Joints

Introduction: Frailty is a state of increased vulnerability to physiological stressors, which is associated with increased risk of adverse outcomes such as falls and delirium in older adults. For this patient group, healthcare decisions (as in whether to undergo elective surgery or continue a burdensome outpatient treatment) often have far-reaching consequences. Despite broad consensus that healthcare decision making should be a collaborative process, studies have shown frail older adults struggle to make healthcare choices and often do not feel fully involved in the decision-making process. We wanted to understand more about how frail older adults experience healthcare decision making, specifically whether they feel empowered to exercise autonomy. We also wanted to gather suggestions on how to improve the experience of healthcare decision making for this patient group.

Methods: We developed a questionnaire to assess frailty in older adults and gather data on healthcare decision making experiences. A pilot-study was undertaken to test questionnaire efficacy and accessibility. The questionnaire was distributed UK-wide to community groups. Participants completed the questionnaire independently and anonymously. Frailty was accessed based on responses to activities of daily living questions.

Results: 116 older adults completed the study, with 18 judged to be frail. 27.8% of frail adults felt never or usually not listened to by doctors, compared to 8.7% of non-frail adults. 94% of frail adults definitely or probably wanted to be involved in their treatment plans. 61.5% of frail adults wanted to see changes in how they were involved in healthcare decision making.

Conclusion: Most frail older adults want make healthcare choices, yet a significant minority do not feel listened to. Suggestions to improve healthcare decision making for frail older adults arising from this work include addressing concerns across repeated patient-doctor consultations and providing literature in appropriate language to read and digest between consultations.

Introduction Alcohol excess is a risk factor for falls in all ages. However, it is important to establish the relationship in older patients, who are at a greater risk of falling, to allow for appropriate risk management. Methods The Older Persons Assessment Service (OPAS) is an Emergency Department service which, accepting patients on the basis of the presence of frailty syndromes in patients aged >70 years (falls, confusion, care dependence, polypharmacy and poor mobility).The OPAS databank was retrospectively analysed for people with alcohol excess admitted with a fall between June 2020-December 2022. We examined clinical outcomes relating to medication, age, Charlson Co-morbidity index (CCI) and clinical frailty score (CFS). Alcohol Excess was defined by regularly exceeding government guidelines (>14 units a week). We applied the POSAMINO (Potentially Serious Alcohol–Medication Interactions in Older adults) criteria to our database to identify potentially inappropriate medications (PIMS). Results 1067 consecutive patients presenting with falls with 55 (0.05%) having a history of chronic alcohol excess; 3 with acute intoxication at the time of presentation on a background of chronic misuse. Those who presented with alcohol excess were younger (76.5 years (±9.5) vs 84.5 (±7.5) p<0.001) and less frail as per CFS (4.9 (±1.1) vs 5.3 (±1.3) p<0.05). There was a trend towards greater CCI (5.9 (±2.4) vs 5.6 (±1.9) p=0.13) in those who drink more alcohol. There was no significant difference in gender or mortality between the groups. When applying the POSAMINO criteria, the overall number of PIMS identified was 1.7 (±1.4), with those PIMS contributing to increased falls of 1.2 (±1.2). Conclusion Alcohol consumption is associated with an increased risk of falls in older adults. Increased awareness of the POSAMINO criteria can aid clinician de-prescribing decisions, especially in this cohort who are more vulnerable for recurrent falls.

Introduction The Fracture Liaison Service (FLS) is a multidisciplinary service for individuals over 50 presenting with fragility fractures. It is designed to assess future fracture risk, and appropriately diagnose and manage patients with osteoporosis.1 At Wrightington, Wigan and Leigh Teaching Hospitals (WWL), concerns were raised that access to this service was poor, meaning some patients presenting with fragility fractures were not receiving appropriate management to reduce risk of recurrent fracture. This project was designed to increase referrals to the service. Methods A cohort was identified of patients over 50 presenting to WWL with a fractured proximal humerus or distal radius/ulna over a three-month period from January to March 2021. These presentations were reviewed to identify the proportion of these patients who had been appropriately referred to the FLS. Following the initial audit, the FLS referral pathway was reviewed, and discussions were held with multidisciplinary teams (MDTs) in radiology and orthopaedic surgery to highlight the importance of appropriate bone health risk assessment. The number of patients referred each week by radiology were assessed before and after these discussions to assess whether access to the FLS had improved. Results In the initial audit 4.2% of patients with humeral fractures (n=24) and 0% of patients with radial/ulnar fractures (n=29) were appropriately referred to the FLS. Mean weekly referrals from radiology to the FLS significantly increased following the MDT discussions (mean 6.14, SD 4.40 vs mean 22, SD 6.38; t=6.71 p001 conclusions pre-existing referral pathways to the fls were found be resulting in many patients not receiving appropriate care for their bone health. a simple review of pathways, and discussion with mdts other departments was way improving access therefore hopefully reducing risk fracture recurrence. references 1. https: />/theros.org.uk/media/1eubz33w/ros-clinical-standards-for-fracture-liaison-services-august-2019.pdf [Accessed 18.05.2022]

