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Background: UK care home residents are often poorly served by existing healthcare arrangements. Published descriptions of residents’ health status have been limited by lack of detail and use of data derived from surveys drawn from social, rather than health, care records. Aim: to describe in detail the health status and healthcare resource use of UK care home residents Design and setting: a 180-day longitudinal cohort study of 227 residents across 11 UK care homes, 5 nursing and 6 residential, selected to be representative for nursing/residential status and dementia registration. Method: Barthel index (BI), Mini-mental state examination (MMSE), Neuropsychiatric index (NPI), Mini-nutritional index (MNA), EuroQoL-5D (EQ-5D), 12-item General Health Questionnaire (GHQ-12), diagnoses and medications were recorded at baseline and BI, NPI, GHQ-12 and EQ-5D at follow-up after 180 days. National Health Service (NHS) resource use data were collected from databases of local healthcare providers. Results: out of a total of 323, 227 residents were recruited. The median BI was 9 (IQR: 2.5–15.5), MMSE 13 (4–22) and number of medications 8 (5.5–10.5). The mean number of diagnoses per resident was 6.2 (SD: 4). Thirty per cent were malnourished, 66% had evidence of behavioural disturbance. Residents had contact with the NHS on average once per month. Conclusion: residents from both residential and nursing settings are dependent, cognitively impaired, have mild frequent behavioural symptoms, multimorbidity, polypharmacy and frequently use NHS resources. Effective care for such a cohort requires broad expertise from multiple disciplines delivered in a co-ordinated and managed way.

Background: measuring the complex needs of care home residents is crucial for resource allocation. Hospital patient administration systems (PAS) may not accurately identify admissions from care homes. Objective: to develop and validate an accurate, practical method of identifying care home resident hospital admission using routinely collected PAS data. Method: admissions data between 2011 and 2012 (n = 103,105) to an acute Trust were modelled to develop an automated tool which compared the hospital PAS address details with the Care Quality Commission’s (CQC) database, producing a likelihood of care home residency. This tool and the Nuffield method (CQC postcode match only) were validated against a manual check of a random sample of admissions (n = 2,000). A dataset from a separate Trust was analysed to assess generalisability. Results:the hospital PAS was inaccurate; none of the admissions from a care home identified on manual check had a care home source of admission recorded on the PAS. Both methods performed well; the automated tool had a higher positive predictive value than the Nuffield method (100% 95% confidence interval (CI) 98.23–100% versus 87.10% 95%CI 82.28–91.00%), meaning those coded as care home residents were more likely to actually be from a care home. Our automated tool had a high level of agreement 99.2% with the second Trust’s data (Kappa 0.86 P < 0.001). Conclusions: care home status is not routinely or accurately captured. Automated matching offers an accurate, repeatable, scalable method to identify care home residency and could be used as a tool to benchmark how care home residents use acute hospital resources across the National Health Service.

The optimal management of hypertension in people with dementia is uncertain. This review explores if people with dementia experience greater adverse effects from antihypertensive medications, if cognitive function is protected or worsened by controlling blood pressure (BP) and if there are subgroups of people with dementia for whom antihypertensive therapy is more likely to be harmful. Robust evidence is scant, trials of antihypertensive medications have generally excluded those with dementia. Observational data show changes in risk association over the life course, with high BP being a risk factor for cognitive decline in mid-life, while low BP is predictive in later life. It is therefore possible that excessive BP lowering in older people with dementia might harm cognition. From the existing literature, there is no direct evidence of benefit or harm from treating hypertension in people with dementia. So what practical steps can the clinician take? Assess capacity, establish patient preferences when making treatment decisions, use ambulatory monitoring to thoroughly assess BP, individualise and consider deprescribing where side effects (e.g. hypotension) outweigh the benefits. Future research might include pragmatic randomised trials of targeted deprescribing, which include patient-centred outcome measures to help support decision-making and studies to address mechanistic uncertainties.

