219 A SOLITARY AWARENESS - PROFILING TIME TO RECOGNITION OF MEMORY LOSS IN A TERTIARY MEMORY SERVICE

Background

Approximately 64,000 people live with dementia in Ireland with expected increases to 150,000 by 2045. Best practice recommends that patients benefit from timely diagnosis. Whilst the presence of cognitive impairment should prompt early referral for diagnostic clarity, patients frequently present with well-established symptoms. In order to understand this phenomenon it is important to understand the way in which symptoms are recognised by the person, companions and casual observers.

Methods

A chart review was carried out on a convenience sample of patients (n=61) diagnosed with dementia where scores were available from Clinical Dementia Rating Scale (CDR) and AD8. Data extracted included global scores and answers to direct questions regarding symptom recognition by patient and companion. Diagnosis was confirmed using the Electronic Patient Record.

Results

Mean age was 75 (range 57-87). Diagnostic breakdown comprised: Alzheimer Dementia (AD) in 67% (n=41), mixed AD/Vascular Dementia (VaD) in 19.6% (n=12); behavioural variant Fronterotemporal Dementia (bvFTD) in 1.6% (n=1), Dementia with Lewey Bodies (DLB) in 1.6% (n=1), Primary Progressive Aphasia (PPA) in 4.9% (n=3), Primary Parkinson’s Dementia (PPD) in 1.6% (n=1) and VaD in 1.6% (n=1). Average CDR Global Scale was 1.0 and average AD8 score 6/8. Family noticed symptoms of dementia an average of 12 months longer than the person themself. The incidence of anosognosia was 19% (n=12) and associated with a diagnosis of AD (91.6 %, n=11). Where anosognosia existed, symptoms of memory loss had been identified by family up to 60 months before diagnosis, with average time to recognition of 24 months. For 75% of this anosognosia group, family reported indiscernible symptoms on casual inspection (n=9).

Conclusion

Where symptoms of memory loss go unrecognised by patients and casual inspection, family may notice changes for up to five years. It is important to educate and empower the public regarding the benefit of a timely dementia diagnosis. Education should focus on supporting family to navigate sensitive conversations in the event of anosognosia and explore ways in which they might encourage timely review.

334 FASTTRAX - A FRACTURE RESPONSE SERVICE FOR NURSING HOME RESIDENTS

Background

Nursing Home Residents (NHR) are the frailest group of older people and require a gerontologically attuned approach to care. The new FastTrax fracture response service has been developed as a result of a Quality Improvement (QI) project to evaluate the need for this service. The data leading to the development of this pathway is presented here. FastTraX ensures NHR receive optimal orthopaedic and gerontological care without necessity for emergency department (ED) presentation.

Methods

A retrospective, medical chart review was completed on all NHRs who presented over12-months to a level-4 hospital ED following a fall/injury. Included patients were nursing home residents with suspected fracture discussed with the on-call orthopaedic service. Patients who required more complex imaging other than plain film or with known/suspected head trauma were excluded. Data collected included demographics, clinical and imaging details, and care outcomes.

Results

In 2021, there were sixty-nine (mean age 80.3, 82.6% female) NHR presentations to the ED with fracture/ injury where orthopaedic opinion was sought following x-ray. Just-under half, 49.2 % (34/69) of patients were admitted, all of whom had confirmed fractures. However, 32.3% (11/34) of admitted NHRs were conservatively treated with an average length-of-stay of 3.6 days before discharge to NH. 6/34 (17.6%) of admitted NHRs died, and 5 of those deaths occurred post-operatively. Of the 50.7% (35/69) discharged directly back to NH from ED, 45.7% (16/35) of those had no fracture, whereas 54.2% (19/35) were discharged for conservative management. Therefore, potentially only 29/69 (33%) ED presentations required definitive orthopaedic/gerontological intervention necessitating admission and two-thirds are potentially avoidable.

Conclusion

The new FastTraX fracture response service is an Advanced-Nurse Practitioner (rANP) co-ordinated integrated service combining use of on-site mobile radiological diagnostics in the NH, a fast-track ambulatory orthopaedic-consult clinic, and specialist gerontological care delivered in timely response to support NH staff in avoiding ED transfer where appropriate.

16 SARS-COV-2 INFECTION AND VACCINATION PATTERNS DETERMINE LONG-TERM ANTIBODY RESPONSES IN NURSING HOME RESIDENTS: DATA FROM NH-COVAIR

Background

Older Nursing Home Residents (NHRs) are at greatest risk of morbidity and mortality from SARS-CoV-2, particularly in the context of both waning vaccine efficacy and the emergence of Variants-of-Concern (VOCs). However, the determinants of long-term vaccine-induced protective antibody responses are yet to be determined in this group.

Methods

NH-COVAIR recruited older NHRs for comprehensive clinical and frailty (NH-FRAIL) assessment. Blood samples were obtained pre-vaccination, at 6-weeks and 6-months following primary vaccination and 6-months following booster vaccination. Antibody titres were measured using both an electrochemiluminescence assay and a custom bead-based array (Luminex™) to measure antibody titre and avidity for Wuhan strain/major VOC antigens. Stepwise adjusted linear regression (log-transformed) assessed longitudinal determinants of vaccine-induced antibody responses.

Results

Of 86 participants (81.1 ± 10.8 years; 65% female), just under half (45.4%) had evidence of previous SARS-CoV-2 infection. All NHRs mounted a significant antibody-response to vaccination at 5 weeks followed by a significant decrease in antibody titre by 6 months. Previous SARS-CoV-2 infection was the strongest predictor of antibody waning at all timepoints (β: 3.59; 2.89, 4.28; P < 0.001 for 6-months). Independent of infection history, both age (β: –0.05; –0.08, –0.02; p<0.001) and frailty (β: –0.22; –0.33, –0.11; p<0.001) were associated with faster antibody waning at 6-months. Cross-reactivity and avidity were significantly lower for Beta (B.1.351) and Gamma (P.1) VOC strains (all p<0.001). Additionally, there was faster antibody waning and significantly reduced antibody avidity to Beta and Gamma VOCs in SARS-CoV-2 naïve NHRs.

Conclusion

Older NHRs are capable of mounting protective antibody responses to SARS-CoV-2 vaccination. Responses were more durable, with a greater cross-reactivity to and avidity for VOCs in those with previous SARS-CoV-2 infection. Increasing age and greater frailty in NHRs was associated with faster antibody waning. Our findings support ongoing serological surveillance and use of additional vaccine doses in older NHRs, particularly in those without previous SARS-CoV-2 exposure.

317 PREVALENCE OF MOTORIC COGNITIVE RISK SYNDROME IN PATIENTS WITH MILD COGNITIVE IMPAIRMENT ATTENDING A MEMORY CLINIC

Background

Mild Cognitive Impairment (MCI) alone is not predictive of progression to dementia. However, previous research has found that the combination of MCI and slow gait speed, termed Motoric Cognitive Risk syndrome (MCR), is associated with a three-fold increased risk for the development of dementia. This study aimed to identify the prevalence of MCR among patients with MCI attending a memory clinic at a large teaching hospital.

Methods: Participants

Participants were recruited from the memory clinic at the study site. All participants matching the inclusion criteria were invited to participate in the study. Inclusion criteria: Age &gt; 55 years, independently mobile &gt; 50m unaided, diagnosis of MCI. All participants gave informed consent prior to testing.

Procedure

Gait speed (in cm/s) during normal pace walking was measured using a 5-metre computerised walkway with embedded sensors (GaitRite).

Data Analysis

Gait speed data was dichotomised into “normal” or “low” using previously defined gait speed cut-offs derived from age-based norms. Data was analysed using descriptive statistics on Microsoft Excel.

Results

31 participants completed testing (Males: 12; Females: 19). Mean age was 73.65 (range 63-84). Median score on the Montreal Cognitive Assessment (MoCA) was 20 (range 4-28). N = 2 (6.45%) reached criteria for MCR.

Conclusion

Although this study had small numbers, prevalence of MCR was similar to that previously reported among similar populations. This approach to identifying those at high risk for dementia may allow clinicians to target and prioritise further investigations and preventative interventions.

205 DESIGN OF AN AMBULATORY CARE HUB IN AN OLDER PERSONS SETTING

Background

The service was established to deliver rehabilitation based in a day care setting. The Multi-Disciplinary Team (MDT) allocated to cover the unit often had other clinical responsibilities. Therapy was delivered in silo with differing plans/goals for individual patients. There was often reduced with insufficient/no cover to the department. The department was closed during the pandemic. Upon reopening a decision was made to restructure service delivery. A pathway of change was decided on to move from a day care setting to an ambulatory hub model of care.

