bluuebunny/crossref_metadata_2025 huggingface dataset:
97 Potentially Inappropriate Medications in Patients with Alzheimer’s Disease: Data from NILVAD
Authors: Murphy Claire , Dyer Adam H , Lawlor Brian , Kennelly Sean P
Published: September 2019

Background

Prescription of Potentially Inappropriate Medications (PIMs) is common in older adults and is associated with adverse drug events, hospitalisation and mortality. Less well described are the patterns and predictors of PIM usage in patients with Alzheimer’s Disease (AD), a patient group who may be particularly vulnerable to polypharmacy and medication associated adverse events.

Methods

Secondary analysis of the NILVAD trial, an international phase three trial of Nilvadipine in mild/moderate AD. The v2 STOPP/START criteria were individually applied by a physician to each participant’s medication list and cross-reference with their medical history to identify PIM usage. Predictors of PIM usage were modelled using binary logistic regression.

Results

Five-hundred and ten patients with AD were included (mean age 72.8 +/-8.3 years; 62% female). The median number of prescribed medications was 5 (IQR 3-7). Over half (55.5%) were prescribed at least one PIM, whilst a minority of patients (14.8%) were prescribed three or more PIMs. The most frequent PIMs were benzodiazepines >4 weeks without indication (n = 55), long-term Proton-Pump Inhibitor (PPI) use without appropriate indication (n = 49), use of non-steroidal analgesics without use of PPI (n=19) and antimuscarinic use in dementia (n= 18). On multivariate analysis, significant predictors of PIM use were higher total number of medications (p=0.001; OR 1.52; 1.36-1.59) in addition to greater AD severity, as rated using the Clinical Dementia Rating Scale Sum-of-Boxes (CDR-sb) (p=0.024; OR 1.18; 1.02-1.35).

Conclusion

The majority of older patients with AD were prescribed at least one PIM. Usage of PIMs was associated with greater number of medications and increased dementia severity. Particularly concerning is the potentially inappropriate use of benzodiazepines and anti-muscarinic agents in this population, given recent evidence for the adverse cognitive profile associated with these medications. De-prescribing and medication review interventions aimed particularly at patients with AD are warranted.
142 Advance Care Planning in Patients with Dementia: An Audit on End of Life Care in Hospital Deaths
Authors: Sullivan Rachel , Power Clodagh , Greene Elaine , Purcell Roisin
Published: September 2019

Background

End of life care (EOLC) planning is a difficult and often neglected area in dementia. Advanced care discussions play an important role in the planning of future care for patients with dementia. The NICE guidelines recommend that patients with dementia should be given every opportunity to discuss their wishes and preferences regarding their future care. The goal of our study was to explore the extent of EOLC planning in patients with dementia who died in hospital.

Methods

Patients with dementia who died in a large tertiary referral hospital in 2017 were identified via the Hospital Inpatient Enquiry (HIPE) database. A retrospective chart review was completed examining the documentation of Advance Care Planning (ACP) and discussions around end of life care. Charleston Comorbidity Index (CCI) was used to predict 1 year mortality.

Results

HIPE identified 49 patients with dementia who died in hospital. The average age was 84 and 53% were female. The commonest cause of death was respiratory (79.5%). Two thirds lived at home and 30% were nursing home residents. The mean CCI was 3.97 indicating 52% 1-year mortality, however only 34% were hospitalized in the last year. Only 14% had an ACP. Only 22% had resuscitation status recorded on admission. The majority had resuscitation status documented 15 days prior to death. In these cases 70% had clearly documented the discussion with family or patient and 84% documented ceilings of care 6 days prior to death. Palliative care were involved in 40% of cases. Two patients did not have resuscitation status documented prior to death and 3 received CPR.

Conclusion

Our study highlights the urgent need to facilitate conversations around end-of-life care with people with dementia. Advance care planning reduces the use of burdensome treatments, ensures dignity and comfort is prioritized enabling patients to live well until they die.
144 The Use of a Multidisciplinary Team Discharge “Huddle” to Improve Patient Flow and Planning
Authors: Randles Mary , Hickey Sylvia , Cotter Susanne , Walsh Carmel , O'Connor Kieran , O'Sullivan Catherine , McGrath Keith , O'Sullivan Aine , Looney Eileen , Maher Sharon , McGuaran Jane , Higgins Anna , Quirke Anne , Allen Yvonne
Published: September 2019

Background

Patient flow, the movement of patients is an integral part of the patient care pathway. With the goal of improving overall patient care and discharge planning, a hospital wide, multidisciplinary team based, patient discharge meeting or ‘HUDDLE’ was devised with the goal of facilitating onward care planning for all inpatients especially those with complex discharge needs in a city centre teaching hospital.

Methods

The patient flow huddle has evolved to include a Patient Flow Clinical Nurse Manager, Bed Manager, Medicine for Older Persons Clinical Nurse Specialist, Physiotherapist/Occupational Therapist, Consultant Geriatrician and Geriatric Medicine Registrar. Each team in the hospital are requested to attend at least twice a week. Predicted discharge dates are established. Teams discuss patients who have a requirement for rehabilitation, either short-term or complex rehabilitation and patients over 65 years who may need review from Older Persons Services .We sought to optimise issues including housing, home care packages, interim home supports, community intervention team referrals, integrated care and Nursing Home Support Scheme applications.

