bluuebunny/crossref_metadata_2025 huggingface dataset:
182 QUALITY IMPROVEMENT OF THE REFERRAL SYSTEM TO EDITH (EMERGENCY DEPARTMENT IN THE HOME) SERVICE
Authors: Prendergast C , McNamara R
Published: February 2023

Background

Our department has been providing an Emergency Department in the Home (EDITH) service since early 2020. The goal is to bring the emergency services to older people and prevent unnecessary attendances to the ED. With over 3,000 patients seen in its first 14 months, this heavily used service needs a proficient and safe referral system.

The previous referral system predominately involved handwritten referrals and phone calls. Our aim was to streamline this via the introduction of the Siilo Application as a solitary referral source. A referral proforma was also drawn up to ensure all relevant details were included.

Methods

A baseline survey was conducted to establish staff’s opinion on the initial referral system. The questions were.

1. Are you happy with the current system of referring patients to EDITH?

2. Do you think that some referrals are being missed or delayed secondary to the current system?

3. Rank your current satisfaction with the referral system out of ten?

There was also an area for feedback in the survey. The new system was then introduced using the Siilo Application. Staff were trained in its use and a referral proforma was put in place. After three months of use a second survey was conducted with the same questions.

Results

60% were happy with the new referral system, up from 11% on the first survey. Those who believed referrals were being missed had fallen from 88.9% to 70%. The average score out of ten for the current system was 6.9, improved from 5.7.

Conclusion

Having a safe, user friendly and efficient referral system for complex patients is a fundamental part on the service we provide. Staff satisfaction with the referral system, especially in an emergency setting, is paramount to ensure adequate and safe referrals. Satisfaction rates did improve with the introduction of the Siilo Application, but there is room for further improvement.
193 ARE OLDER PATIENTS IN IRELAND BEING ADEQUATELY SCREENED FOR DELIRIUM? RESULTS FROM AN IRISH PERIPHERAL HOSPITAL
Authors: Tan B , Williams R , Cotter P
Published: February 2023

Background

Delirium is associated with increased morbidity and mortality in the older person and still remains poorly detected. The Health Service Executive (HSE) has clear algorithms and guidelines which suggest that any person over the age of 65, especially so for patients with pre-existing dementia, presenting to the Emergency Department (ED) or Acute Medical Assessment Unit (AMAU) should be screened for delirium using the 4AT test. An earlier retrospective audit carried out by the authors in the same hospital showed that only 9% of patients with diagnosed delirium had a 4AT test at any point during inpatient stay and 0% had one on admission. We designed a prospective audit to assess what proportion of patients over 65 coming through the Acute Medical Assessment Unit (AMAU) had a delirium screening test performed on admission.

Methods

We reviewed the admission notes of all patients over 65 admitted through the AMAU over a continuous 14 day period from 10/11/20 to 24/11/2020. The admission notes were reviewed within 24 hours of admission. Exclusion criteria included patients presenting delirium tremens and patients presenting with a stroke.

Results

119 patients were identified. The mean age was 78.1 years. 20 (16.8%) had previously diagnosed dementia. 0 patients had a delirium screening test conducted by AMAU/ED staff on admission. 2 (1.7%) had 4AT tests done by members of the Geriatric Emergency Medical Services (GEMS) team within 24 hours. The GEMS team only sees patients who fulfill certain criteria on admission. 10 (8.4%) had ‘delirium’ listed on their differential diagnoses.

Conclusion

Our results show that the older patient being admitted through the AMAU in this hospital in Ireland is not being adequately screened for delirium. Additionally, even when delirium was suspected, delirium screening tools were not being implemented for further assessment. More needs to be done to ensure patients over 65 are assessed as per guidelines.
196 A QUALITY IMPROVEMENT INITIATIVE TO OPTIMISE PHYSIOTHERAPY FALLS ASSESSMENT AND INTERVENTION
Authors: Mealy B , Keohane N
Published: February 2023

Background

Falls are the most commonly reported incident in the Health Service Executive (HSE 2018). Our aim was to implement the standard: every patient referred to physiotherapy over 65 years or at risk of falls received a personalised falls assessment and intervention.

Methods

Falls assessment and intervention standards were captured through documentation audit in November 2020. Representatives from all physiotherapy specialties were invited to join the physiotherapy falls committee. The falls committee met monthly to review tests of change, discuss audit results and plan further initiatives. A ‘Falls Algorithm’ was developed outlining expectations regarding falls, with three components: ‘Ask, Assess, Intervene’. In-service training on falls was organised and added to induction for staff-grade rotations. Falls champions were identified in each area to promote best practice and induct new staff to expected standards. A falls newsletter was added to the department weekly bulletin to keep a focus on falls. Physiotherapy assessment forms on the electronic patient record were updated, embedding falls assessment and intervention into routine practice. A falls prevention and exercise booklet was developed and the falls education talk was transferred to an online format with Occupational Therapy colleagues.

Audits across all areas were completed weekly, then monthly to track results. The most recent audit was carried out in May 2021.

Results

Falls assessment improved from 57% to 99%.

Fear of falling assessment improved from 30% to 88%.

Completion of falls outcome measures improved from 26% to 74%.

Falls intervention increased from 49% to 100%.

Gait/balance deficits were assessed in 94% of cases in the final audit.

