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Effects of centrally acting ACE inhibitors on the rate of cognitive decline in dementia
(BMJ Publishing Group, 2013-07-22) Gao, Yang; O'Caoimh, Rónán; Healy, Liam; Kerins, David M.; Eustace, Joseph A.; Guyatt, Gordon; Sammon, David; Molloy, D. William; Atlantic Philanthropies; Health Service Executive, Ireland; Irish Hospice Foundation; Canadian Institutes of Health Research
Objectives: There is growing evidence that antihypertensive agents, particularly centrally acting ACE inhibitors (CACE-Is), which cross the blood–brain barrier, are associated with a reduced rate of cognitive decline. Given this, we compared the rates of cognitive decline in clinic patients with dementia receiving CACE-Is (CACE-I) with those not currently treated with CACE-Is (NoCACE-I), and with those who started CACE-Is, during their first 6 months of treatment (NewCACE-I). Design: Observational case–control study. Setting: 2 university hospital memory clinics. Participants: 817 patients diagnosed with Alzheimer's disease, vascular or mixed dementia. Of these, 361 with valid cognitive scores were included for analysis, 85 CACE-I and 276 NoCACE-I. Measurements: Patients were included if the baseline and end-point (standardised at 6 months apart) Standardised Mini-Mental State Examination (SMMSE) or Quick Mild Cognitive Impairment (Qmci) scores were available. Patients with comorbid depression or other dementia subtypes were excluded. The average 6-month rates of change in scores were compared between CACE-I, NoCACE-I and NewCACE-I patients. Results: When the rate of decline was compared between groups, there was a significant difference in the median, 6-month rate of decline in Qmci scores between CACE-I (1.8 points) and NoCACE-I (2.1 points) patients (p=0.049), with similar, non-significant changes in SMMSE. Median SMMSE scores improved by 1.2 points in the first 6 months of CACE treatment (NewCACE-I), compared to a 0.8 point decline for the CACE-I (p=0.003) group and a 1 point decline for the NoCACE-I (p=0.001) group over the same period. Multivariate analysis, controlling for baseline characteristics, showed significant differences in the rates of decline, in SMMSE, between the three groups, p=0.002. Conclusions: Cognitive scores may improve in the first 6 months after CACE-I treatment and use of CACE-Is is associated with a reduced rate of cognitive decline in patients with dementia.
The functional decline of hospitalised older patients – are we doing enough?
(IOS Press, 2014) McCullagh, Ruth; Fitzgerald, Eilis M.; O'Connor, K.; Broderick, Louise; Kennedy, C.; O'Reilly, N.; Martin, R.; Timmons, Suzanne
Screening for markers of frailty and perceived risk of adverse outcomes using the Risk Instrument for Screening in the Community (RISC)
(Biomed Central Ltd., 2014-09-19) O'Caoimh, Rónán; Gao, Yang; Svendrovski, Anton; Healy, Elizabeth; O'Connell, Elizabeth; O'Keeffe, Gabrielle; Cronin, Una; O'Herlihy, Eileen; Cornally, Nicola; Molloy, D. William; Health Service Executive, Ireland
BACKGROUND: Functional decline and frailty are common in community dwelling older adults, increasing the risk of adverse outcomes. Given this, we investigated the prevalence of frailty-associated risk factors and their distribution according to the severity of perceived risk in a cohort of community dwelling older adults, using the Risk Instrument for Screening in the Community (RISC). METHODS: A cohort of 803 community dwelling older adults were scored for frailty by their public health nurse (PHN) using the Clinical Frailty Scale (CFS) and for risk of three adverse outcomes: i) institutionalisation, ii) hospitalisation and iii) death, within the next year, from one (lowest) to five (highest) using the RISC. Prior to scoring, PHNs stated whether they regarded patients as frail. RESULTS: The median age of patients was 80 years (interquartile range 10), of whom 64% were female and 47.4% were living alone. The median Abbreviated Mental Test Score (AMTS) was 10 (0) and Barthel Index was 18/20 (6). PHNs regarded 42% of patients as frail, while the CFS categorized 54% (scoring ≥5) as frail. Dividing patients into low-risk (score one or two), medium-risk (score three) and high-risk (score four or five) using the RISC showed that 4.3% were considered high risk of institutionalization, 14.5% for hospitalization, and 2.7% for death, within one year of the assessment. There were significant differences in median CFS (4/9 versus 6/9 versus 6/9, p < 0.001), Barthel Index (18/20 versus 11/20 versus 14/20, p < 0.001) and mean AMTS scores (9.51 versus 7.57 versus 7.00, p < 0.001) between those considered low, medium and high risk of institutionalisation respectively. Differences were also statistically significant for hospitalisation and death. Age, gender and living alone were inconsistently associated with perceived risk. Frailty most closely correlated with functional impairment, r = −0.80, p < 0.001. CONCLUSION: The majority of patients in this community sample were perceived to be low risk for adverse outcomes. Frailty, cognitive impairment and functional status were markers of perceived risk. Age, gender and social isolation were not and may not be useful indicators when triaging community dwellers. The RISC now requires validation against adverse outcomes.
