bluuebunny/crossref_metadata_2025 huggingface dataset:
11 A QUALITY IMPROVEMENT INITIATIVE TO MAXIMISE UTILISATION OF EARLY SUPPORTED DISCHARGE SERVICE IN A LEVEL 3 HOSPITAL SETTING
Authors: McCarthy K , O'Flynn D , Moynihan B
Published: October 2022

Background

Early Supported Discharge (ESD) originated in stroke care however also applies to general medical patients. This ESD service was funded by the local Integrated Care Programme for Older Persons (ICPOP) and saw over 100 patients in its first year. A review of current ESD criteria and limitations was undertaken

Methods

Data was collected, by chart review, over a 2-week period on medical wards. A general townland was used as the patient's address. All patients aged over 70 were included. ESD criteria include all of: living within 30km of the hospital, not living alone, assistance of 1 with mobility or Activities of Daily Living, medically discharged.

Results

91 patients aged over 70 years included 54 patients were medically discharged 27% of medically suitable patients lived outside the ESD radius 2 of 12 patients that met all ESD criteria but had been referred

Conclusion

From our data 54 patients met some ESD criteria but awaited assessment by the multidisciplinary team (MDT). Only 2 of 12 patients who met all criteria were referred to ESD. Education campaigns are ongoing within the hospital to increase awareness of the service. This includes a daily discharge huddle to identify potential candidates. Distance from the hospital was identified as a limiting factor. A business case is under development to support increasing this radius to allow an increased number of patients to avail of the service. ESD has been utilised successfully in urban settings. The continued success of this new service in a rural setting requires ongoing education to increase awareness of the service and development of existing criteria. Limited access to therapists in hospital reduces the effectiveness of ESD.
18 EDUCATION AND TRAINING TO SUPPORT PHYSIOTHERAPISTS WORKING IN DEMENTIA CARE: A SCOPING REVIEW
Authors: O'Sullivan T , McVeigh JG , Timmons S , Foley T
Published: October 2022

Background

Physical impairments associated with dementia include loss of mobility, diminished postural control and reduced muscle strength, which in turn can lead to an increase in falls, hip fractures and frailty. Physiotherapy can play a key role in many aspects of dementia care. Physiotherapists have reported carrying a high caseload of people with dementia. However, there is a paucity of evidence as to what constitutes effective dementia education and training for physiotherapists. The aim of this scoping review was to explore and map the evidence relating to education and training for physiotherapists, with a view to using these findings to inform the design and delivery of an educational program for physiotherapists.

Methods

This scoping review followed the Joanna Briggs Institute (JBI) methodology for scoping reviews. The protocol for this review was published in March 2021. This review included studies that examined dementia education and training for the wider healthcare team if physiotherapy was an included profession. All studies with a focus on any aspect of physiotherapy dementia education and training were included. Studies conducted in any setting, including acute, community care and residential or any educational setting were included. A chronological narrative synthesis of the data outlined how the results relate to the objectives of this study.

Results

A total of eleven papers were included. The principal learning outcomes evaluated were knowledge, confidence and attitudes. Immediate post intervention scores showed an improvement in all three outcomes. Most educational interventions reached Kirkpatrick level 2, which evaluates learning. A multi-modal approach, with active participation and direct patient involvement seems to enhance learning.

Conclusion

Allowing for the heterogeneity of intervention design and evaluation, some common components of educational interventions were identified that led to positive outcomes. This review highlights the need for more robust studies in this area. Further research is needed to develop bespoke dementia curricula specific to physiotherapy.
28 DRUG-DRUG INTERACTIONS IN OLDER HOSPITALISED PATIENTS: A PROSPECTIVE PREVALENCE STUDY
Authors: Monahan J , O'Mahony D , Curtin D
Published: October 2022

Background

Drug-Drug Interactions (DDIs) are common in older adults and are associated with increased risk of adverse drug events and hospitalisation. Older adults are particularly susceptible to DDIs due to multimorbidity, polypharmacy and age-related changes in pharmacokinetics. A recently published standardised list of 66 potentially significant DDIs specifically relevant to adults aged ≥ 65 years has been validated by an expert consensus group. The aim of the present study was to prospectively assess the prevalence of DDIs in multimorbid older patients with polypharmacy at the point of unscheduled acute hospital admission, using this 66-item DDI list.

Methods

77 unselected consecutive patients aged ≥65 years with ≥3 comorbidities and prescribed ≥5 daily regular medications were included. Medication reconciliations were conducted within 48 hours of admission. Medications were confirmed with two or more sources: the patient, their carer, the general practitioner, or the community pharmacist. Drug prescriptions reflecting pre-admission medication lists were manually screened for DDIs according to the 66-item DDI list.

Results

47 participants (61.04%) had ≥1 listed DDI. The most commonly identified DDI was concomitant use of ≥3 centrally-acting neuropsychiatric drugs (n=18, 23.28%), which increases the risk of falls and impaired cognition. A highly significant correlation was found between the number of daily medications and the number of DDIs experienced (Spearman’s ρ=0.512, P<0.001). No statistically significant relationship was found between the number of comorbidities and the number of DDIs (Spearman’s ρ=0.194, P=0.107). No significant differences were detected in the number of DDIs, medications or comorbidities between men and women (P=0.818, P=0.428, P=0.281, respectively).

