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Purpose Clinical pathways for low back pain (LBP) have potential to improve clinical outcomes and health service efficiency. This systematic review aimed to synthesise the evidence for clinical pathways for LBP and/or radicular leg pain from primary to specialised care and to describe key pathway components. Methods Electronic database searches (CINAHL, MEDLINE, Cochrane Library, EMBASE) from 2006 onwards were conducted with further manual and citation searching. Two independent reviewers conducted eligibility assessment, data extraction and quality appraisal. A narrative synthesis of findings is presented. Results From 18,443 identified studies, 28 papers met inclusion criteria. Pathways were developed primarily to address over-burdened secondary care services in high-income countries and almost universally used interface services with a triage remit at the primary-secondary care boundary. Accordingly, evaluation of healthcare resource use and patient flow predominated, with interface services associated with enhanced service efficiency through decreased wait times and appropriate use of consultant appointments. Low quality study designs, heterogeneous outcomes and insufficient comparative data precluded definitive conclusions regarding clinical- and cost-effectiveness. Pathways demonstrated basic levels of care integration across the primary-secondary care boundary. Conclusions The limited volume of research evaluating clinical pathways for LBP/radicular leg pain and spanning primary and specialised care predominantly used interface services to ensure appropriate specialised care referrals with associated increased efficiency of care delivery. Pathways demonstrated basic levels of care integration across healthcare boundaries. Well-designed randomised controlled trials to explore the potential of clinical pathways to improve clinical outcomes, deliver cost-effective, guideline-concordant care and enhance care integration are required.

AimsType 2 diabetes is a risk factor for late-life dementia, but dementia prevention strategies have yet to be comprehensively evaluated in people with diabetes. The Finnish Geriatric Intervention Study to Prevent Cognitive Impairment and Disability (FINGER) demonstrated cognitive benefits of a 2-year multidomain lifestyle intervention. However, given the intensive nature of FINGER, there is uncertainty about whether it can be implemented in other high-risk populations. Our aim was to explore attitudes towards dementia risk, and barriers to an intervention based on the FINGER model in older adults with type 2 diabetes living in rural areas of Ireland.MethodsFocus groups were conducted with 21 adults (11 men and 10 women) aged 60+ years with type 2 diabetes living in border regions of north and south Ireland. Data were analysed using thematic analysis.ResultsThere was limited understanding of diabetes as a risk factor for late-life dementia. The main barriers to engagement with the multidomain intervention were eating foods that were not compatible with cultural norms, time and travel constraints, and perceived lack of self-efficacy and self-motivation for adopting the desired diet, exercise and computerised cognitive training (CCT) behaviours. Facilitators for intervention acceptability included the provision of culturally tailored and personalised education, support from a trusted source, and inclusion of goal setting and self-monitoring behavioural strategies.ConclusionsWhile there was high acceptability for a brain health intervention, several barriers including cultural food norms and low self-efficacy for adopting the diet, exercise and CCT components would need to be considered in the intervention design. Findings from this study will be used to inform local decisions regarding the adaptation of FINGER for people with type 2 diabetes. The feasibility of the adapted multidomain intervention will then be evaluated in a future pilot trial.

Background Poor COVID-19 outcomes occur with higher frequency in people with rheumatic and musculoskeletal diseases (RMD). Better understanding of the factors involved is crucial to informing patients and clinicians regarding risk mitigation. Aim To describe COVID-19 outcomes for people with RMD in Ireland over the first 2 years of the pandemic. Methods Data entered into the C19-GRA provider registry from Ireland between 24th March 2020 and 31st March 2022 were analysed. Differences in the likelihood of hospitalisation and mortality according to demographic and clinical variables were investigated. Results Of 237 cases included, 59.9% were female, 95 (41.3%) were hospitalised, and 22 (9.3%) died. Hospitalisation was more common with increasing age, gout, smoking, long-term glucocorticoid use, comorbidities, and specific comorbidities of cardiovascular and pulmonary disease, and cancer. Hospitalisation was less frequent in people with inflammatory arthritis and conventional synthetic or biologic disease-modifying antirheumatic drug use. Hospitalisation had a U-shaped relationship with disease activity, being more common in both high disease activity and remission. Mortality was more common with increasing age, gout, smoking, long-term glucocorticoid use, comorbidities, and specific comorbidities of cardiovascular disease, pulmonary disease, and obesity. Inflammatory arthritis was less frequent in those who died. Conclusion Hospitalisation or death were more frequently experienced by RMD patients with increasing age, certain comorbidities including potentially modifiable ones, and certain medications and diagnoses amongst other factors. These are important ‘indicators’ that can help risk-stratify and inform the management of RMD patients.

Background Delirium is associated with a variety of adverse healthcare outcomes but is highly predictable, preventable and treatable. For this reason, numerous guidelines have been developed for delirium recognition, prevention and management across different countries and disciplines. Although research is adduced as evidence for these guidelines, a constant finding is the lack of implementation if they exist at all. Implementation is a human behaviour that can be influenced by various factors including culture at a micro- and macro-level. Hofstede’s model proposes that national cultures vary along six consistent dimensions. Aim Using this model, we examined the nature of delirium guidelines across countries in relation to Hofstede’s six cultural dimensions. Methods Data collected for each country on: the six dimensions of Hofstede’s model, number of delirium guidelines approved by a National professional body of each country (through searching databases), the annual old-age dependency ratio for each country. Results Sixty-four countries had the completed six dimensions of Hofstede’s model. Twenty of them (31%) had one or more delirium guidelines. The total number of different delirium guidelines was 45. Countries with formal delirium guidelines have significantly lower power distance among their members, are more individualistic societies, have lower levels of uncertainty avoidance and higher old-age dependency ratio compared to those without delirium guidelines. Discussion/conclusion The development and implementation of delirium guidelines vary across countries. Specific combinations of cultural dimensions influence the production of delirium guidelines. Understanding these important cultural differences can facilitate more widespread acceptance and implementation of guidelines. Supplementary Information The online version contains supplementary material available at 10.1007/s40520-021-01978-w.

