Abstract Background Urinary incontinence (UI) is an under-reported and treatable condition, associated with reduced quality of life. The Integrated Care programme of Older Persons (ICPOP) supports people with complex care needs in their home. There is no available research on the rate of UI among the ICPOP population. This study aimed to assess UI in this group. Methods A convenience sample of 100 patient records selected randomly from an ICPOP serving approximately 30,000 people from 2017 to present were retrospectively reviewed; including patients charts, Comprehensive Geriatric Assessments (CGAs) and outpatient letters. As part of the CGA each person was assessed for UI on domiciliary visit. Irish geriatric medicine trainees were surveyed to assess their self-reported confidence assessing and treating UI. Results Of the 100 patients CGAs reviewed, 62% were female. 11% had UI reported on their referral to ICPOP. 56% reported UI during their CGA. Only 18% of those with UI had UI generated on to their problem list. Of those patients with UI, polypharmacy (≥5 medications) was noted in 89%. 77% of those with UI were on a medication associated with worsening UI, while only 18% of those with UI were on a treating medication for UI. 25% had their UI assessed at clinic, including 7% who were referred onwards to urology for management of their UI. 80% of geriatric medicine trainees said that they did not feel confident managing UI and 100% said they would like to receive further teaching on UI. Conclusion CGA is an excellent method for identifying UI. This data suggests that UI is more prevalent among the ICPOP as compared with an inpatient population and the general population in the same age group. Further specialist teaching is needed to improve trainee confidence in this area.

Abstract Background Transcutaneous Vagus Nerve Stimulation (tVNS) is a neuromodulation technique which uses a handheld device to peripherally stimulate the afferent vagus nerve. tVNS has shown promise in augmenting memory in cognitively unimpaired populations but data in cognitively impaired populations is sparse. This investigation is timely as new therapeutic strategies to treat Mild Cognitive Impairment (MCI) are urgently needed. Methods VINCI-ad is an investigator-led, single-blind, sham-controlled crossover pilot study assessing the effects of tVNS in amnestic MCI. All participants have MCI (Clinical-Dementia Rating Scale—Global Score of 0.5) with amnestic neuropsychological profile (RBANS delayed memory index <85). Participants are randomised over 3 study visits to baseline (no stimulation) active stimulation (at the CC of left ear) or sham stimulation (earlobe). Cognitive tests include Face-Name Association Task (FNAT), Sustained Attention Response Test (SART) and Sea Hero Quest Navigation Test (SHQ) among others. Results Interim data analysis of 28 participants (planned recruitment n = 40) is presented (mean age 71.5 (range 55–85), 17 male, RBANS DMI 73.3 ± 11.1). CSF ad biomarkers were positive for 75% (21/28) (AB-42460.4 pg/ml (± 83.3 pg/ml) and p-tau181 82.5 pg/ml [± 53.2 pg/ml]) and 78% (22/28) of participants had a Charleston Comorbidity Index of ≥3. Mean tVNS stimulation time pre-cognitive assessments was 21.2 minutes, with mean amplitude setting during active stimulation of 2.5 mA (1.8–4.5) and sham of 2.0 mA (0.9–3.1). During FNAT, active tVNS had no effect on facial recognition or reaction times, however recall accuracy was significantly improved (69.2% ±3.13) compared to baseline (44.7% ±3.51 p = 0.016) and sham (50.1% ±3.28 p = 0.021) and during active tVNS spatial navigation (38.94 sec [±1.68]) was quicker than baseline (51.49 sec (±3.2) p = 0.0164) and sham (51.9 sec (±3.15) p = 0 0.0038). We noted no significant improvements in SART or other cognitive tests performance during tVNS. Conclusion tVNS may be a useful complementary tool to augment spatial and associative memory in MCI. Further larger studies are needed to delineate precise settings in this population.