Conclusion

The majority (61%) of participants had at least one clinically significant DDI. Given the high prevalence of DDIs in this rapidly growing patient population, frequent review and rationalisation of medications using the 66-item DDI list is indicated to minimize DDIs and enhance medication safety.
33 PREVALENCE OF FALLS RISK-INCREASING DRUGS (FRIDS) DEFINED BY STOPPFALL CRITERIA AMONG MULTI-MORBID OLDER PATIENTS PRESENTING TO HOSPITAL WITH FALLS
Authors: Chawla N , O'Mahony D
Published: October 2022

Background

Several drug classes e.g. antidepressants, hypnotics significantly the risk of falls in older people. As an intervention in several studies, withdrawal of Falls Risk-Increasing Drugs (FRIDs) has led to a significantly decreased incidence of falls and injuries in older people. Recently, an explicit deprescribing tool focusing on FRIDs known as STOPPFall (Screening Tool of Older Persons Prescriptions with high Fall risk) has been validated. STOPPFall consists of 14 drug classes, most of which are psychotropics, known to increase falls risk in older people. There are no prospective studies of STOPPFall-defined prevalence of FRIDs in the literature.

Methods

We undertook a prospective study of 200 consecutively enrolled patients aged ≥65 years (mean age ± SD: 80.9±7.4 years) presenting with falls to the emergency department and Geriatric Medicine OPD clinics between August 2021 to February 2022. We screened for STOPPFall criteria FRIDs in this cohort with additional data collected to define age, sex and comorbidity status.

Results

STOPPFall FRIDs were detected in 59.5% of this cohort which was predominantly female (68%). Comparison of falls incidence between the youngest subgroup (65-74 years) and the oldest subgroup (>85 years) showed that patients aged >85 years fell repeatedly (i.e. ≥ 2 falls in the previous year) more than younger fallers (35.5% vs 21%). Of the 14 drug classes in STOPPFall criteria, antidepressants were the most prevalent FRID category (24%), followed by diuretics (17%). There was a significant positive correlation between the number of reported falls and the number of STOPPFall FRIDs prescribed (R=0.17; p=.016). Almost two-thirds of fallers were prescribed two or more STOPPFall drugs.

Conclusion

STOPPFall medications are highly prevalent among older people presenting to hospital with falls. STOPPFall represents an important tool for attending doctors to identify and deprescribe medications contributing to falls in older people.
35 GERIATRIC EMERGENCY MEDICINE (GEM)’ PEARLS AND PITFALLS’- AN INTERDISCIPLINARY APPROACH TO EDUCATION
Authors: McGettigan L , Abdullahi AS , Loughlin KM , Lyons C , Reddin C , Keane O
Published: October 2022

Background

In recent years we have seen increased awareness of the terms ‘frailty’ and ‘GEM’ in many of our Emergency Departments (ED). A clear understanding of these terms within the context of ED is essential to provide a holistic care and to best meet the needs of older adults. It has been highlighted internationally that current training programmes do not sufficiently address learning needs of trainees to optimise care of this cohort of patients. The European Geriatric Medicine Society and the European Society for Emergency Medicine has attempted to address this gap through the introduction of a core GEM curriculum in 2016, however, at a local level many EDs are not utilising this resource for a number of reasons including lack of awareness and prioritisation of other local learning needs as determined by specialist training. To address the GEM learning needs at a local level an initiative idea was trialled in the form of a GEM teaching wall with dedicated monthly topics chosen from the above curriculum.

Methods

The initiative was led by a Senior Physiotherapist working on the Frailty Intervention Therapy Team and a Senior House Officer (SHO) working in ED with collaboration from other ED members as identified. A brainstorming session took place to identify potential topics. A poster was created by the project leads each month focusing on a core topic including an overview on the subject, national/international guidelines and top tips how to best manage in ED. Relevant team members contributed to different topics. Monthly posters were displayed in the ED.

Results

The project has been successfully running for 4 months with topics including Abdominal pain, Silver trauma Delirium and Falls.

Conclusion

GEM teaching is a cornerstone of successful management of older adults presenting to our EDs. Novel MDT teaching approaches can address the identified learning gap in this area and highlight international recommendations with minimum cost.
36 WHAT DO OLDER ADULTS AND HEALTH CARE PROFESSIONALS LOOK FOR IN A FOOD PRODUCT?
Authors: O'Mahony L , O'Shea E , O'Connor E , Tierney A , Dunne N , Harkin M , Harrington J , Tobin K , Kennelly S , Arendt E , O'Toole P , Timmons S
Published: October 2022

Background

The Mediterranean diet (Medi-diet) has proven benefits for healthy ageing but isn’t the habitual diet of most middle-aged or older adults in Ireland; there can be accessibility and tolerability issues with high amounts of fresh fruit and vegetables. Providing key Medi-diet nutrients in a food product is a novel approach to this challenge. This research aims to explore what ‘younger-old’ adults and healthcare professionals (HCPs) would value in such a novel food product.

Methods

Semi-structured 1:1 interviews and Focus Groups (FGs) were conducted remotely from July 2021 to January 2022. Older adults, defined as over 55’s, were recruited through relevant social, retirement and disease-support groups. Purposive sampling recruited a gender balance and a range of ages and disease profiles. HCPs were recruited through researcher networks and professional associations. Interviews/FGs were recorded, transcribed, and subsequently examined using inductive thematic analysis.

