Age and Ageing

BackgroundNIDUS-Family is a manualised intervention, deliverable by non-clinical facilitators which is clinically (on Goal Attainment Scaling - GAS) and cost effective over 12 months. AimsTo evaluate whether goal setting plus NIDUS-Family was more effective than control (goal-setting and routine care) in supporting dyads (family carers and care recipients with dementia) attainment of personalised goals at 18 and 24 months; and participant perceived goal relevance over 24-months. MethodA single-masked, randomised controlled trial recruiting dyads from community settings. Randomisation used a 2:1 ratio (intervention: control). NIDUS-Family is tailored to goals dyads set by selecting modules involving behavioural interventions, carer support, psychoeducation, communication, enablement and environmental adaptations. It involved 6-8 video-call/telephone sessions over 6 months, then follow-ups 2-3 monthly for 6 months. Our primary outcome was GAS at 18 and 24 months. Secondary outcomes assessed care recipient functioning, quality of life, time until care home admission or death, carer anxiety and depression. Primary analysis, a mixed-effects model, accounted for randomization group, study site, time, intervention-arm facilitator and repeated measurements. ResultsIn 2020-21, 204 participants were randomised to intervention and 98 to control. 164 (54.3%) and 141(46.7%) dyads completed 18 and 24-month outcomes respectively. In the primary analysis, including 277 participants contributing 6-, 12-, 18- or 24-month outcomes, adjusted GAS mean differences (intervention-control) at 18 and 24-months were 11.78 (95% CI (Confidence Interval) 6.64,16.93) and 8.67 (3.31,14.02). Secondary outcome comparisons were not significant. The hazard ratio for dying or care home admission was 0.80 (0.45,1.42) (intervention v control); and 0.87 (0.41,1.82) and 0.59 (0.26,1.33) for death and care home admission respectively. Of baseline GAS goals, carers considered 436 (78.0%) relevant at 18 and 383 (78.5%) at 24 months. ConclusionsThe NIDUS-Family intervention improved personalised attainment of GAS goals that remained relevant for most dyads, over two years. Trial Registration Number: ISRCTN11425138.

BackgroundDementia is associated with frailty leading to increased risks of falls and hospitalisations. Interventions are required to maintain functional ability, strength and balance. DesignMulti-centre parallel group randomised controlled trial, with embedded process evaluation. Procedures were adapted during the COVID-19 pandemic. ParticipantsPeople with mild dementia or mild cognitive impairment (MCI), living at home, and a family member or carer. ObjectivesTo determine the effectiveness of an exercise and functional activity therapy intervention compared to usual care. InterventionA specially-designed dementia-specific rehabilitation programme focussing on strength, balance, physical activity and performance of ADL, which was tailored, progressive, addressed risk and the psychological and learning needs of people with dementia, providing up to 50 therapy sessions over 12 months. The control group received usual care plus a falls risk assessment. Main outcome measureThe primary outcome was the informant-reported Disability Assessment for Dementia (DAD) 12 months after randomisation. Secondary outcomes were: self-reported ADL, cognition, physical activity, quality of life, frailty, balance, functional mobility, fear of falling, mood, carer strain and service use (at 12 months) and falls (between months 4 and 15). Results365 people were randomised, 183 to intervention and 182 to control. Median age of participants was 80 years (range 65-95), median Montreal Cognitive Assessment score 20/30 (range 13-26), 58% were men. Participants received a median of 31 (IQR = 22-40) therapy sessions out of a possible maximum of 50. Participants reported completing a mean 121 minutes/week of PrAISED activity outside of supervised sessions. Primary outcome data were available for 149 (intervention) and 141 (control) participants. There was no difference in DAD scores between groups: adjusted mean difference -1.3/100, 95% Confidence Interval (-5.2 to +2.6); Cohens d effect size -0.06 (-0.26 to +0.15); p=0.5. Upper 95% confidence intervals excluded small to moderate effects on any of the range of secondary outcome measures. Between months 4 and 15 there were 79 falls in the intervention group and 200 falls in the control group, adjusted incidence rate ratio 0.78 (0.5 to 1.3); p= 0.3. ConclusionThe intensive PrAISED programme of exercise and functional activity training did not improve ADLs, physical activity, quality of life, reduce falls or improve any other secondary health status outcomes even though uptake was good. Future research should consider alternative approaches to risk reduction and ability maintenance. Trial registrationISRCTN15320670. FundingNational Institute for Health and Care Research What is already knownO_LIDementia is associated with progressive loss of functional ability, including activities of daily living and mobility, and a high risk of falls C_LIO_LIExercise programmes and rehabilitation therapies may improve ability, or slow the rate of decline, but evidence from trials and systematic reviews is equivocal C_LI What this study tells usO_LIWe developed an intensive dementia-specific exercise and functional activity rehabilitation programme, lasting 12 months, taking account of motivation, learning needs and context, in particular the need to engage carers, and evaluated it in a randomised controlled trial C_LIO_LIThe programme was very well received by participants and therapists, but had no effect on activities of daily living, physical activity, quality of life, falls, cognition or any other health status outcome C_LIO_LIWe are unlikely to be able to change rate of loss of ability in dementia through exercise or functionally orientated rehabilitation therapy. C_LIO_LIWe need different ways of defining wellbeing after a dementia diagnosis. C_LI

