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The World Health Organization (WHO) advocates investment in high-quality undergraduate education in geriatric medicine as a means of meeting the future needs of the aging population. However, there is a lack of evidence for the optimal delivery of training in this area. Rigorous pedagogical research is required to determine the most effective way to equip tomorrow’s doctors with the skills and knowledge to care for older adults with complex health and social care needs. The transition between two undergraduate medical curricula meant that Bristol Medical School (BMS) was uniquely positioned to innovate and evaluate undergraduate education in geriatric medicine. This transition marked BMS’ departure from a ‘traditional’ curriculum to case-based learning. The outgoing curriculum included a 4-week unit in geriatrics, whilst the new programme includes an 18-week clerkship titled ‘Complex Medicine in Older People’ (CMOP). CMOP is a clinical clerkship with 18 cases at its core, covering the fundamental aspects of geriatric medicine. The core cases and clinical learning are enhanced with five expert lectures, six tutorials and three journal clubs. Reflective practice is modelled and promoted with Balint groups and a book club. Consolidative workplace-based assessments and clinical portfolio mirror those used in postgraduate training, preparing students for professional practice. CMOP is iteratively improved in real-time using staff and student feedback. This marked shift in mode and duration of teaching affords the opportunity to evaluate the impact of differing education in geriatrics, providing an evidence-based model for teaching on aging.

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ContextNeurological disease can affect the rate of urine production and bladder storage function, increasing nocturia severity, with additional risks if mobility or cognition is impaired.ObjectiveTo conduct a systematic review (SR) of nocturia in neurological diseases and achieve expert consensus for management in clinics without neurologist input.Evidence acquisitionFour databases were searched from January 2000 to April 2020. A total of 6262 titles and abstracts were screened and 43 studies were included for full-text screening. Eleven of these met the inclusion criteria and two studies were identified through other sources. The nominal group technique (NGT) was used to develop consensus in panel comprising experts and public representation.Evidence synthesisThirteen studies (seven in Parkinson’s disease, five in multiple sclerosis) were included, all undertaken in secondary care. Neurological disease severity was incompletely described, and nocturia severity was generally measured subjectively. NGT consensus supported basic neurological assessment, and the use of bladder diaries where neurological impairment permits. Treatments include pelvic-floor muscle training, review of medications, risk mitigation, improving bowel function, therapy for overactive bladder syndrome (if urgency is reported in association with nocturia episodes), treatment of postvoid residual and desmopressin according to licence. Measures to improve mobility and mitigate risk when using the toilet overnight should be considered. Multifactorial issues such as obstructive sleep apnoea and hypoventilation must be considered.ConclusionsNocturia in neurological disease is complex and lacks a robust evidence base, with very little research done in the primary care context. Guidance should be pragmatic, with reduction of risk a key requirement, until a multidisciplinary evidence base can be developed.Patient summaryPeople with a neurological disease can suffer severe sleep disturbance because of the need to pass urine several times overnight (called nocturia). We looked at published research and found very little information to help general practitioners in managing this condition. We assembled a group of experts to develop practical approaches for assessing and treating nocturia in neurological disease.

ContextSleep disorders affect responsiveness to sensory information and can cause nocturnal polyuria and reduced sleep depth; hence, these are potentially influential in understanding the mechanism of nocturia.ObjectiveTo report the systematic review (SR) and expert consensus for primary care management of nocturia in sleep disorders.Evidence acquisitionFour databases were searched from January to April 2020. A total of 1658 titles and abstracts were screened, and 23 studies potentially applicable were included for full-text screening. The nominal group technique (NGT) was used to derive a consensus on recommendations for management using an expert panel with public involvement.Evidence synthesisThirteen studies met the SR inclusion criteria, all of which studied obstructive sleep apnoea (OSA), with ten evaluating the effect of continuous positive airway pressure. The NGT consensus discussed the assessment of OSA with other key sleep disorders, notably insomnia, restless legs syndrome/periodic limb movements of sleep, and parasomnias, including non–rapid eye movement (non-REM) parasomnias and REM sleep behaviour disorder (RBD). The NGT considered that the use of screening questions to reach a clinical diagnosis is a sufficient basis for offering conservative therapy within primary care. Reasons for referral to a sleep clinic are suspected sleep disorder with substantially impaired daytime function despite conservative treatment. Suspected RBD should be referred, and if confirmed, neurology opinion is indicated. Referrals should follow local guidelines. Persisting nocturia is not currently considered an indication for referral to a sleep clinic.ConclusionsSleep disorders are potentially highly influential in nocturia, but are often overlooked.Patient summaryPeople with sleep disorders can experience nocturia due to easy waking or increased bladder filling. We looked at published research, and information was limited to one form of sleep disturbance—obstructive sleep apnoea. We assembled a group of experts, to develop practical approaches for assessing and treating nocturia in the potentially relevant sleep disorders.

