ObjectivesPolypharmacy and multimorbidity are common in long-term care facilities (LTCFs). Reducing polypharmacy may reduce adverse events and maintain quality of life. Deprescribing refers to reducing medications after consideration of therapeutic goals, benefits and risks, and medical ethics. The objective was to use nominal group technique (NGT) to generate then rank factors that general medical practitioners (GPs), nurses, pharmacists and residents or their representatives perceive are most important when deciding whether or not to deprescribe medications.DesignQualitative research using NGT.SettingParticipants were invited if they worked with, or resided in LTCFs across metropolitan and regional South Australia.Participants11 residents/representatives, 19 GPs, 12 nurses and 14 pharmacists participated across six separate groups.MethodsIndividual groups of GPs, nurses, pharmacists and residents/representatives were convened. Using NGT each group ranked factors perceived to be most important when deciding whether or not to deprescribe. Then, using NGT, the prioritised factors from individual groups were discussed and prioritised by a multidisciplinary metropolitan and regional group comprised of resident representatives, GPs, nurses and pharmacists.ResultsNo two groups had the same priorities. GPs ranked ‘evidence for deprescribing’ and ‘communication with family/resident’ as most important factors. Nurses ranked ‘GP receptivity to deprescribing’ and ‘nurses ability to advocate for residents’ as most important. Pharmacists ranked ‘clinical appropriateness of therapy’ and ‘identifying residents’ goals of care’ as most important. Residents ranked ‘wellbeing of the resident’ and ‘continuity of nursing staff’ as most important. The multidisciplinary groups ranked ‘adequacy of medical and medication history’ and ‘identifying residents’ goals of care’ as most important.ConclusionsWhile each group prioritised different factors, common and contrasting factors emerged. Future deprescribing interventions need to consider the similarities and differences within the range of factors prioritised by residents and health professionals.

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Despite the significant advancements being made in the neurogenetics for mental health, the identification and validation of potential endophenotype markers of risk and resilience remain to be confirmed. The TWIN-E study (The Twin study in Wellbeing using Integrative Neuroscience of Emotion) aims to validate endophenotype markers of mental health across cognitive, brain, and autonomic measures by testing the heritability, clinical plausibility, and reliability of each of these measures in a large adult twin cohort. The specific gene and environmental mechanisms that moderate prospective links between endophenotypephenotype markers and the final outcome of wellbeing will also be identified. TWIN-E is a national prospective study with three phases: I) baseline testing on a battery of online questionnaires and cognitive tasks, and EEG, MRI, and autonomic testing; II) 12-month follow-up testing on the online assessments; and III) randomized controlled trial of brain training. Minimum target numbers include 1,500 male/female twins (18-65 years) for the online assessments (Phase I and II), 300 twins for the EEG testing component, and 244 twins for the MRI testing component. For Phase III, each twin out of the pair will be randomized to either the treatment or waitlist control group to test the effects of brain training on mental health over a 30-day period, and to confirm the gene-environment and endophenotype contributions to treatment response. Preliminary heritability results are provided for the first 50% of the MRI subgroup (n = 142) for the grey matter volume, thickness, and surface area measures, and white matter diffuse tensor imaging fractional anisotropy.

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ObjectiveTo evaluate a holistic multidisciplinary outpatient model of care on hospital readmission, length of stay and mortality in older patients with multimorbidity following discharge from hospital.Design and ParticipantsA pilot case-control study between March 2006 and June 2009 of patients referred on discharge to a multidisciplinary, integrated outpatient model of care that includes outpatient follow-up, timely GP communication and dial-in service compared with usual care following discharge, within a metropolitan, tertiary referral, public teaching hospital. Controls were matched in a 4:1 ratio with cases for age, gender, index admission diagnosis and length of stay.Main outcome measuresNon-elective readmission rates, total readmission length of stay and overall survival.ResultsA total of 252 cases and 1008 control patients were included in the study. Despite the patients referred to the multidisciplinary model of care had slightly more comorbid conditions, significantly higher total length of hospital stay in the previous 12 months and increased prevalence of diabetes and heart failure by comparison to those who received usual care, they had significantly improved survival (adjusted hazard ratio 0.70 95% CI 0.51–0.96, p = 0.029) and no excess in the number of hospitalisations observed.ConclusionFollowing discharge from hospital, holistic multidisciplinary outpatient management is associated with improved survival in older patients with multimorbidity. The findings of this study warrant further examination in randomised and cost-effectiveness trials.

BackgroundWe explored experiences of depression diagnosis and treatment amongst multimorbid patients referred to a metropolitan multidisciplinary outpatient clinic to identify commonalities across this patient group.MethodsPatients with two or more chronic conditions and a diagnosis of depression participated in semi-structured interviews that were digitally recorded and transcribed. Thematic analysis was performed on the transcriptions.ResultsMultimorbid patients attributed depressive symptoms to the loss of ‘normal’ roles and functionality and struggled to reconcile the depression diagnosis with their sense of identity. Beliefs about themselves and depression affected their receptivity to diagnosis and intervention strategies. These included prescribed interventions, such as psychotherapy or pharmacotherapy, and patient-developed strategies.ConclusionsFunctional and social role losses present a clear context in which GPs should raise the subject of mood, with the situational attribution of depression suggesting that psychotherapy, which is rarely offered, should be prioritised in these circumstances.

Objectives: Depression may be under-diagnosed and under-treated amongst older adults with multiple chronic illnesses. The current study explores the prevalence of depression diagnosis and Geriatric Depression Scale (GDS) symptoms amongst older multimorbid outpatients, and agreement between GDS scores and doctor-diagnosed depression. Method: Deidentified data from the files of 452 patients aged over 64, with chronic conditions present in two or more organ domains, were extracted from the clinical database of a tertiary referral hospital multidisciplinary outpatient clinic in South Australia between 2005 and 2011. Frequency calculations determined the prevalence of depression diagnosis and GDS categories. Logistic regression, cross-tabulation, kappa and ROC graphs explored relationships between variables. Results: A depression diagnosis had been recorded for 71 (15.7%) patients. Using the recommended cut-off scores for the GDS, 225 (49.8%) patients met criteria for mild-severe depressive symptoms, and 96 (21.3%) met criteria for moderate-severe symptoms. Poor agreement was found between doctor diagnosis of depression and a positive screen for depression using a GDS cut-off score of either 5, k = 0.112 (p = 0.001), or 9, k = 0.189 (p < 0.001), although logistic regression found an association between severity of depression and depression diagnosis, OR = 1.15, p < 0.001 (CI = 1.08 - 1.22). Con-clusion: A much higher proportion of patients with multimorbidities reported threshold level depression symptoms than had a recorded diagnosis of depression, suggesting that although likelihood of diagnosis increases with symptom severity, depression often goes undetected in this population. Depressions’ negative impact on prognosis calls for further investigation of the barriers to screening and diagnosis of depression in multimorbid patients.

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