Deprescribing Medications that Increase the Risk of Falls in Older People: Exploring Doctors' Perspectives Using the Theoretical Domains Framework (TDF).

BACKGROUND: Falls can lead to hospitalisation and death in older people. Polypharmacy is a major risk factor, and deprescribing fall-risk increasing drugs (FRIDs) is one of several possible important preventive measures. The objective of this study was to explore the factors that influence doctors when deprescribing FRIDs in a hospital setting. METHOD: Semi-structured interviews were conducted with consultant geriatricians and hospital doctors experienced in dealing with patients aged 65 years or older, at a large academic teaching hospital (~ 1000 beds), Dublin, Ireland. The interviews were directed by an interview guide and audio recorded and transcribed verbatim, with subsequent thematic analysis in NVivo 12 software. RESULTS: A total of 18 participants were interviewed. Barriers to deprescribing included: insufficient time, incomplete patient records, changing medications initiated by other specialists and difficulties following up patients after discharge. Facilitators included: enhanced documentation through electronic patient records, the support of other healthcare professionals such as clinical pharmacists, and patients' engagement, which is considered essential for the success of the deprescribing process's outcome. CONCLUSION: Deprescribing FRIDs in older adults in the hospital setting is challenging. Implementation of the process in practice requires combined effort from stakeholders to tackle everyday work environment challenges. Future studies are required examining the clinical effect of the suggested interventions and exploring patients' involvement in deprescribing decisions.

Progressive resistance training in a post-acute, older, inpatient setting: A randomised controlled feasibility study.

OBJECTIVES: Progressive resistance training can successfully target functional decline in healthy older community-dwelling adults. There are concerns about the safety and acceptance of its use in frail older populations. The aim of this study was to evaluate the feasibility of using progressive resistance training in an older, post-acute, inpatient setting. METHODS: A randomised controlled feasibility study was conducted. Appropriate older inpatients undergoing post-acute rehabilitation were recruited. Feasibility measures examined were safety, recruitment, outcome measurement, adherence and retention rates and satisfaction. A range of clinical measures were used to capture changes in body structure and function, activity and participation. Assessments were performed on admission to the study and six weeks later. RESULTS: A sample of 33 patients were included and randomised to the treatment group (n=16) or the control group (n=17). There were no serious adverse events, adherence rates were 63% and retention rates were 82%. While both groups improved between time 1 and 2, there were no significant differences in clinical measures between the groups. CONCLUSION: Progressive resistance training is a safe and acceptable intervention for use with this population. Further work on the effectiveness of progressive resistance training in this setting is now required.

Effect of Area-Level Socioeconomic Deprivation on Risk of Cognitive Dysfunction in Older Adults.

OBJECTIVES: To investigate the relationship between area-level deprivation and risk of cognitive dysfunction. DESIGN: Cross-sectional analysis. SETTING: The Trinity, Ulster, and Department of Agriculture (TUDA) study from 2008 to 2012. PARTICIPANTS: Community-dwelling adults aged 74.0 ± 8.3 without dementia (N = 5,186; 67% female). MEASUREMENTS: Adopting a cross-jurisdictional approach, geo-referenced address-based information was used to map and link participants to official socioeconomic indicators of deprivation within the United Kingdom and the Republic of Ireland. Participants were assigned an individual deprivation score related to the smallest administrative area in which they lived. These scores were categorized into comparable quintiles, that were then used to integrate the datasets from both countries. Cognitive health was assessed using the Mini-Mental State Examination (MMSE); cognitive dysfunction was defined as a MMSE score of 24 or less. RESULTS: Approximately one-quarter of the cohort resided within the most-deprived districts in both countries. Greater area-level deprivation was associated with significantly lower MMSE scores; fewer years of formal education; greater anxiety, depression, smoking and alcohol use, and obesity; and more adverse outcomes, including higher blood pressure and diabetes risk. After adjustment for relevant covariates, area deprivation was associated with significantly higher risk of cognitive dysfunction (odds ratio = 1.40, 95% confidence interval = 1.05-1.87, P = .02, for most vs least deprived). CONCLUSION: This analysis combining data from two health systems shows that area deprivation is an independent risk factor for cognitive dysfunction in older adults. Adults living in areas of greatest socioeconomic deprivation may benefit from targeted strategies aimed at improving modifiable risk factors for dementia. Further cross-national analysis investigating the impact of area- level deprivation is needed to address socioeconomic disparities and shape future policy to improve health outcomes in older adults.© 2018 American Geriatrics Society and Wiley Periodicals, Inc.

