Building resilience and reversing frailty: a randomised controlled trial of a primary care intervention for older adults.

BACKGROUND: There is a need for effective primary care interventions that help older people combat frailty and build resilience. OBJECTIVE: To study the effectiveness of an optimised exercise and dietary protein intervention. DESIGN: Multicentre, randomised-controlled, parallel-arm trial. SETTING: Six primary care practices, Ireland. METHODS: Six general practitioners enrolled adults aged 65+ with Clinical Frailty Scale score ≤5 from December 2020 to May 2021. Participants were randomised to intervention or usual care with allocation concealed until enrolment. Intervention comprised a 3-month home-based exercise regime, emphasising strength, and dietary protein guidance (1.2 g/kg/day). Effectiveness was measured by comparing frailty levels, based on the SHARE-Frailty Instrument, on an intention-to-treat basis. Secondary outcomes included bone mass, muscle mass and biological age measured by bioelectrical impedance analysis. Ease of intervention and perceived health benefit were measured on Likert scales. RESULTS: Of the 359 adults screened, 197 were eligible and 168 enrolled; 156 (92.9%) attended follow-up (mean age 77.1; 67.3% women; 79 intervention, 77 control). At baseline, 17.7% of intervention and 16.9% of control participants were frail by SHARE-FI. At follow-up, 6.3 and 18.2% were frail, respectively. The odds ratio of being frail between intervention and control groups post-intervention was 0.23 (95% confidence interval: 0.07-0.72; P = 0.011), adjusting for age, gender and site. Absolute risk reduction was 11.9% (CI: 0.8%-22.9%). Number needed to treat was 8.4. Grip strength (P < 0.001) and bone mass (P = 0.040) improved significantly. 66.2% found the intervention easy, 69.0% reported feeling better. CONCLUSION: A combination of exercises and dietary protein significantly reduced frailty and improved self-reported health.

Nursing home patients and Emergency Department attendance in a single urban Irish catchment area: an observational study surrounding the introduction of a community medicine for older person service.

BACKGROUND: Nursing home (NH) patients are at a high risk of Emergency Department (ED) attendance, and adverse events in the ED. With an increasing NH population, monitoring trends in ED utilization is important to aid service planning, and attention to potentially preventable attendances should be paid, to identify areas that may benefit from specialist support. AIMS: This 12-year (2008-2019) study aimed to observe trends in ED utilization of NH patients in a single urban Irish catchment area, surrounding the introduction of a Community Medicine for the Older Person (CMOP) outreach program. METHOD: A retrospective review of all NH attendances within the catchment area was performed based upon NH address. Attendance, admission, discharge, and died in department (DID) were adjusted per annual NH bed numbers (PBC). Trends were observed and compared pre and post the CMOP activation. Comparisons of continuous variables were performed using an unpaired parametric Student's t test. RESULTS: There were 6877 attendances, with 58% (n = 3989) admitted, 40% (n = 2785) discharged, and 2% (n = 123) DID. There was a statistically significant difference in mean discharge rate PBC pre and post the CMOP introduction (0.22 vs 0.16, P = 0.04). There was no statistically significant difference in attendance, admission, or DID. CONCLUSION: This is the first Irish study of NH ED utilization over an extended period. ED attendances PBC have not decreased since the introduction of the CMOP. Discharges PBC, however, have decreased and may represent a decrease in potentially preventable attendance/improvement in appropriateness of ED transfers, following the introduction of this intervention.

A Smart Health Platform for Measuring Health and Well-Being Improvement in People With Dementia and Their Informal Caregivers: Usability Study.

