bluuebunny/crossref_metadata_2025 huggingface dataset:
13 Effects of Benzodiazepines on Orthostatic Blood Pressure in Older People
Authors: Rivasi Giulia , Anne Kenny Rose , Ungar Andrea , Romero-Ortuno Roman
Published: September 2019

Background

Older people taking benzodiazepines (BDZs) have higher risk of falling, which is mainly attributed to unfavorable drug-related effects on cognition and psychomotor functioning. BDZs may also have hypotensive effects, but evidence concerning the relationship between BDZs and orthostatic blood pressure (BP) behaviour in older people is scarce. We investigated the effects of BDZs on BP response to an orthostatic active stand test.

Methods

We performed a retrospective analysis of data from an outpatient research clinic in an Irish university hospital, where people aged 60 or older underwent a comprehensive geriatric assessment between August 2007 and May 2009. Non-invasive beat-to-beat orthostatic BP was measured during active stand, with systolic BP assessed at each 10-second interval. Information on regular BDZs use was collected. Factors independently associated with orthostatic systolic BP were investigated using multiple linear regression.

Results

Of 624 community-dwelling people who underwent a clinic assessment, orthostatic active stand data was collected in 541. Information on regular BDZs use was available in 538 people. Of 538 participants, mean age was 72.7±7.2, 67.7% were female and 33 (6.1%) reported regular use of BDZs. History of falls (p=0.027) and fear of falling (p<0.001) were more prevalent in this subgroup. During active stand, participants on BDZs showed a significantly greater systolic BP drop 10 seconds after the posture change (“immediate” BP drop). No significant differences were detected in orthostatic systolic BP in the latter phases of the active stand. After adjusting for possible confounders, BDZs use was independently associated with a mean immediate systolic BP drop of 12 mmHg after standing.

Conclusion

BDZs may confer higher risk of an immediate systolic BP drop after standing in older people, which may contribute to their known falls risk. BDZ should be avoided in older people at risk of falling.
14 Identifying and Addressing Challenges Experienced by Nurses when Caring for Persons with Dementia Experiencing Responsive Behaviours in Acute Hospitals
Authors: Dookhy Joshi , Daly Louise
Published: September 2019

Background

Due to the increasing number of persons with dementia being hospitalised (Timmons et al., 2015), nurses working in acute hospitals need to be competent in caring for this patient population. Amongst other dementia-care specific competencies, nurses require competence in caring for those with dementia who experience responsive behaviours, a common phenomenon in acute hospitals. The aims of this study were to explore challenges encountered by nurses in caring for persons with dementia experiencing responsive behaviours in an acute hospital and to explore strategies used by nurses to address the encountered challenges.

Methods

A qualitative descriptive study, involving semi-structured interviews with nine nurses was conducted. Ethical approval was received from the School of Nursing & Midwifery Research Ethics Committee in the participating University. Data was collected in 2018 and was analysed using a thematic analysis approach.

Results

An analysis identified three challenging components for nurses, namely: emotional, environmental and organisational challenges.

These challenges in turn contributed to barriers to the provision of nursing care and management of responsive behaviours in the setting. To address these challenges, nurses implemented therapeutic interventions, for example reminiscence, and engaged with other healthcare professionals and caregivers.

Conclusion

This study explored how various emotional, environmental and organisational challenges are experienced and addressed by nurses when managing responsive behaviours in the acute hospital. The increasing number of persons with dementia attending acute hospitals necessitates an urgency for service development to enhance the specific dementia-care competency levels of nurses. Changes at an organisational level, to support competency development in dementia-care in acute hospitals, must also be adopted.
18 A Review of Interventions to Improve Medication Adherence in Patients with Parkinson’s Disease
Authors: McMahon Niamh , Kelly Neasa , Henman Martin
Published: September 2019

Background

In Parkinson’s Disease (PD) medication adherence has been neglected. Despite evidence of successful interventions in other chronic diseases, there is currently no review of medication adherence enhancing interventions in PD populations. This review sought to identify and evaluate interventions to improve medication adherence in patients with PD.

Methods

Six online databases (PubMed, EMBASE, Medline, PsycINFO, CinahlCOMPLETE, AMED) were searched. Key concepts “Medication adherence” and “Parkinson’s disease” were used. Reference lists of retrieved studies were hand searched. Studies were assessed for inclusion against pre-specified eligibility criteria. Data extraction was carried out using a standardised data extraction table. Critical appraisal was undertaken using the JADAD score, CASP Randomised Controlled Trial (RCT) checklist, “Quality Assessment tool for before-after studies with no control group” and the TREND statement checklist.

Results

The search resulted in 612 records of which five met inclusion criteria (3 RCT, 2 before-after studies). A total of 496 PD patients were included. Interventional strategies investigated were educational intervention, adherence therapy, effect of a Parkinson’s Tracker App (PTA) and intervention by a pharmacist. Five (100%) of the studies included in this review reported a statistically significant improvement in medication adherence post-intervention and some improvements in symptoms.