The Frontal Assessment Battery: Normative Performance in a Large Sample of Older Community-Dwelling Hospital Outpatient or General Practitioner Attenders.

BACKGROUND: The Frontal Assessment Battery (FAB) is a short battery designed to assess frontal executive functioning, but data for interpretation of performance are limited. OBJECTIVES: The Trinity, Ulster, Department of Agriculture (TUDA) study provided the opportunity to derive performance data from a large sample of community-dwelling hospital outpatient or general practitioner (GP) attenders. METHODS: Normative analysis based on 2508 TUDA participants meeting these criteria: Mini-Mental State Examination (MMSE) >26/30, not depressed (Center for Epidemiologic Studies Depression <16) or anxious (Hospital Anxiety and Depression Scale <8), no history of stroke, or transient ischemic attack. Correlation and regression analyses were used to evaluate the effects of age, education, gender, and general cognition (MMSE). Norms for FAB were created stratified by age and education, using overlapping midpoint ranges of 10 years with a 3-year interval from age 60 to 97. RESULTS: Age and education accounted for 9.6% of variance in FAB score ( r2 = .096) with no significant effect of gender. The FAB and MMSE were modestly correlated ( r = .29, P < .01) with MMSE increasing the model's total explained variance in FAB score from 9.6% to 14%. CONCLUSION: This is the largest study to date to create normative data for the FAB. Age and education had the most significant impact on FAB performance, which was largely independent of global cognition (MMSE). These data may be of benefit in interpreting FAB performance in individuals with similar demographic/health status characteristics in hospital outpatient or GP settings.

Outcomes among older people in a post-acute inpatient rehabilitation unit.

PURPOSE: Designated multidisciplinary rehabilitation units have been shown to provide several benefits for the frail older population. The aim of this research was to evaluate changes in strength, mobility, balance, endurance, frailty and quality of life (QoL) following a 6-week multidisciplinary inpatient rehabilitation programme. METHOD: This was a prospective, observational study performed in a post-acute multidisciplinary geriatric inpatient rehabilitation service. A consecutive sample of heterogenous frail older adults (n = 32) participated. Subjects were assessed on admission to the rehabilitation service (T1) and following 6 weeks of rehabilitation (T2). A range of outcome measures were used to assess function and QoL: Berg Balance Scale (BBS), Timed Up and Go (TUG), 6-Minute Walk Test (6MWT), Barthel Index (BI), EuroQol-Visual Analogue Scale (EQ-VAS), Clinical Frailty Scale (CFS), lower limb and grip dynamometry. RESULTS: The majority were female (n = 25), the mean age was 82.9 years (SD 6.35). The median length of stay was 49 days. Patients improved significantly between T1 and T2 assessments in the BBS (p ≤ 0.0001); TUG (p ≤ 0.0001); 6MWT (p ≤ 0.0001); BI (p ≤ 0.0001); EQ-VAS (p = 0.002); CFS (p ≤ 0.0001); and in some aspects of grip and lower limb strength. CONCLUSION: This study has demonstrated that positive outcomes occurred in a range of measures in an older, frail inpatient rehabilitation population.

The effect of sleeping with the head of the bed elevated six inches on elderly patients with orthostatic hypotension: an open randomised controlled trial.

