Cognitive performance in midlife type 2 diabetes: results from the ENBIND study.

AIMS: To establish the impact of uncomplicated type 2 diabetes on cognitive and neuropsychological performance in midlife. METHODS: We performed a cross-sectional study of middle-aged adults with uncomplicated type 2 diabetes and a cohort of healthy control participants. General cognition was assessed using the Montreal Cognitive Assessment test and neuropsychological assessment was undertaken using a detailed neuropsychological assessment battery. RESULTS: A total of 152 participants (102 with type 2 diabetes and 50 controls) were recruited (mean age 52 ± 8 years, 51% women). Participants with midlife type 2 diabetes were more than twice as likely to make an error on the Montreal Cognitive Assessment test [incidence rate ratio 2.44 (95% CI 1.54 to 3.87); P < 0.001]. Further, type 2 diabetes was also associated with significantly lower memory composite score [ß: -0.20 (95% CI -0.39 to -0.01); P = 0.04] and paired associates learning score [ß: = -1.97 (95% CI -3.51, -0.43); P = 0.01] on the neuropsychological assessment battery following adjustment for age, sex, BMI, educational attainment and hypercholesterolaemia. CONCLUSIONS: Even in midlife, type 2 diabetes was associated with small but statistically significant cognitive decrements. These statistically significant decrements, whilst not clinically significant in terms of objective cognitive impairment, may have important implications in selecting out individuals most at risk of later cognitive decline for potential preventative interventions in midlife.

Benchmarking global fisheries discards.

Discarding by fisheries is one of the most wasteful human marine activities, yet we have few estimates of its scale. Reliable estimates of global discards are essential for sustainable fisheries management. Using United Nations Food and Agriculture Organization databases on country-specific landings, we estimated the discard rate and magnitude for global marine and estuarine capture fisheries using fishery-specific discard rates derived from direct observations and global gear-specific discard rates estimated within a Bayesian modelling framework. An estimated 9.1 million tonnes are discarded annually (95% uncertainty interval: 7-16 M t)-or 10.8% of the global catch (95% UI: 10-12%). Encouragingly, this is about half of the annual global discard rate estimated in the late 1980s. Trawl fisheries, especially demersal otter trawls, warrant intensified efforts to reduce discards. Periodic benchmarks of global discards are needed to assess the performance of reduction efforts.

Dementia Friendly Hospital Design: Key Issues for Patients and Accompanying Persons in an Irish Acute Care Public Hospital.

OBJECTIVES: Research was conducted to investigate the impact of the hospital environment on older people including patients with dementia and their accompanying persons (APs). The article presents key research findings in the case study hospital. BACKGROUND: For many patients, the hospital is challenging due to the busy, unfamiliar, and stressful nature of the environment. For a person with dementia, the hospital experience can be exacerbated by cognitive impairment and behavioral or psychological symptoms and can therefore prove to be a frightening, distressing, and disorientating place. METHOD: The findings are based on a stakeholder engagement process where the research team spent approximately 150 hr observing within the hospital, administered 95 questionnaires to patients and/or APs, and conducted 12 structured interviews with patients and APs. A thematic analysis was employed to analyze and generate key themes emerging from the process. RESULTS: Themes were grouped into overarching issues and design issues across spatial scales. CONCLUSION: This research confirms the negative impact of the acute hospital setting on older people with cognitive impairments including dementia and delirium. The multiple perspectives captured in this study, including most importantly people with dementia, ensure that stakeholder needs can be used to inform the design of the hospital environment. The research points to the value of understanding the lived experience of the person with dementia and APs. The voices of patients, particularly persons with dementia and their APs, are a crucial element in helping hospitals to fulfill their role as caregiving and healing facilities.

Non-pharmacological interventions for cognition in patients with Type 2 diabetes mellitus: a systematic review.