Conclusion

This is the first review of medication adherence in the PD population. Several different interventions proved effective in enhancing medication adherence, but the studies were small, short term and the risk of bias ranged from moderate to high. Consequently, the results may not be generalisable to other PD populations.
182 Feasibility and Usability of a New National Transfer Document for Older Persons: A Pilot Study
Authors: Coffey Alice , O'Reilly Pauline , Meskell Pauline , Tuohy Dympna , O'Brien Brid , Murphy Jill , Doody Owen , Graham Margaret , Fahy Anne , Barry Louise , O'Keeffe Jonathan , Kiely Michelle , O'Doherty Jane
Published: September 2019

Background

There is an increasing number of older persons experiencing transfer episodes between residential and acute care facilities (Griffiths et al. 2014). Current transfer documentation is diverse; often only containing basic information and very little person centred patient information. The objective of this HSE National Clinical Programme for Older People funded study was to develop a national person centred transfer tool, for use during patient transfer between residential and acute services. Following an extensive literature review, focus group interviews with stakeholders and input from an expert panel, a pilot transfer document was developed. This paper reports on the pilot study of this document.

Methods

Researchers, in consultation with the expert panel, developed questionnaires. Questionnaires were quantitative, with three open-ended questions. Of the 28 residential settings and 3 acute settings that were contacted, 26 residential and 3 acute settings (93%) participated in the study. The pre-pilot questionnaire asked staff in residential settings their perceptions on current transfer documentation (n=875). The post-pilot questionnaire asked staff in residential and acute care settings their thoughts on the new transfer document which was used for the pilot (n=1085).

Results

Findings suggest that staff agree that the new transfer tool is person centred, contains relevant patient information and could help communication between healthcare professionals in these settings. Findings also indicate that the length of time to complete the document is of concern, particularly in an emergency and there were suggestions from staff in residential care services that some sections could be prepopulated.

Conclusion

In order to have a transfer document that is efficient, and person centred, there is a need for it to be available electronically and easy for staff to fully complete particularly in an emergency transfer.
186 Tailoring Change Management - Learning from “Readiness-to-Change” and Learning Needs Analyses, Focused on Dementia Palliative Care, in Three Long-term Care Settings
Authors: Timmons Suzanne , Cornally Nicola , Hartigan Irene , Lehane Elaine , Buckley Catherine , O’Loughlin Christina , Finn Colette , Lynch Marie , Coffey Alice
Published: September 2019

Background

Over one third of people with dementia in Ireland reside in Long Term Care (LTC) settings. Dementia palliative care is complex; healthcare staff in LTC settings have requested specific guidance to support practice. This participatory action research project will introduce national evidence-based guidance documents relating to pain, hydration/nutrition, and medication management, into three LTC settings in Munster, using a tailored Work-based Learning approach, informed by a baseline multi-modal situational analysis.

Methods

Site and staff data were collected using a site profile tool; staff demographic and learning needs surveys; and the ‘VOCALISE’ readiness-to-change survey, in the three sites.

Results

Within the sites, 42-88% of residents had probable/definite dementia. Multidisciplinary input varied considerably between sites. In total, 69 staff (predominantly nurses and healthcare attendants) completed learning needs surveys. Many reported prior dementia education (range 53-76% across sites). This was twice as often on hydration/nutrition and medication topics than pain. Reflecting this, staff in all sites identified knowledge deficits, but particularly in pain identification, assessment and management. Other learning needs included supporting and communicating with families; resident care planning and advance care planning; and resident ‘comfort’.

Of 58 staff with completed VOCALISE data, 33% were rated as ‘ready to change’, 14% ‘not’, and the remainder ambivalent. Interestingly, staff had high confidence in the ability of change to happen, but low motivation scores; and overall ambivalence towards their own power to make change happen. Some barriers were site-specific, but overall, staffing levels, managing risk during change and perceived reluctance in others were common barriers to change, as was the possibility that patient wishes hadn’t informed the change process.

Conclusion

Our baseline data highlights that education and change implementation needs to be tailored to the recipient site, recognising site-specific barriers to change. We will now use this data in our Work-based Learning intervention.
213 A New Way of Memory Care in an Integrated Care HUB
Authors: Murphy Catherine , Cooke John , Mulchay Riona , Pope George , Bolger Maggie , Roche Suzanne , O'Gorman Millie , Brennan Jacinta , Phelan Niamh , Grant Emma , Doyle Marie
Published: September 2019

Background

The Occupational Therapy (OT) service in the integrated care HUB team was established in January 2018. Prior to this, there was an established memory clinic, however with inconsistent access to OT. The streamlining and structuring of memory clinics further highlighted the need for post-diagnostic support for example individual sessions focusing on memory education and practical strategies to enable independence in daily activities. The integration of OT enabled person-centred strategies to be provided to individuals experiencing memory loss.