Methods

A Delphi method was undertaken and a review of processes conducted by the Clinical Nurse Manager 2 (CNM2). Consequently, all new referrals were screened and virtual telephone clinics held. Nursing Comprehensive Geriatric Assessments (CGA) were conducted on patients referred by their GP or who had not attended the Age-Related Healthcare Department within 6 months. This ensured clarity around patient needs. Individualised care plans were initiated before the patient’s medical appointment took place. Any urgent reviews were flagged to specific therapists by the CNM2.

Results

The service was restructured and is now interdisciplinary in approach. The Service moved from a day care setting reviewing approx. 60 patients weekly to an ambulatory care hub model with over 450 targeted interdisciplinary reviews weekly. A spreadsheet was developed and collated weekly by the CNM2 informing therapists of referrals received hence streamlining care- planning. This enabled MDT collaboration and merging of appointments to prevent multiple attendances. This development has been welcomed by patients and families.

Conclusion

The Ambulatory Care Hub operates at a maximum capacity with patient’s receiving targeted comprehensive interdisciplinary therapy input. There is a greater sense of teamwork within the department and patients benefit from this collaboration. This redesign has shown that a well-structured MDT provides essential support in many areas of disease management.

341 ROLE AND TOLERANCE OF LUMBAR PUNCTURE TESTS FOR CSF BIOMARKERS OF ALZHEIMER'S DEMENTIA IN A SPECIALIZED MEMORY CLINIC

Background

People living with mild cognitive symptoms often require clarity on the underlying aetiology of their symptoms, and with the advent of disease modifying therapies for Alzheimer’s Disease (AD), establishing diagnostic accuracy for amyloid and tau pathology in AD will become more clinically relevant. CSF biomarker analysis via Lumbar Puncture (LP) is the most accurate and cost-effective means of establishing AD pathology. This study aimed to assess memory clinic patients’ tolerance of LP as a diagnostic tool in the work-up of memory symptoms.

Methods

A consecutive sample of patients offered CSF analysis as part of their diagnostic plan in a tertiary memory service of a University Teaching Hospital were included. After clinician discussion, an LP for AD biomarker detection is offered to all patients with amnestic/non-amnestic mild cognitive impairment, or those with atypical motor-cognitive symptoms in this service.

Results

119 patients offered an LP from 2019-2020 were contacted, fifty-four (45%) of whom participated in this study. The average age was 70.1 (±7.5) years, 50% female. Forty-two (42/54, 78%) had an LP performed. More women declined an LP than men (8/12, 66%). Almost all of those who had an LP, (38/42, 90.4%) thought it yielded useful information and would recommend it for others. Side effects included mild back pain relieved with simple analgesia (11/42, 26%) and headache (3/42, 7%). There were no incidences of neurological sequelae or requirements for dural patch. Of the 12/54 (22%) who declined CSF analysis; reasons for same were pre-existing back pain (3/12, 25%), needle-phobia (3/12, 25%), and only 2/12, (16%) declined because they did not wish to know the results of the investigation.

Conclusion

This study highlights high levels of acceptance of CSF analysis when offered as part of routine care, with infrequent side effects. Most patients found the clinical information yielded was useful.

218 DEVELOPING CONSENSUS-BASED INTEGRATED NUTRITION CARE PATHWAYS TO PREVENT, IDENTIFY AND MANAGE MALNUTRITION IN IRELAND

Background

The expected policy and standards of nutritional care in acute settings in Ireland has recently been developed (Department of Health, 2020). Based on these and international guidelines, integrated care pathways have been proposed by a panel of experts for (i) the transition of nutrition care of adult patients (&gt;18 years) from hospital to community and, (ii) screening and identifying nutrition risk among community dwelling older adults (&gt;65 years). The purpose of this study was to develop a consensus amongst diverse stakeholders for the proposed integrated nutrition care pathways.

Methods

A cross-sectional online survey collected data to identify pathway practices for retention. The survey was adapted to the Irish context based on previous research. Relevant stakeholders including healthcare professionals working in hospital, community and primary care, general practitioners, nurses, registered dietitians, healthcare workers from voluntary community services, and patients/patient advocates were recruited. Participants responded on the relevance and importance of discreet care practices in the proposed Nutrition Care Pathway and a consensus was set at ≥ 80%.

Results

Ninety-seven healthcare professionals and eight patient/patient advocates completed the survey. There was no response from healthcare workers from voluntary community services. Most of the discreet care practices gained consensus ratings ≥80% from healthcare professionals. Among the patient/patient advocates, only 3 pathway elements gained consensus ≥80%.

Conclusion

Healthcare professionals’ agreement with the relevance and importance of the proposed integrated nutrition care pathways offer guidance to prevent, identify, and manage malnutrition among older adults transitioning between care settings or living at home. The opinion of patients/patient advocates and healthcare workers of voluntary community services providers requires further engagement using alternative methodologies.

130 CHARACTERISTICS AND OUTCOMES OF OLDER NURSING HOME RESIDENTS ATTENDING AN EMERGENCY DEPARTMENT

Background

Older nursing home (NH) residents are among the most vulnerable members of society, often with multiple comorbidities and complex care needs. The Emergency Department (ED) is a common point of access to the acute hospital for NH residents. This study aims to review characteristics and outcomes of older NH residents presenting to ED over one year.

Methods

A prospective cohort study was carried out. NH residents aged 50 years and older attending ED of a university teaching hospital over one year (01/10/2019-30/09/2020) were included. Data on demographics, comorbidities, functional status, frailty and details of ED attendance were collected.

Results

There were a total of 515 ED attendances by 341 NH residents over one year. Mean age was 76.3 years (50-103 years; SD ± 10.9). 50.9% (n=262) were female. Mean Charlson Comorbidity Index (CCI) was 5 (0-12; SD ± 2.1). 46.6% (n=240) had a dementia diagnosis. A mean of 12.6 medications (0-31; SD ± 5.3) were prescribed in the NH. Mean Clinical Frailty Score (CFS) was 6.5 (3-9; SD ± 0.9). Mean Barthel Index (BI) was 8.9 (0-20; SD ± 6.0). 38.3% (n=197) of presentations occurred “in-hours”. Mean Manchester Triage Score (MTS) was 2.54 (1-5; SD ± 0.7) with 92.0% (n=474) scoring 1-3. Delirium was documented in 31.8% (n=164). Mean ED Length of Stay (LOS) was 13.7hours (0-80hours; SD ± 11.0). 14.6% (n=75) were discharged without follow-up. 61.2% (n=315) were admitted to hospital. Mean hospital (LOS) was 9.7days (0-191 days) and 8.7% (n=47) of those admitted died in hospital. 12 months after ED presentation, 40.4% (n=138) of the cohort had died.

Conclusion

NH residents are a frail group, with high levels of multimorbidity, polypharmacy and significant care needs. This complexity is reflected in the numbers requiring urgent review on attendance, rates of delirium, ED LOS and hospital admission rates. Dedicated NH liaison teams may enhance care and improve outcomes for this cohort.

32 HOLISTIC PERSON-CENTRED CARE FOR PEOPLE LIVING WITH DEMENTIA AND CO EXISTING MENTAL HEALTH ILLNESSES: A CASE FOR INTEGRATION

Background

65,000 people live with dementia in Ireland, many have co-existing or emerging mental health illnesses and non-cognitive symptoms. During the COVID-19 pandemic there was a need to provide innovative solutions to service provision. As Medicine for the Elderly (MEDEL) and Psychiatry of Later Life (PLL) were established stand-alone services, there was no formalised working relationship, resulting in an overlap of cases and disparity in service provision.

Methods

A description of three cases to illustrate the joint working interface with MEDEL and PLL. These cases highlight their complex care needs and the speciality input required by both services within a shared catchment area. The age range was 78-88 years. All presented with at least two medical co-morbidities, including vascular risk factors and delirium. Each had at least one mental health illness including new onset psychotic and mood disorders. Sharing of resources including diagnostic services, nursing, medical, occupational therapy, physiotherapy and social work facilitated cost effective holistic care.

Results

Given the existing structures of MEDEL and PLL, it was possible to link with community partners attached to each service, allowing domiciliary visits for crisis intervention and best use of expertise from both disciplines. This resulted in the provision of timely patient centred care, reduced polypharmacy through a unified pharmacological approach, enhanced communication, shared learning and cost effectiveness. Care that is in the right place at the right time, in line with Sláinte Care, allowed timely access to diagnostics, improved care outcomes and a cohesive response.