BACKGROUND: Registered Nurses (RNs) working in UK care homes receive most of their training in acute hospitals. At present the role of care home nursing is underdeveloped and it is seen as a low status career. We describe here research to define core competencies for RNs working in UK care homes. METHODS: A two-stage process was adopted. A systematic literature review and focus groups with stakeholders provided an initial list of competencies. The competency list was modified over three rounds of a Delphi process with a multi-disciplinary expert panel of 28 members. RESULTS: Twenty-two competencies entered the consensus process, all competencies were amended and six split. Thirty-one competencies were scored in round two, eight were agreed as essential, one competency was split into two. Twenty-four competencies were submitted for scoring in round three. In total, 22 competencies were agreed as essential for RNs working in care homes. A further ten competencies did not reach consensus. CONCLUSION: The output of this study is an expert-consensus list of competencies for RNs working in care homes. This would be a firm basis on which to build a curriculum for this staff group.

Objectives: to describe the views of healthcare workers on the facilitators of communication with people with dementia in a care setting. Design: thematic analysis of semi-structured interviews. Setting: all participants were interviewed in their place of work. Participants: sixteen healthcare workers whose daily work involves interacting with people with dementia. Results: four overarching categories of themes were identified from the interviews that impact on communication: the attributes of a care worker, communication strategies used, organisational factors and the physical characteristics of the care environment. Conclusion: many strategies used by healthcare workers to facilitate communication have not yet been studied in the research literature. Participants’ views on training should be incorporated into future dementia training programmes.

Introduction - Learning about ageing and the appropriate management of older patients is important for all doctors. This survey set out to evaluate what medical undergraduates in the UK are taught about ageing and geriatric medicine and how this teaching is delivered. Methods – An electronic questionnaire was developed and sent to the 28/31 UK medical schools which agreed to participate. Results – Full responses were received from 17 schools. 8/21 learning objectives were recorded as taught, and none were examined, across every school surveyed. Elder abuse and terminology and classification of health were taught in only 8/17 and 2/17 schools respectively. Pressure ulcers were taught about in 14/17 schools but taught formally in only 7 of these and examined in only 9. With regard to bio- and socio- gerontology, only 9/17 schools reported teaching in social ageing, 7/17 in cellular ageing and 9/17 in the physiology of ageing. Discussion – Even allowing for the suboptimal response rate, this study presents significant cause for concern with UK undergraduate education related to ageing. The failure to teach comprehensively on elder abuse and pressure sores, in particular, may be significantly to the detriment of older patients.

Background: Studies have sought to identify the possible determinants of medical students’ and doctors’ attitudes towards older patients by examining relationships with a variety of demographic, educational/training, and job factors. This review collates and synthesises these findings. Methods: An electronic search of ten databases was performed (ABI/Inform, ASSIA, British Nursing Index, CINAHL, Informa Health, Medline, PsycINFO, Science Direct, Scopus, and Web of Science) through to 7 February 2017. Results: The main search identified 2332 articles; 37 studies met the eligibility criteria set. All included studies analysed self-reported attitudes based on correlational analyses or difference testing, therefore causation cannot be determined. However, self-reported positive attitudes towards older patients were related to: (i) intrinsic motivation for studying medicine; (ii) increased preference for working with older patients; and (iii) good previous relationships with older people. Additionally, more positive attitudes were also reported in those with higher knowledge scores but these may relate to the use of a knowledge measure which is an indirect measure of attitudes (i.e. Palmore’s Facts on Aging Quizzes). Four out of the five high quality studies included in this review reported more positive attitudes in females compared to males. Conclusion: This paper identifies factors associated with medical students’ and doctors’ positive attitudes towards older patients. Future research could bring greater clarity to the relationship between knowledge and attitudes by using a knowledge measure which is distinct from attitudes and also measures knowledge that is relevant to clinical care.

Introduction: Accurate measurement of activity in care home residents is important for monitoring and evaluating interventions for activity promotion. Accelerometers provide a potential method. However, their usefulness in this population has not been well documented. We aimed to explore the feasibility of these in care home residents. Method: Mobile residents who had fallen in the past year, were asked to wear a tri-axial accelerometer (ActivPAL3TM) on the lower thigh for 7 days. Care staff were trained in device application. Users’ skin and problems with use were checked daily. Activity data sought were: step count, time sedentary, time standing and Metabolic Equivalent of Task. Care records were checked for falls. Results: 10/16 residents agreed to wear accelerometers. 7 wore them for 7 days and the remainder for 4, 5 and 6 days respectively. No falls were recorded. Data indicated 1 resident continuously standing which was verified not to be the case by observation. Problems were: data disturbance through removal/fidgeting, hydrofilm dressing flaccidity, premature detachment, care staff non-compliance to waterproof continuous wear, resident skin check non-compliance, prior leg ache attributed to accelerometers (with no worsening), pink skin and activity restriction by care staff. The accelerometers and attachment materials cost £2062.59. Conclusion: In this small feasibility study of care home residents tri-axial accelerometers were so problematic to be of negligible use and we will not be using them in our definitive trial. Activity levels, where recorded were in keeping with published literature showing care residents to be highly sedentary

