BACKGROUND: In older patients with progressive neurodegeneration, replacing fixed implant-supported prostheses (FIP) with implant overdentures (IOD) has been proposed to prevent future mucosal injury and create an oral environment that is easier for caregivers to clean. However, there have been no reports on the progress after replacing FIP with IOD. In this report, we present the progress of an older patient with Parkinson\'s disease in whom FIP was replaced with IOD.
METHODS: An 81-year-old male patient with Parkinson\'s disease presented to our outpatient clinic with bruxism and crossbites. FIPs, with five Brånemark system implants, were placed in the bilateral lower molars. The FIP was replaced with an IOD with two locator attachments to create an oral environment that was easier for caregivers to clean and allow easy recovery of masticatory function if residual teeth were fractured in the care environment. As his systemic condition deteriorated, treatment was changed from outpatient to in-home visits. During dental care visits, professional oral cleaning and denture repair were continued, and good nutritional status was maintained. However, the patient developed cholecystitis and was hospitalized. During hospitalization, gastrostomy was performed because he developed aspiration pneumonia. After discharge from the hospital, the patient remained in bed all day and could not wear an IOD, resulting in buccal mucosa ulceration due to abrasion of the locator abutment. We decided to replace the abutment with cover screws; however, not all the implants could sleep submucosally. Although regular oral cleaning was resumed, new ulcers developed even when cover screws were installed. Additionally, swelling and drainage were observed at the peri-implant mucosal site where peri-implantitis had once occurred during an outpatient visit. The patient was readmitted to the hospital for a urinary tract infection, and subsequent visits were abandoned.
CONCLUSIONS: By replacing FIP with IOD in an older patient with Parkinson\'s disease, we addressed a barrier to caregiver-provided oral management. The removable prosthesis facilitated smooth oral care by caregivers and functional recovery in the event of trouble with residual teeth. However, it could not completely avoid the recurrence of buccal mucosal ulcers or peri-implantitis.

Patients with congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD) and dementia are underrepresented in specialist palliative home care (SPHC). However, the complexity of their conditions requires collaboration between general practitioners (GPs) and SPHC teams and timely integration into SPHC to effectively meet their needs.
To facilitate joint palliative care planning and the timely transfer of patients with advanced chronic non-malignant conditions to SPHC.
A two-arm, unblinded, cluster-randomised controlled trial. 49 GP practices in northern Germany were randomised using web-based block randomisation. We included patients with advanced CHF, COPD and/or dementia. The KOPAL intervention consisted of a SPHC nurse-patient consultation followed by an interprofessional telephone case conference between SPHC team and GP. The primary outcome was the number of hospital admissions 48 weeks after baseline. Secondary analyses examined the effects on health-related quality of life and self-rated health status, as measured by the EuroQol 5D scale.
A total of 172 patients were included in the analyses. 80.4% of GP practices had worked with SHPC before, most of them exclusively for cancer patients. At baseline, patients reported a mean EQ-VAS of 48.4, a mean quality of life index (EQ-5D-5L) of 0.63 and an average of 0.80 hospital admissions in the previous year. The intervention did not significantly reduce hospital admissions (incidence rate ratio = 0.79, 95%CI: [0.49, 1.26], P = 0.31) or the number of days spent in hospital (incidence rate ratio = 0.65, 95%CI: [0.28, 1.49], P = 0.29). There was also no significant effect on quality of life (∆ = -0.02, 95%CI: [-0.09, 0.05], P = 0.53) or self-rated health (∆ = -2.48, 95%CI: [-9.95, 4.99], P = 0.51).
The study did not show the hypothesised effect on hospitalisations and health-related quality of life. Future research should focus on refining this approach, with particular emphasis on optimising the timing of case conferences and implementing discussed changes to treatment plans, to improve collaboration between GPs and SPHC teams.