BACKGROUND: Dementia is a neurodegenerative chronic condition characterized by a progressive decline in a person's memory, thinking, learning skills, and the ability to perform activities of daily living. Previous research has indicated that there are many types of technology interventions available in the literature that have shown promising results in improving disease progression, disease management, and the well-being of people with dementia (PwD) and their informal caregiver, thus facilitating dementia care and living. Technology-driven home care interventions, such as Connected Health (CH), could offer a convenient and low-cost alternative to traditional home care, providing an informal caregiver with the support they may need at home while caring for a PwD, improving their physical and mental well-being. OBJECTIVE: This study aimed (1) to create a multidimensional profile for evaluating the well-being progression of the PwD-informal caregiver dyad for a year during their use of a CH platform, designed for monitoring PwD and supporting their informal caregivers at home, and (2) to conduct a long-term follow-up using the proposed well-being profile at different time-interval evaluations. METHODS: The PwD-informal caregiver well-being profile was created based on the World Health Organization International Classification of Functioning considering the following outcomes: functional status, cognitive status, and quality of life for the PwD and mental well-being, sleeping quality, and burden for the informal caregiver. Over a year, comprehensive assessments of these outcomes were conducted every 3 months to evaluate the well-being of PwD-informal caregivers, using international and standardized validated questionnaires. Participants' demographic information was analyzed using descriptive statistics and presented as means and SDs. A nonparametric Friedman test was used to analyze the outcome changes and the progression in the PwD-caregiver dyads and to determine if those changes were statistically significant. RESULTS: There were no significant changes in the well-being of PwD or their caregivers over the year of follow-up, with the majority of the PwD-caregiver dyads remaining stable. The only instances in which significant changes were observed were the functional status in the PwD and sleep quality in their caregivers. In each of these measures, post hoc pairwise comparisons did not indicate that the changes observed were related to the deployment of the CH platform. CONCLUSIONS: The follow-up of this population of PwD and their informal caregivers has shown that disease progression and physical and mental well-being do not change significantly during the time, being a slow and gradual process. The well-being profile created to analyze the potential impact of the CH platform on the PwD-informal caregiver dyad well-being, once validated, could be used as a future tool to conduct the same analyses with other CH technologies for this population. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR2-10.2196/13280.

Protocol for a randomised controlled trial of a primary care intervention to Reverse Frailty and Enhance Resilience through Exercise and dietary protein Education (REFEREE) in community-dwelling adults aged 65 and over.

Introduction: Resistance exercises and dietary protein have been shown to reverse frailty, yet they are not commonly offered in clinical practice. We aim to measure changes in health outcomes, including physical frailty status (SHARE-FI), clinical frailty status (CFS) and muscle mass, as a result of an optimised exercise and dietary intervention versus usual care in a primary care (PC) setting. The intervention has been derived from our systematic review and meta-analysis findings and optimised through patient and public involvement and multidisciplinary team input. Methods: This study is a multicentre randomised controlled parallel arm trial with a three month follow up. 210 eligible people aged 65 and over, no more than mildly frail, will be recruited in seven PC practices in Ireland and randomly assigned to 'intervention' or 'usual care'. Intervention participants will be provided a leaflet with strength exercises, protein dietary guidance and educational discussion. Baseline measurements will include demographics, health indicators, comorbidities, malnutrition universal screening tool (MUST), frailty status (SHARE-FI, CFS) and muscle mass (bioelectrical impedance). Primary outcome will be frailty status measured by SHARE-FI at three months. Secondary outcomes include CFS, muscle mass, in-patient hospitalisation, long term care admission, and subjective ease of intervention and difference to general health. Statistical analysis will be undertaken by an independent statistician. Discussion: The diversity of tested frailty interventions and lack of clear guidance may contribute to low implementation rates. The REFEREE trial focusses on an optimised intervention for a syndrome that poses growing individual and societal challenges. It is hoped results can encourage mainstream adoption of interventions to reverse clinical frailty and build resilience in primary care. Trial registration: ClinicalTrials.gov ID NCT04628754; registered on 13 November 2020.

Development of a Caregivers' Support Platform (Connected Health Sustaining Home Stay in Dementia): Protocol for a Longitudinal Observational Mixed Methods Study.

