Dementia

Introduction Many patients admitted with fragility femoral fractures have established cognitive impairment but no formal diagnosis of dementia. This lack of pre-existing diagnosis impacts care, counselling and discharge planning. This audit assessed how many people aged >65 admitted with a fragility fracture had information, at the time of admission, suggesting a likely but unconfirmed diagnosis of dementia and how their length of stay (LOS) and discharge destination compared to patients with confirmed dementia.

Methods 47 consecutive patients aged >65, admitted with a fragility femoral fracture had their electronic care records reviewed to identify information suggesting the presence of cognitive impairment/dementia. 30-day mortality, LOS and discharge destination was compared for three groups, 1) dementia, 2) informal dementia diagnosis and 3) no evidence of cognitive impairment.

Results Of 47 patients reviewed, 35(74%) were female, mean age 80.6 years (range, 68-94). Of these, 7/47(15%) had an established dementia diagnosis (mean age 82.4 years), 9/47 (19%) had unconfirmed cognitive impairment/dementia but without a formal diagnosis (mean age 82.2years) and 31/47 (66%) had no evidence of cognitive impairment(mean age 79.7 years). In cases of confirmed dementia diagnosis, the mean LOS was 54.7 days (range, 16-114). One patient died 1/7 (14.3%) and 3/7 (42.9%) were discharged home. For patients with an informal dementia diagnosis, the mean LOS was 35 days (range, 7-74). Two patients (2/9) died (22.2%), and 3/9 (33.3%) were discharged home. For those with no cognitive impairment, the mean LOS was 36 days (range, 7-92). Three patients 3/31 (9.7%) died, and 22/31 (71.0%) were discharged home.

Conclusion A significant minority of patients had likely undiagnosed dementia, with mortality and discharge destinations similar to patients with recognised dementia. Services need to consider how best to identify and diagnose cognitive impairment/dementia at the time of admission for fragility fractures.

“I would imagine it needed a review…” A qualitative study exploring the experiences of people with dementia and their informal carers of long-term condition reviews in primary care

Introduction

Multimorbidity is common for people with dementia (PWD) and is associated with increased healthcare utilisation and poorer outcomes. Part of the management of long-term conditions (LTCs) occurs through annual LTC reviews conducted in primary care. Little is known about the experiences or needs of people with dementia and informal carers in regard to LTC reviews.

Aim

To explore the experiences of PWD and their informal carers of the review and management of LTCs in primary care.

Method

Qualitative research study, protocol informed by discussion with people with lived experience as an informal carer. Institutional ethical approval (ref ETH2122-1035, University of East Anglia) was granted 25/3/2022. Semi-structured interviews were conducted with PWD and informal carers recruited through Join Dementia Research and local (to Norfolk, UK) charities. Thematic analysis was undertaken with reference to Braun and Clarke (2006).

Results

16 participants were interviewed: two PWD, 10 informal carers and two informal care/PWD dyads. Our findings fall into four main themes: 1) What matters to people; medication optimisation and holistic care 2) What is a review; the diversity of experiences 3) The importance of communication and 4) Preference for shared decision making.

Conclusion

Consideration should be given to ensuring patients and carers are aware when a LTC review will take place and providing an opportunity to be involved, thus allowing shared decision making and patient centred care. Further research into the clinician experience and their views on patients’ needs and how to meet them is required to inform how LTC reviews for people with dementia can be optimised.

Author names: M Mintun1; C Ritchie2; P Solomon3; JR Sims1; S Salloway4; O Hansson5; LG Apostolova6; JA Zimmer1; CD Evans1; M Lu1; P Ardayfio1; JD Sparks1; AM Wessels1; S Shcherbinin1; H Wang1; ESM Nery1; EC Collins1; EB Dennehy1; DA Brooks1; DM Skovronsky1; TRAILBLAZER-ALZ 2 Investigators; A Farquharson (Non-author presenter)1

Author provenances: 1. Eli Lilly and Company, USA; 2. Scottish Brain Sciences, UK; 3. Boston Center for Memory and Boston University Alzheimer's Disease Center, USA; 4. Departments of Neurology and Psychiatry, Alpert Medical School of Brown University, USA; Butler Hospital, USA; 5. Clinical Memory Research Unit, Department of Clinical Sciences Malmö, Lund University, Sweden; Memory Clinic, Skåne University Hospital, Sweden; 6. Department of Neurology, Indiana University School of Medicine, USA

Introduction: In TRAILBLAZER-ALZ donanemab (DONA) cleared brain amyloid plaques, significantly slowing disease progression in early symptomatic Alzheimer’s disease (ESAD).