Conclusion

The aim that all patients referred to physiotherapy over 65 years or at risk of falls receive a personalised physiotherapy falls assessment and intervention was achieved.
20 FALLING THROUGH THE CRACKS: AN EXPLORATION OF SOCIAL WORKERS’ PERCEPTIONS OF THE NEED FOR ADULT SAFEGUARDING LEGISLATION
Authors: Donnelly S , O'Brien M
Published: February 2023

Background

The investigation of, and interventions on, the alleged abuse of vulnerable adults, including older people,has become an important feature of social work.Policy and practice in adult safeguarding is characterised by competing debates about how regulators define core concepts and reporting systems. It has been argued that the introduction of specialist legislation could enhance responses to adult safeguarding (Montgomery et al.2016). This study sets out to shed light on how social work practitioners are navigating cases in the absence of primary legislation and to explore what benefits or challenges there might be should adult safeguarding legislation be fully enacted in the Irish context.

Methods

Focus Groups (N = 2) and face to face interviews (N = 14) were held with social work practitioners using a critical incident technique.An online survey questionnaire was also administered with N = 116 responses.

Results

Social workers reported that adults at risk were ‘falling through the cracks’ due to the absence of adult safeguarding legislation. In relation to older people, the issue of coercive control by another family member was repeatedly highlighted as a significant issue for which there was no legislative intervention available. Legislative powers such as a duty to cooperate, duty to share information and a duty to involve the adult at risk in the safeguarding process were deemed critically important but absent. In addition, social workers reported that the lack of access to support services for the adult at risk was significantly impacting on their ability to safeguard.

Conclusion

Whilst the current policy measures in place offer some protection, it is evident that social work practitioners believe that safeguarding procedures should be placed on a statutory basis to ensure the safeguarding process is applied in a consistent and effective way.

Reference

Montgomery, L., Anand, J., McKay, K., Taylor, B., Pearson, K. C., & Harper, C. M. (2016). Implications of divergences in Adult Protection legislation. Journal of Adult Protection, 18(3).
200 AN EXAMINATION OF THE FACTORS ASSOCIATED WITH PNEUMOCOCCAL VACCINATION UPTAKE IN THE OVER 50’S IN IRELAND
Authors: Organ K , Kenny R A
Published: February 2023

Background

Community acquired pneumonia presents a significant risk for morbidity and mortality in older adults. We aimed to look at the prevalence of pneumococcal vaccination in the over 50’s as well as which factors may influence it’s uptake by this group by using a nationally representative sample of adults from The Irish Longitudinal Study on Ageing (TILDA), a population-based study of community dwelling adults aged ≥50 years.

Methods

Cross-sectional data from the fifth wave of TILDA data collection (n = 5,020) was analysed. Several self-reported measures of pneumococcal vaccination uptake were examined that covered questions such as whether they had received a pneumococcal vaccination and whether any healthcare professionals had discussed vaccination with them. Logistic regression was performed to examine whether differing levels of healthcare entitlement was associated with higher pneumococcal vaccination uptake when adjusting for factors such as age, sex, education and self-reported health.

Results

Of the 5,206 participants over 50 who took part in Wave 5 data collection, 22.97% had reported receiving a pneumococcal vaccination. Of the 4,020 individuals who have not received a pneumococcal vaccination, only 5.79% had their GP discuss pneumococcal vaccination with them, 6.18% had discussed it with other providers such as nurses & pharmacists and 88.03% reported that they had never been spoken to about pneumococcal vaccination by any of their healthcare providers. Medical card coverage, OR = 2.48 (CI = 1.64:3.74, p = <.000) and dual coverage, OR = 3.71 (CI = 2.45:5.61, p = <.000) were associated with higher rates of pneumococcal vaccination but this association was not present with insurance coverage only, OR = 1.18 (CI = 0.778:1.79, p = <.431).

Conclusion

These findings suggest that differences in levels of healthcare entitlement can affect access to preventative measures such as routine vaccinations, with those with both insurance coverage and a medical card being most likely to be vaccinated. It has also highlighted a need for more healthcare professionals to discuss routine pneumococcal vaccination with their patients.
206 EXPLORING THE RELATIONSHIP BETWEEN LONELINESS, FRAILTY, AND HEALTHCARE UTILISATION IN IRELAND’S OLDER ADULTS DURING THE COVID-19 PANDEMIC
Authors: Gyenes M , Jones C , Madigan R , Grunner M , Sheehan O C
Published: February 2023

Background

The COVID-19 pandemic has disproportionately affected older adults, both in morbidity and mortality1. The effects of the pandemic go beyond contracting the SARS-CoV-2 virus, leading to devastating consequences, particularly for individuals over the age of 60. In Ireland, isolation in older adults was exacerbated by cocooning measures and geographical limitations. The purpose of this study was to explore the relationship between loneliness, frailty, and the utilisation of health services in a sample of sexagenarians in Ireland.

Methods

Adults aged 60–70 attending COVID-19 vaccine appointments at a Level 3 Hospital in Ireland (n = 75) were invited to participate in a 36-item questionnaire. Participants reported demographic information and questions regarding physical well-being, healthcare utilisation, lifestyle and behaviours, and impact of vaccination. The survey also included three validated questionnaires: PRISMA-7 for frailty, SARC-F for sarcopenia, and the UCLA 3-Item Loneliness Scale (UCLA-3ILS).