Abstract Background People living with mild cognitive symptoms often require clarity on the underlying aetiology of their symptoms, and with the advent of disease modifying therapies for Alzheimer’s Disease (AD), establishing diagnostic accuracy for amyloid and tau pathology in AD will become more clinically relevant. CSF biomarker analysis via Lumbar Puncture (LP) is the most accurate and cost-effective means of establishing AD pathology. This study aimed to assess memory clinic patients’ tolerance of LP as a diagnostic tool in the work-up of memory symptoms. Methods A consecutive sample of patients offered CSF analysis as part of their diagnostic plan in a tertiary memory service of a University Teaching Hospital were included. After clinician discussion, an LP for AD biomarker detection is offered to all patients with amnestic/non-amnestic mild cognitive impairment, or those with atypical motor-cognitive symptoms in this service. Results 119 patients offered an LP from 2019-2020 were contacted, fifty-four (45%) of whom participated in this study. The average age was 70.1 (±7.5) years, 50% female. Forty-two (42/54, 78%) had an LP performed. More women declined an LP than men (8/12, 66%). Almost all of those who had an LP, (38/42, 90.4%) thought it yielded useful information and would recommend it for others. Side effects included mild back pain relieved with simple analgesia (11/42, 26%) and headache (3/42, 7%). There were no incidences of neurological sequelae or requirements for dural patch. Of the 12/54 (22%) who declined CSF analysis; reasons for same were pre-existing back pain (3/12, 25%), needle-phobia (3/12, 25%), and only 2/12, (16%) declined because they did not wish to know the results of the investigation. Conclusion This study highlights high levels of acceptance of CSF analysis when offered as part of routine care, with infrequent side effects. Most patients found the clinical information yielded was useful.

Abstract Introduction Lack of home ownership is associated higher rates of mental and physical ill-health and death1. According to longitudinal data in Ireland, 92% of persons aged 75 and over own their homes outright with approximately 8% living in rented accommodation2. We sought to compare characteristics of a cohort of patients open to our Integrated Care for Older Persons (ICOP) team with this national Irish dataset. Method A convenience sample of 50 patients reviewed by the ICOP team in a University Teaching Hospital was analysed. Data was anonymised and stored via encrypted key. Analysis was performed using SPSS v.27. Results The average age was 82.5 (±8.1) with 70% women in the sample. There was a lower prevalence of home ownership in this group of patients than the national norm (66% vs 92%) ie 34% were living in rental accommodation, majority Local Authorities. Those living in Local Authority accommodation had lower overall time spent in full time education than those who owned their own home (9.3 ± 3.1 vs 11.5 ± 3.3 p = 0.013), they were more likely to require external assistance with finances (54.5% v 88.2% p = 0.026) and less likely to have a Will (63.6% vs 35.2% p = NS) or EPOA (33.3% vs 23.5% p = 0.053) established. There was no significant difference in age, CFS, MMSE, Waterlow or polypharmacy rates between these groups. Discussion This report highlights a divergence between community dwelling older adults referred to ICOP teams and national standard data. Targeted social work interventions should be operationalised to assist financially vulnerable older adults. 1: Marmot M, Geddes I, Bloomer E, Allen J, Goldblatt P. The health impacts of cold homes and fuel poverty. London: Friends of the Earth. 2011. 2: Orr, J, Scarlett S, Donoghue, O, McGarrigle, C. Housing conditions of Ireland’s older population. Implications for physical and mental health, 2016. Available from https://tilda.tcd.ie/publications/reports/pdf/Report_HousingConditions.pdf

