Long-term antipsychotic use, orthostatic hypotension and falls in older adults with Alzheimer's disease

PURPOSE

Antipsychotic use in Alzheimer disease (AD) is associated with adverse events and mortality. Whilst postulated to cause/exacerbate orthostatic hypotension (OH), the exact relationship between antipsychotic use and OH has never been explored in AD-a group who are particularly vulnerable to neuro-cardiovascular instability and adverse effects of medication on orthostatic blood pressure (BP) behaviour.

METHODS

We analysed longitudinal data from an 18-month trial of Nilvadipine in mild-moderate AD. We assessed the effect of long-term antipsychotic use (for the entire 18-month study duration) on orthostatic BP phenotypes measured on eight occasions, in addition to the relationship between antipsychotic use, BP phenotypes and incident falls.

RESULTS

Of 509 older adults with AD (aged 72.9 ± 8.3 years, 61.9% female), 10.6% (n = 54) were prescribed a long-term antipsychotic. Over 18 months, long-term antipsychotic use was associated with a greater likelihood of experiencing sit-to-stand OH (ssOH) (OR: 1.21; 1.05-1.38, p = 0.009) which persisted on covariate adjustment. Following adjustment for important clinical confounders, both antipsychotic use (IRR: 1.80, 1.11-2.92, p = 0.018) and ssOH (IRR: 1.44, 1.00-2.06, p = 0.048) were associated with a greater risk of falls/syncope over 18 months in older adults with mild-moderate AD.

CONCLUSION

Even in mild-to-moderate AD, long-term antipsychotic use was associated with ssOH. Both antipsychotic use and ssOH were associated with a greater risk of incident falls/syncope over 18 months. Further attention to optimal prescribing interventions in this cohort is warranted and may involve screening older adults with AD prescribed antipsychotics for both orthostatic symptoms and falls.

Achievement of Target Gain Larger than Unity in an Inertial Fusion Experiment

On December 5, 2022, an indirect drive fusion implosion on the National Ignition Facility (NIF) achieved a target gain G_{target} of 1.5. This is the first laboratory demonstration of exceeding "scientific breakeven" (or G_{target}>1) where 2.05 MJ of 351 nm laser light produced 3.1 MJ of total fusion yield, a result which significantly exceeds the Lawson criterion for fusion ignition as reported in a previous NIF implosion [H. Abu-Shawareb et al. (Indirect Drive ICF Collaboration), Phys. Rev. Lett. 129, 075001 (2022)PRLTAO0031-900710.1103/PhysRevLett.129.075001]. This achievement is the culmination of more than five decades of research and gives proof that laboratory fusion, based on fundamental physics principles, is possible. This Letter reports on the target, laser, design, and experimental advancements that led to this result.

Clinical performance, safety, and patient-reported outcomes of an active osseointegrated bone-conduction hearing implant system at 24-month follow-up

PURPOSE

To investigate 2-year post-operative hearing performance, safety, and patient-reported outcomes of hearing-impaired adults treated with the Osia® 2 System, an active osseointegrated bone-conduction hearing implant that uses piezoelectric technology.

METHODS

A prospective, multicenter, open-label, single-arm, within-subject clinical study conducted at three tertiary referral clinical centers located in Melbourne, Sydney and Hong Kong. Twenty adult recipients of the Osia 2 System were enrolled and followed up between 12 and 24 months post-implantation: 17 with mixed or conductive hearing loss and 3 with single-sided sensorineural deafness. Safety data, audiological thresholds, speech recognition thresholds in noise, and patient-reported outcomes were collected and evaluated. In addition, pre-and 6-month post-implantation data were collected retrospectively for this recipient cohort enrolled into the earlier study (ClinicalTrials.gov NCT04041700).

RESULTS

Between 6- and 24-month follow-up, there was no statistically significant change in free-field hearing thresholds or speech reception thresholds in noise (p =  > 0.05), indicating that aided improvements were maintained up to 24 months of follow-up. Furthermore, improvements in health-related quality of life and daily hearing ability, as well as clinical and subjective measures of hearing benefit remained stable over the 24-month period. No serious adverse events were reported during extended follow-up.

CONCLUSIONS

These study results provide further evidence to support the longer term clinical safety, hearing performance, and patient-related benefits of the Osia 2 System in patients with either a conductive hearing loss, mixed hearing loss, or single-sided sensorineural deafness.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT04754477. First posted: February 15, 2021.

A comparative analysis exposes an amplification delay distinctive to SARS-CoV-2 Omicron variants of clinical and public health relevance

ABSTRACTMutations in the SARS-CoV-2 genome may negatively impact a diagnostic test, have no effect, or turn into an opportunity for rapid molecular screening of variants. Using an in-house Emergency Use Authorized RT-qPCR-based COVID-19 diagnostic assay, we combined sequence surveillance of viral variants and computed PCR efficiencies for mismatched templates. We found no significant mismatches for the N, E, and S set of assay primers until the Omicron variant emerged in late November 2021. We found a single mismatch between the Omicron sequence and one of our assay's primers caused a > 4 cycle delay during amplification without impacting overall assay performance.Starting in December 2021, clinical specimens received for COVID-19 diagnostic testing that generated a Cq delay greater than 4 cycles were sequenced and confirmed as Omicron. Clinical samples without a Cq delay were largely confirmed as the Delta variant. The primer-template mismatch was then used as a rapid surrogate marker for Omicron. Primers that correctly identified Omicron were designed and tested, which prepared us for the emergence of future variants with novel mismatches to our diagnostic assay's primers. Our experience demonstrates the importance of monitoring sequences, the need for predicting the impact of mismatches, their value as a surrogate marker, and the relevance of adapting one's molecular diagnostic test for evolving pathogens.

An electronic medical record reminder is independently associated with improved opportunistic influenza vaccination rates for older inpatients

BACKGROUND

Influenza vaccination will have added importance this winter given the possibility of further waves of the COVID-19 pandemic. This study examines the impact of an electronic medical record (EMR) reminder on influenza vaccine uptake among eligible hospital inpatients.

METHODS

We included a convenience sample of 750 adults (median age 77 years) who are eligible for influenza vaccination (⩾65 years and/or length of stay >30 days). A live electronic dashboard identified patients eligible for vaccination, prompting reminders sent to the clinical teams via the EMR.

RESULTS

The EMR reminder was associated with almost a 50% higher likelihood of vaccination after adjusting for other covariates (odds ratio 1.48 (95% confidence interval 1.00-2.20); p = 0.048).

DISCUSSION

Reminders sent to the clinical team via the EMR appear to be an effective means of increasing vaccine uptake and should be considered as part of this year's drive to vaccinate eligible patients in hospital.

Applying systems thinking to unravel the mechanisms underlying orthostatic hypotension related fall risk

Orthostatic hypotension (OH) is an established and common cardiovascular risk factor for falls. An in-depth understanding of the various interacting pathophysiological pathways contributing to OH-related falls is essential to guide improvements in diagnostic and treatment opportunities. We applied systems thinking to multidisciplinary map out causal mechanisms and risk factors. For this, we used group model building (GMB) to develop a causal loop diagram (CLD). The GMB was based on the input of experts from multiple domains related to OH and falls and all proposed mechanisms were supported by scientific literature. Our CLD is a conceptual representation of factors involved in OH-related falls, and their interrelatedness. Network analysis and feedback loops were applied to analyze and interpret the CLD, and quantitatively summarize the function and relative importance of the variables. Our CLD contains 50 variables distributed over three intrinsic domains (cerebral, cardiovascular, and musculoskeletal), and an extrinsic domain (e.g., medications). Between the variables, 181 connections and 65 feedback loops were identified. Decreased cerebral blood flow, low blood pressure, impaired baroreflex activity, and physical inactivity were identified as key factors involved in OH-related falls, based on their high centralities. Our CLD reflects the multifactorial pathophysiology of OH-related falls. It enables us to identify key elements, suggesting their potential for new diagnostic and treatment approaches in fall prevention. The interactive online CLD renders it suitable for both research and educational purposes and this CLD is the first step in the development of a computational model for simulating the effects of risk factors on falls.

The use of the World Guidelines for Falls Prevention and Management's risk stratification algorithm in predicting falls in The Irish Longitudinal Study on Ageing (TILDA)

BACKGROUND

the aim of this study was to retrospectively operationalise the World Guidelines for Falls Prevention and Management (WGFPM) falls risk stratification algorithm using data from The Irish Longitudinal Study on Ageing (TILDA). We described how easy the algorithm was to operationalise in TILDA and determined its utility in predicting falls in this population.

METHODS

participants aged ≥50 years were stratified as 'low risk', 'intermediate' or 'high risk' as per WGFPM stratification based on their Wave 1 TILDA assessments. Groups were compared for number of falls, number of people who experienced one or more falls and number of people who experienced an injury when falling between Wave 1 and Wave 2 (approximately 2 years).

RESULTS

5,882 participants were included in the study; 4,521, 42 and 1,309 were classified as low, intermediate and high risk, respectively, and 10 participants could not be categorised due to missing data. At Wave 2, 17.4%, 43.8% and 40.5% of low-, intermediate- and high-risk groups reported having fallen, and 7.1%, 18.8% and 18.7%, respectively, reported having sustained an injury from falling.

