Older adults experience of transition to the community from the emergency department: a qualitative evidence synthesis.

AIM: Older adults comprise a growing proportion of Emergency Department (ED) attendees and are vulnerable to adverse outcomes following an ED visit including ED reattendance within 30 days. Interventions to reduce older adults' risk of adverse outcomes following an ED attendance are proliferating and often focus on improving the transition from the ED to the community. To optimise the effectiveness of interventions it is important to determine how older adults experience the transition from the ED to the community. This study aims to systematically review and synthesise qualitative studies reporting older adults' experiences of transition to the community from the ED. METHODS: Six databases (Academic Search Complete, CINAHL, MEDLINE, PsycARTICLES, PsycINFO, and Social Science Full Text) were searched in March 2022 and 2023. A seven-step approach to meta-ethnography, as described by Noblit and Hare, was used to synthesise findings across included studies. The methodological quality of the included studies was appraised using the 10-item Critical Appraisal Skills Programme (CASP) checklist for qualitative research. A study protocol was registered on PROSPERO (Registration: CRD42022287990). FINDINGS: Ten studies were included, and synthesis led to the development of five themes. Unresolved symptoms reported by older adults on discharge impact their ability to manage at home (theme 1). Limited community services and unresolved symptoms drive early ED reattendance for some older adults (theme 2). Although older adults value practical support and assistance transporting home from the ED this is infrequently provided (theme 3). Accessible health information and interactions are important for understanding and self-managing health conditions on discharge from the ED (theme 4). Fragmented Care between ED and community is common, stressful and impacts on older adult's ability to manage health conditions (theme 5). A line of argument synthesis integrated these themes into one overarching concept; after an ED visit older adults often struggle to manage changed, complex, health and care needs at home, in the absence of comprehensive support and guidance. DISCUSSION/ CONCLUSION: Key areas for consideration in future service and intervention development are identified in this study; ED healthcare providers should adapt their communication to the needs of older adults, provide accessible information and explicitly address expectations about symptom resolution during discharge planning. Concurrently, community health services need to be responsive to older adults' changed health and care needs after an ED visit to achieve care integration. Those developing transitional care interventions should consider older adults needs for integration of care, symptom management, clear communication and information from providers and desire to return to daily life.

Comprehensive Geriatric Assessment in the Emergency Department: A Prospective Cohort Study of Process, Clinical, and Patient-Reported Outcomes.

Background: This study aimed to explore the process, clinical, and patient-reported outcomes of older adults who received an interdisciplinary Comprehensive Geriatric Assessment (CGA) in the emergency department (ED) over a six-month period after their initial ED attendance. Patients and Methods: A prospective cohort study recruited older adults aged ≥65 years who presented to the ED of a university teaching hospital in Ireland. Baseline assessment data comprising a battery of demographic variables and validated indices were obtained at the index ED attendance. Telephone interviews were completed with participants at 30- and 180-day follow-up. The primary outcome was incidence of hospital admission following the index ED attendance. Secondary outcomes included participant satisfaction, incidence of functional decline, health-related quality of life, incidence of unscheduled ED re-attendance(s), hospital (re)admission(s), nursing home admission, and death. Results: A total of 133 participants (mean age 82.43 years, standard deviation = 6.89 years; 71.4% female) were recruited; 21.8% of the cohort were admitted to hospital following the index ED attendance with a significant decline in function reported at hospital discharge (Z = 2.97, p = 0.003). Incidence of 30- and 180-day unscheduled ED re-attendance was 10.5% and 24.8%, respectively. The outcome at the index ED attendance was a significant predictor of adverse outcomes whereby those who were discharged home had significantly lower odds of multiple adverse process outcomes at 30- and 180-day follow-up, and significantly higher function and health-related quality of life at 30-day follow-up. Conclusion: While this study was observational in nature, findings suggest CGA in the ED may improve outcomes by mitigating against the adverse effects of potentially avoidable hospital admissions and focusing on a longitudinal approach to healthcare delivery at the primary-secondary care interface. Future research should be underpinned by an experimental study design to address key limitations in this study.

Exploring stakeholders' experiences of comprehensive geriatric assessment in the community and out-patient settings: a qualitative evidence synthesis.