BackgroundFalls are a major cause of morbidity in older adults. Low-cost wearable devices track potential falls risk factors, but adoption in older adults remains uncertain. MethodsWe conducted a 6-month prospective observational study in community-dwelling adults who self-reported a recent fall or were deemed at increased risk. Participants were given a wrist-worn wearable device (Fitbit, Garmin or Polar), synced with a smartphone application (Smplicare app) to collect additional information by questionnaires, including self-reported falls. We analysed adherence wearing the devices, and studied step count and sleep data in relation to falls. ResultsOf 284 people (74.2{+/-}9.0 years, 68% women) in the study, 266 (94%) provided at least 7 days of data, with 196 (76%) engaged on at least half of study days. Engagement did not differ by self-reported technology confidence. There were 81 (30%) people who reported a fall during follow-up, but only 5 (6%) resulted in hospital attendance. Each additional hour of average sleep was associated with a 24% reduction in falls risk (HR 0.76, 95% CI 0.63 to 0.92), but in multivariable models only carer support (aHR 3.47, 95% CI 1.46 to 8.26) and incontinence (aHR 2.26, 95% CI 1.34 to 3.82) remained independently associated with falls. No changes in step or sleep patterns were noted after falls, but there was high individual heterogeneity. ConclusionWearable adoption, risk factor identification and digital self-reporting of falls is feasible in older adults using low-cost commercial technology. The importance of simple wearable measures like sleep for fall risk were outweighed by markers of frailty. Future research should understand how these granular wearable data could add to proactive falls risk assessment.

BackgroundA substantial number of emergency department (ED) attendances from care homes could be classed as avoidable. HealthCall is a technology that aims to streamline residents care by recording their observations electronically. Observations are fed to remote clinical staff to triage referrals. This study assessed the effectiveness of the HealthCall technology to safely reduce unplanned secondary care usage and associated costs. MethodsThe study involved 118 care homes across the North East from 2018-2021. Routinely collected NHS secondary care data from County Durham and Darlington NHS Foundation Trust was linked with data from the HealthCall technology App. Four outcomes were modelled monthly using Generalised Linear Mixed Models: counts of emergency attendances, emergency admissions, emergency readmissions (28-days), and length of stay of emergency admissions. A similar approach was taken for costs. The impact ofHealthCall was tested on each outcome using the models. FindingsData from 8,702 residents was used in the analysis. Results show HealthCall reduces the number of emergency attendances by 11%[6%-15%], emergency admissions by 25% 20%-39%], readmissions reduced by 29%[24%-33%] and length of stay by 11%[3%-18%] (with an additional month-by-month decrease of 28%[24%-34%]). The cost analysis found a cost reduction of {pound}57 per resident in 2018, increasing to {pound}113 in 2021. InterpretationThe introduction of a digital technology, such as HealthCall, significantly reduces contacts with and costs resulting from unplanned secondary care usage by care home residents. FundingThis work was funded by Health Data Research UK, CFC0124.

Purpose Aging in place has become a central objective of health and social policies across the world, yet frailty and multimorbidity significantly undermine individuals capacity to remain safely at home. The aim was to identify the potential components of a home visit intervention led by nurse practitioners for frail populations. Design A consensus study using a two-round Delphi method Methods A two-round Delphi study was conducted in summer 2024 with 15 experts from four French-speaking countries (French Canada, Switzerland, Belgium, and France). The questionnaire was based on documented needs of frail patients and their caregivers. Results Experts identified the target population as older adults needing home care, people with physical or cognitive impairments, those requiring end-of-life care, and individuals experiencing difficulties remaining at home. Eligibility criteria included frailty, multiple chronic conditions, mobility issues, social isolation, and low socio-economic status. The nurse practitioner s role should include clinical assessment, treatment adjustments, care coordination, therapeutic education, support for patients and families, and promotion of self-care. Nurse practitioners may also serve as a reference for other healthcare professionals. Home visits should be initiated by healthcare providers, patients, or family members, with visit frequency and duration adapted to individual needs. Conclusions This study identified components of a nurse practitioner-led home visit intervention for frail individuals that achieved expert consensus, while highlighting areas where consensus was not reached. Clinical Relevance These findings will inform the development and future evaluation of such an intervention in real-world settings.

