Promoting Activity, Independence and Stability in Early Dementia (PrAISED) research programme
Proactive Healthcare of Older People in Care Homes (PEACH)
Perindopril and Leucine to improve muscle function in older people. (LACE Study)
The loss of muscle mass and strength with age (sarcopenia) cause many problems, such as falls, but a drug called perindopril and a food supplement, the amino acid leucine could be effective treatments for this.
The loss of muscle mass and strength with age is called sarcopenia. An obvious and important consequence of such weakness is that people with sarcopenia are prone to fall. Resistance exercise is a treatment for this, but sometime this is hard to do (perhaps because of pain on exercise), or not sufficient to make enough difference. A drug called perindopril which is (widely used to lower blood pressure and help in heart failure) is associated with less sarcopenia, and an amino acid called leucine is a food component that is particularly important in triggering muscle synthesis. This study tests whether giving them to people with sarcopenia makes any appreciable difference.
The study resign is a factorial randomised controlled trial in which some participants will take either perindopril or leucine, some will take both and some will take neither.
Professor Tash Masud leads the Nottingham arm of this study, which is led by a study team in the University of Dundee by Dr Miles Witham.
Study dates: 2015-2020
Funder: NIHR Efficacy and Mechanism Evaluation Programme
Novel non-invasive techniques to means muscle mass, synthesis, and breakdown.
At present, measuring muscle mass usually requires scans that have to be done in hospital, and measuring muscle synthesis and breakdown requires invasive laboratory experiments. Together, the difficultly of making these measures hampers research in this field. Colleagues in the University of Nottingham in Derby have developed non-invasive techniques in which muscle mass, synthesis and breakdown which are tested in this study
The loss of muscle mass and strength with age (sarcopenia) is believed to be a core part of the ageing process, and of great clinical significance – not least in causing the muscular weakness that predisposed to falls. Sarcopenia is understood to develop due to an imbalance between the amount of muscle synthesis and the amount of muscle breakdown. It is vital to understand what reduces or stimulates muscle synthesis, and what worsens or prevents muscle breakdown. This will allow us to develop better exercises, drugs, and foods that can prevent or reverse this aspect of ageing. The trouble is that measuring muscle mass is not easy but, more importantly, measuring muscle synthesis and breakdown is very difficult. However, Dr Phil Atherton and his colleagues in the University of Nottingham in Derby has developed non-invasive techniques to do this, using analysis of the excretion of a dose of simple molecules used by the body in the synthesis and breakdown of muscle labelled with stable (non-radioactive) isotopes. This technique can be used in community dwelling people and study them over time as it only requires some simple periodic blood and urine tests. This study, undertaken by a PhD student, examines how well this technique compares to other techniques.
Old and young patients will be studied using the new technique, first to establish how it compares to existing techniques to measure muscle mass (DEXA scanning).
Later studies will examine how sensitive the technique is to the effects of resistance exercise (known to increase synthesis) and limb immobilisation (known to increase breakdown).
The principal supervisor is Dr Phil Atherton, in the University of Nottingham in Derby, supported by Professor Gladman, Sahota, and Masud.
Study Dates: 2016-2019
Funder: Abbeyfield Society
Osteoporosis and spinal fracture study
The aim of the research is to define a care model for the management of older people with osteoporotic spinal fractures in hospital
Osteoporotic spinal fracture is associated with significant pain, deterioration in physical function and leads to worse health care outcomes. Patients with these fractures who require hospital admission are frailer, older, in significant pain and have poor mobility. Treating their fracture needs to be done in conjunction with other age-related co-morbidities, polypharmacy, cognitive impairment, sensory impairment and frailty.
Orthogeriatric medicine brings together expertise in fracture management (invasive and non-invasive), peri-operative medicine, rehabilitation and bone health optimisation in a patient centred, co-ordinated multidisciplinary fashion. This has proven to be successful in the management of hip fractures and should offer the same benefits in spinal fractures.
This research aims to describe a spinal orthogeriatric model of care. It will comprise:
- A literature review of the management of osteoporotic spinal (vertebral and sacral) fractures
- An expert panel consensus regarding how acute osteoporotic spinal fractures should be managed in hospital
- An observational study of patients admitted to hospital with acute osteoporotic spinal fractures to look at the care processes and healthcare outcomes
Dates: August 2015 - 2018
Funder: Dunhill Medical Trust
LPZ and United Kingdom Care Homes (LaUNCH study)
This study will consider whether a once yearly in-depth audit of the prevalence of care problems in UK care homes can act as a mechanism to support quality improvement in the UK long-term care sector.
Long-term care homes often provide excellent care but the population they support is vulnerable and prone to health problems, some of which can be made worse if the correct care arrangements are not in place. Such care problems (e.g. pressure ulcers, incontinence, falls, malnutrition, taking multiple drugs) are the cause of significant suffering for residents in long-term care. At present there is no consistent or robust way of reporting how many care problems exist in UK long-term care to enable patient safety and quality improvement programmes to take place. This project seeks to understand whether such a measure can be implemented and how care homes might use it to improve patient care.
The Landelijke Prevalentiemeting Zorgproblemen (LPZ) - translated as International Prevalence of Care Problems Measure – was developed at the Maastricht University and is used across the Netherlands, in Germany, Switzerland, Austria, New Zealand, Indonesia and Brazil as once yearly audit of care problems. It uses standardised patient measures which are uploaded via a web-based interface for analysis by University-based academics. Care homes are provided with individualised dash-boards showing the prevalence of care problems in their home and whether they are taking the right preventative measures to avoid these. They then use this to drive quality improvement programmes prior to repeat measurements the following year.
