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Background Aging affects immunity, potentially altering fever response to infection. We assess effects of biological variables on basal temperature, and during COVID-19 infection, proposing an updated temperature threshold for older adults ≥65 years. Methods Participants were from 4 cohorts: 1 089 unaffected adult TwinsUK volunteers; 520 adults with emergency admission to a London hospital with RT-PCR confirmed SARS-CoV-2 infection; 757 adults with emergency admission to a Birmingham hospital with RT-PCR confirmed SARS-CoV-2 infection and 3 972 adult community-based COVID Symptom Study participants self-reporting a positive RT-PCR test. Heritability was assessed using saturated and univariate ACE models; mixed-effect and multivariable linear regression examined associations between temperature, age, sex, and body mass index (BMI); multivariable logistic regression examined associations between fever (≥37.8°C) and age; receiver operating characteristic (ROC) analysis was used to identify temperature threshold for adults ≥ 65 years. Results Among unaffected volunteers, lower BMI (p = .001), and increasing age (p < .001) was associated with lower basal temperature. Basal temperature showed a heritability of 47% (95% confidence interval 18%–57%). In COVID-19+ participants, increasing age was associated with lower temperatures in Birmingham and community-based cohorts (p < .001). For each additional year of age, participants were 1% less likely to demonstrate a fever ≥37.8°C (OR 0.99; p < .001). Combining healthy and COVID-19+ participants, a temperature of 37.4°C in adults ≥65 years had similar sensitivity and specificity to 37.8°C in adults Conclusions Aging affects temperature in health and acute infection, with significant heritability, indicating genetic factors contribute to temperature regulation. Our observations suggest a lower threshold (37.4°C/97.3°F) for identifying fever in older adults ≥65 years.

Background for shared decision-making, it is important to discuss of the patients’ priorities in order to align treatment decisions with these priorities. Objective to assess the most important health outcome for older patients on the verge of making a treatment decision, using the Outcome Prioritization Tool (OPT). Secondary objectives were the feasibility of the OPT and patient variables associated with prioritising different health outcomes. Design retrospective cohort study. Setting and subjects at the University Medical Hospital Groningen, the Netherlands, 350 patients were included who visited the geriatric outpatient clinic during the work-up regarding a complex treatment decision (such as cancer treatment or heart valve replacement). Methods during geriatric assessment, patients prioritised between four health outcomes, using the OPT. Results median age was 78.5 years, 172 (49.1%) were referred regarding a treatment decision for a malignant disease. Cognitive impairment was present in 23.6%. Most patients (55.2%) prioritised maintaining independence as their most important goal, followed by extending life in 21.1%. Only cognitive impairment was significantly associated with prioritising extending life as the most important health outcome. For 107 patients (30.6%), the OPT was not feasible; these patients more often had malnutrition and assisted living. Conclusions the main health outcome of older patients on the verge of making a treatment decision was maintaining independence, followed by extending life. Patients with cognitive impairment more often prioritised extending life. The OPT was feasible as a decision aid for most patients. For optimal shared decision-making, it is crucial to take patient preferences into account.

Background after hospitalisation for cardiac disease, older patients are at high risk of readmission and death. Objective the cardiac care bridge (CCB) transitional care programme evaluated the impact of combining case management, disease management and home-based cardiac rehabilitation (CR) on hospital readmission and mortality. Design single-blind, randomised clinical trial. Setting the trial was conducted in six hospitals in the Netherlands between June 2017 and March 2020. Community-based nurses and physical therapists continued care post-discharge. Subjects cardiac patients ≥ 70 years were eligible if they were at high risk of functional loss or if they had had an unplanned hospital admission in the previous 6 months. Methods the intervention group received a comprehensive geriatric assessment-based integrated care plan, a face-to-face handover with the community nurse before discharge and follow-up home visits. The community nurse collaborated with a pharmacist and participants received home-based CR from a physical therapist. The primary composite outcome was first all-cause unplanned readmission or mortality at 6 months. Results in total, 306 participants were included. Mean age was 82.4 (standard deviation 6.3), 58% had heart failure and 92% were acutely hospitalised. 67% of the intervention key-elements were delivered. The composite outcome incidence was 54.2% (83/153) in the intervention group and 47.7% (73/153) in the control group (risk differences 6.5% [95% confidence intervals, CI −4.7 to 18%], risk ratios 1.14 [95% CI 0.91–1.42], P = 0.253). The study was discontinued prematurely due to implementation activities in usual care. Conclusion in high-risk older cardiac patients, the CCB programme did not reduce hospital readmission or mortality within 6 months. Trial registration Netherlands Trial Register 6,316, https://www.trialregister.nl/trial/6169

Background Severe acute respiratory coronavirus 2 (SARS-CoV-2) was first recorded in Ireland in February 2020. Several studies have explored the association between age and SARS-CoV-2, showing that there were poorer outcomes in older people. Our objective was to evaluate the impact of age on outcomes such as hospital length of stay, mortality, and re-hospitalisation. Methods We performed a single-centre, retrospective observational cohort study, using an electronic microbiology database of recorded index admissions of SARS-CoV-2 positive patients aged 65 years and older during SARS-CoV-2 wave one (March 1st to May 31st 2020). PCR testing of nasopharyngeal and/or sputum samples was used to confirm positivity. Our clinical outcomes measured included hospital length of stay, mortality and re-admission rate within 6 months. Results 153 patients 65 years and above were admitted. The male to female ratio was 1.3 with 90% admitted medically. 79 patients were aged between 65–79 years; 84 patients ≥80 years; and 12 patients ≥90 years. Mortality was 25%, 31% and 42%, respectively. Median length of stay remained 14 days for ages 65–89 rising to 17.5 days for those ≥90 years. Re-hospitalisation rates at 6 months were similar for ages 65–79 and 89–89 years at 42% and 40%, respectively. One patient (14%) over 90 years was re-hospitalised. Conclusion SARS-CoV-2 has disproportionately impacted on general medical services treating older hospitalised people. In our centre, mortality for patients ≥65 years was 28.1% which compared favourably with 35.6% internationally as outlined by Victor et al. (2020) based on Spanish data. Treatment of SARS-CoV-2 is not futile in older patients with 58% of nonagenarians and 69% of octogenarians surviving, however re-hospitalisation rates are high at 40%. A targeted approach to discharge support via integrated care may ameliorate this.

Background The aging population of Ireland continues to increase rapidly. As the age continues to increase, so too does the need for long-term care (LTC). In 2006 LTC utilisation was estimated between 4.4%–4.8% of the over 65s population. It was proposed that this would increase to between 4.8%–5.3% by 2021 (Wren et al., 2012). This study intended to explore if this projection was evident in discharges from an acute Care of the Older Person’s setting between 2016 and 2021. Methods A random selection approach was used to retrospectively review 45 patients seen by occupational therapy in an Irish acute Care of the Older Person’s service in 2016. Discharge destinations were recorded. These were then compared to the discharge destinations of 45 randomly selected patients open to occupational therapy in the same service during the first half of 2021. Results The review of 2016 found that 15.56% (n = 7) of those seen by occupational therapy discharged to a LTC facility, and 4.45% (n = 2) discharged home with a back-up LTC plan. Additionally, 33.33% (n = 15) transferred to a rehabilitation facility and 42.22% (n = 19) went home with community supports, 4.44% (n = 2) passed away. Contrastingly, in 2021, 28.89% (n = 13) patients discharge to LTC with an additional 6.66% (n = 3) going home with 24/7 private care in place, and 4.45% (n = 2) went home with a LTC back-up plan. Just 22.22% (n = 10) went for rehabilitation and 26.67% (n = 12) went home with community supports. In 2021, 11.11% (n = 5) of those randomly selected passed away during their admission. Conclusion A significant increase of the number of inpatients discharging to LTC between 2016 and 2021 was found. These findings are greater than that previously proposed and may suggest that COVID-19 has caused a further increase in individuals requiring LTC. However, this sample size was small and other factors such as age, physical ability and cognition were not explored. Further studies are recommended.

Background Simulation-based medical education (SBME) is emerging as a key method of medical education, particularly in the setting of the COVID-19 pandemic. As part of a simulation development competition (SimStars) run by the National Doctors Training and Planning Unit and the South–South West Hospital Group, we brought together an inter-disciplinary team to develop a simulation scenario on hip fracture. Methods Our development team consisted of members of the Geriatric Medicine and Orthopaedic Departments. We developed a scenario that can be adapted to suit the needs of learners in orthopaedics, medicine, or nursing. We ran the simulation on a medical ward with one candidate and four facilitators from the Geriatric Medicine Department. The candidate (medical SHO) was presented with a patient (facilitator one), who had sustained a hip fracture following a fall. The candidate was directed to elicit a falls and bone health history, screen for delirium, and suggest further investigations and management. Subsequently, feedback was sought from all participants. Results The simulation took twenty minutes, debriefing took fifteen minutes. All considered, the simulation an enjoyable and feasible method for teaching and learning, and a novel way to promote team-building. The candidate felt competent in some areas, reporting that the scenario provided positive reinforcement. She reported feeling supported in identifying areas for further learning. The facilitators also considered this method a useful way to highlight a candidate’s learning needs and direct further teaching. The candidate requested further SBME-based sessions. Conclusion This SBME session in Ortho-Geriatrics was well-received by the candidate and facilitators. All participants enjoyed teaching and learning through this medium. Areas of high competency were reinforced and areas for future learning were identified. Further SBME was requested across more topics and for simulation training to be brought in as part of formal training.

