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BACKGROUND: Residential aged care facility (RACF) staff are well placed to identify opportunities for more appropriate prescribing. However, little is known about their views of polypharmacy, deprescribing and specific medications. OBJECTIVE: The objective of this study was to establish the beliefs and attitudes of RACF staff towards polypharmacy and medication use in residents. METHODS: A cross-sectional survey was conducted on RACF staff in metropolitan New South Wales, Australia using a self-administered questionnaire. The questionnaire was drafted based on the available literature and research team expertise and then piloted by a mixed group of 13 RACF staff. The final version of the questionnaire consisted of 28 questions. A total of 38 RACFs were contacted about the study. The questionnaire was distributed to eligible RACF staff between October 2017 and October 2019. The RACF staff were eligible if they provided direct patient care to residents or worked as a facility manager. Participants were excluded if they had insufficient English language skills. The results were presented in two groups, the nursing and care staff, using descriptive statistics. RESULTS: A total of 176 individuals from nine RACFs completed the questionnaire of whom 160 were eligible for study inclusion. Most considered polypharmacy to be five or more different tablets and capsules per day (95% nursing and 82% care staff respectively). A wide range of beliefs about medication use and deprescribing that centred on what constitutes appropriate polypharmacy was identified. Most thought that preventive medications were essential for residents. Most nurses agreed that sleeping tablets and pharmacological management of verbal aggression and wandering behaviours should be used less frequently whilst most care staff agreed that medications should be used more frequently to manage physical aggression. CONCLUSIONS: To successfully and sustainably optimise medication use in RACF residents, it is important to consider the variation in views of nurses and care staff.

Background Multimorbidity and polypharmacy are very common in older adults in primary care. Ideally, general practitioners (GPs), should regularly review medication lists to identify inappropriate medication(s) and, where appropriate, deprescribe. However, it remains challenging to deprescribe given time constraints and few recommendations from guidelines. Further, patient related barriers and enablers to deprescribing have to be accounted for. The aim of this study was to identify barriers and enablers to deprescribing as reported by older adults with polypharmacy and multimorbidity. Methods We conducted a survey among participants aged ≥70 years, with multimorbidity (≥3 chronic conditions) and polypharmacy (≥5 chronic medications). We invited Swiss GPs, to recruit eligible patients who then completed a paper-based survey on demographics, medications and chronic conditions. We used the revised Patients’ Attitudes Towards Deprescribing (rPATD) questionnaire and added twelve additional Likert scale questions and two open-ended questions to assess barriers and enablers towards deprescribing, which we coded and categorized into meaningful themes. Result Sixty four Swiss GPs consented to recruit 5–6 patients each and returned 300 participant responses. Participants were 79.1 years (SD 5.7), 47% female, 34% lived alone, and 86% managed their medications themselves. Sixty-seven percent of participants took 5–9 regular medicines and 24% took ≥10 medicines. The majority of participants (77%) were willing to deprescribe one or more of their medicines if their doctor said it was possible. There was no association with sex, age or the number of medicines and willingness to deprescribe. After adjustment for baseline characteristics, there was a strong positive association between willingness to deprescribe and saying that because they have a good relationship with their GP, they would feel that deprescribing was safe OR 11.3 (95% CI: 4.64–27.3) and agreeing that they would be willing to deprescribe if new studies showed an avoidable risk OR 8.0 (95% CI 3.79–16.9). From the open questions, the most mentioned barriers towards deprescribing were patients feeling well on their current medicines and being convinced that they need all their medicines. Conclusions Most older adults with polypharmacy are willing to deprescribe. GPs may be able to increase deprescribing by building trust with their patients and communicating evidence about the risks of medication use. Supplementary Information The online version contains supplementary material available at 10.1186/s12877-020-01843-x.

IntroductionMultimorbidity and polypharmacy are current challenges when caring for the older population. Both have led to an increase of potentially inappropriate medication (PIM), illustrating the need to assess patients' attitudes towards deprescribing. We aimed to assess the prevalence of PIM use and whether this was associated with patient factors and willingness to deprescribe.MethodWe analysed data from the LESS Study, a cross-sectional study on self-reported medication and on barriers and enablers towards the willingness to deprescribe (rPATD questionnaire). The survey was conducted among multimorbid (≥3 chronic conditions) participants ≥70 years with polypharmacy (≥5 long-term medications). A subset of the Beers 2019 criteria was applied for the assessment of medication appropriateness.ResultsData from 300 patients were analysed. The mean age was 79.1 years (SD 5.7). 53% had at least one PIM (men: 47.8%%, women: 60.4%%; p = 0.007). A higher number of medications was associated with PIM use (p = 0.002). We found high willingness to deprescribe in both participants with and without PIM. Willingness to deprescribe was not associated with PIM use (p = 0.25), nor number of PIMs (p = 0.81).ConclusionThe willingness of older adults with polypharmacy towards deprescribing was not associated with PIM use in this study. These results suggest that patients may not be aware if they are taking PIMs. This implies the need for raising patients' awareness about PIMs through education, especially in females, in order to implement deprescribing in daily practice.