Results

Older adults (n=47; 50% male) were mostly aged 60-69 years (48.9%). Recruited HCPs (n=26) included dieticians (n=8); geriatricians (n=5); therapists (n=4); and nurses, pharmacists, catering managers (community; residential), and meal delivery service coordinators (n=2 each). Participants supported a food product for older adults requiring a nutrient-dense “boost”, or supplementary fibre or protein, but generally preferred a “food-first” approach, as opposed to a “silver bullet” product. Older adults largely associated functional foods with probiotic products “to repair the gut”, something to have “every now and then”. Product texture and portion size should consider changing dentition and appetite, and consider packaging (dexterity) and preparation ease, but should not stigmatize older adults through targeted branding. Participants felt pre-made soups or cake-type bars would be appealing, but not drinks.

Conclusion

A novel food product could supplement a balanced diet for older adults, providing high-protein content, and high-fibre for gut health, complimenting an overall lifestyle approach to health improvement and disease prevention.
37 RE-AUDIT OF VITAMIN D SUPPLEMENTATION IN FRAIL OLDER ADULTS PRESENTING TO AN IRISH LEVEL 5 EMERGENCY DEPARTMENT
Authors: Pender C , O'Caheny C , Byrne C , Magner S , Carey S , Carrabine N , Mitchell M , Laguna R , Harrington G , Buckley B , Smyth H
Published: October 2022

Background

The Department of Health published new guidance in November 2020 “Vitamin D advice for people aged 65 and older” which recommended that all adults ≥65 years should be supplemented with 15micrograms of Vitamin D daily. 55.5% of adults ≥65 years have insufficient/deficient vitamin D levels in winter (TILDA 2020). The Frailty Intervention Team (FIT) assess frail adults ≥65 years in the Emergency Department using medication review and Comprehensive Geriatric Assessment to identify vitamin D supplementation. The audit aim was to determine if compliance with the new guideline improved since the initial audit in January 2021.

Methods

All patients who had a medicine reconciliation completed by the FIT Pharmacist in January 2022 were included in a retrospective audit. Patients were identified from the pharmacist’s worklist. Data was collected from a Hospital Clinical System using a Microsoft Excel®. The data recorded included: Age, Sex, Rockwood Clinical Frailty Score (CFS) and vitamin D supplementation.

Results

The FIT Pharmacist completed 66 medicine reconciliations in January 2022. The mean age (+/-SD) was 82.4 (+/-7.6) years.The male to female ratio was 1:1.75The median CFS was 5 (mildly/moderately frail) with an IQR of 1.

68% (n=45) were prescribed vitamin D. Of those 89% (n=40) were prescribed a supplement containing at least 15micrograms of vitamin D. 32% (n=21) were not prescribed any vitamin D supplementation. 8% (n=5) were prescribed doses lower than 15micrograms of vitamin D.

Conclusion

Compliance with the new guideline was 61% (n=40) in comparison to 65% (n=39) in the initial audit. The results are reflective of adherence to the new guideline in the community. The policy update and education provided post the initial audit has possibly influenced the prescribing of vitamin D in the acute setting which unless patients are re-presenting will not have been captured in the outcome of this re-audit.
38 IDENTIFICATION OF POTENTIALLY INAPPROPRIATE MEDICATIONS IN FRAIL OLDER ADULTS RESIDING IN LONG-TERM CARE: A RETROSPECTIVE CHART REVIEW STUDY
Authors: Heinrich CH , McHugh S , McCarthy S , Donovan MD
Published: October 2022

Background

Deprescribing is associated with positive health outcomes for older adults in long-term care, however deprescribing is not universally implemented. This study aims to identify the most prevalent Potentially Inappropriate Medication (PIM) used among frail older adults resident in Irish Long-Term Care Facilities (LTCFs), as identified by the Screening Tool of Older Persons Prescriptions in Frail adults with limited life expectancy version 2 (STOPPFrail V2), to form the basis of a deprescribing intervention.

Methods

A retrospective chart review was conducted in two publicly-funded LTCFs in the South/Southwest of Ireland (‘Site 1’ and ‘Site 2’). Eligible participants were those: (i) ≥65 years, (ii) resident in Site 1 or 2, (iii) eligible as per the STOPPFrail v2 criteria by the site’s medical officer, and (iv) receiving regular prescribed medication. Data collected included age, gender, drug, dose, frequency, regular/pro re nata and indication/relevant diagnoses. Descriptive and associative statistics were calculated. STOPPFrail was used to identify PIMs. Polypharmacy (taking ≥ 5 medications) and excessive polypharmacy (taking ≥10 medications) were calculated on the percentage of STOPPFrail eligible patients.

Results

Of the 103 residents screened, 89 were eligible and included in the analysis (86%). The prevalence of frailty for residents aged ≥65 was 93.7% (n=89), polypharmacy 95.5% (n=85) and excessive polypharmacy 64% (n=57). The mean number of regular medications (standard deviation) was 10.8 (±3.8), total medications 17.7 (±5) and diagnoses 5.5 (±2.5). A significant relationship existed between the number of PIMs and the number of medicines prescribed (ρ 0.525, p<0.01). The most common PIMs were those with no clear indication, followed by the antihypertensive medications and ergocalciferol/cholecalciferol.