Background Nationally agreed standards improve the level of care delivered to all older, frail, multi-morbid patients presenting with hip fractures. Dedicated Orthogeriatric services allow for these standards to be achieved in a multi-disciplinary team (MDT) setting. As the COVID-19 pandemic reached our shores, the model of care set out by the Irish Hip Fracture Standards (IHFS) was under threat. Our dedicated Orthopaedic Trauma ward became an acute COVID ward and the Orthogeriatric service was re-deployed to acute medicine for Quarter 2. Methods Using the Irish Hip Fracture Database, local data was analysed and compared with national data from Quarter 1 to 4 (Q1–4) in 2020. Results When comparing local IHFS’s with national figures, ongoing challenges and future goals are highlighted. In 2020, there were 222 hip fracture patients (mean age 81.8 years) in our hospital. Standard 1, time to the ward In Q1, 56%, or over 1 in every 2 patients with hip fractures, met all of the Irish Hip Fracture Standards in our hospital. In Q2, only 18% of patients met all of the IHFS’s. Q3 saw improvements with 47% of all hip fracture patients achieving all IHFS’s. Q4 showed maintenance with 45% of all patients achieving all IHFS’s. Conclusion These findings highlight the need for a dedicated Orthogeriatric Service and Orthopaedic ward at all times. Going forward with the risk of future waves and the emergence of new variants, every effort should be made to maintain a comprehensive orthogeriatric service to minimise a negative impact on patient care.

Background The COVID-19 pandemic is recognised as having a significant impact on older people, particularly on those within nursing homes. Prior to the pandemic, a significant focus was placed on the application of a social model of care within nursing homes. We know that COVID-19 has required the stringent application of infection prevention and control measures as well as the provision of increased amounts of clinical care. This has resulted in the recent stronger application of a medical model of care within nursing homes. Methods A roundtable event attended by twenty-six people took place. Attendees represented clinical Gerontology, the Irish College of General Practitioner, Sage Family Forum, The Health Information and Quality Authority, Nursing Homes Ireland and nursing home providers. A number of presentations were made, and a roundtable discussion took place about the model of nursing home care post pandemic. Key messages from presentations and the discussion were captured. A report was compiled and shared with attendees to check for accuracy. Results The following key messages were identified: 1. Social care is a cornerstone of nursing home care 2. Increased integration of nursing homes within the wider health and social care system is required 3. Increased access to services for nursing home residents is required 4. Regulatory reform is required 5. Resourcing of nursing home care needs to be appropriately addressed 6. The nursing home sector need to be included in conversations around policy and service development affecting nursing home care in Ireland. Conclusion Nursing homes are an essential part of the healthcare system in Ireland and have been shown to be adaptable throughout the course of the pandemic. A one size fits all approach is an unlikely fit for purpose approach as we look towards the future with COVID-19.

Background In assessing the global impact of the COVID-19 pandemic on society, it is important to understand the communities most affected and develop methods of support. Family carers provide a vital, yet often invisible role in our society and healthcare system. Identifying research priorities for carers helps establish overall gaps in the research agenda and increases awareness of the role of carers in the community. Methods A priority setting partnership methodology was engaged and through collaboration with carers, healthcare professionals and researchers, a participatory process was conducted to identify gaps in the current literature and prioritise research questions and uncertainties. Focus group discussions followed, the first consisted of family carers (n = 5). The second (n = 3) interviewed stakeholders namely healthcare professionals, researchers and policy makers. After collating the data, researchable questions were developed through an iterative process with a Multi Stakeholder Advisory Committee to identify the top 10 research priorities for Family Carers Ireland. Results The top 10 researchable questions were distilled from a list of 16 and fit into 7 broad categories. 1) economic impact and financial strain 2) Systemic issues, education, resources and policy 3) technology 4) support services and infrastructure 5) mental health and wellbeing of the carer 6) carers in society 7) Recognition and acknowledgment of the family carer. Conclusion The partnership focus of this project allowed the ‘ground-up’ development of research priorities for carers by carers. The COVID-19 pandemic served to magnify systemic issues already present in society, as well as highlight new burdens. As a result, the subsequent development of 10 researchable questions will guide further investigation to improve the support and wellbeing of family carers.

Background The coronavirus 2019 (COVID-19) pandemic impacted significantly on the lives of older adults in Ireland, including the cancellation or postponement of healthcare services. This study examined the relationship between healthcare delay and older adults (50 years and over) with chronic conditions in Ireland. Methods This study used data from the Irish Longitudinal Study on Ageing (TILDA) COVID-19 study and previous waves of TILDA. The COVID-19 study data was collected between July 2020 and November 2020. Taking existing healthcare demand into account, logistic regression analysis was used to examine the relationship between healthcare delay and older adults with chronic conditions. Additional analysis, using multinomial logit regression, explored the reasons for healthcare delay, whether the delays were on the participants behalf or the health service provider. Results In total, 31.6% of participants reported healthcare delay. Older adults with two or more chronic conditions were more likely to experience healthcare delay than those with no chronic conditions. In the second analysis, older adults with two or more chronic conditions were more likely to have healthcare delayed by the provider and were also more likely to delay their own healthcare than those with no chronic conditions. Additionally, some other groups were more likely to experience healthcare delay such as: people aged 70 years and over, females, those with problematic alcohol consumption, those with third-level education, those who had visited the GP and those who reported polypharmacy. While older adults living with others and those living outside Dublin were less likely to experience healthcare delay. Conclusion The findings suggest that some groups of older adults may have been impacted more than others by healthcare delay during the pandemic. Policy and practice should focus on effective strategies to support the healthcare needs of these older adults going forward. Additionally, future research should examine the implications of healthcare delay on health outcomes.

Background The COVID19 pandemic highlighted deficiencies in interdisciplinary risk-communication in an intermediate care unit, based in a 30 bed independent care home, into which the hospital organisation assigns medical, pharmacy, physiotherapy, occupational therapy and social work teams to provide post-acute care rehabilitation for adults. Mean length of stay is 20 days and > 75% return home. Weekly bed turnover is approximately 15%. Methods Semi-structured interviews with nursing leaders and a weighted questionnaire for multidisciplinary team were used to determine baseline levels of confidence around environmental and resident-specific risk awareness. An Ishikawa diagram analysed factors contributing to risk-communication. The ‘Chain Of Care’ vision for care home environments incorporated a Multidisciplinary Safety Brief. Five iterations occurred before reaching standardisation. A post-implementation weighted questionnaire collated qualitative information on confidence change. The Safety Brief supplements intra-professional group handover processes. Duration ranged 90-120 seconds, occurring at shift commencement and 12.00 h daily. Retained documentation is available for inspectors. Results The Safety Brief as a communication tool: 86% of the team found it useful; 71% found that it had the ‘right amount’ of detail; and 62% found that it was of the ‘right duration’. Areas of greatest ‘swing’ towards INCREASED or SLIGHTLY INCREASED confidence in awareness of...: 72%, deaths in last 24 hours; 68%, planned discharges today; 67%, residents at risk of falling/had fallen within 48 hours; 67%, residents with same name; 66%, bed-availability; 63%, infection risks; 62%, experiencing delirium; 62%, living with dementia; 59%, scheduled appointments today; and 52%, those receiving palliative care. Conclusion A Multidisciplinary Safety Brief increased/slightly increased multidisciplinary team confidence in environmental and resident-specific risks in a care home environment. Risk-communication in any environment is complex especially if subject to frequent change. Communication tools need to be tailored to microsystem, systematic, comprehensive, yet brief and intuitive. Generalisability to non-intermediate care, non-geriatrician supported care home environments was considered iteratively.

Background The COVID19 pandemic highlighted deficiencies in the recognition, monitoring, escalation and de-escalation of the acutely unwell care home resident. RESTORE2 is endorsed by the British Geriatric Society as the preferred tool for use in a care home setting. It incorporates: recognition of soft-signs; NEWS2 (National Early Warning Score 2); and SBAR-D (Situation Background Assessment Recommendation-Decision). Implementing RESTORE2 required a series of change interventions in a mesosystem environment in intermediate care bed-based rehabilitation setting in an independent care home. Methods The Flow Coaching Academy ‘5Vs’ Framework was used. A vision of ‘CHAIN of CARE’ was developed (Care Home Assessment of Intervention Need and Communicate Act Review Evaluate). Stake-holder mapping was undertaken. A Sinek Circle distilled intentions. A global aim led to specific aims and informed driver diagrams. Problems and risks were mapped out with an Ishikawa diagram. A high-level process map of future state was and cross-functional swim-lane chart for RESTORE2 use were devised. A clinical value compass map was used to consider outcomes. PDSA cycles were used. Results The FCA Framework methodology, albeit without the ability to undertake ‘Big Room’ meetings due to the COVID19 pandemic restrictions, enabled the development of a care-home tailored Treatment Escalation Plan; an electronic template Nursing Handover; Multidisciplinary Safety Brief; training of all nursing team in RESTORE2; and use of NEWS2 for all residents in the intermediate care setting. Additional prompt for how to use RESTORE2 was developed. Conclusion Bringing about complex change in a complex mesosystem benefits from different techniques than microsystem change methodology. The 5Vs: Visualisation, Vision, Value, eVidence and inVolvement in the FCA Framework are an effective approach. The residents’ voice was largely absent in the pressures of the COVID19 pandemic. ‘The Chain of Care’ proved helpful in visualising the global aims for the clinical team.