Published by Elsevier Ltd., Background: Differences in the distribution of individual-level clinical risk factors across regions do not fully explain the observed global disparities in COVID-19 outcomes. We aimed to investigate the associations between environmental and societal factors and country-level variations in mortality attributed to COVID-19 among people with rheumatic disease globally. Methods: In this observational study, we derived individual-level data on adults (aged 18-99 years) with rheumatic disease and a confirmed status of their highest COVID-19 severity level from the COVID-19 Global Rheumatology Alliance (GRA) registry, collected between March 12, 2020, and Aug 27, 2021. Environmental and societal factors were obtained from publicly available sources. The primary endpoint was mortality attributed to COVID-19. We used a multivariable logistic regression to evaluate independent associations between environmental and societal factors and death, after controlling for individual-level risk factors. We used a series of nested mixed-effects models to establish whether environmental and societal factors sufficiently explained country-level variations in death. Findings: 14 044 patients from 23 countries were included in the analyses. 10 178 (72·5%) individuals were female and 3866 (27·5%) were male, with a mean age of 54·4 years (SD 15·6). Air pollution (odds ratio 1·10 per 10 μg/m3 [95% CI 1·01-1·17]; p=0·0105), proportion of the population aged 65 years or older (1·19 per 1% increase [1·10-1·30]; p, MAG is supported by the National Institute of Arthritis and Musculoskeletal and Skin Diseases (grant numbers K01 AR070585 and K24 AR074534 [JY]). KDW is supported by the Department of Veterans Affairs and the Rheumatology Research Foundation Scientist Development award. JAS is supported by the National Institute of Arthritis and Musculoskeletal and Skin Diseases (grant numbers K23 AR069688, R03 AR075886, L30 AR066953, P30 AR070253, and P30 AR072577), the Rheumatology Research Foundation (K Supplement Award and R Bridge Award), the Brigham Research Institute, and the R. Bruce and Joan M. Mickey Research Scholar Fund. NJP is supported by the National Institute of Arthritis and Musculoskeletal and Skin Diseases (T32-AR-007258). AD-G is supported by grants from the Centers for Disease Control and Prevention and the Rheumatology Research Foundation. RH was supported by the Justus-Liebig University Giessen Clinician Scientist Program in Biomedical Research to work on this registry. JY is supported by grants from the National Institutes of Health (K24 AR074534 and P30 AR070155).

The Wender Utah Rating Scale (WURS) is a widely used retrospective scale in adults presenting for ADHD evaluations which features items relating to childhood symptoms. The aim of this study is to establish if certain childhood symptoms (including ADHD) as identified by the WURS-61 are associated with specific mental health disorders in adulthood. Case-control study of N=630 attending Adult Mental Health Services (AMHS) and a control group without mental disorders (N=96). The mean age of the participants was 39.81 (SD 12.94) of which 387 (53.3%) were females. There were no significant differences between cases and controls in terms of age (t= 1.829, df 724, p=.068) and gender (x2=1.123, df 1, p=.289). Exploratory factor analysis of WURS-61 reveals 5 factors. Using factor scores and after cross-tabulation, we found that: The presence of childhood impulsivity, emotional lability and distress in addition to inattention/disorganisation were significantly associated with adult ADHD diagnosis (F90). WURS items which suggests childhood conduct problems were associated with a number of adult diagnoses, when present either on its own (psychoactive substance use, or when present in combination with childhood impulsivity, emotional lability and distress (personality disorders). There is an association between certain childhood behaviours and risk for later development of personality disorders, and psychoactive substance use. There is overlap of childhood symptoms to those who later diagnosed in adulthood with ADHD, personality disorders, and substance abuse.

BACKGROUND Delirium is a common disorder in elderly medical inpatients with serious adverse outcomes and is characterized by sudden onset, disturbance in attention, awareness, consciousness and cognition, and often with behavioural disturbances. Central to understanding delirium, is understanding mechanisms by which body and brain wellbeing are linked and in particular how brain responses to bodily homeostatic stress is mediated. A number of studies have investigated the relationship between insulin-like growth factor I (IGF-I) and delirium in medically ill hospitalised patients with conflicting results. However, none have investigated growth hormone (GH) which is related to IGF-I via negative feedback. AIM To investigate the relationship between serum levels of IGF-I and GH, and the occurrence of delirium. METHODS Prospective, longitudinal, observational study. Consecutive elderly inpatients (aged 70+), were assessed twice weekly with Montreal cognitive assessment (MoCA), Confusion assessment method (CAM), Acute Physiology and Chronic Health Evaluation II. Delirium was defined using CAM. Previous history of dementia was evaluated with the Informant Questionnaire on Cognitive Decline in the Elderly. IGF-I and GH levels were estimated with the ELISA method. Generalized estimating equations (GEE) model was applied for the first five assessments to analyze those longitudinal data. RESULTS The sample consisted of 198 participants (mean age 80.63 ± 6.81; range 70-97). Of these 92 (46.5%) were females. Eighty six (43.4%) were identified with a history of dementia. Incident or prevalent delirium during hospitalisation was identified with CAM in 40 participants (20.2%). Evaluation of missing values with Little's MCAR test indicated that they were missing completely at random (MCAR χ2 = 12.24, u: 9, P = 0.20). Using GEE for the analysis we found that low MoCA scores, low levels of IGF-I and high levels of GH were significantly associated with any delirium (prevalence, incident, or fluctuating , during the study period (Wald χ2 = 12.231; u: 1, P < 0.001, Wald χ2 = 7.196, u: 1, P = 0.007, Wald χ2 = 6.210; : u: 1, P = 0.013 respectively). CONCLUSION The results show that low levels of IGF-I, high levels of GH and low scores in cognition are independently associated with the occurrence of any delirium during the hospitalisation of medically ill older people. The results of the study supports the hypothesis that deficits in the immunoreactivity of the brain (low cerebral reserve) may be associated with delirium.

The Coronavirus Disease 2019 (COVID-19) has accounted for more than 25 000 cases in Ireland with approximately 28% of the clusters in nursing homes as of June 2020. The older population is the most vulnerable to serious complications from this illness and over 90% of deaths due to COVID-19 to date have been in patients over the age of 65. Continuing to provide routine care within nursing homes in these challenging times is an essential part of ensuring that presentations to hospitals for non-essential reasons are minimized. In this article, we describe a project being undertaken by a rural Psychiatry of Old Age Service in the northwest of Ireland. We aim to provide ordinary care in extraordinary times by using mobile tablets within the nursing homes and long-stay facilities in our region for remote video consultations during the COVID-19 crisis.

