bluuebunny/crossref_metadata_2025 huggingface dataset:
211 A Novel Integrated Care Approach: Supporting Older Persons to Remain at Home
Authors: Tormey Sarah , Binions Laura , Dunne Aoife , Soh Josephine , O'Connor Marie , Kennelly Siobhan
Published: September 2019

Background

An Integrated Care Team (ICT) was established within our Day Hospital in September 2018 serving a catchment of older persons encompassing 3 Community Healthcare Organisations. The geographical spread of our patients poses challenges to the ICT in establishing an integrated network of services for patients. Provided here is a descriptive analysis of our patient cohort including basic demographics, co-morbidities, interventions and outcomes.

Methods

The team comprises of a Senior Physiotherapist, Occupational Therapist and Medical Social Worker supported by two Geriatricians. Referrals to the ICT are via the Day Hospital with a weekly multi-disciplinary team (MDT) meeting where they are discussed and prioritised. Interventions offered include domiciliary and day hospital based assessments. Following assessment appropriate targeted therapeutic intervention is provided which includes rapid access to enabling equipment, access to community supports and rapid access Geriatrician review. Additionally the ICT communicate with the acute and primary care services to identify existing or previous resource utilisation.

Results

In the inaugural 15 weeks of the service,132 referrals were received. This cohort had a mean age of 81,range (60-102) years; 58% female, 42%male. The Charlson Co-morbidity Index (CCI) score ranged from 2-9 with a mean score of 5. Of these, 50% had a Dementia diagnosis, 33% had a Falls history and 17% had a Stroke diagnosis. The mean Rockwood Clinical Frailty Scale score was 5; range ( 2-7). 62% of referrals were reviewed by both Physiotherapy and Occupational therapy, 58% by Medical Social Work. 34/132 required input from all 3 disciplines.

Conclusion

The ICT service has augmented the existing Day Hospital with timely multi-disciplinary assessment and treatment enabling older persons’ independence within their home in addition to forward planning if dependency levels increase. Additional benefits include reduction of primary care team waiting lists and forging links with our community and local rehab services. Future ambitions include recruitment of specialist nursing and direct referral pathways from our community colleagues.
221 Delirium Detection in the ED Utilizing the 4AT Delirium Screening Tool
Authors: Kelly Louise , Whelan Caitriona , Ryan Maeve , Wade Ruth , Boyle Orla , Brady Deirdre , Doherty Orlaith , Kennelly Sean , Mello Sarah , Gray James , Murphy Maeve , McElwaine Paul , Hayden Derek
Published: September 2019

Background

Delirium is a medical emergency and is associated with increased risk of mortality, in-hospital complications, length of stay and institutionalisation. Delirium screening is recommended for patients at risk on admission. Despite this, delirium screening is frequently not undertaken in the acute setting leading to undiagnosed delirium and sub-optimal clinical care.

We aim to investigate the prevalence of delirium in patients aged ≥75 years attending the Emergency Department (ED) of a tertiary referral centre.

Methods

Patients aged ≥75yrs presenting to the ED between 08.30 and 18.30, Monday- Friday were assessed by an interdisplinary gerontological service using a standardised assessment tool including the 4AT to screen for delirium. Data was collected and analysed via Excel.

Results

Of 163 patients screened over a 4 week period 47.9% (78/163) were male with a mean age of 81.8 years (SD 2.7). Twenty three percent (34/148) scored ≥4 indicating a possible delirium. Patients with delirium were older (85 yrs vs. 80 yrs, P<0.001), were more likely to score ≥4 on Clinical Frailty Scale (97% vs. 56%, P<0.001), and at risk of, or have malnutrition (MNA SF score <12) (86% vs. 40%, P<0.001).

Conclusion

Routine screening of patients in the acute setting detected a high rate of delirium at a level which is consistent with previous studies. Patients with delirium were older, more frequently frail and at risk of malnutrition. Our results support the evidence for routine screening for delirium in the acute setting.
232 The Timing of “Do Not Attempt Resuscitation” Decisions in an Older, Frail Inpatient Population
Authors: McDonough Anna , O'Hanlon Shane
Published: September 2019

Background

Ascertaining and discussing resuscitation status should be a routine part of medical practice. However, it is frequently neglected until a patient is acutely unwell. The National Consent Policy1 recommends that discussion around “Do not attempt cardiopulmonary resuscitation” (DNACPR) orders should occur for patients with “an identifiable risk of cardiorespiratory arrest occurring”. The Clinical Frailty Scale is a useful tool for providing predictive information about the risk of death in older patients2. Along with the presence of comorbidities, it can assist with determining prognosis and identifying patients for whom early discussion about resuscitation status is appropriate.

Methods

A chart review was carried out of all 106 inpatients in a model 3 hospital. Data was extracted on demographic information, frailty score and resuscitation status.

Results

The average age of inpatients was 79.8 years. On admission, the average Clinical Frailty Scale score was 5 (mildly frail), with 15% having a frailty score of 7 or more, and 28% a diagnosis of dementia. 25.5% of inpatients had a DNACPR order in place. It took an average of 32.4 days (range 0-224 days) from admission until this decision was made.