BACKGROUND: The seven tiered behavioural and psychological symptoms of dementia (BPSD) model of service delivery has been used by inpatient units. The classification of each tier is broadly defined and not always agreed upon by clinicians. The case study uses novel approach by combining the BPSD classification criteria with clinical presentation to identify the clinical characteristics of the case and match these characteristics against the BPSD classification. This process was enhanced by using case specific measures such as the Neuropsychiatric Inventory (NPI) and Cohen Mansfield Agitation Inventory (CMAI) scales and key clinical data.
METHODS: A case study of 76 year old male diagnosed with mixed Alzheimer\'s and Vascular dementia. The clinical presentation of the symptomatology was deemed to be extreme, thus fitting into the seventh tier (Extreme) of the BPSD model of service delivery. The case is considered to fit into the Extreme BPSD category given the high levels of aggression, which were consistently reflected in high scores on NPI and CMAI, as well as long length of inpatient stay (over 3 years). The average number of Pro re nata (PRN) psychotropics medications per month was 56 and seclusion episodes of 6 times per month, with each episode lasting on average 132 min shows severity of behaviours. His level of aggression had resulted in environmental damage and staff injuries.
CONCLUSIONS: We recommend patient clinical characteristics, relevant hospital data and specific measures should be used to develop consensus around defining and classifying cases into Extreme BPSD.

BACKGROUND: The international scale and spread of evidence-based perioperative medicine for older people undergoing surgery (POPS) services has not yet been fully realised. Implementation science provides a structured approach to understanding factors that act as barriers and facilitators to the implementation of POPS services. In this study, we aimed to identify factors that influence the implementation of POPS services in the UK.
METHODS: A qualitative case study at three UK health services was undertaken. The health services differed across contextual factors (population, workforce, size) and stages of POPS service implementation maturity. Semi-structured interviews with purposively sampled clinicians (perioperative medical, nursing, allied health, and pharmacy) and managers (n = 56) were conducted. Data were inductively coded, then thematically analysed using the Consolidated Framework for Implementation Research (CFIR).
RESULTS: Fourteen factors across all five CFIR domains were relevant to the implementation of POPS services. Key shared facilitators included stakeholders understanding the rationale of the POPS service, with support from their networks, POPS champions, and POPS clinical leads. We found substantial variation and flexibility in the way that health services responded to these shared facilitators and this was relevant to the implementation of POPS services.
CONCLUSIONS: Health services planning to implement a POPS service should use health service-specific strategies to respond flexibly to local factors that are acting as barriers or facilitators to implementation. To support implementation of a POPS service, we recommend health services prioritise understanding local networks, identifying POPS champions, and ensuring that stakeholders understand the rationale for the POPS service. Our study also provides a structure for future research to understand the factors associated with \'unsuccessful\' implementation of a POPS service, which can inform ongoing efforts to implement evidence-based perioperative models of care for older people.

UNASSIGNED: Retropharyngeal abscess (RPA) is an uncommon infection in older people, which usually presents with localized upper airway symptoms.
UNASSIGNED: We present a case of RPA in a 69-year-old frail woman with co-morbidities, who presented atypically with delirium. She initially complained of general symptoms of malaise, body aches and general decline. Her symptoms progressed to hypoactive delirium before she started to localize her complaints to the upper airway. The delirium presentation of RPA is not commonly reported in the literature. Co-morbidities and frailty are likely to be the underlying risk factors for delirium presentation in this case. Most of the RPA cases reported in older people in the literature presented typically with localized symptoms, however these cases had lower burden of morbidities and reported no frailty. In our case report, poor mouth hygiene and dental caries were thought to be the source of infection. Early intervention with antibiotic treatment for total of four weeks resulted in a full recovery.
UNASSIGNED: RPA may present with delirium in older people with frailty and co-morbidities. Poor oral hygiene and dental caries, if left untreated, may progress into serious deep space neck infection.

This study aimed to explore the motivations, attitudes, care management strategies and training needs of paid caregivers. Data were collected through 51 semi-structured interviews with paid caregivers and analyzed using thematic analysis. Their motivations included economic stability, the inability to secure other employment, a desire to secure independence through regularly paid employment and a passion and a love of caring. Their role involved being a key communicator of care between medical personnel and relatives, and participants emphasized the importance of paid caregivers being loving, caring, calm, patient, having the ability and willingness to cope with challenging situations. They outlined some specific challenges of the role of caregiving and expressed the importance of gaining recognition for the role as well as the need for bespoke and tailored training to underpin it. This study adds to the growing international literature around the needs of the paid carer workforce and has the potential to inform policy and training around the provision of a better-equipped workforce to meet the growing needs of the aging population.

