Australian studies suggest a lack of consensus in interpreting mobility recommendations, particularly affecting the terms “supervision” and “stand by assistance”, was common and a contributing factor in patient falls. In a web-based survey, where responses were obtained from 102/150 (68%) therapists, 79/152 (52%) nurses and 97/132 (73%) doctors, we asked participants about their understanding of what requiring “supervision” or “stand-by assistance” when walking means. Responses to all questions differed significantly between the groups and the magnitude of the differences was greatest for the “supervision” questions. Asked if stand by assistance means the same as supervision, 71% of doctors, 35% of nurses and 14% of therapists said yes (p < 0.0001). There were also substantial within-group differences even among therapists. The widespread confusion regarding the interpretation of mobility terminology among and between different healthcare groups may impact on patient safety, and standardisation of mobility terminology is required.

We used a reduction in funding for a private nursing home-based Irish post-acute care scheme as a natural experiment to explore the effectiveness of this scheme in a single large general hospital. Those admitted to PAC after restriction of funding spent 6 days longer in acute care but had significantly reduced readmissions to hospital within 90 days of discharge and discharge to long-term care from the PAC facility. Our results suggest that the longer stay in acute care was beneficial for patients and led to improved outcomes and question the value of this approach to PAC. To determine the effectiveness of a post-acute care scheme by exploiting a natural experiment. We used a reduction in funding for an Irish PAC scheme based in private nursing homes as a natural experiment to explore the effectiveness of this scheme in a single large general hospital. Compared with an equivalent 3-month period in 2017 (pre-change, N = 169), those admitted to PAC in 2019 (post-change, N = 179), spent a median 6 days longer in acute care, although total duration spent in healthcare settings was the same. Compared with 2017, readmissions to hospital within 90 days of discharge (43/179 (24.0% v 58/169 (34.3%), p = 0.03) and discharge to long-term care from the PAC facility (3 (1.7%) v 14 (8.3%), p = 0.004) were significantly lower in 2019. Our results suggest that the longer stay in acute care and shorter stay in PAC was beneficial for patients and led to improved outcomes.

BACKGROUND:Hypernatraemia arises commonly in acute general medical admissions. Affected patients have a guarded prognosis with high rates of morbidity and mortality. Age-related physiology and physical/cognitive barriers to accessing water predispose older patients to developing hypernatraemia. This study sought to perform a descriptive retrospective review of hypernatraemic patients admitted under acute general medicine teams.METHODS:A retrospective cross-sectional study of a sample of acute medical in-patients with serum[sodium]>145 mmol/L was conducted. Patients were exclusively older(>69 years) and admitted from Nursing homes (NH)(41%) and non-NH pathways(59%). A comparison of management of NH /non-NH patients including clinical presentation, comorbidities, laboratory values, [sodium] monitoring, intravenous fluid regimes and patient outcomes was performed.RESULTS:In total, 102 consecutive patients (males, n=69(67.6%)) were included. Dementia and reduced mobility were more common in NH residents and admission serum [Sodium] higher (148 vs 142 mmol/L/p=0.003). Monitoring was inadequate: no routine bloods within the first 12h in >80% of patients in both groups. No patient had calculated free water deficit documented. More NH patients received correct fluid management (60% vs 33%/p%0.015). Incorrect fluid regimes occurred in both groups (38% vs 58%/p=0.070). Length of stay in discharged patients was lower in NH, (8(4-20) vs 20.5(9.8-49.3 days)/p=0.003). Time to death for NH residents was shorter (9(5.5-11.5) vs 16 (10.25-23.5) days/p=0.011).CONCLUSION:This study highlights suboptimal management of hypernatraemia. Implementation of hypernatraemia guidelines for general medical older inpatients are clearly required with mechanisms to confirm adherence. Health care workers require further education on diagnostic challenges of dehydration in older people and the importance of maintaining adequate hydration.