Results

There were 3918 Emergency Department presentations by adults over 75 in 2018 and 2113 admissions (3704, 2081 respectively in 2017). Accuracy for discharge within one day of PDD ranged from 52.5% (Jan) to 72.6 % (Nov). The average length of stay was 6.2days (SD 0.47). 172 patients (84 female, 88 male) were admitted for slow stream rehabilitation (median length of stay 30 days).

Conclusion

Rather than using a negative view of older adults as potential ‘bed blockers’, the discharge huddle allowed a pro-active approach to assist medical and surgical teams in the management and re-enablement of patients with complex care needs. Early identification of such patients with complex care and discharge needs allowed greater focus on appropriate planning earlier in the patient’s hospital journey.
150 Severe Drug Interactions (SDIs) and Potentially Inappropriate Prescriptions (PIPs) in Older Adults with Cancer
Authors: Lavan Amanda , O'Mahony Deirdre , Buckley Mary , O'Mahony Denis , Gallagher Paul
Published: September 2019

Background

The objectives of this study were to identify the prevalence of severe drug interactions (SDIs) and potentially inappropriate prescriptions (PIPs) in older adults with cancer.

Methods

A 12-month prospective observational study of patients ≥65 years admitted to an oncology centre was conducted. SDIs were assessed using Stockley’s interaction checker; PIPs were identified using STOPP/START criteria. Logistic regression was applied to determine the influence of age, gender, co-morbidities and medication number on the likelihood of an SDI and a PIP.

Results

We enrolled 186 participants; mean age 72.5 (SD5.7) years, 46.2% female, mean co-morbidity number 7.5 (SD3.4), median medication number 7 (IQR4-9). Polypharmacy (≥6 medications) and major polypharmacy (≥11 medications) were identified in 60.8% and 17.7% respectively. Systemic anti-cancer therapies (SACTs) were concomitantly prescribed to 60.2%.

SDIs were identified in 50.5% participants; 7.5% ≥1 SACT-SACT SDI, 41.4% ≥1 drug-drug SDI and 10.2% ≥1 drug-SACT SDI. The most common SDIs were beta-blocker/alpha-blocker (n=12), Selective serotonin re-uptake inhibitor (SSRI)/proton pump inhibitor (PPI) (n=11) and SSRI/Aspirin (n=8). A strong correlation between medication and SDI number was identified (r2=0.61, p-value <0.001). For each additional prescription, the odds of an SDI increased by 50.8% (Odds ratio 1.508, 95% CI1.288–1.764, p<0.001).

PIPs were observed in 73.1%; median 2(IQR1-3). The most common PIPs were drugs prescribed beyond the recommended duration (46.8%), high-dose PPIs >8 weeks (34.9%) and regular opioids without laxatives (20.4%). Patients prescribed ≥1 PIP had more co-morbidities (8.4(SD3.4) vs 5.2(SD2.4), p< 0.001), a higher cumulative illness rating score (18(IQR12-20) vs 11(IQR10-14), p<0.001) and more prescribed medications (8(IQR6-10) vs 3(IQR1-4.25), p<0.001). For each additional prescription, the odds of receiving a PIP increased by 79.2% (Odds ratio 1.792, 95% CI1.459–2.02, p<0.001).

Conclusion

SDIs and PIPs are common in older adults with cancer and higher than previously reported. Comprehensive specialist medication evaluation, by a Geriatrician, may benefit patients.
170 Admissions to a Stroke Unit in an Irish Rehabilitation Hospital: A Review from Speech and Language Therapy
Authors: Dhufaigh Niamh Ní , Haughey Marie , Gillen Cliodhna
Published: September 2019

Background

Communication disorders and dysphagia are debilitating sequelae associated with stroke. Speech and Language Therapy (SLT) has a pivotal role in stroke rehabilitation, and in improving outcomes. The research into dysphasia, dysphagia, and dysarthria post-stroke is extensive. In comparison, the research into cognitive-communication difficulties post-stroke is still emerging. Cognitive-communication difficulties (CCDs) are communication impairments resulting from underlying cognitive deficits due to neurological impairments1. The aim of this audit was to review SLT referrals in an Irish Stroke Rehabilitation Unit.

Methods

Single-centre retrospective review of all stroke admissions from January to December 2018. Communication outcomes were assessed using the Functional Independence Measure and Functional Assessment Measure (FIM+FAM)2 a 7-point disability rating scale. Standard Bayesian statistics were employed for analysis.

Results

SLT received referrals for 66% (n=41) of all stroke admissions (n=62). Mean age was 68 years (SD+/-14), compared with 70 years (SD+/-14) for patients not referred. 65% were female and 35% male. Patients requiring SLT had significantly longer length of stay (p=0.0072). 83% of referrals were for communication, 12% dysphagia, and 5% inappropriate. Of communication referrals, primary diagnoses were as follows: 17.5% dysarthria (n=6), 26.5% dysphasia (n=9) and 56% CCD (n=19). Patients with dysphasia showed greater improvement in FIMFAM scores (x̄=1.3) than those with CCD (x̄=0.9) or dysarthria (x̄=0.7). Patients with CCD comprised the largest cohort who required SLT on discharge (68%).

