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Frailty is a common clinical syndrome that predisposes older adults to an increased risk of adverse health outcomes. With population aging, this will become an increasing challenge for the healthcare services; therefore, different models of healthcare training and provision are required to address these increasing demands. In Ireland, the National Clinical Programme for Older People (NCPOP) has partnered with The Irish Longitudinal Study on Ageing (TILDA) to deliver the National Frailty Education Programme. This demonstrates an innovative way in which evidence-based longitudinal research can be translated into clinical education and practice to improve patient care, following a Knowledge to Action (KTA) process. To the authors' knowledge, it is the first time that a longitudinal research study such as TILDA has employed such methods of translation and therefore, this collaboration could serve as an international model of translation and implementation for frailty and other areas of clinical priority.

Background : Frailty is associated with a prodromal stage called pre-frailty, a potentially reversible and highly prevalent intermediate state before frailty becomes established. Despite being widely-used in the literature and increasingly in clinical practice, it is poorly understood. Objective : To establish consensus on the construct and approaches to diagnose and manage pre-frailty. Methods : We conducted a modified (electronic, two-round) Delphi consensus study. The questionnaire included statements concerning the concept, aspects and causes, types, mechanism, assessment, consequences, prevention and management of pre-frailty. Qualitative and quantitative analysis methods were employed. An agreement level of 70% was applied. Results : Twenty-three experts with different backgrounds from 12 countries participated. In total 70 statements were circulated in Round 1. Of these, 52.8% were accepted. Following comments, 51 statements were re-circulated in Round 2 and 92.1% were accepted. It was agreed that physical and non-physical factors including psychological and social capacity are involved in the development of pre-frailty, potentially adversely affecting health and health-related quality of life. Experts considered pre-frailty to be an age-associated multi-factorial, multi-dimensional, and non-linear process that does not inevitably lead to frailty. It can be reversed or attenuated by targeted interventions. Brief, feasible, and validated tools and multidimensional assessment are recommended to identify pre-frailty. Conclusions : Consensus suggests that pre-frailty lies along the frailty continuum. It is a multidimensional risk-state associated with one or more of physical impairment, cognitive decline, nutritional deficiencies and socioeconomic disadvantages, predisposing to the development of frailty. More research is needed to agree an operational definition and optimal management strategies.

Background The Royal College of Physicians of Ireland and the National Clinical Programme for Older People conducted a national survey of Specialist Geriatric Services (SGS) in 2014. The survey was repeated in 2018-2019 period to collect data on the resources available for the care of older people attending hospitals and associated communities in Ireland. Methods Participants were geriatrician leads or proxies in each hospital in Ireland. Questions based on the 2014 survey were updated to include frailty and dementia-delirium specific questions. Data were collected between September 2018 and April 2019 using an electronic survey. Comments from open-ended questions were analysed using qualitative analysis methods. Results In total, 20 fully complete and 18 incomplete responses were received. Most complete responses were from model 3 or 4 hospitals (n= 14/20). Less than half (47%) reported having a dedicated specialist geriatric ward in their institution. Half (50%) reported currently developing an integrated plan for services for frail older people with complex care needs. Barriers to managing frailty that were identified included limited access to funding and staffing. 82% reported that their group/area/unit/department engaged in case-finding for frailty. The most commonly used frailty-specific screening tools were the CFS (n=9), VIP (n=6), FRAIL scale (n=4), and PRISMA-7 (n=3). A National Frailty Education Programme governance structure was operational in 9/20 sites. Half (50%) reported that their hospital has an integrated pathway for people with dementia and/or delirium, although (82%) stated that their hospital does not formally screen all older people for cognitive impairment in the ED/AMAU, and does not formally screen people at risk for delirium on wards on a daily basis (100%). Conclusion Limited staffing and resources were reported for many aspects of SGS in Ireland. Although frailty and dementia-delirium are recognised as priority areas, there is need for standardised assessment and screening approaches.

Background Frailty can contribute to poor clinical outcomes including disability, illness, and death. Intervention against frailty may help older adults maintain overall health and independence, and a growing body of recent literature describes interventions specifically targeting frailty. The diversity of measurement constructs and intervention types raises a challenge for those seeking to identify best-practice strategies to manage frailty in the primary care setting, therefore this study aimed to quantify the relative effectiveness of reported interventions. Methods PubMed, CINAHL, Cochrane Register of Controlled Trials, and PEDr databases were interrogated, and reference lists of retrieved studies were also examined. For comparisons, articles were grouped by intervention and meta-analysis using the random effects model was performed wherever two or more studies examined the same outcome measure using similar interventions. Results 29 studies with a total of 4430 participants were included in this series of meta-analyses. Interventions included exercise (alone or plus nutrition supplementation or education), nutrition supplementation alone, comprehensive geriatric assessment (CGA), and hormone supplementation. Outcome measures included frailty (Fried criteria), physical performance, leg strength, and grip strength, among others. Interventions varied in relative effectiveness. When comparing studies that assessed frailty status using Fried’s criteria, exercise alone (n=3, RR=0.63 (CI 0.47–0.85), I2=0%) appeared effective versus control in improving status, as did exercise plus nutritional supplementation (n=2, RR=0.62 (CI 0.48–0.79), I2=0%), and exercise plus nutritional education (n=3, RR=0.69 (CI 0.58–0.82), I2=0%). CGA also appeared effective in improving frailty status (n=3, RR=0.77 (CI 0.64–0.93), I2=0%). Conclusion This series of meta-analyses indicates that several intervention types are associated with positive improvements in frailty status, and frailty-associated indicators. These results agree with previous findings, and represent an up-to-date quantitative synthesis of available literature on primary care interventions addressing frailty among older adults.

