Elderly Wards Research Articles

Improving compliance of the ‘Malnutrition Universal Screening Tool (MUST)’ within an acute care of the elderly ward

Prevalence of malnutrition in acute setting is thought to be 29% on admission, however, older adults are considered to be particularly high risk especially those with multiple comorbidities or frailty1. The MUST tool has been validated for use in the acute setting to identify patients at risk who may require additional nutritional support with/without the input of a Dietitian2. NICE guidelines advise that clinical staff screen all patients for malnutrition on admission or on transfer to a ward within 24 hours and ongoing weekly3.

Malnutrition risk and the need for dietetic intervention post COVID-19 infection on a care of the elderly rehab ward

Patients recovering from COVID-19 are at high risk of malnutrition, reduced nutritional intake and decline in muscle mass and strength with many requiring significant rehabilitation. The aim of this service evaluation is to quantify the risk of malnutrition and provide an overview of nutritional status and outcomes with dietetic input on a care of the elderly rehab ward.

737 STOOLS FOR STOOLS - COMBINING MEDICAL AND CONSERVATIVE TREATMENTS TO REDUCE CONSTIPATION IN THE ELDERLY INPATIENT POPULATION

Abstract Introduction Constipation is a common cause of morbidity in the elderly. Its management is particularly challenging in the inpatient population, where many factors exacerbate constipation. We describe a Quality Improvement Project to reduce the rates of constipation on a female Medicine for the Elderly ward. Aims Our aim was to increase bowel chart documentation (nursing and doctor entries) and increase patient frequency of bowel motions to at least once every two days. In particular we focused on conservative measures such as the use of footstools to optimise posture when using commodes and toilets [R Hari Krishnan, Proc Inst Mech Eng H, 2019, 233(4):464–475]. Method • Weekly monitoring of ward inpatients. • Measurements taken were: days since last bowel motion, laxatives prescribed, bowel chart and ward round documentation, and episodes of diarrhoea over the past week. • One episode of diarrhoea was defined as 3 motions of type 6 or type 7 stool in 24 hours. • A new intervention was introduced every two weeks, over a total of 2 months. Interventions: 1. Recording bowel motions at the daily ‘Board Round’ Multi-Disciplinary Meeting. 2. Ward staff education sessions. 3. Footstools for use with commodes and toilets. 4. High-fibre foods to patients with constipation. Results Level of constipation was successfully reduced, with 100% patients moving bowels every 2 days from a baseline of 68%. Ward round and bowel chart documentation improved to 100% and 93.3% respectively (from 41.3% and 33.3%). However, incidence of diarrhoea increased from 0 episodes/week to 8 episodes/week, with laxative prescriptions similarly increased from 50% to 86%. Conclusion Constipation improved with our interventions, but at the unintended cost of laxative-associated diarrhoea. Our next steps will be to reduce laxative prescriptions in favour of conservative measures, in order to reduce episodes of loose stool while maintaining our improved constipation rates.

781 IMPROVING THE QUALITY OF DO NOT ATTEMPT CARDIO-PULMONARY RESUSCITATION (DNACPR) FORM COMPLETION

Abstract Introduction The completion of a Do Not Attempt Cardio-Pulmonary Resuscitation (DNACPR) form represents an important part of patient care. However, this can be a sensitive process that has gained national media interest. The aim of this Quality Improvement (QI) Project was to improve the quality of DNACPR form completion in a Care of the Elderly Department. Methods The QI project ran from May 2019 to January 2021 and was overseen by a multi-disciplinary team (including patient representation). DNACPR forms on the Care of the Elderly wards were audited monthly against 7 standards which correspond to key sections on the DNACPR form. During the data collection process, interventions were implemented using Plan-Do-Study-Act cycles. Interventions included: appointing ‘DNACPR Champions’ to complete monthly audits and provide personalised clinician feedback, the introduction of a new mandatory e-learning module, the creation of an alert system on nerve centre (the Trust’s electronic handover system) and the development of new DNACPR patient information including webpage development, videos and leaflets. Results The project has led to sustained improvements in majority of the 7 standards. The biggest improvements were seen in the inclusion of a review date, correct completion of the mental capacity assessment and the use of patient information leaflets. The documentation of discussions with patient and relatives remained below the audit standards and was largely unchanged during the QI project. Conclusion A multi-disciplinary and multi-faceted QI approach has shown to improve the quality of DNACPR form completion. Further work is needed to continue this process and a focus on staff training and ward-level processes will be the priority.

