The CARTS (community assessment of risk and treatment strategy) programme is a risk intervention strategy that aims to screen, triage, assess and manage risk of three adverse outcomes (institutionalization, hospitalization, death) among community dwelling older adults. The screening instrument quantifies the impact of multiple predictors of adverse outcomes to generate a unique risk score for each of the three outcomes of interest. The goal of the CARTS programme is to keep older adults healthy, independent and active in their own homes by developing tailored, cost effective health intervention strategies in an expedient way and to manage the factors that are putting older adults at risk.
Let Me Decide Advanced Care Planning Programme
An Irish Hospice Foundation-funded award was granted in 2012 to conduct a pilot study evaluating the implementation of the ‘Let Me Decide’ Advance Care Directive (ACD) in long-term care settings. Subsequently, a further funding award from the Health Research Board was leveraged to undertake a three-year randomised controlled trial (RCT) with a view to expanding this research activity. Working with our colleagues in the School of Nursing and Midwifery, the objective of this study is to evaluate the effectiveness of systematically implementing advance care planning (ACP) with “Let Me Decide” and a palliative care programme (focusing on the educational and resource needs pertaining to end-of-life care) on quality of care at end-of-life in six long-term care facilities in Southern Ireland. This project commenced in 2015 and is currently underway.
The ‘Let Me Decide’ ACD has been implemented in the three intervention homes and positive feedback has been received from the education workshop provided to the programme participant staff. Data collection is actively underway and will be analysed accordingly in due course.
Cork Dementia Study (ODCACS)
The Health Research Board-funded Cork Dementia Study (alias Optimal Dementia Care in Acute Care Settings: ODCACS) recruited 606 people over 70 years of age admitted to six regionally-clustered Irish hospitals and determined the prevalence and outcomes of dementia in acute hospital care, and of delirium/challenging behaviour. All data has been collected and the first papers published.
This study found that dementia was dramatically more common in public hospitals, especially rural hospitals (37%), and in acute, medical patients (p<0.001). Delirium rather than dementia however influenced outcomes, in hospital and at one year. This study, combined with the delirium prodrome study, is the first research to give accurate multi-hospital data in Europe for dementia and delirium, using two robust prospective studies with shared methodology to maximise data transference.
Timmons S, Manning E, Barrett A, Brady N, Browne V, O' Shea E, Molloy DW, O'Regan N, Trawley S, Cahill S, O'Sullivan K, Woods N, Meagher D, Ni Chorcorain A, Linehan J. Dementia in older people admitted to hospital: a regional multi-hospital observational study of prevalence, associations, and case recognition. Age and Ageing Age and Ageing, 2015; 44(6): 993-999. DOI: 10.1093/ageing/afv131.
Brady, N. M., Manning, E., O’Shea, E., O’Regan, N. A., Meagher, D., & Timmons, S. Letter to the Editor: Hospital discharge data-sets grossly under-represent dementia related activity in acute hospitals: a cohort study in five Irish acute hospitals. International Journal of Geriatric PsychiatrY, 2016. DOI: 10.1002/gsp.4478.
Meagher J, Leonard M, Donoghue L, O’Regan N, Timmons S, Exton C, Cullen W, Dunne C, Adamis D, Maclullich AJ, Meagher D. Months backward test: A review of its use in clinical studies. World Journal of Psychiatry. 2015 Sept 22;5(3):305-314.
A Coffey, M Tyrrell, M Buckley, E Manning, V Browne, A Barrett,S Timmons. A multicentre survey of acute hospital nursing staff training in dementia care. Clinical Nursing Studies. 07/2014; 2(4):39-46. DOI: 10.5430/cns.v2n4p39.
A report on the first Irish National Audit of Demetia Care in Acute Hospitals (INAD) was published and launched in January 2014 at the National Conference http://www.ucc.ie/en/inad/inadfullreport2014/. The audit, kindly funded by Atlantic Philanthropies and The Meath Foundation, was carried out in all 35 acute hospitals in Ireland for their care of people with dementia. The INAD report contained forty seven recommendations for better dementia care in acute hospitals, which fed into the draft Irish National Dementia Strategy, due to be published later this year, thus directly influencing national policy. An audit in Northern Ireland is currently in the planning stages.
National and international research confirms that an admission to an acute hospital can be distressing and disorientating for a person with dementia, and is often associated with a decline in their cognitive ability and levels of functioning around activities of daily living. In response to the need for more Irish data on dementia care in acute hospitals, the first Irish National Audit of Dementia care in acute hospitals was undertaken in 2013 to measure criteria relating to care delivery known to impact on people with dementia admitted to hospital.
The results from this audit have fed into the development of the Irish National Dementia Strategy.
Please see the INAD website for further information about the audit.
Further to the publication of the INAD (2014), the Northern Ireland Audit of Dementia Care in Acute Hospitals (NIAD) was carried out in 2014. The audit took place in all 12 acute hospitals in Northern Ireland, with a view to obtaining a baseline picture of the quality of care from admission through to discharge. It included four key work packages; hospital- and ward-level organisation modules, a patient healthcare record review and a physical ward environment checklist.
The Northern Ireland Health Minister, Simon Hamilton, welcomed the findings of the audit, saying “The recommendations from this audit highlight the importance of understanding the care needs of patients with dementia when they are admitted to an acute hospital ward. This information will shape the implementation of the regional dementia strategy, in particular the actions relating to hospital care.”
The implementation of the recommendations of the audit report is currently being steered by Seamus McErlean (Commissioning Lead for Older People and Adult Services at the Health and Social Care Board) and Eleanor Ross (Nurse Consultant, Public Health Agency), the leads for the regional dementia strategy implementation working group.