Conclusion

As we are caring for an older population with frailty; care planning, including resuscitation status should be discussed at an earlier stage. Ideally, this should occur on admission for certain patients, particularly those with high levels of frailty and multiple comorbidities. Our current practice, in which DNACPR decisions sometimes take place after a prolonged admission, is suboptimal. A change to the medical admission proforma, adding a prompt for discussion of DNACPR orders will be considered.
236 Socioeconomic and Social Factors among Community-Dwelling Dependent Older People with Cognitive Impairment in Ireland
Authors: Swan Lauren , O'Sullivan Maria , Warters Austin , Irving Kate
Published: September 2019

Background

Dementia, and related cognitive impairment, is prevalent in dependent older adults in receipt of formal home care; importantly, this is a determinant of transition into long-term care (Aspell., 2019). Our study aimed to explore social and socioeconomic factors in community dwelling older people in receipt of formal home care. To our knowledge social deprivation has not been previously investigated in this population in Ireland.

Methods

This study comprised a large cohort (n=1597) of community-dwelling adults aged 65 years or older who were in receipt of formal home care. Demographic, living setting, dependency (Barthel Index) were recorded; cognitive dysfunction (CD) included dementia and related cognitive impairment (Aspell., 2019). Social deprivation was captured by the Pobal HP Deprivation index which categorises affluence or disadvantage by residential area in Ireland.

Results

The study population (n=1597) was of mean age 83.3 ± 7.2, supported by 11.1 ± 7.2 hours of home care per week and 10.8% and 31.7% were categorised as of disadvantaged and affluent deprivation status, respectively. Those who received home support in areas of disadvantage were significantly younger than in affluent areas (79.1 ± 7.3 v 85.6 ± 6.87 years, p< 0.001). Prevalence of CD was 43.3%. CD vs non-documented CD were characterised by a significantly higher proportion of females (66.5% v 61.4%, p <0.05), widowed (47.4% v 41.8%, p <0.05) and very disadvantaged (7.4% vs 5.0%, p <0.05). Furthermore, the CD group had a significantly higher falls risk but lower physical dependency (Barthel), lower requirement for mobility support and higher need for meal assistance. Home care hours were higher (11.6 ± 7.2 v 10.8 ± 7.2 p <0.001) for the CD group, and comprised generic, rather than dementia-specific support.

Conclusion

The findings have implications for developing personalised dementia-specific home support and interventions. Further research is needed into disadvantaged deprivation and the need for home support at a younger age.
237 Systematic Review of Fibrinogen and Risk of Recurrent Stroke and Vascular Events after Ischaemic Stroke or Transient Ischaemic Attack (TIA)
Authors: McCabe John J , O'Reilly Eimear , Coveney Sarah , Collins Ronan , Cronin Simon , Harbison Joe , Cassidy Tim , Dolan Eamon , O'Connor Margaret , Williams David , Pope George , Murphy Sean , J Kelly Peter
Published: September 2019

Background

Inflammation is thought to play an important role in atherosclerotic stroke mechanisms. There is growing interest in the prognostic role of inflammatory biomarkers as risk factors for recurrent vascular events, after ischaemic stroke or transient ischaemic attack (TIA). Elevated fibrinogen levels are independently-associated with the risk of first-ever stroke. However, the prognostic value of fibrinogen, after ischaemic cerebrovascular events is uncertain.

Methods

We searched EMBASE and Ovid Medline, from 1970-January 2019, for any study that measured Fibrinogen after stroke or TIA, and related it to the risk of recurrent stroke or recurrent vascular events. All records were assessed by 2 independent reviewers. Any disagreements between authors regarding eligibility were resolved by consensus.

Results

We identified 2,520 publications, of which, 15 articles from 16 individual studies were eligible (11 observational cohorts, 3 cohort studies within randomized control trials, 2 case-control studies). The sample size for recurrent stroke and recurrent vascular events was 9,963 and 7,381 patients, in 11 and 10 studies, respectively. The time from event to phlebotomy was <7 days in 5, 7-90 days in 6, and >90 days in 5 studies, respectively. There was marked heterogeneity in statistical methodologies employed to examine the relationship between fibrinogen and outcomes, which did not allow valid meta-analysis (above/below specified threshold (n=4), differences in means/medians (n=5), risk per unit increase (n=1), per standard deviation (n=3), per quartile (n=1), per decile (n=1) or not specified (n=1)). 4 studies adjusted for all conventional vascular risk factors (age, smoking, diabetes, hypercholesterolaemia/statin use, and hypertension). 2 of 11 studies found a positive association with recurrent stroke. 5 of 10 studies found a positive association with recurrent vascular events.

Conclusion

The prognostic value of Fibrinogen after stroke or TIA remains unclear. Standardised methods and fully-adjusted multivariable analysis are needed in future prognostic studies.
253 An Overview of the Current Status of Specialist Geriatric Services in Ireland
Authors: Sezgin Duygu , O’Donovan Mark , Whitty Helen , O’Shea Diarmuid , Liew Aaron , O’Caoimh Rónán
Published: September 2019

Background

The Royal College of Physicians of Ireland and the National Clinical Programme for Older People conducted a national survey of Specialist Geriatric Services (SGS) in 2014. The survey was repeated in 2018-2019 period to collect data on the resources available for the care of older people attending hospitals and associated communities in Ireland.

Methods

Participants were geriatrician leads or proxies in each hospital in Ireland. Questions based on the 2014 survey were updated to include frailty and dementia-delirium specific questions. Data were collected between September 2018 and April 2019 using an electronic survey. Comments from open-ended questions were analysed using qualitative analysis methods.