BackgroundCare home residents have complex needs, and minimum data sets (MDSs) provide a unique source of information on their health and wellbeing. Although MDSs were first developed to monitor quality and costs of care, they can make an important contribution to research. AimTo describe the research applications of data from care home MDSs, and identify key outcome variables and measures used. DesignMapping review of published empirical studies using data generated from minimum data sets in long term care facilities for older adults. MethodsWe performed a comprehensive search of electronic databases (Medline OVID, CINAHL, Embase and ASSIA), using bespoke search strategies to identify English language publications 2011 - 2024. Articles were screened by two independent reviewers. They were grouped by study topic and data (on publication date, country, MDS, outcome variables and specific items or measures) were charted without quality assessment. The key features of the data are described in a narrative synthesis. FindingsSearches identified 18588 articles published 2011-2024, of which 661 met inclusion criteria. 72% were from the USA, 12% from Canada and the remaining 16% from four European countries, South Korea and New Zealand. The studies encompassed individual resident functioning (e.g. mobility, incontinence), health conditions and symptoms (e.g. depression, pain), healthcare in the home (e.g. prescribing, end of life care), hospital attendances and admissions, transitions to and from care homes, quality of care and systemwide issues. Measures used reflected the content of the major MDSs, but there was a mismatch between the importance of some topics to care homes (e.g. incontinence) and the range of published papers, and limited consensus over how to measure quality of life. ConclusionsCare home MDSs are a unique resource to support study of care home residents and impact of interventions over time. They are a powerful resource when linked to other datasets, and as an adjunct to primary data collection This analysis may serve as an accessible guide to the content and applications of MDS, allowing researchers to consider the sort of questions that can be posed and the different components of resident care or experience that can be evaluated.

TOPLINE SUMMARYO_ST_ABSWhat is a Rapid Review?C_ST_ABSOur rapid reviews use a variation of the systematic review approach, abbreviating or omitting some components to generate the evidence to inform stakeholders promptly whilst maintaining attention to bias. They follow the methodological recommendations and minimum standards for conducting and reporting rapid reviews, including a structured protocol, systematic search, screening, data extraction, critical appraisal and evidence synthesis to answer a specific question and identify key research gaps. They take 1-2 months, depending on the breadth and complexity of the research topic/question(s), the extent of the evidence base and type of analysis required for synthesis. Background / Aim of Rapid ReviewCare for older and vulnerable people must sustain core infection prevention and control (IPC) practices and remain vigilant for COVID-19 transmission to prevent virus spread and protect residents and healthcare professionals from severe infections, hospitalisations and death. However, these measures could potentially lead to adverse outcomes such as decreased mental wellbeing in patients and staff. A recent publication by Public Health England examines the effectiveness of IPC practices for reducing COVID-19 transmission in care homes (Duval et al., 2021). We explore evidence relating to adverse outcomes from IPC practices to help inform policy recommendations and identify gaps within the literature where further research can be prioritised. Key FindingsO_ST_ABSExtent of the evidence baseC_ST_ABSO_LI15 studies were identified: 14 primary studies and one rapid review C_LI Recency of the evidence baseO_LIOf the primary studies, six were published in 2020 and eight were published in 2021 C_LIO_LIThe rapid review was published in 2021. C_LI Summary of findingsThis rapid review focuses on adverse outcomes resulting from increased IPC measures put in place during the COVID-19 pandemic. Whilst there is some evidence to show that there may be a link between IPC measures and adverse outcomes, causation cannot be assumed. O_LIDuring the COVID-19 restrictions, the cognition, mental wellbeing and behaviour of residents in care homes were negatively affected C_LIO_LIIncreased IPC procedures during the COVID-19 pandemic increased stress and burden among care staff because of increased workload and dilemmas between adhering well to IPC procedures and providing the best care for the care recipients C_LIO_LICOVID-19 IPC procedures were not well developed at the beginning of the COVID-19 pandemic, but evidence from 2021 suggests that good adherence to IPC measures can enable visitations by family members and medical professionals into care homes C_LIO_LIOnly one study investigating domiciliary care was found. Therefore, it is difficult to make conclusions related specifically to this care setting C_LIO_LINo published studies have reported on the costs or cost-effectiveness of IPC measures or have explored the cost implications of adverse outcomes associated with IPC measures C_LI Best quality evidenceOnly one study was deemed as high quality based on the quality appraisal checklist ranking. This was a mixed methods study design (Tulloch et al., 2021). Policy ImplicationsSince March 2020, there have been many changes to government guidelines relating to procedures to keep the population safe from COVID-19 harm. Policies vary according to country, even within the UK. Important issues such as care home visitation policies have changed in such a way that care home staff have felt it difficult to keep up with the changes, which in itself increased the burden on those staff. The following implications were identified from this work: O_LIIPC policies should be clear, concise and tailored to care homes and domiciliary care settings C_LIO_LIIncreased attention to workforce planning is needed to ensure adequate staffing and to reduce individual burden C_LIO_LIRestrictions (e.g. visitation) for care home residents needs to be balanced by additional psychological support C_LIO_LIFurther research with robust methods in this area is urgently needed especially in the domiciliary care setting C_LI Strength of EvidenceOne limitation is the lack of high-quality evidence from the included studies. Confidence in the strength of evidence about adverse outcomes of COVID-19 IPC procedures was rated as low overall. Whilst the majority of studies achieved a moderate score based on the quality appraisal tools used, due to the nature of the methods used, the overall quality of evidence is low.