CONCLUSION

the implementation of the WGFPM risk assessment algorithm was feasible in TILDA and successfully differentiated those at greater risk of falling. The high number of participants classified in the low-risk group and lack of differences between the intermediate and high-risk groups may be related to the non-clinical nature of the TILDA sample, and further study in other samples is warranted.

Psychotropic medication use and future unexplained and injurious falls and fracture amongst community-dwelling older people: data from TILDA

PURPOSE

Psychotropic medications (antidepressants, anticholinergics, benzodiazepines, 'Z'-drugs and antipsychotics) are frequently identified as Falls Risk Increasing Drugs. The aim of this study is to clarify the association of psychotropic medication use with future falls/fracture amongst community-dwelling older people.

METHODS

Participants ≥ 65 years from TILDA were included and followed from Waves 1 to 5 (8-year follow-up). Incidence of falls (total falls/unexplained/injurious) and fracture was by self-report; unexplained falls were falls not caused by a slip/trip, with no apparent cause. Poisson regression models reporting incidence rate ratios (IRR) assessed the association between medications and future falls/fracture, adjusted for relevant covariates.

RESULTS

Of 2809 participants (mean age 73 years), 15% were taking ≥ 1 psychotropic medication. During follow-up, over half of participants fell, with 1/3 reporting injurious falls, over 1/5 reporting unexplained falls and almost 1/5 reporting fracture. Psychotropic medications were independently associated with falls [IRR 1.15 (95% CI 1.00-1.31)] and unexplained falls [IRR 1.46 (95% CI 1.20-1.78)]. Taking ≥ 2 psychotropic medications was further associated with future fracture (IRR 1.47 (95% CI 1.06-2.05)]. Antidepressants were independently associated with falls [IRR 1.20 (1.00-1.42)] and unexplained falls [IRR 2.12 (95% CI 1.69-2.65)]. Anticholinergics were associated with unexplained falls [IRR 1.53 (95% CI 1.14-2.05)]. 'Z'-drug and benzodiazepine use were not associated with falls or fractures.

CONCLUSION

Psychotropic medications, particularly antidepressants and anticholinergic medications, are independently associated with falls and fractures. Regular review of ongoing need for these medications should therefore be central to the comprehensive geriatric assessment.

Potential costs and consequences associated with medication error at hospital discharge: an expert judgement study

OBJECTIVES

Assessing the cost-effectiveness of complex pharmaceutical care interventions and medication error outcomes is hindered by lack of available data on actual outcomes consequent to errors that were intercepted for patient safety reasons. Expert judgement is an approach to acquire data regarding unknown parameters in an economic model which are otherwise insufficient or not possible to obtain. The aim of this paper is to describe a method to approach this problem using findings from a single intervention study and to calculate the potential costs and consequences associated with discharge medication error.

METHODS

Using data from a previous intervention study, the hypothetical consequences of medication error(s) at hospital discharge, in terms of diagnosis, healthcare resource utilisation and impact on health-related quality of life, were identified by expert judgement of anonymised cases. Primary healthcare utilisation costs were derived from published tariffs, inpatient costs were derived by simulation in the hospital discharge activity database test environment and the difference between adjudicated baseline and posterror health state was expressed as quality-adjusted life year (QALY) decrement.

RESULTS

Four experts provided judgement on 81 cases. Of these, 75 were judged to have potential clinical consequences. Between 56 and 69 of the 81 cases were variably judged to require remedial healthcare utilisation. The mean calculated cost per case (representing an individual patient), based on all 81 cases, was €1009.58, 95% CI 726.64 to 1585.67. The mean QALY loss was 0.03 (95% CI 0.01 to 0.05).

CONCLUSION

An expert judgement process proved feasible and useful to estimate financial cost and QALY loss associated with hospital discharge medication error. These estimates will be employed in model-based economic evaluation. This method could be transferred to other prospective observational patient safety research which seeks to assess value for money of complex interventions.

The 'Bermuda Triangle' of orthostatic hypotension, cognitive impairment and reduced mobility: prospective associations with falls and fractures in The Irish Longitudinal Study on Ageing

BACKGROUND

Orthostatic hypotension (OH), cognitive impairment (Cog) and mobility impairment (MI) frequently co-occur in older adults who fall. This study examines clustering of these three geriatric syndromes and ascertains their relationship with future falls/fractures in a large cohort of community-dwelling people ≥ 65 years during 8-year follow-up.

METHODS

OH was defined as an orthostatic drop ≥ 20 mmHg in systolic blood pressure (from seated to standing) and/or reporting orthostatic unsteadiness. CI was defined as Mini Mental State Examination ≤ 24 and/or self-reporting memory as fair/poor. MI was defined as Timed Up and Go ≥12 s. Logistic regression models, including three-way interactions, assessed the longitudinal association with future falls (explained and unexplained) and fractures.

RESULTS

Almost 10% (88/2,108) of participants had all three Bermuda syndromes. One-fifth of participants had an unexplained fall during follow-up, whereas 1/10 had a fracture. There was a graded relationship with incident unexplained falls and fracture as the number of Bermuda syndromes accumulated. In fully adjusted models, the cluster of OH, CI and MI was most strongly associated with unexplained falls (odds ratios (OR) 4.33 (2.59-7.24); P < 0.001) and incident fracture (OR 2.51 (1.26-4.98); P = 0.045). Other clusters significantly associated with unexplained falls included OH; CI and MI; MI and OH; CI and OH. No other clusters were associated with fracture.

DISCUSSION

The 'Bermuda Triangle' of OH, CI and MI was independently associated with future unexplained falls and fractures amongst community-dwelling older people. This simple risk identification scheme may represent an ideal target for multifaceted falls prevention strategies in community-dwelling older adults.

Hypotensive unawareness in Parkinson's disease-related autonomic dysfunction

This case demonstrates how orthostatic hypotension in the absence of typical symptoms of light-headedness/dizziness when changing posture, can contribute to the burden of falls in Parkinson's disease. At least one-third of people with severe orthostatic hypotension do not report typical symptoms, and this figure appears to be higher in patients with Parkinson's disease. This is important clinically as it can increase the difficulty in ascribing falls to orthostatic hypotension, especially given the other competing reasons in Parkinson's disease and orthostatic hypotension symptoms can act as a prompt for the patient to act to prevent falls-related injuries. There is a clinical requirement, therefore, to screen for and manage orthostatic hypotension in patients with Parkinson's disease to prevent falls, even in those who do not report typical symptoms.

The bi-directional association between loneliness and depression among older adults from before to during the COVID-19 pandemic

BACKGROUND

Older adults have both the highest risk of contracting SARS-CoV-2 and in many jurisdictions have had additional restrictions placed on the social interactions. As a result, the COVID-19 pandemic has led to increased depression and loneliness among older adults. Using data from an established cohort of older adults, the aims of this study was to describe changes in loneliness and depression and to examine the directionality of the association between depression and loneliness over a 5-year period that included the early months of the pandemic.

METHODS

Data were from The Irish Longitudinal Study on Ageing (TILDA), a large cohort of community-dwelling adults aged 54+. We applied an auto-regressive cross-lagged panel modelling approach to estimate the effect of depression on loneliness and vice versa over three time points.

RESULTS

Both depression and loneliness increased significantly in the early months of the pandemic. While the association between loneliness and depression was bi-directional, loneliness was a stronger predictor of depression.

CONCLUSION

The strength and bi-directionality of the association between loneliness and depression suggests that interventions to alleviate loneliness may also help reduce depressive symptoms and vice versa.

Asymptomatic orthostatic hypotension and risk of falls in community-dwelling older people

INTRODUCTION

Many older people with orthostatic hypotension (OH) may not report typical symptoms of dizziness, light-headedness or unsteadiness. However, the relationships between OH and falls in the absence of typical symptoms are not yet established.

METHODS

Continuous orthostatic blood pressure (BP) was measured during active stand using a Finometer at Wave 1 of The Irish Longitudinal Study on Ageing in participants aged ≥ 70 years.OH, with and without dizziness, was defined as a sustained drop in systolic BP ≥ 20 and/or diastolic BP ≥ 10 mm Hg at 30, 60 and 90 seconds post-standing.The association between symptoms of dizziness and orthostatic BP was assessed with multi-level mixed-effects linear regression; logistic regression models assessed the longitudinal relationship between OH and falls at 6-year follow-up (Waves 2-5).

RESULTS

Almost 11% (n = 934, mean age 75 years, 51% female) had OH, two-thirds of whom were asymptomatic.Dizziness was not associated with systolic BP drop at 30 (β = 1.54 (-1.27, 4.36); p = 0.256), 60 (β = 2.64 (-0.19, 5.47); p = 0.476) or 90 seconds (β = 2.02 (-0.91, 4.95); p = 0.176) after standing in adjusted models.Asymptomatic OH was independently associated with unexplained falls (odds ratio 2.01 [1.11, 3.65]; p = 0.022) but not explained falls (OR 0.93 [0.53, 1.62]; p = 0.797) during follow-up.

CONCLUSIONS

Two-thirds of older people with OH did not report typical symptoms of light-headedness. Dizziness or unsteadiness after standing did not correlate with the degree of orthostatic BP drop or recovery. Participants with asymptomatic OH had a significantly higher risk of unexplained falls during follow-up, and this has important clinical implications for the assessment of older people with falls.