Midlife Type II diabetes mellitus (T2DM) is an important yet often unrecognized risk factor for the later development of dementia. We conducted a systematic review to assess the efficacy of non-pharmacological interventions (namely diet, exercise and cognitive training) for T2DM on cognition. A search strategy was constructed and applied to four databases: EMBASE, Medline, CINAHL and Web of Science. Peer-reviewed journal articles in English were considered assessing the effect of exercise, dietary or cognitive training/stimulation-based interventions (or any combination of these) in patients with T2DM on cognition. Results were dual-screened and extracted by two independent reviewers. Of 4820 results, 3782 remained after de-duplication. Forty full-texts were screened and two studies were included in the final review. The first assessed the impact of a 10-year intensive lifestyle intervention on T2DM-related complications (Look-AHEAD study) and the second was a post hoc analysis of T2DM patients from a trial of a physical activity intervention in older non-demented adult with functional limitations (LIFE study). Whilst the Look-AHEAD study found no impact on diagnosis of mild cognitive impairment or dementia, the LIFE study demonstrated beneficial effects on global cognitive function and delayed memory specifically in older adults with T2DM. There is insufficient evidence to fully assess the effect of non-pharmacological interventions on cognition in T2DM. Well-constructed trials must be designed to specifically assess the effect of non-pharmacological and multi-domain interventions for cognition in patients with T2DM in midlife. All trials examining interventions in T2DM should consider cognition as at least a secondary outcome.

Dementia Diagnosis and Referral in General Practice: A Representative Survey of Irish General Practitioners

Aims Most of those with a memory problem or concern over cognition present to their General Practitioner (GP) in the first instance. Despite this, the current diagnostic and referral patterns of Irish GPs remains unclear. Methods A survey was distributed to three separate cohorts of GPs (n=692) Results Ninety-Five (14%) responded. Most personally diagnose 1-3 (69%; 65/95) or 4-6 (21%; 20/95) patients with dementia per year. Two-thirds (62%; 59/95) refer >80% of those with possible dementia for further assessment/support, most commonly to support/clarify a diagnosis (71%; 67/95) and most frequently to a geriatrician (79%; 75/95). In half of cases (51%; 48/95), referral is to a professional working as part of an established memory clinic. One-fifth reported receiving dementia-specific postgraduate training (19%; 18/95) and over four-fifths (82%; 78/95) would welcome further training. Discussion Further attention to the ongoing establishment of memory clinic services and dedicated referral pathways, as well as increasing emphasis on dementia assessment and diagnosis in medical curricula, is warranted.

Patterns of mortality in modern stroke care

Background Stroke is a leading cause of death. We looked at the causes (direct and indirect) of in-hospital mortality in a modern stroke unit over a two-year period. Methods We reviewed medical charts of stroke deaths in hospital from 2014-2015 inclusive. Data on stroke type, aetiology, age, length of stay, comorbidities, and documented cause of death were recorded. All patients were included. Results 518 patients were admitted acutely to the stroke service. Overall death rate was 7.5% (n=39). Of fatal strokes 29 (74%) were ischaemic. Average age 78.6 years. Mean survival was 26.4 days (range 1-154). 19 (49%) patients had atrial fibrillation. Forty-nine percent of deaths were due to pneumonia, and 33% were due to raised intracranial pressure. Discussion Mortality rate in our stroke service has decreased from 15% in 1997, and now appears dichotomised into early Secondary Stroke Related Cerebral Events (SSRCEs) and later infections.

Structuring Diabetes Mellitus Care in Long-Term Nursing Home Residents.

Nursing home residents with diabetes have more complex care needs with higher levels of comorbidity, disability and cognitive impairment. We compared current practice in the 44 long-term residents in Peamount hospital with the standards recommended in the Diabetes UK "Good Clinical Practice Guidelines for Care Home Residents with Diabetes". Of 44 residents, 11 were diabetic. Residents did not have specific diabetes care plans. There were some elements of good practice with a low incidence of hypoglycaemia and in-house access to dietetics and chiropody. However, diabetes care was delivered on an ad-hoc basis without individualised care plans, documented glycaemic targets, or scheduled monitoring for complications and no formal screening for diabetes on admission. National and local policy to guide management of diabetes mellitus should be developed. There should be individualised diabetes care plans, clear policies for hypoglycaemia, hyperglycaemia and long-term diabetes complications, screening on admission and increased uptake of the national retinal screening and foot care programmes.

The association between antidepressant use and orthostatic hypotension in older people: a matched cohort study.