Conclusion

Medication and PIM usage was high among LTCF residents, with inappropriate polypharmacy of concern. Potential deprescribing interventions include documenting indications for medications, incorporating routine blood pressure measurements and drug-specific guidelines to support deprescribing PIMs, reducing drug-related morbidity and medication burden.
48 EXPLORING RESIDENTS’ PERCEPTIONS OF SOCIAL AND LEISURE OCCUPATIONAL CHOICE WITHIN NATIONAL NURSING HOME CARE FACILITIES
Authors: Ryan C , Keane J , Usher R
Published: October 2022

Background

National standards state that nursing homes in Ireland must provide residents with a variety of engaging activities that accommodate their needs and preferences. Despite this, residents are at risk of experiencing occupational deprivation as a result of limited choices within these settings. Due to the subjective nature of occupational choice, the objective of this study is to analyse residents’ perceptions of leisure and social occupational choice in nursing homes in Ireland.

Methods

The study adopted a qualitative-descriptive design. Six residents from three different nursing homes participated in two semi-structured interviews that analysed their leisure and social occupational engagement within their nursing home.

Results

The data identified two main themes that were divided into six related sub-themes. Residents' felt their social and leisure occupational choice was influenced by: (1) environmental factors (the cultural, social, physical, and temporal contexts of the nursing home) and (2) personal attributes (residents' health status and personal attitudes).

Conclusion

Residents' leisure and social occupational choices are substantially influenced by the cultural context of the nursing home. This stresses the significant need for person-centred care in nursing homes, in order to promote occupational choice. The findings also highlight the benefits of accessible communal spaces to enable unstructured social interaction. Occupational therapists are essential to support the leisure and social occupational choices of nursing home residents and minimise occupational deprivation, by building residents’ skills, providing staff education and modifying tasks and/or the environment.
50 SERVICE EVALUATION COMPARING ACUTE CARE AT HOME FOR OLDER SEOPLE SERVICE AND CONVENTIONAL ACUTE HOSPITAL CARE OF THE ELDERLY WARD
Authors: Tierney B , Todd S , Melby V
Published: October 2022

Background

Globally, there has been an increased demand for healthcare services caused by population growth and a rise in chronic conditions and an ageing population. Acute Care at Home services offer acute, hospital-level care in a person's own home. Five services have been commissioned across Northern Ireland since 2014 with limited research investigating their feasibility and effectiveness. This study evaluated the impact of a consultant-led Acute Care at Home service in comparison with conventional hospital admission to a care of elderly ward.

Methods

Quantitative design, using service evaluation methodology. A 1-year retrospective chart review was undertaken exploring admission demographics and post-discharge clinical outcomes of patients admitted to a Northern Ireland, Care of the Elderly ward (n = 191) and a consultant-led Acute Care at Home Service (n = 314) between April 2018–March 2019. Data were analysed using descriptive and inferential data analysis methods including frequencies, independent t tests and chi-square analysis. Outcome measurements included length of stay, 30-day, 3-and 6-month readmission and mortality rates, functional ability and residence on discharge. STROBE checklist was used in reporting this study.

Results

Acute Care at Home services are associated with higher readmission and mortality rates at 30 days, 3 and 6 months. Patients admitted to the Acute Care at Home services experience a reduced length of stay and decreased escalation in domiciliary care packages and are less likely to require subacute rehabilitation on discharge. There is no difference in gender, age and early warnings score between the two cohorts.

Conclusion

The Acute Care at Home service is a viable alternative to hospital for older patients. It prevents functional decline and the need for domiciliary care or nursing home placement. Acute Care at Home service has higher mortality and readmissions rates due to treating a higher proportion of dependent, frail older adults.
55 A MOBILITY PROFILE OF STROKE PATIENTS ADMITTED TO A LEVEL 4 ACUTE HOSPITAL OVER A 6-MONTH PERIOD
Authors: Murphy D , Crowley A , Fitzpatrick M
Published: October 2022

Background

In order to best direct physiotherapy stroke resources and further service development it is important to characterise the mobility of stroke patients presenting to an acute hospital.

Methods

A previous audit completed in 2018 in the same organisation established that by using the Berg Balance Scale (BBS) and the Mobility Scale for Acute Stroke (MSAS) as admission outcome measures, a baseline profile could be established while limiting the floor and ceiling effects. A retrospective audit was completed of all patients referred to the stroke physiotherapy service admitted with acute stroke in a 6 month period. An excel spreadsheet was used to record patients’ admission BBS and MSAS. This was recorded along with the mainstay of physiotherapy treatment and discharge destination.

Results

145 stroke patients were assessed by stroke physiotherapy between Oct 2021 and April 2022. Of those patients 30% scored full marks on the MSAS which indicates that they were independently mobile with or without an aid post stroke. 26% of patients scored 3 or less on the BBS which would imply they were unable to sit without help.

Conclusion

This audit provides valuable information on the mobility profile of stroke patients presenting to an acute Level 4 hospital. On admission, patients seem to fall into 3 distinct categories based on their physical function post stroke. One group remained independently mobile post stroke, one group were heavily dependent being unable to sit without assistance and the final cohort requiring some level of supervision or assistance for mobility and balance. This information could be used to facilitate therapy and resource planning.
60 POWER-AGERS: IMPLEMENTING PROGRESSIVE RESISTANCE TRAINING TO MANAGE SARCOPENIA AMONG COMMUNITY DWELLING OLDER ADULTS
Authors: Gilheany Á , Synnott E , McDonnell I , McDaid E , Ross E , Boyle N , Carey G
Published: October 2022

Background

The prevalence of sarcopenia among community dwelling older adults is between 10-40%. Progressive Resistance Training (PRT) improves sarcopenia and functional performance among older-adults. A PRT programme was introduced to a Day Hospital service as part of a sarcopenia management quality improvement initiative.