Conclusion

This cohort present with complex care needs. An integrated approach enables patients to receive holistic care without duplication of resources or disparity of treatment and care options. Going forward this should involve a fully integrated memory service, with shared governance.

356 OLDER PERSONS LIVING ALONE IN INTEGRATED CARE: DEPRESSION, LOW EDUCATION AND FUEL POVERTY

Background

An important consequence of population ageing has been the increasing number of older adults who live alone. According to TILDA data, older adults with the lowest levels of education tend to experience most social isolation and there is a strong association between living alone and loneliness. We sought to compare the cohort of patients open to the Integrated Care for Older Persons (ICPOP) team in a University Teaching Hospital serving a community area of approx. 300,000 population, to this national dataset.

Methods

A convenience sample of 174 patients who underwent comprehensive geriatric assessment via domiciliary visit between July 2021-May 2022 by was analysed. Data was anonymised and analysis was performed using SPSS v.27.

Results

The average age was 81.5 (±8.1) with 63% women in the sample. Eighty-five older adults i.e. 49% of the sample either lived alone or spent more than 21 hours alone per 24-hour period. Compared to those who live with someone, those who lived alone had higher rates of likely depression as determined by Geriatric Depression Score (6.6 vs 4.8 p=0.007). They were also likely to have less educational attainment, as determined by years spent in full time education (11.81 vs 10.42 42 p= 0.0016) and those living alone had overall less central heating in their homes than those not living alone (64/85 vs 81/89 p=0.0109). There were no significant differences in the rates of polypharmacy, falls, dementia and home ownership between groups. There were higher levels of frailty in the group living with someone than those living alone as determined by Clinical Frailty Scale (6.14 vs 5.23 p&lt;0.001).

Conclusion

A high proportion of patients seen by our ICPOP team live alone and have complex care needs that require an innovative, multidisciplinary approach. Financial vulnerability in this group is likely to compound isolation and loneliness.

136 DIABETES IS ASSOCIATED WITH IMPAIRED PERIPHERAL AND CEREBRAL HAEMODYNAMIC RESPONSES IN OLDER ADULTS

Background

Diabetes is associated with slower gait speed and adverse brain health outcomes in older adults. However, the putative mechanisms underlying these associations remain poorly explored. One such mechanism is via altered cerebral perfusion, which may represent an important intermediate phenotype in the association between diabetes and slower gait. We assessed the impact of diabetes on peripheral and cerebral haemodynamic responses during active stand as part of The Irish Longitudinal Study of Ageing (TILDA).

Methods

We assessed: (i) peripheral haemodynamic responses (heart rate, blood pressure, cardiac output) using finometry and (ii) Tissue Saturation Index (TSI) using Near-Infrared Spectroscopy (NIRS) during active stand in older adults.

Function-on-scalar regressions were used to model the impact of diabetes on the dynamic response to standing. Subsequently, multivariable linear models were used to model usual gait speed.

Results

Of 3,011 older adults (mean age: 64.2; 55.2% female) completing active stand, diabetes (n =193, 6.4%) was associated with significantly higher heart rate (mean 3.2, s.e. 0.02 bpm), higher cardiac output (mean 0.16, s.e. 0.04 L/min) and lower systolic blood pressure (mean –6.9, s.e. 1.8 mmHg) during standing. Additionally, diabetes was associated with significantly lower TSI from 10 seconds post-stand (mean –1.2%, s.e. 0.49%). Associations persisted following robust covariate adjustment. Diabetes was associated with significantly slower gait speed (-5.3 cm/s, CI (-8.4,-2.1)). In analysing the relationship between cerebral perfusion and gait speed, poorer recovery of TSI at 60-120 seconds post standing was associated with slower gait speed (0.53 cm/s slower gait speed per unit increase in TSI, p = 0.007).

Conclusion

Diabetes is associated with impaired peripheral and cerebral haemodynamic responses in addition to slower gait speed in community-dwelling older adults. Neuro-cardiovascular instability and altered cerebral perfusion may represent an important intermediate phenotype between diabetes and adverse health outcomes in older adults.

149 A PROFILE OF THE COMMUNICATION NEEDS OF NEW PATIENTS ATTENDING A MEMORY ASSESSMENT AND SUPPORT SERVICE

Background

Communication is a key factor in maintaining quality of life and well-being. This is of core importance for people with dementia who experience changes to their communication abilities. The role of the Speech and Language Therapist working with people with dementia is well documented. Speech and Language Therapists support people with communication and swallowing disorders however in practice the focus is often on swallowing disorders with less emphasis on communication. The recommended allocation of Speech and Language Therapy (SLT) for a Memory and Support Service (MASS) is 0.5 Senior Speech and Language Therapist. A pilot SLT service was trialled in a MASS to identify the SLT service needs and the benefit of introducing SLT earlier for people with Dementia.

Methods

A retrospective caseload review was completed of ten patients seen by SLT as part of the MASS assessment. Communication profiles and SLT interventions were analysed.

Results

The majority of the ten patients reviewed self-reported communication and speech and language changes, such as word finding difficulties and difficulties understanding conversations. Patient's self-report often corresponded with formal assessment results. On formal assessment 30% of patients presented with slight cognitive-communicative changes and 30% of patients presented with slight-mild cognitive-communicative changes. 10% of patients presented with mild cognitive-communicative changes and 30% of patients presented with mild-moderate cognitive-communicative changes. SLT interventions included conversational strategies, language strategies, language tasks and conversation partner training. 50% of patients were referred to Primary Care SLT.

Conclusion

SLT interventions support patients’ cognitive-communication abilities in dementia. SLT within a MASS adds clinical value by supporting assessment and diagnosis of dementia and developing patients’ communication profiles to highlight communicative abilities. Furthermore, SLT input supports developing communication strategies for the patient and communication partner training. In summary these interventions support improved quality of life and well-being for the person with dementia and their family.

36 WHAT DO OLDER ADULTS AND HEALTH CARE PROFESSIONALS LOOK FOR IN A FOOD PRODUCT?

Background

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

Methods

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

Results

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

Conclusion

A novel food product could supplement a balanced diet for older adults, providing high-protein content, and high-fibre for gut health, complimenting an overall lifestyle approach to health improvement and disease prevention.

231 NURSING HOME RESIDENTS PRESENTING TO THE EMERGENCY DEPARTMENT WITH FALLS

Background

Nursing Home Residents (NHR) are the most-frail group of older persons, with many comorbidities that increase their risk of falling. Falls are a frequent reason for ED attendance by NHR’s as it is for all older persons, but little is reported on their characteristics and outcomes specifically.

Methods

A prospective cohort study of all NH presentations with falls to the ED of a university teaching hospital over a one-year period. Detailed operational and clinical phenotype characteristics, and outcomes were recorded in all instances.

Results

There were 519 ED presentations by 344 NHR over one year. Almost half of all presentations (48.2%, 250/519), were as result of a fall, by 172 residents. The majority were female (137/250, 55%), with an average age of 77.8 years (±10.8). Many, 84.3% (145/172), had a prior fall in the past six-months. Almost half had a diagnosis of dementia (124/250, 49.6%). A third mobilised with a Zimmer-frame (83/250), and 10.8% (27/250) wheelchair. 33.2% (83/250) had visual impairment. The mean Barthel Index was 9.55 (±5.12) indicating high-dependency. NHRs fallers frequently attended ED outside routine working hours, with 36.8% (92/250) and 27.6% (69/250) presenting after 5pm (Monday to Friday), or at the weekend respectively. 54.8% of patients were admitted (137/250), and only 25.6% of patients had review by a GP prior to ED-referral (64/250). The average Length Of Stay (aLOS) for admitted NHR fallers was 10.4 (±9.1) days. Injurious falls were noted in only 10.4% (26/250) presentations. aLOS for those admitted with documented injuries (14/26, 54%) was 5.0 days (±7.0, n=14).

Conclusion

NH residents have complex clinical needs and falls is a frequent reason for attending ED. Better access to “out of hours” clinical support within the NH, and better integrated falls prevention programmes/ care pathways between NHs and primary/secondary services are necessary to enhance care and optimise falls prevention.

277 The ‘Bermuda Triangle’ of Orthostatic Hypotension, Cognitive Impairment and Reduced Mobility: Associations with Falls and Fractures in Community-dwelling Older People

Background

Orthostatic Hypotension (OH), cognitive impairment and mobility impairment frequently co-occur in older adults who fall. The aim of this study was to examine the clustering of these three geriatric syndromes and ascertain their longitudinal associations with falls and fractures in a large cohort of community-dwelling older people (≥65 years).