BACKGROUND: the evidence for 6-inch tilt sleeping-head-up (SHU), a common therapy for the treatment of orthostatic hypotension (OH) in older people, is unavailable. OBJECTIVE: to investigate the effects of 6-inch SHU for 6 weeks in community-living patients with chronic OH. DESIGN: open labelled randomised controlled trial. METHODS: one hundred patients aged ≥60 with chronic OH were randomised into SHU or control groups. Primary outcome measures were mean arterial pressure (MAP) and symptoms. Repeated measures of orthostatic haemodynamic parameters (systolic blood pressure, diastolic blood pressure, MAP, heart rate, percentage change of Modelflow parameters), weight, frequency of dizziness, 24-h urinary sodium and volume, 24-h ambulatory blood pressure (24-ABPM) and presence of ankle oedema were collected at baseline and at 6 weeks. RESULTS: symptoms improved, to a similar extent, in both groups. There were no differences in MAP or other haemodynamic parameters, weight, urinary volume or 24-ABPM between SHU and controls. SHU were more likely to have leg oedema. CONCLUSIONS: these findings suggested that SHU at 6 inches has no additional effects on symptoms or haemodynamic parameters at 6 weeks than existing non-pharmacological measures in older patients with OH. Its use in this group should therefore be discouraged.

Acute haemodynamic response to sleeping head-up at 6 inches in older inpatients.

OBJECTIVE: Our aim was to investigate the effect of monotherapy of sleeping head-up (SHU) at 6 in. in a group of older inpatients with OH from all causes. METHODS: We recruited nine consecutive inpatients (mean age (SD) 76(5) years) with persistent, symptomatic OH with a mean systolic blood pressure (SBP) drop on standing and nadir SBP of 68 (27.8) and 94 (19.2) mmHg respectively. All patients underwent SHU for 1 week. Beat-to-beat haemodynamics during lying and standing, 24-hour ambulatory blood pressure, supine haematocrit, urea/electrolytes, plasma renin activity and aldosterone were measured before and after intervention. RESULTS: One week after SHU, SBP, stroke volume and cardiac output increased significantly (all P < 0.05) by 12 mmHg, 15 ml and 1.3 l/minutes respectively while heart rate and total peripheral resistance were significantly reduced by 3.6 bpm and 0.355 dynes/s/cm(5) respectively during 2 minute of standing. Serum creatinine was also significantly lower. Five patients improved in their mobility following SHU. INTERPRETATIONS: SHU for 1 week at 6 in. was well tolerated by older in-patients with OH, associated with improved orthostatic tolerance, and with haemodynamic changes in keeping with increased extracellular volume. SHU at 6 in. has a role in the acute treatment of OH for patients in hospital, but its longer-term effects and in the out-patient setting require further study.

Recovery after stroke: a 1-year profile.

PURPOSE: To document the course of recovery in a group of first stroke patients, with stroke of moderate severity, over a 1-year period. Evaluation of recovery is important for estimating rehabilitation needs. METHOD: One-year observational study of 23 acute first stroke patients. Recovery was assessed at 15 specific intervals using measures of impairment, activity, social participation and quality of life. RESULTS: There were significant changes in impairment (p < 0.05) and motor disability over 1 year (F ratio = 75.627, d.f. = 4, p < or = 0.0001) including the period between 6 and 12 months though recovery did appear to slow down after a 9-week 'turning point'. Significant improvements in social participation were also seen between 6 and 12 months (p = 0.0021). Quality of life did not change and patients' quality of life scores indicated levels of 'severe distress' at 6 (57.8 [8.8]) and 12 months (58.9 [8.6]). CONCLUSIONS: Recovery after stroke was detectable beyond 6 months using detailed measures. This demonstration of late recovery has therapeutic implications. An increased understanding of the course of recovery following stroke could provide a basis for evaluating the varied aspects of therapeutic intervention in stroke rehabilitation.

Management of syncope in the Emergency Department: a single hospital observational case series based on the application of European Society of Cardiology Guidelines.

AIMS: The aim of this study was to evaluate the effect of introducing a European Society of Cardiology guideline-based Integrated Care Plan (ICP) for Syncope on hospital admissions and referral patterns to an outpatient Syncope Management Unit, of patients presenting to an Emergency Department (ED) with a syncopal episode and to determine the underlying causes of syncope. METHODS AND RESULTS: This study is a single-centre observational case series of consecutive adult patients presenting to the ED over a 5-month period. Two hundred and fourteen of 18 898 patients (1.1%) had a syncopal episode, 110 (51.4%) of whom were admitted. Forty-six (41.8%) admissions were indicated by the ICP. All potential cardiac syncope cases were admitted. There was a 500% increase in the overall number of referrals to the Syncope Management Unit with a small increase in the number of unnecessary referrals. CONCLUSION: The introduction of an ICP for syncope was not associated with any cases with potential adverse outcomes being lost to follow-up and resulted in increased referral rates to the syncope unit. However, hospitalization rates for syncope remain high, and a large number of patients requiring early outpatient assessment were not referred. There remains a need to develop further interventions to guide appropriate and safe syncope management in the ED.

