Digital Health

Introduction:

Post-diagnostic support is key to ensuring the well-being of people with dementia and unpaid carers. The COVID-19 pandemic has caused a shift from in-person to remote service delivery, often with the use of information communication technologies (ICT) formats. This systematic review examined how ICT has been used to access remote post-diagnostic support services that address the needs people with dementia, or those of dyad, and explored care recipients’ views on accessing dementia-related support remotely.

Method:

Concepts relating to dementia and ICT were searched across six databases (PsychInfo, PubMed, Cochrane Library, CINAHL, Social Care Online, and Web of Science) in March 2021 and updated in March 2022. Studies published from 1990 and written in English, German or French were considered for inclusion. Methodological quality was appraised using the Hawker quality assessment tool and reporting structured according to PRISMA guidelines.

Results:

The search yielded 8,485 citations. Following the removal of duplicates and two screening processes, 18 studies were included. Studies described a range of post-diagnostic support, including exercise classes and therapeutic sessions, which were largely delivered remotely on a one-to-one basis. Videoconferencing software was the most employed ICT format, and people with dementia were directly engaging with ICT to access post-diagnostic support in 13 studies. Whilst studies demonstrated the feasibility of accessing post-diagnostic service remotely, overall, care recipients’ views were mixed.

Conclusions:

Following the increased reliance on ICT during the pandemic, it is likely that service delivery will continue with a hybrid approach. Accessing post-diagnostic support remotely is likely to benefit some care recipients. However, to prevent widening inequalities in access, service provision is required to accommodate to people with dementia and unpaid carers who are digitally excluded. Future research should capture the support provided by unpaid carers facilitating the engagement of the person with dementia when accessing remote post-diagnostic support.

INTRODUCTION 
Video-recordings of patients may offer advantages over text-based documentation to supplement assessment and decision-making – particularly for older patients with complex needs. Our systematic review aimed to evaluate the application, acceptability, and impact of video-based records; here we highlight current evidence on using video-recordings to support direct care delivery for older patients.

METHODS 
Five electronic databases (Medline/Embase/PsycInfo/Cochrane/HMIC) were searched from 2012-2022. Studies involving videorecording patients aged ≥ 18 years for diagnosis, care, or treatment were identified. Study quality was assessed using published appraisal tools. Acceptability was evaluated through i) recruitment/retention rates, and ii) synthesis of patients’ and professionals’ perspectives and experiences. Sekhon’s Theoretical Framework of Acceptability (TFA), consisting of seven constructs (affective attitude/burden/ethicality/ intervention coherence/opportunity costs/self-efficacy), underpinned the synthesis. 

RESULTS 
Of 14,221 citations, 27 studies (mainly low-quality) met inclusion criteria. 10/27 studies recruited older patients including those with Parkinson’s Disease (PD), dementia, stroke, end-of-life care, average age was 69. Video-recording was used in diagnosis, management/monitoring, and rehabilitation of older patients. Mean recruitment rate was 58.8% (34.2%-73.7%): mean retention rate was 81.3% (73.4%-100%). Reasons for non-participation/withdrawal related to the video-recording intervention itself (privacy concerns/poor video quality) and other factors (patients lost to follow-up). Framework synthesis generated 17 sub-themes linked to the seven TFA constructs. Attitudes to video-based records were largely positive. Video-recordings were perceived to be helpful in facilitating diagnosis/treatment/care for patients with movement disorders (PD; high-risk fallers), including in dementia populations. Digital literacy, illness severity and cognitive impairment influenced patients’ capacity to consent to video-recording.  Healthcare professionals were concerned about technical challenges but burden was minimised through using portable devices (e.g.iPad) for video capture. 

CONCLUSION 
Video-based records may be acceptable to older patients and professionals, providing valid consent is obtained and the potential benefits are recognised. Further research is needed to evaluate the acceptability, feasibility, and effectiveness of this approach.

Introduction:

Traumatic Brain Injury (TBI) is the most common fall-related injury among adults 65 and older, despite the high incidence there is a paucity of research to guide management of older adult TBI . Simple passive remote home monitoring systems can be used to unobtrusively track markers of health and function in older adults and enhance clinical decision making in community-based care models, such as ‘hospital at home’. There are few studies to-date examining healthcare practitioners (HCPs) views on this technology. We aimed to explore HCPs insights on how to best develop the technology and examined barriers and facilitators to the adoption of passive remote monitoring in the community to track health and function in older adults following TBI.