Methods

The PRT programme was implemented on a phased basis. Phase 1 evaluated the feasibility, safety and participant satisfaction. Phase 2 then collected pre and post outcome measures (gait-speed, grip strength and 5-Times-Sit-to-Stand [5TSTS]), and a patient perception questionnaire. The intervention consisted of a physiotherapist-lead PRT programme (weekly in phase 1 and biweekly in phase 2). Recent community dwelling Day Hospital attendees were recruited by the physiotherapist to participate. The class consisted of a circuit of 4-6 exercises targeting upper and lower limbs, along with an educational component. Exercises were progressively overloaded on an individual basis.

Results

Ten participants attended the PRT programmes (phase 1 [n=5], phase 2 [n=5]). Most were female (n=6), mean age was 84 years. None had prior formal experience of PRT. The phase 1 PRT group was deemed feasible and safe in an outpatient setting. All phase 1 participants (n=5) felt it was beneficial and rated it 5/5. All phase 2 participants had improvements in sarcopenia markers (grip strength [range=1kg-9kg], gait-speed [range=0.04m/s-0.19m/s], and 5TSTS [range=5.1sec-11sec]). All participants reported that the programmes improved their confidence in PRT and that they were interested in continuing PRT in the future.

Conclusion

This supports that PRT a clinical setting with community dwelling older adults is safe, feasible and effective in improving sarcopenia markers. Furthermore, the high rate of satisfaction supports its use with this population. Further research is required to examine the impact of combined nutritional education with strength training as an intervention for older adults with sarcopenia.
64 HIGH-DOSE STEROIDS IN HAEMATOLOGICAL MALIGNANCY: A RED FLAG FOR BONE HEALTH
Authors: Kemple O , Brady S , McHugh J , Desmond R , Meade L , Enright H
Published: October 2022

Background

Bone-protective treatment should always be considered when commencing glucocorticoid therapy in individuals at high risk of fracture, as outlined in recent guidelines (National Osteoporosis Guideline Group, July 2018). Despite this, many patients receive high dose glucocorticoids (>7.5mg/kg/day or equivalent for >3 months) during treatment of haematological malignancy without formal assessment of bone health.

Methods

Twenty-five patients with Non-Hodgkin’s Lymphoma (NHL) on high dose steroid chemotherapy protocols were retrospectively assessed. The inclusion criterion was defined as any patient commenced on a cyclophosphamide, doxorubicin, vincristine and prednisolone (CHOP) containing protocol from 1/8/2020 to 1/8/21. Data was collected from electronic and written patient records. Information regarding patient age, diagnosis, steroid preparation and dose, presence of risk factors for osteoporosis and calcium and vitamin D prescriptions were collected. Radiological imaging was reviewed to assess for the occurrence of fragility fractures. Each patient had a FRAX® score calculated to assess fracture risk.

Results

The mean age of patients studied was 67 years and equally distributed between males and females. All patients had NHL. 32% (n=25) of patients were identified to be at high risk for fracture (FRAX® score >20% ten-year probability of major osteoporotic fracture). 16% had already established fragility fractures prior to commencing steroid treatment. 28% of patients were females over the age of 70 years. Only 12% of patients received vitamin D and calcium supplementation. No patient commenced bone protection therapy.

Conclusion

Omission of bone health assessment prior to high dose glucocorticoid treatment is prevalent in haematological malignancy and places patients at risk of significant morbidity. Patients are not routinely considered for protective measures including calcium and vitamin D supplementation and bone protection therapy. A simple risk-assessment tool and education to staff and patients prior to glucocorticoid therapy could significantly improve practice in this area. It is now planned to introduce routine risk assessment for this cohort of patients, with re-audit following implementation.
69 BUILDING TOWARDS COMPREHENSIVE GERIATRIC ASSESSMENT (C.G.A.) – A STEP-BY-STEP CPD PROGRAM
Authors: O'Connor S
Published: October 2022

Background

The National Clinical Programme for the Older Person (2016) advises Comprehensive Geriatric Assessment (CGA) as the gold standard for the management of frailty in older people. Over the past three years the Medicine for the Elderly (MedEl) OT service have introduced a number of key quality initiatives as part of a wider Continuous Professional Development (CPD) program to support adherence to the CGA guidelines. These initiatives have focused on implementing staff development and training, and clinical processes to provide OTs with the necessary knowledge, skills and structures to carry out CGA

Methods

An audit of OT initial assessments was completed in which data pertinent to CGA was collected, this identified poor compliance and led to the re-design of the OT MedEl Staff Grade competencies in line with CGA guidelines. The team In-services and staff grade peer support were also re-designed into cycles based on the key performance domains within CGA such as upper limb and cognition. It was hoped that a more coordinated approach to CPD, beginning with the structures in place would result in improved knowledge and skills to carry out CGA.

Results

An audit of OT initial assessments was completed in which data pertinent to CGA was collected pre and post in-service cycles. This demonstrated an average increase of 21% across the 9 performance domains. Staff also self-rated their knowledge, skills and confidence in relation to the key performance domains within CGA which demonstrated an average improvement of 12.5%.

