'It helps you forget your worries': A pilot study exploring music therapy in the acute hospital aged care setting.

OBJECTIVES: Few studies have explored music therapy (MT) in an acute aged care inpatient setting. We aimed to assess feasibility and patient/staff perceptions of an 8-week MT program on an acute geriatric ward. METHODS: An 8-week in-person MT program, comprising brief receptive musical interventions up to twice-weekly. All patients admitted to the aged care ward were eligible for inclusion. A hard copy survey was used to assess patient and staff perceptions of MT. Themes raised in free-text responses were manually coded within a thematic analysis approach. A mixed methods approach was used to obtain and analyse data relating to feasibility and patient and staff perceptions of the MT intervention. RESULTS: The 8-week program ran to completion and was delivered to a median of 11 patients (IQR 9-12) each session (median 8 new/day). In total, 10 patients completed surveys, mean age 81.1 (SD 7.7); 60% were women and all had cognitive impairment. Following an MT session, eight of eight responding patients reported feeling happy and eight of eight reported they would recommend MT. Staff respondents (n = 19) reported patients appeared happy (19/19), relaxed (13/19) and all would recommend MT to other patients. Common themes were that MT was followed by improved patient behaviour and mood, and stimulated patients. CONCLUSIONS: An acute aged care inpatient MT program proves feasible and well-received by staff and patients. Future research may focus on more robust data collection in larger sample sizes, specific types of MT and more in-depth exploration of the patient and carer experiences.

Strategies adopted by informal carers to enhance participation in daily activities for persons with dementia.

OBJECTIVE: Carers for people with dementia commonly experience difficulty assisting the care-recipients with their daily activities and may adopt specific strategies to decrease the difficulties experienced. The objective of this qualitative study was to explore and understand the strategies used by carers to assist with daily activities for persons living with dementia. METHODS: Individual semi-structured interviews via face-to-face or telephone mode were conducted with 62 carers of persons living with dementia in Australia. Carers were asked about the strategies they have used previously, or are currently using, to assist with daily activity completion. Data were analysed via constant comparison and thematic analysis. RESULTS: All carers reported the need for strategies to accommodate the varying behaviour and functioning of the care-recipients. Participants reported a total of 207 strategies that fell into four main categories: (i) engage; (ii) adapt; (iii) orientate; and (iv) sense. The most used strategies were reported as those aimed at adapting the activity by using equipment to facilitate completion. CONCLUSIONS: Carers help persons living with dementia complete their daily activities by developing their own strategies based on the care-recipients' needs and personal preferences through a trial-and-error process. Carers can benefit if more advice is provided to them by health/social care professionals regarding what strategies may be helpful. Further studies are needed to develop these strategies into an educational package so that carers can be guided to use these strategies appropriately.

Introduction of enhanced weekend physiotherapy for patients with hip fracture is associated with improved early mobility outcomes.

OBJECTIVE: To assess whether enhanced daily weekend physiotherapy (EWP) for patients with hip fracture was associated with improved clinical outcomes. METHODS: We retrospectively analysed all previously ambulatory adults admitted with hip fracture to our tertiary hospital, comparing 'usual' ('control') care (09/19-03/20) to EWP (09/20-03/21). Outcomes included Day-7 mobility ≥20 m (primary), additional mobility measures, specified postoperative complications, new residential facility placement, acute length-of-stay (LOS) and 30-day death. RESULTS: Amongst 235 eligible patients (128 control, 107 EWP), 66% were female, mean age was 80.4 years (SD 10.5), 20% from residential care and 49% (114/235) were mobilising without aid at baseline (no between-group differences; all p ≥ .20). Median acute LOS was 10 days (IQR 6-15), total hospital LOS was 21 days (IQR 12-37) and 3% (n = 6) died by Day 30. Median Day-7 distance mobilised was 25 m (IQR 7-50) with EWP versus 10 m (3-40) (p = .06). No EWP patients developed pressure injury (0 vs. 6, p = .02); other outcomes were similar between groups. Adjusting for age, residence, baseline cognitive impairment, American Society of Anesthesiologist score and preadmission mobilisation without aids, EWP was independently associated with increased likelihood of mobilising ≥20 m at Day 7 (aOR 1.83, 95% CI 1.04-3.23, p = .03). CONCLUSIONS: Enhanced daily weekend physiotherapy was associated with improvement in early mobility, but not other outcomes assessed. These data would be strengthened by randomised controlled trial data exploring more intense physiotherapy, cost-benefit analysis and patient experience measures.

