bluuebunny/crossref_metadata_2025 huggingface dataset:
230 DEVELOPMENT AND IMPLEMENTATION OF A STROKE PASSPORT IN THE HYPER-ACUTE STROKE UNIT: SUPPORTING PEOPLE POST-STROKE
Authors: O'Kane A , McCaffrey S , McNally S , Duffy F , Cassidy T
Published: October 2022

Background

A Multi-Disciplinary Team (MDT) approach is instrumental to post-stroke management in the Hyper Acute Stroke Unit (HASU). There is strong evidence highlighting the importance of patients’ social needs post-stroke (UK National Clinical Guideline for Stroke, 2016) and the need for a clear plan and resource combining both health and social care. This is outlined in the National Stroke Strategy (2020-2025). Stroke care involves a cohesive multi-disciplinary approach. In 2021, members of the MDT in HASU identified a service gap and implemented a unified tool. The aim of this project was to develop a user-friendly resource “Stroke Passport” to ensure the patient was central to their own stroke journey.

Methods

National and international guidelines were reviewed and benchmarking of other acute services was completed. The Stroke Passport was specialised to the HASU to include key stakeholders including stroke Consultant, stroke MDT and stroke Nursing Staff. Key stakeholders contributed to the development and adjustments were made after feedback. A sample of stroke patients piloted the passport (n=10). Education was provided for staff and patients through information sessions.

Results

This project resulted in the development of a resource that captured the following key areas:(i)Causes of Stroke (ii) Risk Factors (iii) Stroke Team (iv) Rehabilitation Goals (v) Useful Contacts (vi) and Medication List (vii). Qualitative feedback from the pilot study included: consistent awareness into stroke type, rehabilitation goals and discharge plan. The passport was successfully implemented to meet the organisational demands of the service while including the patient’s voice and is now embedded into standard practice in the HASU.

Conclusion

The development and implementation of a Stroke Passport ensured inclusion of the patient central to rehabilitation goal setting and discharge planning. The project supports an integrated approach to care and allows for patient centred care from admission to safe discharge.
232 WORKING-UP DEMENTIA, A RETROSPECTIVE COHORT STUDY OF REFERRALS TO A SPECIALIST DEMENTIA SERVICE
Authors: Loughlin E , Gibbons O , Burke S , Okon M , O'Sullivan F , Drumm B , O'Donnell M , Patel S , Hickey P , McCarthy G , O'Malley G
Published: October 2022

Background

Rates of dementia in Ireland are rapidly increasing in line with our ageing population. Cases are predicted to more than double in the next 30 years from a prevalence of 55,000 in 2018, to 141,000 in 2050. Dementia services will be placed under significant pressure. It is essential that patients referred to specialist memory services are appropriately worked-up prior to referral, to ensure efficiency and optimise the running of these services, and also to improve patient experience.

Methods

We carried out a retrospective review of patients referred to the Psychiatry of Later Life Team for specialist dementia care by General Practitioners. We obtained date of referral to the service, and carried out an electronic chart review to evaluate the work-up performed prior to referral. Our standard work-up criteria consisted of neuroimaging (CT brain or MRI brain), and blood tests including B12, folate, and thyroid function tests within 12-months. Results were analysed descriptively.

Results

104 patients were included in the study, from referrals dated Nov 2014-June 2019. Neuroimaging had been performed in 79.8% (n=83) prior to referral- 89.1% CT, 9.6% MRI, 1.2% both CT and MRI. Of those who had neuroimaging, n=37 had been performed in the previous 12-months, representing 35.6% of overall cohort. In terms of blood work-up, 23.1% (n=24) had bloods performed in the 12 months prior to referral- 70.8% B12, folate and thyroid function tests; 20.8% TFTS only; 8.3% B12 and folate levels only).

Conclusion

Referrals to specialist memory services by General Practice often lack the appropriate first line investigations, which introduces delay in review and the need for further assessment once baseline investigations have been done. There is a need for a standardised work-up prior to referral for optimum running of such services.
233 COGNITIVE OUTCOMES AFTER A FIRST EPISODE OF DELIRIUM IN HOSPITAL – RESULTS FROM AN ADVANCED NURSE PRACTITIONER DELIRIUM CLINIC
Authors: Ryan S , Sayers K , King L , Maher J , O'Reilly A , Donnellan C , Pillay I
Published: October 2022

Background

Cognitive outcomes for frail older adult inpatients with a first episode of Delirium are unknown. Aim: To determine cognitive outcomes of frail older inpatients after a first episode of Delirium.

Methods

Consecutive frail older inpatients with a 4AT score >/= 4, without a previous history of cognitive impairment, over a 12-month period (January to December 2021) were invited for formal cognitive assessment 8-12 weeks after their delirium occurred. Collateral history, medication review, Addenbrookes (ACE III), bloods and CT brain were undertaken. Data was prospectively entered onto Excel and analysed using descriptive statistics.