BACKGROUND: Dementia disease is a chronic condition that leads a person with dementia (PwD) into a state of progressive deterioration and a greater dependence in performing their activities of daily living (ADL). It is believed nowadays that PwDs and their informal caregivers can have a better life when provided with the appropriate services and support. Connected Health (CH) is a new technology-enabled model of chronic care delivery where the stakeholders are connected through a health portal, ensuring continuity and efficient flow of information. CH has demonstrated promising results regarding supporting informal home care and Aging in Place, and it has been increasingly considered by researchers and health care providers as a method for dementia home care management. OBJECTIVE: This study aims to describe the development and implementation protocol of a CH platform system to support informal caregivers of PwDs at home. METHODS: This is a longitudinal observational mixed methods study where quantitative and qualitative data will be combined for determining the utility of the CH platform for dementia home care. Dyads, consisting of a PwD and their informal caregiver living in the community, will be divided into 2 groups: the intervention group, which will receive the CH technology package at home, and the usual care group, which will not have any CH technology at all. Dyads will be followed up for 12 months during which they will continue with their traditional care plan, but in addition, the intervention group will receive the CH package for their use at home during 6 months (months 3 to 9 of the yearly follow-up). Further comprehensive assessments related to the caregiver's and PwD's emotional and physical well-being will be performed at the initial assessment and at 3, 6, 9, and 12 months using international and standardized validated questionnaires and semistructured individual interviews. RESULTS: This 3-year funded study (2016-2019) is currently in its implementation phase and is expected to finish by December 2019. We believe that CH can potentially change the PwD current care model, facilitating a proactive and preventive model, utilizing self-management-based strategies, and enhancing caregivers' involvement in the management of health care at home for PwDs. CONCLUSIONS: We foresee that our CH platform will provide knowledge and promote autonomy for the caregivers, which may empower them into greater control of the care for PwDs, and with it, improve the quality of life and well-being for the person they are caring for and for themselves through a physical and cognitive decline predictive model. We also believe that facilitating information sharing between all the PwDs' care stakeholders may enable a stronger relationship between them, facilitate a more coordinated care plan, and increase the feelings of empowerment in the informal caregivers. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/13280.

Preparedness of newly qualified doctors in Ireland for prescribing in clinical practice.

AIM: The aim of the study was to investigate the level of preparedness of newly qualified Irish-trained doctors for prescribing, and to investigate their attitudes towards prescribing and prescribing education, through a national survey. METHODS: A 29-item online survey was distributed to 686 newly qualified doctors 1 month prior to the completion of their first year of clinical practice (internship). Only graduates from Irish medical schools were included. RESULTS: The response rate was 20.4% (n = 140; female : male 56%:44%). The majority of respondents felt confident in prescription writing (89%), medication history taking (81%) and accessing drug information in the hospital setting (80%). Only 58% of respondents felt confident in drug dose calculation, and 35% felt confident in preparing and administering drugs. When asked if their undergraduate medical education had prepared them for prescribing in clinical practice, 28% of respondents agreed. Confidence that their undergraduate education had prepared them was associated with receiving formal training in prescribing skills (P = 0.0045; 27% vs. 0%). Thirty-seven per cent of respondents agreed that they felt stressed about prescribing medications. CONCLUSION: This survey of newly qualified doctors in Ireland found that only 28% of respondents agreed that their undergraduate medical education had prepared them for prescribing, which was comparable to a previous survey of UK medical students and graduates. Investigating confidence and preparedness for prescribing provides important insights for educators. Dedicated teaching of prescribing, with an emphasis on practical training and assessment, may help graduates to feel more prepared for the challenges of prescribing in the clinical setting.

The Virtual Tray of Objects Task as a novel method to electrophysiologically measure visuo-spatial recognition memory.

We explored a novel method to electrophysiologically measure visuo-spatial recognition memory using a modified version of the Virtual Tray of Objects Task (VTOT). Event-related potentials (ERP) were recorded from 18 healthy volunteers during performance in the VTOT. Participants were required to detect random repetitions of three-dimensional visual stimuli (OLD) and to refrain from responding to non-repeated stimuli (NEW). Differences in ERP between the NEW and OLD conditions were tested for statistical significance using assumption-free non-parametric analyses. Further, a correlation between ERP and behavioral measures was sought. Significant OLD-NEW effects were found for four ERP components showing distinct spatio-temporal characteristics: a posterior positive component appearing at 100 ms (P100), a left-lateralized negative component peaking at ≈250 ms (N250), a frontal negative component at ≈300-450 ms (FN400), and a right late frontal negativity (rLFN) at ≈500-720 ms. Moreover, individual differences in the OLD-NEW effect computed for the rLFN positively correlated with repeated stimulus recognition efficiency. However, there were no late left parietal P600 old/new effects. These findings suggest that the P100 component might reflect early visual perception processes taking place during performance in the task, whereas the N250 and FN400 components could be linked to stimulus-dependent access to visual memory representations and familiarity-related processes, respectively. In contrast, we propose that the rLFN component could be associated with higher-level cognitive functions, such as attention and monitoring processes. Altogether, our results suggest that the ERP version of the VTOT could play a role in the electrophysiological assessment of visuo-spatial memory and related sub-processes.

Effects of a vitamin D and leucine-enriched whey protein nutritional supplement on measures of sarcopenia in older adults, the PROVIDE study: a randomized, double-blind, placebo-controlled trial.

