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Pain is common in people with dementia, and pain can exacerbate the behavioural and psychological symptoms of dementia. Effective pain management is challenging, not least in people with dementia. Impairments of cognition, communication and abstract thought can make communicating pain unreliable or impossible. It is unclear which biopsychosocial interventions for pain management are effective in people with dementia, and which interventions for behavioural and psychological symptoms of dementia are effective in people with pain. The result is that drugs, physical therapies and psychological therapies might be either underused or overused. People with dementia and pain could be helped by assessment processes that characterise an individual’s pain experience and dementia behaviours in a mechanistic manner, phenotyping. Chronic pain management has moved from a ‘one size fits all’ approach, towards personalised medicine, where interventions recommended for an individual depend upon the key mechanisms underlying their pain, and the relative values they place on benefits and adverse effects. Mechanistic phenotyping through careful personalised evaluation would define the mechanisms driving pain and dementia behaviours in an individual, enabling the formulation of a personalised intervention strategy. Central pain processing mechanisms are particularly likely to be important in people with pain and dementia, and interventions to accommodate and address these may be particularly helpful, not only to relieve pain but also the symptoms of dementia.

Background C-reactive protein (CRP) is a non-specific acute phase reactant elevated in infection or inflammation. Higher levels indicate more severe infection and have been used as an indicator of COVID-19 disease severity. However, the evidence for CRP as a prognostic marker is yet to be determined. The aim of this study is to examine the CRP response in patients hospitalized with COVID-19 and to determine the utility of CRP on admission for predicting inpatient mortality. Methods Data were collected between 27 February and 10 June 2020, incorporating two cohorts: the COPE (COVID-19 in Older People) study of 1564 adult patients with a diagnosis of COVID-19 admitted to 11 hospital sites (test cohort) and a later validation cohort of 271 patients. Admission CRP was investigated, and finite mixture models were fit to assess the likely underlying distribution. Further, different prognostic thresholds of CRP were analysed in a time-to-mortality Cox regression to determine a cut-off. Bootstrapping was used to compare model performance [Harrell’s C statistic and Akaike information criterion (AIC)]. Results The test and validation cohort distribution of CRP was not affected by age, and mixture models indicated a bimodal distribution. A threshold cut-off of CRP ≥40 mg/L performed well to predict mortality (and performed similarly to treating CRP as a linear variable). Conclusions The distributional characteristics of CRP indicated an optimal cut-off of ≥40 mg/L was associated with mortality. This threshold may assist clinicians in using CRP as an early trigger for enhanced observation, treatment decisions and advanced care planning.

Purpose To investigate the longitudinal associations between pain and falls risks in adults. Methods Prospective cohort study on data from 40,636 community-dwelling adults ≥ 50 years assessed in Wave 5 and 6 in the Survey of Health, Ageing and Retirement in Europe (SHARE). Socio-demographic and clinical information was collected at baseline (Wave 5). At 2-year follow-up (Wave 6), falls in the previous 6 months were recorded. The longitudinal associations between pain intensity, number of pain sites and pain in specific anatomic sites, respectively, and falls risk were analysed by binary logistic regression models; odds ratios (95% confidence intervals) were calculated. All analyses were adjusted for socio-demographic and clinical factors and stratified by sex. Results Mean age was 65.8 years (standard deviation 9.3; range 50–103); 22,486 (55.3%) participants were women. At follow-up, 2805 (6.9%) participants reported fall(s) in the previous 6 months. After adjustment, participants with moderate and severe pain at baseline had an increased falls risk at follow-up of 1.35 (1.21–1.51) and 1.52 (1.31–1.75), respectively, compared to those without pain (both p p for interaction p Conclusions Moderate, severe and multisite pain were associated with an increased risk of subsequent falls in adults.