Background Falls are a leading cause of injury-related hospital admissions among older adults with substantial burden on health and social care systems. Digital exercise programmes may improve physical function at scale and complement traditional services. Keep-On-Keep-Up (KOKU) is an NHS-approved digital programme offering progressive, evidence-based exercises and education on fall prevention. We aimed to evaluate the effectiveness and cost-effectiveness of KOKU for improving balance, physical function and reducing fall risk among community-dwelling older adults. Methods A two-arm, parallel group randomised controlled trial was conducted with community-dwelling older adults (>=60 years). Participants were randomised (1:1) to receive KOKU alongside standard care (strength and balance exercise advice and a falls prevention leaflet) or standard care alone. The primary outcome was balance function at 12 weeks (Berg Balance Score). Secondary outcomes included lower limb strength, concerns about falling, falls, mood, pain, fatigue, healthcare utilisation, health-related quality of life and usability. A modified intention-to-treat approach was used to analyse effectiveness and cost effectiveness. Results A total of 202 older adults (mean age 76.8 years, 72.8% female) were enrolled (102 intervention; 100 control). Retention at 12-weeks was 89.1% (91 intervention; 89 control). Compared with standard care, KOKU significantly improved balance function at 12 weeks after adjusting for baseline scores (mean difference: 6.35, 95% CI: 4.48, 8.22). KOKU was associated with lower mean falls related costs (incremental cost (GBP): -62.98, 95% CI -218.54 to 40.22) and a QALY gain of 0.020 (95% CI 0.003 to 0.035). Conclusion The KOKU programme improves balance with preliminary evidence of cost-effectiveness among community-dwelling older adults.

BackgroundDelirium is strongly associated with subsequent dementia, but this is often assumed to reflect underlying associations of baseline health with dementia. We examined the associations of delirium on admission with incident dementia across the spectrum of multimorbidity. MethodsRetrospective population-based cohort study using linked primary care and hospital data for emergency admissions aged [≥]65 years in Lothian, Scotland, from 1 Apr 2017 to 1 Apr 2020. Delirium on admission was assessed at the bedside for all patients using the 4AT (www.the4AT.com). Associations of delirium, multimorbidity, and their interaction with incident dementia and mortality were examined using Fine-Gray competing-risks regression and Cox proportional hazards models. ResultsOf 23,558 people without pre-existing dementia (mean age 78.9 years, 54% female), 4135 (18%) had an admission with delirium. Delirium was associated with higher incident dementia risk. The relative risk was highest in those without multimorbidity (adjusted Hazard Ratio (aHR) 3.38, 95% CI 2.46-4.63) and decreased with an increasing number of long-term conditions. Delirium was also associated with increased mortality, regardless of multimorbidity. In those without multimorbidity, delirium was associated with higher early mortality ([≤]90 days: aHR 4.23, 95% CI 3.27 to 5.49) and late mortality (>90 days: aHR 1.64, 95% CI 1.33 to 2.03). ConclusionDelirium is strongly associated with incident dementia in older adults across the multimorbidity spectrum, with the highest relative risk in people without multimorbidity. Findings support routine delirium assessment on hospital admission for all older adults and highlight need to further investigate neurodegenerative mechanisms in delirium.

BackgroundDementia diagnoses are captured across multiple routine data sources, but discrepancies between these may affect care and research. This study determined the prevalence and overlap of recorded dementia across primary care, hospital, and community prescribing data sources in a UK regional cohort, and examined whether outcomes differed by the setting in which dementia was first recorded. MethodsRetrospective cohort study of adults [&ge;]65 years (n=133,407) in a large Scottish health board. Dementia diagnoses recorded from 01/04/2016 to 01/04/2020 were identified across linked primary care, hospital discharge, and prescribing records. Associations between source of first recorded dementia diagnosis and subsequent mortality and emergency hospitalisation were estimated using Cox proportional hazards and Fine-Gray competing risks models. ResultsAt baseline (01/04/2016), 7544/133407 individuals (5.7%) had recorded dementia: 95.1% in primary care, 73.3% in hospital, and 54.3% in prescribing records. Over four years, 7359 of the remaining 125,863 individuals (5.8%) had newly recorded dementia: 70.2% in primary care, 22.2% in hospital, and 7.6% in prescribing records. Only 35.9% of hospital-recorded diagnoses were coded in primary care records within a year. People first diagnosed in hospital were older, more frail, more socioeconomically deprived, and had higher mortality than those first diagnosed in primary care (<30days: adjusted Hazard Ratio (aHR) 8.96, 95%CI 6.94-13.52; >365days: aHR 1.29, 95%CI 1.19-1.41). ConclusionsDementia is variably recorded across routine datasets, and the setting in which dementia is first recorded identifies groups with markedly different prognosis. Improved data source integration and scrutiny of hospital-based diagnostic pathways are needed to ensure diagnoses are reliably transferred and people with dementia receive timely, equitable post-diagnostic care.