This study will use the LPZ in UK care homes across the East Midlands and consider whether the tool is feasible in the UK setting, what are the barriers and enablers that allow it to be used and whether and how care homes can use data from the dashboard to drive quality improvement. It is supported by the East Midlands Patient Safety Collaborative, part of the East Midlands Academic Health Sciences Network, and is run in collaboration with the School for Public Health and Primary Care at Maastricht University.
Study dates: July 2015-July 2016
Funder: The East Midlands Patient Safety Collaborative
Contact: Associate Professor Adam Gordon:
Understanding the barriers and drivers to providing and using dementia friendly community services in rural areas
Scaling the Peaks; Understanding the barriers and drivers to providing and using dementia friendly community services in rural areas: the impact of location, cultures and community in the Peak District National Park on sustaining service innovations.
In recent years there have been major initiative to change the way that society is able to respond to the growing number of people with dementia - we are aiming for "dementia friendly societies" where people with dementia and those who care them are not alienated, or even merely tolerated, but enabled to have meaningful lives and to contribute meaningfully to society. There are concerns that, despite the idyllic scenery of rural areas such as the English Peak District, the challenges to developing dementia friendly societies in rural areas are different from those in urban areas.
This study will map the services and resources available to people with dementia and their carers, and examine how these are affected by the local geography. It will also study people with dementia in rural settings with a particular interest in the influence their locality, culture and community have upon their experiences and well-being.
Dates: June 2015 - May 2019
Funder: Alzheimer's Society (Research Fellowship)
PI: Dr Fiona MarshallContact: firstname.lastname@example.org
Communication skills training for healthcare professional caring for people with dementia
The development and testing of a communication skills training intervention for healthcare professionals caring for people with dementia in acute hospitals.
Successful communication between health care staff and patients and their families is central to safe, effective and high quality health care. Dementia often causes deficits that make communication difficult, and this requires health care staff to have greater communication skills.
The study will examine the types of communication are most beneficial in promoting positive interactions with patients with dementia using observations and video recording. A toolbox of effective practice will be produced. We will develop a training course using actors to simulate real world situations and an online e-learning resource. We will test our training intervention on forty healthcare professionals to see if it improves their skills and confidence in communicating with people with dementia.
Dates: June 2015 - June 2018
Funder: NIHR (HS&DR programme 13/114/93)
PI: Professor Rowan Harwood
The Peri-operative Enhanced Recovery hip FracturE Care of paTiEnts with Dementia (PERFECTED) study
Recovery after hip fracture
PERFECTED (Peri-operative Enhanced Recovery hip FracturE Care of paTiEnts with Dementia) is a National Institute for Health Research (NIHR) funded Applied Research Programme aiming to improve hospital care for patients with Dementia who break their hip.
This five-year programme is investigating how better standards of care can be implemented across the NHS. Despite one quarter of acute NHS hospital beds being occupied by people with dementia, there is little research on how best to look after these people in hospital. They are exceptionally vulnerable and at high risk of serious complications.
The programme will develop and pilot evidence based interventions to improve the hospital care of physical and mental health problems in people with dementia. The research programme will lead to the creation of an Enhanced Recovery Pathway (ERP) for the care and rehabilitation of people with dementia who break their hip. The development of implementation principles will be central and include the consideration of patients, families and staff. Our team of national and international experts from diverse disciplines in the field will use this programme of research to address the Ministerial Advisory Group on Dementia's research priorities.
The main aims of the programme are :
1. Determine best practice in care using existing evidence and the perspectives of service users, carers, healthcare professionals, health service managers and recognised experts (Work Package 1)
2. Define from best practice in care an optimised care pathway-the Enhanced Recovery Pathway (Work Package1)
3. Determine the training required to implement and maximise adherence to the Enhanced Recovery Pathway in hospital clinical settings (Work Package 2)
4. Produce a Manual to maximise adherence to the Enhanced Recovery Pathway (Work Package 2)
5. Undertake a pilot study to assess feasibility of procedures and provide information to inform a definitive trial to investigate clinical and cost-effectiveness of the Enhanced Recovery Pathway (with training). (Work Package 3)
6. Disseminate the results of the programme (Work Package 4)
Dates: March 2013-Feb 2018
Funder: NIHR PGfAR DTC-RP-PG-0311-12004
PI and lead organisation: C. Fox, University of East Anglia
Contact: Nottingham co-investigator Professor Opinder Sahota
Hypertension in Dementia (HIND)
While the benefits of medication against high blood pressure have been established in many large clinical trials, this has never been investigated for people with dementia who have been consistently excluded from these trials.
In addition, the risk for harmful side effects, such as falls or effects resulting from taking many medications is larger in people with dementia than without dementia.
Therefore, the balance of beneficial and harmful effects of medication against high blood pressure might be different in people with compared to those without dementia.
The Hypertension in dementia team includes researchers from the Universities of Nottingham and Leicester, who are working on several research projects:
- We have studied whether there is good evidence that lowering blood pressure in people with dementia is a good thing to do or not. We found that there is very little evidence one way or the other, mainly because people with dementia were not entered into the trials.
- We have showed that hypertension in people with dementia has historically been managed just as for those without dementia, but some GPs are a little uncomfortable with this, and many take special care to take individual factors such as dementia into account.