Results

Fifty-one patients with a mean age of 82 years (SD=6) were referred to the Advanced Nurse Practitioner (ANP) Delirium Clinic. Median Clinical Frailty Score (CFS) was 6 with a male: female ratio of 1:2. Forty- seven percent (n=24) attended; 35 % (n-18) did not attend; 18 % (n=9) died prior to assessment. The ratio of male to female attendees was 1: 2.4. There was no difference in CFS or age between attenders and non-attenders. Thirty-three percent (n=8) of patients who attended had potentially reversible causes (high anti-cholinergic burden, folate deficiency, sleep disorder) of cognitive impairment requiring intervention. Sixty-seven percent (n=16) were diagnosed with dementia at the Delirium Clinic; 16.6% (n=4) were diagnosed with Mild Cognitive Impairment; 4% (n=1) had a resolved delirium; 8% (n=2) were referred to consultant Memory Clinic and one patient remained too unwell to assess. The median ACE III score of patients diagnosed with dementia was 54/100 (SD = 18).

Conclusion

Pro-active follow up of patients with a first episode of Delirium led to early diagnosis of dementia and mild cognitive impairment with supportive interventions. Earlier ANP intervention, during the acute phase of delirium, has been introduced in order to improve clinic attendance.
235 EYES WIDE SHUT: A CASE OF BILATERAL PTOSIS FOLLOWING STROKE
Authors: McDonnell M , Kelly N , Mullaney G , O'Malley T
Published: October 2022

Background

Bilateral ptosis is a rare manifestation of midbrain stroke. It has been reported in case studies only, with no data on incidence rate, and no published case report in Ireland to date.

Methods

This is a retrospective case study of a man admitted to an acute stroke unit following collapse and unresponsiveness. A review of his medical records and radiological database was conducted. A PUBMED database search was conducted to search for similar cases.

Results

We present the case of a man who had a witnessed collapse whilst farming and was brought to hospital and presented with a Glasgow Coma Scale of 3. Imaging showed a normal CT Brain. MRI revealed 2cm acute bilateral thalamic and midbrain infarction. Following a brief period in ICU he was transferred to the acute stroke unit for multidisciplinary care. Despite improvements in his medical status and communication efforts, his inability to open his eyes contributed to a persistently low GCS. Neurological assessment revealed bilateral ptosis, fixed dilated pupils and oculomotor paralysis. These symptoms had a profound impact on his stroke recovery, impeding assessments and interventions and engagement in all realms (swallow and communication; mobility and function, cognitive-perceptual) whilst also limiting opportunities for social interaction. Once staff became aware of the ophthalmoplegia, strategies were implemented to optimise his participation and provide opportunities of recovery. Three months post stroke, he began to experience some return of unilateral eye-opening and bilateral horizontal movements (with diplopia) which greatly improved his overall performance. He was then transferred to the rehabilitation unit where he continues to progress.

Conclusion

Bilateral ptosis post stroke is rare and has a debilitating effect on participation in all aspects of living and interaction with the environment. This presentation has previously been described as “reverse locked-in-syndrome” which accurately represents its impact.
245 A PILOT STUDY EVALUATING USE AND ACCEPTABILITY OF A NATIONAL AUDIT TOOL AND MANUAL FOR PSYCHOTROPIC MEDICATIONS IN RESIDENTIAL CARE
Authors: Allen Y , Timmons S
Published: October 2022

Background

Psychotropic medications are frequently prescribed for long-term care residents, even though the risks frequently outweigh the benefits. A draft tool was developed for self-audit of the appropriateness of psychotropic medications prescribed for non-cognitive symptoms for people with dementia in Residential-Care Facilities (RCF). Prior to national use, the audit tool, audit manual and training required piloting.

Methods

The case notes of ten residents with dementia were selected at random within a single RCF. A set of notes were audited by professional staff after online (pre-recorded) audit training, with subsequent feedback by the auditors on the process via focus groups/individual interviews. A second set of notes were then audited, with feedback via a brief survey.

Results

All auditors (7 nurses, 4 doctors, and 4 therapists) gave feedback via a focus group(n=4) or 1:1 interviews; 7 also completed the second-round survey. The pre-audit online training was welcomed but some auditors required additional support during the audit, especially if inexperienced or if there was a gap between training and audit performance. Improvement suggestions for the audit manual included shortening it; adding a glossary of terms, and additional information for decisions on the appropriateness of “as needed” (PRN) medications. Auditors reported difficulties with reading handwriting, locating information in the chart, and determining if a medication was newly or previously prescribed on occasion (due to inconsistencies with prescribing documentation).

Conclusion

Overall, the feedback was positive; all reported that the audit was relevant to their practice, and the manual and online training were useful. Future audits could be facilitated by electronic prescriptions, protected time to complete audits, and site audit leads (senior nursing or medical staff who are familiar with the residents, the audit topic, and with performing the audit). Inexperienced auditors should have, in addition to a training session, a supported auditing session.
246 THE ROLE OF AGEING ON SELF-REPORTED ABILITY ACROSS MULTIPLE SENSES: A LONGITUDINAL ANALYSIS OF DATA FROM THE TILDA STUDY
Authors: O'Dowd A , Hirst R , Setti A , Kenny RA , Newell F
Published: October 2022

Background

During the healthy ageing process, sensory degeneration typically occurs and often in more than one sensory modality. This can present significant challenges to the well-being and quality of life of older adults. However, it is unclear whether senses decline into impaired functioning in a manner that is independent from each other or that is suggestive of a common, amodal mechanism related to the ageing process.