336 ASYMPTOMATIC ORTHOSTATIC HYPOTENSION AND RISK OF FALLS IN COMMUNITY-DWELLING OLDER PEOPLE

Background

Many older people with Orthostatic Hypotension (OH) may not report typical symptoms of dizziness, light-headedness, or unsteadiness. However, the relationships between OH and falls in the absence of typical symptoms are not yet established.

Methods

Continuous orthostatic BP was measured during active stand using a Finometer at Wave 1 of TILDA in participants aged≥70 years. OH, with and without dizziness, was defined as a sustained drop in systolic BP≥20 and/or diastolic BP≥10 mm Hg at 30, 60 and 90 seconds post-standing. The association between symptoms of dizziness and orthostatic BP was assessed with multi-level mixed-effects linear regression; logistic regression models assessed the longitudinal relationship between OH and falls at 6-year follow-up (Waves 2-5).

Results

Almost 11% (n=934; mean age: 75 years; 51% female) had OH, two-thirds of whom were asymptomatic. Dizziness was not associated with systolic BP drop at 30 (β=1.54; –1.27, 4.36; p=0.256), 60 (β=2.6; –0.19, 5.47; p =0.476) or 90 (β=2.02; –0.91, 4.95; p=0.176) seconds after standing in adjusted models. Asymptomatic OH was independently associated with unexplained falls (Odds Ratio: 2.01; 1.11, 3.65; p=0.022) but not explained falls (OR 0.93; 0.53, 1.62; p=0.797) during follow-up.

Conclusion

Two-thirds of older people with OH did not report typical symptoms of light-headedness. Dizziness or unsteadiness after standing did not correlate with the degree of orthostatic BP drop or recovery. Participants with asymptomatic OH had a significantly higher risk of unexplained falls during follow-up, and this has important clinical implications for the assessment of older people with falls.

179 WHAT IS THE RISK OF FALLS DUE TO PSYCHOTROPIC MEDICATIONS IN A LARGE POPULATION-REPRESENTATIVE COHORT OF COMMUNITY-DWELLING OLDER PEOPLE?

Background

Psychotropic medications including antidepressants, anticholinergics, benzodiazepines, ‘Z’ drugs and antipsychotics, are frequently identified as Falls Risk Increasing Drugs (FRIDS), yet there is a relative lack of robust data detailing the prospective risk of falls associated with these drug classes.

Methods

Participants aged ≥65 years from the Irish Longitudinal Study on Ageing (TILDA) were included and followed from Waves 1 to 5 (Mean 7.6 years follow-up). Incidence of falls was ascertained by self-report and unexplained falls were defined as falls not caused by a slip or trip with no apparent cause. Medication lists were examined for medications of interest. Logistic Regression models, reporting odds ratio with 95% confidence intervals, were used to assess the association between medication classes and incident fall types and were adjusted for relevant covariates.

Results

2,090 participants were included (mean age at baseline 72 years, 53% female). During follow-up, over half of participants (52%, n=1,089) had a fall, with one quarter (25%, n=526) reporting an unexplained fall and almost one fifth (19%, n=394) reporting a fall causing injury. Anti-depressants were associated with an increased risk of falling (OR=3.01, 1.98-4.58, p&lt;0.001), injurious falls (OR=1.96, 1.37-2.81, p&lt;0.001) and unexplained falls (OR=2.71, 1.88-3.91, p&lt;0.001) in fully adjusted models. Anti-cholinergic medications were associated with an increased risk of falling (OR=1.79, 1.11-2.88, p=0.017) and of unexplained falls (OR=1.89, 1.19-3.01, p=0.007). ‘Z’ drugs were associated with an increased risk of falling (OR=2.96, 1.64-5.32, p&lt;0.001) and of injurious falls (OR=2.05, 1.26-3.34, p=0.004). Benzodiazepines and Anti-psychotics were not associated with incident falls in fully adjusted models.

Conclusion

Anti-depressants, anti-cholinergic medications and ‘Z’ drugs are independently associated with an increased falls risk. Given the profound impact falls can have on functional trajectory and quality of life, regular review of ongoing need for these medications should be central to the comprehensive geriatric assessment.

105 EVALUATION OF A NEW PHYSIOTHERAPY-LED VESTIBULAR SERVICE EMBEDDED IN THE FALLS AND SYNCOPE UNIT

Background

Clinical presentations in the falls and syncope unit (FASU) are diverse and require a range of skillsets. Vestibular disorders amount to a significant proportion of presentations. In our FASU, we embedded a 0.5 FTE specialist physiotherapist with expertise in vestibular disorders to work alongside medical and nursing staff. We conducted a service evaluation of the activity of this new service.

Methods

Retrospective Service Evaluation Approval was granted by our Research & Innovation Office. Pseudonymised data was collected corresponding to all new FASU physiotherapy service attendances between August 2021 and May 2022. Descriptive statistics were complemented by a binary logistic regression model to establish independent predictors of more than one physiotherapy session being required over the period.

Results

There were 104 episodes recorded by the new service, corresponding to 101 unique patients. Mean age was 67.7 (SD 19.0, range 17-93), and 73.1% were women. 67% were treated and discharged in 1 session. On average, patients had had a mean of 2 falls prior to the consultation (range 0-25). 28.8% were using a walking aid, and 54.8% self-reported fear of falling. 25% of the referrals to the service were due to suspected vestibular disorders, 62% of which were directly treated by the physiotherapy service. The logistic regression model adjusting by age, sex, use of walking aid, number of falls, and fear of falling showed that only referral for vestibular disorder was an independent predictor of patients needing more than 1 physiotherapy treatment (OR 3.91, 95% CI 1.32-11.58, P=0.014).

Conclusion

Vestibular disorders are common in FASU, and a majority can be treated by a specialist physiotherapy service. Repeated vestibular maneuvers are often needed in such patients. A responsive, embedded physiotherapy service in FASU can directly address this need and further evaluation will focus on the impact of this service on avoidance of ED attendances.

347 LONELINESS AMONGST OLDER INPATIENTS IN THE CONTEXT OF COVID-RELATED VISITING RESTRICTIONS

Background

Loneliness can affect people at all stages of life, but appears to be more closely linked to adverse health outcomes such as quality of life and healthcare use amongst older people. There are concerns that restrictions on hospital visits due to infection control policies related to the COVID-19 pandemic may exacerbate loneliness amongst older inpatients. The aim of this study is to quantify the burden of loneliness amongst older inpatients on a specialist geriatric medicine unit.

Methods

The study site is a large urban university teaching hospital with a 150-bed specialist geriatric medicine unit, comprising acute medical, rehabilitation and long-stay wards. The University of California, Los Angeles (UCLA) Scale was used to measure symptoms of loneliness with scores≥43 indicating high levels of loneliness.

Results

Over 84% of patients were lonely at some time while in hospital, with over one-third (24/76) reporting high levels of loneliness. The mean number of days since last visit from a relative or friend for patients reporting high degrees of loneliness was 11.4 (1.2 – 21.6) days, compared to 5.2 (3.2 – 7.1) days for those with reporting lower levels or no loneliness, though confidence intervals overlapped (p = 0.108). Similarly, patients with higher levels of loneliness had a longer length of stay (68.2 (49.4 – 87.1) compared to 47.9 (33.1 – 62.6) but again findings did not reach significance (p = 0.098). Linear regression models, controlling for competing covariates, found that depressive symptoms, were independently associated with burden of loneliness with a β-Coefficient = 10.69 (5.00 – 16.39).

Conclusion

Loneliness is particularly prevalent amongst older inpatients, with a trend towards higher levels of loneliness in those with less frequent visits. Interventions to help older people stay in touch with family and friends, and maintain social connectedness while in hospital, allowing for COVID-related restrictions, would be welcome, particularly for those with longer lengths of stay.

281 PREVALENCE OF STOPPFALL FALLS-RISK-INCREASING DRUGS (FRIDS) IN PATIENTS PRESENTING TO HOSPITAL WITH A FALL

Background

Falls cause presentation and admission to hospital. Falls-Risk-Increasing-Drugs (FRIDs) are a modifiable risk factor. STOPPFalls criteria was developed, using an expert Delphi panel, to achieve consensus on a comprehensive list of FRIDs. The aim of this study was to identify the prevalence of STOPPFall PRIDs in patients presenting to hospital with falls and identify whether review by a specialist Falls and Syncope Service (FASS) reduces FRIDs.

Methods

This was a retrospective observational study. Patients ≥65 years reviewed by the hospital FASS in the emergency department (over 6-months) and in house (over 2-months), were included. Medication appropriateness at admission and discharge were assessed using STOPPFall criteria. Ethical approval was received from the local research and innovation office (ref7013).

Results

Of 156 patients, 87(55.8%) were ≥65 years; 46% female, mean age 78.1(SD7.5) years. The mean number of conditions was 4(SD4.4); the mean number of regular medications was 6.9(SD4.5). Reasons for referral to FASS included falls (34.5%), dizziness/near fall (35.6%), and transient loss of consciousness (29.9%). For 21.8% there was an associated injury; 11.5% a fracture. Thirty-seven (42.5%) had experienced at least one fall in the previous 12-months.