Background Influenza vaccination, particularly for vulnerable, older adults, will have added importance this winter given the possibility of further waves of COVID-19 pandemic. Previous interventions at the study site noted poor awareness on the need for inpatient Influenza vaccination1. This study examines a vaccination reminder process using an electronic patient record (EPR) to identify high-priority eligible inpatients. Methods The study site is a 900-bed university teaching hospital with all clinical notes accessed via an EPR. We included a convenience sample of 750 adults aged≥50 years (mean age 75.9 +/− 0.4 years, 48% female) and high-priority for influenza vaccination (Age > 65 years and/or length of stay (LOS) >30 days) from October 1st 2020 to January 12th 2021. A live electronic dashboard identified eligible inpatients for vaccination, prompting vaccination reminders to the clinical teams via the antimicrobial pharmacist. Data was collected retrospectively. Logistic regression models reporting odds ratios were used to assess the association of these reminders with vaccine uptake. Results Over one third (35%, 264/750) of high-priority patients received the Influenza vaccine while inpatients, including 40% aged ≥80 years. The reminder was sent on 41% (305/750) of patients and was associated with an almost 50% higher likelihood of vaccination after adjusting for other covariates (Odds Ratio 1.48 (95% CI 1.00–2.20); p = 0.048). Other factors independently associated with vaccination were advancing age (Odds Ratio 2.69 (95% CI 1.12–6.47) for age ≥ 80 years); LOS (4% higher likelihood of vaccination for every additional day in hospital) and admission under geriatric medicine (Odds Ratio 3.71 (95% CI 2.45–5.62) when compared to other specialities). Conclusion Our study shows relatively low uptake of inpatient Influenza vaccination and strategies to improve uptake are required. Reminders sent to clinical teams using the EPR appear to be an effective means of increasing Influenza vaccination and should be considered as part of this year’s inpatient vaccination drive.

Background The Sars-CoV-2 global pandemic placed an unprecedented demand on acute health services and led to significant morbidity and mortality in older populations. Nearly half of attendances to this ED are over the age of 65 years and there are over 80 nursing homes in the catchment area. A pilot study in January 2021 showed that nursing home attendances increased significantly during the third wave of COVID-19 with many of these attendances potentially avoidable and suitable for optimised care in the nursing home. The primary objective of this quality improvement project was to enhance the older person’s care and experience when presenting to ED or being reviewed in the community with symptoms and signs of COVID-19. Secondary aims were reduced nursing home attendances to ED and subsequent admissions from these attendances. Methods A guideline was constructed based on the RCEM standard for Quality Care for Older People and using the HSE guidelines for managing COVID-19 in nursing home patients. The guideline was introduced to staff and implemented in ED and via the EDITH service. Results Two PDSA cycles were undertaken post guideline implementation. There were substantial improvements in the frequency of discussion and documentation of advanced directives with increased numbers of patients being discharged directly back to the nursing home or treated in the nursing home using the guideline. There was a decrease in the number of nursing home attendances throughout the project. Conclusion This successful QIP shows the importance of manging older patients appropriately, while considering their wishes. Post-COVID work should centre on managing all older patients with optimised treatment and considering how they will benefit most from their attendance to ED.

Background ‘What Matters to You’(WMTY) is a routine question in the comprehensive geriatric assessment (CGA) of the frail older person. The aim was to categorise WMTY and investigate changes during COVID-19. Methods WMTY, clinical frailty score (CFS), age, gender, vision and hearing impairment, malnutrition risk, modified Barthel Index (mBI), living alone status, 4AT and dementia screening results were prospectively entered onto MS Excel. Answers were retrospectively categorised and compared, pre-COVID-19 (April to June 2019) and during COVID-19 (April to June 2020). Descriptive statistics and MS Excel T-test were used for data analysis. Results The mean CFS (5), age (82 years), male: female ratio (1:1.3), prevalence of visual and hearing impairment (20–30%) and malnutrition risk were similar (23%) in both groups mBI was non-significantly reduced by a 1 point average during COVID-19. Less patients lived alone during COVID-19 (p = 0.05). Positive delirium screen doubled (12% vs 26%) during COVID-19. Positive dementia screen doubled (10% vs 20%) during COVID-19. Themes in decreasing order were family, health, home, functional independence, pets, discharge plan, religion, work, social activities and other pre-COVID-19. Family and health accounted for 49% of responses. During COVID-19, the order changed to health, family and home, functional independence, work and discharge planning, pets, religion and social activities. There was a 50% increase in functional independence as a response, a 40% increase in home and a 58% decrease in family as a response. Conclusion Cognitive vulnerability doubled during COVID-19. Nine themes were identified. WMTY themes shifted during COVID-19. Health become the most frequent response. Family became a less frequent response with less people living alone. Functional independence was more frequent reflecting the need for self-reliance during COVID-19. Home, where all COVID-19 life was lived, was expressed as WMTY by a greater number of respondents. Promotion of functional independence has been identified as a key driver for practice change.

Background The clinical frailty score (CFS) is a 9 point validated outcome measure used to measure function, mobility, cognition and co-morbidities in patients aged 65 or older. The physiotherapy department was restructured due to COVID-19 pandemic. This resulted in the formation of a mixed specialty team which consisted of Frailty Intervention Team (FIT), Medical Respiratory, Acute Medicine Service, Orthopaedics, General Rehabilitation and Care of the Older Person (COTOP). This service review aimed to identify frailty using the CFS across services and to compare CFS versus age, length of stay, falls history and discharge outcomes. Methods The CFS data was collected over two weeks. Inclusion criteria included patients who scored ≥4 on the CFS. Exclusion criteria included patients aged under 65. Variables such as age, history of falls, LOS and discharge destinations were compared across all services using Microsoft Excel. Results 166 patients were included, the average CFS was 5.24 and the average age was 77.2 years. COTOP had the oldest (Av. age 85.4), frailest (Av. CFS 6.1) and longest avLOS (25.3 days) across all services. Frailty was prevalent across all services, with 81% of patients on the medical respiratory service classed as frail. Patients who scored a CFS of ≥4 had higher falls risk and greater LOS. Of the medical respiratory cohort only 12% were discharged to rehabilitation with 77% discharged home. Orthopaedics had the highest percentage of patients discharged to rehabilitation (44%), followed by the general rehabilitation (34%). Only 14% of the COTOP patients were transferred to rehabilitation. Conclusion A high incidence of frailty and falls history was identified across all services. Patients who scored lower on the CFS resulted in reduced LOS and were more likely to be discharged directly home. Proactive screening and detection of frailty allows for targeted interventions that may improve outcomes and inform early discharge planning.

Aerobic exercise is a promising intervention to attenuate frailty, but preclinical studies have used only male animals. We investigated the impact of voluntary aerobic exercise on frailty, biological age (FRailty Inferred Geriatric Health Timeline [FRIGHT] clock), predicted life expectancy (Analysis of FRAIlty and Death [AFRAID] clock), and mortality in both sexes and determined whether exercise was associated with changes in inflammation. Older (21–23 months) male (n = 12) and female (n = 22) C57Bl/6 mice matched for baseline frailty scores were randomized into exercise (running wheel) and sedentary (no wheel) groups. Frailty index scores were measured biweekly (13 weeks), and 23 serum cytokines were measured at midpoint and end point. Exercise levels varied between mice but not between the sexes. Exercise had no effect on mortality, but it attenuated the development of frailty in both sexes (female = 0.32 ± 0.04 vs 0.21 ± 0.01; p = .005; male = 0.30 ± 0.02 vs 0.22 ± 0.02; p = .042) and reduced frailty in older females after 10 weeks. FRIGHT scores were unaffected by exercise but increased with time in sedentary males indicating increased biological age. Exercise prevented the age-associated decline in AFRAID scores in older females such that exercised females had a longer life expectancy. We investigated whether aerobic exercise was associated with changes in systemic inflammation. Cytokine levels were not affected by exercise in males, but levels of pro-inflammatory cytokines were positively correlated with the frequency of exercise in females. Despite increases in systemic inflammation, exercise reduced frailty and increased life span in older females. Thus, voluntary aerobic exercise, even late in life, has beneficial effects on health in both sexes but may be especially helpful in older females.

Background Older patients have a less pronounced immune response to infection, which may also influence infection biomarkers. There is currently insufficient data regarding clinical effects of procalcitonin (PCT) to guide antibiotic treatment in older patients. Objective and design We performed an individual patient data meta-analysis to investigate the association of age on effects of PCT-guided antibiotic stewardship regarding antibiotic use and outcome. Subjects and methods We had access to 9,421 individual infection patients from 28 randomized controlled trials comparing PCT-guided antibiotic therapy (intervention group) or standard care. We stratified patients according to age in four groups (85 years [n = 505]). The primary endpoint was the duration of antibiotic treatment and the secondary endpoints were 30-day mortality and length of stay. Results Compared to control patients, mean duration of antibiotic therapy in PCT-guided patients was significantly reduced by 24, 22, 26 and 24% in the four age groups corresponding to adjusted differences in antibiotic days of −1.99 (95% confidence interval [CI] −2.36 to −1.62), −1.98 (95% CI −2.94 to −1.02), −2.20 (95% CI −3.15 to −1.25) and − 2.10 (95% CI −3.29 to −0.91) with no differences among age groups. There was no increase in the risk for mortality in any of the age groups. Effects were similar in subgroups by infection type, blood culture result and clinical setting (P interaction >0.05). Conclusions This large individual patient data meta-analysis confirms that, similar to younger patients, PCT-guided antibiotic treatment in older patients is associated with significantly reduced antibiotic exposures and no increase in mortality.