Methods: TRAILBLAZER-ALZ2 enrolled participants with ESAD and amyloid and tau pathology by positron-emission tomography, randomizing (multicenter) those with low/medium-tau (n=1182) and high-tau (n=552) (missing tau n=2). Participants (randomized double-blind,1:1) received DONA (n=860)/placebo (n=876) IV every 4w for 72w. DONA participants meeting amyloid clearance treatment completion criteria at 24/52w had blinded switched to placebo. Primary outcomes: Integrated AD Rating Scale(iADRS) change from baseline at 76w in low/medium-tau or combined (low/medium- and high-tau) populations. Statistical testing allocated most power (80% α spend) to low/medium-tau population outcomes, with the remainder for combined population outcomes, including clinical and biomarker assessments.

Results: In the low/medium-tau population iADRS change at 76w: −6.02 (DONA) and −9.27 (placebo) (difference 3.25; 95%CI, 1.88-4.62; P<.001), 35.1% slowing of disease progression. change in clinical dementia rating scale (cdr)–sum boxes: 1.20 (dona) and 1.88 (placebo) (difference −0.67; 95% ci −0.95 to −0.40; p<0.001), 36.0% slowing. participants receiving dona experienced 38.6% less risk progressing next stage vs placebo over 76w (cdr-global score, hr="0.61;" p<0.001). amyloid clearance at 24 />52/76w: achieved in 34.2%/71.3%/80.1% DONA-treated participants. Significant, positive results were observed in the combined population. Serious AEs: 17.4% (DONA), and 15.8% (placebo), with 3 deaths among DONA patients who experienced serious amyloid-related imaging abnormalities (ARIA). AEs with DONA included ARIA-E (24.0%, 6.1% symptomatic); ARIA-H (31.4%); infusion-related reactions (8.7%).

Conclusion: DONA treatment significantly slowed clinical progression at 76w with a safety profile consistent with earlier studies.

Presented: AAIC2023.

Introduction

Community-based comprehensive geriatric assessment (CGA) reduces hospital admissions but the optimal way in which CGA can be delivered is not well understood. Digital and Remote Enhancements for the Assessment and Management of older people living with frailty (DREAM) is a programme of research seeking to develop an enhanced community CGA intervention.

We aimed to identify candidate cognitive assessment tools (CATs) that could be undertaken remotely and enhance CGA.

Methods

Searches were carried out on Medline, PsycINFO, CINAHL and Cochrane databases. Papers published since 2008 were included if they analysed the validity, reliability or acceptability of CATs that could be undertaken remotely in a domestic setting and were tested on older people.  

Results

Of 4286 papers identified, 56 were included. Four types of CAT were identified: computer/tablet/smartphone applications (23tools/27papers), telephone (16tools/23papers), video (2tools/2papers) and specialist equipment (4tools/4 papers). 14 tools demonstrated excellent accuracy for identifying mild cognitive impairment or dementia (specified as AUC >0.80 or sensitivity/specificity>80%). 42 papers presented concurrent/convergent validity, 14 reliability and 16 acceptability data. Time taken to perform tests ranged between 2-30 mins. Of the 23 computer/tablet/smartphone applications, 7 tools are currently available to download.

Key conclusions

Remote CATs could be used in CGA.  Computer/tablet/smartphone applications and some specialist equipment could enhance assessment by quickly and accurately identifying cognitive impairment, in some cases with greater accuracy than traditional tests. Tools that use ‘games’ may be more appealing than conventional pen and paper tools. ​However, many of the computer/tablet/smartphone applications tested are not available for clinical use.

Introduction

The Mental Capacity Act is designed to protect patients who may lack the mental capacity to make decisions about treatment. At the Nuffield Orthopedic Centre (NOC) in Oxford, nurses obtain a baseline AMTS during the pre-operative assessment clinic. Following on from this, any patient over 64 years old that is seen by the orthogeriatrics team will have a post-op AMTS done to assess for cognitive impairment. If the AMTS is less than 8, or the patient is clinically believed to be delirious, then an MCA form will be completed for the decision to accept treatment. The aim of this QI project was to widen this practice to all the junior doctors at the NOC.