Concordance between DSM-IV and DSM-5 criteria for delirium diagnosis in a pooled database of 768 prospectively evaluated patients using the delirium rating scale-revised-98
(Biomed Central Ltd., 2014-09-30) Meagher, David J.; Morandi, Alessandro; Inouye, Sharon K.; Ely, Wes; Adamis, Dimitrios; Maclullich, Alistair J.; Rudolph, James L.; Neufeld, Karin; Leonard, Maeve; Bellelli, Giuseppe; Davis, Daniel; Teodorczuk, Andrew; Kreisel, Stefan; Thomas, Christine; Hasemann, Wolfgang; Timmons, Suzanne; O'Regan, Niamh; Grover, Sandeep; Jabbar, Faiza; Cullen, Walter; Dunne, Colum P.; Kamholz, Barbara; Van Munster, Barbara C.; de Rooij, Sophie E.; de Jonghe, Jos; Trepacz, Paula T.; Johns Hopkins University, United States; Wellcome Trust, United Kingdom; Swiss Alzheimer Association; Alzheimervereinigung beider Basel, Switzerland; Health Research Board; All-Ireland Institute of Palliative Care
BACKGROUND: The Diagnostic and Statistical Manual fifth edition (DSM-5) provides new criteria for delirium diagnosis. We examined delirium diagnosis using these new criteria compared with the Diagnostic and Statistical Manual fourth edition (DSM-IV) in a large dataset of patients assessed for delirium and related presentations. METHODS: Patient data (n = 768) from six prospectively collected cohorts, clinically assessed using DSM-IV and the Delirium Rating Scale-Revised-98 (DRS-R98), were pooled. Post hoc application of DRS-R98 item scores were used to rate DSM-5 criteria. ‘Strict’ and ‘relaxed’ DSM-5 criteria to ascertain delirium were compared to rates determined by DSM-IV. RESULTS: Using DSM-IV by clinical assessment, delirium was found in 510/768 patients (66%). Strict DSM-5 criteria categorized 158 as delirious including 155 (30%) with DSM-IV delirium, whereas relaxed DSM-5 criteria identified 466 as delirious, including 455 (89%) diagnosed by DSM-IV (P <0.001). The concordance between the different diagnostic methods was: 53% (ĸ = 0.22) between DSM-IV and the strict DSM-5, 91% (ĸ = 0.82) between the DSM-IV and relaxed DSM-5 criteria and 60% (ĸ = 0.29) between the strict versus relaxed DSM-5 criteria. Only 155 cases were identified as delirium by all three approaches. The 55 (11%) patients with DSM-IV delirium who were not rated as delirious by relaxed criteria had lower mean DRS-R98 total scores than those rated as delirious (13.7 ± 3.9 versus 23.7 ± 6.0; P <0.001). Conversely, mean DRS-R98 score (21.1 ± 6.4) for the 70% not rated as delirious by strict DSM-5 criteria was consistent with suggested cutoff scores for full syndromal delirium. Only 11 cases met DSM-5 criteria that were not deemed to have DSM-IV delirium. CONCLUSIONS: The concordance between DSM-IV and the new DSM-5 delirium criteria varies considerably depending on the interpretation of criteria. Overly-strict adherence for some new text details in DSM-5 criteria would reduce the number of delirium cases diagnosed; however, a more ‘relaxed’ approach renders DSM-5 criteria comparable to DSM-IV with minimal impact on their actual application and is thus recommended.
Which part of a short, global risk assessment, the Risk Instrument for Screening in the Community, predicts adverse healthcare outcomes?