- We have shown that people with dementia might be at greater risk of side effects from anti-hypertensive drugs than those without dementia, and many of these potential side effects were not studied in the original trials of anti-hypertensive medication.
- We have noted evidence that lowering blood pressure might worsen the progress of dementia, and that some older and disabled patients, many likely to have dementia, may be particularly susceptible to vigorous blood pressure lowering.
- We have confirmed that hypertension management in people with dementia in the modern NHS is in line with modern best practice for those without dementia, but there is a higher than expected incidence of potential drug related side effects, and a high rate of heart attacks and strokes. This information can help doctors and patients make decisions about treatment.
- We have shown that it is acceptable and feasible to use ambulatory blood pressure monitoring people with dementia, although this is not so clear in people with severe dementia in whom it might be particularly useful.
- Our study of the feasibility to conduct a trial in which the effect of withdrawing anti-hypertensive drugs in people with dementia showed that recruitment to such a study is likely to be poor and that those who might have most to gain from doing so are unlikely to be recruited. At present, we do not think that a large scale study is feasible in the UK.
- A current study explores the relationship between antihypertensive drugs and a range of adverse outcomes in people with and without dementia as observed in large GP databases.
Study dates: The programme has been running since 2013
Funders: British Geriatrics Society; NIHR RfPB Alzheimer's Society. ABPM funded from the Nottingham University Hospitals League of Friends charity. This is a multicentre study.
Contacts: Dr Veronika van der Wardt, Prof. John Gladman, Prof. Sarah Lewis
Link to podcast: http://www.youtube.com/watch?v=g-ABWCgEyh0
• Welsh TJ (2016). The treatment of hypertension in people with dementia. PhD thesis, University of Nottingham. http://eprints.nottingham.ac.uk/33468/
• Conroy SP, Harrison JK, van der Wardt V, Harwood R, Logan P, Welsh T, Gladman JRF. Ambulatory blood pressure monitoring in older people with dementia: a systematic review of tolerability. Age Ageing Age and Ageing 2016; http://dx.doi.org/10.1093/ageing/afw050
• Harrison JK, Van der Wardt V, Conroy SP, Stott DJ, Dening T, Gordon AL, Logan PA, Welsh T, Taggar J, Harwood RH, Gladman JRF. New horizons: The management of hypertension in people with dementia Age Ageing 201645 (6): 740-746 http://dx.doi.org/10.1093/ageing/afw155
• Harrison JK, Conroy SP, Welsh T, Van der Wardt V, Gladman JRF Proposed Antihypertensive Medication Withdrawal Protocol. East Midlands Research into Ageing Network (EMRAN) Discussion Paper Series. Issue 8. June 2016 http://www.nottingham.ac.uk/emran/documents/issue-8-emran-aht-jun-16.pdf
• Van der Wardt V, Conroy S, Taggar J, Gladman JRF. General Practitioners’ views of blood pressure control in people with and without dementia. East Midlands Research into Ageing Network (EMRAN) Discussion Paper Series. Issue 1, May 2015. ISSN 2059-3341 http://www.nottingham.ac.uk/emran/documents/issue-1-emran-may-2015.pdf
• Harrison JK, Gladman JRF, Van Der Wardt V, Conroy SP. Preparatory review of studies of withdrawal of anti-hypertensive medication in older people. East Midlands Research into Ageing Network (EMRAN) Discussion Paper Series. Issue 3, July 2015. ISSN 2059-3341 http://www.nottingham.ac.uk/emran/documents/issue-3-emran-july-2015.pdf
• Welsh TJ, Gordon AL, Gladman JR. Should the treatment of hypertension in people with coexisting dementia be attenuated? European Geriatric Medicine. 2015;6S1:S56.
• Van der Wardt V, Conroy S, Welsh T, Logan P, Harrison J, Taggar J, Gladman J. Recruitment of people with dementia in primary care – experiences from the HIND study. European Geriatric Medicine. 2015: 6S1;S55-S56
• Welsh TJ, Gladman JR, Gordon AL. Hypertension is less likely to be treated in those with lower MMSE scores. Preliminary data from the HIND (Hypertension in dementia) study. Age Ageing 2015;44(suppl_2): ii14.
• Welsh TJ, Gladman JR, Gordon AL. Hypertension in care home residents: More medication but no better control. Age Ageing 2015:44 (suppl_2): ii14
• Welsh T, Gladman JRF, Gordon A. The Treatment of Hypertension in Care Homes: A systematic review of observational studies. JAMDA 2014 15:8-16. http://www.jamda.com/article/S1525-8610(13)00383-6/pdf
• Welsh TJ, Gordon AL and Gladman JR. The treatment of hypertension in people with dementia: A systematic review of observational studies. BMC Geriatrics 2014;14:19. http://dx.doi.org/10.1186/1471-2318-14-19
• van der Wardt V, Logan P, Conroy S, Harwood RH, Gladman JRF. Antihypertensive treatment in people with dementia. JAMDA 2014 15(9):620-629. http://dx.doi.org/10.1016/j.jamda.2014.03.005
• Beishon LC, Harrison JK, Harwood RH, Robinson TG, Gladman JRF, Conroy SP. The evidence for treating hypertension in older people with dementia – a systematic review. Journal of Human Hypertension first published on line 7 November 2013 http://dx.doi.org/10.1038/jhh.2013.107
Anaemia after hip fracture (IVANOV)
Anaemia after hip fracture
Anaemia is common after hip surgery, it impedes recovery, and treatment can be burdensome.