OBJECTIVE: Identify the incidence of intracranial haemorrhage in people from residential aged care facilities following falls who had a CT head performed. The secondary objectives were to identify predictor variables for intracranial haemorrhage to inform person-centred shared decision making.
METHODS: Retrospective chart review of aged care residents who presented to ED with a triage of fall. Documented evidence of vomiting, headache, external signs of head injury, deviation from baseline neurology and the presence of anticoagulation or antiplatelet agents was reviewed. The rates of CT head, intracranial haemorrhage, emergent interventions, disposition and mortality were assessed.
RESULTS: Of the 2546 presentations, 1732 (68.0%) had a CT head and intracranial haemorrhage was found in 76 (4.4%) patients. External signs of head injury and deviation from neurological baseline have a strong association with intracranial haemorrhage in 26 (22.2%) patients, only 4 (0.61%) patients with intracranial haemorrhage had neither. There was a strong association between these clinical features and identification of intracranial haemorrhage on CT head. Anticoagulation and antiplatelet use had no association with intracranial haemorrhage. A 30-day mortality was increased in patients with deviation from neurological baseline. No neurosurgical intervention was performed, and there was inconsistent advice regarding anticoagulation or antiplatelet agents.
CONCLUSIONS: Deviation from neurological baseline or external signs of head injury may be predictors of intracranial haemorrhage. Vomiting, headache, anticoagulation or antiplatelets were not associated with intracranial haemorrhage. A person-centred decision-making approach, that is informed by treatment options could better guide clinicians on when to order a CT head after a fall.

Older people living in their homes might experience growing loneliness, detachment from their social environment, and decreased functional ability. In this community case study, we report on a project we initiated to enhance the functional ability of older people by creating musical life reviews (MLR) with them. We connected seven of our music therapy graduates (MT) to older people living in the neighborhood across the street from campus. MTs were first trained to work by a protocol for creating MLRs with older people, developed by the authors of this article. They then worked with older people from the neighborhood for 10 one-on-one sessions, on personally tailored MLRs. MTs kept on meeting in weekly group supervision sessions, thus learning from each other- and forming a community of their own. Participants expressed their high satisfaction with the process and reported that their MLRs became increasingly important to them. Most of them were interested in taking their MLR one step ahead, and playing it to family and/or friends, and, as part of the process, planned a personal event to do this. Further, two big community events were initiated by participants and MTs. To conclude, we show how the community project enhanced the functional ability of those participating in it. We also point at possible challenges and recommendations for further implementation of the project.

Myasthenia gravis (MG) is a rare autoimmune neuromuscular disorder characterised by varying degrees of skeletal muscle weakness. Diagnosing MG represents a challenge for clinicians due to the diversity of disease manifestations. We present an unusual case of this disease in an older gentleman in which the patient reported swollen tongue and lips which was incorrectly diagnosed and treated as angioedema. Months later, he developed progressive dysphagia, dysarthria and weight loss. The diagnosis was further delayed by the identification of a hiatal hernia and Zenker\'s diverticulum after extensive investigation for dysphagia. A total of 15 months on prompted by persistent symptoms, the patient was found to have MG by positive antibody test and Electromyogram. Treatment was initiated which led to a rapid and significant relief of his symptoms.

Falls in older people are common, leading to significant harm including death. Coroners have a duty to report cases where action should be taken to prevent future deaths, but dissemination of their findings remains poor.
To identify preventable fall-related deaths, classify coroner concerns and explore organisational responses.
A retrospective systematic case series of coroners\' Prevention of Future Deaths (PFD) reports, from July 2013 (inception) to November 2022.
England and Wales.
Reproducible data collection methods were used to web-scrape and read PFD reports. Demographic information, coroner concerns and responses from organisations were extracted and descriptive statistics used to synthesise data.
Five hundred and twenty-seven PFDs (12.5% of PFDs) involved a fall that contributed to death. These deaths predominantly affected older people (median 82 years) in the community (72%), with subsequent death in hospital (70.8%). A high proportion of cases experienced fractures (51.6%), major bleeding (35.9%) or head injury (38.7%). Coroners frequently raised concerns regarding falls risks assessments (20.9%), failures in communication (20.3%) and documentation issues (17.5%). Only 56.7% of PFDs received a response from organisations to whom they were addressed. Organisations tended to produce new protocols (58.5%), improve training (44.6%) and commence audits (34.3%) in response to PFDs.
One in eight preventable deaths in England and Wales involved a fall. Addressing concerns raised by coroners should improve falls prevention and care following falls especially for older adults, but the poor response rate may indicate that lessons are not being learned. Wider dissemination of PFD findings may help reduce preventable fall-related deaths in the future.