Abstract Introduction People with mild cognitive symptoms often require diagnostic clarity and with the advent of disease modifying therapies for Alzheimer’s disease (ad), establishing diagnostic accuracy for amyloid and tau pathology in ad will become more clinically relevant. CSF biomarker analysis via lumbar puncture (LP) is the most accurate and cost-effective means of establishing ad pathology. Despite their clinical validation, few centres offer LP biomarker analysis, frequently citing patient intolerance and reluctance as factors. This study aimed to assess memory clinic patients’ tolerance of LP as a diagnostic tool in the work-up of memory symptoms. Method A consecutive sample of patients offered CSF analysis as part of their diagnostic plan in a tertiary memory service of a University Teaching Hospital were included. After clinician discussion, an LP for ad biomarker detection is offered to all patients with amnestic/non-amnestic mild cognitive impairment, or those with atypical motor-cognitive symptoms in this service. Results 119 patients offered an LP from 2019–2020 were contacted, fifty-four (45%) of whom participated in this study. The average age was 70.1 (±7.5) years, 50% female. Forty-two (42/54, 78%) had an LP performed. More women declined an LP than men (8/12, 66%). Almost all of those who had an LP, (38/42, 90.4%) thought it yielded useful information. Side effects included mild back pain relieved with simple analgesia (11/42, 26%) and headache (3/42, 7%). There were no incidences of neurological sequelae or requirements for dural patch. Of the 12/54 (22%) who declined CSF analysis; reasons included pre-existing back pain (3/12, 25%), needle phobia (3/12, 25%), and only 2/12, (16%) declined because they did not wish to know the results. Conclusion This study highlights high levels of acceptance of CSF analysis when offered as part of routine care, with infrequent side effects. Most patients found the clinical information yielded was useful.

Abstract Background Impaired mobility is associated with incident cognitive impairment and dementia. However, the complex bi-directional temporal relationships between subtle impairments in neuropsychological performance, mobility trajectories and falls is poorly understood. Methods Using data from the Trinity, Ulster Department of Agriculture (TUDA/TUDA5+) study, we evaluated cross-sectional and longitudinal relationships between impaired mobility, neuropsychological performance and falls using regression models adjusted for important clinical confounders. Older adults with potential cognitive impairment (Mini-Mental State Examination score <25) were excluded. Detailed neuropsychological assessment was performed using the RBANS (Repeatable Battery for Neuropsychological Assessment) and FAB (Frontal Assessment Battery). Impaired mobility was assessed using Irish population-specific age/sex/height-specific Timed-Up-and-Go (TUG) cut-offs. Results Of 4,103 participants (72.9 ± 7.9 years; 67.4% female), just under one-fifth (17.5%) met criteria for impaired mobility. Older adults with impaired mobility had significantly greater likelihood of impaired neuropsychological performance, in particular for language (OR 1.77; 1.35-2.31; p<0.001) and attention (OR 1.69; 1.37-2.08; p<0.001) domains. In 953 participants followed for a median 5.2 (IQR: 4.83-7.26) years, impaired mobility at baseline significantly predicted incident impairment in immediate memory (OR 2.56; 1.33-4.95; p<0.001). Stronger relationships were seen for impaired neuropsychological performance predicting mobility decline rather than impaired mobility predicting cognitive decline (all p<0.001). Both impaired mobility and neuropsychological performance were associated with incident falls, particularly for impairments in executive function and attention (all p<0.001). Impaired mobility in isolation had poor performance as a sole test to predict incident cognitive impairment (AUC: 0.55-0.65). Conclusion In both cross-sectional and longitudinal analyses, impaired mobility is associated with subtle impairments in neuropsychological performance. Whilst impaired neuropsychological performance was a greater predictor of impaired mobility rather than vice versa, our findings highlight the complex relationship between mobility and cognitive trajectories in older adults, emphasising the need for comprehensive cognitive and falls assessment in those presenting with new-onset subtle impairments in mobility and cognition.

Abstract Background An important consequence of population ageing has been the increasing number of older adults who live alone. According to TILDA data, older adults with the lowest levels of education tend to experience most social isolation and there is a strong association between living alone and loneliness. We sought to compare the cohort of patients open to the Integrated Care for Older Persons (ICPOP) team in a University Teaching Hospital serving a community area of approx. 300,000 population, to this national dataset. Methods A convenience sample of 174 patients who underwent comprehensive geriatric assessment via domiciliary visit between July 2021-May 2022 by was analysed. Data was anonymised and analysis was performed using SPSS v.27. Results The average age was 81.5 (±8.1) with 63% women in the sample. Eighty-five older adults i.e. 49% of the sample either lived alone or spent more than 21 hours alone per 24-hour period. Compared to those who live with someone, those who lived alone had higher rates of likely depression as determined by Geriatric Depression Score (6.6 vs 4.8 p=0.007). They were also likely to have less educational attainment, as determined by years spent in full time education (11.81 vs 10.42 42 p= 0.0016) and those living alone had overall less central heating in their homes than those not living alone (64/85 vs 81/89 p=0.0109). There were no significant differences in the rates of polypharmacy, falls, dementia and home ownership between groups. There were higher levels of frailty in the group living with someone than those living alone as determined by Clinical Frailty Scale (6.14 vs 5.23 p<0.001). Conclusion A high proportion of patients seen by our ICPOP team live alone and have complex care needs that require an innovative, multidisciplinary approach. Financial vulnerability in this group is likely to compound isolation and loneliness.