BACKGROUND: Comprehensive Geriatric Assessment (CGA) is a multidimensional interdisciplinary process that addresses an older adult's biopsychosocial capabilities to create an integrated and co-ordinated plan of care. While quantitative evidence that demonstrates the positive impacts of CGA on clinical and process outcomes has been synthesised, to date qualitative research reporting how older adults and service providers experience CGA has not been synthesised. This study aimed to systematically review and synthesise qualitative studies reporting community-dwelling older adults', caregivers' and healthcare professionals' (HCP) experiences of CGA in the primary care and out-patient (OPD) setting. METHOD: We systematically searched five electronic databases including MEDLINE, CINAHL, PsycINFO, PsycARTICLES and Social Sciences Full Text targeting qualitative or mixed methods studies that reported qualitative findings on older adults', caregivers' and HCPs' experiences of CGA in primary care or out-patient settings. There were no language or date restrictions applied to the search. The protocol was registered with the PROSPERO database (Registration: CRD42021283167). The methodological quality of the included studies was appraised using the Critical Appraisal Skills Programme checklist for qualitative research. Results were synthesised according to Noblit and Hare's seven-step approach to meta-ethnography, which involves an iterative and inductive process of data synthesis. RESULTS: Fourteen studies were included where CGA was completed in the home, general practice, out-patient setting in acute hospitals and in hybrid models across the community and hospital-based OPD settings. Synthesis generated four key themes: (1) CGA is experienced as a holistic process, (2) The home environment enhances CGA, (3) CGA in the community is enabled by a collaborative approach to care, and (4) Divergent experiences of the meaningful involvement of older adults, caregivers and family in the CGA process. CONCLUSION: Findings demonstrate that CGA in a home-based or OPD setting allows for a holistic and integrated approach to care for community-dwelling older adults while increasing patient satisfaction and accessibility of healthcare. Healthcare professionals in the community should ensure meaningful involvement of older adults and their families or caregivers in the CGA process. Further robustly designed and well reported trials of different models of community-based CGA informed by the findings of this synthesis are warranted.

Stakeholders' experiences of comprehensive geriatric assessment in an inpatient hospital setting: a qualitative systematic review and meta-ethnography.

BACKGROUND: Comprehensive geriatric assessment (CGA) is considered the gold standard approach to improving a range of outcomes for older adults living with frailty admitted to hospital. To date, research has predominantly focused on quantitative syntheses of the international evidence with limited focus on qualitative synthesis of stakeholder perspectives. This review aims to resolve this research gap by identifying and synthesising qualitative studies reporting multiple stakeholders' experiences of inpatient CGA. METHODS: A systematic search of five electronic databases was conducted. Qualitative or mixed methods studies that included qualitative findings on the experiences of CGA in an inpatient hospital setting from the perspective of healthcare professionals (HCP), older adults, and those important to them were included. The protocol was registered on PROSPERO (Registration: CRD42021283167) and the 10-item Critical Appraisal Skills Programme checklist was used to appraise the methodological quality of included studies. Results were synthesised as a meta-ethnography. RESULTS: Eleven studies, which reported on the experiences of 153 HCPs, 91 older adults and 57 caregivers were included. The studies dated from 2011 to 2021 and three key themes were identified: (1) HCPs, older adults and caregivers report conflicting views on CGA as a holistic process, (2) most HCPs, but only some older adults and caregivers view CGA goalsetting and care planning as collaborative, and (3) all stakeholders value care continuity during the transition from hospital to home but often fail to achieve it. CONCLUSION: While HCPs, older adults, and caregivers' values and ambitions related to CGA broadly align, their experiences often differ. The identified themes highlight organisational and relational factors, which positively and negatively influence CGA practices and processes in an inpatient hospital setting.

Clinical Frailty Scale as a predictor of adverse outcomes following aortic valve replacement: a systematic review and meta-analysis.

