David William Molloy

Dementia in older people admitted to hospital: a regional multi-hospital observational study of prevalence, associations and case recognition

Background: previous studies have indicated a prevalence of dementia in older admissions of ∼42% in a single London teaching hospital, and 21% in four Queensland hospitals. However, there is a lack of published data from any European country on the prevalence of dementia across hospitals and between patient groups. Objective: to determine the prevalence and associations of dementia in older patients admitted to acute hospitals in Ireland. Methods: six hundred and six patients aged ≥70 years were recruited on admission to six hospitals in Cork County. Screening consisted of Standardised Mini-Mental State Examination (SMMSE); patients with scores <27/30 had further assessment with the Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE). Final expert diagnosis was based on SMMSE, IQCODE and relevant medical and demographic history. Patients were screened for delirium and depression, and assessed for co-morbidity, functional ability and nutritional status. Results: of 598 older patients admitted to acute hospitals, 25% overall had dementia; with 29% in public hospitals. Prevalence varied between hospitals (P < 0.001); most common in rural hospitals and acute medical admissions. Only 35.6% of patients with dementia had a previous diagnosis. Patients with dementia were older and frailer, with higher co-morbidity, malnutrition and lower functional status (P < 0.001). Delirium was commonly superimposed on dementia (57%) on admission. Conclusion: dementia is common in older people admitted to acute hospitals, particularly in acute medical admissions, and rural hospitals, where services may be less available. Most dementia is not previously diagnosed, emphasising the necessity for cognitive assessment in older people on presentation to hospital.

The Community Assessment of Risk Instrument: Investigation of Inter-Rater Reliability of an Instrument Measuring Risk of Adverse Outcomes.

BACKGROUND Frailty is increasingly common in community dwelling older adults and increases their risk of adverse outcomes. Risk assessment is implicit in the Aged Care Assessment Teams process, but few studies have considered the factors that influence the assessors decision making or explored the factors that may contribute to their interpretation of risk. OBJECTIVE to examine the inter-rater reliability of the Community Assessment of Risk Instrument (CARI), which is a new risk assessment instrument. DESIGN A cohort study was used. SETTING AND PARTICIPANTS A sample of 50 community dwelling older adults underwent comprehensive geriatric assessment by two raters: a geriatrician and a registered nurse. Procedure and measurements: Each participant was scored for risk by the two raters using the CARI. This instrument ranks risk of three adverse outcomes, namely i) institutionalisation, ii) hospitalisation and iii) death within the next year from a score of 1, which is minimal risk to 5, which is extreme risk. Inter-rater reliability was assessed with Gamma, Spearman correlation and Kappa statistics. Internal consistency was assessed with Cronbachs alpha. RESULTS There were 30 female (mean age 82.23 years) and 20 male (mean age 81.75 years) participants. Items within domains showed good-excellent agreement. The gamma statistic was >0.77 on 6/7 Mental State items, 14/15 items in the Activities of Daily Living domain. In the Medical domain, 6/9 items had Gamma scores >0.80. The global domain scores correlated well, 0.88, 0.72 and 0.87. Caregiver network scores were 0.71, 0.73 and 0.51 for the three domains. Inter-rater reliability scores for global risk scales were 0.86 (institutionalisation) and 0.78 (death). The gamma statistic for hospitalisation was 0.29, indicative of lower inter-rater reliability. Cronbachs alpha was 0.86 and 0.83 for the Activities of Daily Living domain, 0.51 and 0.42 for the Mental state domain and 0.23 and 0.10 for the Medical state domain. CONCLUSIONS Overall, the instrument shows good inter-rater reliability. Poor correlations on some items relate to poor communication of clinical data and variable interpretation based on professional background. Lack of internal consistency in the medical condition domain confirms the discrete nature of these variables.

Five short screening tests in the detection of prevalent delirium: diagnostic accuracy and performance in different neurocognitive subgroups

Delirium is prevalent and serious, yet remains under‐recognised. Systematic screening could improve detection; however, consensus is lacking as to the best approach. Our aim was to assess the diagnostic accuracy of five simple cognitive tests in delirium screening: six‐item cognitive impairment test (6‐CIT), clock‐drawing test, spatial span forwards, months of the year backwards (MOTYB) and intersecting pentagons (IPT).

34 An investigation of gastrointestinal symptoms, psychological well-being and cognitive performance in informal dementia caregivers

Background Caring for a relative with dementia is considered particularly stressful and is associated with numerous adverse health effects at multiple levels of the brain-gut axis. There is also evidence that long-term family caregivers are more likely to develop irritable bowel syndrome. Aim The current study aimed to compare family dementia caregivers to a non-caregiver control group, and to examine the impact of interventions, designed to help dementia caregivers manage stress and the caregiving role, on gastrointestinal symptoms, cognitive performance and psychological well-being. Method Caregiver participants were recruited via clinics at St. Finbarr’s Hospital, Cork and control participants via the university community. Participants completed the irritable bowel syndrome symptom severity scale, as well as validated tests of stress, anxiety, and depression. Participants also completed cognitive tasks from the CANTAB battery. A subset of caregivers completed both a carer training program and mindfulness-based stress reduction program. Each program was delivered in a group setting by an experienced instructor and lasted 6-8 weeks. Results Although caregivers had higher levels of stress and poorer cognitive performance, gastrointestinal symptoms were not altered compared to controls. Following both interventions, caregivers had improved cognitive performance. However, reported stress, anxiety and depression were not significantly altered following the interventions. Stress-reduction interventions also had no significant impact on gastrointestinal function. Conclusions The stress associated with informal dementia caregivers does not manifest across gastrointestinal symptoms and stress-reduction techniques do not improve gastrointestinal well-being. This is in contrast to the impact of caregiving at higher levels of the brain-gut axis.

