Paul Claffey

173The Alzheimer’s Questionnaire: Optimising Cut Points for an Irish Memory Clinic Population

Oisín Hannigan, Ontefetse Ntlholang, Clodagh Power, Paul Claffey, Ruth Roseingrave, Rachel Farley, Irene Bruce, Matthew Gibb, Marie McCarthy, Keneilwe Malomo, Robert Coen, Mircea Balasa, Brian Lawlor, David Robinson Mercer’s Institute for Successful Ageing, St. James’s Hospital, Dublin 8, Ireland Global Brain Health Institute, Trinity College Dublin, Dublin 2, Ireland Cappagh National Orthopaedic Hospital, Finglas, Dublin 11, Ireland

055Point Prevalence of Malignancy in a Geriatric Medicine Inpatient Cohort

Background: With Ireland’s ageing demographics and increasing risk factor prevalence, the incidence of cancer is expected to double by 2040 [1]. This will lead to a fourfold increase in its prevalence, presenting an important challenge for the provision of optimal cancer care to older persons. We set out to evaluate the point prevalence of current and prior diagnosis of malignancy in a specialised geriatric medicine inpatient population of an acute hospital. Methods: Data was extracted by reviewing the electronic patient record and paper chart of each patient under the care of the geriatric medicine service on a single week day. Information regarding demographics, current and prior cancer diagnosis and treatment was recorded. Results: On the day of data collection, there were 154 inpatients under the care of our geriatric service. The median age was 83 years; 71 (46.1%) were male. The prevalence of current diagnosis of cancers excluding non-melanoma skin cancer was 12.34% while the prevalence of previous cancer diagnosis was 16.23%. The commonest current cancer diagnoses were that of female breast (n = 3), lung (n = 2), colorectal (n = 2), mouth & pharynx (n = 2), multiple myeloma (n = 2) and others (n = 8). Twelve had had surgery or were undergoing treatment during this hospitalisation. Six were being managed conservatively. Of those that received treatment, 4 were treated with surgery alone and 3 were on hormonal therapy. Conclusion: Geriatric oncology is an increasingly recognised and evolving subspecialty. Our findings highlight the prevalence of current and prior malignancy in a geriatric medicine inpatient cohort and support the need for further interspecialty training, opportunities for shared learning and the potential for increased integration of clinical services in the future. Reference 1. National Cancer Registry. Cancer projections for Ireland 2015–2040. Cork: National Cancer Registry, 2014.

198Red and Green Bed Day Patient Flow System in an Acute Geriatric Medicine Unit

Background: Patient flow through acute hospital facilities is a challenge to healthcare organisations particularly in relation to older frailer individuals with multiple comorbidities and complex care needs. The Red and Green Bed Day patient flow system developed by Dr I. Sturguss in the NHS has been demonstrated to reduce acute hospital inpatient length of stay. Methods: We used the Red and Green Bed Day patient flow system, over 12 consecutive weekdays within 2 geriatric medical teams. A red-bed day was identified as a bed day where no activity had occurred to progress a patient to discharge and where patients were in receipt of care that did not require an acute hospital bed. Results: Over the 12 days of the study, there were 510 inpatient bed days assessed with the red and green bed day protocol. On average there were 45 (range 41 to 53) patients per day under the 2 teams with a median age of 82 years (range 71 to 98). The study identified 275 (54%) red days and 235 (46%) green days. Commonest reasons for redbed days included (n, %): awaiting long-term care (110, 40), awaiting home care package (91, 33.1), awaiting offsite transitional care (18, 6.5) awaiting care planning meeting (11, 4), awaiting diagnostics (10, 3.6), awaiting interventional procedure (14, 5.1), awaiting transfer to a hospice facility (8, 2.9) and awaiting specialist consultation (5, 1.8). Red-bed days due to community and hospital factors were 227 (82.5%) and 48 (17.5%) respectively. Conclusions: We established that the Red and Green Bed Day patient flow system can be used in an acute geriatric medicine unit. It served as a valuable tool in objectively identifying and quantifying factors contributing to unnecessary prolongation of acute hospital stay.

238Hyperparathyroidism: How Much do Calcium and Vitamin D Matter?