OBJECTIVES: Assessment of frailty prior to aortic valve intervention is recommended in European and North American valvular heart disease guidelines. However, there is a lack of consensus on how it is best measured. The Clinical Frailty Scale (CFS) is a well-validated measure of frailty that is relatively quick to calculate. This meta-analysis sought to examine whether the CFS predicts mortality and morbidity following either transcatheter aortic valve implantation (TAVI) or surgical aortic valve replacement (SAVR). METHODS: Nine electronic databases were searched systematically for data on clinical outcomes post-TAVI/SAVR, where patients had undergone preoperative frailty assessment using the CFS. The primary endpoint was 12-month mortality. TAVI and SAVR data were assessed and reported separately. For each individual study, the incidence of adverse outcomes was extracted according to a CFS score of 5-9 (ie, frail) versus 1-4 (ie, non-frail), with meta-analysis performed using a random effects model. RESULTS: Of 2612 records screened, nine were included in the review (five TAVI, three SAVR and one which included both interventions). Among 4923 TAVI patients, meta-analysis showed 12-month mortality rates of 19.1% for the frail cohort versus 9.8% for the non-frail cohort (RR 2.53 (1.63 to 3.95), p<0.001, I2=83%). For the smaller cohort of SAVR patients (n=454), mortality rates were 20.3% versus 3.9% for the frail and non-frail cohorts, respectively (RR 5.08 (2.31 to 11.15), p<0.001, I2=5%). CONCLUSIONS: Frailty, as determined by the CFS, was associated with an increased mortality risk in the 12 months following either TAVI or SAVR. These data would support its use in the preoperative assessment of elderly patients undergoing aortic valve interventions.

Screening instruments to predict adverse outcomes for undifferentiated older adults attending the Emergency Department: Results of SOAED prospective cohort study.

BACKGROUND: frailty screening facilitates the stratification of older adults at most risk of adverse events for urgent assessment and subsequent intervention. We assessed the validity of the Identification of Seniors at Risk (ISAR), Clinical Frailty Scale (CFS), Programme on Research for Integrating Services for the Maintenance of Autonomy seven item questionnaire (PRISMA-7) and InterRAI-ED at predicting adverse outcomes at 30 days and 6 months amongst older adults presenting to the Emergency Department (ED). METHODS: a prospective cohort study of adults ≥65 years who presented to the ED was conducted. The ISAR, CFS, PRISMA-7 and InterRAI-ED were assessed. Blinded follow-up telephone interviews were completed at 30 days and 6 months to assess the incidence of mortality, ED re-attendance, hospital readmission, functional decline and nursing home admission. The sensitivity, specificity, negative predictive value and positive predictive value of the screening tools were calculated using 2 × 2 tables. RESULTS: a total of 419 patients were recruited; 47% female with a mean age of 76.9 (Standard deviation = 7.2). The prevalence of frailty varied across the tools (CFS 57% versus InterRAI-ED 70%). At 30 days, the mortality rate was 5.1%, ED re-attendance 18.1%, hospital readmission 14%, functional decline 47.6% and nursing home admission 7.1%. All tools had a high sensitivity and positive predictive value for predicting adverse outcomes. CONCLUSION: older adults who screened positive for frailty were at significantly increased risk of experiencing an adverse outcome at 30 days with the ISAR being the most sensitive tool. We would recommend the implementation of the ISAR in the ED setting to support clinicians in identifying older adults most likely to benefit from specialised geriatric assessment and intervention.

A physiotherapy-led transition to home intervention for older adults following Emergency Department discharge: a pilot feasibility randomised controlled trial.

INTRODUCTION: Older adults frequently attend the emergency department (ED) and experience high rates of adverse outcomes following ED presentation including functional decline, ED re-presentation and unplanned hospital admission. Our aim was to evaluate the feasibility of a physiotherapy-led integrated care intervention for older adults discharged from the ED (ED-PLUS). METHODS: Older adults presenting to the ED with undifferentiated medical complaints and discharged within 72 hours were computer randomised in a ratio of 1:1:1 to deliver usual care, Comprehensive Geriatric Assessment (CGA) in the ED, or ED-PLUS (trial registration: NCT04983602). ED-PLUS is an evidence-based and stakeholder-informed intervention to bridge the care transition between the ED and community by initiating a CGA in the ED and implementing a 6-week, multi-component, self-management programme in the patient's own home. Feasibility (recruitment and retention rates) and acceptability of the programme were assessed quantitatively and qualitatively. Functional decline was examined post-intervention using the Barthel Index. All outcomes were assessed by a research nurse blinded to group allocation. RESULTS: Twenty-nine participants were recruited, indicating 97% of our recruitment target; 90% of participants completed the ED-PLUS intervention. All participants expressed positive feedback about the intervention. The incidence of functional decline at 6 weeks was 10% in the ED-PLUS group versus 70%-89% in the usual care and CGA-only groups. DISCUSSION: High adherence and retention rates were observed among participants and preliminary findings indicate a lower incidence of functional decline in the ED-PLUS group. Recruitment challenges existed in the context of COVID-19. Data collection is ongoing for 6-month outcomes.