Results

Of the 75 survey respondents, the mean age was 63.2. 72% (n = 54) identified as female. 28% (n = 21) reported that they had been cocooning during the past year. While 84% (n = 63) of respondents reported that they cancelled routine medical appointments during the pandemic, none reported avoiding attending hospital. Five respondents met the criteria for frailty and four were identified as probable sarcopenic. There was no significant difference (p = 0.64) in mean scores on the UCLA 3-ILS between frail and non-frail individuals. Persons identified as sarcopenic were more likely to have higher scores on the UCLA-3ILS (p = 0.0005).

Conclusion

This research highlights the multifaceted relationship between frailty, loneliness, and healthcare utilisation among Irish adults ages 60–70 during the COVID-19 pandemic. Future research in program, policy, and intervention development for at-risk older adults, particularly those who are frail, sarcopenic, and/or lonely, can work to reduce associated negative outcomes.

Reference

1. Kang S-J and Jung, SI. (2020). Age-Related Morbidity and Mortality among Patients with COVID-19. Infect Chemother., 52(2): 154–164.
216 IMPROVING INPATIENT INFLUENZA VACCINATION RATES—THE VALUE OF AN ELECTRONIC PATIENT RECORD REMINDER SYSTEM
Authors: Chapman L , Piggott R S , Kelly M , O'Connell B , Bannon C , Cunningham C , Briggs R
Published: February 2023

Background

Influenza vaccination, particularly for vulnerable, older adults, will have added importance this winter given the possibility of further waves of COVID-19 pandemic. Previous interventions at the study site noted poor awareness on the need for inpatient Influenza vaccination1. This study examines a vaccination reminder process using an electronic patient record (EPR) to identify high-priority eligible inpatients.

Methods

The study site is a 900-bed university teaching hospital with all clinical notes accessed via an EPR.

We included a convenience sample of 750 adults aged≥50 years (mean age 75.9 +/− 0.4 years, 48% female) and high-priority for influenza vaccination (Age > 65 years and/or length of stay (LOS) >30 days) from October 1st 2020 to January 12th 2021.

A live electronic dashboard identified eligible inpatients for vaccination, prompting vaccination reminders to the clinical teams via the antimicrobial pharmacist.

Data was collected retrospectively. Logistic regression models reporting odds ratios were used to assess the association of these reminders with vaccine uptake.

Results

Over one third (35%, 264/750) of high-priority patients received the Influenza vaccine while inpatients, including 40% aged ≥80 years.

The reminder was sent on 41% (305/750) of patients and was associated with an almost 50% higher likelihood of vaccination after adjusting for other covariates (Odds Ratio 1.48 (95% CI 1.00–2.20); p = 0.048).

Other factors independently associated with vaccination were advancing age (Odds Ratio 2.69 (95% CI 1.12–6.47) for age ≥ 80 years); LOS (4% higher likelihood of vaccination for every additional day in hospital) and admission under geriatric medicine (Odds Ratio 3.71 (95% CI 2.45–5.62) when compared to other specialities).

Conclusion

Our study shows relatively low uptake of inpatient Influenza vaccination and strategies to improve uptake are required. Reminders sent to clinical teams using the EPR appear to be an effective means of increasing Influenza vaccination and should be considered as part of this year’s inpatient vaccination drive.
220 WEEKEND WARRIORS—GETTING OLDER REHABILITATION PATIENTS MORE ACTIVE OVER THE WEEKEND
Authors: McDonnell I , McDaid E
Published: February 2023

Background

Reduced physical activity levels in hospital can increase an older person’s risk of deconditioning, frailty, sarcopenia (Guy et al., 2012). Older people can spend only 60 minutes upright per day in an in-patient rehabilitation setting (Smith et al., 2008). This can be further reduced at weekends when therapy services are often unavailable. The Weekend Warriors was introduced to older persons’ services in a post-acute rehabilitation hospital to combat this.

The aims were:

1. Examine patient perception of physical activity at weekends

2. Examine the feasibility of a weekend activity self-management programme

3. Evaluate patient satisfaction with a self-directed weekend activity programme

4. Evaluate whether a self-directed activity programme lead to increased patient-reported weekend activity levels

Methods

A pre-intervention anonymous survey was distributed to rehabilitation patients in the older persons’ services examining weekend activity levels and the patients’ perception of same. The Weekend Warriors packs consisted of 4 levels of difficulty and were distributed based on the patient’s ability. A post intervention anonymous survey was distributed. Data was analysed using Microsoft Excel.

Results

At completion, 19 patients participated in the pre-intervention survey. 10 patients participated in the post-intervention survey.

Pre-intervention survey findings show that 74% of patients carried out 30+ minutes of exercise on weekdays, compared to only 21% on weekend days. Post-intervention, this increased to 70% on weekend days.

Pre-intervention, 74% of patients felt good about their weekday exercise, while only 36% felt good about exercise on the weekend. Post- intervention, 90% of patients felt good about their weekend exercise.