774 KEEP SMILING! IMPROVING ORAL HEALTH ON AN ACUTE MEDICINE FOR THE ELDERLY WARD

Abstract Good oral health in older patients is important for numerous reasons including facilitating fluid and nutritional intake, communication and quality of life. It is an essential component of providing holistic care and should be a daily care requirement during a hospital admission. Poor oral health leads to adverse outcomes including periodontitis, tooth loss, pneumonia and cardiovascular disease. Frail, elderly and those with dementia are at increased risk of poor oral health. Our group decided to undertake quality improvement work to improve our patient’s oral health care during their hospital stay. Baseline data was collected in our acute medicine for the elderly ward which looked at a variety of factors which influence good oral health. This included access to drink, nursing assessment of dentition on admission and daily review of mouth care documented by nursing and medical staff. Following this, we implemented an educational session for medical staff to promote good oral care. Results showed an improvement in ensuring patients had their drink within arm’s reach (94% to 100%). Daily medical review of a patient’s oral health also increased from 0% to 24%. Conclusion We have made small steps in improving medical review and documentation of our patient’s oral health whilst in hospital. There is still a need for further improvement in assessment and documentation in order to minimise complications associated with poor mouth care. We have undertaken further educational sessions to our nursing colleagues and we plan to introduce a ward ‘oral health champion’ as part of our ongoing improvement work.

The Pedagogy of Reciprocity in Digital Applied Theatre Practice: The antithesis to unjust responses to the COVID-19 pandemic that have devalued and ignored the rights and lives of older adults living with dementia

In this article, I will offer case study insights into the value of digital applied theatre practice that has evolved to remain person-centred, valuing what Gail Mitchell et al. (2020) termed a ‘relational ethic of care' that seeks to enable active citizenship at the heart of hospital-based practice for patients living with dementia. ‘Innovating Knowledge Exchange: Student Involvement in Delivering Better Patient Experience in the NHS (National Health Service)', is a digital applied theatre project jointly funded by Research England and the Office for Students, in partnership with Imperial College Healthcare NHS Trust's Dementia Care Team. The project offers six interventions that happen via zoom to support patients living with dementia who have had little social interaction and thereby cognitive stimulation in COVID-19 and medicine for the elderly wards. The emphasis of each project is to create bespoke workshops that embody a term I have coined, a ‘pedagogy of reciprocity', which is an approach that has evolved over the course of the translation and implementation of the project practice in a digital form. The relationship between arts and health has a long, rich history, but recently known models of practice have either stopped or had to adapt to happen online through digital practice. Moving to online interventions can be exclusionary for artist practitioners who are less familiar with platforms such as Teams, Zoom, Google Meet and Skype, and for those who are familiar, the challenge of ensuring meaningful participation has been complicated. However, the need to continue to be responsive practitioners is vital, and the urgency for arts intervention to support positive wellbeing in the midst of the pandemic has only grown. Arts and healthcare hold a long-standing relationship that should not be compromised because of the necessity to traverse new terrain by entering the domain of the digital, I will argue that in fact this process is vital, and one that I will unpack and interrogate from my own experience working in a hospital during our third national UK lockdown and continuing digital arts and health projects. The reality of the pandemic and the severity of its impact on the mental health and wellbeing of older adults is profound. The International Psychogeriatric Association have discussed the ongoing impact on the mental health and wellbeing of older adults forced to socially isolate. This circumstance is unavoidable for the prevention of the spread of COVID-19, but the fear of contracting COVID-19, or not receiving hospital treatment for particular age brackets, and the impact of not being able to socialise with family and friends is causing a rise in suicide, anxiety, agitation and loneliness. Myrra Vernooij-Dassen (2020) argues that social, mental and cognitive health are not considered by policy makers, and the impact of a lack of social health for people living with dementia is particularly detrimental causing conditions to rapidly deteriorate without social interactions. In this article, I will set out the conceptual framework for the pedagogy of reciprocity as a methodology for responsive digital applied theatre practice that has emerged directly from my experience running projects in the pandemic in acute hospital settings.