Method:

This was a multi-center mixed methodology qualitative study. HCPs opinions were explored during and online focus group and individual interviews. Purposive sampling was used to provide balanced representation of healthcare professionals (physicians, nurses and therapists) from both community and acute multidisciplinary teams. Data were analysed using the framework approach.

Results:

The perspectives of 6 HCPs were analysed. Potential barriers to adoption were HCPs lack of familiarity with technology, skepticism over the reliability of technology, the potential for nefarious use of patient’s data and concerns over how data will be managed and interpreted for clinical use. Facilitators were the promotion of safety and independence at home, reduced workload for HCPS, the potential to target appropriate healthcare interventions and flag issues early in cognitively impaired older adults.

Conclusion(s):

HCPs felt that passive remote monitoring holds potential to improve care for older adults following TBI. However, its implementation demands thoughtful planning and clear guidelines for its use and interpretation of data. Iterative development of these systems, incorporating HCPs insights will be key to successful and sustained use in research and clinical practice.

Background: Language is a social determinant of health, as constituted by the World Health Organisation (WHO) back in 1948. UK migration rates have risen exponentially recently, and with it the inability for patients to speak functional English is a growing concern. Poorer health information and avoidance of service use creates fundamental health inequity within this demographic. The UK’s ever-changing sociodemographic landscape necessitates a growing focus on health outcomes within non-English speaking patients.

Aim: To explore the barriers towards interpreter service use within South Yorkshire and how to improve communication with non-English speaking patients.

Method: Data was collected in a mixed quantitative-qualitative approach. A yes/no approach was adopted to answer the study objectives (ie., whether family members had translated on behalf of relatives or if interpreter service use was documented). Observational comments from the notes were used to contextualise the data for further discussion. This was compared to available UK guidelines.

Findings: There was a widespread reliance on family members to interpret on patients’ behalf, seen in 75% of non-English speaking patients on the sampled wards. Only 50% of these patients had documented use of interpreter phone lines across the wards, significantly below the audit’s standards.

Discussion: Barriers to interpreter services may be attributed to inefficiencies within its online nature, including queues and connectivity issues. This discourages its uptake, especially in the face of increasing hospital pressures. The high reliance on family members requires ethical considerations. These include issues with confidentiality, poor safety netting and disjointed communication of diagnoses when family members are used to translate. Ultimately, reliance on family members should be actively discouraged. This project recommends a language assessment tool and identification charts to guide NHS staff to appropriate interpreter services, preventing care delays.

Introduction:

The local issue tackled was the suboptimal compliance with the Patient Fall Management Assessment (PFMA) on the Electronic Patient Record (EPR) due to assessments being completed on alternative electronic documents.The goal was to emphasize on this to improve patient safety.

Methods:

Audit data was collected by reviewing incident reports of inpatient falls across various complex care wards over a 12-month period each, with 109 notes reviewed in the first cycle and 204 in the second.

Interventions:

The approach involved conducting repeated training sessions for all grades of training doctors within the trust.

Results:

The first audit cycle revealed fair compliance with the PFMA document (87%), documenting events (94%), examinations (87-96%), further investigations and management (80-86%). However, these were lacking for past medical history (61%), medications, especially anticoagulation/antiplatelets (58%), although antihypertensives/sedative reviews were better (75%).

The interventions led to a small (2%) increase in the use of the PFMA document but a 100% compliance in recording fall events and a 13% improvement in documenting histories. Review of blood thinners and other medications improved by 17% and 8% respectively. Significant improvements were also seen in examinations and developing management plans. Despite these advancements, 14% of patients experienced recurrent falls, indicating a need for ongoing efforts.

Conclusions:

The audit highlighted the effectiveness of continuous training to ensure regular understanding of the importance of completing the PFMA. Given the frequent rotation of junior doctors as well as the increasing variety of allied health care professionals reviewing patients, especially out of hours, this presents a particular challenge. Future efforts will focus on more sustainable methods of increasing awareness of the PFMA such as discussion at multi-disciplinary staff inductions and welcome packs. Sustaining these improvements will involve regular audits and feedback loops as well as feedback on the document itself to assess for future improvements.