Methods

We used discrete survival analysis to explore the longitudinal (10-year) associations between a number of measures (including age, lifestyle factors and measures of sensory, physical, mental and cognitive health) and the probability of transitioning from normal to impaired sensory function for vision, audition, olfaction and gustation. Sensory impairment was captured as self-report measures for a large sample of older adults (N = 5,066) from The Irish Longitudinal Study on Ageing.

Results

Auditory impairment was most prevalent, followed by impaired vision, olfaction and gustation. Multivariable regression models revealed an increased probability of impairment in one modality for those reporting impairments in other modalities, although this pattern was not consistent for all modality combinations. Visual impairment was associated with socioeconomic status, education, eye disease, smoking and depression. Auditory impairment was associated with age, the sex of participant, hearing aid use and difficulty following group conversations. Olfactory impairment was associated with age, the sex of participant, smoking and difficulty following group conversations. Gustatory impairment was associated with age, smoking and depression. Importantly, self-rated decline in general health was associated with an increased probability of reporting an impairment across all sensory modalities.

Conclusion

Our results suggest that older adults report a decline across multiple senses over time, but the rates are of decline are not consistent. Sensory decline appears associated with both global and modality-specific factors, providing some insights into the impact of sensory health in ageing.
247 QUALITY IMPROVEMENT IN DEMENTIA CARE: STREAMLINING CARE PATHWAYS IN A PSYCHIATRY OF OLD AGE SERVICE
Authors: Byrne R , Elzain M , Amosu E , Lim SA , Walsh A , McLaughlin K , McMorrow S , Matthews K , Sweeney G , McCarthy G , Dolan C
Published: October 2022

Background

Dementia is increasingly considered a public health priority worldwide in the context of predicted increased prevalence. In Ireland, there are an estimated 67,000 persons living with dementia and by 2041 it is expected to rise to 145,000 persons. Challenges in dementia care have been highlighted in health services across Europe and the ineffective structure of dementia care with fragmented non-person-centred pathways has been identified.

Methods

An initial review of the existing cognitive impairment diagnostic pathways in our specialised Psychiatry of Old Age (POA) Service was undertaken. This included surveying the multidisciplinary team to identify challenges, clinical chart review and audit of physical examination equipment. Diagnostic pathway was updated based on findings and informed by the developing national ‘Model of Care for Dementia in Ireland’ and best practice.

Results

Review findings included lack of standardisation of memory assessment, delays in accessing neuroimaging and laboratory results, gaps in staff training. A care pathway document was developed detailing requirements for care from the point of referral through to cognitive impairment diagnosis. Staff training was completed to accompany the introduction of standardised dementia assessment scales. Access to laboratory/radiology booking was enhanced. A cognitive remediation group was developed by Occupational Therapy as part of post-diagnostic supports for service users. Preliminary data indicates improvements in satisfaction of those attending the group. Physical examination equipment audit resulted in quality improvements.

Conclusion

We demonstrate that a quality improvement approach can be implemented to enhance assessment, diagnosis and care provided to support diagnosis of cognitive impairment and dementia in POA service. The enhanced diagnostic care pathways will be assessed over time to assess impact on care of service users. Preliminary findings are positive and it is an approach that can be adopted in other services and inform development of national memory service developments.
250 AUDIT INTO THE USE AND COMPLICATIONS OF MAINTENANCE INHALER THERAPY IN MEDICALLY ADMITTED PATIENTS OVER THE AGE OF 65 YEARS
Authors: Walsh S , Mulroy M
Published: October 2022

Background

Adequate maintenance inhaler use is associated with improved symptom control and reduced exacerbation rates, however, cognitive impairment and limitations in dexterity can be a barrier to inhaled therapy.

Methods

Between the 20th of April and 30th May 2022 patients admitted to our ward over the age of 65 years had their maintenance inhaler technique assessed using the National Asthma Council of Australia checklist. Symptom control was assessed by either the Asthma Control Test (ACT) or the Chronic Obstructive Pulmonary Disease (COPD) assessment tool (CAT). The 4 AT score was used to screen for neurocognitive impairment.

Results

20 patients were recruited to the study. 40% were male. Mean age 81.5 years +- 6.8years. The respiratory diagnosis was COPD in 70%, Asthma 20%, Interstitial Lung Disease 5% and bronchiectasis 5%. 65 % had pulmonary function testing performed. Asthma symptom control was within target in 75% of the asthma patients (ACT score >20). Mean score 21 +- 2.5. COPD symptom control was within target in 31% of patients (CAT score <10) . Mean CAT score of 19.3 +- 8. 4. 20% had a pre-admission diagnosis of neurocognitive impairment. The mean 4AT score of the cohort was 1.2. 35% had audible wheeze at the time of review. 80% of inhalers were prescribed for the licensed indication. 35% had potential complications of inhaler therapy – 25% pneumonia and 10% oral candidiasis. Notably all pneumonias were associated with fluticasone. Inhaler technique was associated with errors in almost a quarter of all patients (24%). Increasing 4AT score correlated with high likelihood of inhaler errors, R = 0.63.

