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.

249 A SURVEY OF IRISH DOCTORS VIEWS ON FLEXIBLE TRAINING

Background

We aimed to establish the views of non consultant hospital doctors working in Ireland on the options available for ‘Flexible Training’ or ‘Less-Than-Full-Time-Training’. Our population is ageing rapidly, and an expanding workforce will be required. Difficulties with doctor retention and recruitment are growing challenges in Ireland.

Methods

An anonymised survey of 9 questions was carried out using Survey Monkey®. Question format included multiple choice, yes/no or a free text box. This was disseminated via the Royal College of Physicians of Ireland to 1,557 trainees of the Institute of Medicine, the national postgraduate body for medical specialties. It was also circulated to members of the Irish Medical Organisation, the national medical organisation, and to approximately 200 doctors across two hospitals on social media.

Results

There were 674 (84.3%) respondents in training- 46.3% BST, 53.7% HST; and 125 (15.6%) non-training respondents. Doctors overwhelmingly felt trainees should have access to flexible training (n = 849, 99.41%), with 82.39% reporting they would apply (n = 702). Most (92.5%) felt that 16 WTE positions was inadequate (n = 789). Reasons chosen for not applying for flexible training included- 36.1% (n = 169) felt it could impact their career, 25.4% (n = 119) identified they did not meet the criteria, 14.32% (n = 67) reported no interest, while 24.1% (n = 113) gave ‘other’ reasons including lengthy training, salary impacts, and not having a requirement for flexible training. When asked about suggestions for improving flexible training, 19.7% chose ‘offer more places’, 6.7%-‘remove eligibility criteria’, 19.6% -‘offer job sharing options’, 9.5%- ‘allow more flexible training years’, 17.7% -‘regional based training’, 22.5% -‘all of the above’, 4.9%—‘other’.

Conclusion

Our survey suggests non consultant hospital doctors in Ireland strongly desire an expansion of current flexible training options. This is essential to ensure Ireland is an attractive place for doctors to work, to support their health and wellbeing, and to ensure an adequate workforce to care for an ageing population.

247 BENCHMARKING STROKE SERVICES TO INFORM A QUALITY IMPROVEMENT INIAITIVE

Background

Stroke is a leading cause of death and disability in Ireland. Continuous audit and quality improvement is essential in the delivery of stroke care where the evidence basis is constantly changing. This helps to ensure the delivery of high quality stroke care and compliance with evidenced based guidelines. We aimed to assess stroke care at an Irish university teaching hospital.

Methods

Patients with a HIPE discharge diagnosis of Cerebral Infarction or Cerebral Haemorrhage (1st January-31st December 2019) were identified through both the HIPE database and the institutional Stroke Portal. Data was benchmarked against national (Irish National Audit of Stroke 2019) and international (6th SSNAP Annual Report; American Heart Association, 2013) practice and used to inform a quality improvement strategy.

Results

419 patients were included (56.6% male, median 57 years). 75.9% were aged 65 years or older. We compared favourably with Irish National Audit of Stoke national indicators on the following: thrombolysis rates-10%; median door to needle time-60 mins; stroke unit admissions- 78.5%; median duration of symptoms- 3 hours 6 minutes; swallow assessment- 81.1%; in-patient mortality- 10.5%; rates of institutionalisation- 3.8%. Areas identified for improvement were: thrombectomy rates- 1.9%; median length of stay- 12 days; door to imaging time- median 104 minutes; mood screening- 11.5%.

Conclusion

International and national data is a useful benchmark against which local hospitals can assess the quality of their service. By completing this quality improvement initiative we identified areas to target resources in our centre, including mood screening, swallow screening, thrombectomy rates, length of stay and time to neuroimaging. An ongoing quality improvement process using ‘PDSA’ methodology is being carried out with an annual audit to monitor progress.