Sixty-four (73.6%) were on ≥1 STOPPFall FRID. The most common STOPPFall FRID prescribed to older adults were diuretics (24.1%), anti-depressants (20.7%) and benzodiazepines/benzodiazepine-related drugs (13.8%). At least 1 STOPPFall FRID was stopped in 31.3%. The most commonly deprescribed STOPPFall FRIDs were diuretics (20%), alpha blockers (6%) and benzodiazepines/benzodiazepine-related drugs (4.7%). Adults &lt;65years (n=69) were more likely to be prescribed a STOPPFall FRID at admission than older adults (≥65years); 88.4% vs 73.6%, p=0.021.

Conclusion

STOPPFall FRIDs are prevalent in fallers of all ages. Even one review by a specialist FASS leads to medication optimization. The effectiveness of STOPPFalls criteria in the prevention of falls should be evaluated further in intervention studies.

273 ‘HOME ON TIME’: MULTIDISCIPLINARY INTERVENTION REDUCES LENGTH OF STAY AND DELAYS IN CARE TRANSFERS ON AN ACUTE GERIATRIC MEDICINE WARD

Background

Unnecessarily prolonged hospital admission can have a profound effect on a frail, older person’s confidence, mood, functional status and cognition.This study examined whether a structured multidisciplinary intervention, embedded within an acute geriatric medicine ward, could reduce unnecessary days in hospital for acutely unwell older patients.

Methods

The study site is a 28-bed acute geriatric medicine ward in a large urban teaching hospital; data was collected from 1/1/22 to 11/4/22. Patients aged ≥70 years and admitted to the ward were randomly allocated to the Home On Time (HOT) Pathway (n=50) or usual care (n=100). All patients were cared for by a specialist geriatric team. The HOT Pathway involved daily multidisciplinary team (physiotherapy, nursing, occupational therapy, social work and medical) huddles focusing on enhanced communication, early discharge planning and identification of barriers to discharge home. Huddles typically lasted for &lt;15 minutes.

Results

Almost two-thirds (92/150) of the study sample (mean age 83 years, 60% female) were discharged directly from the ward while one-fifth (29/150) were transferred for rehabilitation and one-tenth ultimately to long term care (16/150). The average acute ward Length-of-Stay (LOS) for HOT pathway patients was 10.4 days, compared to 14.4 days for usual care. The average LOS for HOT pathway patients discharged directly home (i.e. not via rehabilitation or to long-term care) was 8.0 days, compared to 10.2 days for usual care. One-fifth (10/50) of HOT pathway patients were discharged home within 48 hours of admission compared to one tenth (10/100) of usual care patients.

Conclusion

A structured, multidisciplinary intervention focusing on enhanced communication and early discharge planning within a geriatric medicine ward can reduce length of inpatient stay, delays in transitions of care and increase the rate of discharge home within 48 hours, potentially averting complications related to prolonged hospital admission.

136 DIABETES IS ASSOCIATED WITH IMPAIRED PERIPHERAL AND CEREBRAL HAEMODYNAMIC RESPONSES IN OLDER ADULTS

Background

Diabetes is associated with slower gait speed and adverse brain health outcomes in older adults. However, the putative mechanisms underlying these associations remain poorly explored. One such mechanism is via altered cerebral perfusion, which may represent an important intermediate phenotype in the association between diabetes and slower gait. We assessed the impact of diabetes on peripheral and cerebral haemodynamic responses during active stand as part of The Irish Longitudinal Study of Ageing (TILDA).

Methods

We assessed: (i) peripheral haemodynamic responses (heart rate, blood pressure, cardiac output) using finometry and (ii) Tissue Saturation Index (TSI) using Near-Infrared Spectroscopy (NIRS) during active stand in older adults.

Function-on-scalar regressions were used to model the impact of diabetes on the dynamic response to standing. Subsequently, multivariable linear models were used to model usual gait speed.

Results

Of 3,011 older adults (mean age: 64.2; 55.2% female) completing active stand, diabetes (n =193, 6.4%) was associated with significantly higher heart rate (mean 3.2, s.e. 0.02 bpm), higher cardiac output (mean 0.16, s.e. 0.04 L/min) and lower systolic blood pressure (mean –6.9, s.e. 1.8 mmHg) during standing. Additionally, diabetes was associated with significantly lower TSI from 10 seconds post-stand (mean –1.2%, s.e. 0.49%). Associations persisted following robust covariate adjustment. Diabetes was associated with significantly slower gait speed (-5.3 cm/s, CI (-8.4,-2.1)). In analysing the relationship between cerebral perfusion and gait speed, poorer recovery of TSI at 60-120 seconds post standing was associated with slower gait speed (0.53 cm/s slower gait speed per unit increase in TSI, p = 0.007).

Conclusion

Diabetes is associated with impaired peripheral and cerebral haemodynamic responses in addition to slower gait speed in community-dwelling older adults. Neuro-cardiovascular instability and altered cerebral perfusion may represent an important intermediate phenotype between diabetes and adverse health outcomes in older adults.

343 RIGHT CARE, RIGHT PLACE, RIGHT TIME? WHAT PROPORTION OF ACUTELY-UNWELL OLDER PATIENTS UNDERGO EVIDENCE-BASED COMPREHENSIVE GERIATRIC ASSESSMENT?

Background

There is robust evidence that Comprehensive Geriatric Assessment (CGA) improves outcomes for acutely unwell older people. Relatively little research has examined how this translates to real life clinical settings, however. The aim of this study therefore was to ascertain how many older people admitted to hospital underwent CGA and how this impacted on readmission rates.

Methods

The study site is a large teaching hospital with 150 specialist geriatric medicine beds and ‘specialty-take’ of frail, older people by the geriatric medicine service. Data pertaining to contact with a geriatric medicine service were collected for 400 consecutive ED presentations of patients aged ≥70 years from 1/1/21, as well as Clinical Frailty Scale (CFS) and readmission within 30 days.

Results

Over one-third (139/400, mean CFS 3.7) of patients were discharged home directly from the ED, with the remainder (261/400, mean CFS 4.5) admitted to hospital. Almost-half overall (122/261, mean CFS 4.7) and 58% of those ≥80 years, were admitted under the care of a geriatrician, with 73% (89/122) cared for on a specialist geriatric medicine ward. Of those not admitted under a geriatrician, 10% (13/139) subsequently underwent CGA on a consultation basis. In total, 48% (126/261, mean CFS 3.7) of patients ≥70 years, including one-third of those ≥80 years with a CFS≥5 (36/99), completed their admission without undergoing CGA. Of those ≥80 years with a CFS≥5 who did not receive CGA, readmission within 30 days was 24% compared to 13% for those who underwent CGA.

Conclusion

Patients who underwent CGA were older, with higher levels of frailty. However, one-third of those aged ≥80 years with CFS ≥5 did not undergo CGA and early readmission was higher in this cohort. CGA in the acute setting is a finite resource and it is imperative it is delivered to those who require it most.

327 REVIEW OF ONCOLOGY PATIENTS ADMITTED FROM 2019-2021: DEFINING THE NEED FOR AN ONCO-GERIATRIC SERVICE

Background

With an aging population, there is an increased need to consider older patients for cancer treatment. Involvement of a Comprehensive Geriatric Assessment (CGA) in an oncology workup can help guide cancer treatment and non-pharmacological treatment in older patients. We undertook a retrospective study looking at older patients admitted during their cancer treatment to establish the need for an onco-geriatric service in our hospital.

Methods

All patients over 85 admitted under oncology from 2019-2021 had a retrospective chart review. Patient demographics, indication for admission and discharge destination were collected. Clinical markers, such as total medications, comorbidities and social history were used to generate an overall understanding of the patient’s Clinical Frailty Score (CFS). We then retrospectively implemented a geriatric assessment to see how patients would benefit from a CGA if an onco-geriatric service was implemented in our hospital.

Results

A total of 22 patients over 85 accounted for 33 admissions, with 54.5% female (n=12). The median CFS was 4 (3-5). At time of admission, 90.1% were on concomitant cancer treatment; 41.7 concurrent chemo, 13.6% concurrent RT. The mean patient had conditions 5.61 (SD3.2 and took an average of 9.2 (SD3.7) regular medications. Most admissions (n=18) required at least one consult from another service (54.5%), with palliative care and cardiology having the highest burden of consults at 11 (33%) and 8 (26.7%) respectively. Only 1 patient had a geriatric consult, while another was seen by our Falls and Syncope Unit after a fall leading to admission. Patients following each attendance were discharge home in 75.7% cases (n=25). Hospice (12.1%), convalescence (3%) and nursing home (3%).

Conclusion

We identified multiple areas in which a CGA can improve management of older patients undergoing cancer treatment, including medication rationalisation. We feel that a onco-geriatric service development in our hospital will lead to better patient care for our older population.

345 HOW PREVALENT ARE UNDETECTED DEPRESSIVE SYMPTOMS AMONGST OLDER HOSPITAL INPATIENTS?

Background

Depression in later life can have a profound effect on quality of life, functional independence, healthcare use and early mortality. For multiple reasons however, depression in later life may often go undetected. The aim of this study is to ascertain the point prevalence of depressive symptoms on a specialist geriatric medicine unit, examining the rate of detection of clinically significant symptoms.

Methods

The study site is a large urban university teaching hospital with a 150-bed specialist geriatric medicine unit, comprising acute medical, rehabilitation and long-stay wards. Depressive symptoms were assessed using the Centre for Epidemiological Studies Depression Scale (CES-D) with a score ≥16 indicating significant symptoms. Medical notes were examined for documentation of screening for/assessment of depression since admission. Patients were included if they were aged ≥70 years, a current inpatient and able to give informed consent.

