227 UNSCHEDULED ACUTE HOSPITAL ADMISSIONS FROM A COMMUNITY REHABILITATION TEAM – GERIATRIC GIANTS OR “ACOPIA”?

Background

The Integrated Care Team (founded 2018) provides community rehabilitation in the home for frail older adults. Frail older adults are at increased risk of hospitalisation, and frailty is associated with increased length of stay and mortality. This retrospective cohort study aims to explore the acute hospital admissions of this frail cohort from July 2019 to December 2021.

Methods

Patients were identified from the integrated care team database who had a discharge destination of “Acute Hospital”. Hospital IT system data and discharge summaries were used to analyse inpatient Length of Stay (LOS), presenting complaints and discharge diagnosis. The study period was from July 2019 to December 2021.

Results

67 patients were admitted to hospital during the study period from the care of the integrated care team, accounting for 98 individual hospital admissions. This accounted for 19.8% of discharges from the team during the study period, with 77% of patients discharged to community support. 23.8% of patients (n=16) had multiple admissions, with the majority of these(n=14) admitted twice. The average age of patients was 82.6 years. 58% of admitted patients were female. The longest LOS was 99 days, and shortest less than one day. The average LOS was 12.9 days for the total population. Excluding two outlier stays of 99 and 82 days, the average LOS was 11.27 days.

32% of patients presented with functional decline, 28% with falls, 18% with shortness of breath and 19% with delirium. Infections were diagnosed in 28% of patients, neurological events in 12% and bleeding diagnoses in 11% of patients. 1 patient died during admission. Only 12.2% of stays (n=12) were less than 72 hours in duration.

Conclusion

This frail patient cohort presented with a range of frailty syndromes and complications of medical comorbidities. The low prevalence of short hospital stays may reflect the ongoing role of the community team supporting patients in the community.

232 WORKING-UP DEMENTIA, A RETROSPECTIVE COHORT STUDY OF REFERRALS TO A SPECIALIST DEMENTIA SERVICE

Background

Rates of dementia in Ireland are rapidly increasing in line with our ageing population. Cases are predicted to more than double in the next 30 years from a prevalence of 55,000 in 2018, to 141,000 in 2050. Dementia services will be placed under significant pressure. It is essential that patients referred to specialist memory services are appropriately worked-up prior to referral, to ensure efficiency and optimise the running of these services, and also to improve patient experience.

Methods

We carried out a retrospective review of patients referred to the Psychiatry of Later Life Team for specialist dementia care by General Practitioners. We obtained date of referral to the service, and carried out an electronic chart review to evaluate the work-up performed prior to referral. Our standard work-up criteria consisted of neuroimaging (CT brain or MRI brain), and blood tests including B12, folate, and thyroid function tests within 12-months. Results were analysed descriptively.

Results

104 patients were included in the study, from referrals dated Nov 2014-June 2019. Neuroimaging had been performed in 79.8% (n=83) prior to referral- 89.1% CT, 9.6% MRI, 1.2% both CT and MRI. Of those who had neuroimaging, n=37 had been performed in the previous 12-months, representing 35.6% of overall cohort. In terms of blood work-up, 23.1% (n=24) had bloods performed in the 12 months prior to referral- 70.8% B12, folate and thyroid function tests; 20.8% TFTS only; 8.3% B12 and folate levels only).

Conclusion

Referrals to specialist memory services by General Practice often lack the appropriate first line investigations, which introduces delay in review and the need for further assessment once baseline investigations have been done. There is a need for a standardised work-up prior to referral for optimum running of such services.

329 ANTICHOLINERGIC BURDEN IN PEOPLE LIVING WITH DEMENTIA ATTENDING GERIATRIC MEDICINE AND PSYCHIATRY FOR OLDER PERSONS SERVICES

Background

Anticholinergic burden is associated with an increase in cognitive decline, delirium and confusion. We aimed to examine the Anticholinergic Cognitive Burden (ACB) of patients referred to local dementia services, and the prescribing of acetylcholinesterase inhibitors in patients with a significant anticholinergic burden. We also looked at frequency of prescribing of classes of some medications known to increase anticholinergic burden.