BackgroundFalls are a common complication of Parkinson’s disease. There is a need for new therapeutic options to target this debilitating aspect of the disease. Cholinergic deficit has been shown to contribute to both gait and cognitive dysfunction seen in the condition. Potential benefits of using cholinesterase inhibitors were shown during a single centre phase 2 trial. The aim of this trial is to evaluate the effectiveness of a cholinesterase inhibitor on fall rate in people with idiopathic Parkinson’s disease.MethodsThis is a multi-centre, double-blind, randomised placebo-controlled trial in 600 people with idiopathic Parkinson’s disease (Hoehn and Yahr stages 1 to 4) with a history of a fall in the past year. Participants will be randomised to two groups, receiving either transdermal rivastigmine or identical placebo for 12 months. The primary outcome is the fall rate over 12 months follow-up. Secondary outcome measures, collected at baseline and 12 months either face-to-face or via remote video/telephone assessments, include gait and balance measures, neuropsychiatric indices, Parkinson’s motor and non-motor symptoms, quality of life and cost-effectiveness.DiscussionThis trial will establish whether cholinesterase inhibitor therapy is effective in preventing falls in Parkinson’s disease. If cost-effective, it will alter current management guidelines by offering a new therapeutic option in this high-risk population.Trial registrationREC reference: 19/SW/0043.EudraCT: 2018–003219-23.ISCRTN:41639809(registered 16/04/2019).ClinicalTrials.gov Identifier:NCT04226248Protocol at time of publicationVersion 7.0, 20th January 2021.

Background Executive dysfunction and risk of falling are hallmarks of Parkinson’s disease (PD). However, it is unclear how executive dysfunction predisposes people with PD to falling. Objectives To: (i) identify sensorimotor, balance, and cardiovascular risk factors for falls that discriminate between those with normal executive function and those with mild and marked executive dysfunction in people with PD and (ii) determine whether mild and marked executive dysfunction are significant risk factors for falls when adjusting for PD duration and severity and freezing of gait (FOG). Methods Using the Frontal Assessment Battery, 243 participants were classified into normal executive function (n = 87), mild executive dysfunction (n = 100), and marked executive dysfunction (n = 56) groups. Participants were asked if they had episodes of FOG in the last month and were assessed with the Movement Disorders Society – Unified Parkinson’s Disease Rating Scale (MDS-UPDRS), the Hoehn and Yahr Scale, the physiological profile assessment, and tests of orthostatic hypotension, coordinated stability, and gait and were then followed-up prospectively for falls for 32–52 weeks. Results Several PD-specific (elevated Hoehn and Yahr stage, higher MDS-UPDRS scale scores, a history of FOG, Postural Instability and Gait Difficulty subtype, and longer PD duration), sensorimotor (poor vision, knee extension weakness, slow simple reaction time), and balance (greater postural sway and poor controlled leaning balance) factors discriminated among the normal executive function and mild and marked executive dysfunction groups. Fall rates (mean ± SD) differed significantly among the groups (normal executive function: 1.0 ± 1.7; mild executive dysfunction: 2.8 ± 5.2; marked executive dysfunction: 4.7 ± 7.3) with the presence of both mild and marked executive dysfunction identified as significant risk factors for falls when adjusting for three measures of PD severity (Hoehn and Yahr scale scores, disease duration, and FOG). Conclusions Several PD-specific, sensorimotor, and balance factors differed significantly among the normal, mild, and marked executive dysfunction groups and both mild and marked executive dysfunction were identified as independent risk factors for falls in people with PD.

Ward rounds are integral to maintaining patient safety in everyday clinical care. Junior doctors are often expected to conduct independent rounds on graduation, but many feel ill-equipped to do so. We developed a safety checklist and simulation sessions to improve junior-led ward round practice at one district general hospital. We found that embedding a checklist within simulation is an effective way to teach ward round skills and increase confidence amongst undergraduate and postgraduate medical trainees.

BackgroundBone health and fracture risk reduction are increasingly recognized as important issues in Parkinson’s disease (PD). However, the evidence for fracture risk management in atypical parkinsonism (AP) is less clear. Guidance on management of bone health in PD has recently been published. ObjectivesTo evaluate the outcome of fracture risk assessment in a cohort of patients with AP, compared to a population with idiopathic PD.MethodsWe did a cross-sectional study of patients with PD or AP who had fracture risk assessed at two tertiary movement disorder centres. Data on fracture risk as assessed using QFracture and FRAX were collected. To assess for the effect of age on fracture risk we compared the risks of PD and AP patients aged ≤70 and >70 years.ResultsWe assessed 71 patients with AP and 267 with PD. Age, sex and body mass index were similar between groups; patients with AP were more likely to have fallen in the previous year. Major osteoporotic fracture risk was greater in patients with AP aged ≤70 compared to PD; no differences between groups were seen in those aged >70 years. 76% of those with AP, and 63% with PD, had an estimated fracture risk indicating bone-sparing treatment, but only 33% of patients with AP were receiving this where it was indicated.ConclusionThere is scope for considerable improvement in fracture risk assessment and treatment in atypical parkinsonism, taking into account the worse prognosis of this patient group.