Objectives To assess the concurrent and lagged associations between quality of primary care and planned and unplanned secondary care use for patients with multimorbidity, examining the modifying role of frailty. Design A retrospective cohort study Setting This population-level analysis included 468,172 patients with multimorbidity in England from the Discover research platform (April 2022-March 2024). Participants Patients with multimorbidity Main outcome measures We used principal component analysis to combine a set of quality indicators (QIs) and assessed the impacts of QIs on both planned and unplanned care. Results Generally, patients with higher QI attainment also had higher likelihood of planned (outpatient visits) and unplanned care (emergency admissions and ED visits) utilisation. There was a lower lagged odds of elective hospital admissions in the following 12 months among those with higher attainment of multimorbidity-specific QIs (OR=0.94, 95%CI 0.93-0.95). In the complex multimorbidity cohort ([&ge;]3 conditions), multimorbidity-specific QIs were longitudinally associated with lower odds of elective admissions (OR=0.94, 95%CI 0.92-0.95) and outpatient visits (OR=0.96, 95%CI 0.95-0.98), while generic QIs were related to lower odds of outpatient non-attendance (OR=0.95, 95%CI 0.91-0.99). In non-frail patients with multimorbidity, multimorbidity-specific QIs were longitudinally associated with reduced odds of outpatient visits (OR=0.98, 95%CI 0.97-0.99), elective admissions (OR=0.92, 95%CI 0.90-0.94) and prolonged elective hospital stay (IRR=0.94, 95%CI 0.89-0.99). Conclusions Attainment of generic and multimorbidity QIs was generally associated with slightly increased planned and unplanned care. However, patients for whom we identified higher attainment of multimorbidity-specific QIs had lower odds of elective admissions and outpatient visits, especially for those with complex multimorbidity. Our research suggests that the quality of primary care may influence patients' use of secondary care, with the potential to improve care for people with multimorbidity and warrant further investigation into management strategies.

ObjectiveSystematically review and critically appraise evidence for the association between delirium and falls in community-dwelling adults aged 60 years and above MethodsWe searched EMBASE, MEDLINE, PsycINFO, Cochrane Database of Systematic Reviews, CINAHL and Evidence-Based Medicine Reviews (EBMR) databases in April 2023. Standard methods were used to screen, extract data, assess risk of bias (using Newcastle Ottawa scale), provide a narrative synthesis and where appropriate conduct meta-analysis. ResultsWe included eight studies, with at least 3505 unique participants. Five found limited evidence for an association between delirium and subsequent falls: one adjusted study showed an increase in falls (RR 6.66;95% CI 2.16-20.53) but the evidence was low certainty. Four non-adjusted studies found no clear effect. Three studies (one with two subgroups treated separately) found some evidence for an association between falls and subsequent delirium: meta-analysis of three adjusted studies showed an increase in delirium (pooled OR 2.01; 95%CI 1.52-2.66), one subgroup of non-adjusted data found no clear effect. Number of falls and fallers were reported in the studies. Four studies and one subgroup were at high risk of bias and one study had some concerns. ConclusionsWe found limited evidence for the association between delirium and falls. More methodologically rigorous research is needed to understand the complex relationship, establish how and why this operates bi-directionally and identify potential modifying factors involved. We recommend the use of standardised assessment measures for delirium and falls. Clinicians should be aware of the potential relationship between these common presentations. Key pointsO_LIThis is the first systematic review of the association between delirium and falls in the wider community population. C_LIO_LIThere is relatively limited but consistent evidence on the direction of effect for both delirium preceding falls and falls preceding delirium. C_LIO_LIMore high-quality longitudinal work is needed to explore the nature of this potentially complex and bidirectional relationship. C_LIO_LIHistory of falls and delirium should be considered when assessing patients with incidence/suspected incidence of falls or delirium. C_LI