Methods

This study utilized data from Waves 1-5 of TILDA. OH was defined as a drop of ≥20 mmHg in systolic blood pressure when measured after standing from a seated position and/or reporting unsteadiness when getting up from a chair. Cognitive impairment was defined as MMSE ≤24 and/or self-reporting memory as fair or poor. Mobility impairment was defined as 'Timed Up and Go' ≥12 seconds. Logistic regression models, including 3-way interactions, were used to assess the longitudinal associations of the three geriatric syndromes with future falls (explained and unexplained) and fractures.

Results

Of those with at least one geriatric syndrome (993/2108, 47%), over two-thirds (644/993) had any one of the three, one-quarter had any two (261/993) and almost 10% (88/993) had all three syndromes. One-fifth of the study sample had an unexplained fall during follow-up (mean 6.6 years), while one-tenth had a fracture. In fully adjusted models, the cluster of OH, cognitive impairment and mobility impairment was associated with a greater than 4-fold likelihood of unexplained fall (Odds Ratio 4.36 (2.61–7.28); p&lt;0.001) and double the likelihood of incident fracture (Odds Ratio 2.51 (1.27–4.96); p=0.008) during follow-up, when compared to other clusters. There was no association with explained falls.

Conclusion

The ‘Bermuda Triangle’ of co-existing OH, cognitive impairment and mobility impairment, was independently associated with increased risk of future unexplained falls and fractures amongst community-dwelling older people. This simple risk identification scheme may represent an ideal target for multifaceted falls prevention strategies in community-dwelling older adults.

271 DEVELOPMENT OF AN INNOVATIVE INTER-DISCIPLINARY PARKINSON’S CLINIC IN AN AMBULATORY CARE SETTING

Background

Ambulatory services provide specialist outpatient care, reducing costs associated with inpatient admissions and enabling the person to remain at home for longer (Report of the National Acute Medicine Programme, 2010). An Older Person’s Ambulatory Care Hub was established in a large teaching hospital. Prior service evaluation demonstrated that approximately one third of patients attending had a diagnosis of Parkinson’s Disease (PD). People with PD should have a collaborative approach between patient, family and healthcare providers to optimally manage their condition (NICE, 2017), therefore, the need was identified to evolve the traditional medical model to an interdisciplinary approach. The aim of this project was to complete a service evaluation and breakdown of Interdisciplinary Team (IDT) referrals.

Methods

An IDT working group including Clinical Nutrition (CN), Medical, Nursing, Occupational Therapy (OT), Physiotherapy (PT), and Speech and Language Therapy (SLT) was established. A comprehensive assessment form was developed and outcome measures were chosen. A short pilot was conducted and necessary amendments were made. A weekly clinic was established which included an IDT assessment, followed by a huddle with the medical team where referrals were generated. Data pertaining to the number of attendees and referrals generated were collected over a 3-month period.

Results

Over the data collection period, 31 patients attended the clinic. Referrals were as follows; Medical: 19, PT: 13, SLT: 10, OT: 7, CN: 6, Medical Social Work: 2. Patients requiring urgent medical review were seen immediately after the IDT huddle.

Conclusion

This project demonstrates a service evaluation of a novel IDT PD Clinic. This clinic highlights the need for an IDT approach to management of people with PD. Future service developments include obtaining patient feedback, pre-clinic calls to patients by a Healthcare Assistant to explain the purpose of the clinic, and adapting the clinic as appropriate.

1003 UTILITY AND TOLERABILITY OF CSF AD BIOMARKERS IN A GERIATRICIAN-LED MEMORY SERVICE

Introduction

People with mild cognitive symptoms often require diagnostic clarity and with the advent of disease modifying therapies for Alzheimer’s disease (ad), establishing diagnostic accuracy for amyloid and tau pathology in ad will become more clinically relevant. CSF biomarker analysis via lumbar puncture (LP) is the most accurate and cost-effective means of establishing ad pathology. Despite their clinical validation, few centres offer LP biomarker analysis, frequently citing patient intolerance and reluctance as factors. This study aimed to assess memory clinic patients’ tolerance of LP as a diagnostic tool in the work-up of memory symptoms.

Method

A consecutive sample of patients offered CSF analysis as part of their diagnostic plan in a tertiary memory service of a University Teaching Hospital were included. After clinician discussion, an LP for ad biomarker detection is offered to all patients with amnestic/non-amnestic mild cognitive impairment, or those with atypical motor-cognitive symptoms in this service.

Results

119 patients offered an LP from 2019–2020 were contacted, fifty-four (45%) of whom participated in this study. The average age was 70.1 (±7.5) years, 50% female. Forty-two (42/54, 78%) had an LP performed. More women declined an LP than men (8/12, 66%). Almost all of those who had an LP, (38/42, 90.4%) thought it yielded useful information. Side effects included mild back pain relieved with simple analgesia (11/42, 26%) and headache (3/42, 7%). There were no incidences of neurological sequelae or requirements for dural patch. Of the 12/54 (22%) who declined CSF analysis; reasons included pre-existing back pain (3/12, 25%), needle phobia (3/12, 25%), and only 2/12, (16%) declined because they did not wish to know the results.

Conclusion

This study highlights high levels of acceptance of CSF analysis when offered as part of routine care, with infrequent side effects. Most patients found the clinical information yielded was useful.

1062 GAIT SPEED AND EXECUTIVE PERFORMANCE IN PEOPLE WITH MILD COGNITIVE IMPAIRMENT

Introduction

The Motoric Cognitive Risk Syndrome has highlighted the link between cognitive and motor performance, and the associated incremental higher risk of developing dementia. There is considerable debate regarding what aspects of cognition (working memory, executive function, attention) are most associated with gait changes. This study investigates the relationship between mobility scores and cognitive profiles in individuals with Mild Cognitive Impairment (MCI) specifically with regard to executive performance and amnestic/non-amnestic profiles.

Method

Participants diagnosed with MCI, (Clinical Dementia Rating scale global score of ≤0.5, sum of boxes score ≤ 4.0), attending a regional specialist memory service had a three-meter Timed Up and Go (TUG) gait assessment and multi-domain neuropsychiatric assessment undertaken. Amnestic neuropsychiatric profile was defined as Repeatable Battery for the Assessment of Neuropsychological Status (RBANS) delayed memory subset score &lt; 1SD i.e. ≤16th centile below norm for age/education. Executive function performance was assessed using the Executive Interview (EXIT-25) where higher scores reflect poorer executive performance.

Results

Data was reviewed for 161 patients with MCI; 53% (86/161) women. 80% (129/161) had an amnestic neuropsychiatric profile, mean age 73.8 ± 7.2 (51–94). 20% (32/161) had non-amnestic MCI, mean age 74 ± 7.07 (60–87). There was no significant difference in TUG results between amnestic and non-amnestic MCI patients (11.2 ± 3.3 vs 10.7 ± 3.1 p = NS). There was a significant increase in TUG values with worsening executive function performance [EXIT-25 score 0–9 (88/161) mean TUG = 10.5 ± 3.3 seconds vs EXIT-25 score 10–14 (43/161) mean TUG =11.9 ± 2.8 seconds vs EXIT-25 score 15–25 (30/161) mean TUG = 12.1 ± 3.9 seconds; p = 0.021] which persisted after controlling for age, gender and other relevant cofactors.

Discussion

Reflective of the importance of frontal lobe integration to the respective tasks, subtle differences in gait performance are associated with executive function performance regardless of predominant amnestic or non-amnestic MCI profile.

89 CSF BIOMARKER UTILITY IN SUPPORTING ALZHEIMER’S DISEASE DIAGNOSIS: CLINICAL PERSPECTIVES FROM AN IRISH REGIONAL SPECIALIST MEMORY SERVICE

Background

CSF (cerebrospinal fluid) biomarkers [amyloid- beta-42 (AB-42), phosphorylated tau (p-tau)] are increasingly used in supporting clinical diagnosis of Alzheimer’s Disease (AD). Both elevated CSF p-tau and reduced AB-42 are necessary for pathological diagnosis of AD. The aim of this study is to apply recent international recommendations to patients attending a regional specialist memory service, evaluating consistency with detailed clinical, neuroimaging, and neuropsychological ad-phenotype profiling.

Methods

All patients age &lt; 80, with mild/subjective cognitive and/or atypical neurobehavioral symptoms, non-significant vascular burden on neuroimaging, and without contraindication to lumbar puncture are offered CSF analysis. Clinical diagnosis was ascribed on the basis of specialist multi-disciplinary consensus review. We undertook a case-note and database retrospective review of those who had ad-biomarker CSF analysis, collecting demographic, clinical phenotype diagnosis, and neuropsychological performance. Data was extracted and analysed using SPSS v.25.