The prevalence of Parkinson's disease (PD) increases with age. Caring for people with this condition frequently requires it to be considered within a wider context of both health and social factors. Diagnosis is made eliciting the hallmark motor signs, which can be confounded by signs from other co-morbidities such as depression, arthritis and cognitive impairment. The disease can be divided into four stages – diagnostic, maintenance, complex and palliative – reflecting an individual's needs. Alternative approaches include the Braak, and Hoehn and Yahr, stagings, using pathophysiological and clinical features, respectively. Dopaminergic therapies are as effective in older people, but compliance, tolerability, drug–disease and drug–drug interactions must be considered. Complications of disease are prevalent in older adults and include falls, fractures, cognitive impairment and orthostatic hypotension. Proactive screening and intervention are warranted to prevent the excess risk of morbidity and mortality associated with these events. Providing holistic and integrated care for older adults is complex and therefore best delivered by a multidisciplinary team with a proactive and patient-focused approach. A skilled and meticulous approach is required to tackle the complexity that results from the interplay between PD, co-morbidity, frailty and wider care and psychosocial factors.

In functional urology, “If getting nowhere with treatment, review the diagnosis” is an important aphorism. The most recent edition of Abrams’ Urodynamics describes a man with bothersome nocturia who received 11 different drugs over a 5-yr period [ [1] ]. All were “urological” drugs (except for two rounds of furosemide) yet none had worked, so the patient was referred for urodynamics with a view to prostate surgery. When he presented for the test, he was soon identified as having a low chance of benefiting, as indicated by the recent UPSTREAM results [ [2] ]. New enquiry revealed that he intermittently stopped breathing at night, which fundamentally altered the trajectory of his management. Identification of obstructive sleep apnoea (OSA), and requisite treatment, led to almost full resolution of the troubling nocturia.

ContextReduced renal function impairs salt and water homeostasis, which can drive nocturnal or 24-h polyuria. Nocturia can arise early in chronic kidney disease (CKD). Evidence-based recommendations can facilitate management outside nephrology clinics.ObjectiveTo conduct a systematic review (SR) of nocturia in CKD and achieve expert consensus for management in primary care and in specialist clinics outside nephrology.Evidence acquisitionFour databases were searched from January 2000 to April 2020. A total of 4011 titles and abstracts were screened, and 108 studies underwent full-text screening. Seven studies met the inclusion criteria and two were identified through other sources. Consensus was achieved among an expert panel with public involvement using the nominal group technique (NGT).Evidence synthesisSeveral plausible mechanisms contribute to nocturnal or 24-h polyuria in CKD, but there is little evidence on interventions to improve nocturia. NGT assessment recommendations for nocturia (at least two voids per night) in patients with CKD or at risk of CKD being assessed in a non-nephrology setting are: history (thirst, fluid intake), medication review (diuretics, lithium, calcium channel antagonists, nonsteroidal anti-inflammatory medications), examination (oedematous state, blood pressure), urinalysis (haematuria and albumin/creatinine ratio), blood tests (blood urea, serum creatinine and electrolytes, estimated glomerular filtration rate), and a bladder diary. Renal ultrasound should follow local CKD guidelines. Treatment options include optimising blood pressure control, dietary adjustment to reduce salt intake, fluid advice, and a medication review. Referral to specialist nephrology services should follow local guidelines.ConclusionsCKD should be considered when evaluating patients with nocturia. The aim of assessment is to identify mechanisms and instigate therapy, but the latter may be more applicable to reducing wider morbidity associated with CKD than nocturia itself.Patient summaryPeople with kidney disease can suffer severe sleep disturbance because of a need to pass urine overnight. We looked at published research and found some useful information about the underlying mechanisms. A group of experts was able to develop practical approaches for assessing and treating this condition.

ContextSalt and water homeostasis is regulated hormonally, so polyuria can result from endocrine disease directly or via secondary effects. These mechanisms are not consistently considered in primary care management of nocturia.ObjectiveTo conduct a systematic review (SR) of nocturia in endocrine disease and reach expert consensus for primary care management.Evidence acquisitionFour databases were searched from January 2000 to April 2020. A total of 4382 titles and abstracts were screened, 36 studies underwent full-text screening, and 14 studies were included in the analysis. Expert and public consensus was achieved using the nominal group technique (NGT).Evidence synthesisTwelve studies focused on mechanisms of nocturia, while two evaluated treatment options; none of the studies took place in a primary care setting. NGT consensus identified key clinical evaluation themes, including the presence of thirst, a medical background of diabetes mellitus or insipidus, thyroid disease, oestrogen status, medications (fluid loss or xerostomia), and general examination including body mass index. Proposed investigations include a bladder diary, renal and thyroid function, calcium, and glycated haemoglobin. Morning urine osmolarity should be examined in the context of polyuria of >2.5 l/24 h persisting despite fluid advice, with urine concentration >600 mOsm/l after fluid restriction excluding diabetes insipidus. Treatment should involve education, including adjustment of lifestyle and medication where possible. Any underlying endocrine disorder should be managed according to local guidance. Referral to endocrinology is needed if there is hyperthyroidism, hyperparathyroidism, or morning urine osmolarity ConclusionsEndocrine disease can result in nocturia via varied salt and water regulation pathways. The aim of management is to identify and treat causative factors, but secondary effects can restrict improvements in nocturia.Patient summaryPeople with altered hormone function can suffer from severe sleep disturbance because of a need to pass urine caused by problems in controlling water and salt levels. An expert panel recommended the best ways to assess and treat these problems on the basis of the rather small amount of up-to-date published research available.