Introduction: in 2008, the British Geriatrics Society (BGS) developed the Recommended Undergraduate Curriculum in Geriatric Medicine. This was subsequently mapped to the second edition of Tomorrows' Doctors (TD2, 2003). Following the publication of the third edition of Tomorrow's Doctors in 2009 (TD3), the mapping exercise was repeated to verify the extent to which the updated General Medical Council recommendations supported teaching in ageing and geriatric medicine. Method: we analysed TD3 and identified 48 aspects of its general guidance that were relevant to the teaching of medicine for older people. We then mapped these to the 2009 BGS curriculum. Results: the BGS curriculum was supported in full by TD3. However, learning outcomes relating to the interpretation and conduct of research in TD3 had no corresponding outcomes in the BGS curriculum. Conclusion: the BGS curriculum for medical undergraduates continues to provide a specific and complete list of learning objectives, all of which could help to operationalise the general statements made in TD3 with relation to ageing and geriatric medicine. Learning outcomes in research in frail older patients have been added following this mapping exercise.

Background: There is global concern that there are insufficient numbers of geriatricians to meet the needs of the ageing population. A 2005 survey described factors that influenced why UK geriatricians had chosen to specialise in the field - in the decade since, UK postgraduate training has undergone a fundamental restructure. Objective: To explore whether the reasons for choosing a career in geriatric medicine in the UK had changed over time, with the goal of using this knowledge to inform recruitment and training initiatives. Design: An online survey was sent to all UK higher medical trainees in geriatric medicine. Methods: Survey questions that produced categorical data were analysed with simple descriptive statistics. For the survey questions that produced free-text responses, an inductive, iterative approach to analysis, in keeping with the principles of framework analysis, was employed. Results: 269 responses were received out of 641 eligible respondents. Compared with the previous survey, a substantially larger number of respondents regarded geriatric medicine to be their first-choice specialty and a smaller number regretted their career decision. A greater number chose geriatric medicine early in their medical careers. Commitments to the general medical rota and the burden of service provision were considered important downsides to the specialty. Conclusions: There are reasons to be optimistic about recruitment to geriatric medicine. Future attempts to drive up recruitment might legitimately focus on the role of the medical registrar and perceptions that geriatricians shoulder a disproportionate burden of service commitments and obligations to the acute medical take.

There is currently wide variation in the structure and content of higher medical training in geriatric medicine across Europe and no common framework within which existing efforts can be compared. We set out to develop an audit tool to compare training between countries. An initial review of indexed and grey literature was used to develop an audit tool which was used as the basis of an Internet-based modified Delphi process incorporating the views of 14 expert geriatricians from across Europe. Items in the audit tool were included or excluded when supported by ≥75% or <50% of respondents, respectively. Items supported by 50–74% of respondents were carried forward with additional suggestions and modifications included following Round 1. Thirteen experts representing 12 countries responded to both rounds. 40/45 items were supported at Round 1. Five items were carried forward. A further 13 elements were introduced for consideration at Round 2. Consensus was gained after the second round. The final tool describes 52 items across four domains: general considerations, topics referring to knowledge in patient care, different roles that should be considered in medical training and topics regarding assessment. The resulting tool can be used as a basis for comparing higher medical training programmes in geriatric medicine between countries. Individual countries can use this to audit current practice. At an European Union level, the insights gained through such audit will form the basis of future work to develop an agreed postgraduate curriculum in the specialty.

