Older People & Complex Health Needs 2021

A list of ACF 2021 projects within the speciality of Geriatric Medicine.

Project lead: Prof Simon Conroy: spc3@le.ac.uk

The vison of these posts is to improve outcomes for older people across the whole system. Accordingly, there are a number of projects that relate to improving care and outcomes for older people in the emergency department, cancer services and primary care.


Loneliness

Loneliness is a complex issue with many causes and outcomes that requires an approach that takes into account its complexity. We have used the methods of realist evaluation to study loneliness interventions in Leicester and Leicestershire. By analysing and combining information from policy and strategy documents, data on services in the region and interviews with service users and service providers it was possible to categorise loneliness by a predominant driver and provide a list of interventions which may help improve outcomes. The ACF/ACL will be involved in working with stakeholders to develop a collaborative project to prospectively evaluate loneliness interventions, thus filling an important evidence gap that will inform local and national policy.

 

Cancer care

This project will allow the ACF/ACL to build upon a recently completed NIHR HSDR project (acute hospital care for frail older people), which attempted to embed frailty attuned care within oncology services.  In Leicester Cancer services, the provision of specialist care in this area is a strategic priority.  The ACF/ACL will work with oncologists and geriatricians to design, develop and eventually evaluate a frailty attuned care pathway. There will be opportunities to use bid data (for example the Hospital Frailty Risk Score), as well as mixed methods to design the intervention. There are also opportunities to collaborate with the Specialised Clinical Frailty Network (an improvement collaborative that has focused upon frailty attuned care in specialised services, including cancer chemotherapy).  The Cancer Centre Clinical Academics have an excellent track record in supporting ACF/ACLs.  The Hope Clinical Trials Unit is a purpose built early phase facility, central to the research infrastructure which is embedded within the NHS service.  This provides a stimulating environment with a multidisciplinary research team and a large patient population.  Bespoke training opportunities for the ACF/ACL would be available depending on their chosen specialism; nationally there is a plan to develop the field of Geriatric Oncology and therefore the training would be designed to aligned with this.

 

Urgent care

Urinary Tract Infection (UTI) is especially common in older people; whilst in most people UTI is usually a relatively self-limiting condition, in older people with frailty it can be associated with catastrophic deterioration and poor outcomes. Non-specific presentations, highly prevalent asymptomatic bacturia and poorly validated near patient tests make the diagnosis (and management) of UTI especially difficult in frail older people in the urgent care context. Given that it is not currently clear how to diagnose UTI, a common condition with poor outcomes in older people with frailty, we propose to undertake a cohort study to examine the clinical, blood and microbiological phenotype of UTI and examine the role of novel near patient tests. This will include a range of discovery biomarkers found in blood, urine and breath. As the cohort will include a number of older people with non-specific presentations and a range of underlying precipitating causes, there will be ample opportunity for an ACF/ACL to develop an interest in this area from a range of perspectives.

 

Care Homes

Care home residents are typically the ‘oldest old’ and the ‘frailest frail’ and research is needed to shape the personalised, high quality services that are envisioned in the NHS plan to meet the needs of this vulnerable group.  Particular areas of interest include:

(i)         Training and development: This project will involve a detailed literature review, mixed methods research (to understand the learning needs and preferences of staff) and the opportunity to develop and evaluate learning materials.

(ii)        Clinical communication: This project will use human factors and ergonomics (HFE) techniques to understand and strengthen clinical communication in care homes, with ethnographic observation and focus groups to study clinicians’ views and experiences of communication.

(iii)        Escalation of treatment: It is recognised that a wide range of non-clinical factors influence decisions about escalation of treatment in care home residents. This project will complement an ongoing study and will use qualitative methods to explore hospital transfers from the perspective of paramedics and primary care professionals

 

Uncertainty in Healthcare

More older people are living with frailty, multi-morbidity and polypharmacy. They require holistic and person-centred care, requiring clinicians and patients to engage and communicate effectively in uncertain situations (when it is unclear from existing scientific information how treatments may affect an individual in their unique circumstances, and which treatment may be best in individual circumstances). Uncertainty is ubiquitous within healthcare decision-making but its impact on older people, carers and professionals is poorly understood.  This project will evaluate interventions to support professionals and patients in uncertain situations, using qualitative and psychometric methods.


Project Lead: Dr Victoria Haunton vjh12@le.ac.uk

Project 1) Cerebral haemodynamics in ageing, mood, and cognitive disorders:

We have a strong track record in studies investigating the physiological changes to cerebral haemodynamics associated with ageing and age-related disorders (dementia, Parkinson’s disease, stroke). This project would seek to continue this work by exploring alterations in neurovascular coupling and dynamic cerebral autoregulation in chronic (i.e. mild cognitive impairment, Alzheimer’s disease, vascular dementia), and acute (i.e. delirium) cognitive disorders, and mood disorders in older people. Acute cognitive disorders such as delirium, significantly increase the risk of future dementia. This project would focus on identifying predictive physiological (haemodynamic) markers of future dementia in people with acute delirium. This will help further our understanding of the pathological mechanisms of conversion from acute to chronic cognitive disorders, but also highlight possible new therapeutic approaches to dementia risk reduction.

Disturbances of cerebral haemodynamics in depression have been demonstrated, but are poorly understood and research in this field has been limited. Furthermore, depression and cognitive function are closely linked, and depression can potentiate and exacerbate cognitive decline. This project will investigate the relationship between altered cerebral haemodynamics, mood disorders, and cognitive function. This will further our understanding of the complex interplay between these factors.

