Management Of Older People Research Articles

Continuous Glucose Monitoring in Comorbid Dementia and Diabetes: The Evidence So Far.

Type 2 diabetes mellitus (T2DM) and dementia are two of the leading chronic diseases in aging and are known to influence each other's disease progression. There is well-established evidence that T2DM increases the risk for cognitive decline and dementia. At the same time, people with cognitive changes or dementia can find it difficult to manage their diabetes, resulting in hyper- or hypoglycemic events which can exacerbate the dementia disease progression further. Monitoring of glucose variability is, therefore, of critical importance during aging and when people with T2DM develop dementia. The advent of continuous glucose monitoring (CGM) has allowed the monitoring of glucose variability in T2DM more closely. The CGM seems to be highly feasible and acceptable to use in older people with T2DM and has been shown to significantly reduce their hypoglycemic events, often resulting in falls. Less is known as to whether CGM can have a similar beneficial effect on people with T2DM who have cognitive impairment or dementia in community or hospital settings. The current perspective will explore how CGM has made an impact on T2DM management in older people and those with comorbid cognitive impairment or dementia. We will further explore opportunities and challenges of using CGM in comorbid T2DM and dementia in community and hospital settings.

Evaluating pain management in older people after orthopaedic surgery - a study in Jordan.

Pain management in older people presents unique challenges due to age-related physiological changes, altered responses to medicines, comorbidities and polypharmacy. These challenges, which are exacerbated in those aged ≥75 years, can compromise the efficacy and safety of pharmacological treatment, including after discharge following orthopaedic surgery. To evaluate pain management and follow-up care provided in primary care settings in Jordan to older people who had undergone orthopaedic surgery. For this descriptive study, data were collected from the discharge summaries and electronic health records of older people who were receiving support from community nurses in rural primary care units in the Aqaba Governorate in Jordan after undergoing orthopaedic procedures in hospital. Of the 100 participants, 63 lived in a nursing home and 30 had been diagnosed with dementia. Hip fractures, diagnosed in 56 participants, were the most common reason for surgery. Thirty-two participants had a documented post-discharge follow-up plan regarding pain management in primary care. Of the 90 participants who were still being followed up 12 weeks after discharge, 51 (57%) were still being prescribed opioids for regular use or as required. Nurses have a crucial role in ensuring effective and safe pain management in older people, particularly when using opioids, due to the heightened risk of adverse effects and medicine interactions. Tailored pain management involves careful initiation of medicines; regular monitoring and assessment of pain levels, adherence to medicines and monitoring of potential side effects; and individualised follow-up plans.

Desprescribing antihypertensives in older people in primary care: subgroup analysis of the MINOR randomised clinical trial.

Polypharmacy is often required for older adults with hypertension, and excessive treatment is associated with a high risk of adverse reactions, including hypotension. To evaluate the deprescribing of antihypertensive medications guided by pharmacists using home blood pressure monitoring in older adults with hypotension. A subgroup of older adults with signs or symptoms of hypotension, included in the MINOR clinical trial, was analysed. In the MINOR procedures, each patient was provided with a device to conduct blood pressure measurement at home for 1week, following which a report was generated and shared with pharmacists (intervention group) or family physicians (control group). In the intervention group, a pharmacist suggested optimising pharmacotherapy; meanwhile, in the control group, a family physician alone determined the necessary treatment adjustments. Differences in mean blood pressure, the patients with symptoms/signs of hypotension, and the antihypertensive medication deprescribing between both groups were analysed. Seventy-two patients were evaluated (35, control group; 37, intervention group). The intervention group showed a significant reduction in medication prescriptions (- 28.6%; P < 0.001), especially beta-blockers (- 74.2%), loop diuretics (- 83.3%), and aldosterone antagonists (- 80%). The mean office blood pressure in the intervention group increased (14.1mmHg systolic and 6.9mmHg diastolic), remaining below the target range (140/90mmHg). The intervention group showed a significantly reduction in hypotensive symptoms than the control group (64.9% vs. 20%) (P < 0.001). The data highlight an important role for pharmacists in optimizing hypertension management in older people. Deprescribing antihypertensives can limit symptomatic hypotension. Registered on ClinicalTrials.gov under number NCT04861727.

Heart Failure in Older People Part 1: Disease State Review and Lifestyle Interventions.