The IVANOF study is a pilot study to investigate the effect of intravenous iron on postoperative transfusion requirements in hip fracture patients.
80 patent will be recruited with the overall aim to investigate whether intravenous iron given as three 200mg doses over three days in patients with hip fracture causes an increased reticulocyte count in the early postoperative period and whether intravenous iron has beneficial effects on other measures of haematopoiesis, transfusion requirements and patient outcomes.
Jan 2013-Dec 201 Funder:
National Academic Institute of Anaesthesia Local contact:
Professor Opinder Sahota email@example.com
Promoting Activity, Independence and Stability in Early Dementia (PrAISED)
Health benefits of chair based exercises for frail older people
Finding ways of encouraging chair based exercises in frail older people, and then testing the health benefits
Frail older people who find usual exercise programmes too strenuous may be encouraged to carry out exercises while remaining seated - chair based exercises.
But our research group has found very little research on the topic, with little consensus about what the treatment should be, or whether it has any effects on physical or mental health.
That is not to say that chair based exercise is no use: the point is that we do not know if it is of use or not.
We want to find the way of encouraging chair based exercises in frail older people, and then to test this in a good research study to find out whether it has health benefits or not.
First we need to work out the best way of delivering chair based exercises. To do this we will ask expert therapists and of course patients themselves.
We will use our findings to help our therapy team develop a treatment approach, and we will try to ensure that this approach is feasible and acceptable. We will do this through a proof of concept study to ensure the treatment approach can demonstrate potential health benefits and is acceptable to patients and through a feasibility study to address the methodology for future evaluation.
Study dates: 2013-2017
Funder: This programme of work has a number of component which are funded by the following:
- Flexibility & Sustainability Funding from Nottinghamshire County Primary Care Trust (Development Work) NUH Charitable Trust Pump Priming Grant (Proof of Concept Study)
- NIHR Research for Patient Benefit (Feasibility Study to address trial methodology)
CLAHRC East Midlands (Studentship to support PhD study for K. Robinson: Developing a chair based exercise programme for older people in community settings)
Principal investigator(s): Prof Tahir Masud
Contact: Katie Robinson (research physiotherapist)
Falls in Care Homes (FICH)
A falls prevention study in care homes investigating feasibility, acceptability, tolerability and integrity parameters related to the design and application for a multi-centre definitive cluster randomised controlled trial to answer the question: Does the Guide to Action in Care Homes (GtACH) fall prevention intervention reduce falls in care homes?
Fall rates in care home residents are 5 times more frequent than in community dwelling adults. Major mortality and morbidity are associated with falls, with some bone damage and deaths being irreversible consequences.
Hip fractures alone cost over 1 billion pounds per year; set to double by 2050. Community falls prevention interventions reduce falls by 30%, but care home literature to date has reported no conclusive reduction in falls. Since compliance and adherence to fall prevention methods may be lower in cognitively impaired groups, the high prevalence of cognitive impairment in care home residents (84%) may explain the lower success. When devising a fall prevention intervention for use in the care home setting length of stay, target group and careful selection of content is needed.
Our research team has developed and published a falls prevention intervention called the Guide to Action Care Home (GtACH) but it has not been tested to see if it can prevent falls without restricting liberty. This two year feasibility study which is funded by the NIHR Research for Patient Benefit grant scheme will recruit 68 care home residents from six care homes in Nottingham. We will be trying out the GtACH with residents and trying the research processes to see if we could run a larger study in the future to determine the impact of the Guide to Action Care Home.
The GtACH has been designed to address the downfalls of current practice and meet recommended guidelines. It aims to primarily prevent falls, through better integration of services and knowledge exchange; facilitating change in the care home itself & continuity of care at a reduced cost with sustainable improved outcomes in long stay care homes. The GtACH is a programme designed to assess risk of falling on an individual basis to enable the implementation of personalised fall prevention orientated changes. All care home staff receive one hour’s training in the use of the GtACH programme.
This includes a falls risk assessment, a list of recommended interventions and an intervention manual with the opportunity of telephone support from a specialist in falls where needed. The falls risk assessment and recommended interventions are tailored around a person’s fall history, Medical history, Movement & Environment, and Personal care needs. Routine medical care will also be provided.
Study dates: 2012-2014
Funder: Research for Patient Benefit (RfPB)
Professor Pip Logan
0115 82 30239
OPTIMAL study of health care in care homes
The Optimal study aims to describe what the key components of a healthcare intervention to support care home residents are, in order to deliver effective care.
Existing models of healthcare delivery for UK care home residents fail to meet the needs of a patient cohort with a high prevalence of cognitive impairment, multimorbidity, polypharmacy and functional dependency. A number of innovative service models have been developed within the National Health Service (NHS) in an attempt to better meet the needs of this group.
It is not clear which of the healthcare models developed for care home residents best meets the needs of patients. It is possible that no model is superior but that structures of care delivery simply establish a context in which good working relationships between health and social care professionals must be established in order to deliver effective care.