This study investigated caring behaviors and anxiety levels among registered nurses (N = 280) working in acute hospitals. The Theory of Human Caring guided the study. A correlational design was employed. The Caring Behaviors Inventory-24 measured caring and the State Trait Anxiety Inventory measured anxiety. Nurses reported high levels of caring and low levels of anxiety. A statistically significant relationship was found between caring and anxiety, caring and supportive work environment, and caring and job satisfaction. Recommendations to support nurses working in acute hospitals are offered.

Background Delirium is extremely prevalent, yet underdiagnosed, in older patients and is associated with prolonged length of hospital stay and higher mortality rates. Impaired attention is the cardinal deficit in delirium and is a required feature in diagnostic criteria. The verbal months backwards test (MBT) is the most sensitive bedside test of attention, however, hospital staff occasionally have difficulty with its administration and interpretation. We hypothesise that the MBT on an electronic tablet may be easier and more consistent to use for both experienced and unexperienced medical professionals and, if the diagnostic efficacy was similar, aid delirium diagnosis. Aim We aim to investigate the correlation of the verbal MBT with a computerised MBT application. Methods Participants recruited (age > 65, n = 75) were allocated to different cohorts (Dementia and Delirium (DMDL), Dementia (DM), Delirium (DL), No Neurocognitive Disorder (NNCD)) and were administered both the verbal and electronic versions. Results Correlation between measurements were: overall Spearman’s rho = 0.772 (p p p = 0.039); DM rho = 0.378 (p = 0.203); NNCD rho = 0.143 (p = 0.559). Discussion Overall, and for the delirious subset, statistically significant agreement was present. Poor inter-test correlation existed in the groups without delirium (DM, NNCD). Conclusions The MBTc correlates well with the MBTv in patients who are clinically suspected to have delirium but has poor correlation in patients without delirium. Visuospatial cognition and psychomotor deficits in a dementia cohort and mechanical factors (such as tremor, poor fingernail hygiene and visual impairment) in a group with no neurocognitive disorder may limit the utility of the MBTc in a hospitalised older population.

IntroductionEducational Environment (EE) is of paramount importance in Medical Education, but can be intangible and hard to clearly determine. Professional satisfaction and patient care improve in a pleasant learning environment; where postgraduate physicians are encouraged, suitably supervised, and fostered. A negative learning environment can be detrimental to trainees’ and teams’ morale and can jeopardize the multidisciplinary working relationship.ObjectivesThe objective of this study was to measure the Educational Environment (EE) of Psychiatry postgraduate training in the Midwest of Ireland training Deanery; what aspects of training are working well and what areas are seen as not optimal.MethodsThis study took place between April and June 2021. A mixed methods approach was adopted, using the Postgraduate Hospital Educational Environment Measure (PHEEM) and semi-structured one-to-one interviews.ResultsResponse rate was 88% (n=22). The total PHEEM score was 105.64±23.52, indicating a postgraduate EE with more positive than negative aspects, but with room for improvement. There were no differences in overall PHEEM and subscale scores between trainees’ gender, training grades or years of working experience. Three themes were identified that contribute to trainees’ perception of EE: the commitment of the trainees’ supervisors to the role they play in trainees’ overall development, the clinical workload of the trainee, and the day-to-day working conditions of the trainee. Definite disparities between work placements were evident in the collected data across these three themes.ConclusionsAlthough the training program had an overall positive EE, specific answers and interview themes indicated some areas of weakness that may contribute to trainee dissatisfaction and possible burnout. Planned interventions targeting these areas and tracking changes in EE and burnout rates over time may be useful measures going forward.Declaration of InterestNone

Summary Background Patients with primary systemic vasculitis or polymyalgia rheumatica might be at a high risk for poor COVID-19 outcomes due to the treatments used, the potential organ damage cause by primary systemic vasculitis, and the demographic factors associated with these conditions. We therefore aimed to investigate factors associated with COVID-19 outcomes in patients with primary systemic vasculitis or polymyalgia rheumatica. Methods In this retrospective cohort study, adult patients (aged ≥18 years) diagnosed with COVID-19 between March 12, 2020, and April 12, 2021, who had a history of primary systemic vasculitis (antineutrophil cytoplasmic antibody [ANCA]-associated vasculitis, giant cell arteritis, Behcet's syndrome, or other vasculitis) or polymyalgia rheumatica, and were reported to the COVID-19 Global Rheumatology Alliance registry were included. To assess COVID-19 outcomes in patients, we used an ordinal COVID-19 severity scale, defined as: (1) no hospitalisation; (2) hospitalisation without supplemental oxygen; (3) hospitalisation with any supplemental oxygen or ventilation; or (4) death. Multivariable ordinal logistic regression analyses were used to estimate odds ratios (ORs), adjusting for age, sex, time period, number of comorbidities, smoking status, obesity, glucocorticoid use, disease activity, region, and medication category. Analyses were also stratified by type of rheumatic disease. Findings Of 1202 eligible patients identified in the registry, 733 (61·0%) were women and 469 (39·0%) were men, and their mean age was 63·8 years (SD 17·1). A total of 374 (31·1%) patients had polymyalgia rheumatica, 353 (29·4%) had ANCA-associated vasculitis, 183 (15·2%) had giant cell arteritis, 112 (9·3%) had Behcet's syndrome, and 180 (15·0%) had other vasculitis. Of 1020 (84·9%) patients with outcome data, 512 (50·2%) were not hospitalised, 114 (11·2%) were hospitalised and did not receive supplemental oxygen, 239 (23·4%) were hospitalised and received ventilation or supplemental oxygen, and 155 (15·2%) died. A higher odds of poor COVID-19 outcomes were observed in patients who were older (per each additional decade of life OR 1·44 [95% CI 1·31–1·57]), were male compared with female (1·38 [1·05–1·80]), had more comorbidities (per each additional comorbidity 1·39 [1·23–1·58]), were taking 10 mg/day or more of prednisolone compared with none (2·14 [1·50–3·04]), or had moderate, or high or severe disease activity compared with those who had disease remission or low disease activity (2·12 [1·49–3·02]). Risk factors varied among different disease subtypes. Interpretation Among patients with primary systemic vasculitis and polymyalgia rheumatica, severe COVID-19 outcomes were associated with variable and largely unmodifiable risk factors, such as age, sex, and number of comorbidities, as well as treatments, including high-dose glucocorticoids. Our results could be used to inform mitigation strategies for patients with these diseases. Funding American College of Rheumatology and the European Alliance of Associations for Rheumatology.