Conclusion

CCDs are highly prevalent and represented the largest subtype of communication disorders in this cohort. FIMFAM scores appear useful in assessing CCDs however they display insufficient sensitivity in capturing change within this population. This audit highlights the need for further interdisciplinary research, education and training into cognitive-communication difficulties with post-stroke populations.
235 Pyjama Paralysis: Time to Make a Move!
Authors: Fitzpatrick Donal , Doyle Kate , Finn Gerard , Gallagher Paul
Published: September 2019

Background

The adverse effects of inpatient falls are well known. The harms of unwarranted bedrest and prolonged immobilisation present insidiously but, arguably, have a greater impact. Deconditioning, itself, is a major contributor to falls in older adults. There is still a troubling assumption that falls can be prevented through restraint and preventing at-risk patients from mobilising.

Methods

We reviewed medical and nursing notes and conducted brief-structured interviews with nurses and brief bedside observations for medical inpatients aged ≥75. We constructed a research template based on the UK National Falls audit 20151 and the Hospital Elder Life Program (HELP) - mobility toolkit2. We included all patients on medical wards over the age of 75, admitted for 3 or more days. We excluded patients who were critically unwell or imminently dying.

Results

We reviewed 100 medical inpatients aged over 75. Patients’ mobility deteriorated significantly from their baseline, with 73% of patients requiring assistance compared to 22% at baseline. PJ paralysis was endemic with only one third of patients wearing day clothes. 75% of patients spent more than half of the day in bed. There were 8 falls during the entire study period. Poorer levels of mobility correlated with delirium and incontinence.

Conclusion

The deleterious effects on older patient of the traditional model of acute hospital care with gratuitous bedrest are universally acknowledged. Falls should be prevented through supervision rather than restraint. Campaigns such as “End PJ Paralysis” and the HELP mobility toolkit can enable a cultural change within hospitals. Such change is impossible without the staffing and leadership to endorse it.
273 Characteristics of Centenarians in the Irish Hip Fracture Database
Authors: Hogan Patrick , Ferris Helena , Brent Louise , McElwaine Paul , Coughlan Tara
Published: September 2019

Background

In 2017 the Central Statistics Office reported that there were 465 people over the age of 100 in Ireland. This number is likely to increase and, as hip fracture increases exponentially with age, we can expect to see more centenarians experiencing hip fracture. In the UK we have comparative data on such a cohort. We sought to define and describe those aged 100 years and over included in the Irish Hip Fracture Database from 2013-2017.

Methods

A secondary analysis of the 15,603 data entries in the IHFD between 2013 and 2017 was conducted. Those patients aged 100 years and over were identified and the cohort described.

Results

57 patients 100 years and over (average 101 range 100-105) were registered in the IHFD over these 5 years. 91% were female. The most common fractures were intertrochanteric (46%) and displaced intracapsular (30%). 55 patients underwent an operative procedure, the most common being bipolar hemiarthroplasty (28%). Over one third were mobilised on the day of or day after surgery. The average length of stay was 22.5 days with only 13 ICU days for the entire cohort. 7 patients died in hospital. Of those surviving to discharge, discharge destination was recorded for 20. 10 patients returned to nursing home, 5 admitted de novo to nursing home, 5 to offsite rehabilitation and one person discharged directly to home.

Conclusion

This data provides the first insight into hip fractures in the oldest old in an Irish context. Rate of operative intervention was reassuringly high with in-hospital mortality outcomes of 12% which is low by international standards. The age of those sustaining hip fractures is increasing with numbers of the oldest old expected to rise. Orthogeriatric input results in improved care for this population and will require increased resourcing for future cohorts of patients.
277 Frailty and Early Supported Discharge (ESD) Post-Stroke: Are Frail Patients Referred to ESD and is Frailty Associated with Rehabilitation Outcomes?
Authors: Condon Marie , O'Regan Louise , Pope Lucy , Barrett Anne
Published: September 2019

Background

Frailty presents in one in four stroke survivors and can be a determinant of recovery post-stroke. Healthcare services provided at home, instead of in hospitals, results in improved outcomes for frail patients. Early supported discharge (ESD) provides multidisciplinary rehabilitation at home post-stroke. It is unknown if frail stroke survivors receive ESD and if they benefit from it. The objectives were to evaluate the prevalence of pre-stroke frailty among ESD patients and examine if frailty is associated with rehabilitation outcomes.

Methods

Consecutive patients in the ESD programme were assessed for pre-stroke frailty using the Clinical Frailty Scale (CFS) from November 2018 to April 2019. Baseline characteristics and programme outcomes were recorded, including admission and discharge scores on the Functional Independence Measure and Functional Assessment Measure (FIM+FAM) and the Stroke Aphasia Quality of Life-39 measure (SAQOL-39). The duration of ESD rehabilitation and number of therapy sessions provided were also recorded. Distributions using Pearson’s Chi Squared test and associations using the Mann–Whitney U test were calculated.