Methods

A retrospective analysis was completed comparing the number of OT memory patient contacts between January to June 2018 and November 2018 to April 2019 also reflecting the memory care pathway developed during this period. OT assessed all new patients experiencing memory difficulties that impacted on functional activities to initiate referral process. In April 2018, the Memory Technology Resource Room (MTRR) opened and the OT HUB using to facilitate patient contacts. The design/implementation of cognitive rehabilitation groups in May 2018 added another step to pathway. Dementia cafés were established in public cafés in the city and county area, sponsored by local care provider, also supported by HUB team. Feedback was gathered from surveys given to individuals, carers and HUB team in the Café and MTRR.

Results

From January to June 2018 there were 50 memory streamed patient contacts completed by the OT. From November 2018 to April 2019, 206 patient contacts were completed. These include both individual and group cognition focused sessions. Positive qualitative feedback was retrieved from attendees to MTRR and Café all indicating at least one positive outcome from post-diagnostic supports and services.

Conclusion

A multi-domain cognitive OT service when initiated by an integrated care HUB proves to be an effective and acceptable memory care pathway. The development of this holistic pathway enabled the person to be seen in the right place, at the right stage of their journey with memory difficulties.
23 The Implementation of a Hospital “Buddy Walking Programme” to Improve Access to Mobility for Acute Hospital in-Patients
Authors: Lombard Eileen , Higgins Anna , Timmons Suzanne , McCullagh Ruth
Published: September 2019

Background

An acute hospital admission often means that patient’s mobility can decline if not maintained and encouraged throughout their inpatient stay. The “Buddy Walking Programme” is a joint initiative between the physiotherapy department, nursing department and hospital volunteers. The aim of this research was to implement a hospital “Buddy Walking Programme” within a teaching hospital in Cork to allow the provision of accompanied walking sessions by members of the hospital’s volunteer team.

Methods

Ward based physiotherapy staff and nursing staff identify suitable patients and add their bed number and mobility status to a list each morning. Patients are identified who are independently mobile or can safely mobilise with the supervision of one person, with or without a mobility aid and who are cognitively capable of simple commands.

Physiotherapists and nursing staff are made aware of the programme at induction. Volunteers partake in an educational session and manual handling training prior to offering supervised walking sessions.

Results

A standard operating procedure has been developed for the “Buddy Walking Programme”. Training has been rolled out hospital wide amongst nursing staff, physiotherapy staff and hospital volunteers.

Conclusion

This programme will help encourage a culture of physical activity within the hospital in-patient setting and improve mobility levels. Further research is warranted to explore the beliefs and perceptions of hospital staff and volunteers regarding the initiative and to examine barriers and facilitators to the programme.
226 Staff Knowledge of Orthostatic Hypotension
Authors: O'Brien Michelle , Britton Jennifer , Clarke Miriam , Collins Orla
Published: September 2019

Background

The prevalence of orthostatic hypotension increases with age(1). The aim of this audit was to assess healthcare provider’s knowledge of identifying and measuring orthostatic hypotension (OH) in the acute setting. Early identification and management of OH is an important step to prevent adverse outcomes and improve patient’s overall functional performance.

Methods

Fifty-one questionnaires were distributed to a random selection of non-consultant doctors and nurses in our hospital. The questionnaires included questions regarding basic knowledge of OH and its measurement. Questions were based on international guidelines on the appropriate measurement and assessment of OH(1). An education session was then offered to junior doctors and nurses, and subsequently carried out by a senior nurse. Staff were educated on OH and how to correctly assess it. Doctors and nurses were subsequently reassessed using the same questionnaire.

Results

Initial results showed that many of the respondents were interns (37%) and nurses (35%). 94% of respondents had never received formal training in the evaluation of OH. 51% knew that a patient should lie supine for 5 minutes prior to initial BP assessment. 61% knew to take the BP at 1-minute post standing, and 45% knew that the BP should again be taken at 3 minutes. 71% knew to take the pulse alongside the BP checks. The education sessions and repeat audit are ongoing.

Conclusion

Many of the hospital staff who assess for OH have not received specific training on how to evaluate and diagnose OH. It is our aim to educate front line staff as to the importance of looking for OH and how to diagnose it.
228 Potentially Inappropriate Prescribing in Community Nursing Units: Prevalence and Potential for Optimisation
Authors: Collins Neil , Gallagher Paul
Published: September 2019

Background

It is well researched that individuals in long-term care (LTC) are prescribed a greater number of medications, the leading risk factor for inappropriate prescribing, and are thus at greater risk of adverse drug reactions as a result. Many tools with explicit criteria are described in the literature for assessing potentially inappropriate prescribing (PIP) in the general geriatric population, but few have been developed to examine prescribing in LTC.

Methods

This was a point prevalence observational study of patients aged >65 years residing in three HSE-run LTC facilities in Cork. Demographic characteristics, medical diagnoses and medication regimes at time of admission (TOA) to LTC, and time of data collection were recorded and reviewed using STOPPFrail and NORGEP-NH criteria.