Conclusion

As part of an ongoing iterative testing cycle, a further re-audit of the OT Initial Assessment tool will be completed in the next quarter to ascertain the long-term impact of a coordinated, cohesive CPD program to support sustained implementation of CGA within our service.
71 A MOBILITY PROFILE OF THE PATIENTS ADMITTED TO AN ESD SERVICE IN IRELAND
Authors: Crowley A , Dhochartaigh DN , Murphy A , Gough D , Fitzpatrick M
Published: October 2022

Background

Early Supported Discharge (ESD) allows patients to receive multidisciplinary stroke rehabilitation in their own home upon discharge from the acute hospital setting. ESD is recognised as international best practice for patients with mild to moderate impairments post stroke. An ESD team was set up in September 2020 from an acute hospital. A retrospective audit was carried out to profile the mobility of patients referred to the physiotherapy ESD service.

Methods

A retrospective chart audit was carried out on 42 patients referred to physiotherapy during the first six months of the ESD service. Data was collected on admission and discharge from hospital, for those patients being referred to ESD on the following: age, mobility, Berg Balance Scale score and length of stay.

Results

The mean age of the patient group was 70 (range 41 – 80 years). On discharge to ESD, 80 % of patients were independently mobile with or without an aid . Supervision or assistance of one person was required by 20% of patients. Thirty percent of patients were off their baseline mobility on discharge to the ESD service. The average Berg Balance Scale score was 51. The mean length of inpatient stay for ESD patients was 12 days compared to 33 days for those awaiting offsite rehabilitation.

Conclusion

This data demonstrates that the majority of patients admitted to ESD were independent with mobility. This patient cohort most likely required higher level physiotherapy interventions such as exercise tolerance progression, community integration and upper limb rehabilitation. Further research should evaluate the range of interventions provided within this ESD physiotherapy service.
72 SEASONAL VARIATION IN HYPERPARATHYROIDISM IN OLDER IRISH ADULTS
Authors: Fitzpatrick D , Laird E , Hoey L , Hughes C , McNulty H , Ward M , Strain JJ , Tracey F , Molloy A , Cunningham C , McCarroll K
Published: October 2022

Background

Vitamin D deficiency is common in Ireland, varies by season and can result in secondary hyperparathyroidism. High Parathyroid Hormone (PTH) levels due to low vitamin D status are associated with increased bone turnover and lower bone mineral density, especially at cortical sites such as the hip. Given the variation in vitamin D status by time of year, our study aimed to examine for seasonal differences in hyperparthyroidism in older adults.

Methods

Study participants were from a large cross-sectional study of older Irish adults recruited from hospital outpatient services and GP practices. Exclusion criteria were: eGFR< 30ml/min and elevated serum calcium (>2.5 mmol/l) in order to avoid primary hyperparathyroidism or elevated serum PTH due to advanced renal impairment. Hyperparathyroidism was defined as a PTH level > 65 ng/ml. The relationship between hyperparathyroidism and season was examined in regression models adjusting for potential factors affecting PTH.

Results

There were 4324 participants, mean age 73.8 +/- 7.9 years, 65.4% were female. Hyperparathyroidism was more prevalent in Spring versus Autumn (17.4 vs 11.4 %, P = 0.0002). The increased prevalence remained after adjusting for age, gender, body mass index, timed up and go, dairy intake, eGFR, and smoking (OR 1.6, 1.2- 2.0, P=0.0003). This also corresponded to the seasonal variation in vitamin D status with deficiency (25(OH)D < 30 nmol/l) highest in Spring (23.3%) and lowest in Autumn (16.8%).

Conclusion

We found that hyperparathyroidism fluctuates with season in an inverse relationship with vitamin D. Overall, high PTH levels were 60% more likely in Spring versus Autumn. This emphasises the importance of maintaining adequate vitamin D status all year round. While we adjusted for dairy intake, we did not have accurate measures of total dietary calcium intake which could also vary seasonally and be a contributory factor.
77 EXPERIENCES OF OLDER PEOPLE AND CARERS REFERRED TO AMBULATORY OUTREACH TEAM WITHIN INTEGRATED CARE PROGRAMME FOR OLDER PERSONS (ICPOP) SERVICE
Authors: Akhtar A , Lawlor R , Cahalane J , Gillman C , Cronin F , Daly B , Hennessy J , Naughton C
Published: October 2022

Background

Ambulatory outreach services are part of new pathways to reduce reliance on secondary care as outlined in the Integrated Care Programme for Older Persons. Multidisciplinary outreach teams provide urgent medical and rehabilitation services in the person’s home to stabilise a health crisis.

Methods

The study aimed to explore the experiences of older people accessing a ambulatory outreach service and identify development opportunities. Interpretive description, an inductive analytic approach, was used to seek an understanding of clinical phenomena that illuminate their characteristics, patterns and structure. Data collection used qualitative telephone interviews. A purposeful sample of older people and carers were recruited following discharge from the outreach service over a three-month period.

Results

Sixteen participants (patients n=9 and carers n=7) were interviewed, 77% were female with a mean age of 83 years. Three major themes and seven sub-themes were identified:

Theme 1: Gratitude for specialised care: a) Moment of crisis “It was absolutely brilliant”; b) Care in my home: physical and psychological benefits

Theme 2: Living with and managing complexity: c) Resilience and resignation: living in the moment “Well she’s doing good at the moment, God forbids if there is more injuries”, d) Work of patients: maintain motivation & control; task and service boundaries e) Work of Families “We’re doing it so far”.