Background Older people living in nursing homes (NHs) are among the most frail and vulnerable in our community. Over the last 5 years, a review of our local NH admission database revealed a 7% increase in the number of unscheduled hospital attendances from NHs (1015 in 2012/13 vs 1435 in 2016/17). Additionally we have seen an increase in the number of NH residents experiencing ≥2 unscheduled re-admissions within one year (21.1% in 2012/13 vs 30.45% in 2016/17). Our aim was to examine the proportion of patients from NHs who died within 24 hours of presentation, prompting a review of methods that could prevent inappropriate hospital transfers and promoting dignified and comfortable end of life care. Methods A prospective database was collected between 01/01/2016 - 31/12/2017. This recorded all emergency admissions of older people from NHs recording length of stay, readmission rates and mortality. The data was retrospectively analysed, looking specifically at patients who died in hospital ≤ 24 hours Results Of 1435 ED admissions, 49 patients (3.4%) died in hospital ≤ 24 hours after presentation. Of these, 31 patients (61%) died in palliative care suites. 8 patients (16.3%) died in the ED. Conclusion A small number of NH residents presenting to our hospital died within 24 hours. A large proportion of these patients died in a palliative care suite, suggesting poor prognosis was identified rapidly after presentation. We wonder if some of these hospital transfers were avoidable and could certain patients have experienced less disruptive deaths in their NHs? Advanced Care Planning can be difficult for all involved. However, it plays an essential role in ensuring people receive the right care, at the right time, in the right place, from the right team. We support the collaborative roles of a palliative care CNS or Geriatric ANP, and integration with NH Outreach services, to facilitate early decision-making and promote better end of life care.

Background Intracerebral haemorrhage (ICH) accounts for approximately 20% of all strokes and is a leading cause of disability and mortality. The distribution of the ICH(Lobar v Deep) may be explained by the two major aetiologies of ICH, Cerebral Amyloid Angiopathy (CAA) versus hypertensive (HBP) respectively. The aim of our study was to look at outcomes of lobar versus deep ICH stroke patients. Methods We analyzed data of all ICH’s admitted in 2018 using SPSS. Demography, classification of haemorrhage, hypertension, atrial fibrillation (AF) and anticoagulation history, pre and post stroke Rankin and subsequent outcome were analyzed. Results 373 acute strokes were admitted of which 66(18%) were ICH. Mean age was 73yrs (52-93) and 50% were male. On neuroradiology imaging, 40(60%) were lobar and 26(39%) were deep. Lobar haemorrhages were significantly more likely to be older (p = 0.0001) however, there was no significant difference in pre-stroke Rankin. Post stroke the lobar haemorrhages had both a worse outcome from disability (p = 0.005) and mortality (p = 0.0001). 17(26%) patients with a ICH also had AF with 94% were on an oral anticoagulant(OAC).17.5% of the lobar bleeds were on an OAC versus 36% of the deep ICH. Of the lobar bleeds on OAC none died versus 4 of the deep ICH (p = .001). In total, 48(72%) of patients had a history of hypertension, but only 34(51%) were on HBP medication on admission. Conclusion There were a greater proportion of patients with lobar versus deep bleeds in our cohort which may be due to the older population in our area. Mortality and disability was far greater in the lobar cohort. None of the lobar bleeds with AF who were on OAC died in contrast to the deep ICH patients. This may suggest that more aggressive hypertensive treatment is required in this subpopulation.

Background The Integrated Care Programme for Older People has supported the development of integrated care services at pioneer sites in Ireland, each developed to meet local needs. Patient Reported Experience Measures (PREMs have been used to evaluate user experience in intermediate care in the United Kingdom. This project aimed to evaluate client experience of a domiciliary based, multidisciplinary, integrated care service. Methods A qualitative audit of the experience of clients of the Older Persons’ Integrated Care Team (OPICT) was performed. This project was undertaken in conjunction with the Royal College of Physicians of Ireland’s Quality Improvement in Action programme. A feedback questionnaire was designed and distributed to consecutively discharged clients from OPICT from February 2019, providing qualitative assessment for service improvement. The results of feedback from the first questionnaire design are reported. Results Twenty OPICT clients received a feedback questionnaire following their final interaction with the OPICT service. Eighteen clients responded: 11 males and 9 females with mean age 81 years. Two male clients did not return the questionnaire (mean age 86 years). In terms of the treatment and advice provided by the team, all 18 clients agreed with statements that they were involved in decision making, treatment was explained in a way that they could understand and was effective and met their needs. All clients responding indicated that they were listened to, treated with dignity and had confidence and trust in the team. All 18 respondents would recommend the service to another older person. Respondents also provided individual comments which all indicated satisfaction with the service. Conclusion Older people accessing integrated care delivered in their home reported a positive experience and can provide important information on further service development.

Background Informal care is undoubtedly a vital to dementia care in Ireland. To date, little research has been carried out exploring the burden experienced by informal carers of people with mild to moderate dementia. The main aim of this quantitative study is to explore the burden experienced by caregivers, relative to dementia severity. The secondary aim is to identify risk factors which may be contributing to this perceived burden. Methods Fifty-two people with dementia(PwD) and their informal caregivers were recruited by convenience sampling, and data was collected as part of the ‘CHESS’ research trial. Data was collected during baseline assessments between April 2017 and September 2018. Dementia disease severity was measured using the Mini-Mental State Examination(MMSE), the Neuro-Psychiatric Inventory Questionnaire(NPI-Q), and the Disability Assessment for Dementia(DAD) scale. These outcome measures were then compared to levels of caregiver burden, which was measured using the Zarit-Burden Interview(ZBI). These comparisons were completed using Spearman’s correlations. Socio-demographic characteristics of both the carer and PwD were then compared to caregiver burden, using Mann-Whitney and Kruskal-Wallis tests. Results The results of the study substantiate that behavioural disturbances(p=0.000) and increasing disability(p=0.022) of the PwD are associated with higher carer burden. The study also identified potential non-modifiable risk factors for increased carer burden. These include spousal relationship to the PwD(p=0.096), older caregiver age(p=0.208), female carer gender(p=0.083) and higher educational attainment of the caregiver(p=0.035). Some of these differ from factors influencing burden in other international populations. Conclusion This preliminary analysis is the first study of its kind to be carried out in Ireland. It sheds light on potential predictors and risk factors for carer burden and shows need for future research to be carried out in this area. Such research would help to clarify interventions which could minimise the prevalence of the burden experienced by informal caregivers.