The Optimal study team includes researchers from the Universities of Hertfordshire, Nottingham, University College and Kings College London and Surrey University. The research comprises:
A realist analysis, taking account of:
- Interview data from stakeholders involved at a national and regional level in the development and delivery of healthcare to care homes to understand the context, mechanisms and outcomes of effective healthcare delivery
- A supplementary literature review
- An analysis of all national level surveys undertaken in the past decade to describe healthcare delivery to care homes
- These data will be used to describe the context, mechanisms and outcomes influencing delivery of healthcare in care homes
Longitudinal case studies will be undertaken in 12 care homes across three UK regions, each of which operate within different contexts and use different mechanisms to deliver healthcare to care home residents. This will compare how residents across the regions use NHS services over time to see if different models of care delivery result in measurable differences in outcomes. This phase will comprise a mixture of comprehensive longitudinal data collection about how residents interact with healthcare services and detailed interviews to describe the day-to-day healthcare received.
Study dates: Phase 1 started Jan 2013; Phase 2 Jan 2014
Funders: NIHR – HS&DR
Contact: Dr Adam Gordon
Community hospitals study
East Midlands AHSN Frail Older People Programme
Caring for Older People and Stroke Survivors CLAHRC East Midlands theme
Completed projects, or those in the writing-up stage, include:
Evaluation of an in-reach service compared to traditional hospital-based rehabilitation- the Community In-reach Rehabilitation and Care Transition (CIRACT) study
Reducing the length of stay of older people in hospital, safely and affordably is an important aim of health services. Currently, patients are referred by hospital rehabilitation teams to early discharge intermediate care services, and these have been shown to be effective, safe and affordable. This arrangement produces an interface between the hospital and community, which could lead to delays and inefficiencies. This has led to calls for services to be more joined up, or integrated. One way to do this is for a home based team to extend its role to provide the in-hospital rehabilitation as well as the home-based rehabilitation after discharge (“in-reach”), as this might allow the in-reach team to identify patients sooner, more appropriately, and more efficiently than usual. In this study, we compared an in-reach team (called the Community In-reach Rehabilitation and Care Transition (CIRECT) team in a randomised controlled trial (RCT) with an integral health economic study and parallel qualitative appraisal.
250 participants were randomised, 125 to the CIRACT service and 125 to usual care. There was no significant difference in length of stay between those managed by the CIRACT team and those having usual care, or in any other outcome measure. The costs of care were the same, and it was unlikely to be cost effective. Whilst the CIRACT service was highly regarded by those most involved, the emergent configuration of the service working across organisational and occupational boundaries was not easily incorporated by the current, established community services.
This study demonstrates that it may be difficult to achieve in practice the potential benefits of this form of integration of community and hospital care.
For more information see:
Analgesia during hip fracture surgery
Pain following neck of femur (hip) fracture is significant and traditional analgesics have considerable side effects. Regional nerve block analgesia could provide benefit but the exact block and duration remains unclear. We conducted a randomised controlled trial to investigate whether early and continuous use of femoral nerve block results in improvements in pain scores and mobilisation in people with hip fracture.
141 patients were randomised to receive either routine oral analgesia (regular paracetamol and tramadol/ codeine with oral morphine for breakthrough pain) or femoral nerve block (initial block with 0.5mls/kg of 0.25% levo-bupivacaine, continued with 0.2% ropivacaine 5mls/hr delivered by elastomeric pump) up to 48 hours post operatively, looking particularly at pain and walking over the first three days after surgery. 110 participants were followed up and included in the primary analyses. There was no significant differences in the walking scores. Pain when walking was no different, but pain at rest was less in the group given the femoral nerve block.
Early and continuous femoral nerve block is effective in relieving pain at rest, but has no effect on post-operative mobility or pain on walking.
For the protocol see:
For more information contact:
An ethnographic study of knowledge sharing across the boundaries between care processes, services and organisations: the contributions to safe hospital discharge
Patient safety remains a health policy priority. Despite advances in research and policy, studies continue to find worryingly routine levels of patient harm. This study focused on the threats to patient safety associated with hospital discharge. It suggested that hospital discharge is a highly complex process involving multiple clinicians and stakeholders, operating in various settings. The quality and safety of these interactions can be related to the extent of knowledge sharing between stakeholders; where stakeholders openly share knowledge, they can better co-ordinate their work and reduce the complexity of hospital discharge. This study aimed to identify interventions and practices that support knowledge sharing across care settings and thus promote safe hospital discharge by mitigating system complexity. The study showed how hospital discharge does not occur as a single or isolated event, but rather through a complex series of situations and opportunities for knowledge sharing. However, these situations vary according to a number of key factors, such as the range of people involved, the types of resources they have access to and the level of leadership. The study also shows that stakeholders perceive a wide range of threats to safe discharge associated with falls, medicines, infection, clinical procedures, equipment, timing and scheduling, and communication.
For more information see:
Vitamin D receptors in muscles
Vitamin D is well known to be important in the health of bones, but receptors for Vitamin D have also been found in muscles, but the significance of these is not yet clear. This study aimed to examine the relationship between the ageing process, Vitamin D levels in the blood and Vitamin D receptors in human skeletal muscle.
Three groups were studied [8 young participants recruited from a convenience sample aged 18-30 years, 8 older Vitamin D sufficient participants aged ≥65 years (25-OH-D3 ≥50nmol/L) and 10 older Vitamin D insufficient participants (<50nmol/L)]. A muscle biopsy of their thigh (vastus lateralis muscle) was performed. Real time quantitative PCR relative to α-actin was used to measure the expression of the Vitamin D receptor and some of its target genes (myostatin, Sirt1, PPARα and PPARδ).