Improving the supply of critical medicines from pharmacy to reduce the delay in medicines administration on wards

It is nationally and locally recognised that doses of critical medications are missed or omitted on a daily basis. This has been highlighted by a National Patient Safety Agency alert...

Medicine acceptability for older people in hospital and care home: the influence of setting.

Medicines acceptability is likely to have a significant impact on older people's adherence and, consequently, treatment effectiveness. The objective was to explore the influence of setting on medicines acceptability in older people. A multi-centre, prospective, cross-sectional, observational study was conducted in one care home and one elderly care hospital ward in London, UK, involving individuals on ≥1 medicine(s) and aged ≥65 years. Data-driven approach was applied using multiple observer-reported outcomes analysis tool to distinguish between positively and negatively accepted medicines. 263 observer reports from the care home (n = 97) and hospital ward (n = 166) involving 155 distinct medicinal products were assessed. Collectively, medicines appeared better accepted by patients at the hospital. Differences appeared to be driven by variations in solid oral dosage form (SODF) acceptability. Patients with dysphagia poorly accepted medicines in both settings, as expected. SODFs were unexpectedly better accepted in the hospital than in the care home in patients without dysphagia. Medicines acceptability was affected by patient's characteristics, dosage form type and setting. Changes in care practices between care home and hospital may affect medicine administration and lead to variations in the ability and willingness of patients and carers to use the product as intended.

Severe acute respiratory coronavirus virus 2 (SARS-CoV-2) nosocomial transmission dynamics, a retrospective cohort study of two healthcare-associated coronavirus disease 2019 (COVID-19) clusters in a district hospital in England during March and April 2020.

To understand the transmission dynamics of severe acute respiratory coronavirus virus 2 (SARS-CoV-2) in a hospital outbreak to inform infection control actions. Retrospective cohort study. General medical and elderly inpatient wards in a hospital in England. Coronavirus disease 2019 (COVID-19) patients were classified as community or healthcare associated by time from admission to onset or positivity using European Centre for Disease Prevention and Control definitions. COVID-19 symptoms were classified as asymptomatic, nonrespiratory, or respiratory. Infectiousness was calculated from 2 days prior to 14 days after symptom onset or positive test. Cases were defined as healthcare-associated COVID-19 when infection was acquired from the wards under investigation. COVID-19 exposures were calculated based on symptoms and bed proximity to an infectious patient. Risk ratios and adjusted odds ratios (aORs) were calculated from univariable and multivariable logistic regression. Of 153 patients, 65 were COVID-19 patients and 45 of these were healthcare-associated cases. Exposure to a COVID-19 patient with respiratory symptoms was associated with healthcare-associated infection irrespective of proximity (aOR, 3.81; 95% CI, 1.6.3-8.87). Nonrespiratory exposure was only significant within 2.5 m (aOR, 5.21; 95% CI, 1.15-23.48). A small increase in risk ratio was observed for exposure to a respiratory patient for >1 day compared to 1 day from 2.04 (95% CI, 0.99-4.22) to 2.36 (95% CI, 1.44-3.88). Respiratory exposure anywhere within a 4-bed bay was a risk, whereas nonrespiratory exposure required bed distance ≤2.5 m. Standard infection control measures required beds to be >2 m apart. Our findings suggest that this may be insufficient to stop SARS-CoV-2 transmission. We recommend improving cohorting and further studies into bed distance and transmission factors.