Background In Ireland, the Assisted Decision-Making (ADM) (Capacity) Act and emerging Codes of Practice provide a legal framework for Healthcare Professionals (HCPs) to enable ADM for patients with impaired capacity. ADM ensures that a person’s will and preference is at the centre of all decisions related to their care. This study conducted a realist evaluation and developed a Programme Theory (PT) to highlight how ADM for older people can be operationalised within an Acute Care (AC) context. Methods Key informants with interest in ADM informed this evaluation. Interviews were conducted in two Acute Care (AC) sites with multidisciplinary HCPs working within older person services (n=20). Interviews with informants that recently received care within an AC setting involved older people (n=3) people with dementia (n=4) and family carers (n=5). Ethnographic observations from AC multidisciplinary team meetings also informed the review. The framework that guided the qualitative analysis was from a PT informed by literature on ADM implementation in healthcare (O'Donnell, Ní Shé, Davies et al.2018). Results The refined PT is supported by credible evidence that is informed by authentic experiences of decision making support in the AC setting. Validation groups (n=4) with the key informants verified the PT. Three mechanisms were identified as a positive climate and receptive environment for the adoption of formal ADM. These are: AC settings that adopt inter-professional accountability and shared responsibility for patient care that is guided by a clear policy process. Acute care and practice that is informed by a shared commitment to person-centred care and shared decision making. HCPs that operate within an AC setting where organisational learning informs practice through inter-professional training, mentorship and peer support. Conclusion Involving stakeholders in PT development enhances the utility, feasibility and applicability of the results. This PT provides a framework for those planning ADM implementation within the AC settings.

Background The Integrated Care Programme for Older People has supported the development of integrated care services at pioneer sites in Ireland. Key to integrated care is embracing a move away from hospital based assessment and therapy provision, especially for re-ablement and home support care planning, to assessment in the home: “discharge to assess”. Methods The Older Persons’ Integrated Care Team (OPICT) provides a targeted, multidisciplinary domiciliary-based re-ablement programme of care to people aged 65 years and older. Using PDSA methodology for service improvement, the addition of home support provided by healthcare assistants (HCAs) was introduced and evaluated. Data was collected prospectively on baseline service user demographics, service activity and outcome measures. HCA delivered home support services were introduced in November 2017. This study contains data for the period November 2017 to March 2019. Results Since May 2017, OPICT has provided 266 episodes of domiciliary-based re-ablement to 248 clients, with a further 90 clients assessed but ineligible. The median age of clients was 84 years (8% 65-74 years; 49% 75-84 years; 37% 85-94 years; 6% 95 years and older). The majority of clients were female (58.5%), with low dependency (Barthel score 16 to 19) and classified as vulnerable to moderately frail based on the Clinical Frailty Scale (scores 4 to 6). Of 215 eligible clients, 122 received a total of 1293 hours of healthcare assistant delivered care. Flexibility in the availability of carers to meet demand and willingness of HCAs to embrace a more diverse role were important learning points. Conclusion The “discharge to assess” model of integrated care for older people can be achieved in the Irish healthcare setting, with access to flexible HCA delivered home support a key element.

Background Older people living in Nursing Homes (NHs) represent a frail and vulnerable group. With multiple co-morbidities they are at increased risk of acute health deterioration prompting urgent hospital transfer. Our aim was to examine the outcomes for nursing home residents following unscheduled hospital attendances. Methods A prospective database was collected between 1 January 2016 and 31 December 2017. This recorded all emergency admissions of older people from NHs. The data was retrospectively analysed. Outcomes assessed included: length of stay (LOS), 30-day readmission rates, number of readmissions within one year and mortality. We compared these results to similar data collected in 2012-13. Results Over a two-year period, there were 1435 hospital admissions; a 7% increase from 1015 in 2012. 60% were female and 40% male with a mean age of 84.7 years. The average LOS was 9.58 days (vs 11.2 days in 2012-13). The 30-day readmission rate was 9.8% (vs 14% in 2012-13). 30.45% of all patients went on to have 2 or more readmissions within one year, an increase from 21.1% in 2012-13. The total in-hospital mortality was 14%. Conclusion An increase in the number of NH residents presenting to an acute hospital over the past 5 years was observed. Despite this, we have seen reductions in average LOS and 30 day readmission rates. There is, however, an increasing number of recurrent admissions (≥ 2) to the hospital within one year. These results highlight the importance of an integrated approach to patient care; from the primary care team, hospital team, palliative and community care services. We believe the continued development of Nursing Home Outreach Programmes and community liaison services, combined with the evolving role of the in-hospital Geriatric ANP and liaison palliative care team, will help reduce inappropriate ED referrals and encourage advanced care planning.

Background Frailty is associated with a prodromal stage called pre-frailty, a potentially reversible and highly prevalent condition before frailty becomes established. Despite this, there is no widely accepted definition of pre-frailty to support its early identification and management. This study applied an international consensus approach to define and better understand pre-frailty. Methods A modified electronic two-round Delphi Consensus study was conducted. In all, 23 experts from 12 countries with different backgrounds participated. The questionnaire was developed following a systematic literature review. An online consensus meeting was conducted with eight Delphi participants and two external experts. Qualitative and quantitative methods were employed for data analysis. An agreement level of 70% was applied for accepting statements. Results A total of 71 statements were circulated in Round 1. Of these, 52.8% were accepted. Fifty-one statements were re-circulated in Round 2, of which 92.1% were accepted. The online consensus meeting produced a consensus statement describing the concept, multi-factorial nature, and mechanism of pre-frailty as well as assessment, prevention and management approaches. All experts agreed that physical and non-physical factors such as psychological and social capacity are involved in the development of pre-frailty, potentially adversely affecting health and health-related quality of life outcomes. Practitioners should regard pre-frailty as a multi-factorial, multi-dimensional, and non-linear process that does not inevitably lead to frailty. It might be reversed or attenuated by targeted interventions. Brief, feasible and validated tools are recommended for opportunistic screening or case-finding followed by confirmation with multi-dimensional assessment. Conclusion It is difficult to establish consensus on one compact definition of pre-frailty, which is a multi-dimensional concept not only associated with physical impairment, but also with cognitive, nutritional, socioeconomic and other aspects of frailty. However, it may be too early to agree on an operational definition of pre-frailty since none yet exists for frailty.