Preparedness to care for older hospital in-patients: An exploratory survey-based study of medical interns.

Few studies have addressed how well prepared interns feel to manage older persons, and what aspects of their learning and teaching have facilitated this. We explored medical interns' self-assessed preparedness for dealing with older hospital in-patients, using an online survey. Response rate was 36.8% (21/57), with graduates from 7 universities and 11/21 female. Asked 'How prepared have you felt for managing older patients in hospital?', median Likert score (1-5) was 3. However, 19/21 felt able to manage the last older patient seen. Self-assessed preparedness to manage different aspects of aged care varied. 'Real-life experience on the wards' (19/21) was the favored teaching tool. Identification of such self-assessed gaps will better inform teaching of aged care to medical students and junior doctors.

Does Case-Finding for Admission to Aged Care Rapid Investigation and Assessment Unit for Older Patients Improve Hospital Length of Stay? Evaluation of ARIA Unit.

Introduction: Many older people present to emergency departments annually, often with complex geriatric syndromes, yet current acute care models and traditional admissions process may under-serve their needs. The multidisciplinary Aged Care Rapid Investigation and Assessment (ARIA) Unit seeks to bridge this gap, by actively identifying and assessing patients. Methods: A prospective case-control study was undertaken at a single-centre tertiary referral institution. Patients were eligible for inclusion in ARIA group if admitted to ARIA via case-finding by the geriatrician or Aged Care Services Emergency Team, whilst standard geriatric admissions formed the control group. This study evaluates whether ARIA reduced hospital length-of-stay (LOS) and representation rates. Results: 370 patients were included (185 each arm) with similar baseline demographics, frailty scores, and Charlson Comorbidity Indices. Patients admitted to ARIA had significantly shorter hospital LOS than those via standard pathway (3.3 days [IQR2.2-5.8] vs 7.5 days [IQR4.2-13.7], p < 0.00001). There were no significant differences in 90-day representation rates (n = 66 [35.7%] vs n = 64 [34.6%], p = 0.82). Discussion/Conclusion: Introduction of an ARIA unit with a targeted approach to frontline geriatric services and case-finding is associated with improved LOS of older acute hospital patients. An economical cost analysis of this study would be beneficial in exploring potential financial savings.

Advanced care planning in the early phase of COVID-19: a rapid review of the practice and policy lessons learned.

Background: The importance of advance care planning (ACP) has been highlighted by the advent of life-threatening COVID-19. Anecdotal evidence suggests changes in implementation of policies and procedures is needed to support uptake of ACPs. We investigated the barriers and enablers of ACP in the COVID-19 context and identify recommendations to facilitate ACP, to inform future policy and practice. Methods: We adopted the WHO recommendation of using rapid reviews for the production of actionable evidence for this study. We searched PUBMED from January 2020 to April 2021. All study designs including commentaries were included that focused on ACPs during COVID-19. Preprints/unpublished papers and Non-English language articles were excluded. Titles and abstracts were screened, full-texts were reviewed, and discrepancies resolved by discussion until consensus. Results: From amongst 343 papers screened, 123 underwent full-text review. In total, 74 papers were included, comprising commentaries (39) and primary research studies covering cohorts, reviews, case studies, and cross-sectional designs (35). The various study types and settings such as hospitals, outpatient services, aged care and community indicated widespread interest in accelerating ACP documentation to facilitate management decisions and care which is unwanted/not aligned with goals. Enablers of ACP included targeted public awareness, availability of telehealth, easy access to online tools and adopting person-centered approach, respectful of patient autonomy and values. The emerging barriers were uncertainty regarding clinical outcomes, cultural and communication difficulties, barriers associated with legal and ethical considerations, infection control restrictions, lack of time, and limited resources and support systems. Conclusion: The pandemic has provided opportunities for rapid implementation of ACP in creative ways to circumvent social distancing restrictions and high demand for health services. This review suggests the pandemic has provided some impetus to drive adaptable ACP conversations at individual, local, and international levels, affording an opportunity for longer term improvements in ACP practice and patient care. The enablers of ACP and the accelerated adoption evident here will hopefully continue to be part of everyday practice, with or without the pandemic.

