Older people and complex health needs

Urinary Tract Infection (UTI) is common in older people. It can precipitate serious conditions like falls and acute confusion ('delirium'). However, the ability to accurately diagnose it is severely hampered by the lack of accurate and reliable bedside tests. The most commonly used is the urine dipstick test, but its accuracy is no better than tossing a coin (50-50).

We are planning a program of work that will help clinicians better assess, diagnose and treat UTI in older people with urgent care needs.

Firstly we will study the status quo, focusing on urgent care settings, so that any advances in the field can be put into the context of current management. Secondly, we will study a cohort of over 1,000 older people with possible UTI, and apply a number of tests, both existing and some more 'blue-sky' to see if they help clinicians make a better diagnosis. Thirdly, we will develop training materials to help clinicians use the new tools; this might include an 'app' or other computer-based algorithm. Finally, we will undertake simulation of the use of the new diagnostic approach to decide if it is ready to be rolled-out across the NHS, needs more research, or shouldn’t be used at all. Orthostatic hypotension (low blood pressure on standing) is common in Parkinson’s disease (PD) and is associated with falls and reduced quality of life. Recently, it has also been linked with the development of memory problems.  However, this link is not well understood. Post-stroke dementia is where dementia occurs after a stroke. It affects up to 40% of stroke patients. It is thought that abnormal brain blood flow may play a part in both these conditions.

Our group has expertise in using Doppler ultrasound to study brain blood flow. The ACF will use Doppler ultrasound to study brain blood flow in patients with one of these conditions. By better understanding the links between brain blood flow and memory problems, we hope that we may be able to use brain blood flow to identify patients at risk of memory problems, and to develop treatments to help.

Two specific project areas are available:

UTI

In older people with frailty, Urinary Tract Infection (UTI) is common in older people with frailty and can be associated with catastrophic deterioration and poor outcomes. Typical symptoms of UTI might not be present – for example, the presenting feature might be delirium, as opposed to the more typical dysuria and/or urinary frequency. In addition, Asymptomatic Bacturia may be present which means that urine dipstick tests and urine cultures might be positive despite in the absence of clinical symptoms or signs. These issues can make the assessment and diagnosis of UTI more difficult. Near patient assessments, such as urine dipstick testing, have not been well validated in older people with frailty and non-specific presentations and it is not currently clear how to diagnose UTI. We propose to undertake a cohort study to examine the clinical, rheological 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.

Cerebral autoregulation in Parkinson’s disease related Orthostatic Hypotension (OH) and Post stroke Cognitive Impairment

Orthostatic Hypotension (OH) affects up to 60% of patients with idiopathic Parkinson’s disease (PD) and is associated with falls and significant reductions in quality of life. Recently, it has also been identified as an independent risk factor for cognitive decline, and is linked to specific impairments in attention, verbal episodic memory, and visuospatial skills. The link between OH and cognitive decline in PD is poorly understood. Post stroke dementia is defined as dementia following a diagnosis of symptomatic stroke, and it affects between 7% and 41% of stroke patients. Post stroke cognitive impairment (PSCI) is a broader term encompassing all cognitive deficits occurring following stroke. Vascular mechanisms have been proposed as a causal mechanism for both OH and PSCI. Our group has long standing research strengths in cardio-and cerebro-vascular haemodynamics in both stroke and healthy ageing, and now plan to use their expertise to study both OH and PSCI. Using Transcranial Doppler, and arterial blood pressure monitoring, this ACF will study cerebral haemodynamics in patients with PD and OH and/or PSCI. By understanding the relationships between cerebral autoregulation and blood pressure in the development of PSCI/OH we hypothesise that we may be able to use cerebral autoregulation and other haemodynamic data to identify those patients at risk of PSCI/OH related cognitive decline, and to devise novel therapeutic strategies for these debilitating disorders.

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