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Susan Williams,1 Clíona O’Riordan,1 Fiona Steed,2 Aoife Leahy,1,3 Elaine Shanahan,3 Catherine Peters,3 Margaret O’Connor,3,4 Rose Galvin,1 Ann-Marie Morrissey1 1School of Allied Health, University of Limerick, Limerick, Ireland; 2Department of Medicine, University Hospital Limerick, Limerick, Ireland; 3Department of Ageing and Therapeutics, University Hospital Limerick, Limerick, Ireland; 4School of Medicine, University of Limerick, Limerick, IrelandCorrespondence: Susan Williams, School of Allied Health, Faculty of Education and Health Sciences, Ageing Research Centre, Health Research Institute, University of Limerick, Limerick, Ireland, Email Susan.Williams@ul.ieIntroduction: Early supported discharge (ESD) is well established as a model of health service delivery for people with stroke. Emerging evidence indicates that ESD also reduces the length of stay for older medical inpatients. There is a dearth of evidence exploring the views of stakeholders on ESD as a model of care for older medical inpatients. The overall aim of this study is to explore the views and perceptions of older adults, family carers and healthcare professionals on the potential role of ESD for older adults admitted to hospital with medical complaints.Methods: Purposeful sampling was used to recruit older adults and family carers for interview. For Healthcare Professionals (HCPs), snowball purposeful sampling was used. Phone interviews took place following a semi-structured interview guide. Focus groups were moderated by A-MM. Braun and Clarke’s approach to thematic analysis was used. Ethical approval was granted by the HSE Mid-Western Area Regional Ethics Committee in November 2021 (REC Ref. 096/2021).Results: Fifteen HCPs took part across three focus groups, with six older adults and two family members participating in one-to-one interviews. Three themes were identified: 1. Pre-ESD experiences of providing and receiving older adult inpatient care, 2. Navigating discharge procedures from acute hospital services, 3. A vision for more integrated model of care and a medical ESD team.Discussion: This study provided insight into the current discharge experiences of older adult care in the acute setting, the potential role for ESD in this population and the key factors that would need to be considered for the running of an ESD service for older adults admitted to hospital with medical complaints.Conclusion: This research highlights the barriers and facilitators to ESD for older medical inpatients from the perspectives of key stakeholders. Given the adverse outcomes associated with prolonged hospital stay, these findings will help inform the development of a feasibility trial, examining patient and process outcomes for older adults admitted to hospital with medical complaints who receive an ESD intervention.Keywords: early supported discharge, older adults, hospitalised, qualitative, medical inpatient

Background the aim of this systematic review and meta-analysis was to update and synthesise the totality of research evidence on the effectiveness of acute geriatric unit (AGU) care for older adults admitted to hospital with acute medical complaints. Methods MEDLINE, CINAHL, CENTRAL and Embase databases were systematically searched from 2008 to February 2022. Screening, data extraction and quality grading were undertaken by two reviewers. Only trials with a randomised design comparing AGU care and conventional care units were included. Meta-analyses were performed in Review Manager 5.4 and the Grading of Recommendations, Assessment, Development and Evaluations framework was used to assess the certainty of evidence. The primary outcome was incidence of functional decline between baseline 2-week prehospital admission status and discharge and at follow-up. Results 11 trials recruiting 7,496 participants across three countries were included. AGU care resulted in a reduction in functional decline at 6-month follow-up (risk ratio (RR) 0.79, 95% confidence interval (CI) 0.66–0.93; moderate certainty evidence) and an increased probability of living at home at 3-month follow-up (RR 1.06, 95% CI 0.99–1.13; high certainty evidence). AGU care resulted in little or no difference in functional decline at hospital discharge or at 3-month follow-up, length of hospital stay, costs, the probability of living at home at discharge, mortality, hospital readmission, cognitive function or patient satisfaction. Conclusions AGU care improves clinical and process outcomes for hospitalised older adults with acute medical complaints. Future research should focus on greater inclusion of clinical and patient reported outcome measures.