Conclusion

Overall, the Weekend Warriors intervention improved time spent exercising at the weekend and patient satisfaction. Further studies could be carried out on the efficacy of creating exercise videos that could be shown to patients on the weekends, or the inclusion of an objective measure.
228 GENDER DISPARITIES IN DIAGNOSING OSTEOPOROSIS
Authors: Morrison L , Fernandes L , Lyons D
Published: February 2023

Background

It is estimated that up to 300,000 people in Ireland have osteoporosis, however it is a disease most commonly associated with women. Women aged over 50 years have a four times greater rate of osteoporosis and are twice as likely to have osteopenia as men.1 However the recognition and treatment of osteoporosis in men cannot be forgotten. The Irish Hip Fracture Database National Report 2019 showed that 31% of 3,701 hip fractures that year were in males. Hip fractures have been shown to result in higher overall mortality in men than in women.2

Methods

A retrospective observational study was carried out by analysing the reports of all dual-energy X-ray absorptiometry (DEXA) scans performed in a large university teaching hospital from January 1998 to August 2021, collecting data on gender, age, bone mineral density and osteoporosis risk factors.

Results

A total of 39,611 patients having their first DEXA scan in our hospital were included. 85.2% were female and 14.8% male. In all patients over 75 years, only 12.9% of all patients getting a first DEXA scan were male. Of all women who had DEXA scans, 29.1% were diagnosed with osteoporosis and 38.4% with osteopenia and in men 16.6% osteoporosis and 40.7% osteopenia.

Conclusion

Our results highlight that men have DEXA scans performed much less frequently than women. This is seen in all age groups, especially in patients over 75 years old. As in women, the prevalence of osteoporosis in men increases with age. This study demonstrates the importance of evaluating for and treating osteoporosis in men as well as women, as fragility fractures can cause significant mortality and morbidity in both genders.

References

1. Alswat KA. Gender Disparities in Osteoporosis. J Clin Med Res.2017;9(5):382–387. doi: 10.14740/jocmr2970w.

2. Kanis JA et al. The components of excess mortality after hip fracture. Bone.2003;32(5):468–473.
244 ORAL ANTICOAGULANT PRESCRIBING IN OLDER PERSONS: AN AUDIT OF A COMMUNITY HOSPITAL REHABILITATION UNIT
Authors: Ahern E , Condon J , Okpaje B , Mohamed A , Saleh A , Ali B , Mannion M , Walsh A , Gabr A , Shanahan E , Peters C , O'Connor M
Published: February 2023

Background

Prescribing in older persons is complex and involves greater risk of drug-related harm. Prescribing appropriate anticoagulation balancing thromboembolic versus bleeding risk is essential with consideration to multiple comorbidities and polypharmacy. 27% of adults were prescribed inappropriate anticoagulation dosing in the GARFIELD-AF study. The Health Service Executive provides guidelines under the medicines management programme on prescribing anticoagulation treatment. The European Heart Rhythm Association (EHRA) published an updated practical guide on the use of non-vitamin K antagonist oral anticoagulants in patients with atrial fibrillation in 2021.

Methods

A point prevalence audit was carried out in a community hospital rehabilitation unit, including all inpatients receiving oral anticoagulants (OAC). The data collected included: age, OAC prescribed, dose, documentation of indication, length of treatment, if a reduced dose was prescribed and reason why, creatinine clearance and reason for co-prescribing of an antiplatelet agent. Results were collected, analysed, and compared with the above guidelines.

Results

25 inpatients were included. 9 were on an OAC (36%). All patients were 70 years or over. DOACs were prescribed in 7 patients and warfarin in 2. All patients had a prescribing indication documented. All patients had an appropriate treatment duration documented. 3 OAC users were on a reduced dose, all of whom had an indication for a reduced dose documented. 1 patient was on medications with a documented drug–drug interaction. Only 3 patients had their creatinine clearance documented. No inpatients were co-prescribed an antiplatelet agent.

Conclusion

Creatinine clearance is an important factor in prescribing of OAC and must be documented. Interventions to improve documentation of creatinine clearance will be explored and implemented. Consideration to drug–drug interactions in older patients with polypharmacy requires a multidisciplinary approach including pharmacy input.
247 BENCHMARKING STROKE SERVICES TO INFORM A QUALITY IMPROVEMENT INIAITIVE
Authors: Loughlin E , Gannon E , Coughlan A , Cunningham N , Paulose S , O'Brien I , Ryan R , Leahy A , Lyons D , Peters C , McManus J , O'Connor M
Published: February 2023

Background

Stroke is a leading cause of death and disability in Ireland. Continuous audit and quality improvement is essential in the delivery of stroke care where the evidence basis is constantly changing. This helps to ensure the delivery of high quality stroke care and compliance with evidenced based guidelines. We aimed to assess stroke care at an Irish university teaching hospital.

Methods

Patients with a HIPE discharge diagnosis of Cerebral Infarction or Cerebral Haemorrhage (1st January-31st December 2019) were identified through both the HIPE database and the institutional Stroke Portal. Data was benchmarked against national (Irish National Audit of Stroke 2019) and international (6th SSNAP Annual Report; American Heart Association, 2013) practice and used to inform a quality improvement strategy.

Results

419 patients were included (56.6% male, median 57 years). 75.9% were aged 65 years or older. We compared favourably with Irish National Audit of Stoke national indicators on the following: thrombolysis rates-10%; median door to needle time-60 mins; stroke unit admissions- 78.5%; median duration of symptoms- 3 hours 6 minutes; swallow assessment- 81.1%; in-patient mortality- 10.5%; rates of institutionalisation- 3.8%. Areas identified for improvement were: thrombectomy rates- 1.9%; median length of stay- 12 days; door to imaging time- median 104 minutes; mood screening- 11.5%.