287Long Term Care Staff’s Educational Needs and Confidence in Providing End of Life Care Before and After an Educational Initiative

Background: Rising life expectancy, a growing older population and societal trends, have led to increasing numbers of older people residing and ultimately dying in long term care (LTC). It is essential therefore that LTC staff be knowledgeable, skilled and supported in providing high quality end of life (EoL) care. Research has found those dying in LTC have unmet palliative care needs and suboptimal palliative care education amongst LTC staff. Education is optimised if staff ’s training needs are considered. This study aimed to assess these needs and the impact of a general palliative care educational programme on staff perceptions and confidence in providing EoL care for residents in three LTC facilities. Methods: In this qualitative descriptive study, LTC staff completed detailed questionnaires before, and after delivery of a palliative care educational programme tailored to the educational needs identified by staff, which included advance care planning (ACP) training. Results: There were 179 completed questionnaires. Before the programme, up to 58% of staff had no prior palliative care training, this fell to 32% in the period after the educational initiative, which 92% of attendees found useful. There were many common learning needs for nurses and healthcare assistants (HCAs), but nurses looked more for training on pain and symptom management whilst HCAs highlighted symptom assessment, recognising dying and addressing the emotional needs of the patient. Staff who had received palliative care training (and staff overall in the “after” period) were more confident in discussing end of life issues, dealing with bereaved families and nurses were more confident and knowledgeable in using a syringe driver. Interestingly the barriers to ACP changed amongst staff engaged in the process. Delivering education was challenging due to staff turnover and difficulties releasing staff to attend. Conclusions: The tailored palliative care training was well received and had a beneficial effect.

Delirium in Older Hospital Inpatients: Incidence, Prevalence and Motor Subtyping

AIM To identify predictors of negative in-patient outcomes (prolonged hospital stay and death) in nursing home (NH) residents admitted to the hospital as medical emergencies. METHODS This was a retrospective patient series set at St Jamess Hospital (Dublin, Ireland). The participants were all NH patients requiring acute medical admission under the on-call medical team between 1 January 2002 and 31 December 2010. Patient characteristics on admission, such as demographics, comorbidity level, major diagnostic categories, vital signs and laboratory profile, were measured. The outcomes of the study were prolonged hospital stay (≥ 30 days) and in-hospital mortality. The characteristics of NH patients were compared with those of non-NH patients aged ≥ 65 years. Multivariate analyses were based on generalized estimating equations and classification trees. RESULTS There were 55,763 acute medical admissions over the period, of which 1938 (3.5%) were from NH. As compared with non-NH patients aged ≥ 65 years, NH patients had greater acute illness severity. NH patients had a median length of stay of 7 days, and 17% had a prolonged admission. Their overall mortality rate was 23%. However, the classification analysis showed substantial patient heterogeneity; the subgroup with the highest mortality (54%, n = 100) had positive serum troponin and a respiratory major diagnosis. The lowest mortality rate (4%) was seen in those without positive troponin, urea of 12 mmol/L or less, and albumin of more than 37 mg/L (n = 226). CONCLUSIONS Simple serum markers, such as troponin, urea and albumin, might predict mortality in medically admitted NH patients. This might help health-care practitioners to anticipate their clinical course at an early stage.

Screening Cognitive Impairment in a Movement Disorder Clinic: Comparison of the Montreal Cognitive Assessment to the SMMSE

AIM To identify predictors of negative in-patient outcomes (prolonged hospital stay and death) in nursing home (NH) residents admitted to the hospital as medical emergencies. METHODS This was a retrospective patient series set at St Jamess Hospital (Dublin, Ireland). The participants were all NH patients requiring acute medical admission under the on-call medical team between 1 January 2002 and 31 December 2010. Patient characteristics on admission, such as demographics, comorbidity level, major diagnostic categories, vital signs and laboratory profile, were measured. The outcomes of the study were prolonged hospital stay (≥ 30 days) and in-hospital mortality. The characteristics of NH patients were compared with those of non-NH patients aged ≥ 65 years. Multivariate analyses were based on generalized estimating equations and classification trees. RESULTS There were 55,763 acute medical admissions over the period, of which 1938 (3.5%) were from NH. As compared with non-NH patients aged ≥ 65 years, NH patients had greater acute illness severity. NH patients had a median length of stay of 7 days, and 17% had a prolonged admission. Their overall mortality rate was 23%. However, the classification analysis showed substantial patient heterogeneity; the subgroup with the highest mortality (54%, n = 100) had positive serum troponin and a respiratory major diagnosis. The lowest mortality rate (4%) was seen in those without positive troponin, urea of 12 mmol/L or less, and albumin of more than 37 mg/L (n = 226). CONCLUSIONS Simple serum markers, such as troponin, urea and albumin, might predict mortality in medically admitted NH patients. This might help health-care practitioners to anticipate their clinical course at an early stage.