Frailty syndrome is an age-related condition involving a loss of resilience, susceptibility to adverse health outcomes, and poor quality of life. This study was conducted in the framework of InveCe.Ab, an ongoing longitudinal population-based study. Plasma from 130 older individuals (older adults aged 76–78 years) was analyzed and validated (on 303 participants) using mass spectrometry-based metabolomics approaches. Equivalence tests showed that metabolites from the central cellular metabolic pathways were equivalent in frail and fit participants. Hippuric acid was the only cometabolite that distinguished fit from frail older adults. Logistic regression analysis indicated that high hippuric acid levels are significantly associated with a reduction of the risk of frailty after 4 years. Mediation analysis using a Frailty Index, hippuric acid, and fruit–vegetable intake supported the role of fruit–vegetable consumption in the hippuric acid relationship with the Frailty Index. These data point to low plasma hippuric acid as a plausible hallmark of frailty status, associated with lower fruit–vegetable intakes.

Background databases of electronic health records are powerful tools for dementia research, but data can be influenced by incomplete recording. We examined whether people with dementia recorded in a specialist database (from a mental health and dementia care service) differ from those recorded in primary care. Methods a retrospective cohort study of the population covered by Lambeth DataNet (primary care electronic records) between 2007 and 2019. Documentation of dementia diagnosis in primary care coded data and linked records in a specialist database (Clinical Records Interactive Search) were compared. Results 3,859 people had dementia documented in primary care codes and 4,266 in the specialist database, with 2,886/5,239 (55%) documented in both sources. Overall, 55% were labelled as having Alzheimer’s dementia and 29% were prescribed dementia medication, but these proportions were significantly higher in those documented in both sources. The cohort identified from the specialist database were less likely to live in a care home (prevalence ratio 0.73, 95% confidence interval 0.63–0.85), have multimorbidity (0.87, 0.77–0.98) or consult frequently (0.91, 0.88–0.95) than those identified through primary care codes, although mortality did not differ (0.98, 0.91–1.06). Discussion there is under-recording of dementia diagnoses in both primary care and specialist databases. This has implications for clinical care and for generalizability of research. Our results suggest that using a mental health database may under-represent those patients who have more frailty, reflecting differential referral to mental health services, and demonstrating how the patient pathways are an important consideration when undertaking database studies.

Introduction Multicomponent interventions improve physical function and frailty in older adults, but their long-term benefit remains uncertain. Methods This prospective non-randomised study was conducted in 383 older Koreans (mean age, 76.8 years; female 72.3%) who were living alone or receiving medical aid. Of these, 187 individuals chose to receive a 24-week intervention that consisted of group exercise, nutritional supplements, depression management, deprescribing and home hazard reduction. The remaining 196 individuals received usual care. We compared the short physical performance battery (SPPB) score (0–12 points), frailty phenotype scale (0–5 points) and deficit-accumulation frailty index (0–1) at baseline, 6, 18 and 30 months. Results After 1:1 propensity score matching (n = 117 per group), the mean SPPB scores for the intervention and comparison groups were 7.6 versus 7.6 at baseline, 10.7 versus 7.1 at 6 months (mean difference, 3.5; 95% confidence interval [CI], 2.8–4.2), 9.1 versus 7.8 at 18 months (1.3; 95% CI, 0.6–2.0) and 8.6 versus 7.5 at 30 months (1.1; 95% CI, 0.4–1.8). The intervention group had lower frailty phenotype scale (1.1 versus 1.8; difference, −0.7; 95% CI −1.0 to −0.3) and frailty index (0.22 versus 0.27; difference, −0.04; −0.06 to −0.02) at 6 months, but similar scores at 18 and 30 months. The 30-month mean institutionalisation-free survival time was 28.5 months in the intervention group versus 23.3 months in the comparison group (difference, 5.2 months; 95% CI, 3.1–7.4). Conclusions The 24-week multicomponent intervention showed sustained improvement in physical function, temporary reduction in frailty and longer institutionalisation-free survival over 30 months.

Background Care home (CH) residents are mainly inactive, leading to increased dependency and low mood. Strategies to improve activity are required. Design and setting Cluster randomised controlled feasibility trial with embedded process and health economic evaluations. Twelve residential CHs in Yorkshire, United Kingdom, were randomised to the MoveMore intervention plus usual care (UC) (n = 5) or UC only (n = 7). Participants Permanent residents aged ≥65 years. Intervention MoveMore: a whole home intervention involving all CH staff designed to encourage and support increase in movement of residents. Objectives and measurements Feasibility objectives relating to recruitment, intervention delivery, data collection and follow-up and safety concerns informed the feasibility of progression to a definitive trial. Data collection at baseline, 3, 6 and 9 months included: participants’ physical function and mobility, perceived health, mood, quality of life, cognitive impairment questionnaires; accelerometry; safety data; intervention implementation. Results 300 residents were screened; 153 were registered (62 MoveMore; 91 UC). Average cluster size: MoveMore: 12.4 CHs; UC: 13.0 CHs. There were no CH/resident withdrawals. Forty (26.1%) participants were unavailable for follow-up: 28 died (12 MoveMore; 16 UC); 12 moved from the CH. Staff informant/proxy data collection for participants was >80%; data collection from participants was Conclusions Recruiting CHs and residents was feasible. Intervention implementation and data collection methods need refinement before a definitive trial. There were no safety concerns.

Introduction Care homes have been severely affected by the SARS-CoV-2 pandemic. Rapid antigen testing could identify most SARS-CoV-2 infected staff and visitors before they enter homes. We explored implementation of staff and visitor testing protocols using lateral flow devices (LFDs). Methods An evaluation of a SARS-CoV-2 LFD-based testing protocol in 11 care homes in Liverpool, UK, including staff and visitor testing, plus a qualitative exploratory study in nine of these homes. The proportion of pilot homes with outbreaks, and outbreak size, were compared to non-pilot homes in Liverpool. Adherence to testing protocols was evaluated. Fifteen staff were interviewed, and transcript data were thematically coded using an iterative analysis to identify and categorize factors influencing testing implementation. Results In total, 1,638 LFD rapid tests were performed on 407 staff. Protocol adherence was poor with 8.6% of staff achieving >75% protocol adherence, and 25.3% achieving $\ge$50%. Six care homes had outbreaks during the study. Compared to non-pilot care homes, there was no evidence of significant difference in the proportion of homes with outbreaks, or the size of outbreaks. Qualitative data showed difficulty implementing testing strategies due to excessive work burden. Factors influencing adherence related to test integration and procedural factors, socio-economic factors, cognitive overload and the emotional value of testing. Conclusion Implementation of staff and visitor care home LFD testing protocols was poorly adhered to and consequently did not reduce the number or scale of COVID-19 outbreaks. More focus is needed on the contextual and behavioural factors that influence protocol adherence.

Background Cardiometabolic risk (CMR) is a key indicator of physiological decline with age, but age-related declines in a nationally representative older US population have not been previously examined. Methods We examined the trajectory of CMR over 8 years of aging, from 2006/2008 to 2014/2016, among 3528 people older than age 50 in the Health and Retirement Study. We used growth curve models to examine change in total CMR as well as in individual cardiometabolic biomarkers to understand how baseline differences and rates of change vary across sociodemographic characteristics, by smoking status, and medication use. Results Total CMR did not change among respondents who survived over 8 years. Despite significant differences in CMR across demographic and education groups at baseline, the pace of change with age did not differ by these characteristics. Among individual biomarkers, risk levels of diastolic blood pressure, resting heart rate, and total cholesterol decreased over 8 years while glycosylated hemoglobin, waist circumference, and pulse pressure increased over that time. Both the statistical significance levels and the magnitudes of the reduction over time with age in diastolic blood pressure, resting heart rate, and total cholesterol in models adjusted for age, race/ethnicity, gender, smoking, and education were reduced after controlling for blood pressure and cholesterol medication. Conclusions The relatively constant total CMR level over 8 years occurred because some indicators improved with age while some deteriorated in this period. Medication use contributed to the improvement in blood pressure, resting heart rate, and total cholesterol.

Introduction We studied the costs of formal and informal care in relation to Alzheimer’s disease (AD) progression. Methods 231 persons with AD with a family caregiver were followed up for 5 years. The Clinical Dementia Rating Scale—Sum of Boxes (CDR-SB) was used to measure AD progression. Health and social care unit costs were used for formal care costs. An opportunity cost method for lost leisure time was applied to analyse the cost of informal care. Results Total cost of care in early stage AD (CDR-SB ≤ 4) was 16,448€ (95% CI 13,722–19,716) annually. In mild (CDR-SB 4.5–9), moderate (CDR-SB 9.5–15.5) and severe (CDR-SB ≥ 16) AD, the total costs were 2.3, 3.4 and 4.4 times higher, respectively. A one-unit increase in CDR-SB increased the total, formal and informal costs by 15, 11 and 18%, respectively. Conclusions Compared to early AD, the costs of total, formal and informal care are remarkably higher already in mild AD. This finding emphasises early diagnosis, interventions and family support for persons with AD and their caregivers.