Results

In total, 20 fully complete and 18 incomplete responses were received. Most complete responses were from model 3 or 4 hospitals (n= 14/20). Less than half (47%) reported having a dedicated specialist geriatric ward in their institution. Half (50%) reported currently developing an integrated plan for services for frail older people with complex care needs. Barriers to managing frailty that were identified included limited access to funding and staffing. 82% reported that their group/area/unit/department engaged in case-finding for frailty. The most commonly used frailty-specific screening tools were the CFS (n=9), VIP (n=6), FRAIL scale (n=4), and PRISMA-7 (n=3). A National Frailty Education Programme governance structure was operational in 9/20 sites. Half (50%) reported that their hospital has an integrated pathway for people with dementia and/or delirium, although (82%) stated that their hospital does not formally screen all older people for cognitive impairment in the ED/AMAU, and does not formally screen people at risk for delirium on wards on a daily basis (100%).

Conclusion

Limited staffing and resources were reported for many aspects of SGS in Ireland. Although frailty and dementia-delirium are recognised as priority areas, there is need for standardised assessment and screening approaches.
318 Does a Teleconference-Delivered Educational Programme (ECHO) Provided to Nursing Homes Reduce Emergency Hospital Transfers?
Authors: Dowling MJ , Molloy Una , Payne Cathy , McLean Sarah , McQuillan Regina , Noonan Claire , Ryan DJ
Published: September 2019

Background

Nursing home staff manage increasingly complex patients yet struggle to access education programmes due to geographical logistical barriers. The aim of this study is to measure the impact on emergency hospital transfers a novel teleconference-delivered palliative care education programme (ECHO) has on patient transfers from nursing homes to emergency departments.

Methods

Ten interactive sessions were provided to staff from 20 nursing homes, using teleconferencing technology through the “Project ECHO” model. “Transfer forms” were completed by participating staff 6 months before echo, and 6 months from commencement of echo outlining details of emergency hospital transfers. Participating sites must attend 4 or more of 10 sessions for study inclusion.

Results

Of 20 nursing homes, 15 attended sufficient sessions, and they submitted data regarding 260 emergency transfers over a 12-month period. There was no significant difference in the number of transfers pre vs post ECHO (137 of 260 vs 123 of 260, p=0.62). There was no significant difference in likelihood of hospital admission, length of stay, or number of weekend transfers to hospital (p=0.26, 0.68 and 0.6 respectively). Post-echo, patients were less likely to have pain documented as the primary symptom (11 of 137 vs 1 of 123, p=0.006), and it was more likely that transfer wishes were documented in advance (62 of 137 (45%) vs 82 of 123 (67%), p<0.001). Increase in transfer wishes documentation was explained primarily by an increase in a “for transfer” decision (27 of 62 vs 67 of 82) p=<0.001).

Conclusion

This teleconference, ECHO-delivered palliative education programme did not affect overall rates of emergency hospital transfers from nursing homes. However, it did significantly lower rates of transfers reporting pain as the primary symptom, tentatively suggesting a possible impact on “reversible” hospital transfers. ECHO significantly increased likelihood of transfer status discussion, while most “extra” discussions resulted in a “for transfer” decision.
07 Rehabilitation in Patients with Dementia Following Hip Fracture
Authors: Small Cliona , Lennon Emma , Low Rebecca , Doyle Rachael , O'Hanlon Shane
Published: September 2019

Background

Hip fractures are an increasing phenomenon in the older population. Receiving post-operative rehabilitation is associated with better outcomes and a higher likelihood of returning to preexisting level of functioning. Best rehabilitation practices for people with dementia have not been established.

Methods

All patients >/= 60 years old with a hip fracture admitted under the orthopaedic team between March 2016-February 2018 were reviewed. Those with a diagnosis of dementia were extracted from the database. Clinical Frailty Scale (CFS), Zuckermann Functional Recovery Score (FRS) and New Mobility Score (NMS) were documented at baseline and at one year. Outcomes assessed included 1 year mortality, decline FRS/NMS, change in CFS and nursing home (NH) admission rates.

Results

465 patients’ hip fractures were recorded: 175 patients had dementia. 67 patients were dead at 1-year post fracture (38.285% mortality rate). Of the 108 patients with dementia who were living at 1-year; 30.5% (n=33) received offsite rehab. 58.4% (n=63) received routine in-patient rehab. 12 lost to follow-up. Of the 33 patients that received off-site rehab the mean FRS at baseline was 66 and decreased to 45.56 at 1 year (30.9% reduction). The mean CFS at baseline was 5.1, increasing to 6 at 1-year (17% increase). Mean NMS was 5.7 decreasing to 3.7 at 1-year. In those patients with dementia that did not receive off site rehab (n=63); baseline mean FRS was 38 reducing to 30 at 1 year (26.6 % reduction). Mean CFS was 6.25- increasing to 6.47 at 1 year. 41% of patients admitted from home who did not receive off-site rehab were discharged to NH. Of the group discharged to off-site rehab: at 1 year 33% were in a NH and 72% remained at home.