Evidence suggests that mental health interventions are more effective when they consider the whole context of schools; addressing the needs of all students, their families, and staff; otherwise known as a whole-school approach (WSA). The UK Government is piloting WSAs to transform mental health and wellbeing by locating educational mental health practitioners in educational settings across England. This study aims to develop a ‘bottom-up’ understanding of the contextual factors and mechanisms that underlie WSAs in Trailblazer schools in the North East and North Cumbria, to gain insight into the facilitators and barriers of delivering a WSA, and optimal evaluation methods. To undertake a realist evaluation, we included the generation of initial programme theories from existing academic literature and policy documents; ‘theory gleaning’ interviews with NHS/local authority stakeholders, Trailblazer staff and school senior leaders; refining and development of theories; and individual interviews and focus groups with pupils, parent/carers and school staff. The findings will enable Trailblazer partners to better understand how their WSAs to mental health contain the essential components for transformation in schools in the region. This will contribute to the embedding of continuous evaluation into regional Trailblazers’ practice for participating schools, for subsequent annual waves and producing relevant findings for non-Trailblazer schools. Complementing the national evaluation of all 25 Wave 1 Trailblazer pilot sites, this study will generate an explanatory theoretical account of how to optimally design, implement and evaluate WSAs by exploring the contextual factors associated with implementation of WSAs.

Patients with nocturia are commonly referred to urology clinics, including many for whom a nonurological medical condition is responsible for their symptoms. The PLanning Appropriate Nocturia Evaluation and Treatment (PLANET) study was established to develop practical approaches to equip healthcare practitioners to deal with the diverse causes of nocturia, based on systematic reviews and expert consensus. Initial assessment and therapy need to consider the possibility of one or more medical conditions falling into the “SCREeN” areas of Sleep medicine (insomnia, periodic limb movements of sleep, parasomnias, and obstructive sleep apnoea), Cardiovascular (hypertension and congestive heart failure), Renal (chronic kidney disease), Endocrine (diabetes mellitus, thyroid disease, pregnancy/menopause, and diabetes insipidus), and Neurology. Medical and medication causes of xerostomia should also be considered. Some key indicators for these conditions can be identified in urology clinics, working in partnership with the primary care provider. Therapy of the medical condition in some circumstances lessens the severity of nocturia. However, in many cases there is a conflict between the two, in which case the medical condition generally takes priority on safety grounds. It is important to provide patients with a realistic expectation of therapy and awareness of limitations of current therapeutic options for nocturia.Patient summaryNocturia is the symptom of waking at night to pass urine. Commonly, this problem is referred to urology clinics. However, in some cases, the patient does not have a urological condition but actually a condition from a different speciality of medicine. This article describes how best the urologist and the primary care doctor can work together to assess the situation and make sensible and safe treatment suggestions. Unfortunately, there is sometimes no safe or effective treatment choice for nocturia, and treatment needs to focus instead on supportive management of symptoms.

Parkinson’s disease (PD) is a condition that predominantly affects older people. It is imperative that clinical management considers the other significant illnesses that people with PD accumulate as they age in conjunction with their resilience to cope with physiological change. Multimorbidity and frailty act synergistically to heighten the risk of adverse outcomes for older people with PD. These states are associated with increased likelihood of hospitalization, polypharmacy, adverse drug effects including the anticholinergic burden of medications, drug-disease and drug-drug interactions. Management should be integrated, holistic and individualised to meticulously balance the risks of interventions considering the vulnerability of the individual to recover from disturbance to their environmental, physical and cognitive equilibrium.

Chronic neurological diseases are the leading source of disability globally. Yet, our healthcare systems are not designed optimally to meet the needs of the many chronic neurological patients. Care is fragmented, with poor interdisciplinary collaboration and lack of timely access to services and therapies. Furthermore, care is typically reactive, and complex problems are managed inadequately due to lack of disease-specific expertise and insufficient use of non-pharmacological interventions. Treatment plans tend to focus on the disease rather than the individual living with it, and patients are insufficiently involved in clinical decision making. Utilising Parkinson’s disease as a model condition, we illustrate an integrated care concept with a patient-centred perspective that includes evidence-based solutions to tackle the limitations of current healthcare delivery for people with chronic neurological conditions. We anticipate that this integrated care model will improve the quality of lives of patients and create an attractive working environment for professionals, whilst being affordable for future generations.