IntroductionFrailty is associated with adverse outcomes relating to cardiac procedures. It has been proposed that frailty scoring should be included in the preoperative assessment of patients undergoing aortic valve replacement. We aim to examine the Rockwood Clinical Frailty Scale (CFS), as a predictor of adverse outcomes following aortic valve replacement.Methods and analysisProspective and retrospective cohort studies and randomised controlled trials assessing both the preoperative frailty status (as per the CFS) and incidence of adverse outcomes among older adults undergoing either surgical aortic valve replacement or transcatheter aortic valve replacement will be included. Adverse outcomes will include mortality and periprocedural complications, as well as a composite of 30-day complications. A search will be conducted from 2005 to present using a prespecified search strategy. Studies will be screened for inclusion by two reviewers, with methodological quality assessed using the Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2) tool. Relative risk ratios with 95% CIs will be generated for each outcome of interest, comparing frail with non-frail groups. Data will be plotted on forest plots where applicable. The quality of the evidence will be determined using the Grading of Recommendations, Assessment, Development and Evaluation tool.Ethics and disseminationEthical approval is not required for this study as no primary data will be collected. We will publish the review in a peer-reviewed journal on completion.PROSPERO registration numberCRD42020213757.

IntroductionThe increasing number of older adults with multiple complex care needs has placed increased pressure on healthcare systems internationally to reorientate healthcare delivery. For many older adults, their first point of contact with the health service is with their general practitioner (GP) and GP participation with integrated care models is the foundation of a population-based approach. A knowledge gap remains in relation to the effectiveness of GP participation in community-based integrated health and social care approaches for older adults. This systematic review aims to examine the effectiveness of multidisciplinary-integrated care for community-dwelling older adults with GP participation.Methods and analysisThis systematic review will include randomised controlled trials (RCTs), quasi and cluster RCTs focusing on integrated care interventions for community-dwelling older adults by multidisciplinary teams including health and social care professionals and GPs. The databases PUBMED, EMBASE, CINAHL, Central Register of Controlled Trials in the Cochrane Library and MEDLINE will be searched. The primary outcome measure will be functional status. Secondary outcomes will include: primary healthcare utilisation, secondary healthcare utilisation, participant satisfaction with care, health-related quality of life, nursing home admission and mortality. The methodological quality of the studies will be assessed using the Cochrane Risk of Bias Tool V.2. The elements of care integration will be mapped in the individual studies using the Rainbow Model of Integrated Care taxonomy. A meta-analysis will be completed, depending on the uniformity of the data. Grading of Recommendations, Assessment, Development and Evaluation will be used to assess the certainty of evidence.Ethics and disseminationFormal ethical approval is not required as all data included are anonymous secondary data. Scientific outputs will be presented at relevant conferences and in collaboration with our public and patient involvement stakeholder panel of older adults at the Ageing Research Centre at the University of Limerick.PROSPERO registration numberCRD42022309744.

Background Older people account for 25% of all Emergency Department (ED) admissions. This is expected to rise with an ageing demographic. Older people often present to the ED with complex medical needs in the setting of multiple comorbidities. Comprehensive Geriatric Assessment (CGA) has been shown to improve outcomes in an inpatient setting but clear evidence of benefit in the ED setting has not been established. It is not feasible to offer this resource-intensive assessment to all older adults in a timely fashion. Screening tools for frailty have been used to identify those at most risk for adverse outcomes following ED visit. The overall aim of this study is to examine the impact of CGA on the quality, safety and cost-effectiveness of care in an undifferentiated population of frail older people with medical complaints who present to the ED and Acute Medical Assessment Unit. Methods This will be a parallel 1:1 allocation randomised control trial. All patients who are ≥ 75 years will be screened for frailty using the Identification of Seniors At Risk (ISAR) tool. Those with a score of ≥ 2 on the ISAR will be randomised. The treatment arm will undergo geriatric medicine team-led CGA in the ED or Acute Medical Assessment Unit whereas the non-treatment arm will undergo usual patient care. A dedicated multidisciplinary team of a specialist geriatric medicine doctor, senior physiotherapist, specialist nurse, pharmacist, senior occupational therapist and senior medical social worker will carry out the assessment, as well as interventions that arise from that assessment. Primary outcomes will be the length of stay in the ED or Acute Medical Assessment Unit. Secondary outcomes will include ED re-attendance, re-hospitalisation, functional decline, quality of life and mortality at 30 days and 180 days. These will be determined by telephone consultation and electronic records by a research nurse blinded to group allocation. Ethics and dissemination Ethical approval was obtained from the Health Service Executive (HSE) Mid-Western Regional Hospital Research Ethics Committee (088/2020). Our lay dissemination strategy will be developed in collaboration with our Patient and Public Involvement stakeholder panel of older people at the Ageing Research Centre and we will present our findings in peer-reviewed journals and national and international conferences. Trial registration ClinicalTrials.gov NCT04629690. Registered on November 16, 2020