BACKGROUND: Age-related losses of muscle mass, strength, and function (sarcopenia) pose significant threats to physical performance, independence, and quality of life. Nutritional supplementation could positively influence aspects of sarcopenia and thereby prevent mobility disability. OBJECTIVE: To test the hypothesis that a specific oral nutritional supplement can result in improvements in measures of sarcopenia. DESIGN: A multicenter, randomized, controlled, double-blind, 2 parallel-group trial among 380 sarcopenic primarily independent-living older adults with Short Physical Performance Battery (SPPB; 0-12) scores between 4 and 9, and a low skeletal muscle mass index. The active group (n = 184) received a vitamin D and leucine-enriched whey protein nutritional supplement to consume twice daily for 13 weeks. The control group (n = 196) received an iso-caloric control product to consume twice daily for 13 weeks. Primary outcomes of handgrip strength and SPPB score, and secondary outcomes of chair-stand test, gait speed, balance score, and appendicular muscle mass (by DXA) were measured at baseline, week 7, and week 13 of the intervention. RESULTS: Handgrip strength and SPPB improved in both groups without significant between-group differences. The active group improved more in the chair-stand test compared with the control group, between-group effect (95% confidence interval): -1.01 seconds (-1.77 to -0.19), P = .018. The active group gained more appendicular muscle mass than the control group, between-group effect: 0.17 kg (0.004-0.338), P = .045. CONCLUSIONS: This 13-week intervention of a vitamin D and leucine-enriched whey protein oral nutritional supplement resulted in improvements in muscle mass and lower-extremity function among sarcopenic older adults. This study shows proof-of-principle that specific nutritional supplementation alone might benefit geriatric patients, especially relevant for those who are unable to exercise. These results warrant further investigations into the role of a specific nutritional supplement as part of a multimodal approach to prevent adverse outcomes among older adults at risk for disability.

Context aware falls risk assessment: A case study comparison.

This paper describes three retrospective case studies to illustrate the potential clinical value of a system capable of capturing objective gait metrics and environment data from older adults with a history of falls while they go about their daily lives. Participants in this study wore an inertial sensor above each ankle and a wearable camera around their neck for seven consecutive days. Selected metrics are presented to illustrate scenarios where the data collected by the system could be of clinical value. Evidence suggests that obtaining objective gait metrics and environment data from older adults may not only allow healthcare professionals to assess gait more accurately, but also to design treatment plans and falls prevention strategies that are more specifically tailored to each individual.

Context focused older adult mobility and gait assessment.

This paper presents an initial overview of insights gained into how older adults mobilize in the home and community, based on data from inertial sensors which were worn by study participants over a 7-day period. The addition of a wearable camera provided additional contextual information which can be used to assess mobility and understand the factors that influence it in the free living environment. Seven days of data collected from a group of older adults who had experienced one or more falls in the previous six months was compared to that of a control group with no history of falling. Results showed that both groups spent relatively little time walking in challenging environmental conditions, and that the fallers spent significantly less time walking under regular conditions (no effect on gait) and outdoors. Analysis of gait metrics showed that the fallers were slightly slower in general, and more noticeable differences were observed when the participants were regrouped according to mobility levels determined from baseline assessments using traditional methods.

Awareness of osteoporosis, risk and protective factors and own diagnostic status: a cross-sectional study.

UNLABELLED: We conducted a cross-sectional study of the understanding on osteoporosis amongst community-dwelling geriatric patients. Patient understanding on the pathology, risk factors and its complications was suboptimal, but better amongst women and persons with diagnosed osteoporosis. Improving patient osteoporosis education may lead to improved compliance with preventive and therapeutic measures. PURPOSE: Osteoporosis is often preventable and treatable. Establishing levels of understanding in an Irish population will help inform future public and patient education. METHODS: We conducted a cross-sectional survey of 126 randomly selected geriatric day hospital patients, interviewing next of kin where abbreviated mental test score was <6. Questions assessed awareness of (1) basic pathology, (2) predisposing and protective factors, (3) complications and (4) personal osteoporosis status and treatment. RESULTS: Participants included 103 patients and 23 carers; 78.6 % were female; patients' mean age was 81.6 years. Of the patients surveyed, 87.3 % had heard of osteoporosis; 56.1 % knew affected bone; and 30.2 % were cognisant of architectural change. About 65.9 % reported that a doctor had never discussed the condition; 92.9 % correctly identified whether diagnosed with osteoporosis, and >96 % correctly identified their treatment status. Rates of risk factor identification were as follows: 88.9 % for ageing, 83.8 % female gender, 65.1 % smoking, 62.4 % low BMI and 51.6 % alcohol excess; <10 % identified other risk factors. Awareness of complications ranged from 91.3 % for fractures to 44.4 % for height loss. Awareness of protective factors (calcium/vitamin D-rich food, medication and exercise) was >85 % for each. More women had heard of osteoporosis (p = 0.02), knew affected bone (p = 0.005) and recognised gender as a risk factor (p = 0.015) and pain (p = 0.05) or kyphosis (p = 0.014) as complications. Osteoporotic patients (N = 38) were more likely to know it as affected bone (p = 0.006). Amongst patients surveyed [abbreviated mental test score (AMTS) 6-10], AMTS score did not predict understanding. Age did not predict understanding, nor were next of kin more likely to understand osteoporosis than patients. CONCLUSION: There is scope for enhancing patient osteoporosis education, which may improve compliance with preventive and therapeutic measures.