Conclusion

Poor inhaler technique is correlated with neurocognitive impairment. Pneumonia is a potential complication of inhaler therapy and represents an opportunity for deprescribing in patients with COPD.
252 VTUESDAYS: A QUALITY IMPROVEMENT PROJECT TO EMBED THROMBOPROPHYLAXIS REVIEWS IN AN INTERMEDIATE CARE REHABILITATION SETTING
Authors: Trainor R , Atkinson T
Published: October 2022

Background

Venous Thrombo-Embolism (VTE) can be life-threatening. Risk assessment and mitigation is essential to reduce morbidity and mortality in all clinical settings. Northern Ireland Health and Social Care has a standardised, regional thromboprophylaxis risk assessment tool as part of paper-based drug charts in the acute, secondary care setting. Intermediate care setting drug charts incorporate this same tool. The 30-bedded pilot site cares for step-down patients from the acute hospital setting from surgical, orthopaedic and medical specialties, for those aged over 18 years requiring bed-based rehabilitation. Regularisation of reviews of risk assessments to address changes in VTE risk was identified as a need to avoid under-prescribing and over-prescribing.

Methods

Quality improvement methodology was used. Pre-phase, semi-structured interviews with stakeholders took place. An Ishikawa diagram analysed contributory factors to risks. A Sinek circle distilled intentions. A Clinical Value Compass map considered potential outcomes. A vision of “VTuEsdays” was co-designed. Global and specific aims informed driver diagrams. Plan, Do, Study, Act iterations were used in the implementation phase including a decision support tool to guide the appropriateness of deprescribing on the basis of rehabilitation trajectory and changing VTE risk.

Results

We collected baseline data and implemented education of staff working in the intermediate care centre, utilising the ‘PDSA’ Model to guide changes. A bright and easy to use flowchart was used with the title ‘VTuEsdays’. This encouraged the process of VTE risk assessment and weekly review on a Tuesday. There were improvements in: the completion rate of risk assessment tool; the accuracy of this assessment; the under-prescribing and over-prescribing of thromboprophylaxis.

Conclusion

The “VTuEsdays” themed day helped ameliorate under-prescribing and over-prescribing of thromboprophylaxis in an intermediate care bed-based rehabilitation setting. Quality improvement methodology enables a robust approach to risk mitigation. Similar themed days for regularisation of reassessment of clinical risk management in intermediate care settings could improve different aspects of care.
254 AN AUDIT OF DISCHARGE SUMMARY QUALITY AND INTRODUCTION OF A DISCHARGE SUMMARY TEMPLATE IN AN ORTHOGERIATRIC SERVICE
Authors: Rafferty M , Murphy D , Fouhy F , Amumin A , Saidova M , Dukelow T , Ahern E
Published: October 2022

Background

The discharge summary is the main method of communication integrating the care of older adults from the acute hospital admission to their discharge destination. HIQA published standards to ensure high quality and safe information transfer between settings. We designed an audit to evaluate the quality of the discharge summaries from the orthogeriatric service before and after the introduction of a discharge summary template for use by Non-Consultant Hospital Doctors (NCHDs) on the service

Methods

Data were collected anonymously using an excel data collection tool with 51 data points covering the seven key areas outlined in the standards. Initial data collection included patients admitted in November 2021. We introduced a discharge template and education sessions for orthopaedic NCHDs regarding discharge summary completion. We then retrospectively collected data from discharge summaries completed after the intervention in March 2021

Results

We examined discharge summaries of 10 patients in each group. Admission and discharge details, and details of the patient, GP and author met the HIQA standards in all summaries and there was no significant change documented. There was an appropriate clinical narrative included for 8 patients preintervention and all patients after. There was a 70% improvement in documentation of patients’ living circumstances and 90% for details of functional state. Medications on discharge were included for three patients initially and eight after. Specific details regarding medication changes were included for one patient initially and seven after. Details of future management improved in 5, 7 and 3 summaries regarding hospital actions, GP actions and community actions respectively.

Conclusion

High-quality discharge summaries are essential for continuity of care and patient safety. The introduction of a discharge summary template and education of NCHDs significantly improved the quality of the discharge summaries in our unit.
257 THE INTRODUCTION OF THE SSKIN BUNDLE IN A REHABILITATION SETTING
Authors: McDonnell C
Published: October 2022

Background

The SSKIN Bundle is a care bundle in which each component acts as an intervention in preventing pressure ulcers. SSKIN stands for Surface, Skin Inspection, Keep Moving, Incontinence Management, and Nutrition. This quality improvement initiative outlines the introduction of the SSKIN Bundle in an attempt to address the issue of pressure ulcers in a rehabilitation hospital. There is a significant amount of research attesting to the physical, psychological, and economic impact pressure ulcers have on patients, particularly older adults.

Methods

Following the Health Service Executive (HSE) Pressure Ulcer to Zero (PUTZ) campaign (HSE National Wound Management Guidelines 2019), this initiative was introduced to the hospital by an interdisciplinary committee in February 2019. Patients who met the inclusion criteria were regularly assessed using the SSKIN Bundle. Data was visually audited via the PUTZ safety cross and analysed using Run Charts.

Results

Results showed a clear decrease in the number of pressure ulcers following introduction of the SSKIN Bundle. Within a six-month timeframe and following the introduction of the SSKIN Bundle, the incidence percentage of newly acquired pressure ulcers was reduced by 50%. Despite incidences where partial increases occurred, this was quickly rectified by facilitating targeted education sessions to staff and the appointment of a tissue viability nurse.