Low VitD levels were prevalent in young participants (median 16nmol/L; range 12-97nmol/L), but it was not statistically different from the insufficient older participants (p=0.14). Older participants in both sufficient and insufficient group had higher expression of Vitamin D receptor and PPARδ mRNA compared with younger participants (p<0.01). There was higher Sirt1 mRNA expression (p<0.01) and a tendency towards higher PPARα expression (p=0.07) in the older sufficient group only compared to the younger group. There was no difference in skeletal muscle myostatin gene expression between groups. Circulating Vitamin D (25-OH-D3) levels did not appear to correlate with any gene expression.
These findings suggest that the ageing process per se, and not circulating Vitamin D levels, influences Vitamin D receptor expression in human skeletal muscle. We still do not know why the muscles of older people have Vitamin D receptors on them, or if they provide a therapeutic target to overcome muscle weakness.
For more information see: http://ageing.oxfordjournals.org/content/early/2014/07/28/ageing.afu104.full
Dehydration in older patients in hospital
Dehydration is a well-known problem in older people admitted to hospital. Older people coming into hospital have often been unwell for several days and may have been unable to take enough fluid and may have been losing excessive amounts. It is not clear how common this is, and whether it is a cause or consequence of poor outcomes.
In this study, 200 patients aged over 65 admitted to hospital as an emergency were studied. There degree of dehydration was assessed by measuring the osmolarity or concentration of the salts in the blood, and other aspects of their health were also measured, such as illness, co-morbidity and frailty. The main outcome of interest was in-hospital death.
The study found that patients who were dehydrated were six times more likely to die in hospital than those who were not dehydrated, even when the severity of their acute illness, co-morbidity and frailty were taken into account. This implies that dehydration is a major and independent factor that affects survival. Given that it is potentially avoidable or treatable this has very great importance. For example, it justifies greater attention to hydration in pre-hospital care - schemes to provide drips or extra care for hydration for care home residents are being developed. It also justifies greater awareness of dehydration amongst emergency physicians to recognise and act upon it and monitor it early – still many doctors are reluctant to use intravenous fluids as vigorously as required, partly due to being unable to assess the need and hence partly in fear of producing fluid overload.
For more information contact:
Medical Crises in Older People (MCOP)
This programme investigated medical crises in older people by undertaking literature reviews, cohort studies, developing interventions and evaluating them. Three groups of patients were studied: older people discharged from acute medical units; people with delirium and dementia in hospitals; and the residents of care homes.
See MCOP Discussion Paper Series
Regular physical activity reduces the risk of falls and hip fractures, and mortality from all causes. However, activity levels are low in the older population and previous intervention studies have demonstrated only modest, short-term improvements. The objective was to evaluate the impact of two exercise promotion programmes on physical activity in people aged 65 years. The ProAct65+ study was a pragmatic, three-arm parallel design, cluster randomised controlled trial of class-based exercise [Falls Management Exercise (FaME) programme], home-based exercise [Otago Exercise Programme (OEP)] and usual care among older people (aged 65 years) in primary care.
1256 people were recruited: 387 were allocated to the FaME arm, 411 to the OEP arm and 458 to usual care. In 12 months there was a reduction in falls rate in the FaME arm compared with the usual-care arm. Both the FaME and OEP interventions appeared to be safe, with no significant differences in adverse reactions between study arms.
A sub-study looked at the effect of the exercise programmes in this study upon bone health. It showed that, although these exercise programmes both reduced falls and FaME was more effective, neither had any effect upon bone strength. More research is needed to see if different forms of exercise can not only reduce falls but also increase bone strength.
For more information see:
- Kendrick D, Kumar A, Carpenter H, Zijlstra GA, Skelton DA, Cook JR, Stevens Z, Belcher CM, Haworth D, Gawler SJ, Gage H, Masud T, Bowling A, Pearl M, Morris RW, Iliffe S, Delbaere K. Exercise for reducing fear of falling in older people living in the community. Cochrane Database Syst Rev. 2014 Nov 28;11:CD009848. http://dx.doi.org/10.1002/14651858.CD009848.pub2. Review
- Iliffe S, Kendrick D, Morris R, Masud T, Gage H, Skelton D, et al. Multicentre cluster randomised trial comparing a community group exercise programme and home-based exercise with usual care for people aged 65 years and over in primary care. Health Technol Assess 2014;18(49).
- Duckham RL, Masud T, Taylor R, Kendrick D, Carpenter H, Iliffe S, Morris R, Gage H, Skelton DA, Dinan-Young S, Brooke-Wavell K. Randomised controlled trial of the effectiveness of community group and home-based falls prevention exercise programmes on bone health in older people: the ProAct65+ bone study. Age Ageing. 2015 Jul;44(4):573-9. http://dx.doi.org/10.1093/ageing/afv055. Epub 2015 Apr 23
SDO Better Mental Health study
The overall aim of the Better Mental Health study was to understand the care of older people with mental health problems in general hospitals and provide advice to the health services about how things could be improved.
The work was conducted between 2008 and 2011 in the wards of Nottingham University Hospitals NHS Trust. The research included a review of relevant literature, a patient and carer study involving ward observations and interviews of discharged patients and their carers at home, and an interview study of staff caring for confused older patients in the hospital.
The literature review set the context for the work, exploring reasons why training and organization of care seemed to have failed to ensure high quality care for confused older people in hospitals. It also noted that notions of patient-centred and relationship-centred care were believed to provide the best model for good, dignified care.