Background Ireland’s Assisted Decision-Making (Capacity) Act 2015 breaks from traditional views of capacity to consider the uniqueness of each decision with relation to topic, time and place for those with impaired or fluctuating capacity. It has yet to be commenced, however codes of practice and educational strategies are in development to support health and social care professionals (HSCPs) to practice in accordance with the Act. This study set out to examine barriers and enablers to the adoption of assisted decision making (ADM) involving older people in acute hospitals from multiple perspectives. It describes a pre-implementation formative evaluation informed by the perspectives of relevant stakeholders in ADM practice. Methods In total, 12 key informant interviews and two validation groups were conducted with family carers and older people with and without a diagnosis of dementia in two acute hospitals. In addition, 20 interviews and two validation groups were conducted with HSCPs. Interviews focused on contextual characteristics as well as barriers and enablers of ADM. Results Barriers and enablers included supporting capacity through adopting a functional approach, the physical environment where decision-making takes place, meeting information and support needs, methods of communication, upholding will and preferences, relationships and trust. Time and timing were consistently identified as a critical factor. HSCPs also highlighted the need for specialised education and training on ADM practice. Conclusion The issues identified around ADM will inform the development of a serious discussion game on acute care scenarios, which will be deployed for awareness raising and educational purposes. Findings will also help focus attention on how those working within complex health systems and organisations can practically implement changes to practice in line with ADM legislation.

Background The incidence of dementia has reached epidemic levels, both globally and here in Ireland. Many adults with dementia living in the community remain inactive with some also suffering from sleep disturbances. There is evidence to suggest sufficient exercise and sleep can have a positive influence on cognition also. In this study, we explore: physical activity levels sleep patterns, of community dwelling people with dementia and explore the association they have on: cognitive functionquality of life. Methods Each individual was assigned a Withings-Go wrist-watch to wear over a period of 3 months which measured their: daily steps takentime in deep sleeptime in light sleep.total sleep each night MMSE and DEM QoL were used to measure cognitive function and quality of life respectively. Assessed at: baseline & after 3 months. This data was coded and analysed using Microsoft Excel and SPSS. Results An RHO = 0.617 was detected between the DEMQoL scores and the mean steps taken over the last 5 days of data collection. An RHO = -0.127 was detected between steps and sleep time which implied that as steps increased, sleep time was reduced with the opposite being applicable also. The average total sleep time for the sample was 08:03:00 (hh:mm:ss) while the average daily steps taken by the group was 3,266 steps. Conclusion People with dementia living in the community were found to be physically inactive. This study has displayed that increased levels of physical activity can show signs of an improved self-perceived quality of life. This study was a correlational study and causality was not investigated. The association we have identified may provide support and foundation for future studies that explore causal components.

Background Dementia is a neurodegenerative chronic condition characterized by a progressive decline in a person’s memory, thinking, learning skills, and the ability to perform activities of daily living. Previous research has indicated that there are many types of technology interventions available in the literature that have shown promising results in improving disease progression, disease management, and the well-being of people with dementia (PwD) and their informal caregiver, thus facilitating dementia care and living. Technology-driven home care interventions, such as Connected Health (CH), could offer a convenient and low-cost alternative to traditional home care, providing an informal caregiver with the support they may need at home while caring for a PwD, improving their physical and mental well-being. Objective This study aimed (1) to create a multidimensional profile for evaluating the well-being progression of the PwD–informal caregiver dyad for a year during their use of a CH platform, designed for monitoring PwD and supporting their informal caregivers at home, and (2) to conduct a long-term follow-up using the proposed well-being profile at different time-interval evaluations. Methods The PwD–informal caregiver well-being profile was created based on the World Health Organization International Classification of Functioning considering the following outcomes: functional status, cognitive status, and quality of life for the PwD and mental well-being, sleeping quality, and burden for the informal caregiver. Over a year, comprehensive assessments of these outcomes were conducted every 3 months to evaluate the well-being of PwD–informal caregivers, using international and standardized validated questionnaires. Participants’ demographic information was analyzed using descriptive statistics and presented as means and SDs. A nonparametric Friedman test was used to analyze the outcome changes and the progression in the PwD-caregiver dyads and to determine if those changes were statistically significant. Results There were no significant changes in the well-being of PwD or their caregivers over the year of follow-up, with the majority of the PwD-caregiver dyads remaining stable. The only instances in which significant changes were observed were the functional status in the PwD and sleep quality in their caregivers. In each of these measures, post hoc pairwise comparisons did not indicate that the changes observed were related to the deployment of the CH platform. Conclusions The follow-up of this population of PwD and their informal caregivers has shown that disease progression and physical and mental well-being do not change significantly during the time, being a slow and gradual process. The well-being profile created to analyze the potential impact of the CH platform on the PwD–informal caregiver dyad well-being, once validated, could be used as a future tool to conduct the same analyses with other CH technologies for this population. International Registered Report Identifier (IRRID) RR2-10.2196/13280

Background: The National Integrated Care Programme for Older People (NICPOP), formerly NCPOP aims to support older people to live well in their homes by developing primary and secondary care services for older people, especially those with complex needs. The programme develops integrated intermediate care which traverses both hospital and community settings through multidisciplinary and interagency teams. This team-based approach to the integration of health services is a novel innovation in Irish health service delivery and will require, over time, a shift in cultures of care to allow for the development of competencies for inter-professional collaboration across the care continuum. The ECLECTIC project will develop an implementation framework for achieving, maintaining and monitoring competencies for interprofessional collaboration among multi-disciplinary teams charged with delivering care for older people across the continuum from acute to community settings. Design: The ECLECTIC research design has been developed in collaboration with the NICPOP. In phase one of the project, a co-design team will collaborate to define and shape competencies for interprofessional collaboration. Phase two will involve the delivery of a collective leadership intervention over a 10-month period with multidisciplinary professionals working with older people across two geographical regions (Mullingar/Midlands and Beaumont/Dublin North). Each group will comprise of members of two multidisciplinary teams charged with coordinating and delivering care to older people across the continuum of acute to community care. Observations of collaborative inter-professional working will take place before, during, and after intervention. In phase three of the study, analysis of the interview and observation data will be presented to the co-design team in order to develop an implementation framework for future teams. Discussion: The co-design process will develop core competencies and performance indicators for collaborative interprofessional working. The resulting implementation framework will be implemented nationally as part of the NICPOP.