Results

One-hundred-sixteen patients underwent CSF biomarker testing. Forty-nine patients (42%) had positive AD-CSF biomarkers, 41/49 (84%) of whom presented with common ad phenotypes (Amnestic/Logopenic PPA/PCA). Twenty patients (17%) had negative ad-CSF (elevated AB-42, and low p-tau) studies, and half of those (10/20, 50%) had a consistent atypical non-AD clinical phenotype. Patients with negative ad-CSF were younger and tended to have non-amnestic neuropsychological profile. Therefore there was a mismatch in 18/69 (26%) people in these groups with definitive +/− ad biomarker results and ad/Non-ad clinical phenotype. A further forty seven (40%) patients had indeterminate CSF studies with one or other changes in AB-42 or p-tau, but not both as is necessary for definitive diagnosis.

Conclusion

Incorporation of CSF biomarker analysis is quickly being established as a key component of the neurocognitive/dementia diagnostic pathway. However, there are challenges and limitations arising as they are applied in clinical settings, and further research is warranted to explore variations between pathological results and clinical phenotype presentation.

129 MAKING THE CASE FOR ENHANCED INTEGRATION BETWEEN MEMORY ASSESSMENT AND SUPPORT AND COMMUNITY PALLIATIVE CARE SERVICES IN ADVANCED DEMENTIA

Background

In Ireland there are an estimated 64,000 people living with dementia. There is a growing body of evidence that a palliative approach, including access to specialist palliative care in the later stages of dementia is essential for wellbeing and the promotion of holistic, person-centred care. Yet many people living with advanced dementia have limited access to specialist palliative care services and such services often feel ill equipped to meet the unique, complex needs of this cohort.

Methods

This is a case study report of the joint working interface between Memory Assessment and Support (MASS) and Specialist Community Palliative Care (SPPCT). M was a 85 year old lady, with advanced dementia and history of lung cancer. CT Brain showed a large left parietal lobe tumour, probable metastatic lesion. Family agreed that further investigations were inappropriate and care objective was to manage her needs in her home in accordance with her previously known wishes.

Results

A joint initial visit with SCPCT and MASS was carried out which included medication review, symptom management and assessment of additional service need. Regular visits from SCPCT with support from primary care services and MASS ensured that appropriate services were in situ, symptoms were regularly assessed and treatment plan adjusted as needed. M was supported to die at home in the care of her family, as per her wishes.

Conclusion

This case illustrates the value of the partnership between MASS and SCPCT. Services that are responsive to client needs can ensure that appropriate care is given in the right place at the right time in accordance with their will and preference. This is in line with Slainte Care principles and provides an alternative pathway for end of live care for people with advanced dementia away from acute care settings.

209 NEURO-MEDICAL COMPLICATIONS OF STROKE—TRENDS OVER THE DECADES IN AN ACUTE STROKE UNIT

Background

Neuro-medical complications post-stroke are common and often serious [1]. We first described complications in our stroke cohort in 1998 and sought to assess whether the severity and the nature of neuro-medical complications may have changed over time due to changes in presentation and the processes of care [2].

Methods

Analysis of stroke service database, which captures all neuro-medical complications as part of its portal for the Irish National Audit of Stroke (INAS), was completed. The frequency of each of the 19 complications was expressed as the percentage of patients that developed each complication over a certain year and over 5 years. Historical comparison was made with dataset from 1998, which captured six complications.

Results

Data on 1,283 patients presenting over 5 years between 2015–2019 was collected. The median age of all patients was 71 years (Range 21–101). In all, 19 different post-stroke complications were recorded; 48% (n = 622) had post-stroke pain, while 23.85% (n = 306) had cognitive decline. Data on 100 patients from 1998 was compared for a number of common metrics including; 21.82% (n = 275) of patients developed an LRTI in the 2015–2019 cohort compared with 14%(n = 14) in the 1998 cohort (p = 0.09) while 16.29% (n = 209) of patients developed a swallow disorder compared to 21% (n = 21) in 1998 (p = 0.22).

Conclusion

There are high levels of neuro-medical complications in stroke patients. Twenty years has seen extensive investment in hyperacute stroke care yet post-acute care complications did not appear to reduce significantly between this time, albeit with low numbers. Direction of future funding may consider the full spectrum of stroke care.

144 DEVELOPING AN INTEGRATED POST DIAGNOSTIC PATHWAY FOR PERSONS LIVING WITH DEMENTIA—EXPERIENCES OF A REGIONAL SPECIALIST MEMORY SERVICE

Background

The frequently heterogeneous nature of a dementia presentation confers the need for a personalised approach to post-diagnostic supports. It’s an essential right for persons living with dementia (PlwD) and their families/supporters to have access to a comprehensive diagnosis and a responsive holistic pathway of care thereafter. We report our development of an integrated specialist-clinic/community post-diagnostic pathway responsive to the evolving personal needs of PlwD and their care-supporters.

Methods

This pathway was developed in an iterative inclusive-design methodology with input from hospital/community clinical specialists, health and social care professionals, senior nursing, PlwD and their care supporters. The post-diagnostic process starts at diagnosis disclosure, followed for all six-weeks later with a designated post diagnostic clinic, where a single point of contact to address any concerns in between visits is established.

Results

Iterative review cycles have identified integral components of an effective pathway: Guidance to live well with their personal manifestation of dementia; Acknowledgment of biopsychosocial elements of care; Timely access to comprehensive geriatric assessment via ambulatory hub MDT and/or and Integrated care team for older persons offering home assessment & intervention; Prevention of ‘harmful-events’ e.g. falls/delirium/hospitalisation; Timely access to therapies e.g. SLT/OT focussed on enhanced life at home/assistive technology; facilitation and planning of palliative care.

Other aspects include signposting to community resources and forward planning e.g. Citizen’s Information Centres; Peer support and education through designated training; Promotion of brain health- Exercise Programmes; social/cognitive stimulation e.g. Men’s sheds, Walking groups & Memory Resource Rooms; Opportunities for research involvement; Enhanced relationships with national organisations e.g. embedded ASI dementia advisor.

Conclusion

This approach has developed into a fully integrated holistic care-pathway where specialist-clinic, ambulatory-hospital, community older persons, and third sector services work together to provide the right care, at the right time, in the right place for PlwD and their families.

62 GAITKEEPER- A NOVEL ARTIFICIAL INTELLIGENCE BASED VIDEO GAIT ANALYSIS SYSTEM TO OBJECTIVELY MEASURE HEALTH STATUS

Background

Frailty is associated with increased risk of falls, dependency, disability and higher health and social care utilisation. While characterised by a slowly progressive functional deterioration, frailty can be delayed or reversed through timely intervention. Identification of those at risk of new or worsening frailty remains a challenge. How fast we walk (gait-speed) is a reliable correlate of one’s physical, psychological, and cognitive performance. Slow gait speed can discriminate those at high risk of adverse outcomes due to declining health, however current gait-speed assessment instruments are often not feasible in clinical or community settings due to cost, specialist training, and space requirements. Here we introduce GaitKeeper, a system that uses artificial intelligence (AI) to measure gait and step events from video recorded on a mobile phone, thus facilitating identification of those at risk of new or worsening frailty.

Methods

A technical evaluation, in a research setting (n = 30), compared GaitKeeper’s performance capturing accurate positional data in healthy young individuals, versus the Vicon camera motion-capture system as the verification standard.

A subsequent clinical evaluation in people with mild cognitive impairment (n = 30), within an acute hospital, compared GaitKeeper gait speed data with specialist-physiotherapist clinical observational studies, and GaitRite systems during five-meter walking under single and dual-task conditions. Comprehensive measures of frailty (SHARE-FI), cognition (RBANS, MoCA), and physical performance (MiniBEST) were recorded in this clinical evaluation.

Results

The technical evaluation provides evidence of the ability of GaitKeeper to capture accurate gait data from video (n = 30, p &lt; 0.001, error &lt; 3%) versus the Vicon system. The clinical evaluation provides evidence of the accuracy in comparison with the GaitRite gold standard (n = 30, P &lt; 0.001, error &lt; 6%) in clinical setting.

Conclusion

GaitKeeper performance was well validated in comparison to existing gait analysis practices. This innovative AI based solution provides an opportunity to longitudinally monitor and quantify ‘wellness’ in older persons with accessible, accurate gait performance measurements anytime, anywhere, by anyone.