Results

Almost 62% (47/76) of the study sample (Mean age 83 years, 66% female) met criteria for significant depressive symptoms. Almost-half (23/47, 49%) of patients with significant depressive symptoms were screened for depression (either with a structured screening tool, a documented mood assessment or review by psychiatry) while in hospital. The mean length of stay for patients with depressive symptoms who had not yet been screened for depression was 42.7 (23.2 – 62.2) days and over 70% had been in hospital for at least 10 days, with almost two-thirds (15/24, 65%) currently residing on an acute geriatric medicine ward (rather than a rehabilitation or long stay ward).

Conclusion

Our study demonstrates a high burden of depressive symptoms amongst older inpatients, with almost 2 in 3 meeting criteria for clinically significant symptoms. Less than half of those with clinically significant symptoms were screened for depression however, representing an important missed opportunity to identify, and possibly treat, depression.

277 The ‘Bermuda Triangle’ of Orthostatic Hypotension, Cognitive Impairment and Reduced Mobility: Associations with Falls and Fractures in Community-dwelling Older People

Background

Orthostatic Hypotension (OH), cognitive impairment and mobility impairment frequently co-occur in older adults who fall. The aim of this study was to examine the clustering of these three geriatric syndromes and ascertain their longitudinal associations with falls and fractures in a large cohort of community-dwelling older people (≥65 years).

Methods

This study utilized data from Waves 1-5 of TILDA. OH was defined as a drop of ≥20 mmHg in systolic blood pressure when measured after standing from a seated position and/or reporting unsteadiness when getting up from a chair. Cognitive impairment was defined as MMSE ≤24 and/or self-reporting memory as fair or poor. Mobility impairment was defined as 'Timed Up and Go' ≥12 seconds. Logistic regression models, including 3-way interactions, were used to assess the longitudinal associations of the three geriatric syndromes with future falls (explained and unexplained) and fractures.

Results

Of those with at least one geriatric syndrome (993/2108, 47%), over two-thirds (644/993) had any one of the three, one-quarter had any two (261/993) and almost 10% (88/993) had all three syndromes. One-fifth of the study sample had an unexplained fall during follow-up (mean 6.6 years), while one-tenth had a fracture. In fully adjusted models, the cluster of OH, cognitive impairment and mobility impairment was associated with a greater than 4-fold likelihood of unexplained fall (Odds Ratio 4.36 (2.61–7.28); p&lt;0.001) and double the likelihood of incident fracture (Odds Ratio 2.51 (1.27–4.96); p=0.008) during follow-up, when compared to other clusters. There was no association with explained falls.

Conclusion

The ‘Bermuda Triangle’ of co-existing OH, cognitive impairment and mobility impairment, was independently associated with increased risk of future unexplained falls and fractures amongst community-dwelling older people. This simple risk identification scheme may represent an ideal target for multifaceted falls prevention strategies in community-dwelling older adults.

Avoidance of copper by fathead minnows (Pimephales promelas) requires an intact olfactory system

Fish can detect and respond to a wide variety of cations in their environment, including copper. Most often fish will avoid copper during behavioural trials; however, fish may also show no response or an attraction response, depending on the concentration(s) used. While it may seem intuitive that the response to copper requires olfaction, there is little direct evidence to support this, and what evidence there is remains incomplete. In order to test if olfaction is required for avoidance of copper by fathead minnows (Pimephales promelas) copper-induced movement was compared between fish with an intact olfactory system and fish with induced anosmia. Fish in a control group or a mock-anosmic group avoided copper (approximately 10 µg/L or 62.7 nM copper sulphate) while anosmic fish did not. The evidence demonstrates that an intact olfactory system is required for copper sensing in fish.

Comprehensive Geriatric Assessment for community-dwelling, high-risk, frail, older people

BACKGROUND

Comprehensive Geriatric Assessment (CGA) is a multidimensional interdisciplinary diagnostic process focused on determining an older person's medical, psychological and functional capability in order to develop a co-ordinated and integrated care plan. CGA is not limited simply to assessment, but also directs a holistic management plan for older people, which leads to tangible interventions. While there is established evidence that CGA reduces the likelihood of death and disability in acutely unwell older people, the effectiveness of CGA for community-dwelling, frail, older people at risk of poor health outcomes is less clear.

OBJECTIVES

To determine the effectiveness of CGA for community-dwelling, frail, older adults at risk of poor health outcomes in terms of mortality, nursing home admission, hospital admission, emergency department visits, serious adverse events, functional status, quality of life and resource use, when compared to usual care.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, CINAHL, three trials registers (WHO ICTRP, ClinicalTrials.gov and McMaster Aging Portal) and grey literature up to April 2020; we also checked reference lists and contacted study authors.

SELECTION CRITERIA

We included randomised trials that compared CGA for community-dwelling, frail, older people at risk of poor healthcare outcomes to usual care in the community. Older people were defined as 'at risk' either by being frail or having another risk factor associated with poor health outcomes. Frailty was defined as a vulnerability to sudden health state changes triggered by relatively minor stressor events, placing the individual at risk of poor health outcomes, and was measured using objective screening tools. Primary outcomes of interest were death, nursing home admission, unplanned hospital admission, emergency department visits and serious adverse events. CGA was delivered by a team with specific gerontological training/expertise in the participant's home (domiciliary Comprehensive Geriatric Assessment (dCGA)) or other sites such as a general practice or community clinic (community Comprehensive Geriatric Assessment (cCGA)).

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted study characteristics (methods, participants, intervention, outcomes, notes) using standardised data collection forms adapted from the Cochrane Effective Practice and Organisation of Care (EPOC) data collection form. Two review authors independently assessed the risk of bias for each included study and used the GRADE approach to assess the certainty of evidence for outcomes of interest.

MAIN RESULTS

We included 21 studies involving 7893 participants across 10 countries and four continents. Regarding selection bias, 12/21 studies used random sequence generation, while 9/21 used allocation concealment. In terms of performance bias, none of the studies were able to blind participants and personnel due to the nature of the intervention, while 14/21 had a blinded outcome assessment. Eighteen studies were at low risk of attrition bias, and risk of reporting bias was low in 7/21 studies. Fourteen studies were at low risk of bias in terms of differences of baseline characteristics. Three studies were at low risk of bias across all domains (accepting that it was not possible to blind participants and personnel to the intervention). CGA probably leads to little or no difference in mortality during a median follow-up of 12 months (risk ratio (RR) 0.88, 95% confidence interval (CI) 0.76 to 1.02; 18 studies, 7151 participants (adjusted for clustering); moderate-certainty evidence). CGA results in little or no difference in nursing home admissions during a median follow-up of 12 months (RR 0.93, 95% CI 0.76 to 1.14; 13 studies, 4206 participants (adjusted for clustering); high-certainty evidence). CGA may decrease the risk of unplanned hospital admissions during a median follow-up of 14 months (RR 0.83, 95% CI 0.70 to 0.99; 6 studies, 1716 participants (adjusted for clustering); low-certainty evidence). The effect of CGA on emergency department visits is uncertain and evidence was very low certainty (RR 0.65, 95% CI 0.26 to 1.59; 3 studies, 873 participants (adjusted for clustering)). Only two studies (1380 participants; adjusted for clustering) reported serious adverse events (falls) with no impact on the risk; however, evidence was very low certainty (RR 0.82, 95% CI 0.58 to 1.17).

AUTHORS' CONCLUSIONS

CGA had no impact on death or nursing home admission. There is low-certainty evidence that community-dwelling, frail, older people who undergo CGA may have a reduced risk of unplanned hospital admission. Further studies examining the effect of CGA on emergency department visits and change in function and quality of life using standardised assessments are required.

Diagnostic approach to patients at risk of otogenic skull base osteomyelitis

BACKGROUND

Otogenic skull base osteomyelitis (OSBO) is rare and potentially fatal sequelae of otitis externa. Accurate and timely diagnosis is important due to rising incidence, morbidity and costs associated with treatment. Consensus on the diagnostic approach for OSBO has yet to be reached, in particular the utility of imaging modalities.

AIMS/OBJECTIVES

This study reviews a single institution's high-volume experience of OSBO, with the aim of analysing clinicopathologic features and imaging studies to develop a diagnostic algorithm.

MATERIAL AND METHODS

A retrospective review of patients admitted with OSBO from 2009 to 2019, was performed. After applying inclusion and exclusion criteria, 103 patients with 106 unique episodes of suspected OSBO were selected. De-identified information including patient demographics, clinicopathologic features and imaging outcomes was recorded and analysed.

RESULTS

HbA1c ≥ 7% significantly predicted for OSBO in univariate (OR 7.83, 95% CI 1.85-33.16, p = 0.01) and multivariate analyses (OR 5.21, 95% CI 1.05-25.81, p = 0.04). The CT/technetium-99m/gallium-67 combination produced better diagnostic accuracy for OSBO (AUROC 0.96, 95% CI 0.92-1), when compared to a CT/MRI combination (AUROC 0.86, 95% CI 0.79-0.93).

CONCLUSIONS AND SIGNIFICANCE

Once there is a clinical suspicion for OSBO, diagnosis is established by synthesising results from clinical assessment, pathologic investigations and imaging modalities. The imaging utilised to diagnose OSBO should vary according to the clinical situation and limitations of each modality.