Background Early recognition of stroke symptoms and immediate response is necessary to ensure timely access to treatment of stroke. However, many individuals fail identify symptoms of stroke or delay in seeking medical attention. The Irish Heart Foundation launched the “Act Fast” campaign which included three waves of broadcasting on national television and radio, throughout 2010 and 2011. Stroke awareness campaigns may have the potential to influence behaviour and response to stroke. Methods A non-experimental, descriptive, quantitative, cross-sectional study was conducted. The Stroke Action Test (STAT)1 was used to investigate how participants would respond to specific symptoms of stroke. A convenience sample (n=89) of older adults attending an outpatient clinic in a university teaching hospital completed the questionnaire. The mean age of respondents was 79.6 years (SD =9.3). Results Just 4.5% (n=4) of respondents identified what all 4 letters of FAST represent. Overall, 48% (n=43) of respondents recognised all 6 symptoms of stroke and 100% (n=89) recognised at least 2 symptoms of stroke as per STAT. The stroke symptom most frequently recognised was sudden numbness of the face, arm or leg at 99% (n=88). The stroke symptom least frequently recognised was sudden trouble seeing in one or both eyes at 56% (n=50). Despite this 81% (n=64) of respondents would not respond appropriately to 50% of symptoms of stroke described in the STAT. 52% (n=46) of respondents identified irregular heart beat as a risk factor for stroke. Finally, 29% (n=26) of respondents had heard of thrombolysis while just 2% (n=2) had heard of thrombectomy. Conclusion Awareness of stroke symptoms does not necessarily influence response to stroke in older adults. Future stroke awareness campaigns should consider FAST2 which speaks to treatment (thrombolysis or thrombectomy) as well as time.

Introduction: Diagnostic reasoning is a key skill practised by clinicians. It is a process by which correct clinical diagnosis is reached. Learning theories offer some guidance on how this cognitive skill is best taught; what curriculum best supports it and how it is learned and used by expert and novice learners. Novice and expert learners have different needs when it comes to developing this skill. This paper aims to explore the unique role of the medical educator; exploring how they facilitate diagnostic reasoning amongst learners with an emphasis on improving patient safety. Materials and Methods:The bibliography assembled for this literature review includes original articles, quantitative and qualitative papers, narrative review articles, editorials and other documents identified through PubMed, Scopus, ERIC, Australian Education Index, British Education Index and Google Scholar Database searches. Results: Medical educators employ a variety of teaching strategies including ‘thinking aloud’ techniques and hypothesis generation. There is some dispute in the literature as to which teaching strategies and which curricula best support the learning of diagnostic reasoning. The contribution of good diagnostic reasoning skills in reducing clinical error and maintaining patient safety is clear. Conclusion: It is important to continue to encourage the teaching of diagnostic reasoning with an emphasis on patient safety and its role in reducing clinical error and adverse events for patients

Introduction: LBP is a leading cause of disability and exerts a considerable burden on healthcare systems. Management is frequently inconsistent with clinical guidelines, which advocate a demedicalised approach in primary care settings for most patients, with easy access to specialised care when necessary. Integrated care pathways have potential to enhance care quality and cost-effectiveness through bridging the evidence-practice gap and optimising resource use. Care integration across the primary-secondary care continuum aims to address care fragmentation, reduce duplication, improve clinical outcomes and enhance cost-effectiveness. This review aimed to synthesise the evidence for integrated care pathways for LBP from primary to specialised care. Methods: This review was reported in accordance with Preferred Reporting Information for Systematic reviews and Meta-Analyses (PRISMA) guidelines. Electronic database searches (CINAHL, MEDLINE, Cochrane Library, EMBASE) were conducted (2006 onwards) with further manual and citation searching. Search results were exported to Covidence (systematic review software). Two independent reviewers conducted eligibility assessment and data extraction, as well as quality appraisal using the Effective Public Health Practice Project (EPHPP) Quality Assessment Tool for Quantitative Studies or the Critical Appraisal Skills Programme (CASP) qualitative studies checklist. A narrative synthesis of findings is presented. Results: From 18,443 identified studies, 28 papers met inclusion criteria. LBP pathways were reported from high-income countries, primarily to address over-burdened secondary care services with long wait-times for consultant appointments. Pathways almost universally re-organised care using non-consultant interface services to manage the primary-secondary care boundary by triaging patients for surgical opinion or conservative management. Interface services aim to optimise use of the multidisciplinary workforce to ensure judicious use of surgical clinics. Accordingly, evaluation of healthcare resource use and patient flow predominated, with reports of enhanced service efficiency through decreased wait-times and appropriate use of consultant appointments. Interface services were evenly represented across community and hospital settings. Using a model that conceptualises care integration on a five-level continuum, the included pathways demonstrated the two most basic levels of integration, ‘full segregation’ or ‘linkage’. Low quality study designs, heterogenous outcomes and insufficient comparative data precluded definitive conclusions regarding clinical and cost-effectiveness of pathways. Conclusions: Interface services, delivered by non-consultant multidisciplinary team members, to ensure appropriate referrals to specialised care dominated the LBP integrated care pathway literature with enhanced efficiency of care delivery reported. Pathways demonstrated the most basic levels of care integration, ‘full segregation’ and ‘linkage’, across traditional healthcare boundaries. Implications: Further exploration of the potential of care pathways as a model for the delivery of integrated, cost-effective, person-centred, guideline-concordant care which improves clinical outcomes for patients with LBP is required, with patient involvement in integrated care pathway development.