Methods

A retrospective chart review was carried out of new referrals attending local Geriatric Medicine and/or Psychiatry For Older Persons outpatient services with a diagnosis of dementia between 2017 and 2018. Medications in use at the time of patient review were obtained. ACB was calculated using ACB score. Results were analysed descriptively.

Results

163 patients over 65 years old were included in this study, 94 (57.6%) were female. 30% (N = 49) had a significant anticholinergic burden (ACB >3). The mean ACB was 1.69 (Range 0 – 8). 38% of all patients (N = 63) were prescribed an acetylcholinesterase inhibitor, and of those, 20% (N = 13) had a significant anticholinergic burden. Polypharmacy (use of 5 medications or more) was evident with 76% (N = 124) patients. Regarding groups of medications known to increase ACB, 35.5% (N = 58) were prescribed antipsychotics and 18.4% (30) were prescribed benzodiazepines.

Conclusion

There is a significant anticholinergic burden among people living with dementia attending the geriatric medicine and psychiatry of later life services. Some patients with a significant anticholinergic burden were being prescribed acetylcholinesterase inhibitors. This suggests acetylcholinesterase inhibitors may be prescribed without also discontinuing inappropriate medications that are contributing to the anticholinergic burden. We should look to further reduce the anticholinergic burden of patients attending the dementia services by avoiding these medications or using alternatives where available.

338 APPLYING STOPP/START CRITERIA TO A COHORT OF FALL PATIENTS IN THE COMMUNITY

Background

Integrated Care Teams for Older Persons (ICTOP) aim to transform care away from hospitals towards multidisciplinary community team care. Seventy percent of injuries requiring acute admission are caused by falls, costing €59 million annually, in addition to the overall morbidity and mortality burden. The Screening Tool of Older Person’s Prescriptions / Screening Tool to Alert Doctors to Right Treatment (STOPP/START) identifies inappropriate prescribing and prescribing omissions, which should reduce falls risk and optimise patient outcomes.

Methods

This prospective study randomly included 20 active ICTOP patients all of whom had fallen in the last 6 months. The STOPP/START Criteria were used to screen patient’s prescriptions at time of referral.

Results

The average age was 83 years old, 60% were male. Overall 45% had 1 fall, 15% had 2 falls, 20% had 3 falls and 20% had more than 5 falls. The most common comorbidities were hypertension (55%), heart disease (45%), and cognitive decline (40%). Regarding polypharmacy, 95% were prescribed more than 5 drugs, 55% were prescribed more than 10 drugs. Overall, 30% had a diagnosis of osteoporosis, 40% were on a bisphosphonate, while 65% were taking vitamin D and Calcium supplements. Of the 35% (7 patients) who had a previous fragility fracture, 1 had a DEXA scan and a further 3 were on the waiting list. Four of these patients were taking bisphosphonates and 6 were taking vitamin D and Calcium. Regarding STOPP criteria, 30% were taking opioids, 45% Proton Pump Inhibitors, 30% Calcium Channel Blockers, 30% Beta-blockers and 15% were taking Alpha-blockers.

Conclusion

The study identifies a need for community teams to consider medications that increase falls risk and medications that should be initiated to optimise bone health. Community teams should have access to professional medical and pharmacy support, in addition to timely access to DEXA scans.

70 THE RESPONSIVE NATURE OF AN INTEGRATED CARE COMMUNITY REHABILITATION TEAM THROUGHOUT THE COVID PANDEMIC

Background

The Integrated Care Team (founded 2018) provides community rehabilitation in the home. The Covid 19 pandemic, a new Reablement Service (June 2020) and Community Falls Service (September 2020) led to changes in the service, providing access to comprehensive geriatric assessment in the community when hospital outpatient services were limited. The effect of these changes on patient cohorts are explored.

