‘Care of Older People in the Community’

@EMRAN_ageing #EM_Ageing

25 November 2015 – University of Lincoln

Professor Niro Siriwardena– Professor of Primary & Pre-Hospital Health Care

Dr Carlos Rodriguez Pascual - Professor & Honorary Consultant in Care of the Older Person

Dr Jo Middlemass – Research Fellow

Dr Fiona Marshall – Alzheimer's Society Senior Research Fellow

Dr Gill Garden – Consultant in Older People’s Services

What’s been happening…

2 collaborative

projects initiated by

EMRAN

More seminars upcoming

A growing reputation

6 Discussion Papers

Lincoln County Hospital

Frailty and cardiovascular diseases in the elderly

Carlos Rodríguez PascualProfessor and Honorary Consultant in Care of the ElderlyUniversity of Lincoln-Lincoln County Hospital

Lincoln County Hospital

Range Score Dependency on ADL (Katz index) Katz A (dependence in no ADL) Katz B-C (dependence in one or two ADL) Katz D-G (dependence in three or more ADL)

0

1-2 >3

0 1 2

Mobility dependence (six-level qualitative scale) Physical activity carried out without help Requires a person, walking frame or wheel chair Bedridden

0-1 2-4 5

0 1 2

Charlson Comorbidity Score (CCS) 0-1 2-4 >5

0 1 2

Previous cognitive impairment

No Yes

0 2

Number of medications on hospital admission (prescribed and over-the-counter)

0-2 3-7 >8

0 1 2

Follow up (Weeks)1047852260

Surv

ival

1,0

0,8

0,6

0,4

0,2

0,0

Adjusted Survival

0.6

0.4

0.2

0

0.8

1.0

Q4

Q1

Q2Q3

A worse score in geriatric assessment is related with mortality in HFRelevance of frailty measuring in CV diseases

Failty is related with one-year mortality in aortic stenosis

Failty is related with one-year mortality in heart failure

Follow up (weeks)523926130

Surv

ival

1,0

0,8

0,6

0,4

0,2

0,0

3 ó más fragilidades (de 5)-censurado

2 ó menos fragilidades-censurado

3 ó más fragilidades (de 5)

2 ó menos fragilidades

Fragilidad01

Funciones de supervivencia

Non frail 85.1%

Frail 73%

P=0.003

Lincoln County Hospital

Prevalence of cardiovascular disease stratified by frailty statusAfilalo, Am J Cardiol2009

Incident CV disease in pre-frailty statusSergi, JACC 2015

Risk of frailty with CV risk factorsGale, AGE 2014

Risk of frailty in CV diseasesAfilalo, Am J Cardiol2009

Lincoln County Hospital

FRAILTY

DISABILITY

COMORBIDITY

Frailty CVDCognitive frailty

1 2 3

• Relationship among CV risk factors, subclinical CV disease load, biologic pathways, and frailty (physical and cognitive) should be better explored

• Can Interventions to decrease subclinical CV disease load to prevent and delay frailty and disability?

• How can measurement of frailty contribute to decision-making in clinical practice?

Lincoln County Hospital

Atherosclerosis burden, Frailty and cognitive impairment

Cases: mild cognitive impairment Controls: preserved cognition

Atherosclerosis burden: carotid plaque volume measured on 3D echo

(new technology)

Structural and functional (flow) brain assessment: MRI

Question 1: Is macrovascular carotid atherosclerosis burden increased in patients with incident Frailty or cognitive impairment?

Question 2: How does macrovascular carotid atherosclerosis burden affect cerebral circulation?

Biomarkers: oxidative stress, inflamatory, genetic

Lincoln County Hospital

STUDY OF FRAILTY AND AORTIC STENOSIS IN THE ELDERLY(SAS-FRAILTY)

CARE OF OLDER PEOPLE IN THE COMMUNITY UNIVERSITY OF LINCOLN

25/11/2015

CArers of People with Dementia: Empowerment and Efficacy via Education (CAD: E3)

Despina Laparidou, Prof Terence Karran, Prof Niro Siriwardena, Dr John Hudson, Paul Mansfield, Dr Karen Windle.

PPI representatives: Pauline Mountain and Kathy Eborall.

EMRAN Presentation 25th November 2015

Dr Jo Middlemass

On behalf of the CAD:E3 team:

Key findings from systematic review Educational interventions

–Successful in improving most carer and patient related outcomes, except for carer depression and institutionalisation.

