Multimorbidity

Introduction: Severe Mental Illness (SMI), particularly schizophrenia, has been associated with reduced bone mineral density and increased risk of fractures, although some studies have shown inconsistent results. We aimed to examine the effect of SMI on recorded diagnosis of osteoporosis and fragility fracture in older people in the UK, accounting for age, sex, social deprivation and lifestyle factors (smoking, alcohol and Body Mass Index (BMI)).

Methods: We used de-identified data provided as part of routine primary care (IQVIA Medical Research Database). Patients with a diagnosis of SMI (schizophrenia, bipolar disorder, other psychosis) aged 50-99y between 1/1/2000-31/12/2018 were matched 1:8 to age- and sex-adjusted controls without SMI, using Exposure Density Sampling (EDS). We estimated Hazard Ratios (HR) and 95% Confidence Intervals (95%CI) based on Cox Proportional Hazards model. We stratified the analysis by sex, accounting for age, social deprivation, year (model 1), and the above plus smoking, alcohol, and BMI (model 2). We imputed missing lifestyle data using Multiple Imputation.

Results: In total 444,480 people aged ≥50 years were included in the analysis (SMI N=50,006; controls N=394,474). In men, prior diagnosis of SMI increased the risk of osteoporosis diagnosis by 64% (HR 1.64; 95%CI 1.44-1.88) and the risk of fragility fractures by 87% (HR 1.87; 95%CI 1.70-2.06) in model 1. SMI also increased osteoporosis risk by 49% (HR=1.49; 95%CI 1.30-1.71) and fragility fracture risk by 82% (HR=1.82; 95%CI 1.65-2.00) in model 2 in men. In contrast, prior diagnosis of SMI had no significant effect on recorded osteoporosis risk in women. Prior SMI in women increased fragility fracture risk by 53% (HR 1.53; 95%CI 1.45-1.61) in model 1 and by 51% (HR=1.51; 95%CI 1.43-1.58) in model 2.

Conclusions: SMI is associated with increased risk of osteoporosis in men, and fragility fractures in both men and women, with a greater effect in men. 

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: People living with multiple long-term conditions (MLTC) are more likely to experience hospital admission, which is often associated with unintended consequences. Preventing or providing alternatives to admission by predicting adverse admission-related outcomes is important. This study aims to provide an overview of the association between MLTCs and adverse outcomes following hospital admission through a systematic review of systematic reviews.

Method: We searched Medline, Embase, CINAHL, Web of Science and PsycINFO for systematic reviews assessing risk factors/predictors of functional decline (FD), nursing home admission (NHA), or changes in quality of life among adults (≥18 years) experiencing unscheduled acute hospital admission. Eligible reviews had to assess MLTC (LTC counts, indices, or individual LTCs), either alone or with other predictors. Titles/abstracts and full texts were screened in duplicate and candidate predictors were extracted.

Results: 14 systematic reviews assessed predictors of FD (n=8) or NHA (n=6). Reviews focused on studies of general inpatients/mixed presentations (n=8: 6 FD, 2 NHA); hip fracture (n=2: 1 FD, 1 NHA); stroke (n=2: 1 FD, 1 NHA) and cognitive impairment (n=1, NHA) or delirium (n=1, NHA). Assessment of MLTC was heterogenous: comorbidity indices (n=4), counts of LTC (n=2), specific LTC (n=8), and ‘comorbidity’ without further qualification (n=3). Higher comorbidity indices, higher counts, and a range of specific comorbidities (most notably dementia) were associated with FD and NHA. Reviews assessing MLTC alongside other predictors highlighted a broad range of sociodemographic, functional, social, and admission-related factors that were associated with FD and NHA. In general, reviews did not assess the relative importance of MLTC alongside other predictors.

Conclusion: While MLTC may predict unwanted outcomes following admission their qualification is often inconsistent and their relative importance as predictors, alongside broader factors such as social complexity, is rarely assessed in existing systematic reviews.

Objective

Ageing is associated with reduced vaccine efficacy due to immunosenescence. Severe COVID-19 outcomes are associated with comorbidities prevalent in older people. We report results from the INFORM study on severe COVID-19 outcomes in vaccinated older individuals with varying numbers of comorbidities.

Methods

A retrospective observational cohort study was conducted in England using a 25% random sample from NHS databases. COVID-19-related outcomes (hospitalisations and mortality) in fully vaccinated (≥3 doses) older individuals from 1 Jan to 31 Dec 2022 are reported.