Results

98 patients met the inclusion criteria, with 66% being female. The median age was 83 years (IQR 77-88 years), and median length of stay was 31 months (IQR 14-53 months). The median number of medications per person on admission was 8 (IQR 6-11), which increased to 9 (IQR 7-11) at time of review (TOR)(p<0.001). PIP was found in 70 (84.3%) patients at TOA, and 79(80.6%) at TOR using STOPPFrail, and was recorded as 81 (97.6%) at TOA, and 95(96.9%) at TOR using NORGEP-NH. Among the STOPPFrail criteria most commonly implicated were continuous use of nutritional supplements and high dose PPI therapy. With NORGEP, the most commonly implicated were use of antidepressants and antihypertensives. There was an increase in number of patients prescribed benzodiazepines, z-drugs, anti-depressants and anti-psychotics from TOA to TOR, while statins were prescribed less often at TOR (p<0.001).

Conclusion

Potentially inappropriate prescribing is highly prevalent in older residents of community hospitals using validated prescribing indicators. Criteria such as those used in this study could be used to highlight potentially inappropriate or futile medications in older, vulnerable patients. Regular medication review is recommended to facilitate deprescribing of such medications.
243 An Audit of Documentation of Resuscitation Status in a Teaching Hospital
Authors: McDonough Anna , O'Hanlon Shane
Published: September 2019

Background

The documentation of discussions about resuscitation status with patients and their relatives is an important part of medical care, but can be a time-consuming process. These discussions may be difficult, particularly for patients who have cognitive impairment or are acutely unwell. The National Consent Policy1 recommends that resuscitation decisions should be made with patients themselves, or with family members if the patient cannot participate. It also recommends decisions are made by the most senior decision maker with responsibility for the patient’s care and discussions should be carefully documented.

Methods

The charts of all 106 inpatients in our hospital were audited on a single day. Documentation of resuscitation status in the medical and nursing notes was reviewed.

Results

The average age of inpatients was 79.8 years. 25.5% of patients had a DNACPR order. Of these, 92% had their DNACPR status documented in the nursing notes. 100% had a DNACPR form in their medical notes but none were fully completed. 48% had not had the decision endorsed by the consultant in charge of the patient’s care. 74% had not been discussed with the patient or had not had a reason documented as to why the decision had not been discussed. 41% did not have any discussion documented in the medical notes.

Conclusion

The DNACPR form in use includes the details recommended by national guidelines but these forms are not being completed in their entirety. Discussions with patients themselves are possibly inappropriate at the time resuscitation status is being considered, but documentation of the reasons for this is still important. This, in particular is an area which needs to be highlighted to medical staff in our hospital. Results of this audit will be incorporated into an education session, with a view to changing practice.
247 Antipsychotic Medication in the Management of Non-cognitive Symptoms of Dementia: An Updated Evidence Review
Authors: Fox Siobhán , Murphy Ashling , Jennings Aisling , Murphy Kieran , Timmons Suzanne
Published: September 2019

Background

Antipsychotic medications are commonly used in the management of non-cognitive symptoms of dementia (also termed behavioural and psychological symptoms of dementia), such as agitation, calling out, hoarding, or aggression. This is despite increased recognition of adverse effects, including mortality, from these medications for people with dementia. The current aim was to review the most recent evidence for the efficacy and safety of antipsychotic medications in the management of non-cognitive symptoms in dementia.

Methods

Relevant studies published in English from March 2015 through to March 2018 were identified by searches of 5 databases: Medline, EBSCO, PsycINFO, Cochrane DARE, and Cochrane CENTRAL. Systematic reviews, meta-analyses, and controlled trials evaluating the safety of antipsychotic medication, or comparing the effectiveness of antipsychotic medication with placebo, another antipsychotic medication, or non-pharmacological intervention, were included. Independent article review and data extraction was performed by two reviewers. Study quality was appraised using the Joanna Briggs Institute critical appraisal tools.

Results

Thirteen studies were included. Benefits and harms vary among antipsychotic medications for people with dementia, however overall efficacy of antipsychotics remains modest at best. A significant number of side effects are associated with antipsychotics, not least cerebrovascular events, sedation, gait disturbances, falls, fractures, urinary tract infections, cognitive worsening, and mortality. Atypical antipsychotics have a more favourable safety profile in some respects. People with certain dementias, notably Lewy Body Dementia, may experience more severe side-effects.

Conclusion

The evidence reinforces caution when prescribing antipsychotic medications for people with dementia; these medications should only be considered when symptoms are severe or non-pharmacological interventions have failed. Clinicians should closely monitor people with dementia who are prescribed an antipsychotic for side effects, limiting use of these medications to short-term treatment if possible. The forthcoming national clinical guideline for appropriate prescribing of psychotropic medications for non-cognitive symptoms will support clinical decision-making in this regard.
259 The Electronic Patient Record as an Enabler for Hospital Wide Delirium and Dementia Screening -Lessons Learned from a Clinical Implementation
Authors: Chapman Lucy , Corbett Mel , Courtney Grainne , Lawlor Brian
Published: September 2019

Background

The validated 4 As Test (4AT) cognitive screening tool was incorporated into the electronic patient record (EPR) to facilitate hospital wide delirium and dementia screening. Completion of the 4AT was mandated by its incorporation into a computer alert targeted at doctors. This alert was generated on all hospital inpatients aged 65 years and over at 24 hours into admission in keeping with the National Institute for Health and Care Excellence guidelines. An option to bypass the 4AT alert was available.