The patient and carer study concluded that an admission of a person with dementia could be best understood as a process of disruption to the patient and carer routines, and that their responses to these disruptions could be seen as attempts to restore control over the disruptions. The staff study showed that many staff were unable to use such understanding to guide their care in a patient or relationship centred way. Staff also identified organizational factors that prevented or hindered them from delivering good quality care.
The findings presented a challenge to the health care system, as it is unlikely that our observations were unique to the hospitals we studied. Given the huge number of confused people in a typical general hospital in the UK, it is perhaps astounding that workforce education, planning and hospital organization seemed to be unprepared for the task of caring for these people.
The full report of the project is: Gladman J, Porock D, Griffiths A, Clissett P, Harwood RH, Knight A, Jurgens F, Jones R, Schneider J, Kearney F. Care of Older People with Cognitive Impairment in General Hospitals. Final report NIHR Service Delivery and Organisation programme; 2012.
Publications and other outputs arising from the project are shown on the Medical Crises in Older People website: http://www.nottingham.ac.uk/mcop/index.aspx
Intermediate care - at home
An early discharge service being developed for the Nottingham hospitals was subject to a randomised controlled trial to compare the outcomes of those receiving usual, hospital-based care, and an at-home intermediate care service. Patients could have been in hospital because of a stroke, or a fracture, or any general medical condition such as a chest or urinary tract infection. As well as running a RCT, we interviewed people receiving home-based and usual care, and the staff of the service, to find out about their experiences.
The positive results were a little surprising, to some. Some people before the study were confident that early discharge was virtually impossible. We showed this to be wrong. They also expected that readmissions would be increased: they weren’t. Others argued that early discharge would put extra strain upon their carers: it didn’t. In fact carer well-being was enhanced. We think this was because carers feel less stressed if the people they care for have their needs better met.
The interviews were very revealing, as they helped to establish what the necessary conditions for a successful service are. We found evidence of skilled and informed personnel, familiar with problem solving the community. We found evidence of good team working. There was little doubt that the service was well-resourced – but it should be noted that the cost of the service was still cheaper than the cost of the hospital stay that it replaced. Most striking was the way the clinicians worked with the patients. They spent time to listen carefully to the problems of the patients and to find acceptable solutions to them: this contrasted with a rather bureaucratic or one-size-fits-all approach that typified usual hospital and community care.
So, not only did patients get home sooner, the patients and their carers were healthier, and the new approach was cheaper. Clearly, this was a cost effective intervention.
- Cunliffe AL, Gladman JRF, Husbands SL, Miller P, Dewey ME, Harwood RH. Sooner and healthier: a randomised controlled trial and interview study of an early discharge rehabilitation service for older people. Age Ageing 2004;33:246-252
- Miller P, Gladman JRF, Cunliffe AL, Husbands SL, Dewey ME, Harwood RH. Economic analysis of an early discharge rehabilitation service for older people. Age Ageing 2005;34:274-280
Intermediate care - residential
This service was targeted at elderly people in hospital, from whatever cause, who were felt to be at high risk of going unnecessarily into long term care in a care home. The service aimed to give them the time and support to go home.
The outcomes of those referred to the intermediate care units were compared to those who were managed in the usual hospital way, in a randomised controlled trial. There was also a concurrent qualitative study.
The findings were mixed:
- Colleagues from the social services were disappointed to see that it did not reduce the risk of patients going into long term care in a care home. This was particularly concerning given that the social services had made considerable investment in this service and had hoped to recoup some of this through reduce spending on long term care.
- Our study showed that about 20% of both groups ended up in a care home, whether they had usual care or intermediate care - in fact rates were slightly higher in the intermediate care group although this could have occurred by chance.
- Hospital colleagues were more positive, noting that patients had been successfully and safely diverted from hospital to other settings. The research team had mixed views too. We agreed that being able to be diverted safely from hospital to another setting was worthwhile. But we were disappointed to note that outcomes were not improved.
- We were also concerned that patients spent more days in intermediate care than their hospital stays were reduced by, so they took longer to get home. We think the reason why outcomes were not improved and why length of stay in intermediate care was long was the lack of active rehabilitation, which was revealed by the qualitative study.
Since this study, the service in Nottingham has been radically overhauled to provide active rehabilitation. Fortunately, satisfaction with the services has always been high due to the caring attitudes of the staff and the grateful nature of the patients.
The qualitative study also revealed aspects of the development of this service that were not evident by the RCT, such as the development of a changed culture in the care homes where the transitional service was set: care workers started to see that an enabling approach to client care was possible instead of the more traditional task-focussed and dependency re-enforcing style that had been present hitherto.
- Fleming S, Blake H, Gladman JRF, Hart E, Lymbery M, Dewey ME, McCloughry H, Walker M, Miller P. A randomised controlled trial of a care home rehabilitation service to reduce long term institutionalisation for elderly people. Age Ageing 2004;33:384-390
- Hart E, Lymbery M, Gladman JRF. Away from home: an ethnographic study of a Transitional Rehabilitation scheme for older people. Social Science and Medicine 2005;60(6):1241-1250
Cataract surgery in the prevention of falls - first and second eye cataract trials
It has long been known that poor eyesight is associated with falls, but no study before these had shown whether improving vision could reduce falls.
These studies evaluated the effect of cataract surgery on falls, by comparing patients operated on immediately with people kept on the waiting list (at the time there was a very long waiting list for such surgery, which made this study ethical).
The studies looked at the effect of surgery on one cataract, and then upon operating upon the second.