Background the aim of this study was to examine the cross-sectional and longitudinal associations of different multimorbidity patterns with physical frailty in older adults. Methods we used data from the Swedish National study on Aging and Care in Kungsholmen to generate a physical frailty measure, and clusters of participants with similar multimorbidity patterns were identified through fuzzy c-means cluster analyses. The cross-sectional association (n = 2,534) between multimorbidity clusters and physical frailty was measured through logistic regression analyses. Six- (n = 2,122) and 12-year (n = 2,140) longitudinal associations were determined through multinomial logistic regression analyses. Results six multimorbidity patterns were identified at baseline: psychiatric diseases; cardiovascular diseases, anaemia and dementia; sensory impairments and cancer; metabolic and sleep disorders; musculoskeletal, respiratory and gastrointestinal diseases; and an unspecific pattern lacking any overrepresented diseases. Cross-sectionally, each pattern was associated with physical frailty compared with the unspecific pattern. Over 6 years, the psychiatric diseases (relative risk ratio [RRR]: 3.04; 95% confidence intervals [CI]: 1.59–5.79); cardiovascular diseases, anaemia and dementia (RRR 2.25; 95% CI: 1.13–4.49) and metabolic and sleep disorders (RRR 1.99; 95% CI: 1.25–3.16) patterns were associated with incident physical frailty. The cardiovascular diseases, anaemia and dementia (RRR: 4.81; 95% CI: 1.59–14.60); psychiatric diseases (RRR 2.62; 95% CI: 1.45–4.72) and sensory impairments and cancer (RRR 1.87; 95% CI: 1.05–3.35) patterns were more associated with physical frailty, compared with the unspecific pattern, over 12 years. Conclusions we found that older adults with multimorbidity characterised by cardiovascular and neuropsychiatric disease patterns are most susceptible to developing physical frailty.

Background Individual conditions of metabolic syndrome (MetS) have been related to dementia; however, their combined impact on the preclinical stage is unknown. We investigated the associations between MetS and domain-specific cognitive function as well as the role of sociodemographic, cardiovascular, and genetic factors. Methods Within the Gothenburg H70 Birth Cohort Study-Birth cohort 1944, 1131 dementia-free participants (aged 70 years) were examined during 2014–2016. MetS (central obesity plus at least 2 factors [reduced HDL-cholesterol, elevated triglycerides, blood pressure, or blood glucose]) was identified according to the International Diabetes Federation criteria. Five cognitive domains (memory, attention/perceptual speed, executive function, verbal fluency, visuospatial abilities) were generated after z-standardizing raw scores from 10 neuropsychological tests. Education, heart disease, claudication (indicating peripheral atherosclerosis), and apolipoprotein genotype were ascertained by trained staff. Data were analyzed with linear regression models. Results Overall, 618 participants (55%) had MetS. In multiadjusted linear regressions, MetS was related to poorer performance in attention/perceptual speed (β −0.14 [95% CI −0.25, −0.02]), executive function (β −0.12 [95% CI −0.23, −0.01]), and verbal fluency (β −0.19 [95% CI −0.30, −0.08]). These associations were present only among individuals who did not carry any APOE-ε4 allele or were highly educated. However, among those with MetS, high education was related to better cognitive performance. MetS together with comorbid heart disease or claudication was associated with even worse cognitive performance than each alone. Conclusions MetS is associated with poor attention/perceptual speed, executive function, and verbal fluency performance. Education, apolipoprotein E-ε4 allele, and comorbid cardiovascular disease influenced the observed associations.

Background The aim of this study was to determine the relative and absolute reliabilities of 5 key performance-based measures of physical function in the Canadian Longitudinal Study on Aging (CLSA). Methods An age-stratified subsample of 147 participants from the CLSA who were undergoing their 3-year data collection visit participated in 2 repeat visits (within 1 week). Participants underwent tests of grip strength, 4-m gait speed, Timed Up and Go (TUG), chair rise, and single-leg stance (left, right, mean, maximum). Intraclass correlation coefficients (ICCs), standard error of measurement, and minimal detectable change (MDC) values were calculated. Results The relative reliability for grip strength was excellent (ICC = 0.95); the TUG and single-leg stance tests had good reliability (ICC = 0.80 or 0.78–0.82, respectively); gait speed and the chair-rise test had moderate reliability (ICC = 0.64 for both) for participants overall. For participants between 50 and 64 years, TUG and gait speed had poor reliabilities (ICC = 0.38 or 0.33, respectively). For participants aged 75 years and older, the single-leg stance had poor reliability (ICC = 0.30–0.39). The MDC90 was about 6 kg for grip strength, 2.3 seconds for TUG, 0.2 m/second for gait speed, 5.2 seconds for chair rise, and ranged from 22.8 to 26.2 seconds for the single-leg stance. Conclusions Among community-dwelling Canadians older than 50 years, the reliabilities of the CLSA measures were moderate to excellent. The TUG and gait speed in the youngest age group, and the single-leg stance in the oldest age group, showed poor reliability. MDC values can be used to interpret changes over time.

Background Eating and drinking problems are common among people living with later-stage dementia, yet few studies have explored their perspectives. Objective This study aimed to explore how people living with mild dementia understand possible future eating and drinking problems and their perspectives on assistance. Design Qualitative study using semi-structured interviews. Setting Community. Methods We conducted semi-structured interviews with 19 people living with mild dementia. Interviews were transcribed verbatim and analysed thematically. Results Five themes were identified: (i) awareness of eating and drinking problems; (ii) food and drink representing an individual’s identity and agency; (iii) delegating later decisions about eating and drinking to family carers; (iv) acceptability of eating and drinking options; and (v) eating and drinking towards the end of life. For people living with mild dementia, possible later eating and drinking problems could feel irrelevant and action may be postponed until they occur. Fears of being a burden to family and of being treated like a child may explain reluctance to discuss such future problems. People living with mild dementia might wish to preserve their agency and maintain good quality of life, rather than be kept alive at later stages by artificial nutrition and hydration. Conclusion For people with mild dementia, eating and drinking problems may seem unrelated to them and so get left undiscussed. Negative connotations regarding eating and drinking problems may hinder the discussion. The optimal time to discuss possible future problems with eating and drinking with people with mild dementia may need an individual approach.

Background Additional payment approach has been one of the most important incentives in long-term care (LTC) systems for the past 20 years in Japan. Objective To estimate the effect of additional payments on functional decline in long-term care health facility (LTCHF) residents of Japan. Design A 24-month retrospective cohort study. Setting and subjects Residents aged ≥65 years who were newly admitted to LTCHFs in the 2014 fiscal year. Methods National LTC claims data were linked to the survey of institutions and establishments for LTC. Competing risk regression was performed with functional decline as the primary outcome, and additional payments as exposure, controlling for individual and facility characteristics. The level of LTC needs certified in the LTC insurance system was applied as a proxy of functional ability. Death, hospitalisation, discharge to home and transfer to other LTC facilities were treated as competing events. Individual- and facility-level additional payments were presented as binary variables: being reimbursed or not during the follow-up period. Results At baseline, 146,311 residents from 3,724 LTCHFs were included. The vast majority of additional payments were associated with a lower risk of functional decline at follow-up. At the individual level, additional payment for pre/post admission instructions had the strongest association with a lower risk of functional decline. Despite this, only 8% of residents were reimbursed for this additional payment. At the facility level, residents in LTCHFs with additional payments for support for home-life resumption and nutritional management were associated with a decreased risk of functional decline. Conclusions The results of our study may be of particular interest to policymakers in monitoring and evaluating additional payment approaches and provide insight into improving quality of care.

Objective to investigate whether the combination of dynapenia and abdominal obesity is worse than these two conditions separately regarding gait speed decline over time. Methods a longitudinal study was conducted involving 2,294 individuals aged 60 years or older free of mobility limitation at baseline (gait speed >0.8 m/s) who participated in the English Longitudinal Study of Ageing. Dynapenia was determined as a grip strength 102 cm for men and >88 cm for women. The participants were divided into four groups: non-dynapenic/non-abdominal obese (ND/NAO); only abdominal obese (AO); only dynapenic (D) and dynapenic/abdominal obese (D/AO). Generalised linear mixed models were used to analyse gait speed decline (m/s) as a function of dynapenia and abdominal obesity status over an 8-year follow-up period. Results over time, only the D/AO individuals had a greater gait speed decline (−0.013 m/s per year, 95% CI: −0.024 to −0.002; P Conclusion dynapenic abdominal obesity is associated with accelerated gait speed decline and is, therefore, an important modifiable condition that should be addressed in clinical practice through aerobic and strength training for the prevention of physical disability in older adults.