Background 53% of hospital inpatient beds are occupied by patients >/= 65 years. These patients often experience functional decline. In those transferred to our post-acute rehabilitation unit the average length of stay prior to transfer is 16 days and 38 days post transfer. Our hospital has a Community Response Unit (CRU) which provides an alternative to this care pathway, offering direct admission to a 15 bed unit with 24-hour medical cover and full multidisciplinary input. This study reviews the use of this unit over a one year period. Methods We retrospectively reviewed the discharge letter or medical notes of patients admitted to the CRU during 2018. The referral source, indication for admission, length of stay and discharge destination were recorded. Results One-hundred and fourteen patients were admitted over the one year period. Source of referral was identified for 81 patients and included day hospitals (53.1%), acute hospitals (14.8%), respite/ transitional care wards (12.3%), nursing homes (8.7%), home visits (6.2%), community sources (3.7%) and other speciality clinics (1.2%). The most common indications for admission were-mobility/functional decline (26.3%), falls (17.5%), requirement for medical investigations (14.9%), cognitive decline with behavioural issues (11.4%), blood transfusion (10.5%), pain management (7%), general deterioration (7%), requirement for increased home supports (7%), treatment of infection (6.1%), rehab post fracture (5.3%), wound management (4.4%), alcohol detoxification (1.8%) and self-neglect (1.8%). Multifactorial reasons for admission frequently occurred. The median length of stay was 24 days (1-176 days), 67% of patients were discharged to their original residence, 17.4% were newly admitted to residential care, 9.2% required transfer to an acute hospital and 6.4% died during their admission. Conclusion The CRU provides comprehensive Geriatrician led care for a wide variety of indications. This model of care offers a valid alternative to Emergency Department presentation and acute hospital admission.

Background Delirium is common among unwell older adults. Despite this the pathophysiology remains poorly understood. We hypothesised that autonomic dysfunction may be associated with the development of delirium. Methods 35 participants completed a case-control study. Delirium was assessed using DSM-IV and DRS-R98. Autonomic function was assessed with Head-Up Tilt testing (HUT), baroreflex sensitivity (BRS) testing using Baroreflex Effectiveness Index (BEI), 24-hour blood pressure variability (BPV), nocturnal blood pressure dipping status and 24-hour heart rate variability (HRV). A subgroup analysis of those without pre-existing cognitive impairment (CI) was completed. Results During tilting the delirium group (DG) had a median decrease of 1mmHg (IQR 38.5) in systolic blood pressure (SBP) compared to a median decrease of 17.5mmHg (IQR 20.75) in the control group (CG) (p=0.04). Increased delirium severity correlated with a reduction in the decrease in SBP (rs= -0.42, p=0.03). In those without CI, BRS testing during HUT showed that increases in blood pressure were not followed by an appropriate reduction in heart rate with a mean BEI of 36.87% (SD 22.26) in the DG and 56.03% (SD 23.04) in the CG (p=0.05). Nocturnal dipping differed during subgroup analysis. 58.3% (7) of DG were reverse dippers, 33.3% (4) were non-dippers and 8.3% (1) had a normal dipping pattern. In CG 57.1% (4) were non-dippers, 14.3% (1) had a normal dipping pattern and 28.6% (2) were extreme dippers (p=0.01). BPV was measured by average real variability (ARV). In those without CI mean ARV was 13.81 (SD 5.98) in the CG and 9.69 (SD 2.75) in the DG (p=0.05). No difference was detected in HRV. Conclusion We identified differences in autonomic function between the DG and CG. This is the first study to look at several components of autonomic function in delirium and thus can provide insights into physiological abnormalities present during, or contributing to delirium.

Background: Comprehensive geriatric assessment (CGA) has been shown to improve outcomes in hospitalised older adults; however, there is currently no compelling evidence to support CGA interventions within the Emergency Department (ED). The aim of this study is to explore the clinical and process outcomes of older adults who receive ED-CGA over a period of six months after their initial ED attendance. Design: Prospective cohort study. Methods: The STrengthening the Reporting of the OBservational studies in Epidemiology (STROBE) standardised reporting guidelines will be adhered to. Older adults aged ≥65 years who score ≥2 on the Identification of Seniors at Risk (ISAR) tool and present to the ED with a medical complaint during the operational hours of the dedicated interdisciplinary team, will be considered eligible for recruitment. Demographic and health assessment information will be obtained at the ED index attendance followed by completion of an interdisciplinary CGA. A dedicated research nurse will complete follow-up telephone interviews with participants at 30 days and six months. The primary outcome will be incidence of hospital admission from the ED index attendance. Secondary outcomes will include functional decline, patient satisfaction with the ED index attendance, unscheduled ED reattendance(s), unscheduled hospital (re)admission(s), nursing home admission(s), healthcare utilisation, and death. Descriptive statistics will be used to profile the characteristics of the study participants and multivariate logistic and linear regression analysis will be used to analyse risk of adverse outcomes. Ethics and dissemination: Ethical approval was granted by the University of Limerick Hospital Group Research Ethics Committee (107/2021). The authors will disseminate study findings through publication in a peer-reviewed journal and presentation at national and international conferences. Patient and public involvement will be sought from a panel of older adults at the Ageing Research Centre in the University of Limerick. Clinicaltrials.gov Identifier: NCT05252182.

