Dementia

Introduction -The use of anti-psychotics is higher in older people than their younger adult counterparts due to high prevalence of dementia/delirium. Anti-psychotic drugs cause side effects which include cardio vascular, metabolic, extra pyramidal and high risk of falls. So, we set out to do a QIP on antipsychotic medication prescription on our Geriatric wards and compared it with NICE guidelines.

Method- We had 2 approaches to use. Firstly, we prepared a check list for anti-psychotic medication monitoring according to NICE guidelines 2021 and we applied this retrospectively to 17 patients who had been initiated on anti-psychotics within last 12 months, the aim being to compare our practice with best practice. Secondly, we prepared a questionnaire for doctors to assess their knowledge about antipsychotic NICE guidelines and we distributed it to 14 junior doctors in RGH.

Results- • Main Indication for prescribing antipsychotics was Behavioural and psychological symptoms of dementia (BPSD) - 94% of the time • Risperidone was the most commonly prescribed (64%) antipsychotic for our patients • 83% of them had non pharmacological methods tried before considering antipsychotic medications. • 82% had their baseline ECGs checked • 35% had their lipids checked and 47% had their HbA1c checked • 52% of the doctors were aware about NICE guidelines on prescribing anti-psychotic medications • 70% of the doctors had knowledge about the side effects.

Conclusions- Our study showed the most commonly used antipsychotic drug was risperidone. We were good at documenting the indication, trying non pharmacological methods and discussing side effects with patients/family. Hba1c, lipids and prolactin were not often checked, showing room to develop best practice. We therefore are in the process of finalising a sticker so that we can follow the guidance set by NICE for prescription of antipsychotics. To improve knowledge of antipsychotics in doctors, we have presented the findings and aim to put up posters on all medical wards and to teach at our local level during doctor change overs

Introduction: The Community Geriatrician team based at the Countess of Chester Hospital is a multidisciplinary team offering comprehensive assessments at home to older patients with frailty. The team review frail patients identified as being at risk of hospital admission. Cognitive impairment and dementia are increasingly common concerns in our patient group and significant risk factors for admission. Frail patients often struggle to access traditional memory clinics for a variety of reasons and can therefore remain undiagnosed. They often require a more holistic approach in their home environment. We therefore identified a need to offer a dedicated frailty memory pathway within our community geriatrician team enabling better access to dementia assessment and diagnosis in complex frail patients.

Method: A frailty memory assessment pathway was proposed and commenced in 2022. Following identification of a cognitive concern during the initial comprehensive geriatric assessment a further home visit is arranged to assess memory in more depth. Patients are then discussed, and a diagnosis reached via a monthly Frailty memory MDT attended by Consultant psychiatrist, Consultant geriatrician, and Specialist Occupational therapist. Following delivery of a diagnosis our AGE UK well-being coordinator within the team provides post diagnostic support and sign posting to patient and family. A retrospective audit was undertaken reviewing the 44 patients diagnosed since pathway commenced. The number of hospital admissions and number of inpatient bed days was compared in the 3 months pre and post initial assessment.

Results: In the 3 months following assessment 82% of patients had a reduction or unchanged number of admissions, there was a total reduction of 71 inpatient bed days.

Conclusion: We believe our pathway offers a unique multidisciplinary approach to dementia diagnosis in the frail population, improving frail patients access to dementia assessment with a reduction in hospital admissions.

Introduction

Advance care planning is a cornerstone of holistic care in patients with dementia. I conducted a quality improvement project (QIP) in Musgrave Park Hospital on the Orthogeriatrics Ward. The QIP focused on advance care planning in patients with moderate to advanced dementia.

Method

The target cohort was post-operative fracture patients with a formal diagnosis of dementia. Patients with moderate to advanced dementia were identified using the clinical frailty scale. Once a patient was identified, I ascertained whether the patient had capacity. If the patient was not deemed to have capacity, questions were deferred to the next of kin (NOK). The patient or NOK was asked ‘if an ACP was in place?’ and if an ACP was not in place, they were the asked ‘if they were aware of what an ACP is?’.