Early supported discharge for older adults admitted to hospital with medical complaints: a systematic review and meta-analysis.

INTRODUCTION: Early supported discharge (ESD) aims to link acute and community care, allowing hospital inpatients to return home and continue to receive the necessary input from healthcare professionals that they would otherwise receive in hospital. It has been researched extensively in the stroke population, showing reduced length of stay for patients and improved functional outcomes. This systematic review aims to explore the totality of evidence for the use of ESD in an older adult population who have been hospitalised with medical complaints. METHODS: Systematic searches were conducted in MEDLINE, CINAHL, Ebsco, Cochrane Library and EMBASE. Randomised controlled trials (RCTs) and quasi-RCTs were included if they provided an ESD intervention to older adults admitted to hospital for medical complaints compared with usual inpatient care. Patient and process outcomes were explored. The Cochrane Risk of Bias Tool was used to assess methodological quality. A meta-analysis was conducted using RevMan 5.4.1. RESULTS: Five RCTs met the inclusion criteria. The quality of the trials was mixed overall, with high levels of heterogeneity. ESD demonstrated a statistically significant reduction in length of stay (MD -6.04 days, 95% CI -9.76 to -2.32) and improvements in function, cognition, and health-related quality of life, with no increased risk of long-term care admission, hospital re-admission or mortality in the ESD interventions versus usual care groups. DISCUSSION: This review demonstrates that ESD positively impacts patient and process outcomes for older adults. Further consideration should be given to exploring the experiences of those involved in ESD including older adults, family members/caregivers as well as healthcare professionals.

Early Supported Discharge for Older Adults Admitted to Hospital with Medical Complaints: A Qualitative Study Exploring the Views of Stakeholders.

Introduction: Early supported discharge (ESD) is well established as a model of health service delivery for people with stroke. Emerging evidence indicates that ESD also reduces the length of stay for older medical inpatients. There is a dearth of evidence exploring the views of stakeholders on ESD as a model of care for older medical inpatients. The overall aim of this study is to explore the views and perceptions of older adults, family carers and healthcare professionals on the potential role of ESD for older adults admitted to hospital with medical complaints. Methods: Purposeful sampling was used to recruit older adults and family carers for interview. For Healthcare Professionals (HCPs), snowball purposeful sampling was used. Phone interviews took place following a semi-structured interview guide. Focus groups were moderated by A-MM. Braun and Clarke's approach to thematic analysis was used. Ethical approval was granted by the HSE Mid-Western Area Regional Ethics Committee in November 2021 (REC Ref. 096/2021). Results: Fifteen HCPs took part across three focus groups, with six older adults and two family members participating in one-to-one interviews. Three themes were identified: 1. Pre-ESD experiences of providing and receiving older adult inpatient care, 2. Navigating discharge procedures from acute hospital services, 3. A vision for more integrated model of care and a medical ESD team. Discussion: This study provided insight into the current discharge experiences of older adult care in the acute setting, the potential role for ESD in this population and the key factors that would need to be considered for the running of an ESD service for older adults admitted to hospital with medical complaints. Conclusion: This research highlights the barriers and facilitators to ESD for older medical inpatients from the perspectives of key stakeholders. Given the adverse outcomes associated with prolonged hospital stay, these findings will help inform the development of a feasibility trial, examining patient and process outcomes for older adults admitted to hospital with medical complaints who receive an ESD intervention.

Comprehensive geriatric assessment in the emergency department: A protocol for a prospective cohort study.

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

Effectiveness of acute geriatric unit care on functional decline, clinical and process outcomes among hospitalised older adults with acute medical complaints: a systematic review and meta-analysis.

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

Early supported discharge for older adults admitted to hospital with medical complaints: a systematic review and meta-analysis.