Methods

Multidisciplinary clinical stakeholder workshops informed the design of the electronic cognitive screening alert. An implementation strategy was undertaken using intensive clinical engagement. On June 27th 2018, the 4AT electronic alert was deployed. Data entries from the completed electronic 4AT assessments were extracted from the EPR facilitating descriptive statistical analysis and point prevalence analysis for delirium and dementia. Specialty-based comparisons were also made.

Results

During the first 24 hours post-implementation, 4AT screening assessments were completed in 61% of instances equating to 324 completed assessments. Forty eight percent (n=155) had a score of zero suggestive of normal cognitive status. Notably, 20% assessments yielded a score reflective of possible delirium (four or more). Dementia was a recognised clinical diagnosis in 23% (n=76) of patients. One in two of these dementia patients scored four or more indicative of coexistent delirium.

Conclusion

Electronic patient records can be harnessed to facilitate hospital-wide delirium and dementia screening and improve detection. This also represents a novel method to capture data for the purposes of audit and research as well as to inform and improve future directions in clinical care and resource allocation. Innovative computer-based strategies may offer future directions to augment detection of cognitive disorders in hospitalised populations.
264 Incorporating Neurolinguistics and the Role of Speech and Language Therapy in a Specialist Memory Service
Authors: Sheridan Lisa , McHale Cathy , Dookhy Joshi , Coughlan Tara , O'Neill Desmond , Collins Ronan , Ryan Dan , Kennelly Sean
Published: September 2019

Background

Speech and Language Therapy (SLT) is recognised as having a unique role in contributing to the overall neuropsychological assessment of people living with dementia and cognitive impairment. The role of the SLT within a memory clinic has become more widely understood. It is now recognised that speech and language characteristics are reported to be amongst the most reliable behavioural markers for distinguishing amongst different dementia subtypes, and specific analysis of a language production and delivery facilitates timely and more accurate diagnosis.

Methods

Patients with a language predominant presentation or those with subjective complaints of speech/language difficulties were referred for SLT assessment through the tertiary memory assessment and support service from January 2018 – March 2019. Assessment of speech and language skills, and overall cognitive communications skills were reviewed, and this information was used to aid with differential diagnosis and contribute to the person’s overall cognitive profile. The SLT attends weekly memory service interdisciplinary consensus diagnosis conference. Data was collected on these patients to observe the profiles of those patients referred to SLT.

Results

22 patients were seen for full SLT assessment during this period, 13 women, 9 men; mean age 69.5 (range 48- 80). Diagnoses include: AD (32%), FTD behavioural variant (14%), Primary Progressive Aphasia (14%), Non-amnestic MCI (18%), Amnestic MCI (14%), Other neurological disorder (8%). 68% of these patients required ongoing SLT intervention for their cognitive communication difficulties following diagnosis.

Conclusion

SLTs fulfil an integral role in supporting both the diagnostic and post-diagnostic care pathways of people living with dementia and cognitive impairment attending memory services. SLTs have a unique role and skillset in identifying the specific nature of language difficulties for a person with dementia or cognitive impairment and in reducing the impact of the communication difficulties for the person and for their family members.
272 Clinical Audit on Transient Ischaemic Attack Investigations in Acute Medical Unit
Authors: Karpinski Sylvia , Collins Orla , Kelly Emer , Therese Cooney Mary , McGrath Emett
Published: September 2019

Background

TIA (Transient Ischaemic Attack) is a transient episode of neurologic dysfunction.

Patients with a TIA have a high early risk of recurrent stroke. These patients need urgent initial evaluation with brain imaging, neurovascular imaging and cardiac evaluation. We conducted retrospective audit in our Acute Medical Unit (AMU) to assess waiting time and type of investigations completed as per TIA guidelines

Methods

All consecutive admissions with suspected TIAs were evaluated on length of stay, type of imaging tests obtained and how long they awaited for these tests. This was assessed by reviewing discharge summaries, and times and dates of scans on hospital imaging system.

Results

There was a total of 28 patients admitted to AMU with suspected TIA’s. Of these, 16 were female and 12 were male. Mean age was 70. All patients had CT brain done on admission, two out of 28 had to wait more than 12 hours. 25 out of 28 (89%) patients got US Carotid Dopplers, and two had CT intracranial angiograms. Average waiting time for US Carotid Dopplers was 33 hours, shortest wait was 6 hours and longest was 72 hours. 14 out of 24 (58%) had inpatient heart monitoring (24h telemetry or 24h Holter) two were excluded with known atrial fibrillation, one had PPM in situ and one refused monitoring. Average length of stay in AMU was 3 days.