(Hindawi Publishing, 2015) O'Caoimh, Rónán; Fitzgerald, Carol; Cronin, Una; Svendrovski, Anton; Gao, Yang; Healy, Elizabeth; O'Connell, Elizabeth; O'Keeffe, Gabrielle; O'Herlihy, Eileen; Weathers, Elizabeth; Cornally, Nicola; Leahy-Warren, Patricia; Orfila, Francesc; Paul, Constanca; Clarnette, Roger; Molloy, D. William
The Risk Instrument for Screening in the Community (RISC) is a short, global risk assessment to identify community-dwelling older adults' one-year risk of institutionalisation, hospitalisation, and death. We investigated the contribution that the three components of the RISC (concern, its severity, and the ability of the caregiver network to manage concern) make to the accuracy of the instrument, across its three domains (mental state, activities of daily living (ADL), and medical state), by comparing their accuracy to other assessment instruments in the prospective Community Assessment of Risk and Treatment Strategies study. RISC scores were available for 782 patients. Across all three domains each subtest more accurately predicted institutionalisation compared to hospitalisation or death. The caregiver network's ability to manage ADL more accurately predicted institutionalisation (AUC 0.68) compared to hospitalisation (AUC 0.57, P=0.01) or death (AUC 0.59, P=0.046), comparing favourably with the Barthel Index (AUC 0.67). The severity of ADL (AUC 0.63), medical state (AUC 0.62), Clinical Frailty Scale (AUC 0.67), and Charlson Comorbidity Index (AUC 0.66) scores had similar accuracy in predicting mortality. Risk of hospitalisation was difficult to predict. Thus, each component, and particularly the caregiver network, had reasonable accuracy in predicting institutionalisation. No subtest or assessment instrument accurately predicted risk of hospitalisation.
Perceptions, expectations, and informal supports influence exercise activity in frail older adults
(Sage, 2015-04) Broderick, Louise; McCullagh, Ruth; Bantry White, Eleanor; Savage, Eileen; Timmons, Suzanne
This study aims to explore frail older adults’ perceptions of what influences their exercise behaviors. A qualitative descriptive design was used. Semi-structured, open-ended interviews were conducted with 29 frail older adults. Thematic content analysis established the findings. Frail older adults perceive exercise as a by-product of other purposeful activities such as manual work or social activities. Progression into frailty appears to be associated with a decline in non-family support, changing traditional roles within family support networks, and lower baseline activity levels. Frail older adults perceive exercise as incidental to more purposeful activities rather than an endpoint in itself. Therefore, exercise programs concentrating on functional outcomes may be more relevant for this population. Strategies that educate and promote social support networks may also benefit frail older adults.
The Risk Instrument for Screening in the Community (RISC): a new instrument for predicting risk of adverse outcomes in community dwelling older adults
(Biomed Central Ltd., 2015-07-30) O'Caoimh, Rónán; Gao, Yang; Svendrovski, Anton; Healy, Elizabeth; O'Keeffe, Gabrielle; Cronin, Una; Igras, Estera; O'Herlihy, Eileen; Fitzgerald, Carol; Weathers, Elizabeth; Leahy-Warren, Patricia; Cornally, Nicola; Molloy, D. William; Health Service Executive, Ireland
BACKGROUND: Predicting risk of adverse healthcare outcomes, among community dwelling older adults, is difficult. The Risk Instrument for Screening in the Community (RISC) is a short (2-5 min), global subjective assessment of risk created to identify patients' 1-year risk of three outcomes: institutionalisation, hospitalisation and death. METHODS: We compared the accuracy and predictive ability of the RISC, scored by Public Health Nurses (PHN), to the Clinical Frailty Scale (CFS) in a prospective cohort study of community dwelling older adults (n = 803), in two Irish PHN sectors. The area under the curve (AUC), from receiver operating characteristic curves and binary logistic regression models, with odds ratios (OR), compared the discriminatory characteristics of the RISC and CFS. RESULTS: Follow-up data were available for 801 patients. The 1-year incidence of institutionalisation, hospitalisation and death were 10.2, 17.7 and 15.6 % respectively. Patients scored maximum-risk (RISC score 3,4 or 5/5) at baseline had a significantly greater rate of institutionalisation (31.3 and 7.1 %, p < 0.001), hospitalisation (25.4 and 13.2 %, p < 0.001) and death (33.5 and 10.8 %, p < 0.001), than those scored minimum-risk (score 1 or 2/5). The RISC had comparable accuracy for 1-year risk of institutionalisation (AUC of 0.70 versus 0.63), hospitalisation (AUC 0.61 versus 0.55), and death (AUC 0.70 versus 0.67), to the CFS. The RISC significantly added to the predictive accuracy of the regression model for institutionalisation (OR 1.43, p = 0.01), hospitalisation (OR 1.28, p = 0.01), and death (OR 1.58, p = 0.001). CONCLUSION: Follow-up outcomes matched well with baseline risk. The RISC, a short global subjective assessment, demonstrated satisfactory validity compared with the CFS.