IntroductionEarly supported discharge (ESD) aims to link acute and community care, allowing hospital inpatients to return home and continue to receive the necessary input from healthcare professionals that they would otherwise receive in hospital. The concept has been researched extensively in the stroke population, showing reduced length of stay for patients and improved functional outcomes. This systematic review aims to explore the totality of evidence for the use of ESD in an older adult population who have been hospitalised with medical complaints.MethodsA systematic review of randomised controlled trials and quasi randomised controlled trials will be carried out in line with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Studies will be included if they provide an ESD intervention to older adults admitted to hospital for medical complaints compared with continuing inpatient care. MEDLINE, CINAHL, CENTRAL and EMBASE databases will be searched. The primary outcome measure will be length of hospital stay, secondary outcomes will include functional abilities, falls, quality of life, carer and patient satisfaction, unplanned emergency department re-presentation, unscheduled hospital readmission, nursing home admission or mortality. Titles and abstracts of studies will be screened independently by two authors. The Cochrane Risk of Bias Tool will be used independently by two reviewers to assess the methodological quality of the included studies. GRADE will be used to assess the quality of the body of evidence. A pooled meta-analysis will be conducted using RevMan software V.5.4.1, depending on the uniformity of the data.Ethics and disseminationThe authors will present the findings of the review to a patient and public involvement stakeholder panel of older people that has been established at the Ageing Research Centre in the University of Limerick. Formal ethical approval is not required for the review as all data collected will be secondary data and will be analysed anonymously.PROSPERO registration numberCRD42021223112.

Background Delirium is a common condition with poorly understood pathophysiology. Various theories have been proposed including that delirious patients have reduced cerebral blood flow. We hypothesised that patients with delirium could have abnormal autonomic nervous system function, as assessed by tilt table testing, which would explain the alteration in blood flow. Methods A prospective cohort study of medical inpatients aged 65 years and older was undertaken. Delirium was assessed using DRS-R98 and DSM-IV criteria. Beat-to-beat blood pressure (BP) was recorded during tilt testing. Differences in BP changes between the two groups (those with delirium and those without) were explored. The association between severity of delirium and magnitude of BP changes was also examined. Results 64 participants were recruited during hospitalisation. 29 completed follow-up Head-Up Tilt testing. The mean age of participants was 80.8 years (SD 6.2 years). The control group (n = 12) had a median decrease in systolic BP of 17.5 mmHg (IQR 20.75). The delirium group (n = 17) had a median decrease in systolic BP of 1 mmHg (IQR 38.5), p = 0.04. As delirium severity scores increased, systolic BP change during tilting also increased (rs = 0.42, p = 0.03). Conclusion Participants in the delirium group showed different BP responses to tilt test which may represent abnormal sympathetic response. This would be consistent with other features of delirium such as treatment response to centrally acting alpha-2 blockers. Equity of access to research for older, frail and delirious cohorts is essential but feasibility and acceptability needs to be optimised and factored into study design.

Background: The number of older adults with complex medical comorbidities and functional impairment is increasing throughout the world. Frail older adults frequently attend the Emergency Department (ED) and are at increased risk of adverse outcomes following presentation. A number of screening tools exist that aim to screen older adults for frailty and identify those at risk of functional decline, unscheduled readmission, institutionalisation and mortality. We propose to determine the predictive accuracy of four commonly used screening tools, namely the Identification of Seniors at Risk Screening (ISAR), Clinical Frailty Scale (CFS), Program of Research to Integrate Services for the Maintenance of Autonomy (PRISMA 7) and InterRAI ED, to determine adverse events at 30 days and six months among older adults who present to the ED. Methods and analysis: This is a prospective cohort study where patients over the age of 65 will have four screening tools (ISAR, CFS, PRISMA 7, interRAI ED) performed by face-to-face interview with a research nurse during their index visit to one Irish ED. Older adults will be included if they are willing and able to provide written informed consent, have a Manchester Triage Category 2-5 and are resident in the hospital catchment area. Demographic information will be collected at the index visit. A telephone follow up will occur at 30 days and six months, completed by a research nurse who is blinded to the initial assessment. Outcome data will include mortality rates, ED re-attendance, hospital readmission, functional decline and institutionalisation. We will analyse the risk of adverse outcomes using multivariable logistic regression and we will report adjusted risk ratios (RR) with 95% CI. Dissemination: Study findings will be disseminated through publication in peer-reviewed journals and presentations at relevant academic and clinical conferences. National and International gerontology conferences will be targeted.