156 POTENTIAL ELIGIBILITY FOR ADUCANUMAB THERAPY IN A REGIONAL SPECIALIST MEMORY SERVICE UTILISING AD PHENOTYPE, CSF BIOMARKERS AND APPROPRIATE USE CRITERIA

Background

Aducanumab, the first monoclonal antibody directed against amyloid beta peptide has recently been licensed for use by the FDA for treatment of patients with mild cognitive impairment (MCI) due to Alzheimer’s Disease (ad) or mild ad dementia. Appropriate use criteria (AUC) for Aducanumab have recently been released. In light of these AUC, the aim of this study was to review patients in our specialist memory service with positive CSF biomarkers for ad [low amyloid- beta-42 (AB-42), high phosphorylated tau (p-tau)] to assess their hypothetical eligibility for Aducanumab therapy.

Methods

Retrospective database analysis was undertaken of patients with positive (high p-tau, low AB-42) ad-biomarker CSF analysis. Demographic, neuropsychological performance, neuro-radiological, laboratory, and clinical phenotype diagnosis data were reviewed at time of CSF analysis to determine hypothetical eligibility for Aducanumab. Data was extracted and analysed using SPSS v.25.

Results

Forty-nine patients had positive ad-CSF biomarkers, 41/49 (84%) of whom presented with common ad phenotypes. 28/49 (57%) were male. Mean patient age was 71.2 (±5.9) RBANS delayed memory index score mean was 80.2 (±14.5) and mean EXIT-25 scores were 13.2 (±6.7). 63.2% (31/49) patients met eligibility criteria for Aducanumab therapy by AUC guidelines. 12.2% (6/49) wouldn’t have qualified due to abnormal laboratory findings and 14.2% (7/49) due to MMSE &lt;21 or MoCA &lt;17. Two patients would not have qualified due to underlying medical conditions and two were prescribed therapeutic anticoagulation. However by FDA guidelines, a further 30.6% (15/49) of patients may have been unsuitable due to global Clinical Dementia Rating Scale ≥0.5.

Conclusion

AUC for Aducanumab address some of the controversial aspects in its licencing. This report highlights the presence of patients eligible for Aducanumab therapy should a European licence be granted, and the need to develop a system readiness and capacity to deliver this and other emerging disease-modifying ad therapies.

212 BUILT ENVIRONMENT OF NURSING HOMES AND INFECTION CONTROL AND PANDEMIC PREPAREDNESS

Background

The disproportionately high death rate of nursing home (NH) residents from COVID-19 in many countries, including Ireland, has focussed attention on infection prevention and control, including the built environment, in nursing homes. This has been a poorly researched topic to date, and we undertook a systematic review of evidence for architectural design measures which support infection control and pandemic preparedness.

Methods

Databases were screened for keywords related to NHs, built environment, infection prevention and control, and COVID-19; relevant papers were uploaded onto Covidence and screened for relevance. Data extracted from included articles was tabulated under 8 specific aspects of the built environment.

Results

Of 17 papers included in the final analysis, four studies found that larger nursing homes carried an increased risk of COVID-19 infection. Crowding in NHs was also a risk factor for infection, with a high crowding index associated with COVID-19 infection in five studies. Green House care homes, which are based on small clusters of domestic dwellings, fared better than traditional NHs. Two papers found an association between the location of NHs and the risk of COVID-19 infection, with urban NHs and those in areas of high prevalence being more at risk. Two papers identified internal fittings as a target for infection prevention and control. Seven papers highlighted the role of adequate ventilation in NHs in the prevention of spread of COVID-19. Only one paper described easy access to the outdoors as beneficial to infection control.

Conclusion

Residents of NHs are amongst the most vulnerable to COVID-19 infection. When designing and building NHs, the role of the built environment in controlling the spread of the virus should not be underestimated.

This research supported by Science Foundation Ireland.

140 FAMILY DEMENTIA SUPPORT TRAINING—AN INTEGRATED CARE APPROACH

Background

There are approximately 64,000 people living with a diagnosis of dementia in Ireland. This number is expected to double to 150,000 by 2045. The growing need for post diagnostic support has been accentuated by the fact that we are living through an unprecedented Pandemic. Our Dementia Training Network identified the need for a localised educational resource for families supporting those diagnosed with dementia across our service.

Methods

Following a successful pilot in association with the Alzheimer’s Society of Ireland, staff from the Specialist Memory Service, Integrated Care Team, and Primary Care created a service-informed 6 week course aimed at supporting families. A focus group preceded the first course to establish preferred content. The course delivered education on Dementia; Post Diagnostic Steps; Communication; Non cognitive symptoms; Nutrition & hydration; Assistive Technology; Forward planning and Self-care. The multi-dimensional nature of staff delivering the course creates a rich tapestry of advice and information. All staff involved work together to identify, refer and support families living with dementia in the local area. The group takes place in an accessible location and time which accommodates families. Each course attendee completes a questionnaire prior to and after commencing the group. The level of satisfaction will be measured following every course.

Results

By the end of 2021, the group will have delivered education and support to 36 families. The automatic referral of all families to this resource will assist in building up confidence to support and enhance self-care. The combined participants from the catchment area will become a network of families joined together on their journey.

Conclusion

This innovative service collaboration enhances the integrated nature of the Post Diagnostic Care pathway. The Integrated care approach has served to enrich the programme and allow for timely support and advice regarding localised supports.

18 SEDATIVE LOAD IN COMMUNITY-DWELLING OLDER ADULTS WITH MILD–MODERATE ALZHEIMER’S DISEASE: LONGITUDINAL RELATIONSHIPS WITH ADVERSE EVENTS, DELIRIUM AND FALLS

Background

Older adults are frequently prescribed medications with sedative effects, which are associated with numerous adverse consequences. However, the use and longitudinal associations of sedative medication use in older adults with mild–moderate Alzheimer Disease (AD), has not been explored to date.

Methods

The association between Sedative Load (SL) and adverse events, unscheduled healthcare utilisation, delirium and falls over 18 months was assessed in older adults with mild–moderate AD from 9 Countries. Additionally, the impact of SL on dementia progression was evaluated.

Results

Over half (52.35%; 267/510) of those with mild–moderate ad (72.8 ± 8.26 years, 61.89%) were prescribed a regular medication with sedation as a primary effect or prominent side effect with 17.65% (90/510) having a high SL (≥3). The most common medications contributing to SL were antidepressants, antipsychotics, anxiolytics and hypnotics. Over 18 months, greater SL was associated with adverse events (IRR 1.18, 1.14–1.23, p &lt; 0.001)/serious adverse events (IRR 1.32, 1.18–1.49, p &lt; 0.001) and unscheduled GP visits (IRR 1.26, 1.15–1.38, p &lt; 0.001). Further, increasing SL was associated with greater likelihood of incident delirium (IRR 1.47, 1.25–1.73, p &lt; 0.001) and falls (IRR 1.25, 1.06–1.48, p = 0.007) which persisted after covariate adjustment. SL was not associated with accelerated cognitive decline or ad progression.

Conclusion

Most adults with mild–moderate ad are prescribed at least one drug with a sedative effect and a significant minority have a high SL. Increasing SL was associated with a greater likelihood of experiencing adverse events, delirium and falls, highlighting the need for optimal prescribing in this vulnerable cohort.

66 BRAIN HEALTH CLINIC: DEVELOPING INNOVATIVE OPPORTUNITIES TO INTERVENE IN MODIFIABLE VASCULAR RISK FACTORS (VRF) TO IMPROVE COGNITIVE AGEING

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.

54 EXWELL: OUTCOMES FROM A SIX-WEEK COMMUNITY EXERCISE REHABILITATION PROGRAM FOR PEOPLE LIVING WITH CHRONIC ILLNESS

Background

Chronic diseases (CD) are long-term conditions, which often require ongoing medical treatment and have the potential to limit the quality of life of the people who live with them. Exercise rehabilitation has been shown to improve physical functioning and health related quality of life (HRQoL) in this cohort.

ExWell is a community-based exercise rehabilitation (CBER) program that offers group exercise rehabilitation classes to individuals with a range of CD. The purpose of this study was to investigate the impact of 6 weeks of participation in the ExWell Medical program on physical functioning and HRQoL in a diverse CD population.

Methods

Participants with a range of CD were referred by healthcare practitioners to the HSE-funded ExWell Medical program based in a community setting. Outcome variables included measurements of body composition, functional capacity and health related quality of life. Assessments were taken at baseline and 6 weeks. Participants were encouraged to attend ExWell Medical classes twice weekly for the duration of the study. Each forty-five minute class included a warm up, aerobic, resistance, core and balance exercises and a cool-down.