Methods

Anonymised patient data from the team database was extracted for each episode of care under the service from July 2019 to February (Pre-covid), March 2020 to December 2020 (initial lockdown period), and January 2021 to December 2021 and analysed for length of stay (LOS), discharge destination, and reason for referral. A further analysis of discharge summaries for patients with the longest LOS in each period was conducted to assess for factors influencing LOS with the team.

Results

500 episodes of care were captured during the study period, 137 pre-covid, 179 March to December 2020 and 184 in 2021.From Pre-covid to 2021, the average LOS increased from 45.9 days to 57 days. The annual number of new referrals seen by the team was similar across this period (194 in 2019, 204 in 2020 and 190 in 2021). 40 patients with the longest LOS were analysed. No long-stay patients benefited from respite or day-centre care during the studied period (compared to 46% of all patients in 2018). 70% lived alone, 65% had cognitive decline or dementia and only 41% required mobility aids while indoor. Clinical frailty scores were unavailable.

Conclusion

A changing patient cohort may account for the increased length of stay, with less frail patients benefiting from reablement and falls services on hospital discharge, while high levels of cognitive impairment and low mobility aid usage may indicate limited rehabilitation potential. Ongoing access to social prescribing outlets such as respite and daycare are essential to sustain patients in their own homes.

Identification and Management of Children and Adolescents with Obesity Referred to a General Paediatric Outpatient Department

Aims To identify all children and adolescents with overweight or obesity attending the outpatient department and audit our processes in their identification and management against NICE standards. Methods A retrospective chart review was performed. BMI charts were used to identify children and adolescents with overweight/obesity. The patient journey was audited to ascertain if overweight/obesity was identified by the clinician, whether this was communicated to the child or adolescent/their carer and whether intervention was offered. Results There were 669 scheduled appointments and 27.3%(n=127) of children 2 years and adolescents were identified with overweight/obesity. Children and adolescents referred for reasons not primarily related to obesity management were identified (90.6% (n=115)) and this group was analysed. Height and weight and/or BMI were communicated in 13.9% (n=16) of referral letters. A record of discussing growth was observed in 15.7% (n=18) of cases. Growth measurements were included in the post-clinic correspondence to the primary care physician in 56.8% (n=63) of letters. Discussion Further research is required to ascertain what barriers exist to the discussion of growth. Additional education of healthcare providers is necessary to develop standardised procedures around processes related to child and adolescent growth.

Transient receptor potential channels TRPC1/TRPC6 regulate lamina cribrosa cell extracellular matrix gene transcription and proliferation

The lamina cribrosa (LC) in glaucoma is with augmented production of extracellular matrix proteins (ECM) and connective tissue fibrosis. Fundamental pathological mechanisms for this fibrosis comprise fibrotic growth factors and oxidative stress. Transient receptor potential canonical channels (TRPC) channels play a key role in ECM fibrosis. Here, we study TRPC expression in glaucomatous LC cells, and investigate the role of TRPC in oxidative stress induced-profibrotic ECM gene transcription and cell proliferation in normal LC cells. Age-matched human LC cells (normal, n = 3 donors; glaucoma, n = 3 donors) were used. Hydrogen peroxide (H₂O₂, 100 μM), was used to induce oxidative stress in LC cells in the presence or absence of the pan TRPC inhibitor SKF96365 (10 μM) or knockdown of TRPC1/6 with siRNA. After treatments, ECM gene transcription, LC cell viability and proliferation and the phosphorylation of the transcription factor NFATc3, were measured using real time RT-PCR, colorimetric cell counting with the methyl-thiazolyl tetrazolium salt (MTS) assay, and Western immunoblotting, respectively. Results showed that TRPC1/C6 transcript and protein expression levels were significantly (p < 0.05) enhanced in glaucoma LC cells. Both SKF96365 and siRNA-TRPC1/C6 treatments significantly reduced the oxidative stress induced-ECM gene expression (transforming growth factor-β1 (TGFβ1), alpha smooth muscle actin (α-SMA), and collagen type 1A1 (Col1A1)), and cell proliferation in normal and glaucoma LC cells. Also, SKF96365 treatment inhibited the H₂O₂-induced NFATc3 protein dephosphorylation in LC cells. In conclusion, TRPC1/C6 expression is enhanced in glaucoma LC cells. These channels may contribute to oxidative stress-induced ECM gene transcription and cell proliferation in normal and glaucoma LC cells through Ca²⁺-NFATc3 signaling pathway mechanism. TRPC1 and TRPC6 channels could be important therapeutic targets to prevent ECM remodeling and fibrosis development in glaucoma optic neuropathy.