Method

AMTS and MCA data were collected from one month of inpatients >64 years old at the NOC. The AMTS were analysed and the patients with post-op AMTS of <8 were identified and checked for MCA form completions. The data was presented to junior doctors at the NOC, and a repeat cycle was performed to assess if the practice was being implemented.

Results

Data collected from 10/01/23 – 10/02/23 (n=125) showed that out of 10 patients meeting the AMTS criteria, only 4 had MCA forms completed. Once the QI projected was presented on 25/05/23, data collected from 12/06/23 – 15/07/23 showed that out of 5 eligible patients, 4 of them had MCA forms completed.

Conclusion

Prior to this QI project, only 40% of eligible patients from the collected data were having MCA forms completed by junior doctors at the NOC. Following the presentation to raise awareness, the data collected shows that this figure had increased to 80%. In conclusion, this QI project has been a success and should be repeated every 4 months to account for each new rotation of junior doctors.

Background

Patients aged over 65 years old account for a significant proportion of the attendances to emergency departments (EDs). Cognitive impairment (CI), including delirium and dementia, can be a common finding in this population and when undiagnosed, can be a significant contributor to morbidity and mortality. Our aim is to audit, against clinical standards, the assessment of cognitive impairment in those aged over 65 in the Birmingham City Hospital ED.

Standard

1. All patients aged over 65 are assessed for CI in ED, using a validated tool.
2. Whenever CI has been identified, there is documented evidence that this information was included in the ED discharge letter.

Methods

A retrospective pre- and post-intervention audit method was used. Intervention included educational posters displayed amongst clinical areas within the ED and raising clinician awareness on the topic during clinical handovers and educational teaching sessions.

Results

In the pre-intervention period, 7 out of a total of 240 (2.9%) patients had written evidence of a cognitive assessment using a validated tool and this improved to 13 out of a total 100 patients (13%) in the post-intervention period. AMTS was found to be the most common tool used. Communication of any identified cognitive impairment to GP increased from 0 out of 4 identified patients (0%) in pre-intervention period to 3 out of 6 patients (50%) post-intervention.

Conclusion

Despite the potential significant impact of cognitive impairment in older people, there is very little documented evidence of cognitive assessment within our emergency department. We demonstrate an improvement in this following intervention. However, the proportion of cognitive assessments being done remains low.

Introduction: Anti-psychotics and benzodiazepines are commonly prescribed for older people. They are usually indicated in the short term for delirium and agitation. There are known risks associated with these drugs in the older population including functional decline, increased falls risk and overall mortality. Moreover, chemical sedation is a form of restraint and deprives patients of their liberty. Sedative prescribing should be protocol driven and preceded by non-pharmacological intervention. However, these prescriptions are often initiated prematurely and evade review, continuing in the long-term.

Method: Our QI team aimed to reduce prescribing of new sedating drugs by 60% in patients using an MDT approach. Our strategies focused on increasing awareness and utilisation of existing protocols, to improve non-pharmacological management of delirium. This was achieved through the strategic delivery of teaching sessions for nursing, pharmacy and medical staff. Further, we utilised force function techniques and management charts to encourage review of these prescriptions. We gathered our data on a weekly basis over a five-month period by reviewing all prescribed medicines for patients on an older people’s ward.

Results: We exceeded our initial aim achieving a reduction of 82% in the prescribing of new lorazepam and haloperidol. We also attained a significant and sustained uptake of over 95% in the use of the delirium protocol. Where a review sticker was used, 80% led to discontinuation of the target prescription. Although these improvements were focused on one ward, the wider changes and improvements were observed throughout the hospital.

Conclusion: The significant reduction in sedative prescribing demonstrates the need and potential for improving the quality and safety of this aspect of patient care. The wider success of this project highlights the importance of addressing human factors to drive and sustain change. Improving the understanding of MDT members is integral to changing behaviours and improving patient safety.

During the pandemic, diagnosing Dementia has declined significantly by over 35%. A Collateral history refers to information obtained from individuals other than the patient, such as family members, friends, or caregivers. This information is often crucial and can provide valuable insights into a patient's medical history, symptoms, behaviours, and social circumstances. Studies have proven a collateral history can enhance medical assessment, improve treatment planning, aids safety concerns and act as a diagnostic aid. By obtaining information from multiple sources, Doctors can compare the patient's account with the observations and experiences of others. This can help in corroborating or identifying discrepancies, leading to a more accurate diagnosis. 