Introduction: Malnutrition is a debilitating condition in hospitalised older people. There has been limited studies exploring dietary intake and oral nutritional supplement (ONS) compliance in these people. The purpose of this service evaluation was to observe daily energy and protein intake, plate waste and ONS compliance and to report food waste at ward level.

Methods: Three-day dietary (food-only) intake and plate waste of 19 older (≥ 65 years) people on a hospital trauma and orthopaedic (T&O) ward were assessed. Patients were categorised as ‘nutritionally well’ or ‘nutritionally vulnerable’ as per British Dietetics Association’s (BDA) Nutrition and Hydration Digest criteria. Dietary intake was calculated by a Dietitian and compared with adjusted BDA standards to exclude energy and protein from drinks. Ward plate and food trolley waste were weighed after lunch and supper for five days. Thirty-three ONS from 11 patients were collected before disposal and weighed.

Results: Mean age of the patients were 84 ± 9 years (9 female, and 10 male) with the most common injury hip fracture (68.4%). Mean (standard deviation, SD) intake for ‘nutritionally well’ was 1592 (257) kcal/day and 65.7(8.5) g/day protein and ‘nutritionally vulnerable’ (n= 15) 643 (354) kcal/day and 24.8 (14.0) g/day protein. Plate waste for ‘nutritionally well’ was 4.1 (5.8)% at main meals and 1.7 (3.4)% at pudding and for ‘nutritionally vulnerable’ 53.1 (26.6)% at main meals and 38.6 (32.2)% at pudding. Compliance to ONS was 28.3 (38.8)%. The combined mealtime plate waste weighed 6.2 (1.2) kg/day and food-trolley waste 6.2 (0.9) kg/day. This equates to approximately 4526kg/year (4.5T).

Conclusions: Energy and protein intake and compliance to ONS in older T&O patients is sub-optimal. Food waste is high and urgently needs addressing. Further, interventions are warranted to improve dietary intake in hospital and to explore the acceptability of alternative ONS food/drink styles.

Background
This study aimed to determine trajectories of depressive symptoms among older adults in England, overall and for those with hip fracture. The study aimed to explore the differential characteristics of each trajectory identified.
Methods
Analysis of adults aged 60 years or more (n=7,050), including a hip fracture subgroup (n = 384), from the English Longitudinal Study of Ageing. Latent class growth mixture modelling was completed. Depressive symptom prevalence was estimated at baseline. Chi-squared tests were  completed to compare baseline characteristics across trajectories.
Results
Three trajectories of depressive symptoms (no, mild, and moderate-severe) were identified overall and for those with hip fracture. The moderate-severe trajectory comprised 13.7% and 7% of participants for overall and hip fracture populations, respectively. The proportion of participants with depressive symptoms in the moderate-severe trajectory was 65.4% and 85.2% for overall and hip fracture populations, respectively. Depressive symptoms were stable over time, with a weak trend towards increasing severity for the moderate-severe symptom trajectory. Participants in the moderate-severe symptom trajectory were older, more likely to be female, live alone and had worse health measures than other trajectories (p < 0.001).
Conclusions
Older adults, and those with hip fracture, follow one of three trajectories of depressive symptoms which are broadly stable over time. Depressive symptoms’ prevalence was higher for those with hip fracture and, when present, the symptoms were more severe than the overall population. Results suggest a role of factors including age, gender, and marital status in depressive symptoms trajectories.

Introduction

Inpatient falls are a major cause of avoidable harm in patients on elderly care wards. Delays in identification of fall precipitants and recognition of sustained injuries increases morbidity, mortality and length of stay (Cameron et al, Cochrane Database Syst Rev. 2018 Sep; 2018(9)). Patients sustaining falls are often initially assessed by postgraduate year 1 and 2 doctors independently. We aimed to improve patient outcomes following inpatient falls through standardisation of the assessment and documentation following a fall in hospital.

Methods

Using PDSA methodology, incident reports and documentation of inpatient falls were reviewed retrospectively over three 28-bedded elderly care wards. A post-falls proforma was devised that covered various domains of the post-fall assessment and was distributed to doctors throughout the hospital. Following the intervention, a repeat PDSA cycle was performed prospectively over the same wards and the proportion of assessments fulfilling each domain was compared between the cycles.

