item selection considered content validity and feasibility and was undertaken collaboratively with lay research partners. The study involved 3 lay research partners and 4 further lay collaborators throughout all stages, and 14 patient participants were recruited for the cognitive interviews. Twenty-two novel items were appraised. Seven were selected for retention. This preliminary PROM-OPAC comprised 7 items to measure autonomy and was intended for administration alongside a function measure to capture meaningful acute healthcare outcomes. Development will continue with quantitative testing and validation.</p

Single-centre prospective cohort study investigating the associations and one-year trends of frailty, cognition, disability and quality of life pre- and post-intervention for chronic limb-threatening ischaemia

Background: Half of people with chronic limb-threatening ischaemia (CLTI) have frailty. This study aimed to describe the associations of frailty with cognition, disability and quality of life (QoL) among CLTI patients over 1 year following surgical or endovascular procedures. Methods: A single-centre prospective cohort study was undertaken. Patients undergoing a procedure for CLTI between May 2019 and May 2021 were eligible (minimum age >65 initially; >50 from November 2019). Participants underwent preoperative assessments for frailty, physical and cognitive function, disability, mood, disease-specific QoL (Vascular QoL questionnaire (VascuQoL)) and generic health-related QoL (EuroQoL EQ-5D-5L). Follow-up was at 3 months (clinic or telephone) and 12 months (telephone). Baseline frailty was assessed using both the Edmonton frail scale (EFS) and the clinical frailty scale (CFS). Frailty during follow-up was re-assessed at 3 and 12 months using the CFS as it can be performed via telephone. Associations of baseline frailty with disability, QoL and mood scores during follow-up were investigated using repeated measures mixed models. Results: Ninety-nine patients completed the baseline assessments. Forty-five (45%) were classified as frail by the EFS. Frailty was associated with a higher prevalence of cognitive impairment based on the Montreal cognitive assessment (52% vs 17%; p<0.001). Eighty-seven patients were eligible for follow-up. Baseline frailty (EFS) was associated with worse QoL scores at all timepoints (VascuQoL p=0.001; EQ-5D-5L p<0.001). Both those with and without frailty at baseline (EFS) had modest improvement in QoL scores at 12 months (VascuQoL p<0.001; EQ-5D-5L p=0.001). Barthel index (disability) scores were lower for those with frailty at baseline (EFS) (p<0.001) and decreased slightly over 12 months for both groups (p=0.007). Five patients (12%) transitioned from frailty to non-frailty at 12 months based on the CFS. However, 10 patients (23%) transitioned from non-frailty to frailty. Conclusions: CLTI patients with frailty have worse QoL and greater disability both pre- and post-intervention. However, they demonstrate similar QoL benefit to those without frailty at 1 year following intervention. Baseline frailty assessment is important to inform prognostic discussions, expectations and shared decision making in CLTI.</p

A European Research Agenda for Geriatric Emergency Medicine: a modified Delphi study

Purpose: Geriatric Emergency Medicine (GEM) focuses on delivering optimal care to (sub)acutely ill older people. This involves a multidisciplinary approach throughout the whole healthcare chain. However, the underpinning evidence base is weak and it is unclear which research questions have the highest priority. The aim of this study was to provide an inventory and prioritisation of research questions among GEM professionals throughout Europe. Methods: A two-stage modified Delphi approach was used. In stage 1, an online survey was administered to various professionals working in GEM both in the Emergency Department (ED) and other healthcare settings throughout Europe to make an inventory of potential research questions. In the processing phase, research questions were screened, categorised, and validated by an expert panel. Subsequently, in stage 2, remaining research questions were ranked based on relevance using a second online survey administered to the same target population, to identify the top 10 prioritised research questions. Results: In response to the first survey, 145 respondents submitted 233 potential research questions. A total of 61 research questions were included in the second stage, which was completed by 176 respondents. The question with the highest priority was: Is implementation of elements of CGA (comprehensive geriatric assessment), such as screening for frailty and geriatric interventions, effective in improving outcomes for older patients in the ED? Conclusion: This study presents a top 10 of high-priority research questions for a European Research Agenda for Geriatric Emergency Medicine. The list of research questions may serve as guidance for researchers, policymakers and funding bodies in prioritising future research projects