Background The Ambient Intelligent Geriatric Management (AmbIGeM) system augments best practice and involves a novel wearable sensor (accelerometer and gyroscope) worn by patients where the data captured by the sensor are interpreted by algorithms to trigger alerts on clinician handheld mobile devices when risk movements are detected. Methods A 3-cluster stepped-wedge pragmatic trial investigating the effect on the primary outcome of falls rate and secondary outcome of injurious fall and proportion of fallers. Three wards across 2 states were included. Patients aged ≥65 years were eligible. Patients requiring palliative care were excluded. The trial was registered with the Australia and New Zealand Clinical Trials registry, number 12617000981325. Results A total of 4924 older patients were admitted to the study wards with 1076 excluded and 3240 (1995 control, 1245 intervention) enrolled. The median proportion of study duration with valid readings per patient was 49% ((interquartile range [IQR] 25%-67%)). There was no significant difference between intervention and control relating to the falls rate (adjusted rate ratio = 1.41, 95% confidence interval [0.85, 2.34]; p = .192), proportion of fallers (odds ratio = 1.54, 95% confidence interval [0.91, 2.61]; p = .105), and injurious falls rate (adjusted rate ratio = 0.90, 95% confidence interval [0.38, 2.14]; p = .807). In a post hoc analysis, falls and injurious falls rate were reduced in the Geriatric Evaluation and Management Unit wards when the intervention period was compared to the control period. Conclusions The AmbIGeM system did not reduce the rate of falls, rate of injurious falls, or proportion of fallers. There remains a case for further exploration and refinement of this technology given the post hoc analysis findings with the Geriatric Evaluation and Management Unit wards. Clinical Trials Registration Number: 12617000981325

Introduction The COVID-19 pandemic has had an extensive impact on the frail older population, with significant rates of COVID-related hospital admissions and deaths amongst this vulnerable group. There is little evidence of frailty prevalence amongst patients hospitalised with COVID-19, nor the impact of frailty on their survival. Methods Prospective observational study of all consecutive patients admitted to Salford Royal NHS Foundation (SRFT) Trust between 27th February and 28th April 2020 (wave 1), and 1st October to 10th November 2020 (wave 2) with a diagnosis of COVID-19. The primary endpoint was in-hospital mortality. Patient demographics, co-morbidities, admission level disease severity (estimated with CRP) and frailty (using the Clinical Frailty Scale, score 1–3 = not frail, score 4–9 = frail) were collected. A Cox proportional hazards regression model was used to assess the time to mortality. Results A total of 693 (N = 429, wave 1; N = 264, wave 2) patients were included, 279 (N = 180, 42%, wave 1; N = 104, 38%, wave 2) were female, and the median age was 72 in wave 1 and 73 in wave 2. 318 (N = 212, 49%, wave 1; N = 106, 39%, wave 2) patients presenting were frail. There was a reduction in mortality in wave 2, adjusted Hazard ratio (aHR) = 0.60 (95%CI 0.44–0.81; p = 0.001). There was an association between frailty and mortality aHR = 1.57 (95%CI 1.09–2.26; p = 0.015). Conclusion Frailty is highly prevalent amongst patients of all ages admitted to SRFT with COVID-19. Higher scores of frailty are associated with increased mortality.

Introduction The COVID-19 pandemic has brought the decision-making process regarding cardiopulmonary resuscitation into focus. This study aims to analyse Do-Not-Attempt CPR (DNACPR) documentation in older hospitalised patients before and during the COVID-19 pandemic. Methods This was a retrospective repeated cross-sectional study. Data including co-morbidities and resuscitation status was collected on 300 patients with COVID-19 hospitalised from March 1st to May 31 s t 2020. DNACPR documentation rates in patients aged ≥65 years with a diagnosis of COVID-19 were compared to those without COVID-19 admitted during the same period. Pre-COVID-19 pandemic DNACPR documentation rates were also examined. Factors associated with DNACPR order instatement during the first wave of the COVID-19 pandemic were identified. Results Of 300 COVID-19-positive patients, 28% had a DNACPR order documented during their admission. 50% of DNAR orders were recorded within 24 hours of a positive swab result for SARS-CoV-2. Of 131 patients aged 65 years or over within the cohort admitted with COVID-19, 60.3% had a DNACPR order compared to 25.4% of 130 patients ≥65 without COVID-19 (p Conclusion The COVID-19 pandemic has prompted more widespread and earlier decision-making regarding resuscitation status. Although case-fatality-rates were higher for older hospitalised patients with COVID-19, many older patients survived the illness. Advance care planning should be prioritised in all patients and should remain clinical practice despite the pandemic.

Introduction NICE guidance recommends that during the COVID-19 pandemic all adults are assessed for frailty, suitability for resuscitation and escalation to critical care on admission to hospital. Risks, benefits and likely outcomes should be discussed with patients/relatives. Aim To investigate impact of intervention on treatment escalation plan (TEP) use during the first wave (W1) and second wave (W2) of pandemic. Intervention W1: An ethically approved TEP and a Critical Care Decision Aid (CCDA) was added to the admission booklet. W2: The TEP update included a ‘confirm discussed with patient/relatives’ section. Method W1: We conducted retrospective review of 62 case-notes of patients admitted through COVID-19 pathway and grouped into >80 and ≤ 80 years old. Resuscitation, TEP, CCDA and communication with patient/relatives were collected. W2: 60 further case-notes of patients with COVID-19 admitted in January 2021 were analysed. Results W1: 100% patients had resuscitation decisions and 95% had TEPs in both groups. Significantly higher proportions of Frailty scores were calculated in >80s (58% vs 35% p = 0.04). On average resuscitation and TEPs were made within 13.8 hours of admission (range 1–72 hours). 53.2% of resuscitation decisions and 30% TEPs were discussed with patients of whom higher proportions were discussed in younger age group, majority were discussed at the time of deterioration. W2: 98.3% patients had resuscitation decisions made and 96.7% had TEPs across both groups. On average resuscitation decisions were made within 14.9 hours of admission. In the >80s, 86.7% of resuscitation decisions were discussed and 63.3% of the TEPs were discussed with patient/relatives. In the Conclusion We significantly improved Treatment Escalation planning during W1 and W2 of pandemic by introducing the TEP in W1 and adding prompt to improve communication with patients/relatives in W2 (p = 0.02).

Introduction In Wessex Deanery, prior to the COVID-19 pandemic, Geriatric Medicine trainees from 10 NHS trusts attended face-to-face regional teaching sessions. In response to the pandemic, this teaching was suspended to reduce disruption in service provision and support social distancing. There was a clear need to reintroduce teaching for continued professional development and trainee progression. Methods In July 2020, Geriatric Medicine trainees in Wessex completed a questionnaire survey to identify their desire for socially distanced teaching and an acceptable format for delivery. Two half-day pilot teaching sessions via MS Teams were organised in September and October 2020. Trainees provided feedback via a questionnaire survey about the relevance and quality of teaching, and to identify any barriers to attendance. Subsequently, a monthly full-day virtual teaching programme was implemented. We reported reflections of our experiences on our trainee website to support future sessions. Results All trainees (n = 15) were eager for regional teaching to recommence through socially distanced education. Trainees had a preference for MS Teams, which can support interactive teaching. Attendance to the pilot sessions exceeded previous face-to-face sessions. 19 trainees attended the first session; 17 provided feedback. 28 trainees attended the second session; 12 provided feedback. Feedback was overwhelmingly positive; all reported the sessions were interesting and 82% (n = 14) that they would lead to changes in their practice. Some trainees expressed that full-day sessions would enhance curriculum coverage. 94% (n = 16) were positive of the virtual platform; it reduced travel and sessions could be recorded. Local trainees attended the second session in-person, which enhanced interactivity. Conclusion Virtual teaching has been successful in Wessex Deanery, with high attendance and positive feedback. Trainees can engage remotely without the need for travel and disruption. After the pandemic we hope to develop a regional teaching programme integrating virtual and face-to-face sessions to improve attendance and accessibility.

Introduction Higher incidence of COVID-19 and poorer outcomes have been shown to be associated with age, frailty and comorbidity. Older people have more risk of severe COVID 19; hospitalization, ITU admission, ventilation and mortality. Aim To assess the correlation between age, frailty and comorbidity in COVID-19 inpatients 65 years and older. Methods A retrospective, cross-sectional analysis was carried out on COVID 19 inpatients 65 and older in a UK district general hospital. Patients with no microbiological evidence of COVID-19 and patients with incomplete data were excluded from the study. Demographic data, frailty score and comorbidity index were extracted from the electronic records of patients. SPSS 27 statistical software was used to perform descriptive analysis and linear regression coefficient. Results 357 COVID-19 patients 65 and over were assessed; 207 males and 150 females. Mean age was 81.9 +/− 9.31. Frailty scores were measured using the Rockwood Clinical Frailty Scale (CFS) and comorbidity was calculated using the Charlson Comorbidity Index (CCI). There was positive correlation between age and Clinical Frailty Scale (r=. 436; p Conclusion In COVID-19 inpatients 65 and older, there was positive correlation between age and Clinical Frailty Scale, between age and Charlson Comorbidity Index and between frailty and comorbidity. More studies are needed to explore the interaction between age, frailty and comorbidity and COVID 19 morbidity and mortality.

Introduction COVID-19 has had a devastating effect on care homes, increasing both morbidity and mortality of residents and staff. Between 2 March and 12 June 2020, COVID-19 was the main cause of death in male care home residents (33.5%) and second for female (26.6%).1 By 1 May 2020, the death rate from all causes in care homes exceeded that in hospital (6,409 versus 6,397).2 Thus, care homes had to rapidly adapt to facilitate safe care of patients and staff. Method An expert outreach team visited a number of care homes in Surrey and Sussex to explore COVID-19 issues in care homes. Key themes were identified that informed topics for the Virtual Care Home Forum, where a series of virtual teaching, training and peer support sessions were hosted either live or on-demand, accessible for all care home staff. Results 12 sessions were held with an average attendance of 25 people, predominantly care home managers and community healthcare professionals. Real time qualitative feedback was collected and an electronic survey was completed at the end of the series which showed 100% felt the sessions had improved their understanding of the topic, 100% felt the knowledge and skills obtained from the sessions would be useful in their job, 87.5% agreed the sessions would impact or change their practise and 100% felt more supported during the pandemic. Conclusion It has been an unprecedented year for the NHS, and the care home sector has suffered significantly. In order to provide the best level of care for patients and support for our community colleagues, we must work collaboratively, including provision of education and training. To ensure equal access for all, maintaining user-safety and compliance with government legislation, virtual webinars proved to be an excellent modality. We plan to continue providing training, teaching and support through this means in the future.