INTRODUCTION:Lithium has a narrow therapeutic index with a risk of toxicity and potential to increase morbidity and mortality, particularly in the elderly with co-morbid illness and polypharmacy. Lithium therapy and monitoring of lithium levels require precision and several guidelines have been issued including recommendations for strict control of lithium levels in the elderly population.RESEARCH OBJECTIVE:We evaluated the effect of implementation of a multifaceted management programme on the compliance with international practice standards for lithium monitoring in patients under the care of Psychiatry of Old Age (POA), Sligo Leitrim Mental Health Services in the North West of Ireland.METHODS:Results from a prior audit performed in February 2020 involving a cohort of 18 patients prescribed lithium under the care of POA were analysed and compared to accepted standards. The guideline used as the benchmark for compliance was the National Institute for Clinical Excellence (NICE) guidelines on the use and monitoring of lithium therapy, as published in 2014. Several deficits were found and therefore a designated Lithium Management Programme was established. A subsequent audit, performed using a simplified audit tool incorporating the NICE guidelines, delivered results which were directly compared to the initial findings and analysed to evaluate the effect of the implemented management programme.PRELIMINARY RESULTS OF THE ONGOING STUDY:In comparison with findings from 2020, there had been a significant improvement in most facets of lithium management and compliance to practice standards. Of particular note was the improvement of biochemical monitoring, side effect screening, polypharmacy surveillance, patient education and interdisciplinary communication.CONCLUSION:The launch of a dedicated Lithium Management Programme with specific features aimed at identifying and addressing poor compliance with monitoring guidelines has led to improved adherence to accepted international practice standards. Our model provides a dynamic, multi-layered system which paves the way for better patient outcomes, timely access to care and furthering education for patients and staff members.

The Wender Utah Rating Scale (WURS) is a widely used retrospective scale in adults presenting for ADHD evaluations which features items relating to childhood symptoms.The aim of this study is to establish if certain childhood symptoms (including ADHD) as identified by the WURS-61 are associated with specific mental health disorders in adulthood.Case-control study of N=630 attending Adult Mental Health Services (AMHS) and a control group without mental disorders (N=96).The mean age of the participants was 39.81 (SD 12.94) of which 387 (53.3%) were females. There were no significant differences between cases and controls in terms of age (t= 1.829, df 724, p=.068) and gender (xThere is an association between certain childhood behaviours and risk for later development of personality disorders, and psychoactive substance use. There is overlap of childhood symptoms to those who later diagnosed in adulthood with ADHD, personality disorders, and substance abuse.

Objectives Delirium, which is associated with adverse health outcomes, is poorly detected in hospital settings. This study aimed to determine delirium occurrence among older medical inpatients and to capture associated risk factors. Methods This prospective cohort study was performed at an Irish University Hospital. Medical inpatients 70 years and over were included. Baseline assessments within 72 hours of admission included delirium status and severity as determined by the Revised Delirium Rating Scale (DRS-R-98), cognition, physical illness severity and physical functioning. Pre-existing cognitive impairment was determined with Short Informant Questionnaire on Cognitive Decline (IQCODE). Serial assessment of delirium status, cognition and the physical illness severity were undertaken every 3 (±1) days during participants’ hospital admission. Results Of 198 study participants, 92 (46.5%) were women and mean age was 80.6 years (s.d. 6.81; range 70–97). Using DRS-R-98, 17.7% (n = 35) had delirium on admission and 11.6% (n = 23) had new-onset delirium during admission. In regression analysis, older age, impaired cognition and lower functional ability at admission were associated with a significant likelihood of delirium. Conclusions In this study, almost one-third of older medical inpatients in an acute hospital had delirium during admission. Findings that increasing age, impaired cognition and lower functional ability at admission were associated with increased delirium risk suggest target groups for enhanced delirium detection and prevention strategies. This may improve clinical outcomes.

The COVID-19 pandemic has required a rapid evolution of services to maintain routine care in Ireland. Services which had been previously slow to adapt technology in their practices are suddenly integrating various telehealth measures to continue routine practice where possible. In this article, we discuss the challenges we face in rapidly implementing telehealth in a rural Psychiatry of Old Age service in the North-West of Ireland.

Aim: To develop and validate the Spirituality Instrument 27 (SpI-27©) in individuals with chronic illness (n = 249). Background: A need for a rigorously developed spirituality instrument that can be used with people who are religious and non-religious was identified. Methods: The initial 46-item instrument was developed from a concept analysis, a review of theoretical and empirical literature, and an appraisal of instruments measuring spirituality. Content validity was established with user focus groups and an expert panel review. A pilot study evaluated the online mode of administration and a descriptive correlational design assessed the reliability and validity of the instrument. Results: Results of exploratory factor analysis concluded a five-factor solution with 27 items: Connectedness with Others, Self-Transcendence, Self-Cognisance, Conservationism, and Connectedness with a Higher Power. Cronbach's alpha coefficients ranged from 0.823 to 0.911 for the five factors, and 0.904 for the overall scale. Paired t-tests, intra-class correlations, and weighted kappa values supported the temporal stability of the instrument. A significant and positive correlation was found between the SpI-27© and the Spirituality Index of Well-Being (p

Family functioning is influenced by different factors like social context, qualitative characteristics, and an individual’s medical or psychiatric condition. We examine the effects of sociodemographic factors and individual psychopathology on family functioning in a non-clinical sample. Cross- sectional study. Data were collected: age, gender, occupation, education, and description of the family, history and/ or presence of mental or physical illnesses, Family Assessment Device and Symptom Checklist-90-R. A healthy sample of 137 families with a total of 407 individuals was analysed. Multilevel analysis showed that individual psychopathology was the only significant factor for family dysfunction. Thus, there is a strong association between family dysfunction and psychopathology of a member.