ImportanceHealthcare workers (HCWs), including those with mild symptoms, may be an important source of COVID-19 within elderly care. ObjectiveTo gain insight into the spread of SARS-CoV-2 among HCWs working in elderly care settings. DesignCross-sectional study among HCWs working in elderly care in the South-East of the Netherlands, testing for SARS-CoV-2, between March 31 and April 17, 2020. SettingHCWs working in geriatric rehabilitation, somatic and psychogeriatric wards or small-scale living groups and district nursing, with a total of 5245 HCWs within 4 organisations. Participants621 HCWs with mild respiratory symptoms. Main OutcomesNumber of HCWs testing positive for SARS-CoV-2 in pharyngeal swabs, using realtime reverse-transcriptase PCR targeting the SARS-CoV-2 E-gene, N-gene, and RdRP. HCWs filled out a survey to collect information on symptoms and possible sources of infection. Results133/615 (21.6%) HCWs tested positive for SARS-CoV-2, ranging from 15.6 to 44.4% per elderly care organisation, and from 0 to 64.3% per separate location of the organizations, respectively. 74.6% of tested HCWs were nursing staff, 1.7% elderly care physicians, 20.3% other HCWs with patient contact and 3.4% HCWs without patient contact. In the univariate analysis, fever, runny or stuffy nose, anosmia, general malaise, myalgia, headache and ocular pain were associated with SARS-CoV-2 positivity, while gastro-intestinal symptoms and respiratory symptoms, other than runny or stuffy nose were not. Risk factors for SARS-CoV-2 positivity were contact with patients or colleagues with suspected or proven COVID-19. Whole genome sequencing of 22 samples in 2 facilities strongly suggests spread within facilities. Conclusions and RelevanceWe found a high SARS-CoV-2 prevalence among HCWs in nursing homes and district nursing, supporting the hypothesis of undetected spread within elderly care facilities. Structural testing of elderly care HCWs, including track and trace of contacts, should be performed to control this spread, even when only mild symptoms are present.

Clinical trials in dementia face significant recruitment challenges, with only 1% of eligible participants typically engaged in research. The Sativex for the Treatment of AgitatioN in Dementia (STAND) trial implemented innovative recruitment strategies to address these barriers. This study analyses the effectiveness of systematic recruitment approaches combining public outreach, targeted engagement, and electronic consent procedures. A mixed-methods approach incorporated patient and public involvement (PPI), stakeholder mapping, and iterative recruitment channel optimisation. Over 10 months, 98 participant enquiries were received, resulting in 53 participants consented and 29 enrolled (55% screen success rate). Electronic consent emerged as the preferred method (49% of consents), reducing time from first contact to signed informed consent from approximately 34 days (in-person/postal) to just 5 days. Pre-existing research networks provided 83% of participants, demonstrating their value. Despite falling short of the target 60 participants, primarily due to COVID-19 restrictions and drug supply challenges, recruitment exceeded targets in later months following implementation of PPI-informed strategies and protocol amendments. The study demonstrates that systematic recruitment approaches incorporating eConsent can effectively accelerate enrolment in dementia trials, while highlighting the importance of flexibility in protocol design and the value of embedded clinical research infrastructure within healthcare systems. Key pointsO_LISystematic, stakeholder-driven recruitment strategies improved care home dementia trial enrolment rates C_LIO_LIElectronic consent reduced time to consent from 34 days (in-person/postal) to just 5 days C_LIO_LIPre-existing research networks provided 83% of participants, demonstrating their critical value C_LIO_LIProtocol flexibility and PPI enabled rapid adaptation to COVID-19 and operational challenges C_LIO_LICombining eConsent, embedded infrastructure, and adaptive management overcame recruitment barriers C_LI

BackgroundVery many social care clients have dementia, but few social care workers receive dementia-specific training. ObjectiveTo systematically review dementia training interventions for social care, review past policies and hold stakeholder workshops considering how future policy can support quality dementia training in social care. MethodsWe searched electronic databases, November 2015 to February 2024, including studies describing dementia training and support interventions for social care workers, assessing risk of bias with the Mixed Methods Appraisal Tool. We reviewed English policies January 2015 to April 2024 to identify social and policy contexts relevant to dementia training. We consulted home care and care home stakeholders regarding how findings could inform future policy. ResultsWe included 56 studies (50 in care homes, 6 in home care). There was good quality evidence that dementia training interventions in care homes that engaged staff "champions" to integrate practice-based learning reduced agitation, neuropsychiatric symptoms and antipsychotic prescribing and improved life quality of residents with dementia. One study found this approach was cost-effective. In home care, evidence was limited; group training was valued, and improved staff sense of dementia care competence in one study. We identified 27 policies and related documents; and consulted 18 stakeholders. Stakeholders supported mandatory dementia training but considered implementation very challenging in current economic contexts. ConclusionsWe found strong evidence for dementia training in care homes, but a relative lack of research in home care. Policy options identified to implement evidence require investment, which could deliver substantial savings across health and social care.