In this paper we outline the relationship between the need to put existing applied health research knowledge into practice (the “know-do gap”) and the need to improve the evidence base (the “know gap”) with respect to the health care process used for older people with frailty known as comprehensive geriatric assessment (CGA). We explore the reasons for the know-do gap and the principles of how these barriers to implementation might be overcome. We explore how these principles should affect the conduct of applied health research to close the know gap. We propose that impaired flow of knowledge is an important contributory factor in the failure to implement evidence-based practice in comprehensive geriatric assessment; this could be addressed through specific knowledge mobilisation techniques. We describe that implementation failures are also produced by an inadequate evidence base which requires the co-production of research, addressing not only effectiveness but also the feasibility and acceptability of new services, the educational needs of practitioners, the organisational requirements of services, and the contribution made by policy. Only by tackling these issues in concert and appropriate proportion, will the know and know-do gaps for CGA be closed.

Introduction: care home residents have high healthcare needs not fully met by prevailing healthcare models. This study explored how healthcare configuration influences resource use. Methods: a realist evaluation using qualitative and quantitative data from case studies of three UK health and social care economies selected for differing patterns of healthcare delivery to care homes. Four homes per area (12 in total) were recruited. A total of 239 residents were followed for 12 months to record resource-use. Overall, 181 participants completed 116 interviews and 13 focus groups including residents, relatives, care home staff, community nurses, allied health professionals and General Practitioners. Results: context-mechanism-outcome configurations were identified explaining what supported effective working between healthcare services and care home staff: (i) investment in care home-specific work that legitimises and values work with care homes; (ii) relational working which over time builds trust between practitioners; (iii) care which ‘wraps around’ care homes; and (iv) access to specialist care for older people with dementia. Resource use was similar between sites despite differing approaches to healthcare. There was greater utilisation of GP resource where this was specifically commissioned but no difference in costs between sites. Conclusion: activities generating opportunities and an interest in healthcare and care home staff working together are integral to optimal healthcare provision in care homes. Outcomes are likely to be better where: focus and activities legitimise ongoing contact between healthcare staff and care homes at an institutional level; link with a wider system of healthcare; and provide access to dementia-specific expertise.

CONTEXT: Care home residents are at risk of malnutrition through reduced overall food intake, ‘anabolic resistance’ in ageing muscle and high prevalence of medical morbidity and functional dependency. There has been limited consensus regarding effectiveness of a high protein diet on quality of life or clinical outcomes for care home residents. OBJECTIVE: To evaluate the effectiveness of non-meat, high protein supplementation on Health-Related Quality of Life (HRQOL) and relevant clinical and nutritional outcomes in older people in the care home setting. DATA SOURCES: We searched EMBASE, AMED, CINAHL, MEDLINE, and the Cochrane Registry of Clinical Trials, OpenGrey, clinicaltrials.gov, the WHO clinical trial registry and the ISRCTN and NIHR trial portfolio (to February 2018) for randomised controlled trials. DATA EXTRACTION: We extracted data from included trials if they assessed people aged 65 years and over living in care homes, who received a protein supplementation compared to not. DATA ANALYSIS: We assessed trial quality using Cochrane Risk of Bias tool and meta-analysis was undertaken when appropriate. RESULTS: 17 papers with 1,246 participants fulfilled the inclusion criteria. All studies were low or moderate quality. No evidence of improving HRQOL when the SF-36 was used (Standardised Mean Difference (SMD: -0.10; 95% CI: -0.51 to 0.31; p=0.62), although significant improvement was seen in the single trial using EQ-5D (SMD: 2.58; 95% CI: 2.05 to 3.10; p<0.00001). CONCLUSIONS: Non-meat, high-protein oral supplements can improve markers of nutritional status in care home residents. However, there is insufficient high-quality evidence to determine the effect of such interventions for older adults in care homes with regard to HRQOL.