Conclusion

The conclusions of this campaign ultimately found that the introduction of a SSKIN Bundle helped to improve staff knowledge on the monitoring, recognition, grading, and prevention of pressure ulcers. The visual of the safety cross worked particularly well as a means to tailor this education where knowledge gaps existed.
258 RISING TO THE CHALLENGE: ORTHOGERIATRIC SERVICE IMPROVEMENT AND COVID-19
Authors: Stankard A , Thomas N , Cosgrave N , Conlon B , Monaghan P , Halpin T , English D , Byrne P , McShane S , Sohail I , Grogan AM , Reilly A , Thapa A , Alsubaie N , Rane P , O'Connor J , Gray S , Kaja A , Gehani K , Kovalyshyn V , O'Brien H
Published: October 2022

Background

Nationally agreed hip fracture standards have contributed to the improvement of outcomes in hip fracture patients. In 2020, our hospital was awarded “The Golden Hip” for achieving highest compliance with Irish Hip Fracture Standards (IHFS) nationally for 2019.

Methods

Data from the Irish Hip Fracture Database (IHFD)was retrospectively analysed to assess our performance in 2020 versus 2019 in hip fracture patients over sixty. Multiple quality improvement interventions were put in place throughout 2019 to ensure improvement in IHFS1-6 compliance: Creation of the Hip Fracture Pathway Subgroup, IHFS 1 Breaches Audit, Orthogeriatric input at Orthopaedic inductions, weekly Multi-disciplinary Team meetings, a Nutritional Hip Fracture Pathway and addition of the Fracture Liaison Service Advanced Nurse Practitioner.

Results

There were 239 hip fracture patients in 2020 vs 249 in 2019. IHFS1 compliance improved with the percentage of patients admitted to the Orthopaedic ward within 4 hours increasing to 71% in 2020 from 56% in 2019. There was improvement in IHFS2-time to surgery <48 hours- 66% in 2020 vs 60% in 2019. IHFS3-pressure ulcer rate-was at the national average, 3% in 2020 vs 2% in 2019. IHFS4 (reviewed by a Geriatrician), IHFS5 (received a bone health assessment) and IHFS6 (received a specialised falls assessment) were lower overall; 87% in 2020 vs 98% in 2019. For all quarters (Q),43% of patients met all IHFS in our hospital in 2020 vs 32% in 2019, resulting in €90,000 in Best Practice Tariff funding.

Conclusion

Lower results for IHFS 4,5 and 6 reflect the arrival of the COVID-19 pandemic which led to redeployment of the Orthogeriatric Service and redeployment of the MDT from end of Q1 to Q3. When services in 2020 were preserved,1 in 2 hip fracture patients met all IHFS, vs 1 in 3 patients in 2019. Despite the pandemic, we continued to achieve the highest level of IHFS compliance nationally, being awarded a second consecutive “Golden Hip” for 2020.
259 AN AUDIT OF DNACPR FORM USAGE IN A LEVEL 4 HOSPITAL FOLLOWING RE-DESIGN AND IMPLICATIONS FOR ITS FUTURE USE
Authors: Brennan F , Higgins M , Russell S , Sands H , Keogh C , Curran C
Published: October 2022

Background

In 2020 during the Covid-19 pandemic our hospital introduced a new green DNACPR form with 2 significant changes. It now specifies if the patient is or is not for resuscitation (as a yes/no choice) and a Treatment Escalation Plan (TEP) has moved to the front of the page from the back. A subsequent audit found that 19% of inpatients had forms completed, of which 68% stated DNACPR and 29% for CPR. 76% of forms had a TEP (versus 56% on the old forms). We repeated the hospital wide audit in 2022 to assess if the improvement in TEP documentation was sustained, and if it was used on all patients or primarily to document DNACPR decisions.

Methods

The hospital-wide audit was performed on the 25.05.2022. Charts were reviewed on medical and surgical wards. ICU patients were excluded. The following data were recorded: Resuscitation status, form completion, presence of a TEP, if the date of admission and form completion were recorded, if the name of doctor and nature of discussion with patient and family were documented, and if the TEP was consistent with the most recent clinical notes. The data was compared to the 2020 audit and against the Hospital’s DNAR & TEP policy.

Results

634 inpatients were identified. 15.7% (100) had a form completed of which 92% stated DNAR. One of these did not have a TEP. The doctor’s name and grade were clearly documented on all forms.

Conclusion

99% of patients who were not for CPR had a TEP indicating sustained improvement since the introduction of the new form. Given 83.3% of patients did not have any documented resuscitation status the approach of documenting yes or no for resuscitation is not being utilised. A return to a dedicated form that indicates someone should not undergo attempts at resuscitation may offer more clarity.
261 HIGH FRACTURE RISK IN OLDER IRISH ADULT FALLERS
Authors: Breslin L , Bradley E , Fitzpatrick D , Laird E , Hoey L , Hughes C , McNulty H , Strain JJ , Ward M , Tracey F , Molloy A , Cunningham C , McCarroll K
Published: October 2022

Background

Fracture risk due to falls depends on several factors including bone density, quality and size, hip geometry (axis length), direction of fall (forward, backwards or sideways), body mass index (BMI), type of surface impacted, body site of impact and mechanism of fall (eg syncope). We aimed to identify the fracture risk per fall in frail older Irish adults.

Methods

Participants were from the hypertensive and cognitive cohort of the Trinity, Ulster, Dept Agriculture (TUDA) study of Irish adults (aged >60) recruited from hospital outpatient services and GP practises. Falls and falls resulting in fracture in the previous year were self-reported so those with an MMSE < 25 were excluded to avoid recall bias. We identified fallers, recurrent fallers and fractures due to falls in the previous year.