Background To guide decision-making about driving ability, some patients with Parkinson’s disease (PD) undergo specialist driving assessment. However, decisions about driving safety in most patients need to be made without this definitive test. There is no consensus on what predicts unsafe driving in PD nor a validated prediction tool to guide clinician decision-making and the need to refer for further assessment. Objectives To describe the characteristics of patients with PD assessed at a Driving Mobility Centre and investigate factors that predict driving assessment outcome. Methods Retrospective cohort study of patients with PD assessed between 2012 and 2016. Descriptive analyses and logistic models to determine factors predicting a negative outcome. Results There were 86 assessments of patients with PD. The mean age was 70 years (±9.2), 86% were male, median disease duration 7 years (interquartile range 5–12.5 years) and 59% were referred by the Driver and Vehicle Licensing Agency. In total, 62% had a negative ‘not drive’ outcome. The Rookwood Driving Battery (RDB), depth of vision deficit, usual driving frequency, age, duration license held and response time were all predictors in univariable analysis. The RDB was the best predictor of assessment failure, conditional on other variables in a backward stepwise model (odds ratio 1.29; 95% confidence interval 1.05, 1.60; P = 0.015). Conclusions This is the first study to describe patients with PD undergoing driving assessments in the UK. In this population, RDB performance was the best predictor of outcome. Future prospective studies are required to better determine predictors of driving ability to guide development of prediction tools for implementation into clinical practice.

Falls resulting from multifactorial deficits are common in both normal ageing and Parkinson’s disease. Resultant injuries can lead to increased hospitalisation and excess mortality. As the disease progresses, gait and balance deficits are relatively refractory to dopaminergic treatments suggesting another system is involved. Attentional impairment is a significant risk factor for falls, and disruption to both the cortical cholinergic system and striatal dopaminergic system increases falls in rats undergoing a complex motor task with high attentional load. However, it is unclear whether this translates to mice and whether normal ageing induces similar deficits. In this study, we use a complex motor task to test the effects of acute dopaminergic and cholinergic antagonism using alpha-flupentixol and scopolamine, respectively, in mice. We also test the effects of normal ageing on complex motor performance and whether these changes are sensitive to a clinical dose of the non-steroidal anti-inflammatory Rimadyl. Consistent with previous work, we show that cholinergic but not dopaminergic antagonism impaired task performance. However, a combined approach did not potentiate the deficit beyond observed with cholinergic antagonism alone. We also show that task performance is impaired in aged mice relative to younger controls, and that Rimadyl reduces number of foot slips in an age-specific manner. Overall, these data support prior work showing the importance of the cholinergic system in falls. The studies in aged mice found age-related impairments and a role for inflammation but did not find evidence of an interaction with attentional load, although only one manipulation was tested.

BackgroundBladder symptoms are common in Parkinson disease (PD), affecting quality of life. Medications commonly used such as antimuscarinics can cause frequently intolerable side effects, and therefore, new, better tolerated approaches are needed. Neuromodulation techniques have an established role in urologic disorders; these techniques include tibial nerve stimulation (TNS) and sacral neuromodulation (SNM), which are localized therapies lacking the side effects associated with medication.ObjectivesThis study aimed to undertake a systematic review of the literature reporting the use of neuromodulation techniques for the treatment of bladder symptoms in PD and related conditions.Materials and MethodsA systematic search of data bases was conducted including MEDLINE, CENTRAL, and Web of Science. Studies were required to present specific outcomes for individuals with PD for neuromodulation interventions.ResultsTen primary studies were identified concerning detailed outcomes of neuromodulation on bladder symptoms in PD, including seven for TNS, one for SNM, and one using transcranial magnetic stimulation (TMS). Two further mixed cohort studies documented minimal data on individuals with PD. All studies demonstrated benefit in a range of outcome measures following neuromodulation. Two randomized sham-controlled studies were carried out using TNS, with one clearly demonstrating superiority over sham, although difficulties with achieving believable yet ineffective sham treatment are highlighted. Further studies reported limited, uncontrolled outcomes of SNM in patients with PD, demonstrating benefit.ConclusionsEvidence from case series suggests benefit from TNS in PD, with limited literature on SNM or TMS. Placebo effect from neuromodulation is a concern, and only limited controlled data exist. Future well-designed and sham-controlled studies need to be completed to provide definitive data on the benefit of neuromodulation in PD. Definitively proving the utility of a neuromodulation modality will allow better treatment of bladder symptoms without the need for pharmacologic measures that cause side effects.

COVID-19 disproportionately affects older people, with higher rates of infection and a higher risk of adverse outcomes. A brief review of literature was undertaken to inform development of a protocol describing the indications and process of prone positioning to aid the management of COVID-19 infection in non-mechanically ventilated, awake older adults. PubMed was searched up to 14th January 2021 to identify English language papers that described prone positioning procedures used in non-mechanically ventilated patients. Data were pooled to inform the development of a prone positioning protocol for use in hospital ward environments. The protocol was trialled and refined during routine clinical practice. Screening of 146 articles yielded five studies detailing a prone positioning protocol. Prone positioning is a potentially feasible and tolerated treatment adjunct for hypoxaemia in older adults with COVID-19. Future studies should further establish the efficacy, safety, and tolerability in respiratory illnesses in non-intensive care settings.