Background Although not an inevitable part of ageing, frailty is an increasingly common condition in older people. Frail older patients are particularly vulnerable to the adverse effects of hospitalisation, including deconditioning, immobility and loss of independence (Chong et al, J Am Med Dir Assoc 18:638.e7–638.e11, 2017). The ‘Systematic Approach to improving care for Frail older patients’ (SAFE) study co-designed, with public and patient representatives, quality improvement initiatives aimed at enhancing the delivery of care to frail older patients within an acute hospital setting. This paper describes quality improvement initiatives which resulted from a co-design process aiming to improve service delivery in the acute setting for frail older people. These improvement initiatives were aligned to five priority areas identified by patients and public representatives. Methods The co-design work was supported by four pillars of effective and meaningful public and patient representative (PPR) involvement in health research (Bombard et al, Implement Sci 13:98, 2018; Black et al, J Health Serv Res Policy 23:158–67, 2018). These pillars were: research environment and receptive contexts; expectations and role clarity; support for participation and inclusive representation and; commitment to the value of co-learning involving institutional leadership. Results Five priority areas were identified by the co-design team for targeted quality improvement initiatives: Collaboration along the integrated care continuum; continence care; improved mobility; access to food and hydration and improved patient information. These priority areas and the responding quality improvement initiatives are discussed in relation to patient-centred outcomes for enhanced care delivery for frail older people in an acute hospital setting. Conclusions The co-design approach to quality improvement places patient-centred outcomes such as dignity, identity, respectful communication as well as independence as key drivers for implementation. Enhanced inter-personal communication was consistently emphasised by the co-design team and much of the quality improvement initiatives target more effective, respectful and clear communication between healthcare personnel and patients. Measurement and evaluation of these patient-centred outcomes, while challenging, should be prioritised in the implementation of quality improvement initiatives. Adequate resourcing and administrative commitment pose the greatest challenges to the sustainability of the interventions developed along the SAFE pathways. The inclusion of organisational leadership in the co-design and implementation teams is a critical factor in the success of interventions targeting service delivery and quality improvement.

Introduction: The best interventions to address frailty among older adults have not yet been fully defined, and the diversity of interventions and outcome measures makes this process challenging. Consequently, there is a lack of guidance for clinicians and researchers regarding which interventions are most likely to help older persons remain robust and independent. This paper uses meta-analysis to assess effectiveness of primary care interventions for physical frailty among community-dwelling adults aged 60+ and provides an up-to-date synthesis of literature in this area. Methods: PubMed, CINAHL, Cochrane Register of Controlled Trials, and PEDro databases were searched, and RCTs, controlled pilot studies, or trials with similar study designs addressing frailty in the primary care setting among persons aged 60+ were chosen. Study data was abstracted following PRISMA guidelines, then meta-analysis was performed using the random effects model. Results: 31 studies with a total of 4794 participants were analysed. Interventions using predominantly resistance-based exercise and nutrition supplementation seemed to improve frailty status versus control (RR = 0.62 (CI 0.48-0.79), I2 = 0%). Exercise plus nutrition education also reduced frailty (RR = 0.69 (CI 0.58-0.82), I2 = 0%). Exercise alone seemed effective in reducing frailty (RR = 0.63 (CI 0.47-0.84), I2 = 0%) and improving physical performance (RR = 0.43 (CI 0.18-0.67), I2 = 0%). Exercise alone also appeared superior to control in improving gait speed (SMD = 0.36 (CI 0.10-0.61, I2 = 74%), leg strength (SMD = 0.61 (CI 0.09-1.13), I2 = 87%), and grip strength (Mean Difference = 1.08 (CI 0.02-2.15), I2 = 71%) though a high degree of heterogeneity was observed. Comprehensive geriatric assessment (RR = 0.77 (CI 0.64-0.93), I2 = 0%) also seemed superior to control in reducing frailty. Conclusion: Exercise alone or with nutrition supplementation or education, and comprehensive geriatric assessment, may reduce physical frailty. Individual-level factors and health systems resource availability will likely determine configuration of future interventions.

Background Dementia disease is a chronic condition that leads a person with dementia (PwD) into a state of progressive deterioration and a greater dependence in performing their activities of daily living (ADL). It is believed nowadays that PwDs and their informal caregivers can have a better life when provided with the appropriate services and support. Connected Health (CH) is a new technology-enabled model of chronic care delivery where the stakeholders are connected through a health portal, ensuring continuity and efficient flow of information. CH has demonstrated promising results regarding supporting informal home care and Aging in Place, and it has been increasingly considered by researchers and health care providers as a method for dementia home care management. Objective This study aims to describe the development and implementation protocol of a CH platform system to support informal caregivers of PwDs at home. Methods This is a longitudinal observational mixed methods study where quantitative and qualitative data will be combined for determining the utility of the CH platform for dementia home care. Dyads, consisting of a PwD and their informal caregiver living in the community, will be divided into 2 groups: the intervention group, which will receive the CH technology package at home, and the usual care group, which will not have any CH technology at all. Dyads will be followed up for 12 months during which they will continue with their traditional care plan, but in addition, the intervention group will receive the CH package for their use at home during 6 months (months 3 to 9 of the yearly follow-up). Further comprehensive assessments related to the caregiver’s and PwD’s emotional and physical well-being will be performed at the initial assessment and at 3, 6, 9, and 12 months using international and standardized validated questionnaires and semistructured individual interviews. Results This 3-year funded study (2016-2019) is currently in its implementation phase and is expected to finish by December 2019. We believe that CH can potentially change the PwD current care model, facilitating a proactive and preventive model, utilizing self-management–based strategies, and enhancing caregivers’ involvement in the management of health care at home for PwDs. Conclusions We foresee that our CH platform will provide knowledge and promote autonomy for the caregivers, which may empower them into greater control of the care for PwDs, and with it, improve the quality of life and well-being for the person they are caring for and for themselves through a physical and cognitive decline predictive model. We also believe that facilitating information sharing between all the PwDs’ care stakeholders may enable a stronger relationship between them, facilitate a more coordinated care plan, and increase the feelings of empowerment in the informal caregivers. International Registered Report Identifier (IRRID) DERR1-10.2196/13280