The Family Assessment Device (FAD) is a self-report questionnaire, developed to assess the six dimensions of the McMaster Model of Family Functioning. It has been translated into the Greek language but never validated. We aimed to evaluate the psychometric properties of the Greek version of the FAD in a nonclinical sample. In a sample of Greek families, the FAD was administered together with the already validated Family Adaptability and Cohesion Evaluation Scale (FACES-III). In a subsample of 96 individual participants, the scales were administered again after 1 month. The sample of 453 participants (151 families: 194 children and 259 parents) completed both questionnaires. The mean age of the children was 23.62 years (SD = 6.35 years), and 68 (35%) were male. The mean age of the parents was 51.4 years (SD = 8.2 years), and 117 (45.2%) were male. All subscales of the FAD had significant correlation (concurrent validity) with the FACES-III (n = 453, p < .001). Test-retest reliability ranged from .58 to .82 (N = 96, p < .001). Internal consistency (Cronbach's alpha) ranged from .47 to .94. A model with the six factors had a good statistical fit but not all the items were loading in the same components as from the theory assumed. The Greek FAD has good psychometric properties, although its factor structure might differ from the original version.

AimsThe majority of people with dementia will develop one or more behavioural or psychological symptoms of dementia (BPSD) as the illness progresses. Treating these symptoms in diverse residential environments is a challenge, with frequent prescribing of antipsychotic medications. The risks and limited benefits of antipsychotic use in this context are well recognised, prompting national guidelines in Ireland to improve prescribing patterns.1) Assess the frequency and appropriateness of prescribing of antipsychotic medication in older adults with BPSD referred to Psychiatry of Old Age service in the West of Ireland (Sligo) by comparing with best practice guidelines.2) Address identified deficits via quality improvement initiatives within department.MethodAudit standards were set using draft National Clinical Guidelines and NICE guidelines for prescribing in dementia to develop a study specific audit tool.Items assessed included: the frequency of review of antipsychotic use, whether or not non-pharmacological methods were trialled, if there was an assessment of benefit of the antipsychotic and discussion or risks, if a reduction/discontinuation of antipsychotic was considered, if metabolic monitoring was achieved.Clinical records for all patients actively under the care of the clinical team with a diagnosis of BPSD were assessed using this tool at the time of the study.Result49 patients with BPSD were attending the service in this time period. 58% (n = 29) of the entire cohort were prescribed an antipsychotic, most commonly quetiapine. Patients cared for at home showed the lowest levels of antipsychotic use at 50% (n = 18), while those who were in nursing home (80%, n = 8) and hospital care (100%, n = 3) showed higher rates, though this sample size was too small to demonstrate statistical significance, χ2 = 5.12 p = 0.077.Exploration of non pharmacological management of BPSD, documentation of discussion of risks of AP medication (metabolic, cardiovascular, falls, sedation, extrapyramidal), attempt at dose reduction or antipsychotic withdrawal were all achieved in less than 45% of cases (range 33–45%).ConclusionThis audit revealed higher than expected rates of antipsychotic prescribing in our BPSD cohort. It also revealed suboptimal documentation around the use of antipsychotics in this population during clinical interactions.A subsequent intervention to the proforma assessment tool to prompt these discussions improved these behaviours, there was no impact on the rates of antipsychotic prescribing.Despite increased attention regarding the limited benefits of antipsychotic medication in BPSD their use remains widespread. Due attention must be given to changing this practice in order to protect this vulnerable patient group.

AimsTo compare Lithium prescribing practices in a Psychiatry of Old Age (POA) Service in the North-West of Ireland among adults aged 65 years and over with best practice guidelines.MethodReview of the literature informed development of audit standards for Lithium prescribing. These included National Institute for Clinical Excellent (NICE) 2014 guidelines, The British National Formulary (2019) and Maudsley Prescribing Guidelines (2018). Data were collected retrospectively, using an audit-specific data collection tool, from clinical files of POA team caseload, aged 65 years or more and prescribed Lithium over the past one year.ResultAt the time of the audit in February 2020, 18 patients were prescribed lithium, 67% female, average age 74.6 years. Of those prescribed Lithium; 50% (n = 9) had a depression diagnosis, 44% (n = 8) had bipolar affective disorder (BPAD) and 6% (n = 1) had schizoaffective disorder.78% (n = 14) of patients were on track to meet, or had already met, the NICE standard of 3-monthly serum lithium level. Lithium levels were checked on average 4.5 times in past one year, average lithium level was 0.61mmol/L across the group and 39% (n = 7) had lithium level within recommended therapeutic range (0.6-0.8mmol/L).83% (n = 15) of patients met the NICE standards of 3 monthly renal tests, thyroid function test was performed in 89% (n = 16) and at least one serum calcium level was documented in 63% (n = 15). Taking into consideration most recent blood test results, 100% (n = 18) had abnormal renal function, 78% (n = 7) had abnormal thyroid function and 60% (n = 9) had abnormal serum calcium.Half (n = 9) were initiated on lithium by POA service and of these, 56% (n = 5) had documented renal impairment prior to initiation. Of patients on long term lithium therapy at time of referral (n = 9), almost half (n = 4) had a documented history of lithium toxicity.ConclusionThe results of this audit highlight room for improvement in lithium monitoring of older adults attending POA service. Furthermore, all patients prescribed lithium had impaired renal function, half had abnormal calcium and two fifths had abnormal thyroid function. This is an important finding given the associations between those admitted to hospital with COVID-19 and comorbid kidney disease and increased risk of inpatient death.Our findings highlight the need for three monthly renal function monitoring in older adults prescribed lithium given the additive adverse effects of increasing age and lithium on the kidney. Close working with specialised renal services to provide timely advice on renal management for those with renal impairment prescribed lithium is important to minimise adverse patient outcomes.

We describe two young cases of reactive haemophagocytic lymphohistiocytosis (HLH) with the resultant stress cardiomyopathy in the setting of underlying autoimmune diseases, systemic lupus erythematosus (SLE) and Still’s disease. The initial presentation was similar in both cases with fever, hyperinflammatory response, hypotension (vasoplegia), bicytopenia and hyperferritinemia. Despite standard of care and multiple broad-spectrum antibiotics, both cases remained pyrexic and were ultimately admitted to the intensive therapy unit to treat cardiogenic shock. Echocardiogram of both cases showed low ejection fraction, the cause for which was not found until the final diagnosis of HLH was made. Both cases made a complete clinical and cardiac recovery following the initiation of high-dose glucocorticoids and anakinra.