Stools for Stools-combining a multi-disciplinary approach with conservative measures to reduce constipation in the elderly inpatient population

Introduction: Constipation is a common cause of morbidity in the elderly. Its management is particularly challenging in the inpatient population where many factors exacerbate constipation. We describe a Quality Improvement Project to reduce constipation in a Care of the Elderly ward, including conservative measures to complement medical treatment. Aims: To increase bowel motion frequency to at least once every two days in elderly inpatients, and to increase bowel chart documentation. Methods: Weekly monitoring of ward inpatients. Measurements taken were: days since last bowel motion, laxatives prescribed, documentation on bowel charts and ward rounds, and episodes of diarrhea. A new intervention was introduced every two weeks, over a total of 10 weeks. Interventions: The 4 interventions introduced were: 1) Recording bowel motions at the daily ‘Board Round’ Multi-Disciplinary Meeting. 2) Ward staff education sessions. 3) Footstools for use with commodes and toilets. 4) High-fibre foods for patients with constipation. Results: Bowel motion frequency improved, with 100% of patients moving bowels every 2 days from a baseline of 66.6%. Ward round and bowel chart documentation improved to 100% and 92.9% (from 41.6% and 33.3%). Laxative prescriptions increased from 50% to 78.6%, with no increase in episodes of diarrhea. Conclusions: Constipation improved with our interventions but was accompanied by increased laxative prescriptions, which carry a risk of side effects. Our next steps will be to optimize our conservative measures to reduce laxative prescriptions, and to this end, we have developed high-fiber snack boxes to aid constipation in elderly patients.

Service evaluation comparing Acute Care at Home for older people service and conventional service within an acute hospital care of elderly ward.

This study evaluated the impact of a consultant-led Acute Care at Home service in comparison with conventional hospital admission to a care of elderly ward. Globally, there has been an increased demand for healthcare services caused by population growth and a rise in chronic conditions and an ageing population. Acute Care at Home services offer acute, hospital-level care in a person's own home. Five services have been commissioned across Northern Ireland since 2014 with limited research investigating their feasibility and effectiveness. Quantitative design, using service evaluation methodology. A 1-year retrospective chart review was undertaken exploring admission demographics and post-discharge clinical outcomes of patients admitted to a Northern Ireland, Care of the Elderly ward (n=191) and a consultant-led Acute Care at Home Service (n=314) between April 2018-March 2019. Data were analysed using descriptive and inferential data analysis methods including frequencies, independent t tests and chi-square analysis. Outcome measurements included length of stay, 30-day, 3- and 6-month readmission and mortality rates, functional ability and residence on discharge. STROBE checklist was used in reporting this study. Acute Care at Home services are associated with higher readmission and mortality rates at 30days, 3 and 6months. Fewer patients die while under Acute Care at Home care. Patients admitted to the Acute Care at Home services experience a reduced length of stay and decreased escalation in domiciliary care packages and are less likely to require subacute rehabilitation on discharge. There is no difference in gender, age and early warnings score between the two cohorts. The Acute Care at Home service is a viable alternative to hospital for older patients. It prevents functional decline and the need for domiciliary care or nursing home placement. It is likely that the Acute Care at Home service has higher mortality and readmissions rates due to treating a higher proportion of dependent, frail older adults. Acute Care at Home services continue to evolve worldwide. This service evaluation has confirmed that Acute Care at Home services are safe and cost-effective alternatives to traditional older people hospital services. Such services offer patient choice, reduce length of stay and costs and prevent functional decline of older adults. This study accentuates the need to expand Acute Care at Home provision and capacity throughout Northern Ireland.

Use of Multiprognostic Index Domain Scores, Clinical Data, and Machine Learning to Improve 12-Month Mortality Risk Prediction in Older Hospitalized Patients: Prospective Cohort Study.