Poorer outcomes in patients with early postoperative delirium: 120-day follow-up of the Delirium Reduction by Analgesia Management in Hip Fracture (DRAM-HF) study.

OBJECTIVES: The Delirium Reduction by Analgesia Management-Hip Fracture (DRAM-HF) model of care, which incorporated a multicomponent intervention focussing on perioperative analgesia and medication optimisation, was associated with reduced Day 3 postoperative delirium (POD) amongst hip fracture patients. We investigated whether this effect was seen at 120 days postoperatively. METHODS: We assessed 120-day outcomes in all patients who were included in the DRAM-HF study, by telephone, supplemented by electronic medical records, to include death (primary outcome), residential aged care facility (RACF) residence, patient/carer-reported frailty, hospital readmission and new dementia diagnosis. RESULTS: Amongst 300 patients (mean age 81.1, 70% female, none lost to follow-up), by 120 days, 8% (n = 24) had died; 25% of survivors (n = 68/276) were RACF residents. Twenty-two per cent were readmitted (n = 61/281). A new dementia diagnosis was reported by 6% (n = 17/281). Intervention status in the DRAM-HF trial (intervention/control) was not associated with death by 120 days (OR 0.83, 95% CI 0.36-1.93, p = 0.67) or other outcomes assessed. POD was independently associated with 120-day death (aOR 3.3, 95% CI 1.2-9.2, p = 0.02), RACF residence (aOR 2.2, 95% CI 1.1-4.7, p = 0.03) and patient/carer-reported frailty (aOR 5.6, 95% CI 1.0-30.7, p = 0.05), but not readmission (p = 0.21) or new diagnosis of dementia (p = 0.08). CONCLUSIONS: In this cohort, while the DRAM-HF bundle of care did not influence 120-day outcomes, patients who experienced POD had poorer clinical outcomes 120-day postfracture. Given that delirium was associated with death, RACF residence and frailty, models of care which have the potential to reduce POD may have benefits beyond the acute admission, and further investigation is needed.

In-hospital outcomes among older medical inpatients admitted to aged care wards after activation of a 2-tier rapid response system.

BACKGROUND: The outcomes of rapid response systems (RRS) are poorly established in older people. We examined the outcomes in older inpatients at a tertiary hospital that uses a 2-tier RRS, including the outcomes of each tier. METHODS: The 2-tier RRS comprised the clinical review call (CRC) (tier one) and the medical emergency team call (MET) (tier two). We compared the outcomes in four configurations of MET and CRC (MET with CRC; MET without CRC; CRC without MET; neither MET nor CRC). The primary outcome was in-hospital death, and secondary outcomes were length of stay (LOS) and new residential facility placement. Statistical analyses were carried out using Fisher's exact tests, Kruskal-Wallis tests, and logistic regression. RESULTS: A total of 433 METs and 1,395 CRCs occurred among 3,910 consecutive admissions of mean age 84 years. The effect of a MET on death was unaffected by the occurrence of a CRC. The rates of death for MET ± CRC, and CRC without MET, were 30.5% and 18.5%, respectively. Patients having one or more MET ± CRC (adjusted odds ratio [aOR] 4.04, 95% confidence interval [CI] 2.96-5.52), and those having one or more CRC without MET (aOR 2.22, 95% CI 1.68-2.93), were more likely to die in adjusted analysis. Patients who required a MET ± CRC were more likely to be placed in a high-care residential facility (aOR 1.52, 95% CI 1.03-2.24), as were patients who required a CRC without MET (aOR 1.61, 95% CI 1.22-2.14). The LOS of patients who required a MET ± CRC, and CRC without MET, was longer than that of patients who required neither (P < 0.001). CONCLUSIONS: Both MET and CRC were associated with increased likelihood of death and new residential facility placement, after adjusting for factors such as age, comorbidity, and frailty. These data are important for patient prognostication, discussions on goals of care, and discharge planning. The high death rate of patients requiring a CRC (without a MET) has not been previously reported, and may suggest that CRCs among older inpatients should be expediated and attended by senior medical personnel.