Introduction

Multiple long-term conditions (MLTCs) are common in the population, which increase with age and are associated with increased hospital admissions. Identifying early signs of decline, such as restricted physical activity, could help reduce avoidable hospitalisations, however it is not clear how best to do this.

Aim

To co-design with patients, caregivers and primary care professionals (PCPs), an intervention aimed at identifying changes in activity in order to recognise decline in older adults with MLTCs. Methods The Person-Based Approach was followed to plan and develop this intervention. Qualitative interviews were conducted with older patients with MLTCs, caregivers, and PCPs to examine perspectives on an intervention measuring changes in physical activity. A prototype app was developed, using these results and patient and public involvement. This was further optimised through iterative think-aloud interviews with patients, caregivers, and PCPs.

Results

Thirty-six interviews were conducted comprising of 17 patients (mean age 79-years, 23% female), eight caregivers and 11 PCPs (GPs, nurses, occupational therapists, and pharmacists). Interviews were recorded, transcribed, and thematically analysed. Findings highlighted the importance of restricted activity as an indicator of decline. Patients often described their experiences of decline through non-specific symptoms, including changes in physical activity. PCPs emphasised the value of knowing about such changes to clinical decision-making. Different technology options for measuring activity were explored, considering data quality, and acceptability of passive/active data collection. The initial prototype intervention was designed for iterative testing and think-aloud interviews will be completed by November and presented.

Conclusion

This study highlights the utility of measuring changes in activity in older patients, and some benefits and lessons learned from co-design. A proactive approach to detecting early decline within community settings may provide opportunities to unplanned hospital admissions. 

Introduction: Research suggests that physical and cognitive exercise can have a positive effective on those with dementia, but less is known about such interventions in those at risk for dementia. Understanding the feasibility of administering clinical assessments remotely using Zoom for Healthcare^TM in the context of a dementia prevention trial for at risk older adults is not well understood.

Methods: SYNERGIC@Home/SYNERGIE~Chez soi (NCT04997681) is a home-based, remotely delivered clinical trial targeting older adults at risk for dementia. Participants underwent a screening/baseline assessment and were randomized to one of four physical and cognitive exercise intervention arms for 16 weeks (3 times per week). They were reassessed immediately post-intervention and 6-months later. The standardized assessments of cognition, physical activity, mobility, mental health, nutrition, sleep, and quality of life were done at all three points. A research coordinator completed the assessments on a one-on-one basis via Zoom for Healthcare^TM. The quality of life questionnaire was mailed to the participant.

Results: Forty-eight of 60 participants (80%) (mean age 68.7 ± 5.7 years, 81.3% female) completed the study. Most participants (75.0%) were cognitively intact with at least 2 dementia risk factors. No participants withdrew from the trial because of difficulty with the remote delivery of the assessments. There were no statistically significant changes in any of the assessments of cognition, physical activity, mobility, mental health, nutrition, sleep, or quality of life throughout the study.

Conclusion: This study demonstrates it is possible to administer standardized clinical assessments of cognition, physical activity, mobility, mental health, nutrition, sleep, and quality of life remotely in the context of a clinical trial. The study was not powered to detect meaningful differences in these assessments. Nevertheless, this confirms the feasibility of remotely administering clinical assessments to older adults at risk for dementia

Introduction: Wearable technology that continuously monitors physiological metrics has become increasingly popular and allows remote patient monitoring in virtual ward settings. Wearable technology has been shown to be effective in disease monitoring among younger adults. However, its use among older adults, including those with cognitive impairment, is yet to be explored. Aim: We aim to explore the acceptability of remote monitoring using wearable technology among older adults with delirium. Methods: Participants were recruited from an in-patient rehabilitation unit. Inclusion criteria included documented delirium and age over 65 years. Participants were enrolled until delirium resolved or until discharge. Wearable technology was worn continuously, except when being charged or the patient was washing. Device data was recorded every minute. Premorbid Barthel index and Hierarchical Assessment of Balance and Mobility (HABAM) was collected for each participant. Participants were assessed daily for delirium and mobility using the Memorial Delirium Assessment Scale and HABAM respectively. At point of discharge from the study, participants completed a questionnaire to gather feedback on their experience. Results: 20 participants were included, with a mean age of 83.0 years and an average premorbid Barthel’s index of 72. 6. Mean data capture from the wearable technology was 44.1% (12.8-65.8). None of the participants could independently manage the device. Three participants stated that the device interfered with their normal activities with five reporting the device uncomfortable to wear. However, nine participants stated they would wear the device again if asked to by a healthcare professional. Conclusions: Our findings demonstrate that wearable devices are tolerated by delirious older adults with delirium. We found that this group cannot manage these devices independently and need support from either a carer or healthcare professional. These results provides useful information to help pilot these devices among older adults with delirium in virtual ward settings.