Results

Results from 23 patients were analysed, median age 75±14.8 years, 82.6% male. The prevalence of frailty (CFS >5) was 4.3% (1/23) and pre-frailty (CFS=4) was 26.1% (6/23). Patients who were frail or pre-frail (CFS>4) were less likely to receive speech and language therapy (SLT) (z=-2.201; p=0.03) and have a lower SAQOL-39 on discharge (z=-2.294; p=0.02). No significant differences were noted in the FIM+FAM or the number of physiotherapy and occupational therapy sessions provided.

Conclusion

Frail patients are not routinely referred for ESD post-stroke. Patients who are pre-frail or frail make similar improvements with ESD compared to non-frail patient in functional independence but not quality of life. Comparable levels of physiotherapy and occupational therapy are provided but frail patients require less SLT. Further research is needed to ascertain if frail patients are appropriate for ESD.
03 Examining the Resiliency of Visually Impaired Older Adults with Cognitive Decline Aging in Place
Authors: Fletcher Patricia
Published: September 2019

Background

Visual impairment is a leading chronic condition among older adults and is usually connected with a decline in their performance of instrumental activities of daily living. Understanding the challenges of those with visual impairment is paramount as the population ages over the next four decades. This study examined the hypothesis that older adults who were diagnosed with juvenile macular degeneration as young adults and now have a mild cognitive impairment have better coping mechanisms than older adults who were recently diagnosed with age-related macular degeneration.

Methods

This study utilized a mixed-methods approach to address the complexities in health science research and align with the interdisciplinary field of gerontology.

Results

Participants were 27 older adults aged 65 years of age and older. There was no quantitative difference in resiliency between participants with juvenile macular degeneration (n = 7, M = 77.71, SD = 9.46) and those with age-related macular degeneration (n = 10, M = 72.60, SD = 8.25), t(15) = 1.185, p = .254.

Conclusion

The qualitative results revealed that older adults living with visual impairment develop strategies to improve their quality of life and help them age in place.
198 The Next Steps: The Development of Dementia Post-diagnostic Psychoeducational Support Guidance
Authors: Gibb Matthew , O'Caheny Dearbhla , Craig Cecilia , Begley Emer
Published: September 2019

Background

There is often a `care gap' where people are given a clinical diagnosis of dementia but receive no useful support. (Foley, T. et al., 2019) However, the early stages of dementia are a crucial time for supportive interventions such as advice and strategies to cope with impairments and improve wellbeing and signposting through complex healthcare systems to access key supports and services. In February 2018 the National Dementia Office (NDO) commissioned the Dementia Services Information and Development Centre (DSIDC) to develop a guidance document to support health and social care professionals (HSCPs) establish, organise and facilitate evidence-based post-diagnostic pyschoeducatonal interventions in the community.

Methods

The DSIDC undertook an extensive literature review examining the evidence for multi-component psychoeducational interventions. An experienced group of health and social care professionals provided additional material and expertise resulting in the development of the final guidance document. Members of the Irish Working Group of People with Dementia and the Dementia Carers Campaign Network also reviewed the document.

Results

The literature review found a growing evidence base for dyadic interventions. These interventions, directed at the person with dementia and their care partner, were diverse in their content, outcomes, the measures they used, their frequency and the professional background of the facilitators. They were flexible and cost-effective and drew on the HSCP's own professional knowledge, service resources and experiences of what works and what doesn't.

Conclusion

Dyadic interventions (and psychoeducational programmes in particular) have the potential to benefit both people with dementia and their care partners by decreasing depression and anxiety, increasing knowledge and coping skills and helping improve cognitive function. (Moon and Betts Adams, 2012) The practical guidance document developed from this review provides HSCPs with useful advice and information to facilitate the setting up and running of post-diagnostic psychoeducational support programmes.
207 Acute Incidence of Disease at Elevated Levels of Fine Particulate Matter (PM2.5) in Dublin, Ireland
Authors: Byrne Colm , Bennett Kathleen , Hickey Anne , Kavanagh Paul , Broderick Brian , O'Mahony Margaret , Williams David
Published: September 2019

Background

Fine particulate matter (PM2.5) has been associated with disease incidence worldwide. In Ireland this is mainly produced by residential heating systems, particularly peat, coal and wood. This study aimed to explore the relationship between short-term exposure to PM2.5 and hospital admissions due to stroke, atrial fibrillation, myocardial infarction, atrial fibrillation (AF), heart failure, chronic obstructive pulmonary disease (COPD), asthma, Parkinson’s disease, dementia and hip fracture in Dublin City and County between 2013 and 2017.

Methods

This was an ecological time series design utilising routine hospitalisation data collected from the national Health Service Executive (Hospital In-Patient Enquiry (HIPE)). Incidence of hospitalisation for each disease was identified by county of residence. Mean daily PM2.5 levels for Dublin were calculated using monitoring data from the Environmental Protection Agency’s four monitoring sites. Disease incidence was organised by mean PM2.5 levels into 10μg/m3 categories and analysed using Poisson regression models correcting for minimum daily temperature at a lag of zero to five days.

Results

There was a significant increase in the short-term incidence of acute ischaemic stroke, AF, heart failure, Parkinson’s disease, dementia and COPD when PM2.5 levels were above 50μg/m3 compared to when levels were below 10μg/m3 at one day post exposure when correcting for minimum temperature.