Conclusion

Both groups demonstrated decline in function. Those that received off-site rehab had higher premorbid functioning/mobility and reduced frailty. There was a reduced NH admission rate at 1-year in the group that received off-site rehab.
12 `Risk feeding’ for Older People: a Retrospective Case Series to Review the Decision Making Process
Authors: O'Loughlin Niamh , McCarthy Oonagh
Published: September 2019

Background

`Risk feeding' is a term commonly used when an individual continues to eat and drink despite a perceived risk of choking or aspiration. It is suspected that there is significant variability around how a decision of ‘risk feeding’ is made for older people in the acute hospital setting, particularly whether or not the individual and his/her family are involved. This is of particular interest under the Assisted Decision Making (Capacity) Act 2015.

Aims

To investigate individuals' participation in decision-making regarding `risk feeding' To investigate the duration individuals are kept NPO pending `risk feeding' decisions

Methods

A retrospective case series was completed. 18 medical charts were reviewed for collection of the following data: Average length an individual was NPO pending decision regarding oral intakeDiscussion between individual and medical team regarding oral intakeThe individual's capacity for decision making regarding oral intakeDiscussion of what is in the best interests of the individualDiscussion with family/NOKExplicit plan regarding oral intake

Results

Average length NPO: 1 day (range 0-4 days) Discussion with patient: 17% Patient capacity for decision making: 17% Best interests discussion: 66% Discussion with family/NOK: 77% Explicit plan: 66%

Conclusion

There is significant variability in decision making for `risk feeding' with older adults in the acute hospital setting. Individuals are not consistently involved in their plan to `risk feed'. In some cases there was reliance on family members to decide on `risk feeding', in others the medical team made decision in the best interests of the individual. Individuals are being kept NPO for a period of time to allow decision making, without knowledge of why this is so.

The review highlights the need for individual involvement in decision regarding dysphagia and oral intake. Multidisciplinary education and guidance is recommended to ensure consistent ethical decision making.
15 Not all the Hype is about Hypos: Local Experience of a Multidisciplinary Diabetes Consultation Service for Older Persons
Authors: Costello Maria , Newman Christine , Dennehy Karen , Reddin Caitriona , Abdullah Abdullah , Cunningham Aine , Reddington Lisa , Burke Helen , Bell Marcia , Dinneen Sean , O' Sullivan Esther
Published: September 2019

Background

Diabetes is a prominent health problem with prevalence increasing as the population ages. It is estimated that 11.9% of the Irish population aged 75 years and older are living with type 2 diabetes. This condition puts older people at risk of polypharmacy, incontinence in setting of poor control and neuropathic pain. In addition, they are at risk of premature death and functional impairment arising from associated complications. There is an estimated resource use of 10% of the total healthcare budget including medication costs, hospitalisations and attending non-diabetic specialists for disease associated complications.

Methods

We reviewed all acute hospital diabetes consultations over a two-month period to identify persons aged 75 years and over who had contact with our clinical nurse specialists and consult service.

Results

46 patients aged 75 years and older (median age 79 years) were reviewed on request by the consults service. 6.5% (n=3) had Type 1 Diabetes. 41.3% (n=19) were on insulin and the remainder were on oral medications alone. They had a median HbA1c of 63mmol/mol. 91.3% (n=42) were living at home prior to admission. All patients were reviewed and educated by our clinical nurse specialists. Issues addressed included hypoglycaemic awareness, glucometer use and insulin administration. 17.4% (n=8) had medications discontinued due to hypoglycaemia and/or chronic kidney disease. 32.6% (n=15) had up-titration of insulin and/or addition of new agents. 58.7% (n=27) were subsequently followed up in clinic by telephone.

Conclusion

The 2018 American Diabetes Association guidelines now recommend treatment goals based on functional status rather than age. Our experience locally is reflective of the spectrum of issues that arise in management of diabetes in the older person. This highlights the positive impact of a multidisciplinary diabetes service in minimising complications and promoting individualised person-centred care.
174 Benefits of a Self-Management Program for the Older Couple Living with Parkinson’s Disease: A Pilot Study
Authors: Lyons Karen , Zajack Alex , Greer Melissa , Chaimoy Holly , Dieckmann Nathan , Carter Julie
Published: September 2019

Background

Although community-based self-management workshops have been found to benefit older adults with Parkinson’s disease (PD), it is unclear if there could be added value for the couple if the spouse also participated.

Methods

A quasi-experimental two-wave design (0 and seven week follow-up) was used to explore the effects of a self-management program on the health and relational outcomes of older adults with PD and their spouses in comparison to a wait-list control condition. Thirty nine couples were enrolled and completed the study (19 in the intervention group and 20 in the wait-list control).

Results

Adjusting for baseline outcome values, spouses in the intervention group had significantly greater engagement in mental relaxation techniques (p < .001; d = 1.28) than those in the control condition at seven weeks. Additionally, moderate effect sizes were observed for increases in the mental relaxation (d = 0.44) and aerobic activity (d = 0.44) of older adults with PD and the strength-based activities of spouses (d = 0.33) in the intervention group. Small to moderate effects were observed for declines in the depressive symptoms of spouses (d = 0.29) and older adults with PD (d = 0.14) and care strain of spouses (d = 0.15) in the intervention group. Finally, perceptions of marital quality improved for older adults with PD (d = 0.46) and spouses (d = 0.41) and reports of protective buffering (i.e. hiding concerns) declined for older adults with PD (d = 0.24) and spouses (d = 0.33) in the intervention group compared to the wait-list control condition.