Conclusion

International and national data is a useful benchmark against which local hospitals can assess the quality of their service. By completing this quality improvement initiative we identified areas to target resources in our centre, including mood screening, swallow screening, thrombectomy rates, length of stay and time to neuroimaging. An ongoing quality improvement process using ‘PDSA’ methodology is being carried out with an annual audit to monitor progress.
250 EXPANSION OF THE ORTHOGERIATRIC SERVICE: EARLY EXPERIENCES
Authors: Stankard A , Conlon B , O'Brien H
Published: February 2023

Background

The introduction of hip fracture standards has led to improvement in outcomes for hip fracture patients. Other osteoporotic fragility fractures also lead to significant morbidity. They are associated with a high risk of future hip fracture. The Orthogeriatric Service at a model 3 hospital was expanded to proactively undertake comprehensive geriatric assessment(CGA) for patients over 65 with non-hip fragility fractures(NHFF) admitted to the Orthopaedic Ward. Electronic discharge summaries were created for all patients. This study aimed to characterise patients reviewed by Orthogeriatrics and review discharge summary documentation of CGA.

Methods

Patients reviewed by Orthogeriatrics during the period Jan-June 2021 were retrospectively analysed. Discharge summaries of these patients were retrospectively reviewed. The prevalence of documentation of frailty status, delirium screening and bone health plan was recorded.

Results

A total(n = 126) of 91 patients with hip fractures and 35 with NHFF were included. Other fracture types were excluded. The mean age of hip fracture patients was 82.43 compared to 78.2 in the NHFF group. 71%(n = 65) of hip fracture patients were female compared to 80% (n = 28) of NHFF. 80%(n = 73) of hip fracture patients were reviewed within 48 hours of admission, compared to 65%(n = 23) of NHFF. 52.7%(n = 48)of hip fracture patients had frailty status documented on their discharge summary, compared to 37.1%(n = 13) of NHFF. Delirium screening was documented for 58.2%(n = 53) of the hip fracture patients, compared to 40%(n = 14) of NHFF. Bone health plans were documented for 62.6%(n = 57) of hip fracture patients compared to 60%(n = 21) of NHFF.

Conclusion

Expansion of the Orthogeriatric Service to proactively review all NHFF patients will lead to reduced incidence of repeat fracture for this population. A lower percentage of NHFF patients had clear discharge documentation of CGA outcomes and a lower percentage were reviewed within 48 hours. Expansion of hip fracture standards to include all fragility fracture patients should be considered to incentivise improved care for all.
256 USE OF PROTON PUMP INHIBITORS ON SPECIALIST GERIATRICS UNITS
Authors: Mohamed B K , Swar M , Sheehan O
Published: February 2023

Background

Proton Pump Inhibitors (PPIs) prescriptions have increased more than 100% in the past decade. Prior research estimates that only a third of PPI prescriptions are appropriate in older adults. Geriatric patients have increased rates of polypharmacy and adverse drug events. PPIs are associated with significant harms including a higher fracture risk, increased risk of infection and vitamin and electrolyte abnormalities. We aimed to examine the PPI prescribing practice in a Specialist Geriatric Unit (SGU), identify patterns of inappropriate use and reduce inappropriate prescriptions.

Methods

Medical records, kardexes and prescriptions were reviewed for 66 patients admitted in the Special Geriatric Units between April and May 2021. Variables included gender, age, ordinary residence (nursing home or home) and diagnosis on admission. PPI indication was grouped according to symptoms, OGD in the last year, H. Pylori testing in last year and reason/diagnosis leading to PPI prescription. Name and dose of PPI, route of administration and duration of treatment were noted.

Results

38 patients (57.6%) were on a PPI. The mean age was 81.7 years. 79% of the patients were on the PPI at the time of hospital admission. Over 85% of the patients on PPI had no OGD or H. Pylori testing in the last year. Only 42% had a diagnosis justifying the use of PPI (only 25% of whom had their diagnosis confirmed by appropriate investigations). 90% of the patients were on PPI for more than a year.

Conclusion

Inappropriate use of PPIs remains common in the Specialist Geriatric Units. PPI prescriptions need to be optimized so as to reduce harmful effects on geriatric patients. Following a multifaceted PPI deprescribing intervention repeat audit is now planned.
37 ‘FRAIL’ BY DIFFERENT MEASURES: A COMPARISON OF 8-YEAR MORTALITY IN THE IRISH LONGITUDINAL STUDY ON AGEING (TILDA)
Authors: Romero-Ortuno R , Hartley P , Kenny R A , O'Halloran A
Published: February 2023

Background

Frailty is a state of dysregulation in multiple physiological systems and vulnerability to stressors. Many frailty identification tools exist that differ in their conceptualisation vis-à-vis morbidity, disability, cognition, and other geriatric assessment dimensions. We compared the ability of four different frailty identification tools to predict 8-year mortality in TILDA.

Methods

We included TILDA Wave 1 (2010) participants who had data for frail state classification according to four tools: the Fried’s physical Frailty Phenotype (FP: frail if ≥3 features present), Morley’s FRAIL scale (frail if ≥3), a 32-item Frailty Index (FI ≥ 0.25), and the Clinical Frailty Scale classification tree (CFS ≥ 5). Mortality was ascertained at Wave 5 (2018). Binary logistic regression models controlling for age and sex were computed for the extraction of Odds Ratios (OR) and 95% Confidence Intervals (CI).