East Kent has 38,101 people over 80 years, 39, 021 living with moderate or severe frailty and 304 care homes. This population have high levels of unplanned admissions which can put them at risk of long hospital stays, reduced mobility and increased delirium.

East Kent Ambulance services (SECAMB), Acute hospitals (EKHUFT) and Community Services (KCHFT) have piloted a single-point of access consisting of an ED consultant, community frailty clinician, Urgent care senior nurse, advanced paramedic practitioners. They sit together at the ambulance bases, 10am-6pm Monday to Fridays. This team reviews all patients awaiting ambulances to assess whether there are alternative services to ED which would meet the individuals' needs.

Method

The MDT assesses all patients listed as awaiting an emergency ambulance. Clinical records can be accessed from all services including GP records. If patients would benefit from treatment by alternative services, rather than conveyance, the paramedics are asked to call the MDT. This allows clinical assessment, history and investigation results to be taken into account in planning care. Patients and Carers are involved in deciding how they would like to receive medical care via a video or phone link with clinicians.

Results

Conveyance to hospital pre pilot - 62% post pilot less than 50%

Ashford catchment: admissions save weekly 27.3, bed days saved weekly 179.2

Thanet Catchment: admissions saved weekly 19.1, bed days save weekly 106.9

Conclusion

Many people can be treated effectively without conveyance to hospital through pre-hospital triage, consultation and planning by senior clinicians in a multi-disciplinary team.

Introduction:

Older adults are at increased risks of drug-related problems, contributed by increasing incidence of multimorbidity with age, and the consequent polypharmacy. We aim to investigate the drug classes associated with 30-day readmissions in hospitalised older adults.

Method:

We prospectively studied patients aged 65 years and above admitted to a general medical department in Sengkang General Hospital, Singapore, between October 2018 and January 2020. Medication lists were obtained from electronic medical records at admission. Unplanned readmission within 30 days of discharge was tracked through the hospital’s electronic health records. Medications were classified according to the World Health Organisation’s Anatomical Therapeutic Chemical classification system. Univariate logistic regression was performed for the association of drug classes with 30-day readmission.

Results:

We recruited 1507 consecutive admissions with follow-up data. 30-day readmission occurred in 331 patients (22.0%). Greater length of stay, higher comorbidity burden, hospitalisation in the one year preceding index admission, frailty and polypharmacy were more commonly observed among patients who were readmitted within 30 days of discharge. Admission diagnoses associated with 30-day readmission include infections, fluid overload, acute coronary events and constipation. Drug classes associated with a higher risk of 30-day readmission include drugs for acid-related disorder (OR=1.62, 95%CI 1.27-2.07), drugs for constipation (OR=1.96, 95%CI 1.41-2.73), antithrombotic agents (OR=1.40, 95%CI 1.09-1.79), antianaemic preparations (OR=2.22, 95%CI 1.68-2.91), cardiac therapy (OR=1.70, 95%CI 1.23-2.34), diuretics (OR=1.41, 95%CI 1.04-1.90), beta-blocking agents (OR=1.55, 95%CI 1.21-1.99) and analgesics (OR=1.56, 95%CI 1.02-2.39).

Conclusion:

Drug classes associated with 30-day geriatric readmissions include drugs for acid-related disorder, constipation, antithrombotic agents, antianaemic preparations, cardiac therapy, diuretics, beta-blocking agents and analgesics. Patients on the above drug classes should herald a higher index of scrutiny during admissions, and necessitate closer follow-up upon discharge.