BACKGROUND Dementia is a neurodegenerative chronic condition characterized by a progressive decline in a person’s memory, thinking, learning skills, and the ability to perform activities of daily living. Previous research has indicated that there are many types of technology interventions available in the literature that have shown promising results in improving disease progression, disease management, and the well-being of people with dementia (PwD) and their informal caregiver, thus facilitating dementia care and living. Technology-driven home care interventions, such as Connected Health (CH), could offer a convenient and low-cost alternative to traditional home care, providing an informal caregiver with the support they may need at home while caring for a PwD, improving their physical and mental well-being. OBJECTIVE This study aimed (1) to create a multidimensional profile for evaluating the well-being progression of the PwD–informal caregiver dyad for a year during their use of a CH platform, designed for monitoring PwD and supporting their informal caregivers at home, and (2) to conduct a long-term follow-up using the proposed well-being profile at different time-interval evaluations. METHODS The PwD–informal caregiver well-being profile was created based on the World Health Organization International Classification of Functioning considering the following outcomes: functional status, cognitive status, and quality of life for the PwD and mental well-being, sleeping quality, and burden for the informal caregiver. Over a year, comprehensive assessments of these outcomes were conducted every 3 months to evaluate the well-being of PwD–informal caregivers, using international and standardized validated questionnaires. Participants’ demographic information was analyzed using descriptive statistics and presented as means and SDs. A nonparametric Friedman test was used to analyze the outcome changes and the progression in the PwD-caregiver dyads and to determine if those changes were statistically significant. RESULTS There were no significant changes in the well-being of PwD or their caregivers over the year of follow-up, with the majority of the PwD-caregiver dyads remaining stable. The only instances in which significant changes were observed were the functional status in the PwD and sleep quality in their caregivers. In each of these measures, post hoc pairwise comparisons did not indicate that the changes observed were related to the deployment of the CH platform. CONCLUSIONS The follow-up of this population of PwD and their informal caregivers has shown that disease progression and physical and mental well-being do not change significantly during the time, being a slow and gradual process. The well-being profile created to analyze the potential impact of the CH platform on the PwD–informal caregiver dyad well-being, once validated, could be used as a future tool to conduct the same analyses with other CH technologies for this population. INTERNATIONAL REGISTERED REPORT RR2-10.2196/13280

Introduction: Resistance exercises and dietary protein have been shown to reverse frailty, yet they are not commonly offered in clinical practice. We aim to measure changes in health outcomes, including physical frailty status (SHARE-FI), clinical frailty status (CFS) and muscle mass, as a result of an optimised exercise and dietary intervention versus usual care in a primary care (PC) setting. The intervention has been derived from our systematic review and meta-analysis findings and optimised through patient and public involvement and multidisciplinary team input. Methods: This study is a multicentre randomised controlled parallel arm trial with a three month follow up. 210 eligible people aged 65 and over, no more than mildly frail, will be recruited in seven PC practices in Ireland and randomly assigned to ‘intervention’ or ‘usual care’. Intervention participants will be provided a leaflet with strength exercises, protein dietary guidance and educational discussion. Baseline measurements will include demographics, health indicators, comorbidities, malnutrition universal screening tool (MUST), frailty status (SHARE-FI, CFS) and muscle mass (bioelectrical impedance). Primary outcome will be frailty status measured by SHARE-FI at three months. Secondary outcomes include CFS, muscle mass, in-patient hospitalisation, long term care admission, and subjective ease of intervention and difference to general health. Statistical analysis will be undertaken by an independent statistician. Discussion: The diversity of tested frailty interventions and lack of clear guidance may contribute to low implementation rates. The REFEREE trial focusses on an optimised intervention for a syndrome that poses growing individual and societal challenges. It is hoped results can encourage mainstream adoption of interventions to reverse clinical frailty and build resilience in primary care. Trial registration: ClinicalTrials.gov ID NCT04628754; registered on 13 November 2020.

We addressed the research question “what factors enable the successful development and implementation of a frail older person’s pathway within the acute setting”. A rapid realist review (RRR) was conducted by adopting the RAMESES standards. We began with a sample of 232 articles via database searches supplemented with 94 additional records including inputs from a twitter chat and a hospital site visit. Our final sample consisted of 18 documents. Following review and consensus by an expert panel we identified a conceptual model of context-mechanism-(resources)-outcomes. There was overall agreement frailty should be identified at the front door of the acute hospital. Significant challenges identified related to organisational boundaries both within the acute setting and externally, the need to shift outcomes to patient orientated ones, to support staff to sustain the pathway by providing ongoing education and by providing role clarity. RRRs can support research such as the systematic approach to improving care for frail older adults (SAFE) study by producing accounts of what works based on a wide range of sources and innovative engagement with stakeholders. It is evident from our provisional model that numerous factors need to combine and interact to enable and sustain a successful frail older person’s pathway. Health Research Board