The impact of caring for an adult with intellectual disability and psychiatric comorbidity on carer stress and psychological distress

BACKGROUND

Given that carers of individuals with intellectual disability (ID) and carers of individuals with psychiatric disorders experience elevated levels of stress and psychological distress, carers of individuals with both ID and a comorbid psychiatric disorder are potentially at even greater risk for psychological difficulties. The aim of the present study was to investigate the psychological well-being of carers of adults with a dual diagnosis compared with carers of adults with intellectual disability alone.

METHOD

Four-hundred and forty-two questionnaires were sent to four community services and seventy-five family carers of adults with intellectual disability responded. Psychological well-being of carers was assessed using the Questionnaire on Resources and Stress - Friedrich edition (QRS-F) and the General Health Questionnaire (GHQ). Comorbid psychopathology for their family member with ID was assessed using the Reiss Screen for Maladaptive Behaviour (RSMB).

RESULTS

Twenty-four percent of the individuals with ID were reported to have comorbid psychopathology. Between-group analyses compared carers of people with ID and comorbid psychopathology to carers of people with ID alone. Regression analyses examined the relationship between psychopathology and other care-related variables to carer stress and psychological distress. Carers of people with ID and comorbid psychopathology were found to have significantly higher levels of stress and psychological distress than carers of people with ID alone. Autism was found to be the only significant predictor of both stress and psychological distress among measures of psychopathology.

CONCLUSIONS

Additional comorbid psychopathology in individuals with intellectual disability has a significant impact on their carers' psychological well-being.

Acute stroke unit improves stroke management-four years on from INASC

The Irish Heart Foundation carried out the Irish National Audit of Stroke Care (INASC) in 2008. Management practices were significantly poorer than those in the UK Sentinel audits. Since then an acute stroke unit has been established in University Hospital Limerick. A stroke database was established. 12 key indicators of stroke management audited by INASC were identified. Results were compared to those in INASC. 89 stroke patients were admitted. 8 of the 12 key indicators scored significantly better than in INASC. 92.5% had a brain scan within 24hrs (INASC-40%, p = < 0.001). 100% of ischaemic strokes received anti-thrombotics (INASC-85%, p = 0.001). 94% had rehab goals agreed by MDT (22% in INASC p = 0.0000). 55% were treated in stroke unit (2% in INASC, p = 0.0000). MDT input improved with regard to physiotherapy (87% vs 43% in INASC, p = < 0.02) and SALT (74% vs 26%, p = < 0.02). Stroke management has significantly improved from 2008, however some deficiencies remain.

Depression with psychotic features is influenced by the polymorphism of the serotonin transporter gene

INTRODUCTION

Current diagnostic classifications regard psychotic symptoms during depressive episodes as indicators of depression severity. However, growing evidence suggests that depression with psychotic symptoms (MDP) may represent a distinct subtype of depression. In the course of the search for discriminating factors we tested the hypothesis that the serotonin transporter gene (5-HTTLPR) may interact with the manifestation of psychotic symptoms in acute depression.

METHODS

112 inpatients (61 female) with a depressive episode (16 bipolar, 86 unipolar) at admission were genotyped for 5-HTTLPR variants. Psychotic symptoms und general psychopathology were evaluated comprehensively using the Manual of the Association for Methodology and Documentation in Psychiatry (Arbeitsgemeinschaft für Methodik und Dokumentation in der Psychiatrie, 1981). For statistical analysis a chi-square test and a logistic regression model was used.