Results

892 fallers, mean age 76.3 ± 8.4 yrs, 65.2% female. 23.8% had 2 falls and 24.2% ≥3 falls. Mean timed up and go was 17.3 ± 9.5 seconds. Commonest fracture due to falls were hip (20.1%), upper limb (18.5%) and lower limb (17.9%) with one fracture of neck and skull. Fracture rate per fall was 7.1%: 1.7% for hip, 1.3% for lower and 1.2% for upper limb. Annual fracture rate per faller was 16.5%. The only predictors of fall with fracture versus no fracture were female sex (OR 2.4, 1.6-3.6, P<0.001) and lower body mass index (P=0.001).

Conclusion

We identified similar hip fracture rates (1.7%) due to falls as in other studies. However, one in six fallers had sustained a fracture in the previous year reflecting the high proportion of recurrent fallers. Lower BMI and female sex predicted fall with fracture as both are strongly correlated with risk of osteoporosis. Recent guidelines now factor in recurrent falls when estimating the probability of future osteoporotic fractures.
262 THE IMPACT OF COVID-19 PUBLIC HEALTH MEASURES ON THE SOCIAL RELATIONS OF MEN AND WOMEN IN LATER LIFE
Authors: Sheridan C
Published: October 2022

Background

Despite the burgeoning literature on the impact of Covid-19 on the lives of older populations, gaps remain in our knowledge around the lived experience of social relationship change during the pandemic, and the implications for longer-term relational well-being. Even with the clear significance of Covid-19 for older populations across Europe, research involving cross-national comparisons of these experiences is largely absent. Addressing these gaps is critical given concerns for some older people’s social connectedness, their future relational embeddedness, and our societal preparedness for pandemic and other public health crises. The aim of this paper is to chart the impact of the pandemic on older people’s subjective lived experience of social connectedness across seven countries, and to contrast the differential impact of public health measures, if any, in these jurisdictions.

Methods

The analysis draws on 210 semi-structured interviews with men and women aged sixty-five and over across Austria, Czech Republic, Ireland, Israel, Norway, Spain, Sweden (as part of a wider study into exclusion from social relations), with a focus on direct social distancing measures and people’s response to these measures.

Results

Four themes emerged from the data: reduced informal social contact, depleted social opportunities, fear and lack of social confidence, and relational life course and impacts in context. Given the largely common approach to preventing the spread of the virus, more cross-national similarities than differences, although there were clear exceptions to this in relation to approach, and cultural nuances are evident. Cross-cutting these themes, structural and self-ageism emerged as intensifying formal constraints for some participants, in some settings.

Conclusion

For most participants, public health measures had a negative impact on their subjective well-being, while others experienced disruption to their relational life course trajectories. The data points to a clear need to consider the social infrastructure of older people, particularly in times of crises.
263 INFORMING INTERVENTION DESIGN IN COGNITIVELY IMPAIRED POPULATIONS: LESSONS LEARNED FROM THE OPTIMIZE DEPRESCRIBING INTERVENTION
Authors: Sheehan OC , Bayliss EA , Green AR , Drace ML , Norton J , Reeve E , Shetterly SS , Gleason Kathy S , Weffald LA , Maciejewski ML , Kraus C , Maiyani M , Wolff J , Boyd CM
Published: October 2022

Background

Polypharmacy is common in older adults with cognitive impairment and multiple chronic conditions increasing their risks of adverse drug events, hospitalization, further cognitive decline and death and leading to higher health care costs. Deprescribing, the process of reducing or stopping potentially inappropriate medications may improve outcomes. The OPTIMIZE trial examined whether educating and activating patients, family and clinicians about deprescribing reduces number of medications for older adults with cognitive impairment and multiple chronic conditions. Acceptability and challenges of intervention delivery in this vulnerable population are not well understood.

Methods

We explored mechanisms of intervention effectiveness through post hoc qualitative interviews and surveys with 15 patients, 7 family caregivers, and 28 clinicians. We assessed accessibility and delivery of materials as well as the ability of the materials to facilitate conversations and influence decisions around deprescribing.

Results

Acceptance of the intervention was affected by contextual factors including cognition and prior knowledge of deprescribing. Positive effects of the intervention included patients scheduling specific appointments to discuss deprescribing and providers being prompted to consider deprescribing. Recollection of intervention materials by patients was inconsistent but highest shortly after intervention delivery. Short clinic visit times remained the largest clinician barrier to deprescribing.

Conclusion

Our work identifies key learnings in intervention roll out which can guide future scaling of our intervention and other pragmatic deprescribing intervention studies in patients with cognitive impairment. We highlight the critical roles of both timing and repetition in intervention delivery to cognitively impaired populations as well as the barrier to deprescribing posed by short clinic consultation time. Our success in activating deprescribing conversations in this population highlights the need to incentivize medical professionals and health systems to incorporate deprescribing into routine clinical practice and expand proven interventions to other vulnerable populations.
266 MINIMALLY-EFFECTIVE PHYSICAL ACTIVITY DOSE FOR DEPRESSION AMONG OLDER ADULTS: PRELIMINARY FINDINGS FROM THE IRISH LONGITUDINAL STUDY ON AGEING
Authors: Laird E , Rasmussen CL , Kenny RA , Herring M
Published: October 2022

Background

Among older adults, depression is associated with increased risk of lower physical, social, and cognitive function. Physical Activity (PA) has been associated with lower odds of depression; however, the minimally sufficient dose for protection is unknown. Herein, we quantified the association between different PA doses and depressive symptoms and status among older adults across 10 years (waves 1-5) as part of The Irish Longitudinal Study on Ageing.

