Ciaran Donegan

Diagnosis and Management of Asthma in Older Adults

Despite comprehensive guidelines established by the European Global Initiative for Asthma and the U.S. National Asthma Education and Prevention Program on the diagnosis and management of asthma, its mortality in older adults continues to rise. Diagnostic and therapeutic problems contribute to older patients being inadequately treated. The diagnosis of asthma rests on the history and characteristic pulmonary function testing (PFT) with the demonstration of reversible airway obstruction, but there are unique problems in performing this test in older patients and in its interpretation. This review aims to address the difficulties in performing and interpreting PFT in older patients because of the effects of age‐related changes in lung function on respiratory physiology. The concept of “airway remodeling” resulting in “fixed obstructive” PFT and the relevance of atopy in older people with asthma are assessed. There are certain therapeutic issues unique to older patients with asthma, including the increased probability of adverse effects in the setting of multiple comorbidities and issues surrounding effective drug delivery. The use of beta 2‐agonist, anticholinergic, corticosteroid, and anti‐immunoglobulin E treatments are discussed in the context of these therapeutic issues.

POOR RETURN OF FUNCTIONAL MOBILITY AFTER HIP FRACTURE IN OLDER PATIENTS—IT'S TIME TO IMPROVE ON HIP FRACTURE PREVENTION

and Medical Research Council of Australia. Author Contributions: JB was responsible for the study concept. All authors were responsible for the study design, interpretation of data, drafting and critical revision of the manuscript. JL and AD: statistical analysis and preparation of the data. All authors approved the final version of the article. DM is the guarantor. Sponsor’s Role: The funding sources had no role in the design or conduct of the study; collection, management, analysis, or interpretation of the data; or preparation, review, or approval of the manuscript.

Combined hypertension and orthostatic hypotension in older patients: a treatment dilemma for clinicians

The combination of hypertension and orthostatic hypotension in older individuals is becoming increasingly recognized. Managing this combination of disorders presents a treatment dilemma – how to lower blood pressure to provide cardiovascular risk protection without predisposing to syncope. At present, there is no specific evidence base available with regard to managing such patients. Some antihypertensive drug classes (e.g., α-blockers) appear more problematic in this regard than others. In the absence of controlled-trial evidence, use of antihypertensives with a more gradual onset of effect commenced at lower doses and use of lower-limb compression hosiery appears to be a reasonable approach. Abdominal compression devices and elevating the head of the bed may also help to combat orthostatic hypotenstion in older patients with hypertension and warrant future research.

POSTTRAUMATIC SUBGALEAL HEMATOMA WITH ORBITAL EXTENSION ASSOCIATED WITH CLOPIDOGREL USAGE IN AN ELDERLY PATIENT: CASE REPORT

is an early risk factor for the development of Alzheimer amyloid pathology. Neurology 2003;61:199–205. 7. Hall K, Murrell J, Ogunniyi A et al. Cholesterol, APOE genotype, and Alzheimer disease: An epidemiologic study of Nigerian Yoruba. Neurology 2006;66:223–227. 8. Wirths O, Thelen K, Breyhan H et al. Decreased plasma cholesterol levels during aging in transgenic mouse models of Alzheimer’s disease. Exp Gerontol 2006;41:220–224. 9. Simons M, Keller P, De Strooper B et al. Cholesterol depletion inhibits the generation of beta-amyloid in hippocampal neurons. Proc Natl Acad Sci U S A 1998;95:6460–6464. 10. Joseph JA, Villalobos-Molinas R, Denisova NA et al. Cholesterol: A two-edged sword in brain aging. Free Radic Biol Med 1997;22:455–462.

Dispelling myths regarding the safety of ‘bronchoscopy in octogenerians’