Conclusion

Preliminary data showed promise for self-management programs benefiting couples living with Parkinson’s disease. Although larger samples and randomized controlled trials are needed to establish the full benefit of such programs, greater attention to interventions for the older couple is warranted.
185 Revisiting Comprehensive Geriatric Assessment in the Emergency Department
Authors: Edge Lucinda , O'Rourke Brian , Cunningham Conal , Horgan Frances
Published: September 2019

Background

In a large teaching hospital, a specialist interdisciplinary team identify frailty and begin comprehensive geriatric assessment of older adults in the Emergency Department (ED). This study aimed to determine the clinical utility of a range of measures: grip strength, calf circumference, frailty and functional mobility to evaluate whether they help to estimate the care pathways for patients. Objectives included: (1) To ascertain the prevalence of frailty and (2) To profile this population’s demographics, falls history, calf circumference and grip strength.

Methods

This was a cross-sectional study. Inclusion criteria were persons ≥ 70 who presented to ED weekdays during research hours 9:00 – 16:00, with Manchester triage score ≥ 3. Information on gait aids, social supports and falls in the past 6 months was self-reported. Grip strength was assessed using hydraulic hand-held dynamometry. Sarcopenia was measured using calf circumference as a proxy. Frailty was determined using the Clinical Frailty Scale (CFS). Functional mobility was assessed by an interdisciplinary team member. Onward referrals and admission to hospital were recorded. Data was analysed using SPSS statistics software.

Results

One hundred and one participants were included, 39 male (38.6%) and 62 female (61.4%), mean age 79.3 years. Thirty-five percent (n=36) were considered Frail (a CFS score of ≥5), 35.6% (n=36) lived alone, 52.5% (n=53) used a gait aid. Outcomes included admission to hospital (27.7%, n=28) and discharge with onward referral (25.7%, n=26). The most common referral was community physiotherapy (11.9%, n=12). The population identified as frail were more likely to be female (p = 0.036), to use a gait aid (p = 0.001) and to have fallen within the past 6 months (p = 0.007).

Conclusion

The prevalence of frailty was determined in this population and was not significantly associated with hospital admission, grip strength or calf circumference. A focus on alternative pathways to hospital admission with appropriate access to community services is recommended for individuals with frailty.
187 Capturing the Providers of Services to Older Persons – An Exercise in Integration of Care
Authors: Reilly Patrice , Dockery Frances , O'Leary Una , Grogan Sinead , Walsh Joan , Traynor Lydia
Published: September 2019

Background

There is much focus on the dearth of resources within healthcare systems, with a focus on health services. In 2018, we held a speed networking event for two local areas of a HSE Community Healthcare Organisation. This highlighted the vast array of supports available to assist older people to live well. This, alongside a Listening to Older Person’s Workshop, highlighted the need for a local directory of services.

Methods

In considering potential networking attendees, a social determinants of health approach (Dahlgren and Whitehead, 1991) was adopted to scope all supports available across community, acute, voluntary and statutory health and social care services within the area. This was expanded on further to develop the directory.

Results

The directory provides details of 358 organisations, individuals and groups available to support older persons within a catchment area with a population of 13,833 older persons (CSO Census, 2016). Hospital services comprised 27 of these while community HSE and GP health services made up 130. The remaining 201 were local and national NGOs and community groups ranging in service provision, a sample of which as follows: 39 provided some level of social/education engagement, three befriending, 18 counselling, five housing specific, 11 substance dependency, 12 provided supports to persons impacted by abuse. A further 20 national NGOs provided a local service or helpline with a focus on a particular health diagnosis.

Conclusion

This exercise shows the vast number of services available within just one small region, to support older persons to live well at home. The directory has been approved as a template for other networks in the CHO. It is being adapted into an online version by an interagency group. Using this template nationally has the potential to overcome gaps in health service resources, and support true integration, in line with the ICPOP (2016) 10 step framework.
188 The Use of a Group Based Upper Limb Programme in Improving Outcome in Acute Stroke Rehabilitation
Authors: Donnelly Kerri , Mulcahy Enya , Merrick Catherine , Fitzgerald Orla
Published: September 2019

Background

After a stroke 85% of patients experience altered arm function. Current research demonstrates that increasing upper limb rehabilitation results in improved outcomes (Ward et al., 2019). The Graded Repetitive Arm Supplementary Programme (GRASP) group is an established adjunctive therapy in the stroke service. The group provides additional therapy for suitable patients with upper extremity deficits. The group is run jointly by a physiotherapist and an occupational therapist. Patients attend twice weekly for a one hour period in addition to their regular therapy. The GRASP group consists of 3 levels of varying abilities and patients are categorised by their Fugl-Meyer score.

Methods

A prospective audit was completed in 2019 and data was collected using a word document and excel spread sheet. Standardised outcome measures were completed on admission and discharge to establish upper limb ability. The primary outcome measure was the Fugl-Meyer and the secondary outcome measures were the nine hole peg test and grip strength using the Dynamometer.

Results

12 patients attended the GRASP group over this period. 75% were males. The average age was 76 years with the age range from 48-95 years. 58% of patients experienced upper limb weakness in their non-dominant hand. Post intervention data was not obtained for 5 patients due to unforeseeable discharge from the acute setting. Preliminary data to date shows that our primary outcome measure improved in 86% of patients with increases ranging from 2-11 points on the Fugl-Meyer score (Minimally Clinical Important Difference =5points). Our secondary outcome measures demonstrated patients had no change (28%) or an improvement (72%) in grip strength and 100% of patients improved on the time taken to complete the nine hole peg test.