BackgroundThe Multidimensional Prognostic Index (MPI) is an aggregate, comprehensive, geriatric assessment scoring system derived from eight domains that predict adverse outcomes, including 12-month mortality. However, the prediction accuracy of using the three MPI categories (mild, moderate, and severe risk) was relatively poor in a study of older hospitalized Australian patients. Prediction modeling using the component domains of the MPI together with additional clinical features and machine learning (ML) algorithms might improve prediction accuracy.ObjectiveThis study aims to assess whether the accuracy of prediction for 12-month mortality using logistic regression with maximum likelihood estimation (LR-MLE) with the 3-category MPI together with age and gender (feature set 1) can be improved with the addition of 10 clinical features (sodium, hemoglobin, albumin, creatinine, urea, urea-to-creatinine ratio, estimated glomerular filtration rate, C-reactive protein, BMI, and anticholinergic risk score; feature set 2) and the replacement of the 3-category MPI in feature sets 1 and 2 with the eight separate MPI domains (feature sets 3 and 4, respectively), and to assess the prediction accuracy of the ML algorithms using the same feature sets.MethodsMPI and clinical features were collected from patients aged 65 years and above who were admitted to either the general medical or acute care of the elderly wards of a South Australian hospital between September 2015 and February 2017. The diagnostic accuracy of LR-MLE was assessed together with nine ML algorithms: decision trees, random forests, extreme gradient boosting (XGBoost), support-vector machines, naïve Bayes, K-nearest neighbors, ridge regression, logistic regression without regularization, and neural networks. A 70:30 training set:test set split of the data and a grid search of hyper-parameters with 10-fold cross-validation—was used during model training. The area under the curve was used as the primary measure of accuracy.ResultsA total of 737 patients (female: 370/737, 50.2%; male: 367/737, 49.8%) with a median age of 80 (IQR 72-86) years had complete MPI data recorded on admission and had completed the 12-month follow-up. The area under the receiver operating curve for LR-MLE was 0.632, 0.688, 0.738, and 0.757 for feature sets 1 to 4, respectively. The best overall accuracy for the nine ML algorithms was obtained using the XGBoost algorithm (0.635, 0.706, 0.756, and 0.757 for feature sets 1 to 4, respectively).ConclusionsThe use of MPI domains with LR-MLE considerably improved the prediction accuracy compared with that obtained using the traditional 3-category MPI. The XGBoost ML algorithm slightly improved accuracy compared with LR-MLE, and adding clinical data improved accuracy. These results build on previous work on the MPI and suggest that implementing risk scores based on MPI domains and clinical data by using ML prediction models can support clinical decision-making with respect to risk stratification for the follow-up care of older hospitalized patients.

601 IMPROVING DELIRIUM ASSESSMENT IN A DISTRICT GENERAL HOSPITAL

Abstract Introduction Delirium affects a up to 20% of medical inpatients1. Patients in the high-risk category include those over 65, pre-existing cognitive impairment, current hip fracture and those with a serious illness 1,2. Often delirium goes undetected but is often related to high morbidity and motility rates with complications of insitionalisation, increased risk of dementia, high risk of falls and prolonged hospital stays1,2, recognition is the first step to reducing these risks. NICE guidance suggests that those patients showing indicators of delirium should have a formal cognitive assessment and a tailor-made plan should be documented within 24 hours 2. The detection of delirium can be sort using licensed tools including the 4AT score with the 4AT being the most sensitive, specific and practical1. Due to the ongoing risks of delirium, high risk patients on the Geriatric medicine firm and poor detection rate a quality improvement methodology was used to increase the rates of detection of delirium. The aim to have 90% of Geriatric medicine patients screened within 24 h admission and within 24 h of arrival to COTE ward/first consultant ward round within 4 months. Method 4 PDSA cycles were designed to trial changes including education of the Geriatric medicine team, lanyard cards, introduction of 4AT on the frailty proforma and a non-intervention cycle to see if these changes were sustained. Data was collected from the care of the elderly ward not including outliers of 27 patients. Any formal cognitive assessment that was documented either on admission or on arrival to the ward was included. Not included was those patients who were assessed for delirium or change in cognition after first consultant ward round or after 24 h of being on the ward. Results The uptake of 4AT improved by 50% after education and the lanyard cards. This was largely as a shift away from other assessments rather than more cognitive assessments done overall. During service redesign an Older Person’s Assessment Unit was formed with a Geriatrician based at the front door. This will improve the use of the 4AT for older patients admitted to hospital in the near future and is the subject of the next PDSA cycle. Conclusion Our journey to embed the 4AT is ongoing and we will continue to improve uptake using QI methodology.