IntroductionFrailty is a common condition affecting older adults and is associated with increased mortality and adverse outcomes. Identification of older adults at risk of adverse outcomes is central to subsequent resource planning and targeted interventions. This systematic review and meta-analysis will examine the: (1) diagnostic accuracy of the Clinical Frailty Scale (CFS) in identifying hospitalised adults ≥65 years with frailty and a medical diagnosis compared with the reference standard Frailty Index or Frailty Phenotype and (2) predictive value of the CFS in determining those at increased risk of subsequent adverse outcomes.Methods and analysisWe will include cross-sectional, retrospective and prospective cohort studies, and randomised controlled trials that assess either the diagnostic accuracy of the CFS when compared with the reference standard Frailty Index/Frailty Phenotype or the predictive validity of the CFS to predict subsequent adverse outcomes in hospitalised adults over 65 years with medical complaints. Adverse outcomes include falls, functional decline, unplanned Emergency Department attendance, emergency rehospitalisation, nursing home admission or death. A systematic search will be conducted in Embase, AMED, MEDLINE (Ebsco, Ovid, Pubmed), CINAHL, PsycINFO, Cochrane Library. Studies will be limited to those published from 2005 to 30 October 2019. Two independent reviewers will screen all titles and abstracts to identify relevant studies. The methodological quality of studies will be independently assessed using the Quality Assessment of Diagnostic Accuracy Studies-2. A CFS score of >4 will be used to identify frailty. We will construct 2×2 tables and determine true positives, true negatives, false positives and false negatives for each study when compared with the reference standard and for each adverse outcome. A bivariate random effects model will be applied to generate pooled summary estimates of sensitivity and specificity.Ethics and disseminationEthical approval is not required for this systematic review. We will disseminate our findings through a peer-reviewed journal.

Hip fracture is a common serious injury afflicting the geriatric population and is associated with poor clinical outcomes, functional and walking disabilities and high 1-year mortality rates. A multidisciplinary approach has been shown to improve outcomes of geriatric patients with fragility fracture.We piloted a dedicated orthogeriatric service for hip fracture patients to determine if the service facilitated a change in major patient outcomes, such as mortality, length of stay and dependency.A dedicated orthogeriatrics service for hip fracture was established as a collaborative project between the Department of Geriatric Medicine and Department of Orthopaedic Surgery at a university teaching hospital. Orthogeriatrics service data were collected prospectively on an orthogeriatric filemaker database from July 2011 to July 2012 (N = 206). Data were compared to previously recorded data (Irish Hip Fracture Database) on a cohort of hip fracture patients admitted to the same orthopaedic trauma unit from July 2009 to July 2010 (N = 248).Patients in the orthogeriatric service group experienced significant reductions in 1-year mortality (χA multidisciplinary management approach to fragility fracture of the femoral neck that involves comprehensive geriatric assessment, daily medical involvement of a geriatric team and specialised follow-up assessment leads to a significant reduction in mortality and improved outcomes.

Background: delirium is a common neuropsychiatric disorder. The natural course is of an acute, fluctuating and often transient condition; however, accumulating evidence suggests that delirium can be associated with incomplete recovery. Despite a growing body of research, a lack of clarity exists regarding definition and outcomes. Objective: to clarify the definition of recovery of delirium used in the literature. Methods: a Medline search was performed using relevant keywords. Studies were included if they were in English, provided any definition of recovery and were longitudinal. Excluded articles were duplicated studies, case studies, review articles or articles related to alcohol, children, subsyndromal delirium only or those investigating core symptoms such as function. Results: fifty-six studies met the inclusion criteria. Only two studies used clinical criteria alone for the diagnosis of delirium; most studies used at least one validated scale-either categorical or continuous severity scales. A variety of 16 different terms were used to define the 'recovery of delirium'. The definitions of each term also varied. Studies using severity scales used either cut-off points or percentage reduction between assessments, while others using dichotomous scales (yes/no) defined recovery as one or more days of negative delirium. Conclusion: an agreed terminology to define recovery in delirium is required. A distinction should also be made between symptomatic and overall recovery, as well as between long- and short-term outcomes. It is proposed that cognitive recovery should be central to defining recovery in delirium.