The care for patients with heart failure (HF) has evolved greatly over the past decade. While new guidelines have provided more clarity on categorization and staging, and novel agents have been approved for use, there are still questions surrounding the optimal strategies as they relate to diet and exercise. Additionally, overall health care costs have increased for patients, driven in part by medication therapy. Given the myriad comorbidities associated with the diagnosis of HF, senior care pharmacists are positioned to positively impact the care for patients with HF, regardless of setting. As the guidelines continue to evolve, addressing a wider spectrum of the disease, including iron deficiency, mental health, and pain, so must the pharmacist's role in caring for patients with HF. Senior care pharmacists engaged in the management of older people with HF must be especially attuned to the unique and individualized care each patient needs, offering guidance and education in balancing treatment modalities across all aspects of care. In this three-part series, we will explore a number of areas central to the management of HF. This first section will focus on the cost of treatment, pathophysiology, and non-pharmacologic management. Series two and three will address guideline-directed medication therapy and special population management, respectively.

Management of Acute Coronary Syndromes in Older People: Comprehensive Review and Multidisciplinary Practice-Based Recommendations.

Managing health care for older adults aged 75 years and older can pose unique challenges stemming from age-related physiological differences and comorbidities, along with elevated risk of delirium, frailty, disability, and polypharmacy. This review is aimed at providing a comprehensive analysis of the management of acute coronary syndromes (ACS) in older patients, a demographic substantially underrepresented in major clinical trials. Because older patients often exhibit atypical ACS symptoms, a nuanced diagnostic and risk stratification approach is necessary. We aim to address diagnostic challenges for older populations and highlight the diminished sensitivity of traditional symptoms with age, and the importance of biomarkers and imaging techniques tailored for older patients. Additionally, we review the efficacy and safety of pharmacological agents for ACS management in older people, emphasizing the need for a personalized and shared decision-making approach to treatment. This review also explores revascularization strategies, considering the implications of invasive procedures in older people, and weighing the potential benefits against the heightened procedural risks, particularly with surgical revascularization techniques. We explore the perioperative management of older patients experiencing myocardial infarction in the setting of noncardiac surgeries, including preoperative risk stratification and postoperative care considerations. Furthermore, we highlight the critical role of a multidisciplinary approach involving cardiologists, geriatricians, general and internal medicine physicians, primary care physicians, and allied health, to ensure a holistic care pathway in this patient cohort.

Cancer Care in Elderly Patients; A Record Based Retrospective Analysis of Clinical Profile and Overview of Treatment

Background and Objective: Cancer can develop at any age, but the incidence of cancer rises dramatically at a later stage in life. Cancer management in older people can be complex. Comorbidity and Physiologic age-related changes can affect how and when cancer is diagnosed, whether or not treatment is offered and the individual tolerance to anticancer therapy. This retrospective study aimed to assess the clinical profiles of elderly cancer patient to optimize cancer care. Materials and Methods: This retrospective study comprised cancer patients attended our oncology department between 2018 to 2022 who were above the age ≥65 years. All the information regarding the type of cancer, performance status, intent of treatment, treatment completion and follow up status at 3 years were documented and analyzed. Results: A total of 230 patients were included in the study. The common malignancies were Carcinoma Head and Neck and Lung Cancer followed by Esophagus and Colorectal malignancies. Most of the patients presented with Performance Status of 1 (57.8%). The intent of therapy was curative in 49.1% and Palliative in 30.1% patients. At median follow up 36 months 15% of treated patients were on regular follow-up and they were alive without disease. Conclusion: Head and Neck Cancer was the most common cancer seen in our study. Elderly patients with cancer presented with good performance status, hence Elderly Cancer patients deserve same opportunity as younger patients for treatment and survival options.

Acute upper and lower gastrointestinal bleeding management in older people taking or not taking anticoagulants: a literature review.