Dementia patients have greater anti-cholinergic drug burden on discharge from hospital: A multicentre cross-sectional study

IntroductionAnticholinergic medications block cholinergic transmission. The central effects of anticholinergic drugs can be particularly marked in patients with dementia. Furthermore, anticholinergics antagonise the effects of cholinesterase inhibitors, the main dementia treatment.ObjectivesThis study aimed to assess anticholinergic drug prescribing among dementia patients before and after admission to UK acute hospitals.Methods352 patients with dementia were included from 17 hospitals in the UK. All were admitted to surgical, medical or Care of the Elderly wards in 2019. Information about patients’ prescriptions were recorded on a standardised form. An evidence-based online calculator was used to calculate the anticholinergic drug burden of each patient. The correlation between two subgroups upon admission and discharge was tested with Spearman’s Rank Correlation.ResultsTable 1 shows patient demographics. On admission, 37.8% of patients had an anticholinergic burden score ≥1 and 5.68% ≥3. At discharge, 43.2% of patients had an anticholinergic burden score ≥1 and 9.1% ≥3. The increase was statistically significant (rho 0.688; p=2.2x10-16). The most common group of anticholinergic medications prescribed at discharge were psychotropics (see Figure 1). Among patients prescribed cholinesterase inhibitors, 44.9% were also taking anticholinergic medications.ConclusionsThis multicentre cross-sectional study found that people with dementia are frequently prescribed anticholinergic drugs, even if also taking cholinesterase inhibitors, and are significantly more likely to be discharged with a higher anticholinergic drug burden than on admission to hospital.Conflict of interestThis project was planned and executed by the authors on behalf of SPARC (Student Psychiatry Audit and Research Collaborative). We thank the National Student Association of Medical Research for allowing us use of the Enketo platform. Judith Harrison was su

74 Improving Handover Between Doctors and Nurses on An Elderly Care Ward

Abstract Background The Royal College of Physician guidelines (2011) identified handover as a “high risk step” in patient care, especially in recent times within the NHS where shift patterns lead to more disjointed care with a high reliance on effective handover by all staff members. Introduction At Cannock Chase hospital, Fairoak ward is an elderly care rehabilitation ward where there is a large multi-disciplinary team. While working on the ward as doctors we noticed that handover between the MDT was poor. Anecdotal evidence from both doctors and nurses felt that this was a high risk area in need of improvement. Aim to improve handover between doctors and nurses on this elderly care ward. Method To measure the quality of current handover practice we did a questionnaire. A total of 12 questionnaires were completed which showed that 92% of staff felt that handover on the ward was very poor and 50% preferred both written and verbal handover. We measured the number of tasks verbally handed over between doctors and nurses over 3 days. On average 65% of the tasks were completed. We then made the below interventions and re-audited to see if there was any improvement. Interventions over 3 week period: Results Questionnaire: Measuring task completion after interventions; Conclusion This project has made a positive change qualitatively and quantitatively to the ward handover practice. Staff satisfaction regarding handover has improved and the number of “handed over” tasks completed daily has significantly improved. The written handover sheet had poor utilisation by staff but in 4 months we are going to re-audit and trial the handover sheet again to further improve service delivery. We hope this improvement will have a positive impact on patient care on this elderly care ward.