Abstract Background Approximately 64,000 people live with dementia in Ireland with expected increases to 150,000 by 2045. Best practice recommends that patients benefit from timely diagnosis. Whilst the presence of cognitive impairment should prompt early referral for diagnostic clarity, patients frequently present with well-established symptoms. In order to understand this phenomenon it is important to understand the way in which symptoms are recognised by the person, companions and casual observers. Methods A chart review was carried out on a convenience sample of patients (n=61) diagnosed with dementia where scores were available from Clinical Dementia Rating Scale (CDR) and AD8. Data extracted included global scores and answers to direct questions regarding symptom recognition by patient and companion. Diagnosis was confirmed using the Electronic Patient Record. Results Mean age was 75 (range 57-87). Diagnostic breakdown comprised: Alzheimer Dementia (AD) in 67% (n=41), mixed AD/Vascular Dementia (VaD) in 19.6% (n=12); behavioural variant Fronterotemporal Dementia (bvFTD) in 1.6% (n=1), Dementia with Lewey Bodies (DLB) in 1.6% (n=1), Primary Progressive Aphasia (PPA) in 4.9% (n=3), Primary Parkinson’s Dementia (PPD) in 1.6% (n=1) and VaD in 1.6% (n=1). Average CDR Global Scale was 1.0 and average AD8 score 6/8. Family noticed symptoms of dementia an average of 12 months longer than the person themself. The incidence of anosognosia was 19% (n=12) and associated with a diagnosis of AD (91.6 %, n=11). Where anosognosia existed, symptoms of memory loss had been identified by family up to 60 months before diagnosis, with average time to recognition of 24 months. For 75% of this anosognosia group, family reported indiscernible symptoms on casual inspection (n=9). Conclusion Where symptoms of memory loss go unrecognised by patients and casual inspection, family may notice changes for up to five years. It is important to educate and empower the public regarding the benefit of a timely dementia diagnosis. Education should focus on supporting family to navigate sensitive conversations in the event of anosognosia and explore ways in which they might encourage timely review.

Abstract Introduction The Motoric Cognitive Risk Syndrome has highlighted the link between cognitive and motor performance, and the associated incremental higher risk of developing dementia. There is considerable debate regarding what aspects of cognition (working memory, executive function, attention) are most associated with gait changes. This study investigates the relationship between mobility scores and cognitive profiles in individuals with Mild Cognitive Impairment (MCI) specifically with regard to executive performance and amnestic/non-amnestic profiles. Method Participants diagnosed with MCI, (Clinical Dementia Rating scale global score of ≤0.5, sum of boxes score ≤ 4.0), attending a regional specialist memory service had a three-meter Timed Up and Go (TUG) gait assessment and multi-domain neuropsychiatric assessment undertaken. Amnestic neuropsychiatric profile was defined as Repeatable Battery for the Assessment of Neuropsychological Status (RBANS) delayed memory subset score < 1SD i.e. ≤16th centile below norm for age/education. Executive function performance was assessed using the Executive Interview (EXIT-25) where higher scores reflect poorer executive performance. Results Data was reviewed for 161 patients with MCI; 53% (86/161) women. 80% (129/161) had an amnestic neuropsychiatric profile, mean age 73.8 ± 7.2 (51–94). 20% (32/161) had non-amnestic MCI, mean age 74 ± 7.07 (60–87). There was no significant difference in TUG results between amnestic and non-amnestic MCI patients (11.2 ± 3.3 vs 10.7 ± 3.1 p = NS). There was a significant increase in TUG values with worsening executive function performance [EXIT-25 score 0–9 (88/161) mean TUG = 10.5 ± 3.3 seconds vs EXIT-25 score 10–14 (43/161) mean TUG =11.9 ± 2.8 seconds vs EXIT-25 score 15–25 (30/161) mean TUG = 12.1 ± 3.9 seconds; p = 0.021] which persisted after controlling for age, gender and other relevant cofactors. Discussion Reflective of the importance of frontal lobe integration to the respective tasks, subtle differences in gait performance are associated with executive function performance regardless of predominant amnestic or non-amnestic MCI profile.