Introduction By 2021 over one million people will be living with dementia (1) costing the government an estimated £30bn a year (2). However, cognitive decline is often misdiagnosed or missed completely in hospital admissions, resulting in delays in detection and treatment for patients. Quick and simple screening tools such as the Abbreviated Mental Test Score (AMTS) could help provide early detection and faster treatment times for such patients. Data from Queen Elizabeth Hospital Kings Lynn showed that only 56.8% of patients over the age of 75 were being assessed for cognitive function on admission, while the national targets are set at 90%. Methods A multi-cycle, trust wide, quality improvement project was used to improve screening outcomes for dementia in QEHKL. A baseline measure of screening was taken by QEHKL coding department. Five PDSA (Plan Do Study Act) cycles were undertaken, implementing interventions to aid screening at each stage. Examples include improved medical clerking booklets, trust wide education and allocated ward ‘Dementia Champions’. Performance was assessed by auditors, through patient notes and discharge letters. Results Over a 4-month period, 432 patient notes were inspected on six medical wards. Results after interventions showed a significant rise in Dementia Screening from 58.7% to 89.8%. AMTS completion was 70.7% in September 2020 on medical wards which improved to 85.7% in November 2020. Results were collected during the COVID-19 pandemic however, COVID wards were excluded. Conclusion The QI project has highlighted that education and accessible tools can improve cognitive screening numbers. An important note is, due to increased pressures during the COVID pandemic it is plausible that screening rates were adversely affected. Despite this, our figures still show positive improvement. The next cycle of our project includes surgical wards and we expect by the time of presentation to have this data to show.

Background the Geriatric Perioperative Care clinic at North Bristol NHS Trust was suspended in March 2020 during the COVID-19 pandemic. A virtual clinic was piloted to deliver preoperative health optimisation and shared decision-making for patients undergoing critical elective surgery. No literature existed on virtual preoperative clinics for older people to support the development. Objective this healthcare improvement study describes the setup and delivery of the virtual clinic as its primary aim. Secondary aims included: assessing older people’s access to technology and their digital literacy for virtual consultation; to describe barriers and facilitators for consultations, as well as evaluation of patient and clinician satisfaction with the consultations' mode of delivery and outcomes. Methods a mixed methods healthcare improvement study was undertaken through plan-do-study-act cycles, semi-structure interviews, and quantitative service benchmarking. Results the pilot evaluated 67 preoperative consultations (43.3% video, 56.7% telephone, mean age 75) with a mix of surgical pathology (vascular 88.1%, colorectal 10.4%, urological 1.5%). Patient feedback demonstrated improved understanding of conditions (90.6%), and adequate opportunity to express opinions and questions (96.2%). Clinicians preferred video consultations (adequate to deliver services: 89.7% video; 68.4% telephone). The greatest barriers to engagement, none of which were exclusions to participation, included cognitive impairment, sensory impairment, or needing technical assistance setting up video consultations (52.2%). Conclusions delivering a virtual preoperative medical optimisation and shared decision clinic for older people is feasible. This study will aid other units in developing their own virtual preoperative clinics. Future work should evaluate perioperative outcomes of delivering a face-to-face versus virtual clinic.

ImportanceNursing home (NH) residents are particularly vulnerable to SARS-CoV-2 infections and coronavirus disease 2019 (COVID-19) lethality. However, excess deaths in this population have rarely been documented.ObjectivesThe primary objective was to assess the number of excess deaths among NH residents during the first wave of the COVID-19 pandemic in France. The secondary objectives were to determine the number of excess deaths as a proportion of the total excess deaths in the general population and determine whether a harvesting effect was present.DesignWe studied a cohort of 494,753 adults (as of March 1st, 2020) aged 60 and over in 6,515 NHs in mainland France. This cohort was exposed to the first wave of the COVID-19 pandemic (from March 1st to May 31st, 2020) and was compared with the corresponding, reference cohorts from 2014 to 2019 (using data from the French National Health Data System).Main outcome and measuresThe main outcome was all-cause death. Weekly excess deaths and standardized mortality ratios (SMRs) were estimated.ResultThere were 13,505 excess deaths among NH residents. Mortality increased by 43% (SMR: 1.43). The mortality excess was higher among males than among females (SMR: 1.51 and 1.38, respectively) and decreased with age (SMRs in females: 1.61 in the 60-74 age group, 1.58 for 75-84, 1.41 for 85-94, and 1.31 for 95 or over; Males: SMRs: 1.59 for 60-74, 1.69 for 75-84, 1.47 for 85-94, and 1.41 for 95 or over). We did not observe a harvesting effect (up until August 30th, 2020). By extrapolating to all NH residents nationally (N=570,003), the latter accounted for 51% of the total excess deaths in the general population (N=15,114 out of 29,563).ConclusionNH residents accounted for about half of the total excess deaths in France during the first wave of the COVID-19 pandemic. The excess death rate was higher among males than females and among younger residents than among older residents. We did not observe a harvesting effect. A real-time mortality surveillance system and the identification of individual and environmental risk factors might help to design the future model of care for older dependent adults.Key pointsDuring the first wave of the COVID-19 pandemic in France, the mortality among nursing home residents increased by 43%.Nursing home residents accounted for 51% of the total excess deaths in France.The excess mortality was higher among younger residents than among older residents.The excess mortality was higher among males than among females.We did not observe a harvesting effect during the study period (ending on August 30th, 2020, i.e., three months after the end of the first wave).

Background Nursing homes for older adults have concentrated large numbers of severe cases and deaths for coronavirus disease 2019 (COVID-19). Methods Point seroprevalence study of nursing homes to describe the demography and characteristic of severe acute respiratory syndrome by coronavirus 2 (SARS-CoV-2) immunoglobulin G (IgG)-positive residents and staff. Results Clinical information and blood samples were available for 9,332 residents (mean age 86.7 ± 8.1 years, 76.4% women) and 10,614 staff (mean age 45.6 ± 11.5, 86.2% women). Up to 84.4% of residents had frailty, 84.9% co-morbidity and 69.3% cognitive impairment; 65.2% of workers were health-aides. COVID-19 seroprevalence was 55.4% (95% confidence interval (CI), 54.4–56.4) for older adults and 31.5% (30.6–32.4) for staff. In multivariable analysis, frailty of residents was related with seropositivity (odds ratio (OR): 1.19, P = 0.02). In the case of staff, age > 50 years (2.10, P Conclusions Level of dependency influences risk of COVID-19 among residents. Individual and work factors, contacts outside the nursing home are associated with COVID-19 exposure in staff members. It is key to strengthen control measures to prevent the introduction of COVID-19 into care facilities from the community.

Background Frailty is associated with reduced quality of life, poor health outcomes, and death. Past studies have investigated how specific biomarkers are associated with frailty but understanding biomarkers in concert with each other and the associated risk of frailty is critical for clinical application. Methods Using a sample aged ≥59 years at baseline from the Swedish AMORIS (Apolipoprotein MOrtality RISk) cohort (n = 19 341), with biomarkers measured at baseline (1985–1996), we conducted latent class analysis with 18 biomarkers and used Cox models to determine the association between class and frailty and all-cause mortality. Results Four classes were identified. Compared to the largest class, the Reference class (81.7%), all other classes were associated with increased risk of both frailty and mortality. The Anemia class (5.8%), characterized by comparatively lower iron markers and higher inflammatory markers, had hazard ratio (HR) = 1.54, 95% confidence interval (CI) 1.38, 1.73 for frailty and HR = 1.76, 95% CI 1.65, 1.87 for mortality. The Diabetes class (6.5%) was characterized by higher glucose and fructosamine, and had HR = 1.59, 95% CI 1.43, 1.77 for frailty and HR = 1.74, 95% CI 1.64, 1.85 for mortality. Finally, the Liver class (6.0%), characterized by higher liver enzyme levels, had HR = 1.15, 95% CI 1.01, 1.30 for frailty and HR = 1.40, 95% CI 1.31, 1.50 for mortality. Sex-stratified analyses did not show any substantial differences between men and women. Conclusions Distinct sets of commonly available biomarkers were associated with development of frailty and monitoring these biomarkers in patients may allow for earlier detection and possible prevention of frailty, with the potential for improved quality of life.