Background: Hyperparathyroidism is associated with increased bone turnover and fractures. We aimed to determine its prevalence in patients attending our osteoporosis clinic, and investigate relationships between their serum calcium, vitamin D, bone turnover markers, bone mineral density (BMD), DXA T-scores and fracture history. Methods: We identified records from 2003–2017, collecting data on parameters above, and parathyroid imaging. Normal calcium level defined as 2.35–2.50 nmol/litre; normal vitamin D =/> 50 nmol/litre; normal PTH < 2.65 pg/ml. Results: 7624 patients; 364 (4.77%) had elevated PTH; 27 with incomplete data excluded. Of remaining 337, 294 female, 43 male; median age 76, mean T-score spine −2.6, mean T-score hip −2.4; overall osteoporosis prevalence 68.8%; 19% had prior hip fracture, 49% vertebral, and 21% Colles. 16 with eGFR < 30 ml/min excluded. Of the remaining 321, 53 (16.5%) hypercalcaemic, 69 (21.5% normocalcaemic and 199 (62%) hypocalcaemic. 182 had low vitamin D, implying secondary hyperparathyroidism; 139 normal vitamin D, implying primary hyperparathyroidism. Of 139 with likely primary hyperparathyroidism, we compared those with normal calcium level to those with high calcium: No significant differences in BMD spine/hip, prevalence of osteoporosis or fragility fracture. P1NP – a bone formation marker – was significantly higher in normocalcaemic group (mean difference 17.483 ng/ml, p = 0.049). 57 patients had parathyroid ultrasound or isotope scans. 22 positive for adenoma; 35 negative. Scans significantly more likely to be positive in patients with high calcium compared with normal calcium (likelihood ratio 5.671, p = 0.0173, ChiSquare test). 13 positive scans were in patients with low vitamin D. Conclusions: Patients with hyperparathyroidism were relatively older, osteoporotic and had high prevalence of fractures, low serum calcium and vitamin D. Low vitamin D was a poor negative predictor of adenoma. Although normocalcaemic patients were less likely to have a radiologically-proven adenoma, they appeared to carry a similar risk of osteoporosis and fracture as those with high calcium/adenoma.

254Should We Assess and Treat Anterior Choroidal Artery Strokes Differently

Background: Descriptions of the neuroanatomical distribution, clinical manifestations and aetiology of infarction of the anterior choroidal artery (AChA) vary in the literature. Foix’s original syndrome identified features of contralateral hemiplegia, hemihypoaesthesia and homonymous hemianopia. Methods: Ten consecutive patients with probable isolated AChA distribution stroke confirmed on MRI were examined. We compared clinical features found against Foix’s characteristic syndrome. Results: Six subjects were female and six had left hemispheric infarction. Subjects were younger than an unselected stroke register derived group (300 subjects) with cerebral infarct (mean 58.7 vs.70.2 years p = 0.03, t-test). Eight initially presented with hemiplegia, 7 with sensory loss but none with visual field deficit. Nine were identified with dyspraxia of motor and/or speech function during assessment. At discharge median modified Rankin score was 1.5 (range 0–3). Upper limb weakness was the most predominant persistent neurological finding (n = 7). This was characteristically more severe distally (mean MRC score 2.8 vs.3.5 p = 0.2 paired t-test). Aetiologically, 6 were cardioembolic and 4 were cryptogenic. On MRI review, only one AChA infarct involved the ipsilateral uncus and hippocampal region; the rest involved the region of the posterior internal capsule extending in an inverted cone shape into the white matter adjacent to the cella media, an area also commonly affected by M1 distribution Middle Cerebral Artery distribution infarction. Conclusion: In this series, hemiplegia and hemihypoaesthesia were found in the majority of subjects; hemianopia appears infrequent. Dyspraxia of speech and/or motor function seems to be a prominent feature and this is yet to be widely evaluated. If infarction volume is related to the degree of collateralisation within the M1 territory, then the AChA territory may be more susceptible to blood pressure variations. This may present important implications for the way these strokes are managed acutely. Rapid identification by emergent MRI may be warranted for suspected AChA strokes.

147Rapidly-progressive Cerebral Amyloid Angiopathy: A Bleeding Catastrophe

Background: Cerebral amyloid angiopathy (CAA) is increasingly recognised as a cause of intracerebral haemorrhage and dementia in older patients. The deposition of amyloid beta peptide leads to a series of destructive alterations in vascular architecture, predisposing to haemorrhage. The presence of CAA leads to a substantial risk of recurrent haemorrhage, with one cohort of 71 survivors of intracerebral haemorrhage having a 2-year cumulative recurrence rate of 21% (Greenberg and Wilterdink, 2013). Recurrent haemorrhages are associated with a high mortality rate. Methods: This is a qualitative report of 3 patients with recurrent intracerebral haemorrhages at short intervals, with all fulfilling Boston Criteria for probable CAA. All patients came under the care of the Stroke Service at Hospital X, with 2 receiving ongoing care for haemorrhages. Results: The first patient, a 75-year old female, had 3 lobar intracerebral haemorrhages within 4 weeks, and died as a consequence of these. The second patient, a 66-year old female, presented with right occipital and left parietal lobe haemorrhages, and went on to have 2 further haemorrhages within the following 6 months. Interestingly, there were no microhaemorrhages evident on gradient-echo MRI imaging; however, cerebrospinal fluid analysis demonstrated decreased beta amyloid, and high total and phosphorylated Tau, supporting the diagnosis of CAA. The final patient, a 71-year old female, presented with a frontal lobar haemorrhage, and had 2 further lobar haemorrhages over the next month. Conclusions: There is a subgroup of patients in whom the intervals between intracerebral haemorrhages secondary to CAA are short. The factors responsible for this are not well-understood. Further investigation is required to establish the pathophysiology of these cases, with a view to instigating therapeutic interventions. Reference O’Donnell HC et al. “Apolipoprotein E Genotype And The Risk Of Recurrent Lobar Intracerebral Hemorrhage. Pubmed NCBI”. Ncbi.nlm.nih.gov. N.p., 2017. Web. 23 May 2017.