INTRODUCTION: Early supported discharge (ESD) aims to link acute and community care, allowing hospital inpatients to return home and continue to receive the necessary input from healthcare professionals that they would otherwise receive in hospital. The concept has shown reduced length of stay and improved functional outcomes in stroke patients. This systematic review aims to explore the totality of evidence for the use of early supported discharge in older adults hospitalised with medical complaints. METHODS: A literature search of CINAHL in EBSCO, Cochrane Central Register of Controlled Trials in the Cochrane Library (CENTRAL), EMBASE and MEDLINE in EBSCO was carried out. Randomised controlled trials or quasi-randomised controlled trials were included. The Cochrane Risk of Bias Tool 2.0 was used for quality assessment. The primary outcome measure was hospital length of stay. Secondary outcomes included mortality, function, health related quality of life, hospital readmissions, long-term care admissions and cognition. A pooled meta-analysis was conducted using RevMan software 5.4.1. RESULTS: Five studies met the inclusion criteria. All studies were of some concern in terms of their risk of bias. Statistically significant effects favouring ESD interventions were only seen in terms of length of stay (REM, MD = -6.04, 95% CI -9.76 to -2.32, I2 = 90%, P = 0.001). No statistically significant effects favouring ESD interventions were established in secondary outcomes. CONCLUSION: ESD interventions can have a statistically significant impact on the length of stay of older adults admitted to hospital for medical reasons. There is a need for further higher quality research in the area, with standardised interventions and outcome measures used.

A physiotherapy-led transition to home intervention for older adults following emergency department discharge: protocol for a pilot feasibility randomised controlled trial.

BACKGROUND: Older adults frequently attend the emergency department (ED) and experience high rates of adverse outcomes following ED presentation including functional decline, ED re-presentation and unplanned hospital admission. The development of effective interventions to prevent such outcomes is a key priority for research and service provision. This paper reports a protocol designed to evaluate the feasibility of conducting a three arm randomised controlled trial (RCT) within the ED setting and in the patient's home. The interventions are comprehensive geriatric assessment (CGA), ED PLUS and usual care. METHODS: The ED PLUS pilot trial is designed as a feasibility RCT conducted in the ED and Acute Medical Assessment Unit of a university teaching hospital in the mid-west region of Ireland. We aim to recruit 30 patients, aged 65 years and over presenting to the ED with undifferentiated medical complaints and discharged within 72 h of index visit. Patients will be randomised by a computer in a ratio of 1:1:1 to deliver usual care, CGA or ED PLUS during a 6-month study period. A randomised algorithm is used to perform randomization. CGA will include a medical assessment, medication review, nursing assessment, falls assessment, assessment of mobility and stairs, transfers, personal care, activities of daily living (ADLs), social supports and baseline cognition. ED PLUS, a physiotherapist led, multidisciplinary intervention, aims to bridge the transition of care between the index visit to the ED and the community by initiating a CGA intervention in the ED and implementing a 6-week follow-up self-management programme in the patient's own home following discharge from the ED. The outcomes will be parameters of the feasibility of the intervention and trial methods and will be assessed quantitatively and qualitatively. DISCUSSION: Rising ED visits and an ageing population with chronic health issues render ED interventions to reduce adverse outcomes in older adults a research priority. This feasibility RCT will generate data and experience to inform the conduct and delivery of a definite RCT. TRIAL REGISTRATION: The trial was registered in Clinical Trials Protocols and Results System as of 21st July 2021, with registration number NCT049836020 .

Rockwood Clinical Frailty Scale as a predictor of adverse outcomes among older adults undergoing aortic valve replacement: a protocol for a systematic review.

INTRODUCTION: Frailty is associated with adverse outcomes relating to cardiac procedures. It has been proposed that frailty scoring should be included in the preoperative assessment of patients undergoing aortic valve replacement. We aim to examine the Rockwood Clinical Frailty Scale (CFS), as a predictor of adverse outcomes following aortic valve replacement. METHODS AND ANALYSIS: Prospective and retrospective cohort studies and randomised controlled trials assessing both the preoperative frailty status (as per the CFS) and incidence of adverse outcomes among older adults undergoing either surgical aortic valve replacement or transcatheter aortic valve replacement will be included. Adverse outcomes will include mortality and periprocedural complications, as well as a composite of 30-day complications. A search will be conducted from 2005 to present using a prespecified search strategy. Studies will be screened for inclusion by two reviewers, with methodological quality assessed using the Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2) tool. Relative risk ratios with 95% CIs will be generated for each outcome of interest, comparing frail with non-frail groups. Data will be plotted on forest plots where applicable. The quality of the evidence will be determined using the Grading of Recommendations, Assessment, Development and Evaluation tool. ETHICS AND DISSEMINATION: Ethical approval is not required for this study as no primary data will be collected. We will publish the review in a peer-reviewed journal on completion. PROSPERO REGISTRATION NUMBER: CRD42020213757.