92 Clinical Frailty Scoring Is Crucial For the COVID-19 Era and Beyond

IntroductionThe COVID-19 pandemic placed a new focus on provision of clinical resources. With high mortality and limited capacity; appropriate decisions to escalate to critical care were vital for just resource allocation but also to prevent harm where interventions would not change outcomes. NICE guidance highlighted Clinical frailty scoring (CFS) as central to the decision-making process. 1, Despite initial criticism, recent evidence has confirmed increasing CFS as an independent risk factor to inpatient mortality in COVID-19.2 We conducted a quality improvement project with the aim of improving CFS documentation at the Royal Free Hospital.MethodsWe reviewed the notes of 71 inpatients over the age of 65 years from 6 wards on 08/05/20–12/05/20 for both a CFS score documentation and clear treatment escalation plan at time points of initial clerking, post-take and following ward admission with an audit standard of 100%. We developed teaching sessions, promoted the CFS mobile application, developed a post-take sticker and an elderly medicine ward admission proforma. We re-audited 66 inpatient notes from the same 6 wards from 25/06/20–07/07/20.ResultsDocumentation.of CFS improved from 7% to 17% for clerking and post-take and from 13% to 24% on the ward admission. The number of patients with treatment escalation plans was 50%.ConclusionCFS is crucial for the COVID-19 era and beyond. We have demonstrated that increased awareness improves use of CFS, though it is not yet being widely used in escalation decisions. 1. Covid-19 Rapid guideline: Critical Care in adults. NICE guideline [NG159]: https://www.nice.org.uk/guidance/ng159 Accessed July 2020 2. Hewitt J et al (2020): The effect of frailty on survival in patients with COVID -19 (COPE): a multicentre, European, observational cohort study; The Lancet: https://doi.org/10.1016/S2468-2667(20)30146-8.

Secondary care interface: optimising communication between teams within secondary care to improve the rehabilitation journey for older people

Effective communication between members of the multidisciplinary team is imperative for patient safety. Within the Medicine for the Elderly wards at Royal Victoria Hospital (RVH) in Dundee, we identified an...

Malnutrition risk post COVID-19 infection on a care of the elderly rehab ward

Rationale: Patients recovering from COVID-19 are at high risk of malnutrition, reduced nutritional intake and decline in muscle mass and strength with many requiring significant rehabilitation. The aim of this service evaluation is to quantify the risk of malnutrition and provide an overview of nutritional status and outcomes with dietetic input on a care of the elderly rehab ward.

P1221THE VOXEL-BASED SPECIFIC REGIONAL ANALYSIS SYSTEM FOR ALZHEIMER’S DISEASE (VSRAD) BY MAGNETIC RESONANCE IMAGING SCAN IN PERITONEAL DIALYSIS (PD) PATIENTS, COMPARED WITH HEMODIALYSIS (HD) PATIENTS WITH ALZHEIMER’S DISEASE