Results

I collected data between 1^st March 2023 and 1^st April 2023. Eighteen patients were identified. No patients were deemed to have capacity and therefore, all questions were deferred to their NOK. No patients had an ACP in place and only one NOK was aware of what an ACP is.

Conclusion

The data collected showed that no patients had an ACP in place and that there was a significant lack of education regarding what an ACP is. This lack of understanding concerning what an ACP entails may be preventing ACPs from being completed in the community. I designed a leaflet which summarised the key aspects of advance care planning. These leaflets will be handed out to patients or their NOKs. I will follow up on these patients to see if education has led to an ACP being put in place.

Introduction

The Cardiff and Vale Memory Team is comprised of a range of healthcare professionals who provide direct and indirect contact to coordinate the care of dementia patients. Memory link workers (MLWs) are a single point of contact for patients; they contact patient’s post-diagnosis and at 6-month intervals. Clinical Nurse Specialists (CNSs) assist patients with medical aspects of their care, including diagnostic home assessments with the support of the medical team. This evaluation aimed to establish the impact of these roles on people living with dementia and their carers.

Methods

This study is a retrospective service evaluation of 200 patients, who contacted the MLWs and CNSs between early April and mid-May (289 contacts). PARIS, Welsh Clinical Portal and written notes were used to collate information on patient demographics and each contact.

Results

The majority of patients were female (70%), the median age was 83 and Alzheimer’s was the predominant diagnosis. The greatest need identified in both MLW and CNS contacts was social care provision (39%). MLWs predominantly addressed wellbeing (n=55), CNSs had discussions surrounding medication (n=39) and physical health (n=44). The most common subjective outcome in the MLW group, was improvement in quality of life (75%); in the CNS cohort it was addressing acute medical problems (37%). Overall, the contacts were divided as follows, quality of life (50%), admission prevention (24%) and acute medical (24%).

Conclusion

The service is proactive and addresses a variety of needs; it has the potential to improve patients' quality of life and prevent admission. Both professionals were able to identify deteriorating patients and increased carer burden; additionally, patients were able to receive a diagnosis in a home setting. The service could be improved with more frequent contact, streamlined links with social services and increased liaison with mental health services to improve speed of access.

Introduction

Dementia and hearing loss (HL) are becoming increasingly prevalent in society and commonly co-exist. People living with concurrent conditions have complex needs and face additional barriers to diagnosis and management. There is a paucity of research regarding the current and optimal management of HL in people living with dementia. This research aimed to: (1) examine the current clinical provision for people living with HL and dementia within UK audiology services, and (2) explore recommendations for the management of co-existing HL and dementia from professionals and people living with these conditions.

Methods

This was an online, qualitative study with three stages: (1) open-ended survey of 37 audiologists, (2) semi-structured interviews with 13 audiologists, and (3) semi-structured workshops with seven people with lived experience of HL and/or dementia.

Results

Audiologists used various adapted and additional hearing assessments for people with dementia. Audiological interventions for people with dementia included adapted hearing aids, alternative interventions/devices, and involvement of other services/professions. Approaches to ongoing audiological care for people with dementia included providing frequent follow-ups and face-to-face, rather than remote, follow-ups. Overarching approaches to audiological care for this population involved patient-centredness, specialist training, increased carer involvement, and adjusted appointment duration. However, there are no standard procedures/guidelines relating to dementia in UK audiology services. Recommendations included enhanced training in dementia and HL across health and social care, improved multidisciplinary collaboration, appropriate carer involvement, and greater personalised care.

Conclusions

Currently, there is no standard practice for assessing and managing HL in people with dementia in UK audiology services. Although this study identified several beneficial strategies and approaches, there remain significant areas for improvement. The study results could be used in the future to produce national guidelines and training programmes for the assessment and management of HL in people with dementia, which would reduce disparities in care.