Vascular biomarkers of cognitive performance in a community-based elderly population: the Dublin Healthy Ageing study.

BACKGROUND: population studies suggest that cardiovascular risk factors may be associated with cognitive impairment. Epidemiological studies evaluating individual markers of vascular disease as risk factors for cognitive dysfunction have yielded inconsistent results. Homocysteine has emerged as a marker consistently associated with poorer outcomes. Existing studies have largely examined individual vascular risks in isolation and have tended to ignore patient psychological status. OBJECTIVE: to investigate the association between markers of vascular disease and cognition in a community-dwelling non-demented elderly population while adjusting for vascular and non-vascular confounds. DESIGN: cross-sectional community based assessment. PARTICIPANTS: 466 subjects with mean age 75.45 (s.d., 6.06) years. 208 (44.6%) were male. RESULTS: higher levels of homocysteine were consistently associated with poorer performance in tests assessing visual memory and verbal recall. No other vascular biomarker was found to be associated with cognitive performance. Factors such as alcohol use, tea intake, life satisfaction, hypertension and smoking were positively correlated with global cognitive performance. Negative correlations existed between cognitive performance and depression, past history of stroke, intake of fruit and use of psychotropic medication. CONCLUSIONS: homocysteine was the only vascular biomarker associated with poorer function in a number of domains on neuropsychological testing, independent of vascular and non-vascular confounds. Other psychosocial factors may need to be taken into account as potential confounds in future studies investigating cognition.

Investigating the enhancing effect of music on autobiographical memory in mild Alzheimer's disease.

The enhancing effect of music on autobiographical memory recall in mild Alzheimer's disease individuals (n = 10; Mini-Mental State Examination score >17/30) and healthy elderly matched individuals (n = 10; Mini-Mental State Examination score 25-30) was investigated. Using a repeated-measures design, each participant was seen on two occasions: once in music condition (Vivaldi's 'Spring' movement from 'The Four Seasons') and once in silence condition, with order counterbalanced. Considerable improvement was found for Alzheimer individuals' recall on the Autobiographical Memory Interview in the music condition, with an interaction for condition by group (p < 0.005). There were no differences in terms of overall arousal using galvanic skin response recordings or attentional errors during the Sustained Attention to Response Task. A significant reduction in state anxiety was found on the State Trait Anxiety Inventory in the music condition (p < 0.001), suggesting anxiety reduction as a potential mechanism underlying the enhancing effect of music on autobiographical memory recall.

Repetitive behaviour in Alzheimer's disease: description, correlates and functions.

BACKGROUND: Repetitive behaviour is among the most common and burdensome of the behavioural and psychological symptoms of Alzheimer's disease (AD), yet little research has been done to investigate its nature or correlates. Memory impairment may account for repetitive questioning, but its possible role in other repetitive behaviours is unclear. Attention and executive dysfunction may account for both repetitive speech and actions. The role of mood also merits investigation. OBJECTIVES: To investigate cognitive and affective differences between patients with and without repetitive behaviours, and to identify themes and carer attributions for the function of such behaviours. METHODS: Fifty-four participants aged > or = 65, meeting NINCDS-ADRDA criteria for probable AD, were assessed using the MMSE, WMS-III word list, Trailmaking test, Stroop, Modified WCST, Cornell Scale for Depression, DEX and a repetitive behaviour questionnaire. Regression analyses were used to identify significant predictors of repetitive behaviour. RESULTS: Repetitive behaviours were manifest in 87% of the sample, with questions (68.5%) and statements/stories (61.1%) the most common types. Repetitive questions were predicted by high MMSE score (p = 0.013), low immediate list recall score (p = 0.013) and female gender (p = 0.004). Repetitive statements/stories were predicted by dysexecutiveness (p = 0.003) and younger age (p = 0.016). Repetitive actions were predicted by longer illness duration (p = 0.041), depressive symptoms (p = 0.035) and dysexecutiveness (p < 0.001). Themes and patterns were evident in repetitive behaviour. CONCLUSIONS: Repetitive behaviours were common in a sample of patients with AD referred to hospital clinics. Vocal and motor repetitive behaviours were predicted by different cognitive, demographic and mood variables.