Results

At Wave 1, there were 5,700 participants (mean age 63, range 50–98 years, 54% women) with data for frailty classification according to all four tools. The prevalences of frailty were 2.3% by FRAIL, 3.8% by FP, 10.9% by CFS, and 12.8% by FI. 8-year mortality proportions were 41.2%, 44.9%, 25.3% and 27.0%, respectively. The highest age and sex-adjusted OR for 8-year mortality was for FRAIL (OR 4.86, 95% CI 3.18–7.41, P < 0.001), followed by FP (OR 3.72, 95% CI 2.64–5.23, P < 0.001), FI (OR 2.20, 95% CI 1.76–2.74, P < 0.001), and CFS (OR 1.95, 95% CI 1.53–2.47, P < 0.001).

Conclusion

All four frailty tools significantly predicted 8-year mortality in TILDA, but FRAIL and FP seemed more specific. Different frailty identification tools may suit different population screening purposes.
44 BONE HEALTH AND FRACTURE RISK: KNOWLEDGE, OPINION AND PRACTICE OF PHYSIOTHERAPISTS
Authors: Sayers K , Maher J , King L , Ryan S , Murphy R , Pillay I
Published: February 2023

Background

Osteoporotic-related fractures are responsible for excess mortality, morbidity, chronic pain, reduction in quality of life, admission to long-term care and health and social care costs (Papaioannou et al, 2010).

Evidence for using Fracture Risk Assessment Tool (FRAX®) based community-screening in older people is increasing (Kanis et al, 2020). There is no published evidence on the use of FRAX® by Physiotherapists.

Methods

A questionnaire was sent to South Eastern Branch members of the Irish Society of Chartered Physiotherapists (ISCP).

Survey themes were: participant characteristics, knowledge and opinion in the areas of Bone Health and Fracture Risk. Responses were downloaded from Survey Monkey and analysed using descriptive statistics.

Results

The response rate was 27% (n = 56). 72% (n = 40) of those surveyed had at least 10 years clinical experience. For 65% (n = 37) of participants, older people made up more than half of their clinical caseload. 96% (n = 54) of participants treated people with frailty and other bone health risk factors; falls (93%), osteoporosis (89%), fracture or reduced mobility (87%).

On a scale of 1–10 (1 = least confident, 10 = most confident) 49% of respondents rated confidence in prescribing Bone Health Physiotherapy interventions at ≤5.

When interpreting results of a DEXA scan; 80% reported confidence to be ≤5.

Half (49%) of participants had never heard of FRAX®.

95% of respondents felt fracture risk was under addressed in clinical practice. All felt it was within their professional responsibility to discuss fracture risk with patients.

Conclusion

This is the first evaluation of bone health and fracture risk knowledge, opinion and practice of physiotherapists. The need for more knowledge of DEXA, FRAX® and bone health was highlighted. The use of FRAX® may improve fracture risk assessment in patients attending Physiotherapy. Based on these results, FRAX® has been introduced into a Rehabilitation Unit by Physiotherapists as part of Quality Improvement Project.
53 HEALTHCARE PROVISION FOR OLDER PEOPLE IN KILKENNY THROUGH THE IMPLEMENTATION OF THE INTEGRATED CARE PROGRAMME FOR OLDER PEOPLE
Authors: Finegan T , White P J , Casey B
Published: February 2023

Background

An increase in the cost of healthcare provision is directly related to an ageing demographic nationally and internationally. It is, therefore, imperative that the system of health and social care provision for the older person is reformed. The Integrated Care Programme for Older People (ICPOP) envisages moving the locus of care from the acute system to primary and community health and social care. This research looks at the implementation and benefits of ICPOP from a clinicians and third sector organisations perspective.

Methods

Semi-structured interviews were conducted with six clinicians within the acute and community healthcare systems and, with two representatives from older persons third sector organisations. The interviews were held online through conferencing software and recorded. They were transcribed manually to gain a greater understanding of what was said and the context. Using a grounded theory approach, quotes were extracted, clustered together into categories or themes and, through theoretical sampling and comparison an in-depth understanding was gained, and theory developed.

Results

An organisational culture of innovative and collaborative practice is essential to the delivery of ICPOP as it leads to the empowerment of staff to develop integrated healthcare across disciplines and services. It is vital that funding for home support packages that provide both health and social care assistance with an adequate number of carers evenly distributed nationwide be provided. In addition, the ‘Living Well at Home’ piece of ICPOP with its important local community and social connectedness emphasis, needs to be sufficiently funded.

Conclusion

A culture of collaborative and innovated practice of healthcare provision exists in Kilkenny. Implementation of ICPOP is commiserate with appropriate funding for, and even distribution of, home care support packages and carers, as well as support for services that combat loneliness and social isolation enabling older people to age well at home.
55 APPLYING MACHINE LEARNING TO DIFFERENTIATE PREDICTORS OF SYNCOPE, SIMPLE AND COMPLEX FALLS IN THE IRISH LONGITUDINAL STUDY ON AGEING (TILDA)
Authors: Tang Y T , Romero-Ortuno R
Published: February 2023

Background

Falls in older adults are clinically heterogeneous and can be classified as simple (accidental), complex (recurrent, unexplained, injurious), and due to syncope. The aim of this study was to generate machine learning models for these fall types in TILDA using the Syncope-Falls Index (SYFI), a 40-deficit index covering a wide range of risk factors (Fitzpatrick & Romero-Ortuno, 2021).