Introduction: Many people with dementia (PwD) are affected by anxiety and depression, leading to significant changes in patient behaviour, carer burden and negative patient outcomes. Anxiolytics and antidepressants are commonly prescribed for PwD and may contribute to potentially inappropriate prescribing. This study aims to explore patients’ and carers’ experiences and perspectives of the management of depression and anxiety in PwD. Methods: An online discussion forum, Talking Point, hosted by the Alzheimer’s Society, was searched for relevant archived threads and posts. These were identified using 64 search terms such as “depression” and “SSRI”. Data were extracted into Microsoft Word and inductive thematic analysis is ongoing to code the data and identify pertinent key themes. Results: In total, 3539 posts were identified from 931 registered forum users. Initial findings have highlighted that anxiety and depression were commonly experienced by PwD and many described the difficulties in differentiating depression from dementia during the early stages of dementia. “Initially my wife was treated for depression and anxiety but that soon changed to MCI [mild cognitive impairment], then dementia…” [TP019]. Forum users described the use of anxiolytic and antidepressant medications as a process of trial and error: “The GP gave her sertraline but that didn’t work so now on mirtazapine. Only been 10 days and really makes her sleep just with half a tablet but now crying again” [TP022]. Frank accounts of the symptoms that PwD experienced were shared, highlighting the impact depression and anxiety has on both patients and their carers. Conclusion: This online discussion forum is a source of rich and valuable data, which may not be accessible through traditional qualitative methods. This study will provide authentic insights on patients’ and carers’ lived experiences of managing anxiety and depression in PwD and will inform further qualitative work with key stakeholders.

Background: Motoric cognitive risk syndrome (MCR), characterized by slow gait speed (GS) and subjective cognitive complaints, is a simple way to screen older adults at high risk of dementia. In primary care service, however, assessing GS may still be a challenge due to the short consultation time and space constraints common in general practice. Therefore, there is a need to explore alternative MCR subtypes with motor domains that can be measured conveniently. This study aimed to explore a new subtype of MCR, using low handgrip strength (HGS) as the motoric phenotype, and examined its association with the incidence of cognitive impairments among the Chinese community-dwelling older adults.

Methods: We used four-wave data (2011-2018) of participants (≥60 years) in the China Health and Retirement Longitudinal Study. We investigated two MCR subtypes. First, MCRg was defined in the literature as the coexistence of slow GS and cognitive complaints without dementia or morbidity disability. Then, we defined a new subtype, MCRh, by replacing slow GS with low HGS. Cox proportional hazards models were used to examine the association between baseline MCR subtypes (MCRg and MCRh) and incident cognitive impairment, controlling for sociodemographic characteristics, lifestyle behaviors and health conditions.

Results: Of 3325 participants (Mean age: 66.7±5.7, males: 54.9%), 5.2% had MCRg and 5.4% MCRh. Based on Cox models, both MCR subtypes were associated with the increased risk of cognitive impairment, with adjusted hazard ratios (95% CI) of 1.821 (1.402 to 2.368) for MCRg and 2.008 (1.567 to 2.574) for MCRh.

Conclusion: Low HGS, which can be quickly measured and requires no additional space, may be considered as a promising motoric phenotype of MCR subtypes. This study preliminarily supports the potential utilization of the HGS-based MCR subtype for early risk identification of cognitive impairment in primary care settings.

Introduction:

At present no single symptom appears to be favoured in choosing primary outcomes for dementia with Lewy bodies (DLB) trials, nor are the perspectives of people affected by DLB reflected in their design. The aim of this study is to elicit the preferences of DLB patients and their care partners with respect to the DLB symptoms that they would most like to see improved upon by a potential therapy. We will do so using two complimentary health economic approaches in a single online survey: a best-worst scaling (BWS) exercise and a discrete choice experiment (DCE).

Methods:

Using global voluntary sector networks, we will recruit 100 individuals who either have a diagnosis of DLB or who are a care partner for an individual with DLB. The BWS and DCE will be applied together in a self-administered online survey. Both will be informed by evidence from a scoping review of existing literature and piloted in person with a group of local volunteers.