Global climate variabilities have the potential to impact many coastlines around the world, and can have detrimental effects on the stability of coastlines and their function as natural coastal defenses. This paper investigates the impacts of future extreme storms and sea level rise on morphodynamics of the macro-tidal Sefton Coast, UK, taking a process-based model as a tool to simulate a snap-shot of future beach change during storms. Sefton Coast represents one of the largest dune systems in the UK, where frontal dunes function as a natural barrier against extreme conditions. Future storm conditions were determined from global predictions of future waves at the end of the twenty first century. Future sea levels were determined based on climate change allowances set by the UK Environment Agency (EA), while future surge conditions were determined based on the guidelines also provided by EA. A nested numerical modelling approach, that combined a regional scale model with a local scale model with high resolution, is used. The modelling suite was first validated against measured waves, water levels and beach change, before using it to simulate morphodynamic change from numerous statistically significant ‘future’ storm conditions. Future storm-induced morphodynamic change of the Sefton coast was then compared with that from the present storms. The results reveal that this beach will experience significant climate change driven impacts where dune retreat during storms will be considerably higher in future. The results also reveal that due to the shape of the beach and its orientation to predominant wave approach direction, there will be a strong longshore variability of morphodynamic response to storms. It was also found that the water level in front of the dune (and hence surge and future sea level rise) is the most critical factor that determines beach erosion during a storm.

MR 10.08.2017Thoracolumbar spine:- included in these images there are 8 lumbar vertebrae with no ribs, there are 12 included thoracic vertebra (either T1 is not included and there is an additional lumbar vertebra, or more likely T13 is transitional with no ribs.)- For clarity the first vertebra with no ribs is referred to in this report as L1- All included discs have loss of T2W signal from the nucleus pulposus consistent with dehydration.- L2-3 and L4-5 have previous right hemilaminectomy proceedures, the region is infilled with fat intensity material up to the curved profile of the dura. At this margin for both sites there is a well defined T2W and T1W hypointense margin at the dural surface.- Along the length of the L2-3 surgical site there is marked increased intensity of the right 2/3 of the spinal cord with a crescent of recognisable parenchyma at the left.- the spinal cord along the length of the L4-5 disc space there is some increased T2W hyperintensity predominantly within the grey matter. There is also a focal hypointense bulge at the dorsal most margin which may be consistent with some tethering of the spinal cord.- at both these surgical sites there is mild dorsal bulging of the annulus fibrosis.- At L1-2 there is dorsal bulging of the annulus fibrosus with dorsoventral compression of the spinal cord and loss of the T2W signal from the epidural and subarachnoid space. At the left dorsal aspect of the spinal cord is a small focal T1w and T2w hypointense focus that may indicate some fibrous material. There is a faint T2w hyperintense line crossing the spinal cord that may indicate a small amount of material adjacent to the cord (possibly in the right nerve root foramen)- At T13-L1 there is hypoattenuating material in the ventrolateral right vertebral canal immediately dorsal to the disc space, displacing and compressing the cord towards the left and interrupting the T2W signal from the epidural and subarachnoid space. This is currently the most compressive lesion.- At T11-12 there is midline dorsal bulging of the annulus fibrosus with interruption of the ventral T2W signal from the subarachnoid and epidural space.- From mid L1 extending cranially to T12 there is a dorsoventrally oriented T2W hyperintensity within the spinal cord consistent with central canal dilation.Conclusions- There are marked changes within the spinal cord at both previous surgical sites (on the basis of L1 being the first ribless vertebra these are at L2-3 and L4-5) this is most likely due to gliosis, with suspicion of tethering of the cord at L4-5.- there are multiple other disc herniations (T11-12, T13-L1, L1-2) with the most compressive lesion at T13-L1, this is more right sided and is most likely to be the most clinically relevant lesion.- Right sided nerve root foramen changes at L1-2- the more cranial spinal cord parenchymal changes may be recent, or chronic from the multiple previous disc herniations and surgical proceedures.(LR/CWS)