Conclusion

Controls need to be brought in to ensure that PM2.5 does not exceed a 50μg/m3 level due to the increase in disease incidence associated with same. The urban burning of solid fuels should be severely restricted.
229 Advancing Physiotherapy Competence in Dementia Care. A Service Development Initiative
Authors: Jones Claire
Published: September 2019

Background

Older adults are among the most frequent of health service users and often require physiotherapy input. Since the prevalence of dementia rises with age, physiotherapists regularly treat older adults with dementia in the acute setting. However advancing competence in the area of dementia care represents a significant cultural shift for the physiotherapy profession. Dementia education which specifically addresses both the learning needs of physiotherapists and the cultural context in which they work may be the first step to advancing competence and enabling best practice.

Methods

A learning needs analysis was conducted within a physiotherapy department in an acute, level three hospital. An educational programme was subsequently designed and delivered over six weeks. The programme aimed to equip physiotherapists with both the knowledge and skills to best support the person with dementia in the acute care setting. Careful consideration was given to the social construct of dementia, inclusion of the voice of the person with dementia and the historical barriers experienced when accessing therapy services in the acute care environment.

Results

The perceived benefit of the education programme was evaluated by means of a participant survey. 100% of respondents felt that undergraduate training did not sufficiently prepare them to work with adults with dementia. As a result of the educational programme, 100% of participants reported increased competence when treating adults with dementia and a subsequent positive impact on physiotherapy practice. 88% of respondents agreed that ongoing professional development in this area of dementia care would be beneficial and 100% reported that they would recommend the educational programme to a colleague.

Conclusion

The changing landscape of healthcare delivery has opened up new ways of working. Physiotherapists are in a unique position to support the person with dementia in the acute care setting. Participants of this educational programme demonstrated high motivation to advance their knowledge and skills in the area of person-centred dementia care.
234 An Evaluation of Two Frailty Intervention Therapy Team’s (FITT) in the Emergency Department Pilot Services
Authors: Walsh Ciara , McCullagh Ruth , O'Connor Kieran , Higgans Anna , O’Callaghan Donal , Timmons Suzanne
Published: September 2019

Background

Frailty is an important marker of adverse outcomes for older people accessing the Emergency Department (ED). Older patients with frailty have a higher attendance rate to the ED, spend longer in the ED and have a higher rate of admission (HSE, 2017). Frailty Intervention Therapy Teams (FITT) are designed to screen and assess this population in the ED setting, with the aim of early assessment to help decrease length of stay or avoid admission. Two different FIT Teams have recently been formed within the Cork-Kerry region. The aim of this study was to evaluate staff’s experience of these teams.

Methods

This was a mixed methods study. Structured surveys were developed to collect qualitative and quantitative data. The surveys were constructed using themes listed by Proctor et al., (2011) around implementation and service outcomes. Ward and ED staff were provided with paper surveys within the hospital setting and community staff were surveyed via post. Quantitative survey data was analysed using descriptive statistics and qualitative data was analysed with thematic content analysis.

Results

Data from 117 surveys was included for analysis (response rate 49%). Results showed that the majority of staff (89%) reported ED was a suitable setting for the FITT, with 85% reporting the information collected by the FITT impacted their involvement. Other themes emerging from staff’s experience included timeliness, safety and comprehensive assessment.

Conclusion

Overall, staff reported the FITT provided a timely service that assisted with decision making and planning. This involved earlier comprehensive assessment, prompt identification of issues which lead to decreased workload for ward staff. It also created an increased volume of referrals to community and ward staff received in a timelier manner.
242 “I Want to Break Free”: Harming Older Patients Through Restraint, Isolation and Tethering
Authors: Heywood Sarah , Fitzpatrick Donal , Doyle Kate , Finn Ger , Gallagher Paul
Published: September 2019

Background

The older inpatient population is a particularly frail cohort with high rates of delirium, falls and immobility. These patients require skilled gerontological nursing with high levels of supervision. Despite this, restraints such as bed rails continue to be common. Tethering through intravenous drips and urinary catheters are another form of restraint.

Methods

We performed a chart review and a bedside observation of patients aged ≥75 on medical wards admitted for ≥72 hours. We excluded patients who were critically unwell or imminently dying. We used the open source software package PSPP to complete the statistical analysis.

Results

We reviewed 100 patients, of whom 25 were restrained in some way (most commonly by bed rails 80%), 10 were tethered (through intravenous drips, oxygen tubing, urinary catheters and others), 7 were in isolation for infection control reasons. Restraint was associated with greater dependence in mobility and function, reduced time out of bed (Mann Whitney, P< 0.05), delirium and incontinence (chi square, p <0.05). Isolation was associated with greater physical dependence (Mann Whitney, P< 0.05), and tethering was associated with incontinence (chi square, p <0.05). The relatively low number of isolated and tethered patients reduced the power of the study. 50% of patients with a urinary catheter did not have a clear indication and only 14% of catheterised patients had leg bags

Conclusion

Patients who are restrained are clearly frailer, more dependent, spend more time in bed, have higher rates of delirium and incontinence. These are particularly vulnerable patients who need high levels of attention from both medical and nursing staff. Supervision is always superior to restraint but requires investment in staff and resources. Patients who are isolated are also more physically dependent. Tethering should be minimised. Simple measures such as leg bags are underused.
245 Delirium Incidence in Hip Fracture Patients: Awareness on the Orthopaedic Ward
Authors: Jeanne Bermingham Rebecca , McLaughlin Paul , O'Brien Helen
Published: September 2019

Background

Postoperative delirium is a serious neuropsychiatric condition that occurs in up to 65% of hip fracture patients(1). However, it remains poorly recognised as a postoperative surgical complication despite its association with increased mortality, longer length of stay (LOS), cognitive decline and increased risk of discharge institutionalisation.