Low dose hydrophilic statins are the preferred agents for females at risk of osteoporosis.

OBJECTIVES: The correlation between atherosclerosis and osteoporosis, independent of age, is clear. Multifactorial co-dependence between bone mineral density (BMD) and statin dose has been proposed. It is hypothesised that inhibition of the synthesis of cholesterol will also inhibit the synthesis of sex hormones and Vitamin D, negatively affecting BMD. This study aims to evaluate hydrophilic and non-hydrophilic statins effect on osteoporosis and analyse any possible superiority of one agent over the other within the group. METHODS: We identified 538 caucasian females who had a DEXA scan performed between 2002 and 2016 (age 60-89) in one DEXA center in Mid-West Ireland. A DEXA T-score results were analysed in the current study. Two hundred fifty females were not on statin therapy, and 323 females were on statin therapy. Females on therapy were separated into the atorvastatin group (N = 190), rosuvastatin group (N = 97), and pravastatin group (N = 36), comprising low dose and high dose groups. All anonymised data were analysed with SPSS statistical. To test the hypothesis that lower bone density is associated with high dose statins, an independent sample t-test was performed. The one-way between-groups ANOVA test was used to test the hypothesis that the BMD level depended on the statin's potency. RESULTS: Statin-naïve females have a statistically higher bone mineral density in the lumbar spine, t (538) = 3.42, p < 0.05 and in hip t (538) = 4.99, p < 0.05 than females on statin therapy. There was a significant difference in patient's age between the group, and no significant correlation was found between the patient's age and type of statin or bone density. In the atorvastatin group statistically, significant results were obtained both for spine and hip bone mineral density, t (188) = -5.61, p < 0.05 and t (188) = -3.62, p < 0.05, respectively. In the rosuvastatin group, statistically, a significant result was noted for bone mineral density of hip t (95) = -3.52, p < 0.05. This demonstrates a dose-dependency between bone mineral density and the dose of the statin. The independent between-group ANOVA yielded a statistically significant effect, F (2, 59) = 6.69, p < 0.05, η2 = 0.21 in the spine. Thus, patients on lipophilic statins had statistically lower BMD than females on hydrophilic statins. Multilinear regression analysis identified that age is not a statistically significant contributor in our analysis; however, the trend of decrease in bone mineral density with women's age is acknowledged by authors. CONCLUSIONS: The study results support the theory that bone mineral density decreases with an increase in a statin dose, and hydrophilic statins, like pravastatin, have a better metabolic profile in the lumbar spine than lipophilic agents.

Audit of inpatient acute stroke services in a university teaching hospital, 2020.

BACKGROUND: We aimed to assess stroke care at an Irish university teaching hospital and benchmark against national (Irish National Audit of Stroke 2019) and international (6th SSNAP Annual Report; American Heart Association, 2013) practice to inform a quality improvement strategy. METHODS: All patients with a HIPE discharge diagnosis of Cerebral Infarction or Cerebral Haemorrhage (1 January to 31 December 2019) were identified through both the HIPE database and the institutional Stroke Portal. RESULTS: A total of 419 patients were included (56.6% male, mean age 72). The following were comparable/better than findings from the Irish National Audit of Stroke: median duration of symptoms-3 h 6 min; 10% received thrombolysis; median door to needle time-60 min; 78.5% admitted to the stroke unit; 81.1% had a swallow assessment; in-patient mortality rate-10.5%; rates of institutionalisation-3.8%. The following areas were below the national average: overall door to imaging time-median 104 min; rate of thrombectomy-4%; 11.5% had mood screening; median length of stay- 12 days. DISCUSSION: Using national and international audit data as an institutional benchmark provides a standard with which a service can be compared to highlight areas for improvement. We identified mood screening, swallow screening, thrombectomy rates, length of stay and time to neuroimaging as key areas for development in our centre. We are currently completing a process map to determine cause, effect, and solutions, and we will implement change using PDSA methodology as per SQUIRE 2.0 guidelines. The results of the re-audit cycle for 2020 will be available in 2021 to inform our progress. Ongoing quality improvement is essential for stroke care, which is a leading cause of death and disability in Ireland.