Results

Of a reference population of 7,180,205 fully vaccinated individuals ≥12 years, 2,232,140 were ≥65 years. The proportion of older people with ≥1 COVID-19 hospitalisation increased with age (≥65, 0.6%; ≥70, 0.7%; ≥75, 0.9%; ≥80, 1.2%) compared to overall population (OP, 0.2%). Incidence rates (IR) (95% CI) per 100 person years also increased with age for hospitalisation (≥65, 0.58 [0.57-0.59]; ≥70, 0.71 [0.69-0.73]; ≥75, 0.90 [0.88-0.92]; ≥80, 1.20 [1.18-1.22] versus OP, 0.22 [0.21-0.23]) and death (≥65, 0.16 [0.15-0.17]; ≥70, 0.20 [0.18-0.22]; ≥75, 0.28 [0.26-0.30]; ≥80, 0.42 [0.39-0.45] versus OP, 0.05 [0.04-0.06]).

In those ≥65, 1,375,470 were not immunocompromised (IC) but had ≥1 high-risk comorbidity (no-IC/+Com), 586,155 had neither IC or comorbidity (noIC/noCom). An increased number of comorbidities was associated with increased hospitalisation and death IRs. In those ≥65 noIC/+Com, IRs (95% CI) were 0.63 (0.61-0.65), 0.88 (0.86-0.90) and 1.25 (1.22-1.28) for hospitalisation vs 0.20 (0.17-0.23) in noIC/noCom; and 0.16 (0.14-0.18), 0.23 (0.21-0.25) and 0.32 (0.29-0.09) vs 0.06 (0.03-0.09) for noIC/noCom for death where individuals had ≥1, ≥2 and ≥3 noIC/+Com, respectively.

Conclusions

Despite vaccination, older people are at increased risk for severe COVID-19 outcomes, with higher risk associated with more comorbidities. Even older patients with no-IC conditions have increased risk, especially those with other high-risk comorbidities. Additional interventions may be required to protect older people against severe COVID-19 outcomes.

Background

Older people have complex health needs, with the inter-play between physical and mental health being a prominent issue. The ageing population has resulted in a large proportion of older people living with co-occurring physical and mental health disorders, which can prove challenging to manage simultaneously, particularly for serious mental illness. The aim of this systematic review was to explore models of integrated physical-mental health care available for older people, and whether these result in improved health outcomes. Sources of heterogeneity in the current evidence base alongside limitations were also explored.

Methods

Medline, Embase, CINAHL, PsycINFO and Scopus were searched with a predefined search strategy, generating 5257 articles. Studies were suitable for inclusion where an integrated physical-mental health care service model was utilised in a population of older people (aged >60 years) with a mental health diagnosis and at least one concomitant physical health condition requiring physical health care input. All studies were quality assessed for risk of bias and results were synthesised narratively.

Results

Nine studies met the inclusion criteria. All studies incorporated service models involving integrated and/or multidisciplinary care. These included joint medical-mental health wards as well as the implementation of multidisciplinary teams in hospital and care facilities. Overall, this enhanced the quality of care for elderly patients with benefits including but not limited to, enhanced patient experience, the expansion of multidisciplinary team practice, improved management of illness, and timely intervention.

Conclusions

Multidisciplinary and integrated care resulted in improvement of a range of health outcomes for older people with combined physical and mental health needs. Larger and more robust studies are needed to explore the development of these service models further, with cost-effectiveness analyses.

Introduction: Poor oral health is linked to multiple health conditions, for example pneumonia, cardiovascular and cerebrovascular disease, cancer and diabetes. Older people are particularly vulnerable to developing poor oral health due to comorbidities, medications used, and access to dental services, an effect magnified during hospital admissions. The aim of this project is to improve oral health and care received by inpatients on Healthcare for Older People (HfOP) wards.

Methods: A baseline audit of patient-response surveys on oral health access and behaviours, and care during hospital admissions was performed. HfOP inpatients aged >75 with capacity to consent were included. Plan-Do-Study-Act cycles informed interventions, focusing on education of multidisciplinary staff. First round interventions included presenting/discussing initial audit findings at a regional HfOP meeting, and working with Oral Health Practitioners to do ward-based micro-teaching and develop/distribute posters raising awareness. Second round interventions included a more in-depth certified educational session available to all HfOP staff on oral health care and promotion, and posters on how to document oral health aspects on the electronic patient record.

Results: 82% (82/100) patients reported being registered with a dentist, 50% attending a dentist in the last 12 months. Initially, only 17% (17/100) reported ward staff taking measures to ensure/help support their oral health, rising to 46% (46/50) in the second audit.

Conclusions: Though patient surveys may under-represent oral health access/issues by excluding people unable to consent, and may under-represent staff support offered/provided by recall bias, our audit did highlight gaps in staff awareness/practice. Our interventions were designed to benefit all inpatients, via opportunistic ward-based education through the audit process and formal educational sessions. Limitations included logistics of ensuring access to all staff groups. Our goal is to formalise oral health training in core MDT teaching to generate systemic lasting improvement.

Other information: Registered with local trust audit programme.