Conclusion

Patients admitted to AMU with suspected TIAs had relevant imaging and tests completed as per guidelines. 89 % had US Carotid Dopplers which were on average done 33h from admission. 58% of patients had inpatient heart monitoring. The average length of stay was 3 days but three patients stayed in AMU for up to 5 days. Protected imaging slots for AMU would expedite investigations and reduce inpatient stay.
281 Collateral Damage: The Cost of Failing to Take a Comprehensive Collateral History for Older Adults with Cognitive Impairment
Authors: Doyle Kate , Fitzpatrick Donal , Finn Gerard , Gallagher Paul
Published: September 2019

Background

Age-related syndromes of cognitive impairment, including delirium and dementia, are becoming more prevalent in our hospitals. Patients with cognitive impairment are often unable to provide information relating to their pre-morbid cognition and function as well as their admission diagnosis. Such information is essential to correctly identifying delirium and dementia, as well as making an accurate diagnosis and planning appropriate treatment. It is the standard of care recommended by both the Irish National Audit of Dementia 2014 and the UK National Audit of Dementia Care 2017 that a collateral history is obtained.

Methods

We reviewed the medical notes and conducted brief structured interviews with nursing staff for 100 medical inpatients aged ≥75.

Results

Only 44% of patients with cognitive impairment had a collateral history. Half of patients described as having dementia did not have any further detail on the severity of dementia documented. 80% of collateral histories were sourced by the admitting NCHD; if the collateral history was not obtained on admission, it was unlikely to be obtained at all. Among those for whom a collateral history was obtained, the level of detail regarding pre-morbid cognition, function, mobility and continence was sparse. The most common informant was the patient’s son or daughter (66%), followed by spouse (16%). Only 13% of patients had formal cognitive testing.

Conclusion

Acute illness characteristically causes significant impairments in cognition and function in frail older patients. Identifying and reversing these impairments is impossible without a comprehensive collateral history. It is alarming that such an essential component of clinical assessment is so often disregarded and highlights the lack of awareness from clinicians of the importance of collateral history in the management of patients with dementia and delirium. This must be emphasised in both undergraduate and postgraduate teaching. An appropriate admission proforma would also promote competent collateral history taking.
291 The Impact of a Frailty Team Liaison Service on Nursing Home Attendances in an Emergency Department
Authors: Cooney Eamonn , Donnellan Christina , Baburaj Binish
Published: September 2019

Background

Up to 50% of referrals from nursing homes to emergency departments (ED) are considered inappropriate. Interventions such as the introduction of advanced practice registered nurses to nursing homes, and community matrons in other jurisdictions have reduced inappropriate referrals.

Methods

A liaison service with nursing homes was initiated by a candidate Advanced Nurse Practitioner (cANP) supported by the frailty multidisciplinary team in January 2019. It focused on nursing home residents aged 70 years and older. A single point of contact was provided. ED presentations were assessed if possible, and telephone consultations were also available. A database was maintained and the data from the first 3 months of this service was analysed.

Results

The service provided from 7th January and 31st March 2019 was studied. Referrals of patients aged 70 years and over from nursing homes to ED for this period in 2018 were 100. In 2019 it was 73, representing a 27% decrease in referrals. The total number of patients referred in 2019 was 51. Twenty one (41%) patients had an assessment by the cANP. Interventions by the cANP and team included rapid access to other specialties, medication reconciliation, and prescription of antibiotics, diagnostics and referral to the Community Intervention Team (CIT). Telephone liaison from nursing homes resulted in referrals to the palliative care service in 2 cases, prescription of antibiotic in another, rapid access comprehensive geriatric assessment in another case and rapid access to ED for catheter change in another, hence admission avoidance's in all of these cases.

Conclusion

The early experience of this service is that it facilitated more nursing home residents to receive care and support within their care setting. It contributed to reduced referrals of this vulnerable cohort of the population to ED, and also resulted in admission avoidance in some cases.
309 The Growing Need for Advance Care Planning Discussion: An Admission to Die for?
Authors: McFeely Aoife , Small Cliona , Hyland Susan , O'Keeffe Jonathan , Hughes Graham , O'Shea Diarmuid
Published: September 2019

Background

Older people living in nursing homes (NHs) are among the most frail and vulnerable in our community. Over the last 5 years, a review of our local NH admission database revealed a 7% increase in the number of unscheduled hospital attendances from NHs (1015 in 2012/13 vs 1435 in 2016/17). Additionally we have seen an increase in the number of NH residents experiencing ≥2 unscheduled re-admissions within one year (21.1% in 2012/13 vs 30.45% in 2016/17). Our aim was to examine the proportion of patients from NHs who died within 24 hours of presentation, prompting a review of methods that could prevent inappropriate hospital transfers and promoting dignified and comfortable end of life care.

Methods

A prospective database was collected between 01/01/2016 - 31/12/2017. This recorded all emergency admissions of older people from NHs recording length of stay, readmission rates and mortality. The data was retrospectively analysed, looking specifically at patients who died in hospital ≤ 24 hours

Results

Of 1435 ED admissions, 49 patients (3.4%) died in hospital ≤ 24 hours after presentation.