Acute upper and lower gastrointestinal (GI) bleeding may be a potentially life-threatening event that requires prompt recognition and an early effective management, being responsible for a considerable number of hospital admissions. Methods. We perform a clinical review to summarize the recent international guidelines, helping the physician in clinical practice. Older people are a vulnerable subgroup of patients more prone to developing GI bleeding because of several comorbidities and polypharmacy, especially related to an increased use of antiplatelet and anticoagulant drugs. In addition, older patients may have higher peri-procedural risk that should be evaluated. The recent introduction of reversal strategies may help the management of GI bleeding in this subgroup of patients. In this review, we aimed to (1) summarize the epidemiology and risk factors for upper and lower GI bleeding, (2) describe treatment options with a focus on pharmacodynamics and pharmacokinetics of different proton pump inhibitors, and (3) provide an overview of the clinical management with flowcharts for risk stratification and treatment. In conclusion, GI is common in older patients and an early effective management may be helpful in the reduction of several complications.

Perioperative knowledge, self-efficacy and clinical practices related to postoperative delirium care in older people across geographical regions in Australia.

In older people undergoing surgery, there is a lower tolerance for complications. This highlights the need for documented clinical practices on proper prevention, pre-screening and management of complications such as postoperative delirium (POD). Evidence-based clinical practice guidelines exist for delirium management; however, the management of delirium in clinical settings differs widely. This study aims to develop an understanding of the knowledge, components of self-efficacy (confidence/competence), and clinical practice related to POD care among preoperative and recovery nurses across different types of geographical locations in Australia. A 27-item online survey was sent out to professional associations focused on perioperative care across Australia. The participants included practicing registered nurses specialising in perioperative care. The main outcome measures were Knowledge, confidence/competence and clinical practice relating to POD care in older patients. Respondents were categorised into two groups-major cities and rural and remote. Mean age was 46.3 years for respondents in Australian major cities and 49.5 for the comparison group. There was a statistically significant difference between Australian major cities and 'rural and remote' in confidence in detecting hyperactive delirium, 25.2% versus 11.7% respectively as well as managing hyperactive delirium, 13.8% versus 1.7%, respectively. Similar results were also observed on hypoactive delirium. Respondents from both groups did not mirror the ideal situation in managing a hyperactive delirium. Results from this study are inconclusive and there is no clear-cut observation in clinical practice or knowledge between the two geographical categories in this study. The absence of a distinct strategy with POD prevention highlights the need for a uniform approach and consensus on POD prevention and management in older people. This can be achieved by creating more awareness and education through professional development related to POD.

Concussion Management in Older People: A Scoping Review.

To map existing literature about concussion management in older people, identifying and analyzing gaps in our understanding. Concussion injuries affect older people, yet little guidance is available about how to approach concussion management with older people. Research does not always include older populations, and it is unclear to what extent standard concussion management is appropriate for older people. Scoping review. A structured literature search was conducted using 4 databases to identify existing literature relating to concussion management in older people. Studies that assessed outcomes relating to the management of concussion/mild traumatic brain injury in those 65 years or older were included and mapped according to the main themes addressed. The search yielded a total of 18 articles. Three themes related to early management (use of anticoagulants n = 6, intracranial lesions n = 3, and service delivery for older people n = 5), and 1 theme related to general management (cognitive issues n = 4). A lack of articles exploring general management in older people was observed. Existing literature indicates that specific management strategies are needed for older people with concussion, especially in early management. This review highlights that good evidence is available about early management and this is reflected in some guidelines, yet little evidence about general management is available and this gap is not acknowledged in guidelines. Distinct approaches to early management in older people are clearly recommended to mitigate the risk of poor outcomes. In contrast, general concussion management for older people is poorly understood, with older people poorly represented in research. A better understanding is needed because-as observed in early management-older people have distinct characteristics that may render standard management approaches unsuitable.

1866 The impact of patient and public involvement on partnership in the DREAM project

Abstract Introduction Patient and Public involvement is a cornerstone of the DREAM (Digital and Remote Enhancements for the Assessment and Management of older people) project. An advisory group of 10 diverse older people and carers was established to shape the research through regular discussions and explore inclusive involvement approaches for future work. Methods We conducted a reflective process evaluation to highlight the impact of the involvement process on the project and our public partners themselves. We collated impact logs, reflections and feedback from our public partners and an artist recorded the impacts using illustration. Results The advisory group: • helped to lay the foundations of the project and steered its development with their views, knowledge and experiences • shaped how evidence is captured and analysed so that it is usable, acceptable and makes sense to older people and carers • provided insights to consider for implementation and shaped our dissemination strategy Our public partners and researchers also expressed relational impacts such as shared ownership. Public partners joined this project to improve health care for other people. They felt safe to share their experiences and be listened to. It gave them confidence in their health management, and they have built friendships. People also found comfort in the diversity of individuals and sharing common concerns. Conclusion(s) Public partners have been instrumental in the development of the DREAM project and supported the programme by being a critical friend beyond the remit of the research. Continued communication and feedback resulted in public partners feeling heard and their suggestions acted upon. Researchers and public partners felt gratitude, ownership and joy working on this project, and finding shared values. Our involvement approaches have shaped reciprocal relationships and had impact on our research culture, forming a foundation to the values of the people it is serving.