What factors are associated with advance care planning in community-dwelling older people? Data from TILDA

PURPOSE

To assess advance care planning (ACP) in a large population-representative sample of older people.

METHODS

At Wave 4 of the Irish Longitudinal Study on Ageing, participants were asked: Have you made your wishes/preferences known about the kind of care that you would like to receive in the event of serious illness?

RESULTS

One quarter (1153/4831) had discussed ACP. Of those, 90% had discussed with family/friends, 10% documented ACP in writing, while 2% had discussed with a healthcare professional. Age ≥ 80 years [OR 1.63 (1.31-2.02)], female sex [OR 1.58 (1.37-1.83)], higher educational attainment [OR 1.42 (1.18-1.71)], poorer self-rated health [OR 1.67 (1.06-2.62)] and lower levels of religiosity [OR 1.50 (1.02-2.19)] were independently associated with ACP.

CONCLUSION

Only one in four older people had discussed ACP informally, while less than 3% have ACP documented in writing. Further work is required to educate the public and healthcare professionals regarding treatment choices at end-of-life.

168 ANXIETY SYMPTOMS AMONG OLDER PEOPLE DURING THE COVID-19 PANDEMIC: PREVALENCE AND ASSOCIATED FACTORS

Background

There are concerns that the COVID-19 pandemic could lead to a rise in mental health problems including anxiety amongst older people, especially those shielding alone during the pandemic.

The aim of this study therefore is to examine the prevalence of anxiety symptoms during the COVID-19 pandemic amongst older people and clarify factors associated with higher burden of symptoms.

Methods

We analysed data from the COVID-19 study of The Irish Longitudinal Study on Ageing, conducted on over 3,100 community dwelling people aged ≥60 years from July–November 2020.

Anxiety symptoms were measured with the Generalised Anxiety Disorder-7 Questionnaire with a score ≥ 10 indicating moderate–severe anxiety.

Linear regression models were used to assess the association of variables of interest with anxiety symptoms.

Results

Almost 9% of participants (n = 3,128; mean age 71 years) had moderate–severe symptoms of anxiety.

Factors independently associated with a higher burden of anxiety symptoms included female sex (β = 0.60 (0.33–0.87)); living alone (β = 0.72 (0.41–1.02)); ≥2 chronic diseases (β = 0.85 (0.41–1.30); heart disease (β = 0.95 (0.45–1.46)) and reporting frequent loneliness (β = 6.59 (6.03–7.16)). Age ≥ 80 years (β = −0.77 (−1.16—0.37)) and tertiary level education (β = −0.48 (−0.86—-0.10)) were associated with lower anxiety symptom burden.

Conclusion

Almost 1 in 10 of this population-representative sample of older people had moderate to severe anxiety symptoms during the COVID-19 pandemic.

Strategies to address loneliness, which was particularly strongly associated with anxiety symptoms during the pandemic, should be a priority.

165 WHAT FACTORS ARE ASSOCIATED WITH ADVANCED CARE PLANNING IN COMMUNITY-DWELLING OLDER PEOPLE?

Background

Advance Care Planning (ACP) involves expressing wishes regarding your future medical care and/or preferences about your end-of-life in the event of serious illness.

The aim of this study was to clarify the proportion of community-dwelling older people who engage in ACP and what factors are independently associated with ACP.

Methods

Participants aged ≥60 years (n = 4,831, mean age 71 years) at Wave 4 of the Irish Longitudinal Study on Ageing were asked: Have you made your wishes/preferences known about the kind of care that you would like to receive in the event of serious illness? If yes, they were asked if this had been documented informally (family/carers or medical professionals) or formally (by written advanced care plan).

Logistic regression models assessed the association of covariates of interest with ACP.

Results

One quarter of the study sample (1,153/4,831) had an ACP. Only 10% (119/1,153) had ACP documented in writing, while only 2% (27/1,153) had discussed ACP with a healthcare professional.

Age ≥ 80 years (OR 1.63 (1.31–2.02)), female sex (OR 1.58 (1.37–1.83)), higher educational attainment (OR 1.42 (1.18–1.71), poorer self-rated health (OR 1.58 (1.04–2.39) and lower levels of religiosity (OR 1.50 (1.03–2.19) were independently associated with ACP.

Conclusion

While ACP may have benefits in extending autonomy and facilitating decision-making, only 1 in 4 of this population-representative sample of older people had engaged in ACP, with only 1 in 50 having their ACP documented in writing.

Further work is therefore required to educate the public and healthcare professionals regarding the benefits of ACP.

161 THE ROLE OF THE GERIATRIC DAY HOSPITAL DURING THE COVID 19 PANDEMIC

Background

Methods

Results

Conclusion

162 TRENDS IN EMERGENCY DEPARTMENT USE BY OLDER PEOPLE DURING THE COVID-19 PANDEMIC

Background

Older people have been disproportionately affected by the COVID-19 pandemic with reports suggesting that many older people deferred seeking healthcare during the pandemic due to fear of contracting COVID-19.

The aim of this study was to examine trends of emergency department (ED) use by older people during the first wave of the COVID-19 pandemic compared to previous years.

Methods

The study site is a 1,000-bed university teaching hospital with annual ED new-patient attendance of >50,000.

All ED presentations of patients aged ≥70 years from March–August 2020, 2019 and 2018 inclusive (n = 13,989) were reviewed and compared for presenting complaint, Manchester Triage Score, and admission/discharge decision.

Results

There was a 16% reduction in presentations across the 6 months in 2020 compared to the average of 2018/2019. On average 4 fewer people aged ≥70 years presented to the ED per day in 2020.

Much of this was concentrated in March (33% fewer presentations) and April (31% fewer presentations), when the country was in ‘lockdown’, i.e. non-essential journeys were banned.

There was a 20% reduction in patients presenting with stroke and cardiac complaints.

In the three months following easing of restrictions, there was a 25% increase in falls and orthopaedic injuries when compared to 2018/2019.

Conclusion

This study demonstrates a significant decline in the number of older people presenting to the ED for unscheduled care, including for potentially time-dependent illnesses such as stroke or cardiac complaints.

Presenting to the ED remains the most frequent route by which unwell older people access acute hospital care and it is vitally important that they continue to do so in a timely manner when necessary. Given the possibility of further lockdowns and restrictions, this message needs to be communicated to older people clearly by healthcare professionals and governmental bodies to mitigate against adverse outcomes related to delayed or deferred care.

166 HEALTH TRAJECTORIES OF FRAIL, OLDER PEOPLE WHILE COCOONING DURING THE COVID-19 PANDEMIC

Background

Cocooning, i.e. staying at home and reducing interaction with others, was a key part of the strategy to protect older people during the COVID-19 pandemic.

Unfortunately, there are concerns this has had a negative impact on the physical and mental wellbeing of those who have been isolated.

Methods

We completed a survey of 150 patients (55% female, mean age 79.8 years, average Clinical Frailty Scale 4.8) attending ambulatory medical services in a large university hospital.

Questions were focused on: access to healthcare services, mental health, physical health, and attitudes to COVID-19 restrictions.

Results

Almost 40% reported that their mental health was ‘worse’ or ‘much worse’ while cocooning, while over 40% reported a decline in their physical health.

Over 57% had a scheduled healthcare-related visit cancelled while cocooning, most frequently hospital outpatient appointments.

Worryingly, almost 1/6 reported not seeking medical attention for an illness that they would usually. Of these, half did not as they were worried about catching COVID and 46% did not as this service was not currently available to them.

Conclusion

The COVID-19 pandemic and lack of access to essential services, both medical and social, has had a devastating impact on older people.

This is evident in both the acute presentations to hospital and the longer-term impact it has had on health and function.

It is important that in the future clear policies are in place to enable older people to access care when they need it.

171 THE ‘WISH TO DIE’ AMONGST OLDER PEOPLE IN IRELAND IN THE CONTEXT OF THE DYING WITH DIGNITY BILL

Background

‘Wish to Die’ (WTD) involves thoughts of or wishes for one’s own death or that one would be better off dead.

Assisted dying is the act of deliberately providing medical assistance to another person who wishes to end their own life. Currently, in Ireland, it is illegal to provide such assistance to people with WTD or suicidal ideation. However, a new bill that would legalise assisted dying for those with terminal illnesses, the Dying with Dignity Bill 2020, is due to be considered by lawmakers in Ireland in the coming months.

In order to inform discussion around this complex issue, we examine the prevalence and longitudinal course of WTD in a large population-representative sample of older people.

Methods

To define WTD, participants were asked: ‘In the last month, have you felt that you would rather be dead?’

Depressive symptoms were measured using the CES-D.

Mortality data were compiled by linking administrative death records to individual-level survey data from the study.

Results

At Wave 1, 3.5% of participants (279/8,174) reported WTD. Both persistent loneliness (OR 5.73 (95% CI 3.41–9.64)) and depressive symptoms (OR 6.12 (95% CI 4.33–8.67)) were independently associated with WTD.

Of participants who first reported WTD at Wave 1 or 2, 72% did not report WTD when reassessed after 2 years, and the prevalence of depressive symptoms (−44%) and loneliness (−19%) was more likely to decline in this group at follow-up.

Fifteen per cent of participants expressing WTD at Wave 1 died during a 6-year follow-up.