Abstract Background and Aims Japan is currently moving towards an unprecedented aging society and chronic dialysis patients as well. As Aging population increases, in chronic dialysis patients as well, Mild cognitive impairment (MCI) and dementia cases are on the rise, and increasing burden on existing dialysis facilities. Our hospital has not only the outpatient department of Internal medicine, but also peritoneal and hemodialysis facilities, and Regional Dementia Center. We have accepted chronic dialysis patients, in our medical center and elderly ward, who are usually unable to maintain hospitalization or outpatient maintenance dialysis with cognitive impairment by collaborating with psychiatrists. Rehabilitation was instructed in all the patients by physiotherapists for the purpose of improving ADL. We investigated the current status of our PD patients, HD patients who experienced PD, and HD patients with Alzheimer’s type dementia (AZ). Method A: Nine cases of hemodialysis (HD), who subsided peritoneal dialysis (PD), (including 2 DM cases:22%), Average age 75.4± 9.1 years old, 4 males, 5 females; average dialysis duration 322± 126 M:(HD-PD). B: Thirteen cases of PD, (including DM 3 cases: 23%), 6 males, 7 females; average age 71.6± 10.9 years old, average dialysis duration 286± 139 M:(PD). C: Fifteen cases of hemodialysis (HD) who was diagnosed as AZ (including 8 DM cases: 53%), Average age 76.6± 8.5 years old, 9 males, 6 females; average dialysis duration 53.9± 66.1 M:(HD-AD). We examined blood pressure (BP), and laboratory data. Analysis of the body fluid status; extracellular water/ total body water (ECW/TBW; IN BODYR), Skeletal muscle index (SMI) was performed. Average Z-score points of MRI (assessment of hippocampus atrophy evaluation) and total brain atrophy was investigated by VSRAD. Results About 13 PD and 9 HD who experienced PD cases, there were 4 MCI cases, and no Alzheimer type dementia, or cerebrovascular dementia. About PD cases, average Hasegawa’s formula expression average (HDS-R): 28.8±1.8, average BMI: 22.3± 2.9, average skeletal muscle mass index (SMI): 6.6± 1.0 kg/m2, average Lipid ratio (%): 24.3± 7.8, average Z-score points of MRI : 1.02± 0.5 and total Brain atrophy was 4.3± 2.7 %. About HD-PD cases, one case had slight cerebrovascular dementia, and 2 cases are MCI; average Z-score was 1.2± 1.0 total Brain atrophy was 3.8± 1.4 %. Average SMI: 5.9± 1.3 kg/m2, average BMI:20.7± 3.8, average Lipid ratio (%): 21.9± 8.1. Two cases died of malnutrition and sepsis. About 15 HD patients with Alzheimer type (AZ-type) dementia, average HDS-R: 10.4± 9.3, average BMI: 18.9± 2.2, average SMI: 4.7± 1.0 kg/m2, average Lipid ratio (%): 23.5± 6.1, average Z-score points of MRI: 2.6± 0.9 and total Brain atrophy was 9.3± 5.7 %. One-year survival rate of HD patients with AZ was about 20% after transferring to our hospital. The data of SMI and LP% was relatively reserved in PD and HD-PD, but significantly low from that of HD-AZ, and therefore it might not be effective in rehabilitation because of muscle weakness in HD-AZ. There were almost no HD cases with overhydration (ECW/TBW). Almost all dialysis patients had simple some old cerebral infarctions by simple CT examination. Conclusion By CT and MRI image findings, almost PD cases had old low-density area in CT and no acute cerebral infarctions in MRI. The hippocampal atrophy and total brain atrophy of PD and HD-PD was extremely mild, but was very severe in HD-AZ. There were no cases with severe cognitive impairment between PD and HD-PD even if undergoing for over ten years.

Prevalence, nature and predictors of omitted medication doses in mental health hospitals: A multi-centre study.

Limited evidence concerning the burden and predictors of omitted medication doses within mental health hospitals could severely limit improvement efforts in this specialist setting. This study aimed to determine the prevalence, nature and predictors of omitted medication doses affecting hospital inpatients in two English National Health Service (NHS) mental health trusts. Over 6 data collection days trained pharmacy teams screened inpatient prescription charts for scheduled and omitted medication doses within 27 adult and elderly wards across 9 psychiatric hospitals. Data were collected for inpatients admitted up to two weeks prior to each data collection day. Omitted doses were classified as 'time critical' and 'preventable' based on established criteria. Omitted dose frequencies were presented with 95% confidence intervals (CI). Multilevel logistic regression analyses determined the predictors of omitted dose occurrence, with omission risks presented as adjusted odds ratios (OR) with 95% CI. 18,664 scheduled medication doses were screened for 444 inpatients and 2,717 omissions were identified, resulting in a rate of 14.6% (95% CI 14.1-15.1). The rate of 'time critical' omitted doses was 19.3% (95% CI 16.3-22.6%). 'Preventable' omitted doses comprised one third of all omissions (34.5%, 930/2694). Logistic regression analysis revealed that medicines affecting the central nervous system were 55% less likely to be omitted compared to all other medication classes (9.9% vs. 18.8%, OR 0.45 (0.40-0.52)) and that scheduled doses administered using non-oral routes were more likely to be omitted compared the oral route (inhaled OR 3.47 (2.64-4.57), topical 2.71 (2.11-3.46), 'other' 2.15 (1.19-3.90)). 'Preventable' dose omissions were more than twice as likely to occur for 'time critical' medications than non-time critical medications (50.4% vs. 33.8%, OR 2.24 (1.22-4.11)). Omitted medication doses occur commonly in mental health hospitals with 'preventable' omissions a key contributor to this burden. Important targets for remedial intervention have been identified.