This post will provide an excellent grounding in translational research, and the opportunity to scale, via funded fellowship programmes, to projects investigating novel disease mechanisms, biomarkers, and potential therapeutic approaches through clinical trials.

Project 2) Cerebral Haemodynamics in Transient Ischaemic Attack: (Haunton, Robinson, Panerai, Minhas)

Transient Ischaemic Attack (TIA) affects 46,000 new patients each year in the UK, and is strongly predictive of future stroke.  Age is a strong risk factor.  Cerebral autoregulation (CA), which is the ability of the brain to maintain a relatively constant cerebral blood flow (CBF) in response to significant changes in perfusion pressure, is known to be altered in acute stroke (and is an important prognostic factor), but this is less well established in patients with TIA.  Our group has long standing research strengths in the use of Transcranial Doppler (TCD) ultrasound to study cerebral autoregulation and now plan to use this expertise to study TIA patients in a similar case-control study.  Participant recruitment will be from the specialist TIA clinic at University Hospitals of Leicester NHS Trust.

Project 3) Haemodynamic Mechanisms in Post-Stroke Cognitive Impairment (Haunton, Robinson, Panerai, Beishon)

30% of patients with stroke or TIA will be left with long term cognitive impairment.  Recent data from the Oxford Vascular Study suggests that TIA alone can bring forward the prevalence of dementia by two years, rising to 25 years with increasing stroke severity.  Impaired cognitive function is a key priority and un-met need for patients post-stroke, with patients experiencing loss of work and productivity, and poorer quality of life.  In a systematic review and meta-analysis we found clear abnormalities in cerebral hemodynamic and oxygenation parameters, even at early stages of cognitive decline. Further work using Transcranial Doppler ultrasound is planned to investigate the use of cerebral hemodynamic and oxygenation parameters as a sensitive biomarker for dementia.  We hypothesise that we may be able to use cerebral haemodynamic data to identify those patients at risk of post-stroke cognitive impairment, and to trial novel therapeutic strategies.

 

Project Lead: Dr Mervyn Thomas, mt350@le.ac.uk

Two project areas are available within this ACF:

Project 1: Multi-modal imaging to predict risk and clinical sequelae in stroke

Studying the neurosensory retina and retinal vasculature offers a unique opportunity to non-invasively visualise and quantify vascular and central nervous system health. Changes in retinal microvasculature have been identified as independent predictors for hypertension, diabetes, coronary disease, renal disease, and stroke. Moreover, retinal microvascular changes can precede clinical manifestation of end organ damage (for example a cerebrovascular accident). Therefore, this has predictive value and potential window for aggressive risk reduction, thus reducing associated morbidity. Previous approaches have used qualitative descriptors (such as silver wiring, presence of A-V nipping) to assess retinal vascular changes. Differences in retinal vasculature have been described in different types of stroke, for example retinal venules are wider and arteriovenous ratios are smaller in patients with lacunar stroke compared with those in patients with cortical strokes. With deep learning approaches it is now possible to combine both qualitative descriptors (using qualitative coding) with retinal vascular morphometric parameters (from fundus photos) to develop novel risk prediction systems or surrogate biomarkers. This will be achieved in two phases, giving unique training opportunities for the ACF:

 

1)     Training dataset (retrospective): We will utilise UKBIOBANK data and our local dataset annotated with previously published and validated stroke prediction scores. This will form the basis of our training dataset for a novel convolutional neural network (CNN). In this phase of the project the ACF will be supervised by the Professor Yu-Dong Zhang and his team providing training on computational approaches to deal with large datasets, ground truth annotation and building CNNs.

 

2)     Prospective testing: The ACF will subsequently work closely with the clinical teams performing an exploratory pilot study by recruiting and testing the new CNN on patients (independent dataset) from both rapid access TIA clinics, ophthalmology clinics and the hyperacute stroke unit (with range of stroke subtypes and severities). Thus overall, it will include a mixed cohort of patients with confirmed stroke and stroke mimics in addition to healthy individuals.

 

Project 2: Biomarkers of haemorrhagic stroke using high resolution enhanced depth imaging (EDI) of the optic nerve

Identification of stroke subtypes is important due to treatment and prognostic implications. Previous work using ultrasound has shown that the diameter of optic nerve sheath has moderate accuracy in differentiation of haemorrhagic and ischemic stroke. With the advent of optical coherence tomography (OCT) we are now able to obtain ultra-high resolution (<3µm) images of the retina and optic nerve. Moreover, the OCT scans are non-invasive and can be obtained in <5 seconds. Most OCT devices are table mounted thus making it inaccessible to bed bound and acutely unwell patients. In Leicester, we have developed fast acquisition and analysis protocols using a handheld OCT device. These have been developed for paediatric imaging; however, we anticipate it can have more widespread use. Recently, using our handheld OCT device we have developed methods to acquire enhanced depth imaging (EDI) thus improving measurements of optic nerve parameters in adults. In this pilot feasibility and diagnostic accuracy study the trainee will investigate the role of handheld OCT in differentiating haemorrhagic and ischaemic stroke. The trainee will also explore various optic nerve parameters including Bruch’s membrane complex orientation, optic nerve sheath diameter and optic nerve head morphology to monitor changes in intracranial pressure in haemorrhagic stroke.  Performing serial OCT-EDI scans to monitor optic nerve changes in relation to treatments could potentially provide a non-invasive objective measure of therapeutic response in haemorrhagic stroke.

Both projects will provide a strong foundation for a subsequent doctoral research fellowship application.


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