Conclusion

WTD amongst community-dwelling older people is frequently transient and is strongly linked with the course of depressive symptoms and loneliness.

An enhanced focus on improving access to mental health care and addressing social isolation in older people should therefore be a public health priority, particularly in the current context of the Covid-19 pandemic.

163 EVALUATING THE ROLE OF THE GERIATRIC DAY HOSPITAL IN MEDICATION OPTIMISATION

Background

The geriatric day hospital (GDH) provides outpatient geriatric medical, nursing and rehabilitation care to older adults. The aim of this study was to assess whether medication optimisation occurs in this setting. We believe the GDH would be an ideal location for mediation optimisation due to the stable community dwelling patients and close follow up by specialised physicians.

Methods

Electronic patient records of the new patients ≥65 years seen in the GDH over a 3-month period were reviewed. Potentially inappropriate prescriptions (PIPs) and potentially prescribing omissions (PPOs) were identified using the STOPP/START prescribing tool on admission to the GDH and again at discharge from the GDH.

Results

One-hundred and sixty-seven patient records were reviewed; mean age 80.8 (SD6.5) years, 62.9% female, median clinical frailty scale score 6 (IQR5–6), mean number of conditions 5.79 (SD3), mean number of medications 7.57 (SD3.7). Patients had a median of 4 (IQR2–7) consultations. The number of patients prescribed at least 1 STOPP-PIP reduced by 10% (42.4% vs 38%; p &lt; 0.001). Vasodilator drugs in patients with orthostatic hypotension were deprescribed most frequently (6.5% vs 3%; p &lt; 0.001). PPOs were reduced by 36% (47.5% vs 30.6%;p &lt; 0.001). The largest improvement was identified in the prescription of vitamin D in patients experiencing falls (17.4% vs 13.8%;p &lt; 0.001). Logistic regression was performed to ascertain the influence of age, gender, falls, dementia, co-morbidity number and medication number on the likelihood of a patient experiencing a PIP or PPO. For every medication prescribed, the odds of experiencing a PIP increased by 11.8% (OR1.187, 95%CI 1.052–1.339). Being female increased the odds of experiencing a PPO by 21.7% (OR2.17, 95%CI 10.53–4.468).

Conclusion

Medication optimisation is key in avoiding side effects from potentially inappropriate medications. The frequency of patient attendances coupled with geriatricians’ expertise makes the GDH an ideal setting for medication optimisation in multi-morbid frail community-dwelling older adults.

138 DELAYED BLOOD PRESSURE RECOVERY AFTER STANDING INDEPENDENTLY PREDICTS FRACTURE IN COMMUNITY-DWELLING OLDER PEOPLE

Background

Orthostatic hypotension, characterized by delayed blood pressure recovery (DBPR) after standing, is a risk factor for falls but the longitudinal relationship with fracture is not yet known. The aim of this study was to examine the prospective risk of fracture associated with DBPR.

Methods

This study, embedded within the Irish Longitudinal Study on Ageing (TILDA), examined prospective risk of fracture (hip, wrist or vertebral) associated with DBPR at 8-year follow-up in a population-representative sample of more than 3,000 (54% female) community-dwelling older people. Orthostatic blood pressure (BP) was measured using a finometer during active stand at TILDA Wave 1. DBPR was defined as systolic BP ≤ 20 mmHg lower and/or diastolic BP ≤ 10 mmHg from baseline value at 30, 60 and 90 seconds after standing. Participants with a fracture reported at any of Waves 2–5 were defined as having ‘Incident Fracture’. Logistic regression models were used to estimate odds ratios (ORs) for the association between DBPR and incident fracture.

Results

Seven percent (212/3117) of participants sustained a fracture during follow-up. DBPR at 30 seconds was a significant predictor of any fracture [OR 1.80, 95% confidence interval (CI) 1.28–2.53] and hip fracture (OR 4.44, 95% CI 2.03–9.71) in fully adjusted models. DBPR at 30 seconds did not predict wrist or vertebral fracture. DBPR at 60 seconds also predicted any fracture (OR 1.74, 95% CI 1.19–2.54) and hip fracture (OR 4.66, 95% CI 2.12–10.26) whereas DBPR at 90 seconds predicted any (OR 1.99, 95% CI 1.38–2.87), wrist (OR 1.87, 95% CI 1.19–2.95), and hip fracture (OR 3.39, 95% CI 1.45–7.93) in fully adjusted models.

Conclusion

Delayed BP recovery independently predicts fracture in community-dwelling older people, is potentially modifiable, and can be measured in an ambulatory setting. Given the morbidity and mortality associated with fractures, identification of such risk factors is crucial in order to inform preventative strategies.

239 IS ORTHOSTATIC HYPOTENSION ASSOCIATED WITH ALTERED CEREBRAL PERFUSION DURING ACTIVE STANDING?

Background

Orthostatic Hypotension (OH) is associated with poor health outcomes in later life including depression, cognitive impairment, frailty and falls. Whilst it is hypothesised that OH compromises cerebral autoregulation leading to hypoperfusion, this has not been robustly demonstrated to date. This study investigated the association between OH and cerebral perfusion during orthostasis using a non-invasive surrogate of cerebral perfusion, Near Infrared Spectroscopy (NIRS).

Methods

Four hundred and ninety one participants (58% female, median age 65, IQR 38–92) attending a falls and syncope service underwent measurement of beat-to-beat blood pressure (BP) by finometry and real-time frontal lobe perfusion (% TSI: Tissue Saturation Index) by NIRS during the active stand manoeuvre. We examined the association between OH and change in cerebral perfusion (delta TSI) using mixed-effects linear regression, with adjustment for important clinical covariates.

Results

Nearly two-fifths of the sample (189/491,38.5%) met criteria for OH occurring between 30 and 120 seconds after standing. Using mixed effects linear regression models, we observed a significant relationship between OH and TSI at the same timepoint (β −0.53, −0.59 to −0.46, p &lt; 0.001) which persisted following adjustment for confounders including age, sex, baseline blood pressure, cerebrovascular and cardiovascular disease, depression/anxiety, diabetes, systolic blood pressure, antihypertensives, and antidepressants (β −0.51, −0.58 to −0.44, p &lt; 0.001). Cerebral perfusion levels differed for those with OH compared to those without.

Conclusion

OH is independently associated with lower frontal lobe cerebral perfusion. This association may indicate disruption to dynamic cerebral autoregulation and explain the significant link between OH and poor health outcomes.

216 IMPROVING INPATIENT INFLUENZA VACCINATION RATES—THE VALUE OF AN ELECTRONIC PATIENT RECORD REMINDER SYSTEM

Background

Influenza vaccination, particularly for vulnerable, older adults, will have added importance this winter given the possibility of further waves of COVID-19 pandemic. Previous interventions at the study site noted poor awareness on the need for inpatient Influenza vaccination¹. This study examines a vaccination reminder process using an electronic patient record (EPR) to identify high-priority eligible inpatients.

Methods

The study site is a 900-bed university teaching hospital with all clinical notes accessed via an EPR.

We included a convenience sample of 750 adults aged≥50 years (mean age 75.9 +/− 0.4 years, 48% female) and high-priority for influenza vaccination (Age > 65 years and/or length of stay (LOS) >30 days) from October 1^st 2020 to January 12^th 2021.

A live electronic dashboard identified eligible inpatients for vaccination, prompting vaccination reminders to the clinical teams via the antimicrobial pharmacist.

Data was collected retrospectively. Logistic regression models reporting odds ratios were used to assess the association of these reminders with vaccine uptake.

Results

Over one third (35%, 264/750) of high-priority patients received the Influenza vaccine while inpatients, including 40% aged ≥80 years.

The reminder was sent on 41% (305/750) of patients and was associated with an almost 50% higher likelihood of vaccination after adjusting for other covariates (Odds Ratio 1.48 (95% CI 1.00–2.20); p = 0.048).

Other factors independently associated with vaccination were advancing age (Odds Ratio 2.69 (95% CI 1.12–6.47) for age ≥ 80 years); LOS (4% higher likelihood of vaccination for every additional day in hospital) and admission under geriatric medicine (Odds Ratio 3.71 (95% CI 2.45–5.62) when compared to other specialities).

Conclusion

Our study shows relatively low uptake of inpatient Influenza vaccination and strategies to improve uptake are required. Reminders sent to clinical teams using the EPR appear to be an effective means of increasing Influenza vaccination and should be considered as part of this year’s inpatient vaccination drive.

Physical and mental health of older people while cocooning during the COVID-19 pandemic

BACKGROUND

Cocooning or shielding, i.e. staying at home and reducing face-to-face interaction with other people, was an important part of the response to the COVID-19 pandemic for older people. However, concerns exist regarding the long-term adverse effects cocooning may have on their physical and mental health.

AIM

To examine health trajectories and healthcare utilization while cocooning in a cohort of community-dwelling people aged ≥70 years.

DESIGN

Survey of 150 patients (55% female, mean age 80 years and mean Clinical Frailty Scale Score 4.8) attending ambulatory medical services in a large urban university hospital.

METHODS

The survey covered four broad themes: access to healthcare services, mental health, physical health and attitudes to COVID-19 restrictions. Survey data were presented descriptively.