BackgroundObesity is thought to be one of the most serious global public health challenges of the 21st century. The primary care setting is important in terms of the diagnosis, education, and management of obesity in children and young people. This study explored the views of primary care clinicians on the implementation of a quality-of-life (QoL) tool to help young people and their families identify the impact of weight on QoL.AimTo assess the acceptability and feasibility of implementing the Weight-specific Adolescent Instrument for Economic-evaluation (WAItE) QoL tool for young people aged 11–18 years in primary care.Design & settingQualitative study in Northern England, UKMethodOne-to-one, semi-structured interviews were conducted with a purposive sample of primary healthcare clinicians working in practices located in areas of varying deprivation in Northern England, UK. Interview transcripts were coded and analysed using framework analysis in NVivo (version 10).ResultsParticipants (n = 16 GPs; n = 4 practice nurses) found the WAItE tool acceptable for them and their patients, and believed it was feasible for use in routine clinical practice. It was important to primary care clinicians that the tool would provide an overall QoL score that would be easy for GPs and nurses to interpret, to help them identify patients most in need of specialist help.ConclusionThis study has developed a platform for further research around QoL in young people who are overweight and obese. A future feasibility study will focus on implementing the tool in a small number of primary healthcare practices.

Research into ageing covers opportunities and challenges posed by an older population, and research to understand the ageing processes across the lifespan. The evidence base for Comprehensive Geriatric Assessment (CGA) is well established and efforts should now shift to understanding how to implement its principles across different healthcare contexts. Research around syndromes common in older people has progressed with variable success; while effective therapies for falls and cognitive impairment have been identified, older people with advanced frailty have commonly been excluded from Parkinson's disease and continence research. Research to understand the mechanisms of ageing has potential to mitigate against or treat emerging sarcopenia and cognitive impairment, and thus modify frailty trajectories. Pharmacogenetics could individualise therapeutics to reduce polypharmacy. These issues can only be addressed with development of infrastructure, capacity and expertise in ageing research. Commonly used research methodologies must be adapted to take account of frailty, cognitive impairment and functional dependency.

Summary Hyperpyrexia syndrome in Parkinson's disease (PD) is a medical emergency requiring prompt action. This can be precipitated by numerous provoking factors, in particular withdrawal of dopaminergic medication. We report a case of a patient with PD presenting with confusion, dramatic worsening of PD symptoms and pyrexia in the context of a heatwave, potentially mediating its effect through dehydration and impaired medication absorption. Precipitous cooling and conversion of dopaminergic medication to a rotigotine patch due to drowsiness led to her rapid improvement. The possibility of infection was covered however no source of infection or evidence of inflammatory response was found, but remained an important differential. This case highlights the importance of recognising and managing hyperpyrexia syndrome in PD and the possibility of uncharacteristically hot weather being a cause.

Gait dysfunction is a key defining feature of Parkinson’s disease (PD), and is associated with symptoms of freezing and an increased risk of falls. In this narrative review, we cover the putative mechanisms of gait dysfunction in PD, the assessment of gait abnormalities, and the management of symptoms caused by the inherent difficulty in walking. Our understanding of the causes of gait problems in PD has progressed in recent times, moving from neurocognitive theory to correlates of affected neuronal pathways. In particular, this can be shown to correspond with abnormalities in responses to dual-task paradigms and dysfunction in cholinergic signaling. Great progress has been made in the sophistication and precision of gait assessment; however, it has firmly remained in the research domain. There is significant momentum behind wearable technologies that can be used by patients in their own environment, acting as digital biomarkers that can not only reflect progression but also independently discriminate PD from non-PD individuals. The treatment of gait dysfunction has historically relied on physical therapies and training combined with a view to mitigating the impact of such consequences as falls. Pharmacological therapies that are the mainstay of treatment in PD have tended to address symptoms like bradykinesia; however, optimization of dopaminergic therapies likely has a positive effect on quality of gait. Other targets have been assessed with the goal of improving gait, of which medications that improve cholinergic signaling appear most promising. Neuromodulation techniques are increasingly used in the form of deep-brain stimulation; however, standard targets, such as the globus pallidus interna, have a modest effect on gait. Considerable benefit has been seen through targeting the pedunculopontine nucleus, and a dual-target approach may be warranted. Stimulation of the spinal cord and brain through direct or magnetic approaches has been assessed, but requires further evidence.

Background:Parkinson’s disease (PD) and frailty are two conditions that are increasingly common with advancing age, yet little is known about their relationship. Objective:The aim of this study was to examine the co-occurrence of frailty in people with PD; to describe the measures used to assess frailty in PD, and assess the prevalence of frailty in subjects with PD. Methods:We conducted a systematic review of Pubmed and Embase in April 2018. Studies that assessed frailty in subjects with PD were included in the review and data was extracted on the prevalence of frailty in subjects with PD. Due to heterogeneity of studies a meta-analysis was not performed. Results:Eight studies were included in the review, of which 7 were cross-sectional and 1 a prospective cohort study. Mean age of participants with PD in the studies ranged from 66 to 85 years. The majority (6/8) used the 5-item, Fried criteria to measure frailty, with the remainder using index-based measures. 5 studies provided data on the prevalence of frailty in PD, which ranged from 29% to 67%. Conclusions:Few studies have quantified the prevalence of frailty in PD, but those that have suggest a high concurrence of these two conditions.