Conclusion

The GRASP group was found to be effective in improving upper limb outcome measures in an acute stroke inpatient hospital setting.
189 The Fall Champion Toolbox
Authors: Doyle Mary , Coughlan Tara
Published: September 2019

Background

Older adults in residential care setting are three times more likely to fall than those in the community and these falls are associated with a greater risk of injury. More than 400 separate risk factors for falls have been identified with the risk of falling increasing as risk factors accumulate. Multifactorial interventions by an interdisciplinary team to reduce risks have been suggested as the most effective strategy to reduce falls. The aim of this project was to increase fall prevention awareness among staff, reduce fall risk factors and reduce overall fall numbers.

Methods

Fall champions on each unit were identified and equipped with the necessary information in a ‘toolbox’ that was used for short education sessions or ‘toolbox talks’. The toolbox contains 4 fact sheets; each fact sheet designed for a different member of the care team, focusing on their role in reducing fall risks. Fact Sheet 1: Household and Maintenance staff, Fact Sheet 2: Health Care assistants, Fact Sheet 3: Nursing Staff, Fact Sheet 4: Resident information leaflets. A ‘toolbox talk’ takes 10 minutes. The fall champion focuses information at a particular team member by using the fact sheet with specific information targeted to that team member’s role.

Results

An evaluation of the initiative after 3 months demonstrated that the fall champions found the toolbox easy to use (100%). The champions reported that they felt confident that the toolbox had given them the skills to provide each team member with information relevant to their roles (100%).Staff had attended a toolbox talk within 4 weeks of the introduction of the project and reported increased awareness of risks for falls (100%).

Fall numbers for 3 months: Pre introduction =19 Post introduction =10 Reduction of 47%.

Conclusion

The initiative increased staff awareness of fall risks and may have impacted falls rate.
190 Who is ‘Fit to Sit’ in Our Emergency Department?
Authors: Kelly Louise , Ryan Maeve , Whelan Caitriona , Brady Deirdre , Wade Ruth , Boyle Orla , Doherty Orlaith , Mello Sarah , Hayden Derek , McElwaine Paul , Gray James , Murphy Maeve , Malone Brendan , McCabe Aileen
Published: September 2019

Background

Older admitted patients are at risk of deconditioning related to immobility. “Fit to Sit” is a simple change in the Emergency Department (ED) culture and attitude, promoting independence, maximizing well-being and improving health outcomes. We aim to describe the prevalence of patients deemed “Fit to Sit” who were in hospital gowns and lying on trolleys in our ED prior to the commencement of the “Fit to Sit” pilot.

Methods

An observational study was conducted prospectively, over five working days, to determine the proportion of patients present who were dressed and sitting out on a chair, opposed to wearing pyjamas (PJs) and lying on a trolley. Nursing staff familiar with each patient were asked whether or not the patient was fit to sit out in a chair. Statistical analysis was conducted with Microsoft Excel using the chi squared test to calculate differences between the two groups.

Results

Data was collected on 147 patients, median age 66 years (IQR 47-74). 82% were on a trolley and 18% in a chair. 33% were in their clothes, the remaining 67% were in PJs or hospital gowns. 45% of those deemed “Fit to Sit” were on a trolley. Patients 65 and older were more likely to be wearing PJs (p= 0.03), but not more likely to be on a trolley (p= 0.23). Patients in ED for greater than 12 hours were also more likely to be in PJs (p= 0.001) and on a trolley (p= 0.057).

Conclusion

Our study suggests that a significant proportion of ED patients are lying on trolleys despite being deemed to be “Fit to Sit”. Introduction of an ED “Fit to Sit” programme may alleviate deconditioning and promote patient independence.
193 Audit on Inappropriate Prescribing of Proton Pump Inhibitors Amongst Patients over 65 Years in an Acute Rehabilitation Hospital
Authors: O' Reilly Eimear , Gopaul Aquila , Cogan Lisa
Published: September 2019

Background

Proton pump inhibitors (PPIs) are one of the most frequently prescribed drug classes in the older person. Indications for PPI use are outlined in the NICE guidelines, however they are often prescribed without an appropriate indication resulting in increased healthcare costs and increased exposure to potential adverse clinical effects.

Methods

To determine the rate of inappropriate prescribing of PPI’s, an audit was carried out to assess the incidence of inappropriate prescribing in an Acute Rehabilitation facility pre and post Education to Hospital Doctors. An audit was carried out, pre and post intervention, on patients over the age of 65 years admitted to an acute rehabilitation hospital between 2018 and 2019. Patient’s medical charts were reviewed and data was collected on PPI prescribing.

Results

Cycle 1-Pre Education; 83 people included in the audit. Mean age was 80.8 years[SD ±9]. 43% of patients were on a PPI, all of which were prescribed the generic form. 83.4% of patients had no indication for PPI use. Of the 16.6%, indications included GORD, Barrett’s oesophagus, PUD and PPI prophylaxis against NSAID’s including aspirin. 77.7% were on therapeutic dose without any indication. 100% of patients were on PPI for longer than 6 weeks.