In December 2019, in Wuhan, China, the novel coronavirus ‘severe acute respiratory syndrome 2’ (SARS-CoV-2) was discovered as the cause of a pneumonia-like illness and subsequently named coronavirus disease 2019 (COVID-19). COVID-19 spread and is now a global pandemic. With few exceptions, countries in the Northern hemisphere have higher mortality rates from COVID-19. This may be due to an increased prevalence of older people in Northern Europe at higher risk of having cardio-pulmonary and metabolic comorbidities as well as hypovitaminosis D. With increasing age, immunosenescence and ‘inflammaging’ lead to impaired and maladaptive immune responses to SARS-CoV-2 infections, contributing to the enhanced prevalence of severe COVID-19 in older patients. The association of ageing with increased vitamin D deficiency, which is associated with cardiovascular risk factors and disease and worse prognosis in COVID-19 infection, is discussed. Considerable experimental evidence demonstrates the immuno-modulatory properties of vitamin D, in particular, its role in regulating and suppressing the inflammatory cytokine response to viral respiratory infections links the importance of vitamin D sufficiency as a potential protective factor in COVID-19. There is an urgent need for prospective randomised studies to examine whether hypovitaminosis D correlates with severity of COVID-19 disease and the actual benefit of repletion. Moreover, given what has been described as a ‘pandemic of vitamin D deficiency’, especially in Europe, and in the context of the SARS-CoV-2 contagion, the authors support the call for public health doctors and physicians, with support from Governments, to prioritise and strengthen recommendations on vitamin D intake and supplementation.

Abstract Blood cultures should be performed in non‐specifically unwell older adults following nonspecific presentations. Prompt diagnosis and commencement of targeted antimicrobial therapy are essential in older patients with A. defectiva IE.

Severe systemic vasculitis presenting in an 80 year old female involving a presentation with recurrent pyrexia, eosinophilia, mononeuritis multiplex against a background of late onset asthma, consistent with eosinophilic vasculitis with angiitis is described. Despite appropriate management with resolution of systemic symptoms, she failed to return to baseline functionality. Systemic vasculitis is rare in this population cohort, but it is important to consider as it is treatable albeit with a guarded outlook for full neurological recovery.

Extreme weather events including recently experienced prolonged heatwaves are predicted to increase in frequency and intensity as a result of climate change. Vulnerable groups, and particularly older persons, are at increased risk of heat-related illness and mortality. Multimodal interventions that incorporate community, primary and secondary care programmes are required. Social programmes such as early warning systems, regional heat plans and community-led initiatives that specifically target the isolated, dependent older person are protective. Establishing clear and effective communication on health promotion and preventative measures is the key. Energy-efficient building design and eco-city planning are vital to reduce the impact of heatwaves at both a population and individual level. Anticipatory strategies should be adopted to ensure ample access to fluids, target barriers to increase oral intake and allow early identification of intercurrent illness, along with regular medication reviews. Prompt management of risk factors for the development of heat-related illness and treatment of complications such as heat stroke and cardiovascular events are keys to reducing the negative health impact of extreme heat in at-risk populations. Morbidity and mortality in heatwaves should be preventable. Evidence-based interventions are available to mitigate and prevent the negative health impact of extreme heat and should be implemented in all residential settings.

Background: Approximately 1 billion people worldwide have Vitamin D deficiency. The aim of this study was to compare Vitamin D status and serum 25-hydroxyvitamin D (25(OH)D) concentrations among adults sampled in the community, in outpatient clinics, as hospital inpatients and in nursing homes in the West of Ireland. The secondary aim was to determine the associations between length of hospital stay (inpatients) at the time of serum 25(OH)D sampling and Vitamin D status. Methods: A cross-sectional study was carried out. Patients who had serum 25(OH)D analysis carried out in Galway University Hospitals (January 2011-December 2015) were identified following interrogation of the electronic laboratory data system. Baseline demographics, location, and date of sample collection were recorded. Vitamin D deficiency was defined as a serum 25(OH)D concentration <25 nmol/L. Results: In total, 24,302 patient samples were eligible for inclusion: community 15,319; outpatient clinics 6,371; inpatients 2,339; and nursing home residents 273. Vitamin D deficiency was more common in nursing home residents than inpatients, or those sampled in outpatient clinics or in the community (42% vs 37% vs 17% vs 13%; p < .001). Inpatients sampled further into their hospital stay (>= 3 days) had greater Vitamin D deficiency than inpatients sampled on 0-2 days (p = .007). Season (p < .001), sex (p < .001), and age (p < .001) were associated with 25(OH)D concentrations. Vitamin D deficiency was more common in Winter/Spring, in males, and in those aged >= 80 years. Conclusions: Nursing home residents and inpatients are at the highest risk for Vitamin D deficiency. Season, sex, age, and day of hospital stay on which serum 25(OH)D concentrations were sampled were associated with Vitamin D status.