Methods

As part of the delirium audit, all hip fracture patient notes were reviewed from Oct-Nov 2017 pre-implementation of an Orthogeriatric Service and Oct-Nov 2018 post-implementation. Documentation of delirium or use of the terms ‘new confusion, altered attention, change in behaviour’ in the orthopaedic, orthogeriatric and allied health professional notes were reviewed. The 4AT was used to routinely screen for delirium in the pre-and post-operative period by the Orthogeriatrics team(2).

Results

The number of patients in the 2017 group was 24, mean age 78, female 76% compared with 25 in the 2018 group, mean age 75.9, female 81%. In 2017, delirium was diagnosed in 4% of patients by the Orthopaedic surgeons and 37.5% by Allied Health Professionals. In 2018 delirium was diagnosed in 4% by the Orthopaedic surgeons, 40% by Allied Health Professionals and 44% by the Orthogeriatrics team in 2018. Pre-operative delirium occurred in 16% of patients and postoperative delirium occurred in 44% of patients in 2018. A clear delirium management plan was documented in 0% of charts in 2017 versus 100% in 2018. LOS in 2017 was 12.7 days vs 12.4 in 2018. However, discharge location varied greatly with 33.3% discharged to convalescence in 2017 versus 19% in 2018, 12.5% to Longterm care in 2017 versus 4% in 2018, 20.8% to rehabilitation in 2017 vs 52% in 2018 and 16.7% home in 2017 vs 24% in 2018.

Conclusion

Prompt diagnosis and management of delirium is essential in optimising postoperative cognitive function and preserving independence. Our study highlights the need for routine delirium screening and improved awareness of delirium amongst all healthcare professionals.
269 Early Identification of Frailty: Developing an International Delphi Consensus for a Definition of Pre-frailty
Authors: Sezgin Duygu , O’Donovan Mark , Wong Jean Woo , Bandeen-Roche Karen , Liotta Giuseppe , Fairhall Nicola , Laso Angel Rodríguez , Apóstolo João , Clarnette Roger , Holland Carol , Roller-Wirnsberger Regina , Illario Maddalena , Mañas Leocadio Rodríguez , Vollenbroek-Hutten Miriam , Yavuz Burcu Balam , Balci Cafer , Pernas Francisco Orfila , Paul Costança , Ahern Emer , Romero-Ortuno Roman , Molloy William , Cooney Maria Therese , O’Shea Diarmuid , Cooke John , Lang Deirdre , Hendry Anne , Rockwood Kenneth , Clegg Andrew , Liew Aaron , O’Caoimh Rónán
Published: September 2019

Background

Frailty is associated with a prodromal stage called pre-frailty, a potentially reversible and highly prevalent condition before frailty becomes established. Despite this, there is no widely accepted definition of pre-frailty to support its early identification and management. This study applied an international consensus approach to define and better understand pre-frailty.

Methods

A modified electronic two-round Delphi Consensus study was conducted. In all, 23 experts from 12 countries with different backgrounds participated. The questionnaire was developed following a systematic literature review. An online consensus meeting was conducted with eight Delphi participants and two external experts. Qualitative and quantitative methods were employed for data analysis. An agreement level of 70% was applied for accepting statements.

Results

A total of 71 statements were circulated in Round 1. Of these, 52.8% were accepted. Fifty-one statements were re-circulated in Round 2, of which 92.1% were accepted. The online consensus meeting produced a consensus statement describing the concept, multi-factorial nature, and mechanism of pre-frailty as well as assessment, prevention and management approaches. All experts agreed that physical and non-physical factors such as psychological and social capacity are involved in the development of pre-frailty, potentially adversely affecting health and health-related quality of life outcomes. Practitioners should regard pre-frailty as a multi-factorial, multi-dimensional, and non-linear process that does not inevitably lead to frailty. It might be reversed or attenuated by targeted interventions. Brief, feasible and validated tools are recommended for opportunistic screening or case-finding followed by confirmation with multi-dimensional assessment.

Conclusion

It is difficult to establish consensus on one compact definition of pre-frailty, which is a multi-dimensional concept not only associated with physical impairment, but also with cognitive, nutritional, socioeconomic and other aspects of frailty. However, it may be too early to agree on an operational definition of pre-frailty since none yet exists for frailty.
275 A Case Study of Retinal Artery Occlusion Following Mechanical Thrombectomy via Direct Carotid Puncture.
Authors: Woods Brian , Thorpe Owen , Boyle Karl
Published: September 2019

Background

This case study reviews the role of carotid puncture as arterial access in mechanical thrombectomy and an associated rare complication.