Methods

PA was measured at each wave using the short-form International Physical Activity Questionnaire (IPAQ-SF). Five dose categories (0, 1-<600, 600-<1,200, 1,200-<2,400 and ≥2,400 MET.min.week-1) were examined. At all waves, depressive symptoms were assessed using the Center for Epidemiological Studies Depression Scale short form (CES-D) and a score of ≥16 was used to define depression. From Waves 2-5, the Composite International Diagnostic Interview quantified diagnosis of a Major Depressive Episode during the past 12 months, or depression status. Poisson regression quantified associations between PA dose and depressive symptoms and status across time, adjusted for age, health/lifestyle variables and antidepressant medication.

Results

Among 4,017 participants, depression status changed from 8.2% at wave 1 to 12.2% at wave 5. The minimal PA dose associated with lower depressive symptoms was 1-<600 MET.min.week-1 (coefficient = –0.06; 95%CI: –0.10, –0.02; p≤0.003). A dose of 600-<1,200 MET.min.week-1 was significantly associated with lower odds of depression status (OR = 0.66; 95%CI: 0.50, 0.87; p≤0.004). Other positive predictors associated with lower odds of depression included greater age, higher education status, and sufficient vitamin D status.

Conclusion

Present findings suggest that even low physical activity doses appear protective against depressive symptoms among older adults. Moderate PA dose, consistent with WHO recommendations, was protective against major depression over a 10-year period among older adults. However, individuals with chronic conditions may have different PA dose requirements, which should be further investigated.
269 PHARMACIST INTERVENTIONS WITHIN A MULTIDISCIPLINARY CARE TEAM FOR FRAIL OLDER ADULTS PRESENTING TO A LEVEL 4 EMERGENCY DEPARTMENT
Authors: O'Caheny C , Dillon L , Smyth H , Riches R , Laguna R , Magner S , Pender C , Carrabine N , Buckley B , Carey S , Harrington G , Mitchell M , Brown J , Callaly E , Purcell R , Ramiah V , Byrne C
Published: October 2022

Background

Inappropriate polypharmacy and ‘Potentially Inappropriate Prescriptions’ (PIP) are associated with increased morbidity and hospitalisation, in particular among frail older persons. A structured medication review, in conjunction with a Comprehensive Geriatric Assessment (CGA), can address PIP. The aim of the study was to review Frail Intervention Team (FIT) pharmacist interventions for frail, older adults presenting to the Emergency Department (ED) and experiencing medication compliance difficulties, polypharmacy and PIP.

Methods

Patients identified for medication review included those experiencing polypharmacy or medication compliance issues, presenting with a fall, delirium and/or frailty syndromes or complex comorbidities. The medication review process involved completion of medicines reconciliation and medication appropriateness review in accordance with the 7-Steps Medication Review Model (Scottish Government Polypharmacy Model of Care Group, 2018). Pharmacist optimisation recommendations were reviewed by a Consultant Geriatrician or Registrar and discussed with the patient prior to implementation.

Results

The FIT Pharmacist completed medication reviews for 765 patients between May 2021 and April 2022. The mean age (+/-SD) was 83.1 (+/-7.0) years with a median Clinical Frailty Score (CFS) of 5 (mildly/moderately frail). Medication Optimisation recommendations were actioned in 63% (n=483) of patients reviewed. The most commonly encountered PIP’s included: excessive anti-hypertensive/diuretic therapy, long-term acid-suppression therapy, anticholinergics and long-term prophylactic antimicrobials. Prescribing opportunities identified included: bone protection, laxatives and pain management.

Conclusion

FIT pharmacist review, in conjunction with the CGA, led to medication optimisation interventions in the frail older adult cohort presenting to the ED. Future studies should examine the impact of medication review on patient outcomes post-discharge.
273 ‘HOME ON TIME’: MULTIDISCIPLINARY INTERVENTION REDUCES LENGTH OF STAY AND DELAYS IN CARE TRANSFERS ON AN ACUTE GERIATRIC MEDICINE WARD
Authors: Mealy B , Nevin A , Lavan A , Jariol AL , Roll V , Connor SO , Donnell DO , Cummiskey AG , McNulty J , Malley MO , Briggs R
Published: October 2022

Background

Unnecessarily prolonged hospital admission can have a profound effect on a frail, older person’s confidence, mood, functional status and cognition.This study examined whether a structured multidisciplinary intervention, embedded within an acute geriatric medicine ward, could reduce unnecessary days in hospital for acutely unwell older patients.

Methods

The study site is a 28-bed acute geriatric medicine ward in a large urban teaching hospital; data was collected from 1/1/22 to 11/4/22. Patients aged ≥70 years and admitted to the ward were randomly allocated to the Home On Time (HOT) Pathway (n=50) or usual care (n=100). All patients were cared for by a specialist geriatric team. The HOT Pathway involved daily multidisciplinary team (physiotherapy, nursing, occupational therapy, social work and medical) huddles focusing on enhanced communication, early discharge planning and identification of barriers to discharge home. Huddles typically lasted for <15 minutes.