Results

Three hundred and ten people (mean age 70.7 ± 7.7 years, 48.3% Female) participated. Statistically and clinically significant improvements were found in cardiorespiratory fitness, lower body strength, balance, co-ordination, body composition and health related quality of life. The greatest improvements were observed in those with the lowest levels of fitness at baseline, and the oldest participants. Improvements in cardiorespiratory fitness and lower body strength matched the recognized clinically meaningful differences in the entire group sample and greatly exceeded them in those in the lowest tertile of fitness at baseline.

Conclusion

The ExWell mixed CD CBER program is an effective approach to rehabilitation delivery in clinical practice. Clinically meaningful improvements can be achieved within 6 weeks of participation, and older and frail participants show greatest improvements overall.

Cognitive performance in midlife type 2 diabetes: results from the ENBIND study

AIMS

To establish the impact of uncomplicated type 2 diabetes on cognitive and neuropsychological performance in midlife.

METHODS

We performed a cross-sectional study of middle-aged adults with uncomplicated type 2 diabetes and a cohort of healthy control participants. General cognition was assessed using the Montreal Cognitive Assessment test and neuropsychological assessment was undertaken using a detailed neuropsychological assessment battery.

RESULTS

A total of 152 participants (102 with type 2 diabetes and 50 controls) were recruited (mean age 52 ± 8 years, 51% women). Participants with midlife type 2 diabetes were more than twice as likely to make an error on the Montreal Cognitive Assessment test [incidence rate ratio 2.44 (95% CI 1.54 to 3.87); P < 0.001]. Further, type 2 diabetes was also associated with significantly lower memory composite score [β: -0.20 (95% CI -0.39 to -0.01); P = 0.04] and paired associates learning score [β: = -1.97 (95% CI -3.51, -0.43); P = 0.01] on the neuropsychological assessment battery following adjustment for age, sex, BMI, educational attainment and hypercholesterolaemia.

CONCLUSIONS

Even in midlife, type 2 diabetes was associated with small but statistically significant cognitive decrements. These statistically significant decrements, whilst not clinically significant in terms of objective cognitive impairment, may have important implications in selecting out individuals most at risk of later cognitive decline for potential preventative interventions in midlife.

10 Fear of Falling in Community Dwelling Ambulatory Older Patients: Associations with Physiological Falls Risk, Cognition and Mood Disorders

Introduction

Fear of falling (FOF) is associated with a range of adverse health outcomes including increased risk of falls1, and more rapid decline in physical and cognitive function2. We aim to determine the prevalence of FOF amongst ambulatory community dwelling older adults attending an Age-Related Day Hospital, and to describe it’s associations with cognition, mood disorders, frailty and mobility measures.

Methods

A retrospective chart review was conducted on 50 patients attending the Day Hospital. Baseline demographics collected include comorbidities, medications, and falls history. Objective mobility measurements include the Timed Up and Go (TUG) test and grip strength. Patients were divided into two groups based on their answer to the question, “Are you afraid of falling?” Differences between groups were compared using chi-squared test.

Results

The average age of Day Hospital attendees was 85 (SD X). 62% were male. Three quarters of patients experienced a recent fall, and half admitted to FOF. Those with FOF were more likely to be dependent in personal care (27% vs 16%, p = 0.15) and use a walking aid (69% vs 58%, p = 0.02). They were also more likely to be prescribed psychoactive medications (53% vs 45%, p = 0.42), and have a diagnosis of anxiety (4% vs 0%, p = 0.03).

Conclusions

Both having a falls history and FOF is prevalent in our Day Hospital population. FOF is associated with high physiological risk of falling, increased dependency, and anxiety. Standardization of mobility measures and potential screening for cognitive and mood disorders in patients with FOF will aid in further development of targeted interventions.

Letter to the Editor: Covid-19 and the Challenges of Frailty Screening in Older Adults

We read with interest the recent editorial examining the relationship between geriatric syndromes and severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the cause of Covid-19 (1), particularly the authors recognition of the need to identify frailty among older adults presenting with suspected symptoms and the importance of mobilising a range of healthcare professionals to tackle this disease (1). However, the identification of frailty and the utilisation of screening instruments by those without geriatric training and especially in acute care is challenging. Frailty is a complex condition. While age-associated, it is multi-dimensional and remains difficult to define (2). Although the Covid-19 pandemic has disproportionately affected older adults (1), data are lacking and pathophysiological mechanisms and the impact of differential management strategies on the course of the disease among older adults is uncertain (1). Further, the prevalence of frailty among those diagnosed, admitted or dying is not clearly reported at present. Nevertheless, the rationale for using frailty to identify those at risk and to allocate care has been correctly highlighted (1). We suggest however, that the use of instruments such as the Clinical Frailty Scale (CFS) (3) and particularly by non-specialised staff in this setting warrants more careful examination.

Non-pharmacological interventions for cognition in patients with Type 2 diabetes mellitus: a systematic review

Midlife Type II diabetes mellitus (T2DM) is an important yet often unrecognized risk factor for the later development of dementia. We conducted a systematic review to assess the efficacy of non-pharmacological interventions (namely diet, exercise and cognitive training) for T2DM on cognition. A search strategy was constructed and applied to four databases: EMBASE, Medline, CINAHL and Web of Science. Peer-reviewed journal articles in English were considered assessing the effect of exercise, dietary or cognitive training/stimulation-based interventions (or any combination of these) in patients with T2DM on cognition. Results were dual-screened and extracted by two independent reviewers. Of 4820 results, 3782 remained after de-duplication. Forty full-texts were screened and two studies were included in the final review. The first assessed the impact of a 10-year intensive lifestyle intervention on T2DM-related complications (Look-AHEAD study) and the second was a post hoc analysis of T2DM patients from a trial of a physical activity intervention in older non-demented adult with functional limitations (LIFE study). Whilst the Look-AHEAD study found no impact on diagnosis of mild cognitive impairment or dementia, the LIFE study demonstrated beneficial effects on global cognitive function and delayed memory specifically in older adults with T2DM. There is insufficient evidence to fully assess the effect of non-pharmacological interventions on cognition in T2DM. Well-constructed trials must be designed to specifically assess the effect of non-pharmacological and multi-domain interventions for cognition in patients with T2DM in midlife. All trials examining interventions in T2DM should consider cognition as at least a secondary outcome.

98 The Utility of Informant History in Delineating Narratives of Gait Disorder in Older Outpatients

Background

A scholarly focus on informant history is recent in geriatric medicine, mostly focused on cognition and syncope.1 Gait disorders are common in older people and accurate diagnosis facilitates treatment.2

As there is a disparity between self-rated and ‘objective’ estimates of health among older people, and gait disorders often co-exist with cognitive impairment, there may be a significant difference between patient and informant narratives of gait disorder. We investigated the existence and extent of this disparity.

Methods

As no suitable informant measure could be sourced from the biomedical literature, inquiry with senior academic physiotherapists or through appeals on social media relating to physiotherapy, a mobility scale was designed. We included all patients with a gait disorder at serial outpatient clinics. Exclusion criteria were absence of gait disorder and dementia of sufficient severity to be unable to participate in the consent process. Paired t tests and Fischer exact test were used to analyse the data.

Results

Of 45 participants (mean age 79.8; 50% men), 35 (77.7%) had MCI or dementia. Twenty two (47.8%) informants considered an acute event precipitated an acute deterioration in mobility. Twenty seven informants (60%) had a fear of the older person falling compared to 9 (20%) of patients (p=0.0002).

Patient and informant impression of point on mobility scale differed (t=3.61, p=0.0003). Although Informants reported more falls (mean of 1.36 vs 0.91) in the previous year (t=1.63, p=0.055) this did not achieve statistical significance.

Conclusions

Our findings demonstrate a discrepancy between patient and informant narratives of level of mobility, and point to the benefit of obtaining an informant history of loss of gait stability, mobility and falls. In addition, perceptions of fear of falling may be of assistance in managing risk and independence.

References

1. Briggs R, O'Neill D. QJM 2016; 109: 301–2.

2. Briggs R, O'Neill D. Clin Med 2014; 14: 200–2.

282 A Time to Wean: An Audit on Benzodiazepine and Z-drug Use Amongst Patients Attending a Geriatric Ambulatory Care Day Hospital

Background

Benzodiazepine prescription is common among the Irish patient cohort. 23% of medical card holders have been prescribed a benzodiazepine or Z-drug, with a third of these being for a period longer than three months. This is despite these drugs being associated with addiction, falls, cognitive and psychomotor impairment, mood disorder, sleep automatism and drug interactions. We performed an audit looking at the repeat prescriptions of patients attending a geriatric day hospital.