Background : The majority of people with dementia living in the community receive care from family members or other informal carers. Each family carer experiences caregiving differently, all family carers have varying levels of personal resilience when acting in the caregiving role. Defined as a set of personal qualities, resources and factors which allow an individual to maintain normal or enhanced functioning during times of adversity (1), resilience contributes to the carer’s well-being and can influence the quality of care provided to the person with dementia. The aim of this study was to investigate the concepts and interventions related to resilience in dementia caregivers and explore models of resilience applicable to dementia caregiving. Methods : A systematic literature review was conducted to explore resilience, as it applies to and impacts on caregiving. Peer-reviewed articles and grey literature published from 2006-2016 were included in the systematic search criteria, and searched using a range of scholarly databases. Two independent reviewers pre-screened the search results and conducted formal assessments and quality appraisals of the retrieved articles. Results : A total of 13,863 studies were identified from the initial search and, following screening, 89 studies were included in the systematic review exploration of resilience. Based on narrative synthesis of the literature, the study reports a model of resilience for dementia caregivers which focuses on social and cultural factors, aspects of the caregiver-care recipient relationship and the caregiver’s psychological resources. Conclusions : While many studies focus on the area of caregiving, very few examine resilience as an independent construct. The findings build a model of resilience, which can facilitate the design and development of interventions aimed at enhancing resilience in family carers of people with dementia. Strengthening the resilience of families to take care of their loved ones is highly relevant for an integrated approach to caring for people with dementia. This research will help health and social care professionals to enable family caregivers to continue to provide care and facilitate people with dementia to remain in their homes.7 References : 1. Windle G. What is resilience? A review and concept analysis. Reviews in Clinical Gerontology. 2011 May 1;21(02):152-69.

Objective The objective of this review is to critically examine, evaluate, and synthesize the literature on resilience in family caregiving for people with dementia. Methods A systematic literature review was conducted according to PRISMA guidelines to identify articles which examined resilience and related concepts in family caregiving for people with dementia. The review was based on a systematic search of scholarly databases, to yield peer-reviewed articles and grey literature, published between 2006 and 2016. Two independent reviewers prescreened the search results and conducted formal assessments and quality appraisals of the retrieved articles. Results A total of 13 863 articles were identified by the systematic search, and 52 articles were included in the review. Based on a critical narrative synthesis of the literature, the study proposes a model of resilience for family carers of people with dementia, which incorporates the context of caring, social and cultural characteristics, and psychological dimensions of caring. Conclusions The results indicate that there is no single approach to enhancing resilience among family carers of people with dementia. Resilience is a multifaceted response to the caregiving role, and is influenced by a multitude of interrelated factors. However, the factors and resources outlined have been addressed, with limited success in some cases, by psychosocial interventions in the field. While the work conducted to date to develop resilience-enhancing interventions has been marked with some success, the next wave of carer research could usefully examine ecological perspectives on carer outcomes, including carer resilience.

Introduction: Delirium (acute confusion) affects 1 in 8 acute hospital inpatients and is highly distressing for patients and families. It is associated with increased length of hospital stay, risk of falls, mortality and institutionalisation. Early detection improves outcome, whereas established delirium (present for a few days) is difficult to treat. Thus screening for delirium in at-risk patients is key to early detection and treatment to improve outcomes. Description of policy context and objective: NICE guidelines recommend daily delirium screening for high risk patient groups. However, delirium screening and assessment is poorly performed in Irish hospitals (Irish National Audit of Dementia, 2014). We aimed to develop a simple algorithm for delirium screening on hospital wards, helping staff to identify those patients requiring daily delirium screening and outlining the action to be taken when a patient screened positive for delirium. Targeted population: Hospital in-patients on any general medical or surgical ward (i.e. excluding Intensive Care Unit or orthopaedic/neurosurgery wards), with ward nurses performing the daily delirium screening and hospital doctors acting on the abnormal result. Highlights: (innovation, Impact and outcomes) The interdisciplinary national algorithm development team firstly developed an evidence-based algorithm. Two versions were developed- one using the 4AT test (a well-recognised short delirium screening test) and the other using a quicker, deconstructed form. Both versions were piloted in three hospital sites, in a single ward at each site, with extensive user evaluation of the algorithm. Further modification was performed, followed by a second pilot in a single hospital on four wards. The version using the regular 4AT was preferred by users. Staff required pre-use training particularly on how to score patient refusals and using the tool in a patient with severe dementia. A Frequently Asked Questions guide, and an online training tool were developed, to support staff use of the algorithm, based on the pilot studies. This algorithm is being rolled out nationally in 2017 so impact and outcomes can’t be assessed as yet. Comments on transferability: The delirium algorithm was developed for use in all acute hospitals in Ireland. It is highly transferrable to other countries. Conclusions: Any new policy or guideline requires extensive user engagement at all stages of development. Different hospitals have different resources and training needs. Extensive piloting of our proposed algorithm identified areas that required targeted training. This allowed resources to be developed to facilitate adoption of the national policy, targeted to specific end-users needs.