was defined using a reported version of the Edmonton Frail Scale, a validated scale for use by non-clinicians that assesses cognition, health attitudes and mood, medication use, nutrition, continence, burden of medical illness, social support and functional independence [2]. Furthermore, our study found a significant difference in the rates of embolic stroke and death between patients deemed frail and those deemed non-frail. The study also found that frail patients were more likely to have a haemorrhagic event 3 and 6 months post-discharge. Frailty was associated with age but not directly related to age. In fact frailty was better correlated with disability and co-morbidity than with age. Our findings support the view of Drs Khan and Myers that age alone should not (and does not) determine prescribing of antithrombotic medication for older patients with AF. A previous interventional study in the same hospital acknowledged this issue by specifically excluding age per se from the decision-making process, and instead focussing on medical, functional, cognitive, iatrogenic and social factors affecting the use of antithrombotics [3]. The present study follows from this in evaluating additional factors that may help determine the optimum treatment for older patients with AF. We found that frailty may be a useful risk stratification tool for such patients. Most of the factors that Drs Khan and Myers advocate considering in anticoagulation of older patients would be assessed using the frailty tool that was applied in our study. Differences in the event rates observed between our studies may relate to the populations studied: our participants all had AF, were recruited from acute care wards, were followed over 6 months and were not all anticoagulated; while their participants had a range of conditions, were followed for an average of 3.78 years in the community and were all anticoagulated. It is possible that there was a higher prevalence of frailty in our study (64% of participants) than in the population reported by Drs Khan and Myers, which may contribute to the higher rates of adverse events we observed. Risk stratification tools such as frailty are valuable when prescribing for older patients, who have wide inter-individual variability, and potentially have much to gain from medication as well as a high risk of adverse drug reactions.

Management of transient ischemic attack: 2005

Transient ischemic attack is a common presenting problem to clinicians. Historically, these events were defined by the resolution of new neurologic symptoms within a 24-h time-frame; however, recent data suggests that a 1-h time frame is more appropriate. New imaging techniques and clinical evidence suggests that transient ischemic attacks present a higher risk of impending stroke than previously thought. This has led to a redefinition of what constitutes an attack, and also to a focus on both earlier investigation and treatment of correctable causes. New antiplatelet agents are now available and pose a challenge as to how they should be prescribed. Carotid endarterectomy is the standard of care for a subset of transient ischemic attack patients with significant carotid stenosis. Carotid angioplasty and stenting are more recent developments that may further expand treatment options.

4CPS-199 Introducing a clinical pharmacist to a care of the elderly (coe) day hospital

Background Medication review is an essential part of comprehensive geriatric care, and is a primary function of the clinical pharmacist (CP). A new CP service has been established in a Care of the Elderly (COE) Day Hospital with the aim of improving outcomes from medication use. The CP service centres on medication review and patient education. Purpose To develop a clinical pharmacy service in the day hospital to improve the quality of pharmaceutical care provided to care of the elderly patients. Material and methods Data from the first 3 months of the service were collected prospectively to measure the quantity and type of CP interventions. The potential clinical outcome of each intervention was assessed by the day hospital CP and a gerontology SpR using a validated visual analogue scale (0–10, 0 representing no potential effect and 10 representing death). The frequency with which advised changes were acted upon by the treating doctor was also recorded. Results One hundred and ninety-five patients (mean 81 years, age range 58–98 years) were reviewed during 33 clinic days. A current medication list was obtained for all patients and an average of 1.8 pharmaceutical care interventions were identified per patient. Of these 340 interventions, the medical team or patient agreed with 54%, 39% were not accepted and 6% had an unknown outcome. The interventions were classified according to type as follows: 18% actual or potential adverse reaction, 14% each for supratherapeutic dose and untreated indication, 11% subtherapeutic dose and 10% each for improper administration, drug without indication and education provided to the patient. The clinical significance mean scores were categorised as leading potentially to minor harm (<3)=10%, moderate harm (3–7)=89% and severe harm (>7)=1%. Good agreement was observed between the two assessors (Pearson correlation coefficient=0.97). Conclusion CP medication usage review in the day hospital has resulted in a positive contribution to the care of elderly patients. Opportunities to improve visibility of the service will be explored. No conflict of interest

294Working Differently to Greatly Improve Care for Frail Patients Attending the Emergency Department