Studies indicate that DSM-5 criteria for delirium are relatively restrictive, and identify different cases of delirium compared with previous systems. We evaluate four outcomes of delirium (mortality, length of hospital stay, institutionalization, and cognitive improvement) in relation to delirium defined by different DSM classification systems.Prospective, longitudinal study of patients aged 70+ admitted to medical wards of a general hospital. Participants were assessed up to a maximum of four times during two weeks, using DSM-5 and DSM-IV criteria, DRS-R98 and CAM scales as proxies for DSM III-R and DSM III.Of the 200 assessed patients (mean age 81.1, SD = 6.5; and 50% female) during hospitalization, delirium was identified in 41 (20.5%) using DSM-5, 45 (22.5%) according to DSM-IV, 46 (23%) with CAM positive, and 37 (18.5%) with DRS-R98 severity score >15. Mortality was significantly associated with delirium according to any classification system, but those identified with DSM-5 were at greater risk. Length of stay was significantly longer for those with DSM-IV delirium. Discharge to a care home was associated only with DRS-R98 defined delirium. Cognitive improvement was only associated with CAM and DSM-IV. Different classification systems for delirium identify populations with different outcomes.

Background Taking predictors of hospitalization characteristics into consideration internationally would broaden our understanding of this population on a local basis. Aims We aimed to examine and compare socio-demographic profiles along with hospitalization characteristics including length of hospital stay (LOS), reasons for admission and diagnoses among older adult inpatients hospitalized in Ireland and Turkey, and to assess factors predicting these features. Methods The admission charts of 356 psychiatric inpatients over 65 years of age who were admitted to two different acute psychiatric hospitals (Sligo/Ireland and Istanbul/Turkey) were analysed by means of descriptive modalities and logistic regression. Results There were significant differences in several domains of socio-demographics, reasons of admission and diagnoses. LOS was significantly longer in Ireland. Living alone was the only significant predictor for longer LOS in both countries, whereas in addition to living alone, younger age was also a contributor for longer LOS in Turkey. Discussion Given that the only factor predicting LOS both in Turkey and Ireland was living alone, helping to identify more acceptable ways of providing social support for living arrangements constitutes an important service to shorten LOS in old age psychiatric population. Conclusions It is possible to infer that independent from the cultural diversities, living arrangement is a consistent entity to influence length of hospital stay in older adult population.

Motor disturbances in delirious patients are common, but their relationship to cognition and severity of illness has not been studied. We examined motor subtypes in an older age inpatient population, their relationship to clinical variables including delirium, and their association with 1-year mortality in a prospective study, using the Confusion Assessment Method, Acute Physiology and Chronic Health Evaluation II, Montreal Cognitive Assessment (MoCA), Barthel Index, and Delirium Rating Scale-Revised 98 (DRS-R98). Motor subtypes were evaluated using 2 items of DRS-R98. Mortality rates were investigated 1 year later. Two hundred participated (mean age 81.1 [6.5]; 50% female). Thirty-four (17%) were identified with delirium. Motor subtypes were none: 119 (59.5%), hypoactive: 37 (18.5%), hyperactive: 29 (14.5%), and mixed: 15 (7.5%). Hypoactive and mixed subtypes were significantly more frequent in delirious patients. Regression analysis showed that hypoactive subtype was significantly associated with lower MoCA. No relationship between motor subtypes and mortality was found. Motor disturbances are not unique to delirium, with hypoactivity particularly associated with impaired cognition.

Aims and objectives: To measure cancer-related fatigue (CRF), self-care agency (SCA) and fatigue self-care strategies, and to explore the relationship between CRF and SCA. Background: Cancer-related fatigue has been consistently rated as the most elusive, common and severe of symptoms that patients with cancer undergoing chemotherapy experience. Despite its frequency and severity, CRF is poorly managed. A renewed focus on supporting self-care among patients with cancer has been found to reduce symptom burden, empower patients and improve patient satisfaction. Understanding the link between self-care agency (i.e. capability and willingness to self-care) and CRF levels will help practitioners to better support individuals on the cancer journey. Design: A descriptive, correlational survey design was employed. Methods: Patients (n = 362) undergoing chemotherapy with a primary diagnosis of breast, colorectal, Hodgkin's and non-Hodgkin's lymphoma cancers were recruited from four oncology centres in one city in the South of Ireland. Participants completed the Piper Fatigue Scale-Revised, Appraisal of Self-care Agency Scale and a researcher-developed Fatigue Self-Care Survey. Multivariate logistic regression was used to examine the relationship between CRF and self-care agency using a dichotomous dependent variable score of four as the cut-off between those deemed to be fatigued (≥4) and those not fatigued (

AimsMindfulness-based therapies have been demonstrated to be effective in reducing anxiety, stress and depressive symptoms in adults. Depression is a chronic relapsing condition. Major depressive disorder is one of the most common causes of ill health and functional impairment.Our goal was to assess the real world clinical effectiveness of Mindfulness Based Cognitive Therapy (MBCT) for Recurrent Depressive Disorder in three domains:-Depression, anxiety and stress levels-Mindfulness level-Self-compassion levelMethodPatients with a diagnosis of Recurrent Depressive Disorder (primary or secondary diagnosis) were referred by their community mental health team to participate in an 8-week educational MBCT programme. Participants completed the Depression, Anxiety and Stress (DASS), 5-Facet Mindfulness and Self Compassion self-rated scales prior to commencing and at the end of the course. They were also invited to give qualitative feedback at the end of the course.Data were collected from four groups who completed the course over a period of twelve months. A paired samples test was used to compare pre and post intervention scores to determine effect size.ResultWe had complete data for 19 participants out of a cohort of 34. Pre intervention scores were similar for both groups.The mean age of the cohort was 47 years (SD of 10 years), 3 male, 16 female.Patients showed a clinically significant reduction of symptoms in depression, anxiety and stress, with respective reductions of 48%, 26% and 43% post intervention. Results were statistically significant for depressaion and stress p Positive trends were seen in all domains of the 5-Fact Mindfulness and Self Compassions scales, with mean improvements of 28.2% and 35.3% respectively. All results were statistically significant.We also collected anonymized qualitative feedback which highlighted themes of empowerment, skill acquisition and improved coping.ConclusionNumerous studies have demonstrated poor compliance with antidepressant treatments commonly prescribed in Recurrent Depressive Disorder. This small scale study demonstrates a statistical and clinical benefit of MBCT for these patients, supporting greater use of such novel non-pharmacological therapeutic options as treatment strategies..