It was wondered if just doing one eye would be enough to improve balance, or whether doing the second would be necessary to restore stereo vision:
- As expected and already known, cataract surgery improved vision greatly.
- Additionally, falls incidence was reduced by 32% following first eye surgery, and a further (but statistically uncertain) 28% reduction following second eye surgery.
- The fracture rate was significantly reduced after first eye surgery too, despite small numbers.
- Cataract surgery was clearly cost effective.
These trials represented the largest ever European cataract trials, and, so far, the only falls prevention trial to demonstrate a reduction in fracture rate.
- Harwood RH, Foss A, Osborn F, Gregson RM, Zaman A, Masud T. A randomised controlled trial to assess the effect of first-eye cataract extraction on the risk of falling, and health status of women over 70 years. Br J Ophthalmol. 2005 Jan;89(1):53-9. PMID: 15615747
- Foss AJ, Harwood RH, Osborn F, Gregson RM, Zaman A, Masud T. Falls and health status in elderly women following second eye cataract surgery: a randomised controlled trial. Age Ageing. 2006 Jan;35(1):66-71. PMID: 16364936
- Sach TH, Foss AJ, Gregson RM, Zaman A, Osborn F, Masud T, Harwood RH. Falls and health status in elderly women following first eye cataract surgery: an economic evaluation conducted alongside a randomised controlled trial. Br J Ophthalmol. 2007 Dec;91(12):1675-9. PMID: 17585002
- Datta S, Foss A, Grainge MJ, Gregson RM, Zaman A, Masud T, Osborn F, Harwood RH. The importance of acuity, stereopsis and contrast sensitivity for health-related quality of life in elderly women with cataracts. Investigational Ophthalmology and Visual Science 2008;49:1-6
- Sach TH. Foss AJ. Gregson RM. Zaman A. Osborn F. Masud T. Harwood RH. Falls and health status in elderly women following second eye cataract surgery: an economic evaluation conducted alongside a randomised controlled trial. Eye 2009 in press. Eye advance online publication 15 May 2009; http://dx.doi.org/10.1038/eye.2009.112
Falls prevention in a screened population
Falls are so distressing and common in older people, and many of the risk factors are so well known, that we thought it might be feasible and effective to screen community dwelling older people and offer a falls prevention programme in a day hospital to those at high risk of falling. In the past, most of the research has focussed on people who present to their doctors or the hospital with falls, rather than those merely at risk of them.
Contacting people using GP registers, we found that half the people screened responded to the screening test, half of these were at high risk of falls, a quarter of these joined our study, but only a third of those offered the falls programme completed it in full. Despite this, the risk of them falling over the next 12 months was reduced by 27%. When the costs of screening and the treatment were considered, it cost over £3,000 for each fall that was prevented.
Although preventing falls is a good thing, screening and intervening in this way was not good value for money. We feel that work needs to be done to make falls prevention programme more acceptable to people so that they are more likely to complete and hence benefit from them, and also to make them cheaper.
- Conroy S, Kendrick D, Harwood R, Gladman J, Coupland C, Sach T, Drummond A, Youde J, Edmans J, Masud T. A multicentre randomised controlled trial of day hospital-based falls prevention programme for a screened population of community dwelling older people at high risk of falls. Age Ageing 2010;39:704-710 http://dx.doi.org/10.1093/ageing/afq096
- Irvine L, Conroy S, Sach T, Gladman J, Harwood R, Kendrick D, Coupland C, Drummond A, Bartoni G, Masud T. Cost-effectiveness of a day hospital falls prevention programme for screened community-dwelling older people at high risk of falls. Age Ageing 2010;39:710-716 http://dx.doi.org/10.1093/ageing/afq108
Reducing Falls in In-patient Elderly (REFINE)
The REFINE study evaluated chair and bed pressure occupancy sensors incorporating a radio-paging alerting mode to assess whether it was effective and cost-effective in reducing bedside falls in older in-patients.
REFINE used bedside chair and bed pressure occupancy sensors, incorporating a radio-paging alerting mode. The sensors detected a person leaving the bed or chair, and raised an alarm to the nursing staff. The staff, who may not have been in the near vicinity, could respond promptly to avert a potential fall and ensure patient safety whilst performing their daily duties of care.
The primary outcome measure was the number of bedside in-patient falls per 1,000 bed days from time of randomisation until the participant was discharged from the ward. The secondary outcome measures included number of injurious in-patient falls per 1,000 bed days, length of hospital stay, residential status on discharge, functional assessments, fear of falling and health related quality of life. The study also investigated, using qualitative research methods, the acceptability of such technology to patients and staff, and its impact upon practice.
The study found no effect on either the number of falls or any of the secondary outcomes. It was not cost effective. It appeared that although the technology itself produced alerts as intended, these did not lead to a response adequate to prevent falls, indicating that organisational factors and not technical ones were responsible for the failure.
Sahota O, Drummond A, Kendrick D, Grainge MJ, Vass C, Sach T, Gladman JRF, Avis M. REFINE (REducing Falls in In-patieNt Elderly) using bed and bedside chair pressure sensors linked to radio-pagers in acute hospital care: a randomised controlled trial. Age Ageing (2013) http://dx.doi.org/10.1093/ageing/aft155
Home Support for People with Dementia: Developing a Fidelity Index
Dementia is a major public health issue for the 21st Century for which there is presently no cure. The UK National Health Service states that in England there are 570,000 people living with dementia, and this number is expected to double over the next 30 years.
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