Cycle 2, Post education: 86 patients were included in re-audit. Mean age was 81.5[SD ±10]. 60.4% of patients were on PPI. Of those, 55% had no indication for PPI. Of the 44% on PPI, indications were similar to those in Cycle 1. 83% of patients were on PPI longer than 6 weeks. 56.5% were on inappropriate dose of PPI.

Conclusion

This audit highlighted the inappropriate prescribing of PPI’s in the older person. By providing education to Doctors about NICE PPI prescribing guidelines, overall rate of inappropriate prescribing of PPI decreased by 28.4% and accurate dosing of PPI improved by 21.2%.
200 Evaluation of Nutrition Service Provision in a Day Hospital Setting
Authors: Digan Eimear , White Sarah , Fox Emma , Feehan Sinead , Cronin Audrey , Kennelly Sean
Published: September 2019

Background

Malnutrition, frailty and functional impairment adversely impact individuals and should be considered simultaneously in rehabilitation. Individuals in a Day Hospital (DH) setting require a multidisciplinary approach to rehabilitate and nutrition plays a fundamental role in improving patient outcomes. The aim of this study was to establish the nutritional profile of the patients attending the DH and to measure this against current dietetic referral criteria.

Methods

A prospective quality improvement analysis of older adults attending the DH was conducted. Nutritional status, using the mini nutritional assessment short-form, demographic and biochemical information was collected from nursing notes and the software Key. Frailty scores were assigned using Rockwood Clinical Frailty Scale. Nutrition service provision was evaluated in relation to the priority rating system for DH Patients.

Results

Nearly two-thirds of the 57 patients were malnourished (17.5%) or at risk (45.6%), 1 in 4 (26.3%) was obese. Most patients were frail (77.2%). 45.6% of patients were referred to clinical nutrition services. 90% of malnourished patients and 53.8% of those at risk were referred to dietetic services. Patients were seen at 4 ± 2.45 weeks after referral, 19.2% of patients were seen on time. Patients with underweight or obese BMI classifications were at greater risk of malnutrition and frailty. Those referred to the DH for falls review were nutritionally poorer and physically frailer.

Conclusion

This study highlights the need for a focused nutritional service in this environment. Revision of dietetic referral criteria and streamlining strategies are required to provide quality, timely intervention to those who need it most.
21 Prevalence of Potentially Inappropriate Medications (PIMs) in Older Palliative Patients, Defined by STOPPFrail Criteria
Authors: Foo Adeline , O'Brien Tony , O'Mahony Denis
Published: September 2019

Background

Polypharmacy is common in older persons with multi-morbid illness, increasing the risk of adverse drug events. Drug pharmacokinetics and pharmacodynamics are often altered in this group increasing the risk of adverse drug events and many prescribed drugs take considerable time to benefit. STOPPFrail criteria are designed to help prescribers to identify potentially inappropriate medications in older sicker patients with short life expectancy. The aim of this pilot study was to estimate the prevalence of STOPPFrail defined potentially inappropriate medications (PIMs in older patients with terminal illness at the point of admission to specialist hospice care.

Methods

We conducted a prospective analysis of inpatient case records and drug kardexes at a university teaching hospice over a period of one month. We recorded patients’ demographic details, principal symptoms, co-morbidities, medications at admission and at day 3-7. STOPPFrail criteria were applied to patients’ medications lists at both time points.

Results

Of 22 patients studied, 13 were female with a mean (+/- SD) age of 80 years (+/- 6). Eighteen patients were transferred directly from an acute hospital, 4 patients from the community. Common symptoms were pain (72%) and severe lethargy (68%). Twenty out of 22 patients had cancer as the life-limiting condition. There was a significant reduction in the mean (+/- SD) number of medications from admission (11 ± 4.1) to post palliative review (8 ± 4.7; p=0.002). 90% of patients had polypharmacy i.e. ≥ 6 daily medications, 87% had ≥ 1 STOPPFrail PIM on admission. The median number of STOPPFrail PIMs per patient was 1 (1-2, IQR), most commonly high dose proton pump inhibitors, multivitamin supplements, calcium supplements and lipid lowering therapies.

Conclusion

In this small study, STOPPFrail-defined PIMs were highly prevalent in older terminally ill patients. Prescribers should carefully review the medication lists of terminally ill older patients in order to minimize inappropriate polypharmacy.
203 An Evaluation of Polypharmacy and Adverse Drug Events in Older Adults with Rheumatic Disease
Authors: Mooney Niamh , Hannon Evelyn , Buckley Mary , Murphy Grainne
Published: September 2019

Background

Polypharmacy among older adults is a well-documented problem. The practice has been associated with potentially inappropriate medications (PIMs, adverse drug events (ADEs) and hospitalisation. This retrospective cohort study aims to evaluate polypharmacy, ADEs and anticholinergic burden in the ≥65 population with rheumatic disease.

Methods

All patients who were ≥65 and had a diagnosed rheumatic disease were included in this study. Patients' medication lists, specific rheumatic disease, laboratory findings and associated comobidities were obtained from their medical charts at rheumatology outpatient clinics. The data was screened for PIMs using the Screening Tool of Older Persons' Medications (STOPP) criteria and probable ADEs using the WHO-UMC criteria. Anticholinergic burden was determined using the ACB calculator. Polypharmacy in this project was defined as ≥4 regular prescription medications.