Commenting on The burden of nosocomial COVID-19 in Wales: results from a multicentre retrospective observational study of 2508 hospitalised adults. Nosocomial infections are not a new entity. Prior to COVID-19, the prevalence of healthcare-associated infection in the developed world was 4%–7.1%.1 The pandemic brought hospital admissions to the forefront of public awareness. Who should be admitted to hospital, and who should stay at home? Emergency admissions significantly dropped, for fear of being exposed to the virus. This risk was real, as the earliest reports showed that the rate of COVID-19 acquired in hospital in all inpatients with the disease was as high as 12%.2 In this issue, Ponsford and colleagues3 report outcomes of 2508 patients with COVID-19 in multiple Welsh hospitals during the first wave, based on likelihood of source of exposure. Although the majority of all cases acquired infection in …

Introduction A timely diagnosis of dementia is crucial for initiating and maintaining support for people living with dementia. The coronavirus disease (COVID) pandemic temporarily halted Memory Clinics, where this is organised, and rate of dementia diagnosis has fallen. Despite increasing use of alternatives to face-to-face (F2F) consultations in other departments, it is unclear whether this is feasible within the traditional Memory Clinic model. Aims The main aim of this service improvement project performed during the pandemic was to explore feasibility of telephone (TC) and videoconference (VC) Memory Clinic consultations. Methods Consecutive patients on the Memory Clinic waiting list were telephoned and offered an initial appointment by VC or TC. Data extracted included: age, internet-enabled device ownership, reason for and choice of Memory Clinic assessment. We noted Montreal Cognitive Assessment-Blind (TC) and Addenbrooke’s Cognitive Examination-III (VC via Attend Anywhere) scores, and feasibility of consultation. Results Out of 100 patients, 12 had a home assessment, moved away, been hospitalised, or died. 45, 21 and 6 preferred F2F, VC and TC assessments respectively. 16 were not contactable and offered a F2F appointment. The main reason for preferring F2F was non-ownership, or inability to use an internet-enabled device (80%). VC and TC preference reasons were unwillingness to come to hospital (59%), and convenience (41%). Attendance rate was 100% for VC and TC, but 77% for F2F. Feasibility (successful consultations) was seen in 90% (VC) and 67% (TC) patients. Conclusion For able and willing patients, remote Memory Consultations can be both feasible and beneficial. This has implications for future planning in dementia services.

Highlights • Mortality from COVID-19 is not affected by prescription of ACEi and / or ARBs. • Hospital length of stay is reduced in patients prescribed ACEi or ARB when diagnosed with COVID-19. • This study should provide reassurance to patients and clinicians that continuation of ACEi or ARBs is not harmful, and maybe even confer benefit in COVID-19., Objective During the COVID-19 pandemic the continuation or cessation of angiotensin-converting enzyme inhibitors (ACEi) and angiotensin receptor blockers (ARBs) has been contentious. Mechanisms have been proposed for both beneficial and detrimental effects. Recent studies have focused on mortality with no literature having examined length of hospital stay. The aim of this study was to determine the influence of ACEi and ARBs on COVID-19 mortality and length of hospital stay. Methods COPE (COVID-19 in Older People) is a multicenter observational study including adults of all ages admitted with either laboratory or clinically confirmed COVID-19. Routinely generated hospital data were collected. Primary outcome: mortality; secondary outcomes: Day-7 mortality and length of hospital stay. A mixed-effects multivariable Cox’s proportional baseline hazards model and logistic equivalent were used. Results 1371 patients were included from eleven centres between 27th February to 25th April 2020. Median age was 74 years [IQR 61-83]. 28.6% of patients were taking an ACEi or ARB. There was no effect of ACEi or ARB on inpatient mortality (aHR=0.85, 95%CI 0.65-1.11). For those prescribed an ACEi or ARB, hospital stay was significantly reduced (aHR=1.25, 95%CI 1.02-1.54, p=0.03) and in those with hypertension the effect was stronger (aHR=1.39, 95%CI 1.09-1.77, p=0.007). Conclusions Patients and clinicians can be reassured that prescription of an ACEi or ARB at the time of COVID-19 diagnosis is not harmful. The benefit of prescription of an ACEi or ARB in reducing hospital stay is a new finding.