A review of the accuracy and utility of motion sensors to measure physical activity of frail older hospitalised patients.
(Human Kinetics, 2015-11-19) McCullagh, Ruth; Brady, Noeleen M.; Dillon, Christina B.; Horgan, N. Frances; Timmons, Suzanne; Health Research Board
The purpose of this review was to examine the utility and accuracy of commercially available motion sensors to measure step-count and time spent upright in frail older hospitalized patients. A database search (CINAHL and PubMed, 2004–2014) and a further hand search of papers’ references yielded 24 validation studies meeting the inclusion criteria. Fifteen motion sensors (eight pedometers, six accelerometers, and one sensor systems) have been tested in older adults. Only three have been tested in hospital patients, two of which detected postures and postural changes accurately, but none estimated step-count accurately. Only one motion sensor remained accurate at speeds typical of frail older hospitalized patients, but it has yet to be tested in this cohort. Time spent upright can be accurately measured in the hospital, but further validation studies are required to determine which, if any, motion sensor can accurately measure step-count.
Nurses' knowledge of advance directives and perceived confidence in end-of-life care: a cross-sectional study in five countries
(Wiley, 2016-01-28) Coffey, Alice; McCarthy, Geraldine; Weathers, Elizabeth; Friedman, M. Isabel; Gallo, Katherine; Ehrenfeld, Mally; Chan, Sophia; Li, William H. C.; Poletti, Piera; Zanotti, Renzo; Molloy, D. William; McGlade, Ciara; Fitzpatrick, Joyce J.; Itzhaki, Michal
Nurses' knowledge regarding advance directives may affect their administration and completion in end-of-life care. Confidence among nurses is a barrier to the provision of quality end-of-life care. This study investigated nurses' knowledge of advance directives and perceived confidence in end-of-life care, in Hong Kong, Ireland, Israel, Italy and the USA using a cross-sectional descriptive design (n = 1089). In all countries, older nurses and those who had more professional experience felt more confident managing patients' symptoms at end-of-life and more comfortable stopping preventive medications at end-of-life. Nurses in the USA reported that they have more knowledge and experience of advance directives compared with other countries. In addition, they reported the highest levels of confidence and comfort in dealing with end-of-life care. Although legislation for advance directives does not yet exist in Ireland, nurses reported high levels of confidence in end-of-life care.
Interviews with Irish healthcare workers from different disciplines about palliative care for people with Parkinson's disease: a definite role but uncertainty around terminology and timing
(BioMed Central, 2016-02-09) Fox, Siobhán; Cashell, Alison; Kernohan, W. George; Lynch, Marie; McGlade, Ciara; O'Brien, Tony; O'Sullivan, Sean S.; Timmons, Suzanne; Irish Hospice Foundation
Background: An integrated palliative care approach is recommended in all life-limiting diseases, including Parkinson’s disease (PD). However research shows that people with PD have unmet palliative care needs. The study aimed to explore multidisciplinary healthcare workers’ (HCWs) views on palliative care for people with PD, identifying perceived barriers and facilitators. Methods: A qualitative design was used; data was analysed using Thematic Analysis. Semi-structured interviews were conducted with 30 HCWs, working either with people with PD or in a palliative care setting in Ireland. Results: A number of perceived barriers were evident helping to account for the previously reported unmet palliative care needs in PD. A lack of education about PD and palliative care meant that HCWs were unsure of the appropriateness of referral, and patients and carers weren’t equipped with information to seek palliative care. A lack of communication between PD and palliative care specialists was seen to impede collaboration between the disciplines. Uncertainty about the timing of palliative care meant that it was often not introduced until a crisis point, despite the recognised need for early planning due to increased prevalence of dementia. Conclusions: Most HCWs recognised a need for palliative care for people with PD; however several barriers to implementing a palliative care approach in this population need to be addressed. Implications for clinical practice and policy include the need for an integrated model of care, and education for all HCWs, patients, carers, and the public on both the nature of advanced PD, and the potential of palliative care in support of patients and their family members.