Background: Existing electronic frailty indices (eFI) are typically based on structured data and designed for older adults. We developed an eFI that integrates structured and unstructured electronic health records (EHRs) across adulthood and assessed its longitudinal trajectories and associations with adverse outcomes. Methods: We used longitudinal EHR data from 193629 individuals aged 35-103 in the Wellbeing Services County of Central Finland (2010-2023) and constructed a 53-item eFI including diagnosis codes, laboratory tests and items extracted from free-text clinical notes using deep-learning-based natural language processing. Associations with all-cause mortality, severe infections, fractures, and healthcare utilization were assessed using Cox and count models. Predictive performance was compared with Hospital Frailty Risk Score (HFRS) and Charlson Comorbidity Index (CCI). Findings: eFI trajectories accelerated notably from age 65 onwards. Using the eFI as a categorical variable, severe frailty was associated with higher risks of mortality (hazard ratio [HR] 7.31, 95% confidence interval [CI] 6.83-7.83), severe infections (HR 9.22, 95%CI 8.52-9.98), fractures (HR 2.75, 95%CI 2.52-3.01) and increased healthcare utilization (odds ratio [OR] 3.15, 95%CI 2.96-3.35) compared with non-frail. The risks were relatively greater in younger age groups and persisted when using the continuous eFI restricted to non-frail individuals. Across all outcomes, the eFI showed greater model discrimination than HFRS and CCI. Interpretation: An eFI using structured and unstructured EHR data improves risk stratification even in younger adults and at very low levels of frailty. Funding: Research Council of Finland, Instrumentarium Science Foundation, Sigrid Juselius Foundation and Samfundet Folkhalsan.

Background: In the UK, over 36 million contacts are made annually by people living with dementia (PLWD) to either primary or secondary community mental health services. As dementia progresses, PLWD may experience increased distress and resort to 999 calls for an ambulance, which may in turn result in conveyance to Accident & Emergency (A&E). Nearly 1 million A&E attendances are made by PLWD. This trend is set to rise sharply as the prevalence rates of dementia increase over time and as the condition progresses, with associated healthcare costs impacting overall care delivery. This may lead to reduced resource allocation for dementia emergency services, negatively affecting the experiences of both providers and service users. Aim(s): To explore ways to improve access and quality of care to emergency crisis care for PLWD from the perspective of healthcare staff providing this type of support. Methods: This qualitative study explored (1) the experiences, resources, and needs of healthcare professionals in emergency and community settings to support access for PLWD, and (2) the mechanisms influencing dementia crisis response. The COREQ Checklist was used to improve transparency, credibility, and reproducibility. Inter-rater reliability was calculated. PPIE contributors co-developed recommendations for healthcare professionals, and study findings informed a comic-based dissemination resource shared with third-sector organisations to support community awareness and engagement. Results: Fifteen interviews were held with emergency services staff. Inter-rater reliability was substantial between two raters (k = 0.62). Four overarching themes, with associated subthemes, were identified relating to crisis care delivery, barriers to effective response, and strategies employed to address these challenges. Additional themes captured decision-making processes at key points in the care pathway, including initial crisis response, during intervention, and at discharge from emergency and community services. Decision-making was characterised by the need to balance patient safety with autonomy in determining care in the best interests of PLWD and their informal carers. Discussion: This exploratory study reveals frontline staff perspectives on challenges and actionable strategies for dementia crisis care. Findings support targeted service improvements, cross-sector collaboration, and co-produced resources to enhance outcomes for PLWD and their informal carers.

BackgroundSeveral definitions exist for multimorbidity, frailty or polypharmacy, but no formal definition exists for "complex health needs". We aimed to identify and characterise older people with complex health needs based on healthcare resource use (unplanned hospitalisations or polypharmacy) or frailty. MethodsIn this cohort study, data was extracted from UK primary care records (CPRD GOLD), with linked Hospital Episode Statistics inpatient data. People aged >65 on 1st January 2010, registered in CPRD for [&ge;]1 year were included. We identified complex health needs as the top quintile of unplanned hospitalisations, number of prescribed medicines, and electronic frailty index. We characterised all three cohorts, and quantified point-prevalence and incidence rates of preventative medicines use. ResultsOverall, 90597, 110225 and 116076 individuals were included in the hospitalisation, frailty, and polypharmacy cohorts respectively. Frailty and polypharmacy cohorts had the highest bi- directional overlap. Most comorbidities such as diabetes and chronic kidney disease were more common in the frailty and polypharmacy cohorts compared to the hospitalisation cohort. Generally, prevalence of preventative medicines use was highest in the polypharmacy cohort compared to the other two cohorts: For instance, one-year point-prevalence of statins was 64.2% in the polypharmacy cohort vs. 60.5% in the frailty cohort. ConclusionsThree distinct groups of older people with complex health needs were identified. Compared to the hospitalisation cohort, frailty and polypharmacy cohorts had more comorbidities and higher preventative therapies use. Research is needed into the benefit-risk of different definitions of complex health needs and use of preventative therapies in the older population.