Exploring multimorbidity clusters in relation to healthcare use and its impact on self-rated health among older people in India.

The conventional definition of multimorbidity may not address the complex treatment needs resulting from interactions between multiple conditions, impacting self-rated health (SRH). In India, there is limited research on healthcare use and SRH considering diverse disease combinations in individuals with multimorbidity. This study aims to identify multimorbidity clusters related to healthcare use and determine if it improves the self-rated health of individuals in different clusters. This study extracted information from cross-sectional data of the first wave of the Longitudinal Ageing Study in India (LASI), conducted in 2017-18. The study participants were 31,373 people aged ≥ 60 years. A total of nineteen chronic diseases were incorporated to identify the multimorbidity clusters using latent class analysis (LCA) in the study. Multivariable logistic regression was used to examine the association between identified clusters and healthcare use. A propensity score matching (PSM) analysis was utilised to further examine the health benefit (i.e., SRH) of using healthcare in each identified cluster. LCA analysis identified five different multimorbidity clusters: relatively healthy' (68.72%), 'metabolic disorder (16.26%), 'hypertension-gastrointestinal-musculoskeletal' (9.02%), 'hypertension-gastrointestinal' (4.07%), 'complex multimorbidity' (1.92%). Older people belonging to the complex multimorbidity [aOR:7.03, 95% CI: 3.54-13.96] and hypertension-gastrointestinal-musculoskeletal [aOR:3.27, 95% CI: 2.74-3.91] clusters were more likely to use healthcare. Using the nearest neighbor matching method, results from PSM analysis demonstrated that healthcare use was significantly associated with a decline in SRH across all multimorbidity clusters. Findings from this study highlight the importance of understanding multimorbidity clusters and their implications for healthcare utilization and patient well-being. Our findings support the creation of clinical practice guidelines (CPGs) focusing on a patient-centric approach to optimize multimorbidity management in older people. Additionally, finding suggest the urgency of inclusion of counseling and therapies for addressing well-being when treating patients with multimorbidity.

Vitamin B12 deficiency in older people: a practical approach to recognition and management

AbstractVitamin B12 deficiency is common in older people and is linked to anaemia, cognitive decline, and dementia. Clinical presentation is variable, ranging from no symptoms or subtle, non‐specific symptoms, through to serious, irreversible neurological symptoms if left untreated. Although common, it is often under‐recognised, with diagnosis usually occurring on incidental blood test screening. Older people are at increased risk of vitamin B12 deficiency due to insufficient dietary intake, malabsorption associated with aged‐related changes in gastrointestinal function, higher incidence of pernicious anaemia, and chronic use of interfering medications such as metformin and proton‐pump inhibitors. Early detection and treatment in symptomatic deficiency are crucial to prevent irreversible damage. Vitamin B12 intramuscular injection bypasses potential absorption issues and is traditionally the first‐line treatment in older people. However, emerging evidence suggests that high‐dose oral replacement may be as effective. Older people often require lifelong therapy due to the irreversible nature of the underlying cause of deficiency. This review provides an overview of vitamin B12 deficiency and its management in older people.

What happens when pharmacist independent prescribers lead on medicine management in older people’s care homes: a qualitative study

ObjectiveOlder people in care homes frequently experience polypharmacy, increasing the likelihood of medicine-related burden. Pharmacists working within multidisciplinary primary care teams are ideally placed to lead on medication reviews. A...