IntroductionThe COVID-19 pandemic has required services to evolve quickly to continue routine care and telemedicine has been rapidly implemented to facilitate this. Older persons are at high risk of serious complications of COVID-19 and it is essential that their exposure to COVID-19 is minimized.ObjectivesOur aim was to assess staff and patient satisfaction with remote psychiatric assessments using mobile tablets in long-stay facilities.MethodsRemote clinics using Skype video on mobile tablets were conducted with patients in long-stay facilities attending psychiatry in rural North-West Ireland between April and July 2020. At each review, a satisfaction survey was administered to the patient, their keyworker and the clinician. The patient/keyworker survey instrument had four yes/no statements and the clinician survey had four statements with 5-point likert scale responses (1=very low to 5=very high). Open feedback was also obtained for thematic analysis. Descriptive analyses were completed using SPSS software.Results23 patients (mean age 80.9yrs) were assessed in 10 long-stay facilities. All patients were agreeable to participating in video consultation although only 13 patients were able to respond to survey due to cognitive impairment. There was a 92.3% positive patient response (12/13) and 95.7% positive keyworker response (N=22/23) for all statements. The mean score on the assessor response ranged from 3.43 to 4.04 with the lowest rate for quality of transmission. The main themes identified were related to the quality of connection and sensory difficulties.ConclusionsVideo consultations using mobile tablets offer an acceptable form of remote psychiatry assessment for older persons in long-stay facilities.

The association between the socio-demographic characteristics of caregivers, such as gender and caregiver burden, is well documented; however, the process underlying this relationship is poorly understood. Based on the stress process model, we designed a cross-sectional study to examine the mediating and moderating effect of resilience on the relationship between gender and caregiver burden. Caregivers of individuals with severe mental illness (n=201) were recruited in two psychiatric outpatient clinics in Malaysia. The relationship between the gender of the caregiver and caregiver burden was mediated by resilience, thus supporting the stress process model. The findings from the present research contribute to the growing evidence of the interaction between socio-demographic variables of caregivers and resilience, and caregiver burden.

Limited studies of the association between BDNF levels and delirium have given inconclusive results. This prospective, longitudinal study examined the relationship between BDNF levels and the occurrence of and recovery from delirium. Participants were assessed twice weekly using MoCA, DRS-R98, and APACHE II scales. BDNF levels were estimated using an ELISA method. Delirium was defined with DRS-R98 (score > 16) and recovery from delirium as ≥2 consecutive assessments without delirium prior to discharge. We identified no difference in BDNF levels between those with and without delirium. Excluding those who never developed delirium (n=140), we examined the association of BDNF levels and other variables with delirium recovery. Of 58 who experienced delirium, 39 remained delirious while 19 recovered. Using Generalized Estimating Equations models we found that BDNF levels (Wald χ2=7.155; df: 1, p=0.007) and MoCA (Wald χ2=4.933; df: 1, p=0.026) were associated with recovery. No significant association was found for APACHE II, dementia, age, or gender. BDNF levels do not appear to be directly linked to the occurrence of delirium but recovery was less likely in those with continuously lower levels. No previous study has investigated the role of BDNF in delirium recovery and these findings warrant replication in other populations.

DOI: 10.1016/j.dadm.2016.11.002 URL: http://www.sciencedirect.com/science/article/pii/S2352872916300586 Filiació URV: SI Inclòs a la memòria: SI Introduction Subsyndromal delirium (SSD) complicates diagnosis of delirium and dementia, although there is little research comparing their symptom profiles. Methods Cross-sectional study of 400 elderly patients’ admission to a general hospital or nursing home diagnosed with delirium, SSD, dementia, or no-delirium/no-dementia (NDND). Symptom profiles were assessed using the Delirium Rating Scale-Revised-98 (DRS-R98). Results Twenty percent patients had delirium, 19.3% had SSD, 29.8% had dementia-only, and 31% had NDND. Eighty-one percent of subsyndromal and 76% of delirium groups had comorbid dementia. DRS-R98 scores showed ascending severity from NDND < dementia-only < SSD < delirium. DRS-R98 scores for items evaluating the three core symptom domains (cognitive, higher-order thinking, and circadian) distinguished SSD from delirium and both from nondelirium groups. DRS-R98 profiles were essentially the same in delirium and SSD subgroups with or without dementia, although total scale scores were generally higher when in comorbid subgroups. Discussion SSD shared characteristic core domain symptoms with delirium, which distinguished each from nondelirium groups, although severity was intermediate in the subsyndromal group. Delirium core symptoms overshadowed the dementia phenotype when comorbid. Milder disturbances of delirium core domain symptoms are highly suggestive of SSD.

Aim This study aimed to identify levels of depressive symptoms, social and personal college adjustment and peer support among nursing and midwifery students. Background Student mental health is of international concern, particularly among students who are undertaking professional qualifications in health care. Design Cross-sectional design. Methods Data were collected in 2013 using the Centre for Epidemiology Depressive Symptoms Scale, two subscales of the Student Adaptation to College Questionnaire; and a subscale of the Peer Support Evaluation Inventory with 417 students in Ireland. Results Findings indicated that 34% of participants experienced depressive symptoms, 20% were poorly personally adjusted and 9% poorly socially adjusted. Most students had good levels of peer support. Statistically significant relationships were found between all key variables. Students in their second year of study had significantly higher rates of depressive symptoms. Participants who reported having poor relationships with their fathers were at higher risk and had more difficulties personally and socially adjusting to university life and study. The alcohol consumption of participants had a statistically significant relationship with depressive symptoms with higher consumption rates having a positive impact on symptoms. Conclusion The mental health of undergraduates undertaking professional healthcare studies needs to be a key research, educational and clinical priority. High rates of adjustment and mental health difficulties, particularly in the second year of the programme need to be examined and more effective interventions developed.