Background Falls in hospitals are associated with injuries, deaths and poor patient outcomes. Although clinical guidelines recommend educating hospital patients about how to prevent falls, not all hospitals systematically deliver evidence-based patient falls education. The primary aim of this study is to implement and evaluate the effectiveness of delivering a research-informed education program called the Safe Recovery Program with ward support on rates of falls and falls-related injuries in hospitals. The secondary aims include measuring changes in patient and staff knowledge and awareness about falls prevention and identifying barriers and facilitators to staff and patients taking action to reduce hospital falls. Methods The trial will adhere to the Consolidated Standards of Reporting Trials guidelines. Twelve wards will be recruited from five Australian hospitals over a 65-week period. A stepped-wedge cluster randomised controlled trial design will be used with unidirectional crossover from control to experimental conditions together with randomisation of when each cluster makes the transition. The crossovers will occur at 12 timepoints, each five weeks apart. Alongside the trial, patients and staff on participating wards will be recruited for interviews and qualitative data analyses will be conducted to understand how to optimise implementation. The experimental condition involves usual care plus delivery of the Safe Recovery Program. For the Safe Recovery Program, supervised allied health assistants will deliver brief falls education programs to all suitable patients in designated wards, reinforced by all ward staff. Falls champions, who are registered nurses and allied health professionals, will provide Safe Recovery Program training for staff, using a train-the-trainer model. The ward staff will also be trained in how to support hospital patients to adopt safe behaviours. The primary outcome will be falls per 1000 patient bed days. The secondary outcomes will be: (i) injurious falls per 1000 patient bed days (ii) patient and staff changes in falls awareness, knowledge and motivation; and (iii) barriers and enablers to hospital staff engaging in behaviour change and program implementation. An economic evaluation will also be conducted to estimate the incremental cost effectiveness of implementing the Safe Recovery intervention. Ethics and Dissemination Ethics approvals have been obtained from The Royal Melbourne Hospital Human Research Ethics Committee (HREC/113864/MH-2024). The findings will be disseminated through peer-reviewed journals, workshops and conferences. Consumer team investigators will guide the communication of findings to the target audiences, including older patients, hospital staff, healthcare managers and policy makers. Trial Registration Number: ACTRN12624001469505

PurposeNeurogenic dysphagia is prevalent in neurological inpatients and associated with adverse outcomes, yet its independent economic impact after adjustment for frailty and functional status remains poorly quantified. We aimed to estimate the independent effect of dysphagia on hospital length of stay (LOS) and costs, to test whether this effect differs between geriatric and non-geriatric patients, and to quantify the probability and magnitude of cost savings from improvements in swallowing function. MethodsWe analysed 10,375 neurological inpatient cases (2021-2024) at a German university hospital. Dysphagia was defined by fiberoptic endoscopic evaluation of swallowing (FEES) or ICD-10 R13 coding (n = 1,382; 13.3%). Bayesian Gamma-log regression with informative priors from historical data and published literature was used to model LOS and total case costs (German DRG), adjusted for age, sex, Hospital Frailty Risk Score (HFRS, R13-adjusted), self-care index ("Selbstpflege-Index", SPI), stroke status, and emergency admission. A geriatric cohort was defined as age [&ge;]70 and adjusted HFRS [&ge;]5 (n = 2,053; 19.8%). Posterior predictive simulation estimated cost savings for hypothetical improvements of 1-3 points on the Functional Oral Intake Scale (FOIS). ResultsAfter comprehensive adjustment, dysphagia was independently associated with 46.5% longer LOS (posterior ratio 1.465; 95% credible interval [CrI] 1.397-1.537) and 28.2% higher total case costs (ratio 1.282; CrI 1.213-1.354). The dysphagia x geriatric interaction was small but credible and ran in opposite directions: slightly attenuated for LOS (interaction ratio 0.908, CrI 0.837-0.986) but slightly amplified for costs (1.096, CrI 1.012-1.185), consistent with complexity-driven DRG grouping in geriatric patients. The absolute economic burden remained larger in the geriatric cohort due to higher baseline costs. In the geriatric cohort, a one-point FOIS improvement yielded a 74.3% posterior probability of LOS-based savings (mean {euro}555/case); at three points, this rose to 84.2% (mean {euro}1,115/case). The direct cost model confirmed high benefit probabilities from the payers perspective (82.6% at {delta}FOIS = 3). ConclusionsNeurogenic dysphagia is an independent and substantial driver of hospital LOS and costs in neurological inpatients, even after adjustment for frailty and functional status. The proportional effect on costs is slightly larger in geriatric patients, while the LOS effect is slightly smaller, consistent with the mechanics of the G-DRG system. Bayesian simulation indicates that improvements in swallowing function carry a high probability of generating cost savings, supporting the characterisation of dysphagia as a modifiable economic target with particular relevance to geriatric neurology.