Results

Almost two-thirds (92/150) of the study sample (mean age 83 years, 60% female) were discharged directly from the ward while one-fifth (29/150) were transferred for rehabilitation and one-tenth ultimately to long term care (16/150). The average acute ward Length-of-Stay (LOS) for HOT pathway patients was 10.4 days, compared to 14.4 days for usual care. The average LOS for HOT pathway patients discharged directly home (i.e. not via rehabilitation or to long-term care) was 8.0 days, compared to 10.2 days for usual care. One-fifth (10/50) of HOT pathway patients were discharged home within 48 hours of admission compared to one tenth (10/100) of usual care patients.

Conclusion

A structured, multidisciplinary intervention focusing on enhanced communication and early discharge planning within a geriatric medicine ward can reduce length of inpatient stay, delays in transitions of care and increase the rate of discharge home within 48 hours, potentially averting complications related to prolonged hospital admission.
276 SENSORY DEPRIVATION IN OLDER MEDICAL INPATIENTS: ARE WE AWARE ENOUGH?
Authors: McCreery A , Leahy A , Geraghty T , Boyle N
Published: October 2022

Background

Visual and hearing impairment is common amongst older adults admitted to the acute hospital setting. Sensory deprivation can contribute to falls and incidence of delirium, particularly in those who have underlying cognitive impairment. Interventions which reduce sensory deprivation have been recommended to avoid these complication [1].

Methods

Patients over 75 admitted to 11 medical wards in a University Teaching Hospital were assessed. Baseline demographics were collected. Documentation regarding hearing and visual impairment, delirium, completion of 4 AT, and underlying cognitive impairment was reviewed. Inpatient falls were documented.

Results

100 older adults were included in the audit. (Mean age: 83.5 years). 73% of patients had a visual impairment and 23% had a hearing impairment. 67% had access to their glasses and only 27% of patients had access to their hearing aids. Documentation of sensory disability in either medical or nursing notes was 19%. 29% of patients had documented delirium during their inpatient stay. 4AT was performed on 76% of admitted older adults in the selected wards.

Conclusion

Visual and hearing impairment is common amongst older admitted medical inpatients. Despite this, there can be a lack of access to glasses and hearing aids. There is a paucity of documentation regarding sensory deprivation, therefore interventions targeting this risk factor for delirium may not be allocated to the cohort most at risk. We recommend strategies highlighting awareness of sensory deprivation in older adults admitted to hospital.

Reference

1. Surkan MJ and Gibson W. Interventions to mobilize elderly patients and reduce length of hospital stay. Canadian Journal of Cardiology. 2018 34(7), pp. 881–888.
281 PREVALENCE OF STOPPFALL FALLS-RISK-INCREASING DRUGS (FRIDS) IN PATIENTS PRESENTING TO HOSPITAL WITH A FALL
Authors: O'Donnell D , Zainal T , Malomo K , Neasa F , Briggs R , Cunningham C , Romero-Ortuno R , Rice C , Kenny RA , Lavan AH
Published: October 2022

Background

Falls cause presentation and admission to hospital. Falls-Risk-Increasing-Drugs (FRIDs) are a modifiable risk factor. STOPPFalls criteria was developed, using an expert Delphi panel, to achieve consensus on a comprehensive list of FRIDs. The aim of this study was to identify the prevalence of STOPPFall PRIDs in patients presenting to hospital with falls and identify whether review by a specialist Falls and Syncope Service (FASS) reduces FRIDs.

Methods

This was a retrospective observational study. Patients ≥65 years reviewed by the hospital FASS in the emergency department (over 6-months) and in house (over 2-months), were included. Medication appropriateness at admission and discharge were assessed using STOPPFall criteria. Ethical approval was received from the local research and innovation office (ref7013).

Results

Of 156 patients, 87(55.8%) were ≥65 years; 46% female, mean age 78.1(SD7.5) years. The mean number of conditions was 4(SD4.4); the mean number of regular medications was 6.9(SD4.5). Reasons for referral to FASS included falls (34.5%), dizziness/near fall (35.6%), and transient loss of consciousness (29.9%). For 21.8% there was an associated injury; 11.5% a fracture. Thirty-seven (42.5%) had experienced at least one fall in the previous 12-months.

Sixty-four (73.6%) were on ≥1 STOPPFall FRID. The most common STOPPFall FRID prescribed to older adults were diuretics (24.1%), anti-depressants (20.7%) and benzodiazepines/benzodiazepine-related drugs (13.8%). At least 1 STOPPFall FRID was stopped in 31.3%. The most commonly deprescribed STOPPFall FRIDs were diuretics (20%), alpha blockers (6%) and benzodiazepines/benzodiazepine-related drugs (4.7%). Adults <65years (n=69) were more likely to be prescribed a STOPPFall FRID at admission than older adults (≥65years); 88.4% vs 73.6%, p=0.021.

Conclusion

STOPPFall FRIDs are prevalent in fallers of all ages. Even one review by a specialist FASS leads to medication optimization. The effectiveness of STOPPFalls criteria in the prevention of falls should be evaluated further in intervention studies.