Abstract Introduction Fear of falling (FOF) is associated with a range of adverse health outcomes including increased risk of falls1, and more rapid decline in physical and cognitive function2. We aim to determine the prevalence of FOF amongst ambulatory community dwelling older adults attending an Age-Related Day Hospital, and to describe it’s associations with cognition, mood disorders, frailty and mobility measures. Methods A retrospective chart review was conducted on 50 patients attending the Day Hospital. Baseline demographics collected include comorbidities, medications, and falls history. Objective mobility measurements include the Timed Up and Go (TUG) test and grip strength. Patients were divided into two groups based on their answer to the question, “Are you afraid of falling?” Differences between groups were compared using chi-squared test. Results The average age of Day Hospital attendees was 85 (SD X). 62% were male. Three quarters of patients experienced a recent fall, and half admitted to FOF. Those with FOF were more likely to be dependent in personal care (27% vs 16%, p = 0.15) and use a walking aid (69% vs 58%, p = 0.02). They were also more likely to be prescribed psychoactive medications (53% vs 45%, p = 0.42), and have a diagnosis of anxiety (4% vs 0%, p = 0.03). Conclusions Both having a falls history and FOF is prevalent in our Day Hospital population. FOF is associated with high physiological risk of falling, increased dependency, and anxiety. Standardization of mobility measures and potential screening for cognitive and mood disorders in patients with FOF will aid in further development of targeted interventions.

Abstract Background CSF (cerebrospinal fluid) biomarkers [amyloid- beta-42 (AB-42), phosphorylated tau (p-tau)] are increasingly used in supporting clinical diagnosis of Alzheimer’s Disease (AD). Both elevated CSF p-tau and reduced AB-42 are necessary for pathological diagnosis of AD. The aim of this study is to apply recent international recommendations to patients attending a regional specialist memory service, evaluating consistency with detailed clinical, neuroimaging, and neuropsychological ad-phenotype profiling. Methods All patients age < 80, with mild/subjective cognitive and/or atypical neurobehavioral symptoms, non-significant vascular burden on neuroimaging, and without contraindication to lumbar puncture are offered CSF analysis. Clinical diagnosis was ascribed on the basis of specialist multi-disciplinary consensus review. We undertook a case-note and database retrospective review of those who had ad-biomarker CSF analysis, collecting demographic, clinical phenotype diagnosis, and neuropsychological performance. Data was extracted and analysed using SPSS v.25. Results One-hundred-sixteen patients underwent CSF biomarker testing. Forty-nine patients (42%) had positive AD-CSF biomarkers, 41/49 (84%) of whom presented with common ad phenotypes (Amnestic/Logopenic PPA/PCA). Twenty patients (17%) had negative ad-CSF (elevated AB-42, and low p-tau) studies, and half of those (10/20, 50%) had a consistent atypical non-AD clinical phenotype. Patients with negative ad-CSF were younger and tended to have non-amnestic neuropsychological profile. Therefore there was a mismatch in 18/69 (26%) people in these groups with definitive +/− ad biomarker results and ad/Non-ad clinical phenotype. A further forty seven (40%) patients had indeterminate CSF studies with one or other changes in AB-42 or p-tau, but not both as is necessary for definitive diagnosis. Conclusion Incorporation of CSF biomarker analysis is quickly being established as a key component of the neurocognitive/dementia diagnostic pathway. However, there are challenges and limitations arising as they are applied in clinical settings, and further research is warranted to explore variations between pathological results and clinical phenotype presentation.