Theme 3:Scope for pro-active planning & Integration: f) What happens next? an unpredictable future; h) Integration with GP & community, g) Unspoken plan- sub-conscious advanced care planning “Nobody makes the decision on their own they call someone else”

Conclusion

The Outreach Team was highly valued by participants and was seen as vital in regaining functional capability and confidence to cope. Future developments need to examine task and service boundaries that undermine resilience, post outreach follow-up, integration with primary care, and opportunities for advanced care conversations.
81 IMPROVING THE ASSESSMENT AND PREVENTION OF FALLS AND FRACTURES ON A REHABILITATION WARD
Authors: Nzeji CA , Rahaman F , Makhura R , Fallon A , McDonough A
Published: October 2022

Background

The National Steering Group and The National Institute for Health and Care Excellence provide guidelines on medical assessment and prevention of falls and fractures. This audit assesses and compares quality of practice on an Age-Related rehabilitation ward against these guidelines.

Methods

A retrospective audit, including all patients (n=31) on an off-site, Age-Related rehabilitation ward was completed. Data on falls and fractures at emergency department presentation and during admission was obtained through chart review. Following education and implementation of a falls pro-forma, a re-audit was completed at four months including all patients (n=40).

Results

In cycle 1, mean age of patients was 80 years (range 56-94), 39 Percent (%) (n=12) were admitted with a fall of whom 66.7% (n=8) had a resulting fracture. In cycle 2, mean age was 82 years (range 63–95), 48% (n=19) were admitted due to a fall, of whom 53% (n=10) had a fracture.

A falls assessment and bone health review was completed in 39% (n=12) of all patients in cycle 1, and in 37% (n=3) admitted with a fall. This increased to 83% (n=33) of all patients in cycle 2 and 100% (n=40) of those admitted with a fall. Pre-intervention, 23% (n=7) had an inpatient fall compared to 18% (n=7) post-intervention; of these, 43% (n=3) and 14% (n=1) resulted in fractures respectively.

Conclusion

Compliance with national guidelines for prevention of falls and fractures improved with education and implementation of a falls pro-forma. This resulted in a reduction in falls, particularly injurious falls, on a rehabilitation ward. In future, this pro-forma may be implemented in other hospital wards.
87 VERTEBRAL FRACTURES IN OLDER PATIENTS WITH COPD: AN UNDER-DIAGNOSED AND UNDER-TREATED ENTITY
Authors: Brennan M , Nash D , Rutherford R
Published: October 2022

Background

Patients with Chronic Obstructive Pulmonary Disease (COPD) are at increased risk of osteoporosis. Vertebral Fractures (VF) are the most common manifestation of osteoporosis. Only one fourth to one third of incident radiographically identified VF are clinically diagnosed. The aim of this study is to evaluate patients the prevalence of VF in a cohort of patients admitted with Acute Exacerbation of COPD (AECOPD).

Methods

A retrospective review of AECOPD admissions over a four-month period was performed. Information on baseline characteristics, prescribed medications and reports of radiological imaging were obtained from Electronic Healthcare Records, discharge summaries and clinic letters.

Results

In total 116 patients were included over the study period. In 24% (n=28), VF was present on imaging. In those with VF, females accounted for 64.3% (n=18). Median age was 80 (76-85) and median CFS was 6. In 12 cases a single VF was present, in 9 two VFs and in 7 patients 3+ VF were present. There was no documented diagnosis of osteoporosis in 67.8% (n=19). VF were initially detected on CT thorax imaging performed to assess for pulmonary pathology in 35.7% (n=10) cases. Vitamin D3 was prescribed in 60.7% (n=17), concurrently with calcium in 28.6% (n=8). Antiresorptive therapy was prescribed in 39.3% (n=11), oral bisphosphonates in 4 patients and denosumab in 7. Vitamin D (OH) level was measured in 78.6% (n= 22) patients and was insufficient (<50mmol) in 25% (n=7).

Conclusion

Almost one-quarter of patients who were admitted with an AECOPD had vertebral insufficiency fracture on imaging. Identification and treatment of VF was suboptimal. Most were not identified as having osteoporosis nor prescribed antiresorptive therapy. CT imaging should be routinely reviewed for the presence of insufficiency fractures as part of case finding initiatives. Bone health assessment should be routinely performed in patients with COPD, particularly those with frequent corticosteroid usage.
89 DIAGNOSIS AND TREATMENT OF SUSPECTED OBSTRUCTIVE SLEEP APNOEA (OSA) IN OLDER PEOPLE: A RETROSPECTIVE COMPARATIVE ANALYSIS
Authors: Brennan M , Walsh S , Rutherford R , Garvey J , O'Hanlon S , Gargoum F
Published: October 2022

Background

Obstructive Sleep Apnoea (OSA) is common yet often undiagnosed in older people as symptoms of fatigue and poor sleep are common and non-specific. OSA screening tools also lack validity in older patients. This study aims to review the clinical presentation, use of screening tools and treatment adherence in older people.