CONTEXT: Care home residents are at risk of malnutrition through reduced overall food intake, ‘anabolic resistance’ in ageing muscle and high prevalence of medical morbidity and functional dependency. There has been limited consensus regarding effectiveness of a high protein diet on quality of life or clinical outcomes for care home residents. OBJECTIVE: To evaluate the effectiveness of non-meat, high protein supplementation on Health-Related Quality of Life (HRQOL) and relevant clinical and nutritional outcomes in older people in the care home setting. DATA SOURCES: We searched EMBASE, AMED, CINAHL, MEDLINE, and the Cochrane Registry of Clinical Trials, OpenGrey, clinicaltrials.gov, the WHO clinical trial registry and the ISRCTN and NIHR trial portfolio (to February 2018) for randomised controlled trials. DATA EXTRACTION: We extracted data from included trials if they assessed people aged 65 years and over living in care homes, who received a protein supplementation compared to not. DATA ANALYSIS: We assessed trial quality using Cochrane Risk of Bias tool and meta-analysis was undertaken when appropriate. RESULTS: 17 papers with 1,246 participants fulfilled the inclusion criteria. All studies were low or moderate quality. No evidence of improving HRQOL when the SF-36 was used (Standardised Mean Difference (SMD: -0.10; 95% CI: -0.51 to 0.31; p=0.62), although significant improvement was seen in the single trial using EQ-5D (SMD: 2.58; 95% CI: 2.05 to 3.10; p<0.00001). CONCLUSIONS: Non-meat, high-protein oral supplements can improve markers of nutritional status in care home residents. However, there is insufficient high-quality evidence to determine the effect of such interventions for older adults in care homes with regard to HRQOL.

CONTEXT: Care home residents are at risk of malnutrition through reduced overall food intake, ‘anabolic resistance’ in ageing muscle and high prevalence of medical morbidity and functional dependency. There has been limited consensus regarding effectiveness of a high protein diet on quality of life or clinical outcomes for care home residents. OBJECTIVE: To evaluate the effectiveness of non-meat, high protein supplementation on Health-Related Quality of Life (HRQOL) and relevant clinical and nutritional outcomes in older people in the care home setting. DATA SOURCES: We searched EMBASE, AMED, CINAHL, MEDLINE, and the Cochrane Registry of Clinical Trials, OpenGrey, clinicaltrials.gov, the WHO clinical trial registry and the ISRCTN and NIHR trial portfolio (to February 2018) for randomised controlled trials. DATA EXTRACTION: We extracted data from included trials if they assessed people aged 65 years and over living in care homes, who received a protein supplementation compared to not. DATA ANALYSIS: We assessed trial quality using Cochrane Risk of Bias tool and meta-analysis was undertaken when appropriate. RESULTS: 17 papers with 1,246 participants fulfilled the inclusion criteria. All studies were low or moderate quality. No evidence of improving HRQOL when the SF-36 was used (Standardised Mean Difference (SMD: -0.10; 95% CI: -0.51 to 0.31; p=0.62), although significant improvement was seen in the single trial using EQ-5D (SMD: 2.58; 95% CI: 2.05 to 3.10; p<0.00001). CONCLUSIONS: Non-meat, high-protein oral supplements can improve markers of nutritional status in care home residents. However, there is insufficient high-quality evidence to determine the effect of such interventions for older adults in care homes with regard to HRQOL.

CONTEXT: Care home residents are at risk of malnutrition through reduced overall food intake, ‘anabolic resistance’ in ageing muscle and high prevalence of medical morbidity and functional dependency. There has been limited consensus regarding effectiveness of a high protein diet on quality of life or clinical outcomes for care home residents. OBJECTIVE: To evaluate the effectiveness of non-meat, high protein supplementation on Health-Related Quality of Life (HRQOL) and relevant clinical and nutritional outcomes in older people in the care home setting. DATA SOURCES: We searched EMBASE, AMED, CINAHL, MEDLINE, and the Cochrane Registry of Clinical Trials, OpenGrey, clinicaltrials.gov, the WHO clinical trial registry and the ISRCTN and NIHR trial portfolio (to February 2018) for randomised controlled trials. DATA EXTRACTION: We extracted data from included trials if they assessed people aged 65 years and over living in care homes, who received a protein supplementation compared to not. DATA ANALYSIS: We assessed trial quality using Cochrane Risk of Bias tool and meta-analysis was undertaken when appropriate. RESULTS: 17 papers with 1,246 participants fulfilled the inclusion criteria. All studies were low or moderate quality. No evidence of improving HRQOL when the SF-36 was used (Standardised Mean Difference (SMD: -0.10; 95% CI: -0.51 to 0.31; p=0.62), although significant improvement was seen in the single trial using EQ-5D (SMD: 2.58; 95% CI: 2.05 to 3.10; p<0.00001). CONCLUSIONS: Non-meat, high-protein oral supplements can improve markers of nutritional status in care home residents. However, there is insufficient high-quality evidence to determine the effect of such interventions for older adults in care homes with regard to HRQOL.