Of these, 31 patients (61%) died in palliative care suites. 8 patients (16.3%) died in the ED.

Conclusion

A small number of NH residents presenting to our hospital died within 24 hours. A large proportion of these patients died in a palliative care suite, suggesting poor prognosis was identified rapidly after presentation. We wonder if some of these hospital transfers were avoidable and could certain patients have experienced less disruptive deaths in their NHs?

Advanced Care Planning can be difficult for all involved. However, it plays an essential role in ensuring people receive the right care, at the right time, in the right place, from the right team.

We support the collaborative roles of a palliative care CNS or Geriatric ANP, and integration with NH Outreach services, to facilitate early decision-making and promote better end of life care.
314 Audit on Prescription Legibility in an Irish University Teaching Hospital
Authors: McCarthy Christine E , Sebaoui Salim , Saif Kiran , Murphy Elizabeth , Roy Amrita , Hynes Jason , Leahy Aoife , Mohd Asri Nur Atikah , Quinn Colin , Peters Catherine , Lyons Declan , O'Connor Margaret
Published: September 2019

Background

Illegible prescribing can lead to medication error and adverse drug reactions. The HSE Standards and Recommended Practices for Healthcare Records Management and the Practice Standards and Guidelines for Nurses for Prescriptive Authority have highlighted criteria which should be adhered to in relation to prescribing. We set out to audit compliance with these standards in relation to legibility of prescriptions in an Irish University Teaching Hospital.

Methods

Over a 48 hour period, drug kardexes were reviewed on 14 separate in-patient wards. Legibility was judged by a single assessor on each ward. A drug kardex was deemed legible if all of the following criteria were met:

The chi squared test was used to determine the significance of the difference in proportions for categorical variables.

Results

285 drug kardexes were reviewed over the 48 hour period. 41% were on surgical wards, 59% were on medical wards. The median patient age was 70 (IQR:55-78), and 56% were male. 48% of drug kardexes were deemed legible. A higher proportion were deemed legible on medical wards compared to surgical wards (68% vs 19% p<0.05). Upper case was used in 13% of kardexes, with similar proportions on medical and surgical wards.

Conclusion

Poor legibility of drug kardexes may increase risk of medication errors and adverse drug reactions. We plan to commence targeted prescribing education sessions to highlight the current deficiencies and improve current practice. Changes to kardex layout may also aid legibility. Long term planning for electronic prescribing would also help resolve issues in this area.
321 Review of Statin Therapy in Frail Older Patients over 75 Years Old Residing in Long Term Care
Authors: Reilly Eimear O , Everard Cormac , Cogan Lisa
Published: September 2019

Background

Statins are frequently prescribed in older patients for prevention of cardiovascular disease and treatment of hypercholesterolemia. However, there is little evidence to indicate that statins have any benefit in older patients with life expectancy less than 10 years and of those patients in long term care whose average life expectancy is approximately 3-5 years. In addition, statins are associated with significant adverse side effects and contribute to the burden of polypharmacy in older patients.

Methods

Patients residing in a long term care facility were reviewed and data was collected from their medical notes and medication records in order to; (1) Quantify the proportion of patients on statin therapy (2) Review the indication for statin therapy (3) Investigate the inappropriate prescribing of statins in nursing home patients.

Results

55 patients were included in the study. Of the 55 patients, 7 [12.7%] patients were on a statin. Average age of patients on a statin was 77.8 years[SD 9.4]. Of the 7 patients, 2 were on a statin for primary prevention and 5 patients were on for secondary prevention. Average cholesterol in primary prevention group was 3.3mmol/L, average LDL was 1.3 mmol/L. Of the 7 patients on statin for secondary prevention, indications included ischaemic stroke[n= 4] and ischaemic heart disease [n=3]. Average Total cholesterol in secondary prevention group was 3.8 mmol/L and average LDL was 1.91 mmol/L. The average Rockwood Clinical Frailty Scale Score of the patients on statin therapy was 7.

Conclusion

Firstly, this study highlights the incidence of inappropriate prescribing of statins for primary prevention in frail older patients in long term care. It also raises the question surrounding the indication of statin therapy in secondary prevention where cholesterol level are within target range highlighting the need for further studies examining the benefit of statins in frail older patients in LTC.
341 The Prevalence and Factors Associated with Anti-psychotic Prescribing on Admission to a Dementia Specific Nursing Home
Authors: Eustace Andrew , Murray Elaine , Daly Kelley
Published: September 2019

Background

The use of psychotropic medications and their adverse effects in frail adults has been debated extensively. However, it is unclear if antipsychotics are initiated in a nursing home or if the new resident arrives with the medication prescribed. The purpose of this study is to ascertain how many residents arrive already on antipsychotics and which factors, make them more likely to be on this medication.