Rehabilitation Nurses’ Knowledge About Pain in Older Adults in Malta

PurposeRehabilitation nurses require adequate knowledge about pain to improve patient experience and quality of care. We explored nurses’ knowledge and attitudes towards pain in older adults in a large rehabilitation hospital in Malta. DesignA cross-sectional study. MethodsIn total, 130 nurses received a short survey, which gathered sociodemographic data, information regarding usual pain management, and prior education on pain. A modified version of the Knowledge and Attitudes Survey Regarding Pain (KASRP) with 18 questions was used, alongside the 24-item Pain in the Older Adults’ Knowledge Survey (POAKS). Non-parametric tests identified factors associated with KASRP and POAKS scores. ResultsOverall, 89 nurses completed the survey (response rate 68%). The median modified KASRP score was 50% (IQR 3.00), with only two nurses achieving the proposed “adequate” score of >80%. The median POAKS score was 79% (IQR 4.00). The only determinant of performance was nationality, with Maltese nurses performing better in POAKS than non-Maltese nurses (median 20.00 (3.00) vs. 16.50 (5.00); p = .003), indicating a possible language-related performance issue. Nurses scored poorly in some questions relating to analgesia administration, particularly opioids, as well as pain indicators and pain assessment. ConclusionsRehabilitation nurses have fair knowledge of pain management in older people but require further education, particularly in opioid indications for pain management, pain expression, and assessment.

Understanding frailty and pre-frailty to improve chronic wound management in older people: a study protocol

Understanding frailty and pre-frailty to improve chronic wound management in older people: a study protocol

Effects of case management based on preventing falls in older people: A systematic review.

Falls among older adults can lead to negative consequences with physical, functional, social, and psychological functioning, and a high prevalence of mortality. However, it is still unclear whether case management can reduce the number of falls in this population. The aims of this review were to analyze the effects of case management on preventing falls and reducing risk factors for falls in older people. A systematic review was conducted, searching for and synthesizing clinical trials involving case management in older people who had falls or risk for fall outcomes. Two authors extracted data using predefined data fields, and risk of bias was assessed by the Physiotherapy Evidence Database (PEDro) scale. Twelve studies were included in the final review. Case management in older people did not significantly reduce the number of falls, falls per person, or severity of falls compared to control groups. Adherence to recommendations in case management ranged from 25% to 88%. There is limited evidence of reduced rates of falls and specific risk factors for falls among people who received case management interventions. Randomized trials with good quality are needed.

Home care professionals' experiences of successful implementation, use and competence needs of robot for medication management in Finland.

To describe home care professionals' individual experiences of the implementation, use and competence needs of a robot for medication management in older people's home care. A qualitative focus group interview study. Data were collected during spring and autumn 2021 by semi-structured focus group interviews and analysed using inductive content analysis. The participants were 62 home care professionals working in older people's home care. The successful implementation and use of the robot for medication management consisted of a timely and adequate introduction before the implementation of the robot, the fluent usability of the robot in daily work, and confidence in work competence. There is a need for the reorganization of home care professionals' use of digital solutions to make workflow fluent, prevent burnout and turnover among home care professionals. Professionals' competence should also be developed to ensure that it corresponds to digitalized healthcare. No patient or public contribution.

Long-term care professionals' views on pharmacists: a qualitative study using Role Theory.

BackgroundQualitative research investigating pharmacists’ participation in Long-Term Care (LTC) within interdisciplinary teams is scarce.AimTo characterize how pharmacists’ participation in a national network of LTC is perceived by healthcare professionals and other key stakeholders.MethodIndividual, in-depth, semi-structured interviews of participants (nurses, physicians, pharmacists, and LTC researchers) enrolled purposively or through snowballing sampling techniques, with the final sample being comprised of fourteen participants. Data analysis followed a deductive coding approach framed by Role Theory and supplemented with an inductive coding for additional themes.ResultsFour Role Theory constructs were identified from the primary data—role identity, overqualification, ambiguity, underqualification. Clinical pharmacy services, logistics and educational activities were pointed out as representing the identity of pharmacists’ interventions. Despite the clear identification of LTC pharmacists’ interventions, pharmacist expertise on medicine optimization seemed to be underused (role overqualification), as a result of lack of time, lower proactivity in healthcare teams’ integration, and the absence of a legal framework targeted to LTC pharmacy practice (role ambiguity). Additional clinical training, including in the management of older people’s health conditions, nutrition, and palliative care were missing (role underqualification).ConclusionLTC pharmacists can provide essential services (e.g., clinical pharmacy, logistics, educational interventions), although additional training and a clearer legal framework are missing to better define pharmacists’ roles in LTC pharmacy practice.Supplementary InformationThe online version contains supplementary material available at 10.1007/s11096-022-01482-9.