IntroductionCOVID-19 deaths are commoner among care-home residents, but the mortality burden has not been quantified.MethodsCare-home residency was identified via a national primary care registration database linked to national mortality data. Life expectancy was estimated using Makeham-Gompertz models, to (i) describe yearly life expectancy from Nov 2015 to Oct 2020 (ii) compare life expectancy (during 2016-2018) between care-home residents and the wider Scottish population and (iii) apply care-home life expectancy estimates to COVID-19 death counts to estimate years of life lost (YLL).ResultsAmong care-home residents, life expectancy in 2015/16 to 2019/20 ranged from 2.7 to 2.3 years for women and 2.3 to 1.8 years for men. Life expectancy was lowest in 2019/20. Age-sex specific life expectancy in 2016-2018 in care-home residents was lower than in the Scottish population (10 and 2.5 years in those aged 70 and 90 respectively). Rather than using national life tables, applying care-home specific life expectancies to COVID-19 deaths yields, mean YLLs for care-home residents were 2.6 and 2.2 for women and men respectively, with total care-home resident YLLs of 3,560 years in women and 2,046 years in men. In people aged over-70, approximately half of deaths and a quarter of YLL attributed to COVID-19 were accounted for by the 5% of over-70s who were care-home residents.ConclusionPrioritising care-home residents for vaccination is justified not only in terms of total deaths, but also in terms of years of life lost.Research in contextEvidence before this studyWe searched PubMed to 1st December 2020, with the terms (“nursing home” OR “care-home” OR “long-term care” OR “residential care”) AND (“mortality” OR “life expectancy” OR “length of stay”). We also searched for studies specific to the impact of the COVID-19 pandemic on those living in care-homes. We restricted our search to publications in English. Usual care-home life expectancy, in a UK context, has not previously been defined. One systematic review of length of stay was identified, which found significant heterogeneity in factors and associations. The impact of COVID-19 on excess mortality among care-home residents was noted, but the impact on life expectancy was not reported. Studies evaluating life expectancy among older people in the COVID-19 pandemic have not taken account of residency in their estimates.Added value of this studyUsing Scottish national representative linked data we describe the usual life expectancy of older adults (aged ≥70 years) living in care-homes, compared to older people living elsewhere. Deaths among care-home residents account for a considerable proportion of all mortality in older adults, around 19% for men and 30% for women. Life expectancy in care-home residents during the pandemic fell by almost 6 months, from 2.7 to 2.3 years in men and 2.1 to 1.8 years in women. In total, over 5,600 Years of Life were Lost (YLL) by care-home residents in Scotland who died with COVID-19. Around half of COVID-19 deaths and a quarter of YLL in those aged 70 years and over occurred among care-home residents. During the COVID-19 pandemic a smaller proportion of deaths among care-home residents occurred in hospitals.Implications of all the available evidencePrioritising the 5% of older adults who are care-home residents for vaccination against COVID-19 is justified both in terms of total deaths and total years of life lost. Individual and societal planning for care needs in older age relies on understanding usual care-home life expectancy and patterns of mortality. Understanding life expectancy may help clinicians, residents and their families make decisions about their health care, facilitating more informed discussions around their priorities and wishes. Population-wide estimates of YLL and burden of disease should take account of residency status, given the significant differences between life expectancy of those living in care-homes from their peers in other settings.

The need to improve care for people living with dementia in the hospital setting has long been recognised. Person-centred care has the potential to improve the experience of care for persons living with dementia and their carers, and has been shown to improve the experiences of hospital staff caring for the persons living with dementia, however it remains challenging to deliver in a time- and task-focussed acute care setting. This commentary suggests that to embed person-centred care across the hospital environment, cultural changes are needed at organisational and ward levels. In particular there needs to be: leadership that supports and advocates for workforce capacity to recognise and meet both psychological and physical needs of people living with dementia, promotion of physical environments that support familiarisation and social interactions, an inclusive approach to carers and the development of a culture of sharing knowledge and information across hierarchies and roles. An evidence-based set of pointers for service change are described which highlight institutional and environmental practices and processes that need to be addressed in order for person-centred care to become part of routine care.

IntroductionReliable rapid testing on COVID-19 is needed in care homes to reduce the risk of outbreaks and enable timely care. Point-of-care testing (POCT) in care homes could provide rapid actionable results. This study aimed to examine the usability and test performance of point of care polymerase chain reaction (PCR) for COVID-19 in care homes.MethodsPoint-of-care PCR for detection of SARS-COV2 was evaluated in a purposeful sample of four UK care homes. Test agreement with laboratory real-time PCR and usability and use errors were assessed.ResultsPoint of care and laboratory polymerase chain reaction (PCR) tests were performed on 278 participants. The point of care and laboratory tests returned uncertain results or errors for 17 and 5 specimens respectively. Agreement analysis was conducted on 256 specimens. 175 were from staff: 162 asymptomatic; 13 symptomatic. 69 were from residents: 59 asymptomatic; 10 symptomatic. Asymptomatic specimens showed 83.3% (95% CI: 35.9%-99.6%) positive agreement and 98.7% negative agreement (95% CI: 96.2%-99.7%), with overall prevalence and bias-adjusted kappa (PABAK) of 0.965 (95% CI: 0.932 – 0.999). Symptomatic specimens showed 100% (95% CI: 2.5%-100%) positive agreement and 100% negative agreement (95% CI: 85.8%-100%), with overall PABAK of 1. No usability-related hazards emerged from this exploratory study.ConclusionApplications of point-of-care PCR testing in care homes can be considered with appropriate preparatory steps and safeguards. Agreement between POCT and laboratory PCR was good. Further diagnostic accuracy evaluations and in-service evaluation studies should be conducted, if the test is to be implemented more widely, to build greater certainty on this initial exploratory analysis.Key pointsPoint of care tests (POCT) in care homes are feasible and could increase testing capacity for the control of COVID-19 infection.The test of agreement between POCT and laboratory PCR for care home residents and the staff was good.Adoption of POCT in care homes can be considered with appropriate preparatory steps and safeguards in place.Repetitive errors and test malfunctioning can be mitigated with bespoke training for care home staff.Integrated care pathways should be investigated to test the high variability of the context of use.

Background Generalised anxiety disorder (GAD) is the most common anxiety disorder in older people. First-line management includes pharmacological and psychological therapies, but many do not find these effective or acceptable. Little is known about how to manage treatment-resistant generalised anxiety disorder (TR-GAD) in older people. Objectives To examine the acceptability, feasibility and preliminary estimates of the effectiveness of acceptance and commitment therapy (ACT) for older people with TR-GAD. Participants People aged ≥65 years with TR-GAD (defined as not responding to GAD treatment, tolerate it or refused treatment) recruited from primary and secondary care services and the community. Intervention Participants received up to 16 one-to-one sessions of ACT, developed specifically for older people with TR-GAD, in addition to usual care. Measurements Co-primary outcomes were feasibility (defined as recruitment of ≥32 participants and retention of ≥60% at follow-up) and acceptability (defined as participants attending ≥10 sessions and scoring ≥21/30 on the satisfaction with therapy subscale). Secondary outcomes included measures of anxiety, worry, depression and psychological flexibility (assessed at 0 and 20 weeks). Results Thirty-seven participants were recruited, 30 (81%) were retained and 26 (70%) attended ≥10 sessions. A total of 18/30 (60%) participants scored ≥21/30 on the satisfaction with therapy subscale. There was preliminary evidence suggesting that ACT may improve anxiety, depression and psychological flexibility. Conclusions There was evidence of good feasibility and acceptability, although satisfaction with therapy scores suggested that further refinement of the intervention may be necessary. Results indicate that a larger-scale randomised controlled trial of ACT for TR-GAD is feasible and warranted.

Objectives to compare care staff proxies with care home residents’ self-assessment of their health-related quality of life (HRQoL). Methods we assessed the degree of inter-rater reliability between residents and care staff proxies for the EQ-5D-5L index, domains and EQ Visual Analogue Scale at baseline, 3 months and 6 months, collected as part of the PATCH trial. We calculated kappa scores. Interpreted as 0.6 substantial to almost perfect agreement. Qualitative interviews with care staff and researchers explored the challenges of completing these questions. Results over 50% of the HRQoL data from residents was missing at baseline compared with a 100% completion rate by care staff proxies. A fair-to-moderate level of agreement was found for the EQ-5D-5L index. A higher level of agreement was achieved for the EQ-5D-5L domains of mobility and pain. Resident ‘non-completers’ were more likely to: be older, have stayed a longer duration in the care home, have lower Barthel Index and Physical Activity and Mobility in Residential Care (PAM-RC) scores, a greater number of co-morbidities and have joined the trial through consultee agreement. Interviews with staff and researchers indicated that it was easier to rate residents’ mobility levels than other domains, but in general it was difficult to obtain data from residents or to make an accurate proxy judgement for those with dementia. Conclusions whilst assessing HRQoL by care staff proxy completion provides a more complete dataset, uncertainty remains as to how representative these values are for different groups of residents within care homes.

Background The impact of sarcopenia on clinical outcomes of coronavirus disease 2019 (COVID-19) is not clearly determined yet. We aimed to investigate the association between baseline sarcopenia and clinical outcomes in patients with COVID-19. Methods All hospitalized adult patients with COVID-19 who had baseline chest computed tomography (CT) scans at a Korean university hospital from February 2020 to May 2020 were included. The main outcome was time from hospital admission to discharge. Death was considered as a competing risk for discharge. Baseline skeletal muscle cross-sectional area at the level of the 12th thoracic vertebra was measured from chest CT scans. The lowest quartile of skeletal muscle index (skeletal muscle cross-sectional area divided by height-squared) was defined as sarcopenia. Results Of 121 patients (median age, 62 years; 44 men; 29 sarcopenic), 7 patients died and 86 patients were discharged during the 60-day follow-up. Patients with sarcopenia showed a longer time to discharge (median, 55 vs 28 days; p < .001) and a higher incidence of death (17.2% vs 2.2%; p = .004) than those without sarcopenia. Baseline sarcopenia was an independent predictor of delayed hospital discharge (adjusted hazard ratio [aHR], 0.47; 95% confidence interval [95% CI], 0.23–0.96), but was not independently associated with mortality in patients with COVID-19 (aHR, 3.80; 95% CI, 0.48–30.26). The association between baseline sarcopenia and delayed hospital discharge was consistent in subgroups stratified by age, sex, comorbidities, and severity of COVID-19. Conclusions Baseline sarcopenia was independently associated with a prolonged hospital stay in patients with COVID-19. Sarcopenia could be a prognostic marker in COVID-19.