Methods

The repeat prescriptions of all patients currently enrolled at a day hospital were analysed for benzodiazepines or Z-drugs. Medical records were then analysed to look for indication and whether these patients were currently attending psychiatric services. Subsequent to this, notices were placed in the patient consult room in direct line of sight of the registrar reminding them to consider weaning these drugs and detailing the negative side effects and guidelines for weaning from the Canadian National Pain Centre.

Results

59 patients were enrolled at the day hospital when the audit was performed. 11 (19%) had either a benzodiazepine or Z-drug as part of their repeat prescription (benzodiazepine-5, Z-drug-5, both-1). The most common benzodiazepines prescribed were diazepam and clonazepam (2 patients on each). Of those prescribed a benzodiazepine, none were currently being weaned. Of those on benzodiazepines, 4 of 6 had a documented psychiatric diagnosis, and 1 of 6 had documented that they were currently attending psychiatric services. A re-audit three months later showed no change in those prescribed benzodiazepines (5/59), and a non-significant increase in those on Z-drugs (9/59, p=0.26).

Conclusion

This audit showed a significant number of patients attending our day hospital are being prescribed long term benzodiazepines or Z-drugs, and highlights that this setting is an opportune time and place to establish a supported program to wean people off these medications.

Dementia Friendly Hospital Design: Key Issues for Patients and Accompanying Persons in an Irish Acute Care Public Hospital

OBJECTIVES

Research was conducted to investigate the impact of the hospital environment on older people including patients with dementia and their accompanying persons (APs). The article presents key research findings in the case study hospital.

BACKGROUND

For many patients, the hospital is challenging due to the busy, unfamiliar, and stressful nature of the environment. For a person with dementia, the hospital experience can be exacerbated by cognitive impairment and behavioral or psychological symptoms and can therefore prove to be a frightening, distressing, and disorientating place.

METHOD

The findings are based on a stakeholder engagement process where the research team spent approximately 150 hr observing within the hospital, administered 95 questionnaires to patients and/or APs, and conducted 12 structured interviews with patients and APs. A thematic analysis was employed to analyze and generate key themes emerging from the process.

RESULTS

Themes were grouped into overarching issues and design issues across spatial scales.

CONCLUSION

This research confirms the negative impact of the acute hospital setting on older people with cognitive impairments including dementia and delirium. The multiple perspectives captured in this study, including most importantly people with dementia, ensure that stakeholder needs can be used to inform the design of the hospital environment. The research points to the value of understanding the lived experience of the person with dementia and APs. The voices of patients, particularly persons with dementia and their APs, are a crucial element in helping hospitals to fulfill their role as caregiving and healing facilities.

Patterns of mortality in modern stroke care

Background Stroke is a leading cause of death. We looked at the causes (direct and indirect) of in-hospital mortality in a modern stroke unit over a two-year period. Methods We reviewed medical charts of stroke deaths in hospital from 2014-2015 inclusive. Data on stroke type, aetiology, age, length of stay, comorbidities, and documented cause of death were recorded. All patients were included. Results 518 patients were admitted acutely to the stroke service. Overall death rate was 7.5% (n=39). Of fatal strokes 29 (74%) were ischaemic. Average age 78.6 years. Mean survival was 26.4 days (range 1-154). 19 (49%) patients had atrial fibrillation. Forty-nine percent of deaths were due to pneumonia, and 33% were due to raised intracranial pressure. Discussion Mortality rate in our stroke service has decreased from 15% in 1997, and now appears dichotomised into early Secondary Stroke Related Cerebral Events (SSRCEs) and later infections.

Dementia Diagnosis and Referral in General Practice: A Representative Survey of Irish General Practitioners

Aims Most of those with a memory problem or concern over cognition present to their General Practitioner (GP) in the first instance. Despite this, the current diagnostic and referral patterns of Irish GPs remains unclear. Methods A survey was distributed to three separate cohorts of GPs (n=692) Results Ninety-Five (14%) responded. Most personally diagnose 1-3 (69%; 65/95) or 4-6 (21%; 20/95) patients with dementia per year. Two-thirds (62%; 59/95) refer >80% of those with possible dementia for further assessment/support, most commonly to support/clarify a diagnosis (71%; 67/95) and most frequently to a geriatrician (79%; 75/95). In half of cases (51%; 48/95), referral is to a professional working as part of an established memory clinic. One-fifth reported receiving dementia-specific postgraduate training (19%; 18/95) and over four-fifths (82%; 78/95) would welcome further training. Discussion Further attention to the ongoing establishment of memory clinic services and dedicated referral pathways, as well as increasing emphasis on dementia assessment and diagnosis in medical curricula, is warranted.

Structuring Diabetes Mellitus Care in Long-Term Nursing Home Residents

Nursing home residents with diabetes have more complex care needs with higher levels of comorbidity, disability and cognitive impairment. We compared current practice in the 44 long-term residents in Peamount hospital with the standards recommended in the Diabetes UK "Good Clinical Practice Guidelines for Care Home Residents with Diabetes". Of 44 residents, 11 were diabetic. Residents did not have specific diabetes care plans. There were some elements of good practice with a low incidence of hypoglycaemia and in-house access to dietetics and chiropody. However, diabetes care was delivered on an ad-hoc basis without individualised care plans, documented glycaemic targets, or scheduled monitoring for complications and no formal screening for diabetes on admission. National and local policy to guide management of diabetes mellitus should be developed. There should be individualised diabetes care plans, clear policies for hypoglycaemia, hyperglycaemia and long-term diabetes complications, screening on admission and increased uptake of the national retinal screening and foot care programmes.

Screening for frailty in older emergency department patients: the utility of the Survey of Health, Ageing and Retirement in Europe Frailty Instrument

BACKGROUND

Greater numbers of older patients are accessing hospital services. Specialist geriatric input at presentation may improve outcomes for at-risk patients. The Survey of Health, Ageing and Retirement in Europe Frailty Instrument (SHARE-FI) frailty measure, developed for use in the community, has also been used in the emergency department (ED).

AIM

To measure frailty, review its prevalence in older patients presenting to ED and compare characteristics and outcomes of frail patients with their non-frail counterparts.

DESIGN

Patient characteristics were recorded using symphony® electronic data systems. SHARE-FI assessed frailty. Cognition, delirium and 6 and 12 months outcomes were reviewed.

METHODS

A prospective cohort study was completed of those aged ≥70 presenting to ED over 24 h, 7 days a week.

RESULTS

Almost half of 198 participants (46.7%, 93/198) were classified as frail, but this was not associated with a significant difference in mortality rates (OR 0.89, 95% CI 0.58-1.38, P = 0.614) or being alive at home at 12 months (OR 1.07, 95% CI 0.72-1.57, P = 0.745). Older patients were more likely to die (OR 2.34, 95% CI 1.30-4.21, P = 0.004) and less likely to be alive at home at 12 months (OR 0.49, 95% CI 0.23-0.83, P = 0.009). Patients with dementia (OR 0.24, P = 0.005) and on ≥5 medications (OR 0.37, 95% CI 0.16-0.87, P = 0.022) had a lower likelihood of being alive at home at 12 months.

CONCLUSIONS

Almost half of the sample cohort was frail. Older age was a better predictor of adverse outcomes than frailty as categorized by the SHARE-FI. SHARE-FI has limited predictability when used as a frailty screening instrument in the ED.

Investigation and diagnostic formulation in patients admitted with transient loss of consciousness

Several commonly completed tests have low diagnostic yield in the setting of transient loss of consciousness (T-LOC). We estimated the use and cost of inappropriate investigations in patients admitted with T-LOC and assessed if these patients were given a definitive diagnosis for their presentation. We identified 80 consecutive patients admitted with T-LOC to a university teaching hospital. Eighty-eight percent (70/80) had a computerized topography (CT) brain scan and 49% (34/70) of these scans were inappropriate based on standard guidelines. Almost half (17/80) of electroencephalograms (EEG) and 82% (9/11) of carotid doppler ultrasound performed were not based on clinical evidence of seizure or stroke respectively. Forty-four percent (35/80) of patients had no formal diagnosis documented for their presentation. Inappropriate investigation in T-LOC is very prevalent in the acute hospital, increasing cost of patient care. In addition, there is poor diagnostic formulation for T-LOC making recurrent events more likely in the absence of definitive diagnoses.