Psychoeducational interventions–Successful in improving carer-related outcomes - Less successful in improving patient-related outcomes.

Multi-component interventions–Effective across most outcomes, but produced mixed results for care recipient institutionalisation.

Cost-effectiveness– Few studies with mixed results. One showed a multi-component study alleviated some costs of caregiving whereas a systematic review reached no conclusion.

CaHRU@lincoln.ac.uk

Key findings from qualitative interviews – health professionals and carers/patients

• Difficulties in initial diagnosis with health professionals.• Mismatch of expectations and communication. • Need for support and education for carers.

– Understanding of dementia and why their care-recipients act as they do.

– Ways to deal with challenging behaviours. – Knowledge of support services available.

• Carer involvement in the process of care. – support informal monitoring role (diaries).

CaHRU@lincoln.ac.uk

Feasibility study research design

• Research population and interventionPatients and Carers on the waiting list for a Cognitive Stimulation

Therapy (CST) course run by Lincolnshire Partnership Foundation Trust (LPFT). Patients have CST. Carers are randomised into two cluster groups (intervention and control).

CaHRU@lincoln.ac.uk

Existing group activity as usual

Number = 36

An multi-component programme (emphasising

education and communication)Number = 36

Intervention group Control group

Thank you.

CaHRU@lincoln.ac.uk

CARE OF OLDER PEOPLE IN THE COMMUNITY UNIVERSITY OF LINCOLN

25/11/2015

Scaling the Peaks; understanding living with dementia in the Peak District national

park

Contact: fiona.marshall@nottingham.ac.uk for details. Kindly supported by Alzheimer's Society, The Institute of Mental Health, The School of Geography, University of Nottingham

Design of Study• Data Gathering;• Census, epidemiology • Local organisations; NHS,

Social services, Public health, voluntary, farming, church, rural action groups

• Infra-structures; travel, housing, technologies

• Resource locations; shops, GPs, pharmacy, clinics

• Climate & terrain• Closeness to services;

journeys and decisions

• Geo-spatial Science [GIS]

Understanding lives of those living with dementia and caregivers

Where, who, how, when? Mapping the findings;Using GIS and ethnographic enquiry to

determine the expectations and experiences of current provision, support decision-making for resource design and allocation to meeting any unmet needs in the region

This will be achieved by the mixed method approach to support critical analysis of all data, visual mapping and dissemination of findings

CARE OF OLDER PEOPLE IN THE COMMUNITY UNIVERSITY OF LINCOLN

25/11/2015

The Bromhead Care Home Service: Phases 1 & 2

Gill GardenUnited Lincolnshire Hospitals NHS Trust

gill.garden@stbarnabashospice.co.uk

• prioritised)– Care planning

Funding: Bromhead Medical Charity

Staff: 2 RGNs + support (unfunded)

Location: 7 care homes in Boston

Patients: residents with dementia

Service: •Training : delirium, eating, drinking, dysphagia & end of life issues•GSF assessment•Care planning (most frail prioritised)

Phase 1: 2011

Phase 1: Outcomes

Percentage of staff confident or very confident in:

Before training After training P values

Recognition of delirium 20.6 84.4 0.0001

Prevention of delirium 10.9 77.7 0.0001

Management of delirium 8.7 69.3 0.0001

Recognition of dysphagia 19 75 0.0005

Management of dysphagia 23.8 72.2 0.0039

“ My Mum had made a living will & it was something

she always talked about with her family. This process has given me the confidence to know that my mum’s voice will be heard even

though she can no longer communicate effectively. As a

family we also feel we have been given the opportunity to be

heard for the first time”

Funding: The Bromhead Medical CharityStaff: (3.7 WTE): 1Dr, 1 OT, 1 physio, 2 nursesPatients: residents in 26 Lincoln care homesStep wedge cluster model with care homes randomisedIntervention:•Comprehensive Geriatric Assessment for all residents

• Optimisation of function & medication • Anticipatory care planning

Phase 2Phase 2

• Admissions before and after intervention• Health Service Utilisation • Deaths before and after intervention• Proxies of care:

• falls • pressure sores• medication review• nutrition review• death in preferred place of care

Phase 2Phase 2: Service Evaluation

Interviews with families before death and posthumously Comparison of families who opt for palliative care and families who choose escalation with respect to:•Attitudes to death•Satisfaction with care

Phase 2Phase 3: Qualitative Evaluation

CARE OF OLDER PEOPLE IN THE COMMUNITY UNIVERSITY OF LINCOLN

25/11/2015