Fibrinogen concentration and risk of ischemic stroke and acute coronary events in 5113 patients with transient ischemic attack and minor ischemic stroke.

BACKGROUND AND PURPOSE: Fibrinogen is an independent risk factor for coronary events in population-based studies and in patients with coronary heart disease, but there is uncertainty about prediction of stroke, particularly in secondary prevention. METHODS: We studied unpublished data from 3 prospective studies of patients with recent transient ischemic attack (TIA) or minor ischemic stroke: the United Kingdom TIA Aspirin (UK-TIA) trial (n=1860); the Dutch TIA trial (n=2960); and the Oxford TIA Study (n=293). By separate and pooled analysis, we used Cox models to determine the relationship between fibrinogen and risk of ischemic stroke and other vascular events during 23,272 patient-years of follow-up and adjusted for other risk factors. RESULTS: There was no significant heterogeneity in fibrinogen risk associations between studies. Fibrinogen predicted subsequent ischemic stroke, with a pooled hazard ratio (HR) for values above the median of 1.34 (95% CI, 1.13 to 1.60; P=0.001). The association tended to be stronger in patients with nonlacunar (HR=1.42; 95% CI, 1.13 to 1.78; P=0.002) than lacunar syndromes (HR=1.09; 95% CI, 0.80 to 1.49; P=0.58), but was not significantly so (P=0.18). There was no association with hemorrhagic stroke (adjusted HR=1.09; 95% CI, 0.55 to 2.17; P=0.81). Fibrinogen predicted acute coronary events (adjusted HR=1.42; 95% CI, 1.18 to 1.70; P<0.001) and all ischemic vascular events (adjusted HR=1.31; 95% CI, 1.15 to 1.49; P<0.001), but not nonvascular death (adjusted HR=1.24; 95% CI, 0.90 to 1.70; P=0.19). CONCLUSIONS: In patients with a previous TIA or ischemic stroke, risks of recurrent ischemic stroke and acute coronary events increase linearly with fibrinogen levels, but the relationships are weaker than in some previous population-based studies.

A retrospective analysis of the sentence writing component of Folstein's MMSE.

OBJECTIVES: Agraphia is the loss or impairment of the ability to produce written language as a consequence of brain damage and is a well recognised feature of dementia. However there is no generally accepted classification of agraphic disorders. Our aim was to determine the influence of writing style, lettercase and sentence polarity of the writing component of Folstein's MMSE on the overall test score. METHODS: We retrospectively reviewed the 'write a sentence' request of Folstein's MMSE of 280 randomly selected patients attending a geriatric day hospital. We analysed four sentence characteristics: 1 Number of words, 2 Writing legibility, 3 Sentence polarity, 4 Letter case. RESULTS: 280 MMSE forms were examined, 165 were from female patients. Mean age was 81.7(± 6.6) years. Mean MMSE score was 21.6 (males: 21.9, females: 21.4). Significant correlation was detected between the overall MMSE score and both legibility and number of words. Legibility scores were significantly higher for females than for males (7.2 vs. 6.6, p < 0.03). The mean MMSE of females writing in lowercase was significantly higher than for those writing in uppercase (21.5 vs. 18.6, p < 0.05). The mean MMSE score of subjects writing sentences with a positive tone was significantly higher than that of those writing a neutral or negative sentence (22.6 vs. 21.0 p < 0.03). CONCLUSIONS: We have demonstrated a relationship between the content and structure of the writing assessment aspect of the MMSE and the overall test score.