A 73 year old bachelor had multiple presentations to secondary and tertiary care facilities. His symptoms were varied, including headache, falls, marked weight loss and dysarthria. He was investigated as a possible stroke but with subsequent major functional decline. Following extensive investigations and after four months in residential care, major depressive disorder (MDD) was diagnosed. A physical diagnostic label, side effects of, and poor response to, medications complicated the clinical course. Ultimately he was successfully treated with electroconvulsive therapy (ECT). Despite response to ECT, the protracted course contributed to the institutionalisation of the patient. This case highlights the importance of early, accurate diagnosis and effective treatment of depression in older patients.

Background/Aims Readability of written material is essential for effective communication. The readability of 40 healthcare policies published by the NHS or the Health Service Executive were compared and contrasted against 40 newspaper articles regarding healthcare from the Irish Times or the Irish Mirror. Methods Readability was measured using the Flesch reading ease score and the standardised measure of gobbledygook grade. Findings Flesch and the standardised measure of gobbledygook were significantly worse in health policies than in newspaper articles: none of the healthcare policies met a minimum standard of a Flesch score of 50 or more (P<0.0001); 60% of health policies and no newspaper article had a standardised measure of gobbledygook grade of 13 or more, suggesting a need for a university level education for comprehension (P<0.0001). Conclusions The readability of healthcare policies in Britain and Ireland is poor. A stronger emphasis on the use of plain language is needed.

Abstract Background Orthogeriatric services have been shown to improve quality of care for older patients post hip fracture and have an impact on length of stay (LOS), both acutely and in the rehab setting(1) but other key performance indicators (KPIs) have not been examined in detail. Methods Data was prospectively collected on all hip fracture patients seen by the Orthogeriatric service from Aug 2018-Feb 2019 and was retrospectively compared with patients admitted with hip fractures from Aug 2017-Feb 2018. We examined KPIs including LOS on the orthopaedic ward, rehab admissions, rehab LOS, new nursing home (NH) admissions. We compared the proportions discharged directly home instead of to convalescence, and conducted a preliminary cost benefit analysis. Results Similar numbers of patients were seen in each time period (n=146 v n=139). Mean reduction in LOS on the orthopedic ward was 3.5 days (15.5 days vs 19 days). The proportion of patients admitted to rehabilitation increased from 8.8% to 17.5% (p = 0.02). Patients got to rehabilitation faster and for those patients who availed of rehabilitation they had significantly shorter total length of stays (51.1 days vs 71.6 days, p=0.029). Fewer patients went to convalescence. Although not statistically significant there was a trend towards an increased proportion of patients discharged directly home (32.7% to 43.6%) and less new nursing home admissions (6.8% vs 8.4%). A cost benefit analysis incorporating shortened acute and rehab LOS and a reduction in spending on convalescence resulted in a projected saving of €480,390 over a six month period. Conclusion Introduction of OrthoGeriatric services has improved care for older people with hip fractures and has resulted in positive improvements to KPIs, resulting in meaningful improvements in clinical outcomes for patients in a cost effective manner. Monies saved should be redirected into further developing orthogeriatric services.