Screening for mild cognitive impairment: Comparison of "MCI Specific" screening instruments
(IOS Press, 2016-03-15) O'Caoimh, Rónán; Timmons, Suzanne; Molloy, D. William; Health Research Board; Irish Hospice Foundation; Health Service Executive of Ireland
Background: Sensitive and specific instruments are required to screen for cognitive impairment (CI) in busy clinical practice. The Montreal Cognitive Assessment (MoCA) is widely validated but few studies compare it to tests designed specifically to detect mild cognitive impairment (MCI). Objective: Comparison of two “MCI specific” screens: the Quick Mild Cognitive Impairment screen (Qmci) and MoCA. Methods: Patients with subjective memory complaints (SMC; n = 73), MCI (n = 103), or dementia (n = 274), were referred to a university hospital memory clinic and underwent comprehensive assessment. Caregivers, without cognitive symptoms, were recruited as normal controls (n = 101). Results: The Qmci was more accurate than the MoCA in differentiating MCI from controls, area under the curve (AUC) of 0.90 versus 0.80, p = 0.009. The Qmci had greater (AUC 0.81), albeit non-significant, accuracy than the MoCA (AUC 0.73) in separating MCI from SMC, p = 0.09. At its recommended cut-off (<62/100), the Qmci had a sensitivity of 90% and specificity of 87% for CI (MCI/dementia). Raising the cut-off to <65 optimized sensitivity (94%), reducing specificity (80%). At <26/30 the MoCA had better sensitivity (96%) but poor specificity (58%). A MoCA cut-off of <24 provided the optimal balance. Median Qmci administration time was 4.5 (±1.3) minutes compared with 9.5 (±2.8) for the MoCA Conclusions: Although both tests distinguish MCI from dementia, the Qmci is particularly accurate in separating MCI from normal cognition and has shorter administration times, suggesting it is more useful in busy hospital clinics. This study reaffirms the high sensitivity of the MoCA but suggests a lower cut-off (<24) in this setting.
A study protocol of a randomised controlled trial to measure the effects of an augmented prescribed exercise programme (APEP) for frail older medical patients in the acute setting
(BioMed Central, 2016-04-08) McCullagh, Ruth; O'Connell, Eimear; O'Meara, Sarah; Perry, Ivan J.; Fitzgerald, Anthony P.; O'Connor, Kieran; Horgan, N. Frances; Timmons, Suzanne; Health Research Board
Background: Older adults experience functional decline in hospital leading to increased healthcare burden and morbidity. The benefits of augmented exercise in hospital remain uncertain. The aim of this trial is to measure the short and longer-term effects of augmented exercise for older medical in-patients on their physical performance, quality of life and health care utilisation. Design and Methods: Two hundred and twenty older medical patients will be blindly randomly allocated to the intervention or sham groups. Both groups will receive usual care (including routine physiotherapy care) augmented by two daily exercise sessions. The sham group will receive stretching and relaxation exercises while the intervention group will receive tailored strengthening and balance exercises. Differences between groups will be measured at baseline, discharge, and three months. The primary outcome measure will be length of stay. The secondary outcome measures will be healthcare utilisation, activity (accelerometry), physical performance (Short Physical Performance Battery), falls history in hospital and quality of life (EQ-5D-5 L). Discussion: This simple intervention has the potential to transform the outcomes of the older patient in the acute setting.
Economic (gross cost) analysis of systematically implementing a programme of advance care planning in three Irish nursing homes.