What constitutes brilliant aged care? A qualitative study of practices that exceed expectation.

AIM: This study aimed to explore what constitutes brilliant aged care. BACKGROUND: Although many aged care services do not offer the care that older people and carers need and want, some perform better. Rather than focus on problems with aged care, this study examined brilliant aged care-practices that exceeded expectation. DESIGN: The methodology for this study was informed by grounded theory, underpinned by constructionism to socially construct meaning. METHODS: This study invited nominations for a Brilliant Award via a survey, and interviews with the nominees via web conference. After receiving survey responses from 10 nominators, interviews were conducted with 12 nominees. Data were analysed using reflexive thematic analysis and documented according to COREQ guidelines to optimise rigour and transparency. RESULTS: According to participants, brilliant aged care involved being relationally attuned to older people, a deep understanding of the older person, recognition of aged care as more than a job, innovative practices and permission to reprioritise. CONCLUSIONS: This study suggests that, in aged care, brilliance happens. It emphasises the importance of meaningful connections and relationships in aged care, where thoughtful acts acknowledge an older person's value and humanity as well as creativity and innovation. RELEVANCE TO CLINICAL PRACTICE: For those who manage and deliver aged care, the findings suggest that small practice changes can make a positive difference to older people. Brilliant aged care can involve acts of empathy; enthusiasm for aged care; innovative practices, even those that are small scale; and reprioritising workplace tasks to spend time with older people. For policymakers, this study highlights the need to recognise and raise the profile of the pockets of brilliance within the aged care sector. This might be achieved via awards and other initiatives that serve to celebrate and learn from brilliance in its myriad forms. PATIENT OR PUBLIC CONTRIBUTION: The nominees, who included carers, were invited to participate in workshops with other carers and older people to co-design a model of brilliant aged care, during which workshop participants discussed and critiqued the findings constructed from the data.

Delirium in the intensive care unit and its importance in the post-operative context: A review.

The burden of delirium in the intensive care setting is a global priority. Delirium affects up to 80% of patients in intensive care units; an episode of delirium is often distressing to patients and their families, and delirium in patients within, or outside of, the intensive care unit (ICU) setting is associated with poor outcomes. In the short term, such poor outcomes include longer stay in intensive care, longer hospital stay, increased risk of other hospital-acquired complications, and increased risk of hospital mortality. Longer term sequelae include cognitive impairment and functional dependency. While medical category of admission may be a risk factor for poor outcomes in critical care populations, outcomes for surgical ICU admissions are also poor, with dependency at hospital discharge exceeding 30% and increased risk of in-hospital mortality, particularly in vulnerable groups, with high-risk procedures, and resource-scarce settings. A practical approach to delirium prevention and management in the ICU setting is likely to require a multi-faceted approach. Given the good evidence for the prevention of delirium among older post-operative outside of the intensive care setting, simple non-pharmacological interventions should be effective among older adults post-operatively who are cared for in the intensive care setting. In response to this, the future ICU environment will have a range of organizational and distinct environmental characteristics that are directly targeted at preventing delirium.

Higher levels of multimorbidity are associated with increased risk of readmission for older people during post-acute transitional care.