Abstract Background As illustrated in a cross-sectional study at a Galway hospital, delirium is common with a 29% incidence in hospitalised older adults. This is associated with adverse clinical outcomes. Guidelines support specialised environments in the management of delirium to reduce morbidity and mortality. A delirium bay is a specialised unit with a standardised approach to comprehensive geriatric assessment for older adults with delirium. Methods We aimed to improve the care of the delirious older adult within our existing framework by creating a ‘Delirium Bay’ utilising the principles of quality improvement. An interdisciplinary team completed ‘Quality Improvement in Action’ training run by the Royal College of Physicians of Ireland from October 2018-March 2019. This involved defining our problem statement and ‘SMART’ aim (Specific, Measurable, Achievable, Realistic, Timely). Measures for improvement included the rate of adverse events, the duration of episodes, patient/family satisfaction, and the use of one-to-one supervision of patients. Results Stakeholder analysis included nursing, catering, multidisciplinary and healthcare assistance staff. We liaised with hospital management regarding restructuring staffing and maintenance regarding environmental changes. An educational programme on delirium was delivered.. We collected baseline data utilising the ‘Plan, Do, Study, Act’ Model and utilised this to guide our changes. A Standard Operating Procedures document was drafted. We opened our four-bedded delirium bay on 11th March 2019. Preliminary data indicates improved management of delirium with preserved continence, reduced risk of falls and high patient and family satisfaction levels. Interventions have been implemented with minimal funding and infrastructural changes. Staffing reconfiguration involved standardised planning replacing a pre-existing ad-hoc system. Conclusion Delirium in hospitalised older adults is common and associated with increased morbidity and mortality, yet amenable to interventions. We demonstrate that a delirium bay can be set up with a quality improvement approach. Pilot data suggests improved management of these patients within the framework of existing resources. Further collection of data on clinical outcomes is ongoing.

Extremes of temperature are likely to increase in frequency associated with climate change. Older patients are particularly vulnerable to the effects of heat with excess mortality well documented in this population. Age-associated neurohormonal changes particularly affecting the renin angiotensin aldosterone system (RAAS), alterations in thermoregulatory mechanisms, changes in renal function and body composition render older persons vulnerable to dehydration, renal failure, heat stroke and increased mortality. Barriers to diagnosis and recognition of dehydration and renal failure include the absence of reliable clinical signs and cost-effective diagnostic tools. Regularly used medications also impact on physiological responses to excess heat as well as interfering with the recognition and management of dehydration during heat waves. In view of the above, anticipatory measures should be instituted ideally prior to the onset of heat waves to minimise morbidity and mortality for older people during periods of excess heat.

Delirium derives from the Latin “de lira,” or “off the tracks.” We have noted a tendency for students and healthcare professionals to misspell delirium as “delerium.” We examined if this error also occurs in the academic literature. Using Google Scholar, which indexes the full text of up to 400 million documents, including most peer-reviewed journals and books,1, 2 we examined (on November 10, 2019) the annual relative frequency of the exact words “delirium” and “delerium” in the English-language academic literature since 1900. (Quotation marks were included in the search terms to evade automatic spelling corrections.) Citations (where the misspelling arose in the reference list) and references to the band Delerium (a “new-age ambient electronic musical duo” from Canada3) were excluded. We also examined whether misspellings were more likely in the context of references to delirium tremens. The correct and incorrect spellings coexist in some texts and, using the advanced search option in Google Scholar, the number of texts where “delerium” and “delirium” both occurred was also noted. We used PubMed to find articles containing “delerium” from 1946 (when records begin) to 2019 with sufficient data recorded to allow the country of origin to be examined. We examined the main specialty of journals including “delerium” and the proportion of uses from countries with English as an official language.4 Overall, Google Scholar searches for “delerium” and “delirium” yielded 3024 and 344 842 results, respectively, and “delerium” accounted for 0.9% of the total results. The relative frequency of “delerium” was greatest between 1970 and 1989, with a peak misspelling rate of 4.9% in 1975 (Figure 1). In contrast, the misspelling rate was less than 0.5% from 1900 to 1929 and since 2014. Of 3024 texts containing “delerium,” 1010 (33.4%) also contained the correct spelling. Overall, the misspelling rate for “delerium tremens” vs “delirium tremens” (2.9%) was significantly higher than for “delerium” vs “delirium” without “tremens” (1.2%) (χ2 = 21.2; P < .0001). (The Belgian beer Delirium Tremens was spelled correctly in all four search results.) “Delerium” occurred in the title of 12 articles. Other egregious examples included the use of “delerium” once in a British guideline document on delirium,5 twice in a primer on the spelling of medical terms,6 and four times in a seminal article on cognitive assessment.7 Of 1488 PubMed articles from 1946 to 2019 containing “delerium” and with sufficient data for analysis, 1189 (79.9%) came from countries with English as an official language; 219 (14.7%) were from psychiatry journals, 162 (10.9%) were from general medical journals, 126 (8.5%) were from anesthetic journals, 42 (2.8%) were from neurology journals, and 33 (2.2%) were from geriatric medical journals. To put these findings in context, a review of a random selection of 500 articles from the same time span where delirium was spelled correctly indicted that 73.2% of articles came from countries with English as an official language, 23.0% were in psychiatry journals, 16.5% were in geriatric medicine journals, 9.4% were in general medical journals, 3.7% were in neurology journals, and 2.2% were in anesthetic journals. Misspelling of delirium was relatively common in the 1970s and 1980s, reaching almost 5% in 1975. While now much less common, it is nevertheless surprising to find “delerium” surviving, not only peer review, editing, and proofreading, but also modern word processor software to make it into publication. One criticism of Google Scholar is that it does not screen out low-quality journals where the quality of peer review and editing may be poor. However, many of the examples we found came from widely respected journals. Although few misspellings were found in geriatric medical journals, the frequency in psychiatric journals was surprisingly high and misspellings seem disproportionately high in anesthetic journals. Phonetic spelling due to the pronunciation of delirium as del-EE-rium may explain some errors. Often with nonspecialist colleagues, one is so pleased to find, given its previous neglect, a diagnosis of delirium being made that it seems churlish to complain about the spelling. For writers, though, misspelling a common term will not impress reviewers or, if published, readers. The most widely studied, and potentially misleading, misspelling of a medical term is use of “pruritis” instead of “pruritus.”8-10 Pruritus is misspelled in almost 5% of articles on the topic in PubMed, even in recent years, with a real risk that significant articles might be missed in literature searches or that “pruritis” might “overrun the correct form.”10 “Delerium” is not as significant a problem as “pruritis.” Nevertheless, our results suggest that, in addition to being sometimes misdiagnosed and mismanaged, delirium is also prone to being misspelled. The authors report no conflicts of interest. All authors contributed to study design, data collection, and writing of the article. None.