(BioMed Central, 2016-04-26) O'Sullivan, Ronan; Murphy, Aileen; O'Caoimh, Rónán; Cornally, Nicola; Svendrovski, Anton; Daly, Brian; Fitzgerald, Carol; Twomey, Cillian; McGlade, Ciara; Molloy, D. William; Atlantic Philanthropies; Health Research Board; Irish Hospice Foundation
Background: Although advance care planning (ACP) and the use of advanced care directives (ACD) and end-of-life care plans are associated with a reduction in inappropriate hospitalisation, there is little evidence supporting the economic benefits of such programmes. We assessed the economic impact (gross savings) of the Let Me Decide (LMD) ACP programme in Ireland, specifically the impact on hospitalisations, bed days and location of resident deaths, before and after systematic implementation of the LMD-ACP combined with a palliative care education programme. Methods: The LMD-ACP was introduced into three long-term care (LTC) facilities in Southern Ireland and outcomes were compared pre and post implementation. In addition, 90 staff were trained in a palliative care educational programme. Economic analysis including probabilistic sensitivity analysis was performed. Results: The uptake of an ACD or end-of-life care post-implementation rose from 25 to 76 %. Post implementation, there were statistically significant decreases in hospitalisation rates from baseline (hospitalisation incidents declined from 27.8 to 14.6 %, z = 3.96, p < 0.001; inpatient hospital days reduced from 0.54 to 0.36 %, z = 8.85, p < 0.001). The percentage of hospital deaths also decreased from 22.9 to 8.4 %, z = 3.22, p = 0.001. However, length of stay (LOS) increased marginally (7–9 days). Economic analysis suggested a cost-reduction related to reduced hospitalisations ranging between €10 and €17.8 million/annum and reduction in ambulance transfers, estimated at €0.4 million/annum if these results were extrapolated nationally. When unit costs and LOS estimates were varied in scenario analyses, the expected cost reduction owing to reduced hospitalisations, ranged from €17.7 to €42.4 million nationally. Conclusions: Implementation of the LMD-ACP (ACD/end-of-life care plans combined with palliative care education) programme resulted in reduced rates of hospitalisation. Despite an increase in LOS, likely reflecting more complex care needs of admitted residents, gross costs were reduced and scenario analysis projected large annual savings if these results were extrapolated to the wider LTC population in Ireland.
European multicentre double-blind placebo-controlled trial of Nilvadipine in mild-to-moderate Alzheimer's disease - The substudy protocols: NILVAD frailty; NILVAD blood and genetic biomarkers; NILVAD cerebrospinal fluid biomarkers; NILVAD cerebral blood flow
(BMJ Publishing Group, 2016-05-04) Meulenbroek, Olga; O'Dwyer, Sarah; de Jong, Daan; van Spijker, Gerrita; Kennelly, Sean; Cregg, Fiona; Olde Rikkert, Marcel; Abdullah, Laila; Wallin, Anders; Walsh, Cathal; Coen, Robert; Kenny, Rose Anne; Daly, Leslie; Segurado, Ricardo; Borjesson-Hanson, Anne; Crawford, Fiona; Mullan, Michael; Lucca, Ugo; Banzi, Rita; Pasquier, Florence; Breuilh, Laetitia; Riepe, Matthias; Kalman, Janos; Molloy, D. William; Tsolaki, Magda; Howard, Robert; Adams, Jessica; Gaynor, Siobhan; Lawlor, Brian A.; Alzheimer's Drug Discovery Foundation; Dutch Alzheimer Society; Seventh Framework Programme
Introduction: In conjunction with the NILVAD trial, a European Multicentre Double-Blind Placebo Controlled trial of Nilvadipine in Mild-to-Moderate Alzheimer's disease (AD), there are four NILVAD substudies in which eligible NILVAD patients are also invited to participate. The main NILVAD protocol was previously published in BMJ Open (2014). The objectives of the NILVAD substudies are to determine whether frailty, cerebrospinal fluid (CSF), blood biomarker profile and Apolipoprotein E (APOE) status predict response to Nilvadipine, and to investigate the effect of Nilvadipine on cerebral blood flow and blood biomarkers. Methods and analysis: All participants who fulfil criteria for the main NILVAD study are eligible for participation in the NILVAD substudies. Participation is subject to informed consent and whether the substudy is available at a particular NILVAD study site. Each substudy entails extra measurements during the course of the main NILVAD study. For example, in the blood and genetic biomarkers substudy, extra blood (30 mL) will be collected at week 0, week 13, week 52 and week 78, while in the cerebral blood flow substudy, participants will receive an MRI and transcranial Doppler measurements at week 0, week 26 and week 78. In the CSF substudy, 10 mL CSF is collected at week 0 and week 78. Ethics and dissemination: All NILVAD substudies and all subsequent amendments have received ethical approval within each participating country, according to national regulations. Each participant provides written consent to participate. All participants remain anonymised throughout and the results of each substudy will be published in an international peer reviewed journal. Trial registration number EUDRACT 2012-002764-27; Pre-results.