Methods

A retrospective cohort study of patients >65 years attending a tertiary sleep clinic who underwent polysomnography for suspected OSA was performed. Electronic patient records were reviewed to obtain information on clinical presentation, screening scores, polysomnography reports and treatment initiated. Correlation between variables was performed using Pearson’s correlation co-efficient and represented using R-score. To compare CPAP usage with younger people, a cohort of controls <65 years were matched in 2:1 ratio for OSA severity (mild, moderate or severe) at diagnosis. Comparison of adherence rates was performed using Mann-Whitney U-test and represented using Z-scores.

Results

A convenience sample of 100 consecutive older patients were included. Fatigue was present in 53% and witness reported snoring in 86% and apnoeas in 56%. Moderate or severe OSA was confirmed by polysomnography in 91% cases. BMI and the STOP-BANG questionnaire were positively correlated with OSA severity as measured by Apnoea Hypopnea Index, while ESS and Berlin Questionnaire were not. Positive pressure ventilation was initiated in 90% patients. CPAP was extremely effective with the median AHI falling to within normal range on follow up. CPAP usage was significantly higher in older patients compared with younger matched control (85% vs 66% p=013).

Conclusion

Older people with OSA present with classical symptoms. STOP -BANG questionnaire and BMI were positively correlated with AHI values while other screening tools lacked validity. Treatment with CPAP was highly efficacious in older people with high usage rates and should be considered as first-line treatment for moderate and severe OSA in older patients.
90 A RETROSPECTIVE COHORT STUDY COMPARING THE CLINICAL CHARACTERISTICS, TREATMENT AND OUTCOMES OF BIOPSY-CONFIRMED SARCOIDOSIS IN LATE-ONSET AND YOUNGER-ONSET PATIENTS
Authors: Brennan M , Phelan S , Breen D
Published: October 2022

Background

Late-Onset Sarcoidosis (LOS) accounts for up to one-third of cases and is diagnostically challenging due to the difficulty in satisfactorily excluding malignancy and infection, often necessitating repeated investigations. Endobronchial Ultrasound (EBUS) is the gold standard for diagnosing pulmonary sarcoidosis. This study aims to compare the clinical presentation, treatment and outcomes in patients with biopsy confirmed sarcoidosis in older and younger patients

Methods

A retrospective cohort analysis was performed on all patients with EBUS-confirmed sarcoidosis at a tertiary referral centre between 2012 and 2019. Electronic healthcare records were reviewed to obtain information on clinical presentation, confirmatory investigations, treatment and outcomes. LOS was defined as patients aged >65 years

Results

In total, 247 patients were included, 68.8% were male. LOS accounted for 9.3% (n=23).Extra-pulmonary and systemic features were less common in LOS (26.1% vs 58%, p<0.002). There was no difference in systemic treatment between cohorts (84.6% vs 67.9%, p=0.21) and LOS patients experienced comparably high rates of satisfactory outcomes. At follow up, the majority of patients either improved or achieved clinical stability in both groups (92.3% vs 76.1%, p=0.18). Clinical and/or radiological progression occurred in 7% in both groups with no reported deaths. Confirmatory investigations were infrequent and EBUS was safe and well-tolerated in older patients.

Conclusion

LOS was lower than expected and extra-pulmonary involvement was uncommon suggesting a pre-selected population. Referral for EBUS should be considered as first line for older patients with unexplained thoracic adenopathy provided further diagnostic investigations are in line with their goals of care. Clinical outcomes were excellent with low rates of progression, extra-pulmonary organ involvement and systemic therapy initiation, differing from prior studies and may represent less severe disease at diagnosis, enhanced diagnostic certainty or referral bias.
98 PREPARING FOR THE COMMENCEMENT OF THE DECISION MAKING “CAPACITY” ACT (2015): REVIEWING CURRENT PRACTICE WITHIN AN OCCUPATIONAL THERAPY DEPARTMENT
Authors: O'Neill S , McNally A , Treanor C , O'Rourke S
Published: October 2022

Background

The Decision Making ‘Capacity’ Act (2015) will commence in 2022. This will have significant implications for health care professionals. Occupational therapists undertake a wide range of assessments of cognitive, physical and functional ability. There is a need to streamline the recording of comprehensive and holistic assessment outcomes for easier access and interpretation during the interdisciplinary assessment of Decision Making Capacity (DMC) for independent living. A working group was established to review current practices and formulate a document to support the assessment.

Methods

The model for improvement was employed, which incorporates the plan, do, study, act methodology. Current practice of the occupational therapy team was reviewed in relation to assessments used, the format of recording and the knowledge of the DMC act. A working document was formulated and reviewed with medical staff. Team education on the DMC act was provided. A qualitative questionnaire was circulated among the occupational therapy staff to ascertain the educational needs of the department. Perceptions of current practice in DMC assessment of independent living were gathered.

Results

100% of questionnaire respondents identified need for further training and education on the DMC Act 2015. No respondents agreed that the relevant assessment outcomes were easily accessible. 67% of respondents were unsatisfied with the current process in place for DMC assessment of independent living. 45% of respondents do not feel confident in completing assessments contributing to DMC assessment of independent living. There was no consistency in the format of recording assessment outcomes.

Conclusion

The group developed a clinical document to improve easy and consistent interpretation of occupational therapy assessment in relation the DMC assessment of independent living. This ensures person centred, comprehensive assessment to enhance the patient journey. The team are better prepared for the commencement of the DMC act and have identified future training needs.