RESULTS

Almost 40% (59/150) reported that their mental health was 'worse' or 'much worse' while cocooning, while over 40% (63/150) reported a decline in their physical health. Almost 70% (104/150) reported exercising less frequently or not exercising at all. Over 57% (86/150) of participants reported loneliness with 1 in 8 (19/150) reporting that they were lonely 'very often'. Half of participants (75/150) reported a decline in their quality of life. Over 60% (91/150) agreed with government advice for those ≥70 years but over 40% (61/150) reported that they disliked the term 'cocooning'.

CONCLUSIONS

Given the likelihood of further restrictions in coming months, clear policies and advice for older people around strategies to maintain social engagement, manage loneliness and continue physical activity and access timely medical care and rehabilitation services should be a priority.

Glycated haemoglobin (HbA1c ), diabetes and neuropsychological performance in community-dwelling older adults

AIMS

Given that diabetes is associated with cognitive impairment and dementia in later life, we aimed to investigate the relationship between glycated haemoglobin (HbA_1c ), diabetes and domain-specific neuropsychological performance in older adults.

METHODS

Cross-sectional cohort study using data from the Trinity-Ulster-Department of Agriculture (TUDA) study. Participants underwent detailed cognitive and neuropsychological assessment using the Mini-Mental State Examination (MMSE), Frontal Assessment Battery (FAB) and Repeatable Assessment for Neuropsychological Status (RBANS). Linear regression was used to assess associations between HbA_1c , diabetes status and neuropsychological performance, with adjustment for important clinical covariates.

RESULTS

Of 4938 older adults (74.1 ± 8.3 years; 66.9% female), 16.3% (n = 803) had diabetes (HbA_1c  ≥ 6.5%; 48 mmol/mol), with prediabetes (HbA_1c  ≥ 5.7%-6.4%; 39-47 mmol/mol) present in 28.3% (n = 1395). Increasing HbA_1c concentration was associated with poorer overall performance on the FAB [β: -0.01 (-0.02, -0.00); p = 0.04 per % increase] and RBANS [β = -0.66 (-1.19, -0.13); p = 0.02 per % increase]. Increasing HbA_1c was also associated with poorer performance on immediate memory, visuo-spatial, language and attention RBANS domains. Diabetes was associated poorer performance on neuropsychological tests of immediate memory, language, visual-spatial and attention.

CONCLUSIONS

Both increasing HbA_1c and the presence of diabetes were associated with poorer cognitive and domain-specific performance in older adults. HbA_1c , and not just diabetes status per se, may represent an important target in the promotion of optimal brain health in older adults.

Depressive Symptoms Among Older Adults Pre- and Post-COVID-19 Pandemic

OBJECTIVES

It is a concern that public health measures to prevent older people contracting COVID-19 could lead to a rise in mental health problems such as depression. The aim of this study therefore is to examine trends of depressive symptoms before and during the COVID-19 pandemic in a large cohort of older people.

DESIGN

Observational study with 6-year follow-up.

SETTING & PARTICIPANTS

More than 3000 community-dwelling adults aged ≥60 years participating in The Irish Longitudinal Study on Ageing (TILDA).

METHODS

Mixed effects multilevel models were used to describe trends in depressive symptoms across 3 waves of TILDA: wave 4 (2016), wave 5 (2018), and a final wave conducted July-November 2020. Depressive symptoms were measured using the 8-item Center for Epidemiologic Studies Depression Scale (CES-D), with a score ≥9 indicating clinically significant symptoms.

RESULTS

The prevalence of clinically significant depressive symptoms at waves 4 and 5 was 7.2% [95% confidence interval (CI) 6.5, 7.9] and 7.2% (95% CI 6.5, 8.0), respectively. This more than doubled to 19.8% (95% CI 18.5, 21.2) during the COVID-19 pandemic. There was no change in CES-D scores between waves 4 and 5 (β = 0.09, 95% CI -0.04, 0.23), but a large increase in symptoms was observed during the pandemic (β = 2.20, 95% CI 2.07, 2.33). Age ≥70 years was independently associated with depressive symptoms (β = 0.45, 95% CI 0.18, 0.72) during the pandemic but not from wave 4 to 5 (β = 0.09, 95% CI -0.18, 0.36). Living with others was associated with a lower burden of symptoms during the pandemic (β = -0.40, 95% CI -0.71, -0.09) but not between waves 4 and 5 (β = -0.40, 95% CI -0.71, -0.09).

CONCLUSIONS AND IMPLICATIONS

This study demonstrates significant increases in the burden of depressive symptoms among older people during the COVID-19 pandemic, particularly those aged ≥70 years and/or living alone. Even a small increase in the incidence of late life depression can have major implications for health care systems and societies in general. Improving access to age-attuned mental health care should therefore be a priority.

PSXVI-28 Late-Breaking: Effects of Preconditioning (Value Added Programs) on the Health, Performance, Mannheimia haemolytica, and Pasteurella multocida in Cattle Received on Winter Wheat Pasture

Bovine respiratory disease (BRD) is a persistent health problem impacting the beef industry. Research shows improved health and performance in preconditioned (PRECON) calves compared with nonpreconditioned (NONPRE) or commingled (COMM) calves received in the feedlot but little research has been focused on calves received on winter wheat pasture prior to feedlot entry. Our objective for this presentation is to investigate the effects of preconditioning on the health and performance of newly received beef calves on winter wheat pasture. Mixed breed steers (n = 145) were purchased from an auction barn in Dalhart, Texas, as PRECON (n = 70) or NONPRE (n = 75) and were transported to the Clayton Livestock Research Center in Clayton, New Mexico, for this 112-d study trial. Three treatments were used in this completely randomized design: PRECON (n = 50), NONPRE (n = 50) and COMM (n = 45). Upon arrival, steers were offloaded into separate pens. On d 0, steers were processed using a standard health protocol along with collection of nasopharyngeal (NP) swabs, randomly allocated to treatment, and released onto a 120-acre winter wheat pasture split into three paddocks with a common water source; weights were collected again on d 2, 90, and 112. There were no statistical differences in morbidity and mortality rates between treatments. Weight gain was analyzed using PROC GLM of SAS from d 0 to d 90. COMM steers had greater weight gains than PRECON (P = 0.04) and NONPRE (P = 0.02) steers. NP swabs were used to show the distribution of Mannheimia haemolytica (MH) serotype A1, A2, and A6 and Pasteurella multocida (PM) by day and by treatment. No statistical differences were observed in serotype distribution of MH A1, A2, or A6 or in PM. PRECON steers displayed no health or performance advantage over NONPRE or COMM steers.

Exercise Effects on Neck Function Among F-15E Aircrew

BACKGROUND: Neck pain (NP) is common among high performance aircrew, yet evidence remains insufficient to guide examination, treatment, and prevention. The purpose of this randomized pilot study was to collect baseline data for neck function for F-15E aircrew and determine efficacy and feasibility of two separate exercise protocols in measuring short-term outcomes of subjective and objective neck function in order to inform future study design. METHODS: Randomized to either progressive (PRO) or general (GEN) exercise groups were 41 F-15E aircrew. Data collection occurred at baseline, 3 wk, and 3 mo. RESULTS: At baseline, 39% of the subjects reported current NP, 79.5% reported a history of NP attributed to flying, 12.8% reported being removed from flying duties due to NP, and 10% reported receiving medical care for NP. PRO and GEN group randomization showed similar baseline assessment data. Blinding was successful and exercise logs showed 31.6% compliance with prescribed exercise regimens. There were small but statistically significant increases in neck range of motion in both groups over the course of the study. Aircrew with current NP had significantly higher F-15E flight hours. DISCUSSION: This study supports the high prevalence of NP in aircrew, yet low frequency of seeking care for NP. Future studies to assess NP prevention and treatment in aircrew require an integrated approach that includes operational exercise policy and long-term data collection in flying units with dedicated resources for assessment and analysis. Lee MS, Briggs R, Scheirer V, Kearby G, Young BA. Exercise effects on neck function among F-15E aircrew. Aerosp Med Hum Perform. 2021; 92(10):815824.

'Wish to die' is independently associated with cardiovascular mortality in later life. Data from TILDA

BACKGROUND

There is an established bidirectional relationship between mental and heart health in later life but the link between wish to die (WTD) and cardiovascular mortality is less well-defined.

METHODS

This is a longitudinal study examining the association between WTD and mortality over 9-year follow-up in a large population-representative sample of older adults. Individual-level survey data was linked to official death registration data, divided into cardiovascular and noncardiovascular causes. WTD was defined as answering affirmatively when asked 'In the last month, have you felt that you would rather be dead?' Regression models were used to obtain hazard ratios for the association between WTD at Wave 1 and mortality. Kaplan-Meier plots were used to compare survival across groups.

RESULTS

Just over 3% (275/8124) of participants reported WTD. Mortality data was available for 9% of participants (755/8124). WTD was significantly associated with all-cause mortality, with a hazard ratio of 1.41 (95% confidence interval [CI]: 1.00-1.99). Findings were attenuated and no longer significant after excluding participants with heart disease or depression/anxiety/other psychiatric illness. WTD was significantly associated with cardiovascular mortality (hazard ratio: 2.14 [95% CI: 1.21-3.78]), even after excluding participants with depression/anxiety/other illnesses but not heart disease. WTD was not associated with an increased risk of death due to non-cardiovascular causes.

CONCLUSIONS

Older people who report a wish to die have double the risk of death from cardiovascular disease in the following 9 years, even when those with depression, anxiety or other mental health problems are excluded.