Methods

New self-reported events of simple, complex falls, and syncope were recorded in participants two-yearly between Wave 1 (2010) and 4 (2016). The 40 SYFI features, age and sex, were entered into three separate random forest models. The dataset for each model was balanced by equalising the number of participants who did and did not have each event. Feature importances were derived and those with scores of ≥0.05 are reported below.

Results

For simple falls (217 events, balanced dataset N = 434), the most important predictors were age (0.13), pre-existing hypertension (0.07), presence of urine incontinence (0.07), polypharmacy (0.06) and MMSE<24 (0.05) (model accuracy: 0.53). For complex falls (1,077 events, balanced dataset N = 2,154), top predictors were age (0.14), gender (0.07), osteoporosis (0.07), osteoarthritis (0.06) and unsteadiness getting up from a chair (0.05) (accuracy: 0.58). For syncope (185 events, balanced dataset N = 370), top predictors were age (0.16), osteoporosis (0.07), unsteadiness getting up from a chair (0.06) and previous myocardial infarction (0.05) (accuracy: 0.50).

Conclusion

In keeping with the literature, advancing age was the most important feature in all models. Further, a more nuanced understanding emerged highlighting possible roles of reduced cognition in simple falls, musculoskeletal disease in complex falls, and orthostatic intolerance and heart disease in syncope. Many predictors identified as relevant are modifiable, and this ranked approach could help prioritise interventions for maximum population benefit. The accuracy of the models however was moderate, underscoring the known difficulty in predicting falls even when attempting to break their clinical heterogeneity.
59 IMPROVED OUTCOMES WITH DELAYED ADMISSION TO POST-ACUTE CARE: RESULTS OF A NATURAL EXPERIMENT
Authors: McGettigan S , Farrell A , Murphy R , MacGearailt C , O'Keeffe S , Mulkerrin E
Published: February 2023

Background

In Ireland, the national Health Service Executive developed a post-acute care (PAC) scheme in 2016 to provide funds to acute hospitals for beds in nursing homes to allow discharge of patients who would benefit from a period of recovery in a nursing home before returning home when medically fit for discharge with no need for rehabilitation or long-term care (LTC). However, budgetary restrictions introduced from June 2019 resulted in a delay in access to funding. This change in funding was used as a natural experiment of the effectiveness of this scheme in a single large general hospital before and after delays due to funding restrictions.

Methods

Data regarding PAC admissions for those aged 65 years or more from July to October 2017, when there were no budgetary restrictions, and from July to October 2019, when funding was delayed, were compared. Chi-square tests were used to compare proportions, and the nonparametric Mann–Whitney U test was used to compare continuous data.

Results

Compared with the 2017 cohort, those in 2019 spent 6 days longer in the acute hospital following a delay in 2019 between being approved clinically as needing PAC and subsequent admission to a facility. However, readmissions to hospital within 90 days of discharge and directly from PAC were significantly higher in 2017, as was discharge from PAC directly to LTC.

Conclusion

This retrospective study demonstrates restrictive practices regarding discharge to PAC introduced for budgetary reasons caused longer acute bed LOS with reduced LOS in PAC, reduced hospital RAR and reduced admissions to LTC suggesting that a pre-existing liberal selection process may result in poorer identification of appropriate patients for PAC.
60 EVALUATING THE TIME THAT PATIENT’S WITH DEMENTIA/DELIRIUM SPEND IN THE EMERGENCY DEPARTMENT PRIOR TO TRANSFER TO A WARD
Authors: Gibbons C , Diffley K , Riches R , Ramiah V , Byrne C , Kyne L , Gaynor E
Published: February 2023

Background

Patients with dementia and delirium are often waiting long times in the emergency department (ED) prior to being transferred to a ward bed during an acute hospital admission. This may be associated with increased morbidity and mortality. Best practice is for rapid triage to an appropriate bed via a delirium/dementia pathway.

Our aim was to document the patient experience time (PET) for older patients with a diagnosis of dementia or delirium in ED in an urban tertiary-referral hospital.

Methods

Over a two-week period 07/12/20–21/12/20, we identified all patients admitted under a general medical specialty through ED, aged ≥65 years, with a diagnosis of dementia or delirium on the admission sheet. Patients admitted with a stroke or hip fracture were excluded. ED PET was recorded, as well as final ward destination.

Results

We included 29 patients in the study—median age was 82 years (range 71–92); 19 (66%) were female. Delirium was the presenting complaint in 79.31% (n = 23) of cases.

Sixteen (55%) patients presented between 8 am-5 pm. The average time spent from triage to ED doctor review was 1 hour 48 minutes; from ED doctor review to medical referral −1 hour 27 minutes; from medical referral to decision for medical admission—2 hours 28 minutes; from decision for medical admission to ward admission- 5 hours. Overall, the average ED PET for these patients was 10 hours 42 minutes.

Five patients (17%) were admitted directly to a Specialist Geriatric Ward (SGW). Twenty patients (69%) did not reach a SGW during the study period.

Conclusion

Patients with dementia and delirium may spend prolonged periods of time in the ED putting them at risk for multiple complications. We hope that by introduction of a dementia/delirium combined pathway and care bundle that we can reduce PET for these vulnerable patients.
64 MANAGING FRAILTY IN AN IRISH PRIMARY CARE SETTING: A QUALITATIVE STUDY
Authors: Kennedy F , Horgan F , Galvin R
Published: February 2023

Background

Frailty is a complex, age-related condition which confers a risk of adverse outcomes. Evidence supports the effectiveness of screening and Comprehensive Geriatric Assessment (CGA) to meet the needs of frail older people. Little is known about the views of key stakeholders on frailty in a Primary Care context. This study explored the views of healthcare professionals and patients on frailty management in Primary Care in Ireland.