Methods

All admission notes to the centre between 1st Jan 2018 and 31st Dec 2018 were reviewed. Inclusion criteria was any person admitted with a diagnosis of dementia. Exclusion criteria was anyone who had psychiatric diagnosis such as bipolar disorder or schizophrenia. We collected data on age, gender, referral pathway (hospital or community), MMSE, Barthel, Cohen Mansfield Agitation Inventory (CMAI) For comparisons of characteristics between the two groups (psychotropic drugs at admission: yes/no), the independent samples t-test (normally distributed data) or the Mann-Whitney U test (non-normally distributed data) was used for continuous variables and Fisher’s exact test was used for categorical variables.

Results

There was a statistically significant relationship between source of admission and whether or not the patient was receiving psychotropic drugs on admission (p=0.017). 88.0% of patients on psychotropic drugs on admission came from an acute hospital setting. In contrast, only 4.0% of patients receiving psychotropic drugs on admission came from home Patients on psychotropic drugs at admission had higher CMAI scores compared to patients not on psychotropic drugs. Patients on psychotropic drugs at admission were younger (mean(SD): 76.2(8.7) years) than patients not of psychotropic drugs (mean(SD): 82.9(8.3).

Conclusion

Prevalence of prescribing antipsychotics outside of nursing homes is high with many residents being admitted already on these medications. Efforts should be put in place on admission to nursing homes to reduce and stop antipsychotics which have been initiated in the community and hospital setting.
347 Numeracy Performance and the Relationship to Age and Retirement among Community-Dwelling Adults
Authors: Mickus Maureen , Carpenter Craig , Loveridge Scott
Published: September 2019

Background

Remaining in the workforce in later life may be based on financial need, role fulfillment or opportunities for social participation. Employment can also provide intellectual stimulation, including the use of everyday math skills. Normal age-related decline in numeracy performance has been documented, but the role of retirement in the capacity to perform these functions is less understood. This research uses population-based telephone surveys to analyze whether the interaction of age and retirement influences the ability of community-dwelling adults to calculate simple math problems.

Methods

Data was drawn from three independently sampled surveys in 2006 (n=991), 2010 (n=1,023) and 2014 (n=997). In addition to standard demographic questions, the survey measured individuals’ ability to perform basic computations. Three questions were asked regarding temporal (now or 5 years later) preferences about jobs, a community bond, and an inheritance payout. Respondents were then asked to calculate the amount needed to select the other option instead. Deficient numeracy performance was defined as either no response or an irrational choice (e.g. a lesser amount of inheritance with the alternative choice.)

Results

Approximately 30% of persons age 65+ chose not to perform the follow-up calculations for these questions. Moreover, a 1% increase in age decreased the likelihood of rationally calculating the discount rate by between 0.15 and 0.25 percentage points, depending on the scenario. A sharp decline in numeracy was observed starting at age 66 with the addition of an age x retirement interaction, even when controlling for key variables such as education and income.

Conclusion

Retirement may reduce the opportunity for intellectual challenges afforded in the workplace and consequently, the ability to perform math calculations may decline. Alternatively, decisions to retire may be due to declining health, including cognitive impairments. The timing of retirement has major implications for public policy. Future research more deeply exploring the causal influence of retirement on health and well-being is warranted.
352 Grey and White Matters – Designing and Implementing an Acute Stroke Program in a level 3 Hospital
Authors: Daly Bart , Liston Richard , Griffin Susan
Published: September 2019

Background

Following the publication of the National Stroke Audit in 2015 with below the national average rates of thrombolysis – 3.3% versus 11% - there has been a number of initiatives launched to improve stroke care in this hospital.

In 2018 we enrolled in the National Quality Improvement Project for the care of Patients with Acute Ischaemic Stroke run by the RCSI. A stroke steering committee was established consisting of a multi-disciplinary group encompassing all areas of acute stroke care.

Methods

Acute stroke care practice and factors causing sub-optimal management were examined by the committee and compared with national standards.

A ‘3 jobs’ proforma for management and communication of Fast positive cases was designed to address the difficulties identified in stroke care and tailored to the resources available in this hospital. These simplified and standardised roles for all staff members involved, many of whom were unfamiliar with the practical delivery of thrombolysis and thrombectomy. Educational sessions were initiated for all those involved in acute stroke management.

The acute stroke program was implemented as a 6 month pilot before official launch in April 2019 with necessary changes assessed weekly by the stroke committee. Stroke data is continually audited with the National Stroke Register. Key Performance Indicators (KPI’s) in the pilot were thrombolysis/thrombectomy rates and door to needle time.

Results

There were 164 patients admitted to the stroke unit in 2018. In 2018 prior to this initiative, the hospital had a 3% thrombolysis rate in 2018 and a 1% thrombectomy rate.

Amongst FAST positive patients during the pilot period, 10/68 patients were thombolysed (15%) and 6/68 thrombectomies (9%). Average door to needle time for patients was 96 minutes.

Conclusion

The redesigning of the acute stroke care program has led to significant improvements in the identified KPI’s although door to needle times remain below the national target of 30 minutes.