A convenient sample of 20 patients investigating the benefit of a collateral history using it as enhanced information to aid diagnosis of dementia earlier, and in turn, commencing treatment earlier.  

Results showed the collateral history provided more information enabling diagnosis of a delirium or a diagnosis of dementia. If it appeared the diagnosis was dementia, the information was relayed in a multiple disciplinary approach and with multidisciplinary agreement, treatment commenced. 

Early diagnosis of dementia is crucial as it allows for timely intervention, better disease management, and improved quality of life for both patients and their families. Collateral history aids in this process by capturing subtle changes in cognition and behaviour that may not be evident during routine clinical assessments. It provides a broader perspective on the patient's functioning over time and helps differentiate between normal aging and pathological cognitive decline. 

It is important to consider the collateral history limitations as a tool and use it in conjunction with other diagnostic tools to ensure an accurate and comprehensive evaluation.  

Introduction:

A scoping exercise in a residential dementia care home identified high numbers of falls occurring in residents’ bedrooms at night. Assessment and reduction of risk was often difficult since many falls were unwitnessed, and residents had poor recall. Collaborative working between Lewisham Community Falls Service (CFS); and Lewisham Linkline Service; involved the use of the ‘Just Checking’ monitoring system to enhance multifactorial falls assessment.

Method:

The Occupational Therapist (OT) in the CFS completed an initial multifactorial falls assessment. This helped to determine if data on night-time activity would be beneficial. This was discussed with care home staff and patient’s family prior to installation by the Telecare Specialist. The system was left insitu for four weeks with regular analysis of data by the OT and Telecare Specialist.

Results:

Resident A was a new admission with a recent dementia diagnosis and an injurious fall at home. 'Just Checking' was installed to monitor night time orientation and if he used his walking aid. He was refusing to keep a light on and was resistant to staff entering his room for checks. 'Just Checking' data guided intervention which included installation of motion centred lights. The resident started to use his walking aid at night without staff involvement. Resident B who had moderate to severe dementia, had demonstrated some challenging behaviours at night which increased his falls risk. 'Just Checking' data showed that he was restless throughout the night. This lack of quality sleep was identified as a key falls risk factor. Further exploration of his life story found that he had been a night worker for many years. Care home staff changed his day/sleep patterns. He experienced no further falls.

Conclusion:

Used as an adjunct to multifactorial falls assessment; ‘Just Checking’ can provide valuable data to understand falls risk and improve resident safety.

Introduction: Scotland's National Dementia strategy (2017) highlights the need to improve identification and management of dementia. Hospital at Home (H@H) teams often identify undiagnosed cognitive decline as part of comprehensive geriatric assessment. A trainee ANP in dementia services was appointed in 2019 in West Lothian; before this, the average waiting time to memory clinic assessment was 6 months for a home visit, and 12 months for outpatient clinic review. Affiliated with REACT H@H, the ANP identified a significant unmet need for assessment of cognitive decline in a patient cohort referred to H@H.

Method: Baseline data from patients reviewed by the dementia ANP was collected between Sept 2021 – Feb 2022, including referrals from H@H. A new pathway was then introduced to streamline referrals including education and upskilling of the H@H team. Further data was collected between Sept 2022 – February 2023.

Results: In the first cohort, 161 patients were assessed by the Dementia ANP, of which 39 (24%) had been referred from H@H. 60 patients (37%) were seen as a home visit, and 101 (63%) in clinic. 2 (1%) of referrals were managed with advice only. 125 patients (78%) were given a diagnosis of dementia; other diagnoses included delirium, low mood and anxiety. In the second cohort, 168 patients were assessed by the Dementia ANP, 39 (23%) being referred from H@H. 94 (56%) were seen in clinic and 74 (44%) as home visits. 10 (6%) of referrals were managed with advice only. 138 (82%) were given a diagnosis of dementia. Time to diagnosis assessment of dementia was reduced to 1 month for home assessment, and to 4 months for outpatient clinic assessment.

Conclusion Appointment of a Dementia ANP and integration with H@H  services improves time to assessment and diagnosis of dementia.