Acute hospital dementia care: results from a national audit
(BioMed Central, 2016-05-31) Timmons, Suzanne; O'Shea, Emma; O'Neill, Desmond; Gallagher, Paul F.; de Siún, Anna; McArdle, Denise; Gibbons, Patricia; Kennelly, Sean; Atlantic Philanthropies
Background: Admission to an acute hospital can be distressing and disorientating for a person with dementia, and is associated with decline in cognitive and functional ability. The objective of this audit was to assess the quality of dementia care in acute hospitals in the Republic of Ireland. Methods: Across all 35 acute public hospitals, data was collected on care from admission through discharge using a retrospective chart review (n = 660), hospital organisation interview with senior management (n = 35), and ward level organisation interview with ward managers (n = 76). Inclusion criteria included a diagnosis of dementia, and a length of stay greater than 5 days. Results: Most patients received physical assessments, including mobility (89 %), continence (84 %) and pressure sore risk (87 %); however assessment of pain (75 %), and particularly functioning (36 %) was poor. Assessment for cognition (43 %) and delirium (30 %) was inadequate. Most wards have access at least 5 days per week to Liaison Psychiatry (93 %), Geriatric Medicine (84 %), Occupational Therapy (79 %), Speech & Language (81 %), Physiotherapy (99 %), and Palliative Care (89 %) Access to Psychology (9 %), Social Work (53 %), and Continence services (34 %) is limited. Dementia awareness training is provided on induction in only 2 hospitals, and almost half of hospitals did not offer dementia training to doctors (45 %) or nurses (48 %) in the previous 12 months. Staff cover could not be provided on 62 % of wards for attending dementia training. Most wards (84 %) had no dementia champion to guide best practice in care. Discharge planning was not initiated within 24 h of admission in 72 % of cases, less than 40 % had a single plan for discharge recorded, and 33 % of carers received no needs assessment prior to discharge. Length of stay was significantly greater for new discharges to residential care (p < .001). Conclusion: Dementia care relating to assessment, access to certain specialist services, staffing levels, training and support, and discharge planning is sub-optimal, which may increase the risk of adverse patient outcomes and the cost of acute care. Areas of good practice are also highlighted.
Comparison of the Quick Mild Cognitive Impairment (Qmci) screen to the Montreal Cognitive Assessment (MoCA) in an Australian geriatrics clinic
(John Wiley & Sons, Ltd., 2016-07-18) Clarnette, Roger; O'Caoimh, Rónán; Antony, Deanna N.; Svendrovski, Anton; Molloy, D. William
Introduction: The Montreal Cognitive Assessment (MoCA) accurately differentiates mild cognitive impairment (MCI) from mild dementia and normal controls (NC). While the MoCA is validated in multiple clinical settings, few studies compare it with similar tests also designed to detect MCI. We sought to investigate how the shorter Quick Mild Cognitive Impairment (Qmci) screen compares with the MoCA. Methods: Consecutive referrals presenting with cognitive complaints to a teaching hospital geriatric clinic (Fremantle, Western Australia) underwent a comprehensive assessment and were classified as MCI (n = 72) or dementia (n = 109). NC (n = 41) were a sample of convenience. The Qmci and MoCA were scored by trained geriatricians, in random order, blind to the diagnosis. Results: Median Qmci scores for NC, MCI and dementia were 69 (+/−19), 52.5 (+/−12) and 36 (+/−14), respectively, compared with 27 (+/−5), 22 (+/−4) and 15 (+/−7) for the MoCA. The Qmci more accurately identified cognitive impairment (MCI or dementia), area under the curve (AUC) 0.97, than the MoCA (AUC 0.92), p = 0.04. The Qmci was non-significantly more accurate in distinguishing MCI from controls (AUC 0.91 vs 0.84, respectively = 0.16). Both instruments had similar accuracy for differentiating MCI from dementia (AUC of 0.91 vs 0.88, p = 0.35). At the optimal cut-offs, calculated from receiver operating characteristic curves, the Qmci (≤57) had a sensitivity of 91% and specificity of 93% for cognitive impairment, compared with 87% sensitivity and 80% specificity for the MoCA (≤23). Conclusion: While both instruments are accurate in detecting MCI, the Qmci is shorter and arguably easier to complete, suggesting that it is a useful instrument in an Australian geriatric outpatient population.