PURPOSE: Older patients are at high risk for poor outcomes after an acute hospital admission. The Transitional Aged Care Programme (TACP) was established by the Australian government to provide a short-term care service aiming to optimise functional independence following hospital discharge. We aim to investigate the association between multimorbidity and readmission amongst patients on TACP. METHODS: Retrospective cohort study of all TACP patients over 12 months. Multimorbidity was defined using the Charlson Comorbidity Index (CCI), and prolonged TACP (pTACP) as TACP ≥ 8 weeks. RESULTS: Amongst 227 TACP patients, the mean age was 83.3 ± 8.0 years, and 142 (62.6%) were females. The median length-of-stay on TACP was 8 weeks (IQR 5-9.67), and median CCI 7 (IQR 6-8). 21.6% were readmitted to hospital. Amongst the remainder, 26.9% remained at home independently, 49.3% remained home with supports; < 1% were transferred to a residential facility (0.9%) or died (0.9%). Hospital readmission rates increased with multimorbidity (OR 1.37 per unit increase in CCI, 95% CI 1.18-1.60, p < 0.001). On multivariable logistic regression analysis, including polypharmacy, CCI, and living alone, CCI remained independently associated with 30-day readmission (aOR 1.43, 95% CI 1.22-1.68, p < 0.001). CONCLUSIONS: CCI is independently associated with a 30-day hospital readmission in TACP cohort. Identifying vulnerability to readmission, such as multimorbidity, may allow future exploration of targeted interventions.

The burden of peripheral intravenous catheters in older hospital inpatients: A national cross-sectional study part of the ONE MILLION GLOBAL PERIPHERAL INTRAVENOUS CATHETERS COLLABORATION.

OBJECTIVES: To investigate the burden of peripheral intravenous catheters (PIVCs) in older hospitalised patients. METHODS: A cross-sectional prospective observational study (2014/2015) to describe the characteristics, indications and outcomes of PIVCs among patients aged ≥65 from 65 Australian hospitals. RESULTS: Amongst 2179 individual PIVCs (in 2041 patients, mean age 77.6 years, 45% female, 58% in NSW), 43% were inserted by doctors and 74% used that day, meaning 25% were 'idle'. Overall, 18% (393/2179) exhibited signs of PIVC-related complications. Most commonly exhibited PIVC-related complications were tenderness (4.1%) and local redness (1.8%). Nearly one in three (29.1%) dressings was soiled, loosened or had come off, and only 36.8% had the time and date documented on the dressing. Both infusing IV medications (aOR 1.74, 95% CI 1.28-2.38, p < 0.001) and inserting the PIVC in a non-upper limb vein (aOR 3.40 compared to forearm [reference site], 95% CI 1.62-7.17, p < 0.001) were independently associated with PIVC failure. Phlebitis was exhibited in 7% (154) of the patients. Only infusing intravenous medications increased the likelihood of developing symptoms of phlebitis (aOR 1.61, 95% CI 1.01-2.57, p = 0.05). Increasing age was inversely associated with symptoms of phlebitis. Among the 1575 patients (79%) who rated their PIVC experience using the Likert scale 0-10 (where 10 = 'best possible'), the median score was 8 (IQR 6-10). Age in highest quartile (>84 years) was independently associated with lower likelihood of a high score (aOR 0.71, 95% CI 0.54-0.94, p = 0.02). CONCLUSIONS: Given 1 in 5 PIVCs were identified with having complications, further research should focus on optimising PIVC use in older patients.

Clinical and cost-effectiveness of telehealth for Indigenous and culturally and linguistically diverse (CALD) people: a scoping review.

OBJECTIVES: To examine the modalities and clinical and non-clinical effectiveness of telehealth services available to people from Indigenous and culturally and linguistically diverse backgrounds (CALD). MATERIALS AND METHODS: A scoping review of peer-reviewed publications (2000-2021) on the effectiveness of telehealth interventions for Indigenous and CALD groups based on searches of Medline, CINAHL, and PsycInfo and manual searches from reference lists of captured literature reviews. RESULTS: Of the initial 601 articles, 10 met the inclusion criteria (seven of clinical effectiveness and three of non-clinical effectiveness), with participants from the USA, Australia, New Zealand, and Canada, with sample sizes ranging from 19 to 1,665 participants (overall 327 Indigenous and 2,030 CALD patients). Telehealth was delivered via telephone or by videoconference-with or without data uploads-and follow-up ranging from 6 months to 5 years. DISCUSSION: The findings suggest that telehealth shows some promise in: diabetes, depression, neuro/cognitive assessment, and health program adherence/service utilisation/cost. However, our confidence in the accuracy of the results is undermined by the mixed quality of designs and outcome measurements, and the high risk of bias derived from not proper random selections and small sample sizes. CONCLUSIONS: The available literature suggests acceptable clinical and non-clinical effectiveness of telehealth against usual care in Indigenous and/or CALD groups but methodological limitations diminish their value in informing practice. Therefore, we consider it is premature to use the findings of these primary studies to draw conclusive recommendations about clinical or other effectiveness of telehealth for the two target groups. Further randomised trials with adequate sampling frames and objective outcome assessments are warranted.