IntroductionPeople with parkinsonism are a highly heterogeneous group and the disease encompasses a spectrum of motor and non-motor symptoms which variably emerge and manifest across the disease course, fluctuate over time and negatively impact quality of life. While parkinsonism is not directly the result of ageing, it is a condition that mostly affects older people, who may also be living with frailty and multimorbidity. This study aims to describe the broad range of health needs for people with parkinsonism and their carers in relation to their symptomatology, disability, disease stage, comorbidities and sociodemographic characteristics.Methods and analysisIn this single site cross-sectional study, people with parkinsonism will be sent a study information pack for themselves and their primary informal caregiver, if relevant. Data are collected via questionnaire, with additional support, if required, to maximise participation. A specific strategy has been developed to target and proactively recruit patients lacking capacity to consent, including those in residential care settings, with input from a personal consultee prior to completion of a bespoke questionnaire by a representative. Caregivers are also recruited to look at various health outcomes. Results will be displayed as descriptive statistics and regression models will be used to test simple associations and interactions.Ethics and disseminationThis protocol was approved by the London—Brighton & Sussex Research Ethics Committee (REC reference 20/LO/0890). The results of this protocol will be disseminated through publication in an international peer-reviewed journal; presentation at academic meetings and conferences; and a lay summary uploaded to the PRIME-Parkinson website.Trial registration numberISRCTN11452969; Pre-results.

Background: Frailty and Parkinson’s disease (PD) are both highly prevalent in older people, but few studies have studied frailty in people with Parkinson’s. Identifying frailty in this population is vital, to target new interventions to those who would most benefit. Methods: Data were collected as part of the double-blind randomised controlled rivastigmine to stabilise gait ReSPonD trial in 130 people with Hoehn and Yahr 2-3, idiopathic PD who had fallen in the year prior to enrolment. Individuals were assessed at baseline and followed up at 8 months, including determination of frailty status. Results: 120 patients attended for follow-up. At follow-up, the mean (SD) age was 70.2 years (8.0), MDS-UPDRS total score 91.5 (29.1) and MDS-UPDRS motor score (Part III) 42.7 (14.8). Median disease duration was 9.2 years (IQR 4.6 to 13.1), Geriatric Depression Score 4 (IQR 2 to 6). Using the Fried frailty criteria, 31 (26%) were frail and 70 (58%) pre-frail. In univariable analysis, being female, higher depression score and MDS-UPDRS score was associated with greater frailty. Using ordinal regression, in the multivariable model, being female (Odds ratio [OR] 3.10, 95%CI 1.53 to 6.26, p=0.002), higher total MDS-UPDRS score (OR 2.02, 95%CI 1.42 to 2.87, p

Background Culminating evidence shows that current care does not optimally meet the needs of persons with parkinsonism, their carers and healthcare professionals. Recently, a new model of care was developed to address the limitations of usual care: Proactive and Integrated Management and Empowerment in Parkinson’s Disease (PRIME Parkinson). From 2021 onwards, PRIME Parkinson care will replace usual care in a well-defined region in The Netherlands. The utility of PRIME Parkinson care will be evaluated on a single primary endpoint (parkinsonism-related complications), which reflects the health of people with parkinsonism. Furthermore, several secondary endpoints will be measured for four dimensions: health, patient and carer experience, healthcare professional experience, and cost of healthcare. The reference will be usual care, which will be continued in other regions in The Netherlands. Methods This is a prospective observational study which will run from January 1, 2020 until December 31, 2023. Before the new model of care will replace the usual care in the PRIME Parkinson care region all baseline assessments will take place. Outcomes will be informed by two data sources. We will use healthcare claims-based data to evaluate the primary endpoint, and costs of healthcare, in all persons with parkinsonism receiving PRIME Parkinson care (estimated number: 2,000) and all persons with parkinsonism receiving usual care in the other parts of The Netherlands (estimated number: 48,000). We will also evaluate secondary endpoints by performing annual questionnaire-based assessments. These assessments will be administered to a subsample across both regions (estimated numbers: 1,200 persons with parkinsonism, 600 carers and 250 healthcare professionals). Discussion This prospective cohort study will evaluate the utility of a novel integrated model of care for persons with parkinsonism in The Netherlands. We anticipate that the results of this study will also provide insight for the delivery of care to persons with parkinsonism in other regions and may inform the design of a similar model for other chronic health conditions.

Extended family often have an important role in caring for women experiencing perinatal mental illness; but rural women's perspectives are under-researched. We explored women's experiences of living in rural northern England and receiving care from extended family during periods of perinatal mental illness through 21 qualitative interviews. Key findings were that companionship, practical support - informal childcare and transport, and emotional support were important forms of care - filling gaps in formal service provision. Findings highlight women's needs for support from extended families in rural areas. The rural infrastructure and inequity in formal services can create vulnerability for women.