Early supported discharge for older adults admitted to hospital with medical complaints: a protocol for a systematic review.

INTRODUCTION: Early supported discharge (ESD) aims to link acute and community care, allowing hospital inpatients to return home and continue to receive the necessary input from healthcare professionals that they would otherwise receive in hospital. The concept has been researched extensively in the stroke population, showing reduced length of stay for patients and improved functional outcomes. This systematic review aims to explore the totality of evidence for the use of ESD in an older adult population who have been hospitalised with medical complaints. METHODS: A systematic review of randomised controlled trials and quasi randomised controlled trials will be carried out in line with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Studies will be included if they provide an ESD intervention to older adults admitted to hospital for medical complaints compared with continuing inpatient care. MEDLINE, CINAHL, CENTRAL and EMBASE databases will be searched. The primary outcome measure will be length of hospital stay, secondary outcomes will include functional abilities, falls, quality of life, carer and patient satisfaction, unplanned emergency department re-presentation, unscheduled hospital readmission, nursing home admission or mortality. Titles and abstracts of studies will be screened independently by two authors. The Cochrane Risk of Bias Tool will be used independently by two reviewers to assess the methodological quality of the included studies. GRADE will be used to assess the quality of the body of evidence. A pooled meta-analysis will be conducted using RevMan software V.5.4.1, depending on the uniformity of the data. ETHICS AND DISSEMINATION: The authors will present the findings of the review to a patient and public involvement stakeholder panel of older people that has been established at the Ageing Research Centre in the University of Limerick. Formal ethical approval is not required for the review as all data collected will be secondary data and will be analysed anonymously. PROSPERO REGISTRATION NUMBER: CRD42021223112.

Effectiveness of acute geriatric unit care on functional decline and process outcomes among older adults admitted to hospital with acute medical complaints: a protocol for a systematic review.

INTRODUCTION: Older adults are clinically heterogeneous and are at increased risk of adverse outcomes during hospitalisation due to the presence of multiple comorbid conditions and reduced homoeostatic reserves. Acute geriatric units (AGUs) are units designed with their own physical location and structure, which provide care to older adults during the acute phase of illness and are underpinned by an interdisciplinary comprehensive geriatric assessment model of care. This review aims to update and synthesise the totality of evidence related to the effectiveness of AGU care on clinical and process outcomes among older adults admitted to hospital with acute medical complaints. DESIGN: Updated systematic review and meta-analysis METHODS AND ANALYSIS: MEDLINE, Cumulative Index of Nursing and Allied Health Literature, Controlled Trials in the Cochrane Library and Embase electronic databases will be systematically searched from 2008 to February 2021. Trials with a randomised design that deliver an AGU intervention to older adults admitted to hospital for acute medical complaints will be included. The primary outcome measure will be functional decline at discharge from hospital and at follow-up. Secondary outcomes will include length of stay, cost of index admission, incidence of unscheduled hospital readmission, living at home (the inverse of death or institutionalisation combined; used to describe someone who is in their own home at follow-up), mortality, cognitive function and patient satisfaction with index admission. Title and abstract screening of studies for full-text extraction will be conducted independently by two authors. The Cochrane risk of bias 2 tool will be used to assess the methodological quality of the included trials. The quality of evidence for outcomes reported will be assessed using the Grading of Recommendations Assessment, Development and Evaluations framework. A pooled meta-analysis will be conducted using Review Manager, depending on the uniformity of the data. ETHICS AND DISSEMINATION: Formal ethical approval is not required as all data collected will be secondary data and will be analysed anonymously. The authors will present the findings of the review to a patient and public involvement stakeholder panel of older adults that has been established at the Ageing Research Centre in the University of Limerick. This will enable the views and opinions of older adults to be integrated into the discussion section of the paper. PROSPERO REGISTRATION NUMBER: CRD42021237633.

The impact of frailty Screening of Older adults with muLtidisciplinary assessment of those At Risk during emergency hospital attendance on the quality, safety and cost-effectiveness of care (SOLAR): a randomised controlled trial.

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