Methods

This case reviews the management of a 74-year-old gentleman who presented with a left MCA ischaemic stroke. On presentation NIHSS was 21 consistent with a left total anterior circulation stroke syndrome (TACS) with a very severe clinical deficit. He underwent IV thrombolysis and attempted mechanical thrombectomy via femoral puncture. However the intracranial middle cerebral artery (MCA) occlusion could not be reached as a near occlusion at the internal carotid artery (ICA) origin could not be passed. A carotid puncture was successfully attempted followed by mechanical thrombectomy with complete recanalization of occluded MCA. Despite carotid puncture occurring in the setting of IV thrombolysis there were no post procedure bleeding complications. On day 2 post-procedure, the NIHSS score was 1 (residual facial droop) representing remarkable neurological recovery. On day 4 post-procedure, acute left eye vision loss developed with subsequent diagnosis of left central retinal artery occlusion (CRAO). The mechanism of this retinal artery occlusion may have been a direct delayed complication of carotid artery puncture propagating clot into the ophthalmic artery, or may have been due to the underlying stroke mechanism such as new embolism from ICA origin or failure of collaterals.

Results

Persistent residual left eye blurred vision and right facial droop.

Conclusion

Proximal intracranial occlusion can effectively be treated with mechanical thrombectomy. Carotid puncture is a rarely used but effective alternative method of arterial access (11 out of 498 procedures between August 2016 and August 2018). Retinal artery occlusion is a possible complication from mechanical thrombectomy with carotid puncture.
282 A Time to Wean: An Audit on Benzodiazepine and Z-drug Use Amongst Patients Attending a Geriatric Ambulatory Care Day Hospital
Authors: Dowling M J , Doyle Patrick , Kennelly S P
Published: September 2019

Background

Benzodiazepine prescription is common among the Irish patient cohort. 23% of medical card holders have been prescribed a benzodiazepine or Z-drug, with a third of these being for a period longer than three months. This is despite these drugs being associated with addiction, falls, cognitive and psychomotor impairment, mood disorder, sleep automatism and drug interactions. We performed an audit looking at the repeat prescriptions of patients attending a geriatric day hospital.

Methods

The repeat prescriptions of all patients currently enrolled at a day hospital were analysed for benzodiazepines or Z-drugs. Medical records were then analysed to look for indication and whether these patients were currently attending psychiatric services. Subsequent to this, notices were placed in the patient consult room in direct line of sight of the registrar reminding them to consider weaning these drugs and detailing the negative side effects and guidelines for weaning from the Canadian National Pain Centre.

Results

59 patients were enrolled at the day hospital when the audit was performed. 11 (19%) had either a benzodiazepine or Z-drug as part of their repeat prescription (benzodiazepine-5, Z-drug-5, both-1). The most common benzodiazepines prescribed were diazepam and clonazepam (2 patients on each). Of those prescribed a benzodiazepine, none were currently being weaned. Of those on benzodiazepines, 4 of 6 had a documented psychiatric diagnosis, and 1 of 6 had documented that they were currently attending psychiatric services. A re-audit three months later showed no change in those prescribed benzodiazepines (5/59), and a non-significant increase in those on Z-drugs (9/59, p=0.26).

Conclusion

This audit showed a significant number of patients attending our day hospital are being prescribed long term benzodiazepines or Z-drugs, and highlights that this setting is an opportune time and place to establish a supported program to wean people off these medications.
292 Palliative Care for Older People in Residential Care: From the Inside Out
Authors: Molloy Una , Phelan Amanda
Published: September 2019

Background

To enhance the quality of care of older people living and dying in nursing homes, it has been suggested that palliative care should be integrated into this care. This study aims to explore what palliative care means in the context of older person residential care.

Methods

Action research, using a co-operative inquiry (CI) approach was used. A total of 18 healthcare assistants (HCAs) and 16 registered nurses (RGNs) in two residential older person care units, participated. A reflection on deaths that occurred on the units over a six-month period N=23 took place. This facilitated reflection on care given to the residents and assisted in developing an understanding of how palliative care is understood and integrated into caring for residents.

Results

A number of actions took place. A debriefing group, acknowledging the importance of relationships and a sense of loss experienced by staff on the death of a resident, a group reflection on recognising dying and how this might impact on care a resident receives, and a healthcare assistant group which contributed to developing an understanding of the unique role HCA’s have in this context. Categories that evolved to describe palliative care include, communication, decision making, transitions in care, grief, relationships, experience and the importance of knowing a resident.

Conclusion

This study has illustrated that palliative care in older person care, is often aligned with dying. In general, end of life care and person-centred care were more commonly used terms. It was suggested that palliative care is an inherent part of this care. There is a need to value the expertise and experience of the nurses and healthcare assistants caring for older people living and dying in residential care. There is also a need to improve the interdisciplinary roles between older person care and specialist palliative care.
296 Risk-prediction in the Emergency Department: Comparing the Accuracy of Short Frailty Screens to Identify Adverse Healthcare Outcomes among Older Adults
Authors: O'Caoimh Rónán
Published: September 2019

Background

Multiple instruments are available to screen for frailty in the Emergency Department (ED). Despite this, few studies have compared their predictive validity among older adults attending ED. This study aimed to investigate the diagnostic accuracy of a variety of different short frailty and risk-prediction instruments to predict 30-day readmission, length of stay (LOS), one-year mortality and institutionalisation.