Background/AimsCoronavirus Disease 2019 (COVID-19) has presented an unprecedented challenge for non-COVID related clinical trials of investigational medicinal medicines (CTIMPs). These challenges are considerable for trials run in high -risk groups, such as older adults. Clinical trials must ensure the safety of their participants, whilst also considering the potential, and often long-term, benefits of the trial intervention to public health. Here we sought to provide a brief perspective on the response and conduct of CTIMPs relevant to older adults and neurology in the UK to the COVID-19 pandemic.MethodsWe performed a cross-sectional study, surveying CTIMP teams running trials broadly relevant to older adults and neurology in the UK, as well as sponsors and Clinical Trials Units (CTU), to understand the response and preparedness to the pandemic.ResultsDue to the pandemic, active recruitment has been suspended in more than half of the trials. The primary driver for the temporary halt of recruitment activity was considerations of patient safety. Interestingly, the majority of trials, sponsors and CTUs did not consider pandemic or epidemic outbreaks in their risk assessments before January 2020.ConclusionThese findings support the need to re-evaluate the risk-management approach whereby clinical trials establish contingency plans for predicted but rare events to minimise the disruption to recruitment and clinical trial delivery.

The role of a personal care manager in the model is fulfilled by a medical professional (eg, a Parkinson's disease nurse) 3,4 The specific characteristics of the network, including the number of hubs, depend on the prevalence of specific diseases and the travel distances in a country In line with the recommendation of Grimes and colleagues, an extreme focus on patient participation is at the core of every element of this approach 1 We agree with Albanese and Calandrella that we should reach international agreement about relevant outcomes to evaluate the cost-effectiveness of different integrated care models, allowing for benchmarking and enabling a crucial process of learning from the differences ERD has also received honoraria for speaking at American Academy of Neurology courses;received compensation for consulting activities from 23andMe, Clintrex, GlaxoSmithKline, Lundbeck, MC10, MedAvante, Medico Legal services, US National Institute of Neurological Disorders and Stroke, Shire, Teva, and UCB;and research support from AMC Health, Burroughs Wellcome Fund, Davis Phinney Foundation, Duke University, GlaxoSmithKline, Great Lakes Neurotechnologies, Greater Rochester Health Foundation, Huntington Study Group, Michael J Fox Foundation, National Science Foundation, Patient-Centered Outcomes Research Institute, Prana Biotechnology, Raptor Pharmaceuticals, Roche, Saffra Foundation, and University of California Irvine

Introduction the COVID-19 pandemic poses a high risk to older people. The aim of this article is to provide a rapid overview of the COVID-19 literature, with a specific focus on older adults. We frame our findings within an overview of the disease and have also evaluated the inclusion of older people within forthcoming clinical trials. Methods we searched PubMed and bioRxiv/medRxiv to identify English language papers describing the testing, treatment and prognosis of COVID-19. PubMed and bioRxiv/medRxiv searches took place on 20 and 24 March 2020, respectively. Results screening of over 1,100 peer-reviewed and pre-print papers yielded n = 22 on COVID-19 testing, n = 15 on treatment and n = 13 on prognosis. Viral polymerase chain reaction (PCR) and serology are the mainstays of testing, but a positive diagnosis may be increasingly supported by radiological findings. The current evidence for the effectiveness of antiviral, corticosteroid and immunotherapies is inconclusive, although trial data are largely based on younger people. In addition to age, male gender and comorbidities, specific laboratory and radiology findings are important prognostic factors. Evidence suggests that social distancing policies could have important negative consequences, particularly if in place for an extended period. Conclusion given the established association between increasing age and poor prognosis in COVID-19, we anticipate that this rapid review of the current and emergent evidence might form a basis on which future work can be established. Exclusion of older people, particularly those with comorbidities, from clinical trials is well recognised and is potentially being perpetuated in the field of current COVID-19 research.

BackgroundInternational data suggest that living in a rural area is associated with an increased risk of perinatal mental illness. This study tested the association between rurality and risk for two mental illnesses prevalent in perinatal women - depression and anxiety.MethodsUsing a cross-sectional design, antenatal and postnatal women were approached by healthcare professionals and through other networks in a county in Northern England (UK). After providing informed consent, women completed a questionnaire where they indicated their postcode (used to determine rural-urban status) and completed three outcome measures: the Edinburgh Postnatal Depression Scale (EPDS), the Whooley questions (depression measure), and the Generalised Anxiety Disorder 2-item (GAD-2). Logistic regression models were developed, both unadjusted and adjusted for potential confounders, including socioeconomic status, social support and perinatal stage.ResultsTwo hundred ninety-five participants provided valid data. Women in rural areas (n = 130) were mostly comparable to their urban counterparts (n = 165). Risk for depression and/or anxiety was found to be higher in the rural group across all models: unadjusted OR 1.67 (0.42) 95% CI 1.03 to 2.72,p = .038. This difference though indicative did not reach statistical significance after adjusting for socioeconomic status and perinatal stage (OR 1.57 (0.40), 95% CI 0.95 to 2.58,p = .078), and for social support (OR 1.65 (0.46), 95% CI 0.96 to 2.84,p = .070).ConclusionsData suggested that women in rural areas were at higher risk of depression and anxiety than their urban counterparts. Further work should be undertaken to corroborate these findings and investigate the underlying factors. This will help inform future interventions and the allocation of perinatal services to where they are most needed.