Abstract Background Older patients post hip fracture benefit from specialist orthogeriatric care. Best practice tariffs incentivising compliance with the Irish Hip Fracture Standards (IHFS) have been introduced in Ireland(1). We compared levels of compliance to IHFS before and after introduction of a dedicated orthogeriatric service in a tertiary referral hospital. We also hypothesized that improved continuity of care by regular orthogeriatric review would result in less general medical consults to medical teams. We looked at the number of inpatient consults sent for each time period and compared the number of general medical consults sought by orthopaedic teams for similar time periods. Methods Data was prospectively collected on all hip fracture patients seen by the orthogeriatric service from Aug 2018-Feb 2019 and was retrospectively compared with patients admitted with hip fractures from Aug 2017-Feb2018. Results Similar numbers of patients were seen in each time period (n=146 v n=139) with similar age profiles (81.8 vs 79.6 years). Improvements were seen in all of the six IHFS. The most significant improvements were an increase from 31.2% to 96.5% in the proportion of patients seen by a Geriatrician, and an increase from 7.4% to 98.5% in those who had a formal falls assessment. Fewer patients required medical team consults after the service began (32.2% vs 46.8%, p=0.016). The resultant total number of consults sent fell from 120 consults to 59 consults. Conclusion Introduction of an orthogeriatric service has substantially improved compliance with IHFS. The reduction in the number of medical consults requested by orthopaedic teams reflects the improved quality and continuity of care for these patients.

What are the indications and outcomes of home visits and assessments by geriatricians?