RESULTS

16 (14.3%) out of 112 patients were currently presenting with psychotic symptoms. The primary finding of our study was the higher prevalence of the s-allele of the 5-HTTLPR within the group of MDP patients (Pearson χ²=7.87; df=2; p<0.03). Secondly, in a logistic regression model, 5-HTTLPR was found to significantly contribute to the diagnosis of MDP (χ²=6.5; df=1; p=0.01). This effect was even more pronounced upon comparing only severely depressed patients with MDP patients. From a psychopathological perspective, MDP patients showed higher AMDP hostility and apathy scores but equal AMDP depression scores.

DISCUSSION

This is the first study to show an influence of 5-HTTLPR on psychotic symptoms in acutely depressed patients.

LIMITATIONS

The lack of a control group and the relatively small sample size limits the present study's findings, thus replication in a larger sample is necessary.

High normal fasting glucose level in obese youth: a marker for insulin resistance and beta cell dysregulation

AIMS/HYPOTHESIS

A high but normal fasting plasma glucose level in adults is a risk factor for future development of type 2 diabetes mellitus and cardiovascular disease. We investigated whether normal fasting plasma glucose levels (<5.60 mmol/l) are associated with decreases in insulin sensitivity and beta cell function, as well as an adverse cardiovascular profile in obese youth.

METHODS

We performed a cross-sectional analysis in a multiethnic sample of 1,020 obese youth (614 girls and 406 boys; mean age 12.9 years [CI 95% 12.7-13.1], BMI z score 2.34 [CI 95% 2.31-2.38]) with normal fasting plasma glucose. All participants had a standard OGTT, with calculation of indices of insulin sensitivity and beta cell function. For the analysis, prepubertal and pubertal participants were stratified into quartiles of normal fasting plasma glucose.

RESULTS

We observed a significant increase in fasting insulin and AUC 2 h glucose across quartiles. Pronounced changes were observed in insulin sensitivity and secretion, particularly in the pubertal group. Moreover, the odds of presenting with impaired glucose tolerance increased by 4.5% with each 0.06 mmol/l increase in fasting plasma glucose. No significant differences in cardiovascular indices were seen across quartiles.

CONCLUSIONS/INTERPRETATION

These data suggest that in obese youth, independent of age, BMI z score, sex, family history and ethnicity, insulin sensitivity and secretion decline when moving from low to high normal fasting plasma glucose. The simple measure of fasting plasma glucose could assist clinicians in identifying children for targeted diabetes screening and subsequent lifestyle management.

Urinary N tau-methylimidazole acetic acid excretion in respiratory disease

N tau-methylimidazole acetic acid (N tau-MIAA) is the principal urinary metabolite of histamine. The basal urinary excretion rate of N tau-MIAA was determined as 0.117 +/- 0.008 (SE) mg/h, with a renal clearance for N tau-MIAA of 273 +/- 27 ml/min implying active secretion. After subpharmacological infusion of histamine (50 ng.kg-1.min-1 over 2 h) in five volunteers that increased plasma histamine from 0.28 +/- 0.04 to 0.71 +/- 0.15 ng/ml, urinary excretion of N tau-MIAA over 8 h was increased by less than 17% compared with a control saline infusion. Urinary N tau-MIAA excretion in normal controls (273 +/- 14 micrograms/mmol creatinine) was similar to that observed in patients with severe acute asthma (253 +/- 22 micrograms/mmol), antigen-induced bronchoconstriction (269 +/- 21 micrograms/mmol), seasonal allergic rhinitis (304 +/- 31 micrograms/mmol), and clinically stable bronchiectasis (270 +/- 22 micrograms/mmol). In contrast, large increases in metabolite excretion (greater than 7,000 micrograms/mmol creatinine) were observed in a patient with systemic mastocytosis where very high plasma histamine levels were recorded (greater than 500 ng/ml) and marked systemic hemodynamic effects occurred. We conclude that urinary N tau-MIAA will only be increased in pathologies where sustained hyperhistaminemia occurs and that increased local histamine production in the lung or the upper airway does not cause a measurable change in the basal urinary excretion of this metabolite.