Results

Medical assessment of 27 falls from November 2020 to January 2021 was compared to 31 falls occurring between February and May 2022. Use of the proforma in cycle 2 was limited to 8/31 falls following intervention. Post-intervention, the proportion of assessments fulfilling medication review (19% vs 35%, p=0.14) and anticoagulation status (41% vs 55%, p=0.28) was improved. The proportion fulfilling fall circumstances (89% vs 90%, p=0.85), medical precipitant (70% vs 61%, p=0.46) and ordering of appropriate imaging (93% vs 97%, p=0.47) remained high.

Conclusion

Standardisation of post-falls assessment and documentation can improve patient safety outcomes through reducing delay in recognition of medical precipitants of falls and identification and management of sustained injuries. Improved integration of a post-falls proforma into electronic systems is needed to maximise its clinical benefit and would be the target of a further PDSA cycle.

Introduction

NICE guidelines state that fracture risk assessment should occur in all women aged ≥65 and all men aged ≥75. This includes assessing patients’ FRAX score, measuring serum vitamin D and calcium levels. Early detection and treatment can prevent complications like fragility fractures. We conducted a Quality Improvement Project to improve bone health assessments on Geriatric Wards.

Methods

A baseline audit assessed: admission reason, falls history, FRAX score, CFS, previous DEXA scans, whether vitamin D and calcium levels were checked during the admission, and if treatment was commenced (bone resorption medication and vitamin D/calcium supplements). Data was collected two further times following interventions over a 5-month period. The first intervention was an announcement at the morning departmental meeting reminding clinicians. The second intervention was an email reminder.

Results

There were 56, 51, and 58 patients per cycle. 19, 15, and 17 patients were admitted with falls. 23, 14, and 10 patients had a falls history. Average CFS was 5.4, 5.4, and 5.5. Average major osteoporotic fracture FRAX score was 15.8, 16.4, and 12.9. Checking serum calcium was 88%, 100%, and 100%. Checking vitamin D was 30%, 43%, and 60%. 28%, 43%, and 47% of patients were prescribed calcium and vitamin D supplements. Patients on bone resorptive treatment dropped from 7% to 3% to 2%. 8, 12, and 11 patients had a previous DEXA.

Discussion

Verbal announcement had the greatest impact. Visible reminders help sustainability. This QIP highlighted the lack of bone protection treatment with multiple contributing factors including some patients lacking the capacity to follow instructions to take weekly medications or patients requiring vitamin D being replaced initially, with initiation later. This QIP feeds into a larger trust project in developing a ‘Fracture Liaison Service’, which could improve adherence and provide a pathway in utilising annual and bi-annual treatments.

INTRODUCTION Falls have significant morbidity and mortality in Nursing Home (NH) residents. By improving education to NH staff we aim to reduce 999 calls and associated adverse outcomes. . NH residents are more likely to fall than people living in the community and are more at risk of further falls as interventions and risk factor modification is more difficult.

METHODS Phase 1 - Ambulance calls, where a vehicle attended the scene, between 01/01/2020-28/02/2022 from NH in Swansea Bay University Health Board (SBUHB) concerning Falls/?Falls (Haemorrhage/lacerations, Unconscious/fainting, traumatic injuries, sick person, convulsions/fitting) were analysed and survey was sent out to all NH. Phase 2 - Education was provided about CWTCH (hug in Welsh) and staff were surveyed post intervention Can you move them, Will it harm them? - new neck/back pain, anticoagulation, Treat them – analgesia, wound-care, Cup of Tea – can eat & drink , Help – when contact 999.

RESULTS Phase 1 – Between 01/01/2020-28/02/2022 4907 calls, 866 were falls (17.65%) and 1032 ?Falls (21.07%), 60.49% conveyed to hospital. 47% of NH do not have falls guidelines and 100% patients are Nil by Mouth and 88.24% are not moved. Emergency services were contacted 88.24%. Phase 2 - Education was delivered to all NH in Swansea (122 staff). Feedback showed 100% feel more confident in giving food and drink, moving patients with 90.98% less likely to contact 999 and 75.40% not having previous training with 96.72 % more confident in giving analgesia.

CONCLUSIONS Falls remain a significant burden and a rapid service would improve care with conveyance reduction to 53.1% post education (60.55% pre-education). Future directions include offering this education to NH in Neath/Port Talbot. From March 2022, we offer same-day assessment for NH residents (and others) from primary care and ambulances and are developing a PRN analgesia pathway e.g.PENTHROX