Background: Recognising the often complex medical, functional and social care needs of frail older patients presenting to the Emergency Department provided the impetus to improve the care model at the front door. In line with best practice, the principles of A) early identification of need and B) early initiation of treatment were adopted by establishing the Frail Intervention Therapy (FIT) Team in the Emergency Department (ED). The team comprises Physiotherapy, Occupational Therapy, Medical Social Work, Speech & Language Therapy, Dietetics and Pharmacy. Following an interdisciplinary approach to care, within one hour of presentation to the ED, the team assesses all patients over 75 years to determine their treatment needs and the appropriate care pathway. Methods: The team developed a common screening tool to identify the appropriate care pathway i.e. admission or discharge. Working with medical and nursing colleagues, patients deemed suitable for admission are fast-tracked to the Specialist Geriatric Ward or alternatively, those appropriate for discharge are offered follow-up home therapy. Results: Patients suitable for admission receive therapy from the FIT team on their day of presentation. Once admitted, handover is provided to the in-patient Health and Social Care Professional team, thereby avoiding delays thus leading to better outcomes, including reduced readmissions, reduced long term care and lower costs. Encouragingly, in 2016, early initiation of treatment led to a 33% increase in patients being discharged home rather than converting to long-term care. Furthermore, during a five month period in 2016, 6% of patients (55 patients) were successfully discharged and maintained at home (at 30 days), saving over 800 bed days. Conclusions: This successful model has been replicated nationally in 2017. Furthermore, the outreach model has been instrumental in informing the design of the National Integrated Care Teams due for establishment this year supported by the Integrated Older Persons’ Clinical Care Programme.

091Get Rid of the Lid: Reducing the Use of Lidded Beakers on a Care of the Elderly Ward

Background: Drinking from a lidded beaker increases the risk of aspiration as it encourages a head back position where the neck is extended, opening the airway. Carrión et al. (2015) reported that 47.4% of Frail Older Persons admitted to an acute geriatric unit presented with oropharyngeal dysphagia, therefore limiting aspiration risk is an important consideration. It was subjectively observed by ward staff that lidded beakers were commonly being used for patients. This project aimed to investigate and reduce the use of lidded beakers on a care of the older persons’ ward. Methods: A quality improvement methodology was employed. Quantitative and qualitative methods were used to investigate use of lidded beakers on a care of the elderly ward. Discussion groups and questionnaires were used to investigate staff perceptions and knowledge, to inform the intervention. Weekly education sessions were provided to ward staff and weekly auditing was completed to measure the use of lidded beakers throughout the intervention. Descriptive statistics were used to illustrate data collected. Results: The initial audit showed that 80% of patients on a care of the elderly ward received their tea in a lidded beaker. The intervention resulted in a steady decline in the use of lidded beakers over a 7 week period, with only 6% of patients receiving their tea in a lidded beaker by week 7. Conclusions: An education focused quality improvement intervention was successful in reducing the use of lidded beakers on a care of the elderly ward, which is an important consideration in reducing aspiration risk. References Carrión S, Cabré M, Monteis R, Roca M, Palomera E, Serra-Prat M, Rofes L, Clavé P. Oropharyngeal dysphagia is a prevalent risk factor for malnutrition in a cohort of older patients admitted with an acute disease to a general hospital. Clin Nutr 2015; 34: 436–42.

066Concordance of FDG-PET Imaging with Neuropsychological Assessment in Patients Presenting with Cognitive Impairment with Atypical Features

Background: Diagnosis of dementia remains primarily a clinical one and can be challenging in atypical cases. Advances in functional neuroimaging and increased availability have meant that updated guidelines from the National Institute of Ageing and Alzheimer’s Association (NIAA/AA) and the revised Diagnostic and Statistical Manual of Mental Disorders 5th Edition (DSM-5) include the use of such modalities as supportive measures in atypical cases. We sought to compare the concordance of findings on fluorodeoxyglucose-positron emission tomography (FDG-PET) with neuropsychological assessment in a convenience sampling of patients attending the Geriatric Medicine outpatient service of a large teaching hospital. Methods: We identified 11 patients with FDG-PET imaging that had also undergone neuropsychological assessment from a retrospective analysis of attendees to our outpatient clinics. Detailed interpretive reports were available for all FDG-PET studies. Neuropsychological assessments were reviewed and deficits identified, with scores greater than two standard deviations below the mean (both when compared with normative data from age-matched peers and with the patient’s own estimated pre-morbid IQ) considered abnormal. Results: On neuropsychological assessment, 8 out of 11 had abnormalities detected in at least one cognitive domain. Of these, 7 out of 8 had abnormalities on functional imaging. Of those with normal neuropsychological assessments, 2 out of 3 had abnormalities on imaging, giving an overall concordance rate of 73%. Conclusion: Concordance between abnormalities identified on FDG-PET imaging and neuropsychological assessment was high but not absolute, as evidenced by patients with normal neuropsychological findings and abnormal imaging and vice versa. Current functional imaging techniques, while useful, remain only one part of a multifaceted approach to the evaluation of suspected cognitive impairment.