Please see the NIAD website for further information about the audit.
Palliative Care Needs in Parkinson's Disease
This Irish Hospice Foundation-funded project has examined the palliative care needs of people with Parkinson’s disease, from different perspectives, using multiple research methods. Using quantitative (surveys) and qualitative (interviews) methodologies the perceptions of, and attitudes towards, palliative care and assessed palliative care needs, have been explored from the perspectives of people with Parkinson’s disease, their carers and families, and healthcare workers across Ireland.
The first Irish national guidelines for ‘Palliative care for People with Parkinson’s disease and Related Parkinsonian syndromes’ were developed. The guidelines are endorsed by the HSE National Clinical Programmes for Neurology, Palliative Care, and Older People. These were launched to coincide with world Parkinson’s month in April 2016. The results of this research project have been widely disseminated in peer-reviewed journal publications, at national and international conferences, and at local education seminars.
Dr Timmons was awarded an Irish Research Council grant to host an interdisciplinary workshop on the topic of palliative care and neurodegeneration. The workshop was held in May 2016 and achievements include a successful networking event, newly fostered research collaborations, and an upcoming paper on recommendations for future research in this area. Dr Timmons’ research team were also invited to join an international working group of experts on palliative care and Parkinson’s, and have attended two meetings working group meetings in Denver (2015) and Portland (2016).
Physical Activity in Acute Hospitals
A study to determine whether an augmented prescribed exercise programme in the acute hospital setting can shorten patients’ length of stay and improve their physical and psychological well-being is also underway. A randomised controlled trial will be conducted to measure the effects of an augmented prescribed exercise program on physical ability, quality of life and health utilisation for frail older medical inpatients.
It is known that older adults are at risk of functional decline as a result of an acute hospital admission. Up to one third of older inpatients are reported to suffer a long-term functional decline . Many factors may contribute to this but the imposed, or simply accepted low physical activity levels may also be contributory. Studies have shown small positive benefits from additional exercise for older medical patients [2-4]and further meta-analysis suggested that targeting the frailer might strengthen the effects seen .
We conducted a small study in 2011 to measure the effects of an augmented prescribed exercise program (APEP) for frail medical acute in-patients . We recruited 40 frail patients who were aged ≥ 65 years, had an anticipated LOS > 3 days, due for discharge home and needed a walking aid on admission. We allocated them to a usual care group (control) or the APEP group, who were assisted with two exercise-sessions daily, Monday-Friday. The research physiotherapist delivered the exercise prescription which included strengthening, balance and endurance exercises.
Results showed a reduction in the median length of stay (LOS) from 12 days (IQR=9-15 days) to 10 days (IQR=8-12 days) (p=0.17, intention-to-treat analysis, p=0.21) in the APEP group. At discharge, they also showed better physical performance (Short Physical Performance Battery, p=0.03) and HRQOL (EQ-5D Activity, p=0.02, Visual Analogue Scale, p=0.001). Exercise adherence was over 68% (SD=26.5%) in the APEP group.
We are now undertaking a RCT to study a larger cohort (220 patients). The aim of this Health Research Board-funded randomised controlled trial (March 2015 – March 2017) is to measure the effects of an augmented prescribed exercise programme on mobility, quality of life and healthcare utilisation for frail medical inpatients in the acute setting. Both arms receive augmented twice daily exercise; the sham arm receive stretching and relaxation exercises and the intervention arm receive a specifically tailored exercise programme.
The primary outcome of this study is to measure is length of stay (healthcare utilisation). The secondary outcome measures include the Short Physical Performance Battery, (includes walking speed) (physical ability), EQ 5D5L (Quality of Life), and re-admission rates (healthcare utilisation). Patients’ walking activity in hospital is measured using an ankle-worn accelerometer (Stepwatch Activity Monitor).
To date, 153 of the 220 patients have been recruited to the study. Blinded discharge assessments have been completed on all but one patient, and approximately 75% of the blinded follow-up assessments.
McCullagh, R., Brady, N., Dillon, C., Horgan, F., & Timmons, S. A review of the accuracy and utility of motion sensors to measure physical activity of frail older hospitalised patients. Journal of Aging and Physical Activity 2015. [Epub ahead of print]. DOI: 10.1123/japa.2014-0190
McCullagh, R., O'Connell, A.-M., Dillon, C., Horgan, F., & Timmons, S. Measurement of Step-Count Accuracy of Three Motion Sensors for Frail Older Hospitalised Patients. (Resubmitted with minor revisions to Archives of Physical Medicine and Rehabilitation).
Ruth McCullagh, Eimear O’Connell, Sarah O’Meara, Ivan Perry, Anthony Fitzgerald, Kieran O’Connor, Anne Marie Keown, Eleanor Bantry-White, N. Frances Horgan, Suzanne Timmons. A study protocol of a randomised controlled trial to measure the effects of an augmented prescribed exercise programme (APEP) for frail older medical patients in the acute setting. BMC Geriatrics, 2015. In Press.
McCullagh R, Dillon C, Dahly D, Horgan NF, Timmons S. Walking in hospital is associated with reduced length of stay in older medical inpatients. Submitted to Physiological Measurement (invited submission), 2015.
The Genio Trust/HSE partnered Cork Integrated Dementia care Across Settings (Cork-IDEAS) project, 2014-2017, aimed at introducing changes in the acute hospital environment and education/ pathways to support better hospital care and integrated community-hospital working for the person with dementia. This project has a consortium of 45 members and several pilot interventions are planned (http://www.genio.ie/news/2013-12-20-grants-approved-for-dementia-programme-2013).
Cork Delirium Studies
Point Prevalance Study
Prospective Delirium Study
Delirium Screening in the Emergency Department