In the BWS, participants will be presented with a series of choice sets of three symptom domains and asked to determine which domain they consider the most and least important to treat.

In the DCE, participants will be presented with a scenario and asked to choose their preference from one of two hypothetical treatments, each with different characteristics (such as target symptom and side effect profile).

Expected Results:

We will determine the relative importance of DLB symptoms and the potential trade-offs made in benefit-risk decisions related to treatments. Our findings will inform choice of primary and secondary outcomes in DLB trials. They will inform our understanding of the levels of risk and benefit individuals will tolerate, which is important as trials of potentially disease modifying agents, such as amyloid therapies, are pursued.

Introduction
Person-centred care is recognised as best practice for the care of people with delirium or dementia. In Cardiff and Vale University Health Board (CAVUHB), “Read About Me” (RAM) documents are used to support person-centred care in these patient groups. However, there are significant barriers to their routine use in clinical practice (Clark, E, Wood, F, Wood, S. Health Expect. 2022; 25: 1215- 1231). We conducted a two-cycle audit investigating the use of these documents on geriatric wards in two acute hospital sites, and trialled two interventions to increase their usage.
Methods 

Both rounds evaluated patients on 9 acute geriatric wards at CAVUHB. Patients with a diagnosis of dementia or delirium were identified by ward staff and medical notes, which we also used to see if a RAM had been completed. Intervention one was the installation of noticeboards on geriatric wards encouraging RAM usage. Intervention two was the implementation of a ward admission checklist as well as engagement with CAVUHB “dementia champions” to advocate for their usage.
Results 

Taking the 9 wards surveyed individually, in round one, the median usage of RAMs was 25% (range of 0% to 55%), which improved to 33% (range of 15.2% to 66.6%) after our intervention. Re-evaluation 3 months later, prior to intervention two, showed that RAM usage had regressed (median 27.2%, range 0% to 50%). We will re-evaluate after intervention two.

Conclusions

Long-term improvement in RAM usage was not achieved after installation of noticeboards. This loss of drive may be due to the wearing off of the novelty of the noticeboards, leading to prioritisation of other clinical tasks. We believe a better approach could be to combine a checklist to reduce cognitive workload with engagement of dementia champions in order to improve RAM usage and therefore improve person-centred care.

Introduction: With the unprecedented population growth of older adults worldwide, higher life-expectancies are creating increasingly more multigenerational interaction. Funded by the General Research Fund of the Research Grant Council in Hong Kong, the study examined the effects of telephone-administered perspective-taking intervention in the context of intergenerational caregiving. The data was collected from 2019 to 2021 in Hong Kong.

Method: Through a cluster-randomized trial, one-hundred seventy-six adult child caregivers of persons living with Alzheimer’s disease (AD) were randomized into two twelve-week interventions: 1) Connecting through Caregiving with intergenerational perspective-taking reappraisals (n=91) and 2) Basic Skill Building (n=85). All interventions are administered via telephone, Both groups receive the basic skills training including 1) monitoring mood and scheduling pleasant events and 2) communication with the care recipient & 3) communication skills with other family member and helping professionals. The CTC group spends less time on basic skills and focused on perspective-taking reappraisals aiming to promote balance between self-care and caring of others. These reappraisals include: 1) connecting with self through enhancing self-awareness, 2) connecting with the care-recipient and 3) connecting with others who can help.

Results: In terms of primary outcomes, as compared to the BSB group, the CTC group reported significantly greater reductions in depressive symptoms and higher levels of psychological well-being. For the secondary outcomes, the CTC group scored higher in emotional and instrumental support and also lower levels of perceived presence  and reaction to behavioral and memory problems of the care recipient. Perspective-taking was found to mediate between intervention effects and reduction of depressive symptoms of the caregiver.

Conclusion: The results provided evidence for the efficacy of the CTC program. The telephone-administered intervention was very useful in supporting caregivers during COVID.  With population aging, there is a rapid increase of people suffering from dementia and those who will provide caregiving. The study contributes towards enhancing sustainability of caregiving in dementia