Nursing assessment and management of nutrition in older people with cancer: An integrative review

BackgroundThere is a risk of malnutrition when older people are diagnosed with cancer, highlighting the need for nutritional assessments and appropriate management to be undertaken by healthcare professionals including nurses. The absence of a standardised assessment method and management of nutrition in older people creates a gap in clinical practice and warrants further research. AimThe aim of this review was to explore the current nutritional assessment methods and evidence-based interventions for improving nutritional outcomes in older people with cancer. MethodsAn integrative literature review was conducted using electronic databases. Papers were limited to those published in English between 2009 and 2021. Search terms included older adult, elder, geriatric, senior, cancer, nutrition, malnutrition, hospital, and inpatient across four databases: Embase, CINAHL, MEDLINE, and Scopus. Using the inclusion and exclusion criteria, 303 articles were screened. A Mixed Methods Appraisal Tool (MMAT) (2018) was used for quality appraisal. Concept analysis explored themes across the included articles. FindingsThe themes from the analysis of 10 primary research articles, which included 5,327 participants, were (i) types of nutritional assessment and (ii) management of older people with cancer. The main nutritional assessment scales used were the Mini Nutrition Assessment and Patient-Generated Subjective Global Assessment. ConclusionThe completion of a comprehensive nutritional assessment by health professionals, including nurses, could facilitate early dietary intervention in older persons with cancer. This would enable supportive dietary advice and supplementation to improve health outcomes.

MEdication Management in older people with Intellectual Disabilities (MEMID): a scoping review

Abstract Introduction Globally, around 1 in 100 adults have intellectual disabilities (ID) (synonymous with learning disability in the UK) (1) yet their needs in terms of healthcare in general and medication management in particular, are under-researched. People with ID have more comorbidities compared with those without ID and around one third of older people (≥ 50 years) with ID (OPwID) have two or more chronic conditions, putting them at risk of polypharmacy (use of multiple medicines) (2). Aim To undertake a scoping review to gather evidence on the barriers and facilitators in the medication management of OPwID from a multi-stakeholder (patient, carer and healthcare professional) perspective. Methods Standard scoping review methods were used. Electronic databases (Medline, PsycINFO) were searched from 2011-2021 using a range of search terms. Studies were included if they involved: OPwID without dementia (all types); healthcare professionals or caregivers caring for individuals with ID; problems related to medication use. The review was restricted to studies in the English language. The PRISMA-ScR checklist and reporting standards was used to conduct and report the review. Independent duplicate screening and data extraction was undertaken. The quality of studies was not formally assessed. A narrative synthesis was conducted to summarise the results and included barriers and facilitators associated with medicines management from patients’/carers’ and professionals’ perspectives. Results Eight studies were included, of which seven used qualitative methods. The majority of studies were undertaken in Europe ((the Netherlands (2), Norway (1), Belgium (1), UK (3)) and one was conducted in the US. Patients/carers reported several barriers/facilitators: The most cited barriers to medication management of OPwID from professionals’ perspective included: limited knowledge of, and training about, ID; nonadherence to guideline recommendation; and lack of coordination between different professionals in multidisciplinary teams. Conclusion/Discussion The review was restricted to two databases and the English language due to resource- and time-constraints. All the included studies were conducted in developed countries with different healthcare settings/practice. As such, the findings might not be generalisable to other less/under-developed countries or settings. There is limited empirical evidence regarding the medication management of OPwID, in particular, facilitators to medicines management from professionals’ perspective. OPwID are a highly vulnerable population for whom medications have an important role in managing their multiple morbidities. This review highlights an evidence gap regarding the medication management of these individuals. The results will be used to inform the development of personalised intervention(s) to improve the safe and effective use of medication in this population. References (1) Maulik PK, Mascarenhas MN, Mathers CD, Dua T, Saxena S. Prevalence of intellectual disability: a meta-analysis of population-based studies. Res Dev Disabil. 2011 Mar 1;32(2):419-36. (2) Hermans H, Evenhuis HM. Multimorbidity in older adults with intellectual disabilities. Res Dev Disabil. 2014;35(4):776–83.