Post-operative delirium in the patient with hip fracture: The journey from hospital arrival to discharge.

Delirium- an acute disorder of attention and cognition- is the commonest complication following hip fracture. Patients with hip fracture are particularly vulnerable to delirium, and many of the lessons from the care of the patient with hip fracture will extend to other surgical cohorts. Prevention and management of delirium for patients presenting with hip fracture, extending along a continuum from arrival through to the post-operative setting. Best practice guidelines emphasize multidisciplinary care including management by an orthogeriatric service, regular delirium screening, and multimodal interventions. The evidence base for prevention is strongest in terms of multifaceted interventions, while once delirium has set in, early recognition and identification of the cause are key. Integration of effective strategies is often suboptimal, and may be supported by approaches such as interactive teaching methodologies, routine feedback, and clear protocol dissemination. Partnering with patients and carers will support person centered care, improve patient experiences, and may improve outcomes. Ongoing work needs to focus on implementing recognized best practice, in order to minimize the health, social and economic costs of delirium.

The Feasibility of Deriving the Electronic Frailty Index from Australian General Practice Records.

Purpose: Frailty is a prevalent condition in older adults. Identification of frailty using an electronic Frailty Index (eFI) has been successfully implemented across general practices in the United Kingdom. However, in Australia, the eFI remains understudied. Therefore, we aimed to (i) examine the feasibility of deriving an eFI from Australian general practice records and (ii) describe the prevalence of frailty as measured by the eFI and the prevalence with socioeconomic status and geographic remoteness. Participants and Methods: This retrospective analysis included patients (≥70 years) attending any one of >700 general practices utilizing the Australian MedicineInsight data platform, 2017-2018. A 36-item eFI was derived using standard methodology, with frailty classified as mild (scores 0.13-0.24); moderate (0.25-0.36) or severe (≥0.37). Socioeconomic status (Socio-Economic Indexes for Areas (SEIFA) index)) and geographic remoteness (Australian Statistical Geography Standard (ASGC) remoteness areas) were also examined. Results: In total, 79,251 patients (56% female) were included, mean age 80.0 years (SD 6.5); 37.4% (95% CI 37.0-37.7) were mildly frail, 16.7% (95% CI 16.4-16.9) moderately frail, 4.8% (95% CI 4.7-5.0) severely frail. Median eFI score was 0.14 (IQR 0.08 to 0.22); maximum eFI score was 0.69. Across all age groups, moderate and severe frailty was significantly more prevalent in females (P < 0.001). Frailty severity increased with increasing age (P < 0.001) and was strongly associated with socioeconomic disadvantage (P < 0.001) but not with geographic remoteness. Conclusion: Frailty was identifiable from routinely collected general practice data. Frailty was more prevalent in socioeconomically disadvantaged groups, women and older patients and existed in all levels of remoteness. Routine implementation of an eFI could inform interventions to prevent or reduce frailty in all older adults, regardless of location.

Does delirium prevention reduce risk of in-patient falls among older adults? A systematic review and trial sequential meta-analysis.