Abstract Background Hypernatraemia is a surrogate marker of morbidity and mortality, particularly in the older person.(1) Met Eireann defines a heatwave as 5 consecutive days >25°C. HSE guidelines outline preventative strategies for community-dwelling adults and inpatients during heatwaves.(2) Our objective was to compare the prevalence of hypernatraemia (Na>145mmol/l), in biochemical samples during the heatwave of 2018 to the same period in 2017 Methods A retrospective cross-sectional study using patient demographics, biochemical data from Laboratory Information System and meteorological data from Met Éireann was performed. A ten-day period from 24thJune to 3rdJuly was assessed in 2017 and 2018. Patients aged >65 with at least one biochemical sample were included. Only the first sample from each patient was included. Predictor variables of age, gender and source of sample were measured. Results Maximum air temperatures were higher in 2018 than 2017 (mean 27 v 16.8°C, p<0.0001). Hypernatraemia had 3.6% prevalence (66/1840 samples) during the heatwave of 2018 in comparison to 1.4% prevalence (23/1593 samples) in 2017. This corresponds to a prevalence ratio of 2.5 in heatwave 2018 compared with 2017. In 2018 hypernatraemic samples: 56%(n=37) were male, mean age was 75 with 71(n=47) General Practitioner(GP) samples,12%(n=8) inpatients and 17%(n=11) from outpatient department(OPD). In 2017 hypernatraemic samples: 30%(n=7) were male, mean age was 75 and 74%(n=17) were GP samples,17%(n=4) were inpatients, 9%(n=2) from OPD. The sources of total samples (regardless of Na level) were 63% GP, 7% inpatients and 30% outpatients. Conclusion Hypernatraemia was 2.5 times more prevalent during the heatwave in 2018 than the previous year in patients aged over 65. Hypernatraemia is more prevalent in GP and inpatients taking into account the usual distribution of samples by source. Current guidelines are either not being adhered to or ineffective, a matter which merits further evaluation.

An 88-year-old female nursing home resident attended the endocrinology department for routine follow-up of primary hyperparathyroidism. Diagnosed 9 years earlier, she was deemed unsuitable for surgery and treated medically with cinacalcet, a calcimimetic that acts by allosteric activation of the calcium-sensing receptor reducing parathyroid hormone (PTH)6 secretion by the parathyroid gland (1). Several years before her current outpatient attendance, she was diagnosed with vitamin D deficiency (2) \[serum 25-hydroxyvitamin D (25(OH)D), 10.4 ng/mL (26 nmol/L)\] (Table 1). The Endocrine Society Clinical Practice Guideline for the management of vitamin D deficiency considers a 25(OH)D concentration of ≥30 ng/mL (≥75 nmol/L) optimal for bone health (2). Vitamin D supplementation was recommended. Cholecalciferol (vitamin D3) was prescribed (800 IU/day). At clinic, she was medically stable, well hydrated, and normotensive. Her estimated glomerular filtration rate (eGFR) was 30 mL/min/1.73 m2, indicative of impaired renal function. The eGFR estimation [calculated using the Chronic Kidney Disease–Epidemiology Collaboration (CKD-EPI) formula] met the National Kidney Foundation criteria for chronic kidney disease (CKD) stage 3b, or moderate to severe loss of kidney function (3). Measurement of ionized calcium is not routinely available in the outpatient setting and was not requested in this case. However, she was normocalcemic with an adjusted calcium of 9.3 mg/dL (2.33 mmol/L) [reference …

There are many risk factors for Vitamin D deficiency. This study aimed to compare the Vitamin D status and serum 25(OH)D concentrations of adults living in an urban area to adults living in a rural area in the West of Ireland (latitude 53.27° North). A cross-sectional retrospective analysis of clinical records was performed. Following interrogation of the electronic laboratory information system, individuals who had serum 25(OH)D concentrations measured at Galway University Hospitals between January 2011 and December 2015 were identified. Clinical demographics, setting and date of sampling were recorded. In total, 17,590 patients (urban n = 4,824; rural n = 12,766) were eligible for inclusion. Serum 25(OH)D concentrations were lower among rural compared to urban dwellers irrespective of season (spring p < 0.001, summer p = 0.009, autumn p = 0.002, winter p < 0.001). There was a significant difference in Vitamin D status between urban and rural dwellers in three of the four seasons: spring- deficiency: 16%-v-23%, insufficiency: 39%-v-43%, sufficiency: 45%-v-35% (p < 0.001); autumn- deficiency: 11%-v-10%, insufficiency: 30%-v-35%, sufficiency: 59%-v-56% (p = 0.01); winter- deficiency: 23%-v-25%, insufficiency: 35%-v-42%, sufficiency: 41%-v-33% (p < 0.001). Serum 25(OH)D concentrations were higher and the prevalence of deficiency lower in urban/rural females compared to urban/rural males (p < 0.001). Serum 25(OH)D concentrations increased sequentially from the 18-39 year age group to the 60-69 year age group in both urban (p < 0.001) and rural (p < 0.001) dwellers and then decreased progressively as age increased to ≥90 years. The odds of Vitamin D deficiency increased with age, lower daily sunshine hours, male gender, rural address and season.