Abstract Background Aducanumab, the first monoclonal antibody directed against amyloid beta peptide has recently been licensed for use by the FDA for treatment of patients with mild cognitive impairment (MCI) due to Alzheimer’s Disease (ad) or mild ad dementia. Appropriate use criteria (AUC) for Aducanumab have recently been released. In light of these AUC, the aim of this study was to review patients in our specialist memory service with positive CSF biomarkers for ad [low amyloid- beta-42 (AB-42), high phosphorylated tau (p-tau)] to assess their hypothetical eligibility for Aducanumab therapy. Methods Retrospective database analysis was undertaken of patients with positive (high p-tau, low AB-42) ad-biomarker CSF analysis. Demographic, neuropsychological performance, neuro-radiological, laboratory, and clinical phenotype diagnosis data were reviewed at time of CSF analysis to determine hypothetical eligibility for Aducanumab. Data was extracted and analysed using SPSS v.25. Results Forty-nine patients had positive ad-CSF biomarkers, 41/49 (84%) of whom presented with common ad phenotypes. 28/49 (57%) were male. Mean patient age was 71.2 (±5.9) RBANS delayed memory index score mean was 80.2 (±14.5) and mean EXIT-25 scores were 13.2 (±6.7). 63.2% (31/49) patients met eligibility criteria for Aducanumab therapy by AUC guidelines. 12.2% (6/49) wouldn’t have qualified due to abnormal laboratory findings and 14.2% (7/49) due to MMSE <21 or MoCA <17. Two patients would not have qualified due to underlying medical conditions and two were prescribed therapeutic anticoagulation. However by FDA guidelines, a further 30.6% (15/49) of patients may have been unsuitable due to global Clinical Dementia Rating Scale ≥0.5. Conclusion AUC for Aducanumab address some of the controversial aspects in its licencing. This report highlights the presence of patients eligible for Aducanumab therapy should a European licence be granted, and the need to develop a system readiness and capacity to deliver this and other emerging disease-modifying ad therapies.

Abstract Background It is now well established that VRF place immense burden on cognition, including white matter changes, decreased cerebral perfusion and neuro-inflammation. An innovative Brain Health Clinic (BHC) was developed aligned to a specialist memory service to educate people at risk of or living with mild cognitive symptoms, about positive brain health and subsequently design a ‘Personalised Prevention Plan’ to optimise cognitive ageing. The aim of this study is to report the opportunities identified and addressed to mitigate vascular risk-related cognitive decline in people attending the Brain Health Clinic. Methods Modifiable VRF (including HbA1c, cholesterol, Body Mass Index (BMI), smoking, alcohol intake and hypertension) were examined in people who attended the BHC between October 2019 and July 2021. In addition to VRFs, sleep, physical activity, sensory, social, and psychological measures are measured and reported to individuals. The VRF values were examined based on current guidelines from the European Society of Cardiology (2018). Results Forty-five people (mean age 72.6 years, 62.2% females) were included. The average number of modifiable VRF’s per person was 3, and a total of 119 VRF’s were identified overall. One patient had six modifiable VRF’s identified, and 2/45 had none. The most common VRF was elevated BMI present in 33/45 (73.3%). 12/45 (27%) patients were ex-smokers, while 5/45 (11%) still smoked. 5/45 (11%) consumed excess alcohol. 15/45 (33.3%) had elevated cholesterol. 29/45 (64.4%) had elevated systolic blood pressure. Of these, 10/45 (22.2%) were known but poorly-controlled and 19/45 (42.2%) were identified de novo. Similarly, only 1/45 (2.2%) had known diabetes but poorly-controlled, while 9/45 (20.0%) had impaired glucose tolerance identified de novo. Conclusion The BHC aligned to a memory service provides an opportunity to identify modifiable VRF for declining cognition, and supports people in addressing these by sign-posting to relevant services.