Active and healthy ageing and independent living 2016
(Hindawi Publishing Corporation, 2016-08) Illario, Maddalena; Vollenbroek-Hutten, Miriam M. R.; Molloy, D. William; Menditto, Enrica; Iaccarino, Guido; Eklund, Patrik
The inter-rater reliability of the Risk Instrument for Screening in the Community
(Mark Allen Healthcare Ltd., 2016-09) Weathers, Elizabeth; O'Caoimh, Rónán; O'Sullivan, Ronan; Paúl, Constança; Orfilia, Frances; Clarnette, Roger; Fitzgerald, Carol; Svendrovski, Anton; Cornally, Nicola; Leahy-Warren, Patricia; Molloy, D. William
Predicting risk of adverse healthcare outcomes is important to enable targeted delivery of interventions. The Risk Instrument for Screening in the Community (RISC), designed for use by public health nurses (PHNs), measures the one-year risk of hospitalisation, institutionalisation and death in community-dwelling older adults according to a five-point global risk score: from low (score 1,2), medium (3) and high (4,5). We examined the inter-rater reliability (IRR) of the RISC between student PHNs (n=32) and expert raters using six cases (two low, medium and high-risk), scored before and after RISC training. Correlations increased for each adverse outcome, statistically significantly for institutionalisation (r=0.72 to 0.80,p=0.04) and hospitalisation, (r=0.51 to 0.71,p<0.01) but not death. Training improved accuracy for low-risk but not all high-risk cases. Overall, the RISC showed good IRR, which increased after RISC training. That reliability reduced for some high-risk cases suggests that the training programme requires adjustment to further improve IRR.
Perceived risk of death in older primary care patients
(Sage, 2016-09-20) Teixeira, Laetitia; Azevedo, Maria João; Alves, Sara; Duarte, Mafalda; O'Caoimh, Rónán; Molloy, D. William; Paúl, Constança
There is a large gap between life expectancy and healthy life years at age 65. To reduce this gap, it is necessary that people with medical concerns perceived at higher risk of adverse outcomes are readily identified and treated. The same goes for the need to implement prevention plans. The main objectives of this study are to, in a first step, (a) estimate the percentage of medical concerns, (b) identify factors associated with this concern; in a second step, (c) estimate the perceived risk of death, and (d) evaluate the ability of medical concerns to predict this risk. Results show that the existence and severity of medical concerns are crucial in the prediction of perceived risk of death. Early identification of severity of medical concerns and the availability and adequacy of informal caregiving should allow healthcare professionals to promptly initiate an appropriate assessment and treatment of older patients.
Walking in hospital is associated with a shorter length of stay in older medical inpatients
(IOP Publishing, 2016-09-21) McCullagh, Ruth; Dillon, Christina B.; Dahly, Darren L.; Horgan, N. Frances; Timmons, Suzanne; Health Research Board
Evidence suggests that inactivity during a hospital stay is associated with poor health outcomes in older medical inpatients. We aimed to estimate the associations of average daily step-count (walking) in hospital with physical performance and length of stay in this population. Medical in-patients aged ⩾65 years, premorbidly mobile, with an anticipated length of stay ⩾3 d, were recruited. Measurements included average daily step-count, continuously recorded until discharge, or for a maximum of 7 d (Stepwatch Activity Monitor); co-morbidity (CIRS-G); frailty (SHARE F-I); and baseline and end-of-study physical performance (short physical performance battery). Linear regression models were used to estimate associations between step-count and end-of-study physical performance or length of stay. Length of stay was log transformed in the first model, and step-count was log transformed in both models. Similar models were used to adjust for potential confounders. Data from 154 patients (mean 77 years, SD 7.4) were analysed. The unadjusted models estimated for each unit increase in the natural log of stepcount, the natural log of length of stay decreased by 0.18 (95% CI −0.27 to −0.09). After adjustment of potential confounders, while the strength of the inverse association was attenuated, it remained significant (βlog(steps) = −0.15, 95%CI −0.26 to −0.03). The back-transformed result suggested that a 50% increase in step-count was associated with a 6% shorter length of stay. There was no apparent association between step-count and end-of-study physical performance once baseline physical performance was adjusted for. The results indicate that step-count is independently associated with hospital length of stay, and merits further investigation.

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