Background: This project was initially undertaken by the Department of Medicine for Older people in two Academic Teaching Hospitals in Dublin. It is led by two Clinical Nurse Specialists in Gerontology and is supported by geriatricians in both sites. It has recently gained the support of the Irish Hospice Foundation (IHF) Nursing Homes Ireland (NHI) and National Clinical Programme for Older People (NCPOP). Problem: Information sent from local nursing homes to the acute hospital Emergency Department often lacks the information required to provide safe quality care to the older person in an emergency situation. Hence, members of the interdisciplinary team spend inordinate amounts of time contacting these NH’s in order to obtain basic information that will support important care and treatment decisions in the acute setting for this complex, frail patient group. Information on medications, infection status, diet, cognition, functionality, advanced care planning are essential if we are to determine patient need. Assessment of problem and analysis of its causes: A prospective audit was carried out in 2011 to assess the problem outlined above in which 35 transfer letters from 29 different NHs were reviewed. A questionnaire was used to assess 24 aspects of information been received at the point of hospital entry. A template transfer letter was devised from the questionnaire to capture demographic information, baseline medical information, physical information and the cognitive status of the patient being transferred to hospital from each NH. The template was sent at the end of the audit period to all Directors of Nursing in each NH. All were requested to send feedback on the template so it could be modified for phase 2 of the project. Intervention: As a result of the consultative process a new transfer document was developed. Support from the national advisory body Nursing Homes Ireland (NHI) was ascertained. In order to enhance accessibility and promote usage, the document was made available on both hospital websites and a care planning database ‘Epicare’ which is used by 60% of NH’s nationally. Strategy for change: From the outset of the project in 2011, we consulted with Directors of Care from NH’s through NHI; in order to ascertain that: 1) the proposed content of the Transfer letter was appropriate and, 2) that updates on the transfer document were communicated to reflect national standards / guidance. Measurement of improvement: Continuous audit cycles (4) and on-going consultation with NH’s; allowed us measure improvements in the quality of transfer information. In 2015, 62% of NH were using the standardised template document (n=37) a decrease from 73% in 2012. However, baseline demographic & medical information was well documented, as were Functional Scores (90-100%). Other Results show improvements & areas for concern Effects of changes: Improvements in transfer communication meant clinicians in Acute Hospitals (AH)’s and NH’s spent less time looking for information deemed vital to patient care. One of the challenges was that NH’s wanted more information on the document at each stage of the consultation process. Its’ success as a single page document at local level allowed the document to trialled at regional level with funding support from the IHF. 189 NH’s were contacted and 83% (81 replies) used the document and reported it to be useful and comprehensive. Lessons learnt: The document is currently undergoing an integrated consultation process between both the NH & AH Sectors for National application with the support of NCPOP. Other stakeholders challenge its single page status and its’ scope has been be broadened to include other areas of the residential care sector. Quality of transfer information from AH to NH will need to be considered following this phase as requested by NH’s. Messages for others: A single page document with key information that represents patient need is vital during transitions of care. It helps reduce incidences of missed care through the provision of appropriate information between healthcare stakeholders. Consultation with Directors of Care or Clinicians from both NH & AH respectively is essential on behalf of NH patients to ensure that the information been transferred is satisfactory and that patient need is been met through appropriate transfer of information when developing or using a standardised template.

Purpose: Over 5100 colorectal cancers (CRCs) are diagnosed in the United Kingdom in 85 years and older age group per year but little is known of cancer progression in this group. We assessed clinical, pathological and molecular features of CRC with early and late mortality in such patients. Methods: Data were analysed in relation to early mortality and long-term survival in 90 consecutive patients with CRC aged 85 years or older in a single hospital. Results: Patients not undergoing operation, those with an ASA score of III or greater and those with advanced tumour stage were more likely to die within 30 days. Regression analysis showed that 30 day mortality was independently related to failure to undergo resection (odds ratio (O.R.), 10.0; 95% confidence interval [C.I.], 1.7–58.2; p = 0.01) and an ASA score of III or greater (O.R. 13.0; 95% C.I., 1.4–12.6; p = 0.03). All cause three and five year survival were 47% and 23% respectively for patients who are alive 30 days after diagnosis. Three and five year relative survivals were 64% and 54%, respectively. Long-term outcome was independently related to tumour stage (relative risk [R.R.], 2; 95% C.I., 1.3–3.1; p = 0.001), presence of co-morbid diseases (R.R., 2.8; 95% C.I., 1.3–6.0; p = 0.007) and lipid peroxidation status (R.R., 2.9; 95% C.I., 1.1–7.5; p = 0.025). Conclusions: An active multidisciplinary approach to the care of patients with CRC at the upper extreme of life is reasonable. It also seems sensible to individualise care based upon the extent of disease at diagnosis and the presence of co-morbid conditions. Further studies to examine the role of lipid peroxidation are warranted.

Frail individuals are at higher risk of adverse outcomes, and need identification and priority access toComprehensive Geriatric Assessment (CGA). We prospectively collected data on new referrals to our dayhospital. Levels of frailty were measured with the SHARE Frailty Instrument for Primary Care (SHARE-FI). Of257 patients assessed (90 men, 167 women), 110 (43%) were non-frail, 66 (26%) pre-frail and 81 (32%) frail.Mean age was 82 years for the non-frail, 83 for the pre-frail and 84 for the frail. Forty-one percent of the frailreported two or more falls in the preceding year, compared to 38% of the pre-frail and 21% of the non-frail (P fortrend = 0.003). Of 27 patients who were referred for ongoing multidisciplinary assessment and rehabilitation, 16(59%) were frail. The frailty syndrome has the potential to become an advocacy tool for older people and helptarget effective, but finite, CGA resources.

Introduction Warfarin is effective in reducing the stroke risk in atrial fibrillation in the very elderly. This survey aimed to define characteristics and problems of patients aged ≥ 80 with atrial fibrillation attending an outpatient anticoagulant monitoring service (AMS) in a university hospital. Methods All patients aged ≥ 80 from October 2007 to March 2008 were included. Results One hundred and sixty-eight patients, average age 85.8 ± 3.1 years, were included in the study. Average age of commencement was 81.3 ± 4.5 years. Average length of time on warfarin was 4.8 ± 3.3 years. Fifty-three percent of patients managed their own warfarin and took instructions for dosing. In their entire period on warfarin, 61% of patients had problems including bleeding, bruising, falls, medication interactions and erratic International Normalized Ratio (INR) readings. Seven percent of patients had INR readings of > 8.0, necessitating emergency department assessment for reversal with vitamin K. The AMS staff had difficulty contacting 13% of patients with elevated INRs and missed appointments in 11%. In the 6 months, only 45% remained within target INR range of 2.5 ± 0.75 in 90–100% of 10 consecutive readings. Sixteen percent were within target INR in ≤ 60% of readings. Seven percent of patients died, one from a subdural haemorrhage postfall. Fifteen percent were admitted to hospital. Discussion The findings illustrate significant difficulties encountered by this elderly, vulnerable age group in proven effective treatment in atrial fibrillation. Changes need to be made to increase resources for monitoring in the community, including home visits, portable INR monitors and point-of-contact dose adjustment. Patients should be assessed carefully for risk to benefit ratio.