Results

70 patients were studied. The prevalence of polypharmacy was 94%. The median (IQR) number of regular prescription medications was 7 (2-16). PIMs were recorded in 43 patients (61%). Increasing numbers of medications was a significant risk factor for PIMS (p=0.0027). ADEs were detected in 18 patients (26%). The ADE detection rate in PIM positive patients was 35% (15/43) and 11% (3/27) in PIM negative patients. A patient who was PIM positive had a statistically significant risk of having an ADE (p=0.047). Of the ADEs detected, 73% were due to a STOPP PIM.

Increasing numbers of medications was a significant risk factor for an increased anticholinergic burden (p=0.017). An anticholinergic burden of ≥3 was a statistically significant risk factor for falls (p=0.025), however it was not a statistically significant risk factor for cognitive decline (p=0.073).

Conclusion

There is a high prevalence of polypharmacy in older adults with rheumatic disease. Increasing numbers of medications is statistically associated with increased number of PIMs, ADEs and increased anticholinergic burden.
204 Clinicoradiological Diagnosis of Cerebral Amyloid Angiopathy-Related Inflammation (CAA-ri) - a Non-Invasive Approach to Diagnosis and Management
Authors: McCartan Deirdre , Williams David , Moynihan Barry , Boyle Karl
Published: September 2019

Background

Cerebral Amyloid Angiopathy (CAA) is an age-related disorder characterised by deposition of beta-amyloid protein in the walls of small and medium cortical vessels leading to increased risk of intracranial bleeding. CAA-Related Inflammation (CAA-ri) is an under recognised subtype of CAA potentially responsive to immunosuppression and traditionally diagnosed by invasive brain biopsy. CAA-ri is associated with rapid cognitive decline but shows reversibility for some when treated with immunosuppression. We present the case of an 82 year old lady who presented with first seizure, a history of notable cognitive change and neuroimaging consistent with probable CAA-ri.

Methods

Validated clinicoradiological diagnostic criteria for CAA-ri were applied to MRI T2 FLAIR and SWI sequences. CSF, APOE genotyping, EEG and cognitive testing were performed. Interdisciplinary perspectives were sought from Neurology, Neurosurgery and Infectious Diseases colleagues. Consensus opinion opposed brain biopsy on strength of imaging evidence and pulsed intravenous steroid treatment was initiated. BP, anti-convulsant and bone protection were optimised and anti-thrombotics avoided. Repeat imaging and cognitive testing were repeated after four months.

Results

MRI T2-FLAIR revealed an asymmetric multifocal distribution of cortical and subcortical white matter hyperintensities (WMH) with leptomeningeal enhancement while SWI showed extensive multifocal microhaemorrhages with confluent haemorrhage in the right frontal and temporal regions. EEG demonstrated right frontal theta slowing and absence of epileptiform activity. CSF analysis reported raised protein at 53mg/dl. Normal WCC. Formal cognitive testing with ACEIII revealed a score of 79/100. EPOA was advised.

Conclusion

Clinicoradiological diagnosis of CAA-ri permits early initiation of immunosuppressive therapy and avoids invasive brain biopsy. In the absence of clinical suspicion and blood sensitive imaging sequences CAA-ri may be misdiagnosed as Acute Ischaemic Stroke or TIA where the addition of anti-thrombotic therapy could cause harm while early medical management offers potential reversibility.
206 Deprescribing in Frail Older People Transitioning to Long-term Care: a Randomized Controlled Trial Using STOPPFrail Criteria
Authors: Curtin Denis , Jennings Emma , Daunt Ruth , Randles Mary , Gallagher Paul , O'Mahony Denis
Published: September 2019

Background

Older people with advanced frailty are among the highest consumers of prescription medications. When life expectancy is limited, the use of multiple medications may be unnecessary or burdensome. STOPPFrail criteria were recently developed to assist clinicians with deprescribing decisions in frail older people approaching end-of-life. The aim of this study was to examine whether long-term medications could be safely discontinued in frail older people using STOPPFrail criteria.

Methods

We recruited hospitalized adults aged ≥75 years with polypharmacy (≥5 long-term medications) that were transitioning to nursing home care. Participants were eligible if their Clinical Frailty Scale score was ≥7 and if their attending physician indicated that he/she “would not be surprised if the patient died in the next 12 months”. Patients were randomized to single time point pre-discharge STOPPFrail-guided deprescribing or routine pharmaceutical care. The primary outcome was change in the number of regular medications at 3 months. Secondary outcomes included emergency hospital transfers, incident falls, fractures and mortality.

Results

Results are presented for the first 100 enrolled patients. The mean (±standard deviation [SD]) age of study participants was 85.1 (±5.7) and 61% were female. Intervention (n = 49) and control group (n = 51) participants were prescribed a mean (±SD) of 11.5 (±3.0) and 10.9 (±3.5) regular medications, respectively, at baseline. The mean (±SD) change in the number of regular medications at 3 months was -2.7 (±2.8) in the intervention group and -0.6 (±2.6) in the control group (estimated difference 2.1 ±0.6, 95% confidence interval 0.8 -3.3, p=0.001). Ten intervention participants and 14 control participants died within 3 months of randomization (20.4% vs 27.4%, p=0.49). There was no significant difference between groups for emergency hospital transfers, incident falls or fractures.

Conclusion

STOPPFrail-guided deprescribing significantly reduced medication burden in frail older people without adversely affecting clinical outcomes in the prospective 3 months.