Methods

A qualitative descriptive study using semi-structured interviews was conducted. Healthcare professionals and patients were recruited using purposive sampling. Patients were recruited through the Frailty Intervention Team at the local acute hospital. Patients with cognitive impairment were excluded. Written informed consent was provided. Data were audio-recorded, transcribed and analysed using thematic analysis. The research was approved by the local Ethics Committee.

Results

Three patients and 17 healthcare professionals from general practice, public health nursing, physiotherapy, occupational therapy and social work participated. Three themes emerged. (i) Perceptions of Frailty (ii) Current Management of Frailty and (iii) CGA in Primary Care. Results demonstrated variability of perspectives on the concept of frailty, with limited knowledge of screening and CGA. Healthcare professionals described a fragmented service with sub-standard care for frail older patients. Critical weaknesses were: absence of essential services, uni-disciplinary working, inadequate IT systems and integration. Support for screening and CGA in Primary Care was evident. The general consensus was that frailty management required an adequately resourced Primary Care and the suitability of the current pathway for patients requiring CGA should be reviewed.

Conclusion

This study highlights an absence of a complete understanding of frailty among healthcare professionals. Inter-professional training and education is advocated. Further development of a frailty pathway and investment in Primary Care is required to improve care for frail older people. An intermediate interface service with a dedicated frailty management team is suggested.
66 BRAIN HEALTH CLINIC: DEVELOPING INNOVATIVE OPPORTUNITIES TO INTERVENE IN MODIFIABLE VASCULAR RISK FACTORS (VRF) TO IMPROVE COGNITIVE AGEING
Authors: Dookhy J , Hale C M C , Dolphin H , Dukelow T , Fallon A , Kennelly S P
Published: February 2023

Background

It is now well established that VRF place immense burden on cognition, including white matter changes, decreased cerebral perfusion and neuro-inflammation.

An innovative Brain Health Clinic (BHC) was developed aligned to a specialist memory service to educate people at risk of or living with mild cognitive symptoms, about positive brain health and subsequently design a ‘Personalised Prevention Plan’ to optimise cognitive ageing.

The aim of this study is to report the opportunities identified and addressed to mitigate vascular risk-related cognitive decline in people attending the Brain Health Clinic.

Methods

Modifiable VRF (including HbA1c, cholesterol, Body Mass Index (BMI), smoking, alcohol intake and hypertension) were examined in people who attended the BHC between October 2019 and July 2021. In addition to VRFs, sleep, physical activity, sensory, social, and psychological measures are measured and reported to individuals.

The VRF values were examined based on current guidelines from the European Society of Cardiology (2018).

Results

Forty-five people (mean age 72.6 years, 62.2% females) were included. The average number of modifiable VRF’s per person was 3, and a total of 119 VRF’s were identified overall. One patient had six modifiable VRF’s identified, and 2/45 had none.

The most common VRF was elevated BMI present in 33/45 (73.3%). 12/45 (27%) patients were ex-smokers, while 5/45 (11%) still smoked. 5/45 (11%) consumed excess alcohol. 15/45 (33.3%) had elevated cholesterol.

29/45 (64.4%) had elevated systolic blood pressure. Of these, 10/45 (22.2%) were known but poorly-controlled and 19/45 (42.2%) were identified de novo. Similarly, only 1/45 (2.2%) had known diabetes but poorly-controlled, while 9/45 (20.0%) had impaired glucose tolerance identified de novo.

Conclusion

The BHC aligned to a memory service provides an opportunity to identify modifiable VRF for declining cognition, and supports people in addressing these by sign-posting to relevant services.
70 NURSING HOME MODEL OF CARE POST COVID-19
Authors: Shanagher D
Published: February 2023

Background

The COVID-19 pandemic is recognised as having a significant impact on older people, particularly on those within nursing homes. Prior to the pandemic, a significant focus was placed on the application of a social model of care within nursing homes. We know that COVID-19 has required the stringent application of infection prevention and control measures as well as the provision of increased amounts of clinical care. This has resulted in the recent stronger application of a medical model of care within nursing homes.

Methods

A roundtable event attended by twenty-six people took place. Attendees represented clinical Gerontology, the Irish College of General Practitioner, Sage Family Forum, The Health Information and Quality Authority, Nursing Homes Ireland and nursing home providers. A number of presentations were made, and a roundtable discussion took place about the model of nursing home care post pandemic. Key messages from presentations and the discussion were captured. A report was compiled and shared with attendees to check for accuracy.

Results

The following key messages were identified:

1. Social care is a cornerstone of nursing home care

2. Increased integration of nursing homes within the wider health and social care system is required

3. Increased access to services for nursing home residents is required

4. Regulatory reform is required

5. Resourcing of nursing home care needs to be appropriately addressed

6. The nursing home sector need to be included in conversations around policy and service development affecting nursing home care in Ireland.

Conclusion

Nursing homes are an essential part of the healthcare system in Ireland and have been shown to be adaptable throughout the course of the pandemic. A one size fits all approach is an unlikely fit for purpose approach as we look towards the future with COVID-19.