Diarmuid O’Shea

Undertaking a Collaborative Rapid Realist Review to Investigate What Works in the Successful Implementation of a Frail Older Person’s Pathway

We addressed the research question “what factors enable the successful development and implementation of a frail older person’s pathway within the acute setting”. A rapid realist review (RRR) was conducted by adopting the RAMESES standards. We began with a sample of 232 articles via database searches supplemented with 94 additional records including inputs from a twitter chat and a hospital site visit. Our final sample consisted of 18 documents. Following review and consensus by an expert panel we identified a conceptual model of context-mechanism-(resources)-outcomes. There was overall agreement frailty should be identified at the front door of the acute hospital. Significant challenges identified related to organisational boundaries both within the acute setting and externally, the need to shift outcomes to patient orientated ones, to support staff to sustain the pathway by providing ongoing education and by providing role clarity. RRRs can support research such as the systematic approach to improving care for frail older adults (SAFE) study by producing accounts of what works based on a wide range of sources and innovative engagement with stakeholders. It is evident from our provisional model that numerous factors need to combine and interact to enable and sustain a successful frail older person’s pathway.

047The Effectiveness of Stroke Rehabilitation in Older Old Patients Compared to a Group of Younger Stroke Patients

Background: The benefits of rehabilitation post stroke are widely accepted. However, the older old (patients over 80) are underrepresented in previous studies. We aimed to examine whether the benefits differ based on age. Method: All patients admitted to a specialist inpatient rehabilitation hospital post stroke between 2010–2016 were included. Patients were assessed for rehabilitation potential prior to transfer and received an individualised interdisciplinary rehabilitation programme. Admission and discharge Barthel scores were recorded. We analysed the change in Barthel index (BI) and length of stay (LOS) by age group. Results: 185 patients were included, 10 of these were excluded due to death, becoming unwell and self-discharge. Patients (47% men, mean age 77.8, 83% ischaemic strokes) were generally previously independent (81% modified Rankin 0–1). 32.6% of patients admitted for rehabilitation showed no evidence of cognitive impairment, 29.1% had mild cognitive impairment, 22.9% moderate cognitive impairment and 11.4% severe cognitive impairment. Mean increase in Barthel did not differ across the age groups and there was no significant difference in LOS. For all age groups, the mean BI on admission was 13 (4.7 SD), 15.6 on discharge (4.34 SD) with a mean LOS of 82 days. In the under 65’s (n = 13), the mean BI on admission was 13.8 (6.1 SD), 16.1 (4.9 SD) on discharge with a mean LOS of 78 days (70 SD). Over 85 s (n = 35), mean BI on admission 11(4.2 SD), 13.3 (4.8 SD) on discharge, LOS 89 days (67 SD).The mean change in BI was 2.9 for the 76–85 group and 2.3 for other age groups. p values for BI change and LOS trends across age groups were non-significant. 81% of patients were discharged home. Conclusion: Stroke rehabilitation can be as effective in older old people as in younger people. Age should not be a barrier to access rehabilitation and selection criteria should be the same as their younger counterparts.

161Advance Care Plans - A Day Hospital Perspective

Background: Advance Care Plans (ACPs) aim to involve the patient in all aspects of their care, and are known to improve the quality of end of life care. They may be of particular benefit in addressing the needs of people with dementia. We aimed to examine the presence or absence of ACPs in a frail, older population. Methods: 40 randomly selected charts were retrospectively reviewed of patients who had been attending a day hospital for at least two years, with an established diagnosis of a neurodegenerative disorder. Results: Of the 40 patients reviewed, the most common diagnosis was Parkinson’s Disease with or without dementia (15/40) followed by mixed type dementia (7/40), vascular dementia (7/40), Alzheimer’s dementia (5/40), undifferentiated dementia (4/40) and frontotemporal dementia (2/40). The median age was 85 years (range 68–100), and 38/40 were residing in their own home, the remaining two patients were nursing home (NH) residents. The median duration of diagnosis was 4 years (range 1–32) and the median Clinical Frailty Scale (CFS) was 6 (range 4–8). 11/40 had a hospitalisation in the preceding year. 3/40 patients had a written advance care plan in their notes. A discussion had occurred in a further 2/40, but no formal outcomes had been documented. Neither of the two NH residents had an ACP, nor had any of those who had been hospitalised. Conclusions: The day hospital could be an ideal setting to involve patients and their families in discussing future wishes and care considerations in this particularly frail cohort. Consideration should be given to exploring the barriers to advance care plans, within both the medical profession and the general population. When reviewing these patients in the day hospital, there may scope to introduce specific care planning tools such as the Goals of Care Designation document.