OBJECTIVES: To determine whether delirium prevention interventions reduce the risk of falls among older hospitalised patients. METHODS: A systematic search of health-care databases was undertaken. Given the frequency of small sample sized trials, a trial sequential meta-analysis was conducted to present estimate summary effects to date. A Bayesian approach was used to estimate the posterior probability of the delirium prevention interventions reducing falls risk by various clinically relevant levels. RESULTS: Five randomised controlled trials were included in our final meta-analysis. There was a 43% reduction in the risk of falls among participants in the delirium prevention intervention arm, compared to the control; however, confidence intervals were wide (RE RR = 0.57, 95% CI 0.32; 1.00, p = 0.05). This result was found to be statistically significant, according to traditional significance levels (z > 1.96) and the more conservative trial sequential analysis monitoring boundaries. The posterior probabilities of the delirium prevention intervention reducing the risk of falls by 10%, 20% and 30% were 0.86, 0.63 and 0.29 respectively. CONCLUSIONS: The results of this systematic review and trial sequential meta-analysis suggest that delirium prevention trials may reduce the risk of in-hospital falls among older patients by 43%. However, despite significant risk reduction found upon meta-analysis, the variation among study populations and intervention components raised questions around its application in clinical practice. Further research is required to investigate what the necessary components of a multifactorial intervention are to reduce both delirium and fall incidence among older adult in-patients.

Delirium Reduction by Analgesia Management in Hip Fracture surgery (DRAM-HF): Exploration of perceived facilitators and barriers.

OBJECTIVES: In tandem with the implementation of a multidisciplinary protocol which was successful in reducing delirium after hip fracture surgery (DRAM-HF), we sought to investigate enablers and barriers to same. METHODS: Single-centre, prospective, before-and-after questionnaire targeted at health-care professionals involved in DRAM-HF. We assessed respondent-reported enablers and barriers to the multidisciplinary protocol, using 0-100 agreement scales and free-text responses. RESULTS: A total of 134 preintervention and 124 postintervention responses were collated (out of 200, response rates 67% and 62%, respectively). Preintervention support for DRAM-HF was 100% (n = 130) and postintervention 95.9% (n = 116). Study design was well received with a mean score of 76.7 (SD 19.7) for being easy to understand. Support for additional computer alert systems was also high (mean 73.6, SD 23.9). Free-text responses emphasised the need for integration of ward pharmacists into medication optimisation (n = 31) and upskilling nurse practitioners (n = 23). CONCLUSION: Whilst generally supported, DRAM-HF implementation may be streamlined by optimising electronic delivery, offering targeted education and expanding roles.

Older trauma patients are at high risk of delirium, especially those with underlying dementia or baseline frailty.

BACKGROUND: Given the increasing numbers of older patients presenting with trauma, and the potential influence of delirium on outcomes, we sought to investigate the proportion of such patients who were diagnosed with delirium during their stay-and patient factors associated therewith-and the potential associations between delirium and hospital length of stay (LOS). We hypothesized that delirium would be common, associated with certain patient characteristics, and associated with long hospital LOS (highest quartile). METHODS: We conducted a retrospective observational cohort study of all trauma patients aged ≥65 years presenting in September to October 2019, interrogating medical records and the institutional trauma database. The primary outcome measure was occurrence of delirium. RESULTS: Among 99 eligible patients, delirium was common, documented in 23% (23 of 99). On multivariable analysis, adjusting for age, frailty and history of dementia, frailty (OR 4.09, 95% CI 1.08 to 15.53, p=0.04) and dementia (OR 5.23, 95% CI 1.38 to 19.90, p=0.02) were independently associated with likelihood of delirium. Standardized assessment tools were underused, with only 34% (34 of 99) screened within 4 hours of arrival. On univariate logistic regression analysis, having an episode of delirium was associated with long LOS (highest quartile), OR of 5.29 (95% CI 1.92 to 14.56, p<0.001). In the final multivariable model, adjusting for any (non-delirium) in-hospital complication, delirium was independently associated with long LOS (≥16 days; OR 4.81, p=0.005). DISCUSSION: In this study, delirium was common. History of dementia and baseline frailty were associated with increased risk. Delirium was independently associated with long LOS. However, many patients did not undergo standardized screening at admission. Early identification and targeted management of older patients at risk of delirium may reduce incidence and improve care of this vulnerable cohort. These data are hypothesis generating, but support the need for initiatives which improve delirium care, acknowledging the complex interplay between frailty and other geriatric syndromes in the older trauma patients. LEVEL OF EVIDENCE: III.