Assay for N tau-methylimidazoleacetic acid, a major metabolite of histamine, in urine and plasma using capillary column gas chromatography-negative ion mass spectrometry

A gas chromatographic-mass spectrometric assay has been developed for the measurement of N tau-methylimidazoleacetic acid in urine and plasma. The method uses the isopropyul ester 3,5-bistrifluoromethylbenzoyl derivative of N tau-methylimidazoleacetic acid and electron capture negative ion chemical ionisation mass spectrometry. The derivative has very good chromatographic properties and a negative ion mass spectrum which contains only a molecular ion at m/z 422. When this ion is specifically monitored, an amount of derivative equivalent to 1 pg of parent compound can be detected. A deuterated analogue of N tau-methylimidazoleacetic acid was synthesised for use as an internal standard and this allowed the development of an assay for N tau-methylimidazoleacetic acid, in urine with a precision of 2.9% and in plasma with a precision of 1.5%.

Human cytomegalovirus induces stage-specific embryonic antigen 1 in differentiating human teratocarcinoma cells and fibroblasts

Cell surface expression of stage specific embryonic antigen 1 (SSEA-1), or Lex (III3 FucnLC4), was induced in differentiated human teratocarcinoma cells and in human diploid fibroblasts 3-6 d after infection with human cytomegalovirus (HCMV). In parallel, fucosylated lactoseries glycolipids bearing the SSEA-1/Lex epitope were readily detected in the infected cells but not in the uninfected cells. HCMV infection also results in altered expression of several glycosyltransferases. SSEA-1/Lex induction is probably a consequence of both increased expression of beta 1----3N-acetylglucosaminyltransferase, which catalyzes the rate-limiting step in lactoseries core chain synthesis, and subtle alterations in the relative competition for common precursor structures at key points in the biosynthetic pathway. Since SSEA-1 has been suggested to play a role in some morphogenetic cell-cell interactions during embryonic development, the induction of this antigen at inappropriate times might provide one mechanism whereby intrauterine infection with HCMV can damage the developing fetal nervous system.

Human alveolar macrophage activation: inhibition by forskolin but not beta-adrenoceptor stimulation or phosphodiesterase inhibition

Alveolar macrophages are the most numerous cells within human airways. They release inflammatory mediators following immunological challenge and have been implicated in the pathogenesis of asthma. beta-agonists and phosphodiesterase inhibitors are frequently used in the treatment of asthma and are potent inhibitors of human mast cells. We have examined the role of the beta-agonist, isoprenaline, the phosphodiesterase inhibitor Ro-20 1724, and the adenylate cyclase stimulator forskolin on the activation of human alveolar macrophages. This was assessed by monitoring the release of thromboxane B2 (TXB2), leukotriene B4, N-acetyl-beta-D-glucosaminidase (NAG), and superoxide (SO) following stimulation of the cells by opsonised zymosan or IgE/anti IgE complexes. Neither isoprenaline (1nM-10 microM) nor Ro-20 1724 (0.5-50 microM) alone or in combination had any inhibitory effect on release of these mediators. However, forskolin (0.1-100 microM) significantly inhibited release of both TXB2 and SO but not NAG. This result shows that human alveolar macrophages do not possess functional beta-receptors, although stimulation of adenylate cyclase with forskolin, inhibits some of the elements of macrophage activation.

The repair of extracranial carotid artery aneurysms

Aneurysm of the internal carotid artery was repaired in three instances by a combination of gas endarterectomy and aneurysmorrhaphy. No shunt was used during cross clamping. The occlusion was uncomplicated. Both patients (in one the procedure was bilateral) have been well for two years. Because of its simplicity and effectiveness, the method is recommended.