Methods

Consecutive patients aged ≥70 attending a university hospital ED were screened and assessed for frailty. Outcomes were obtained from hospital records. The following instruments were compared: the Clinical Frailty Scale (CFS), PRISMA-7, Identification of Seniors at Risk tool, FRAIL scale, Groningen Frailty Indicator (GFI) and Risk Instrument for Screening in the Community (RISC).

Results

In all, 193 patients were included, median age 79+/-9; 55% were female. Based upon a CGA, 60% (116/193) were classified as frail. Those identified as frail were significantly older (p=0.03) and reported lower quality of life scores (p<0.001). There was no significant difference in co-morbidity using the Charlson Index (p=0.15). The ED conversion rate was 77%, median LOS 8+/-9 days and 20% were re-admitted within 30 days. At one-year, 13.5% were accepted for long-term care and 17% had died. Comparing instruments, the combined RISC was had the highest accuracy based on the area under the ROC curve (AUC) scores for predicting mortality and nursing home admission at one year, AUC 0.77 (95% CI:0.68-0.87) and 0.73 (95% CI:0.64-0.82), respectively. The GFI, CFS and PRISMA-7 had statistically similar, albeit lower scores. No instrument was accurate in predicting 30-day readmission after discharge (AUC <0.70).

Conclusion

Short frailty screening instruments applied in ED have poor-modest predictive validity for important healthcare outcomes, particularly hospital re-admission. The RISC score had the highest diagnostic accuracy for institutionalisation and death but this was fair at best, suggesting that instrument selection should be pragmatic with the expectation of identifying frailty.
297 Re-audit of Swallow Assessment in Acute Stroke Patients Following Introduction of a Full-time Speech Specialist
Authors: Buckley Emily , Alalawi Mazen
Published: September 2019

Background

The National Clinical Guidelines and Recommendations for the Care of People with Stroke recommend that if an initial screen of a patient with an acute stroke indicates swallowing difficulties, the patient should have a specialist swallow assessment within 24 hours of admission and not more than 72 hours afterwards. The aim of this audit was to reassess the rate of specialist assessment in this patient group following the introduction of a full-time speech specialist in an acute hospital.

Methods

This was a clinical audit where all patients who presented with acute stroke, where initial swallow screening indicated problems were reviewed. Data was collected from medical records over a twelve week period from January 2019-April 2019.

Results

Twenty patients presented with an acute stroke, with initial assessment indicating swallow problems; 12 male, 8 female. Mean age was 72 years (ranging from 41 to 96). Eight of these were seen by a speech and language therapist (SALT) within 72 hours; 7 were assessed by SALT <24 hours and 1 was assessed within the 48-72-hour window. Of those seen by SALT; -2 were placed on a normal diet, 2 nil by mouth (NPO), 4 were placed on a modified diet. Two patients were reassessed (3 and 2 times respectively). Of the patients assessed by SALT, 1 passed away and 7 were discharged home (2 referred to community SALT follow-up).

When compared with a previous audit in 2018, swallow assessment by SALT < 72 hours has increased from 14% to 40%. The National Stroke Audit has recorded rates of 37%.

Conclusion

Introduction of a full-time speech and language specialist has increased the rates of swallow assessment in line with the national average. The overall rates of SALT interventions in dietary regimens highlights the need to increase overall assessment rates in patients with acute stroke.
29 Adapting Dementia and Delirium Awareness Training to a Rehabilitation Setting
Authors: O'Brien Emma , Devine Monica , Maxwell Sarah , McDonnell Catherine , Lee Stuart
Published: September 2019

Background

The patient profile in a Dublin rehabilitation hospital has changed in recent years to include older adult rehabilitation alongside orthopaedic rehabilitation. A snapshot audit completed by the occupational therapy department on one day in 2018 demonstrated that 64% of patients had an assessment score indicative of a cognitive impairment.

A subjective gap in knowledge regarding dementia care and a misunderstanding of the ability of people with dementia to engage in rehabilitation was identified. It was imperative that dementia awareness training was provided with a particular focus on modifying rehabilitation techniques to cater for these patients.

Methods

A dementia care committee was established with an Educational Development subgroup responsible for addressing dementia and delirium awareness training. Educational material was received from the field of occupational therapy, nursing, medicine, pharmacy and dietetics. The programme was accredited by the Nursing and Midwifery Board of Ireland.

A focus group was completed pre/post formulation of the presentation with various departmental representatives. Feedback provided was used to inform and finalise the training content.

Results

Sessions are completed once monthly. One hundred and seven participants to date have attended.

Ten-point Likert scales are completed pre and post training.

Data from the Likert scales were analysed revealing on average a 24.4 % increase in knowledge of dementia, a 27.6% increase in awareness of the impact of dementia on function and a 23.3% increase in confidence in caring for a patient with dementia.

Highest contingent of staff members trained were household and catering staff (19%) nursing staff (18%), and health care attendants (13%).

Conclusion

This essential training is ongoing with thirty per cent of staff trained to date. The objective is for all staff to complete this training for enhanced care and rehabilitation for all patients with dementia. It will also aim to review treatment for all patients with cognitive impairment so unique rehabilitation programmes can be tailored.