Driving cessation in patients attending a memory clinic.

BACKGROUND: Driving is an increasingly important form of transport for older people. Dementia is common in later life and will eventually lead to driving cessation, which reduces the public health risk of impaired driving but also impairs access to services. The factors associated with driving cessation in dementia are uncertain. OBJECTIVE: To examine the demographic, psychometric and personal factors associated with driving cessation in patients attending a memory clinic in a European setting. DESIGN, SUBJECTS AND SETTING: A retrospective study of 430 consecutive patients referred over a 21 month period to the memory clinic at a university teaching hospital. METHODS: The data collected included a questionnaire administered to their carers regarding demographic and personal factors as well as driving practices. All subjects had standardised neuropsychological and functional assessments. Dementia diagnosis was recorded using DSM IV criteria. RESULTS: Driving cessation in this population was associated with poorer cognitive and functional status, older age, and living in the city. Of those studied, 22% continued to drive: 63% of these were driving daily, 71% were driving unaccompanied and 31% reported an accident. There was no difference in the neuropsychological testing between those who reported an accident and those who did not report an accident. CONCLUSIONS: Driving cessation was affected not only by psychometric performance but also by demographic and personal factors.

Screening for dementia in an Irish community sample using MMSE: a comparison of norm-adjusted versus fixed cut-points.

BACKGROUND: The MMSE is a widely-used instrument in screening for dementia in the community. The traditional cut-point of <24/30 may be unsuitable for use in some settings, due to biases in age and education. OBJECTIVES: This study aimed to investigate whether cut-points derived from age- and education-specific norms would improve the performance of the MMSE as a screening tool for dementia and cognitive impairment in an Irish community setting, potentially reducing the number of onward referrals. A secondary aim was to obtain score norms in an Irish sample. METHODS: One thousand one hundred and fifteen people aged over 65 (mean age 74.8+/-6.8 years; 68% female) were assessed in their own homes, using MMSE (world) and the AGECAT computerised diagnostic system for mental illness in the elderly. The performance of the MMSE in identifying case- and sub-case-level dementia was investigated using cut-points of <24 and <23, as well as adjusted cut-points based on published norms and norms derived from the Irish sample. RESULTS: Published norms did not prove useful in improving screening accuracy. Cut-points based on 10th percentile Irish norms and the <23 cut-point performed comparably well, both yielding 93% specificity, with overall accuracy of 90% and 91% respectively (as sensitivity was higher for the <23 cut-point). CONCLUSIONS: Locally-derived norms yielded better screening accuracy than did published norms or the traditional <24 cut-point. The importance of selecting an appropriate percentile cut-off when using norms is discussed. The best results were obtained with a simple <23 cut-point, and this may be optimal when screening for dementia in an Irish community setting.

The effect of the menstrual cycle on electrophysiological and behavioral measures of memory and mood.

Event-related potentials (ERPs) were compared between the menses and ovulatory phase of the menstrual cycle in response to visually presented words, some of which were repeated as part of direct and indirect memory tasks. Twelve spontaneously cycling women were tested during the menses and ovulatory phases. For the direct task, participants had to discriminate between new words and those repeated after a mean of six trials. In the indirect task, subjects were required to discriminate between target and nontarget words. Some of the nontarget words were repeated after a mean of six trials. The ERP repetition effect mean amplitude was significantly greater in response to repeated words at both cycle phases but did not differ across the cycle. P300 amplitude was significantly greater during menses than the ovulatory phase. We conclude that context updating mechanisms as indexed by the P300 are sensitive to cyclic hormonal fluctuations.