Orthostatic hypotension (OH) is often reported as a significant potential adverse effect of antidepressant use but the association between phasic blood pressure (BP) and antidepressants has not yet been investigated. This cross-sectional study compares continuously measured phasic BP and prevalence of OH in a cohort of antidepressant users ≥50 years compared with an age- and sex-matched cohort not taking antidepressants. OH was defined as a drop in systolic BP ≥ 20 mm Hg or in diastolic BP ≥ 10 mm Hg at 30 seconds after standing, measured using continuous beat-to-beat finometry. Multilevel time × group interactions revealed significantly greater systolic and diastolic BP drop in antidepressant users than nonusers at 30 seconds after stand. The prevalence of OH among antidepressant users was 31% (63/206), compared with 17% in nonusers (X2 = 9.7; P = .002). Unadjusted logistic regression models demonstrated that selective serotonin reuptake inhibitor use was associated with OH at an odds ratio of 2.11 (95% confidence interval: 1.25-3.57); P = .005, and this association was not attenuated when covariates including cardiac disease and depressive symptom burden were added. There was no statistically significant association between serotonin noradrenaline reuptake inhibitor or tricyclic antidepressant use and OH in unadjusted models although the study was not powered to detect changes within these subgroups. Older people taking antidepressants have a two-fold higher prevalence of OH than nonusers, highlighting the importance of screening the older antidepressant user for OH and dizziness and rationalizing medications to reduce the risk of falls within this vulnerable cohort.

Validation of the 8-item Centre for Epidemiological Studies Depression Scale in a cohort of community-dwelling older people: data from The Irish Longitudinal Study on Ageing (TILDA).

BACKGROUND: The aim of this study was to validate the 8-item Centre for Epidemiological Studies Depression Scale (CES-D-8) against the 20-item version (CES-D-20) in a large sample of community-dwelling older people. METHODS: Scales were compared for correlation and internal consistency. The ideal cut-off score for the CES-D-8 was determined by comparing scores ranging from 7 to 12 on the CES-D-8 to CES-D-20. RESULTS: 8033 participants were included. The Spearman co-efficient between the scales was 0.8980 indicating high degree of correlation. At a score of 9/24, the sensitivity and specificity of the CES-D-8 were 98 and 83%, respectively. The Cohen's κ for a score of 9 was 0.7855, indicating strong agreement and the ROC area was 0.88. CONCLUSION: When compared to the CES-D-20, the CES-D-8 is a valid and reliable measure of depressive symptoms in community-dwelling older people, and a score of 9 can be used to identify those with clinically significant symptoms.

Screening for frailty in older emergency department patients: the utility of the Survey of Health, Ageing and Retirement in Europe Frailty Instrument.

BACKGROUND: Greater numbers of older patients are accessing hospital services. Specialist geriatric input at presentation may improve outcomes for at-risk patients. The Survey of Health, Ageing and Retirement in Europe Frailty Instrument (SHARE-FI) frailty measure, developed for use in the community, has also been used in the emergency department (ED). AIM: To measure frailty, review its prevalence in older patients presenting to ED and compare characteristics and outcomes of frail patients with their non-frail counterparts. DESIGN: Patient characteristics were recorded using symphony® electronic data systems. SHARE-FI assessed frailty. Cognition, delirium and 6 and 12 months outcomes were reviewed. METHODS: A prospective cohort study was completed of those aged ≥70 presenting to ED over 24 h, 7 days a week. RESULTS: Almost half of 198 participants (46.7%, 93/198) were classified as frail, but this was not associated with a significant difference in mortality rates (OR 0.89, 95% CI 0.58-1.38, P = 0.614) or being alive at home at 12 months (OR 1.07, 95% CI 0.72-1.57, P = 0.745). Older patients were more likely to die (OR 2.34, 95% CI 1.30-4.21, P = 0.004) and less likely to be alive at home at 12 months (OR 0.49, 95% CI 0.23-0.83, P = 0.009). Patients with dementia (OR 0.24, P = 0.005) and on ≥5 medications (OR 0.37, 95% CI 0.16-0.87, P = 0.022) had a lower likelihood of being alive at home at 12 months. CONCLUSIONS: Almost half of the sample cohort was frail. Older age was a better predictor of adverse outcomes than frailty as categorized by the SHARE-FI. SHARE-FI has limited predictability when used as a frailty screening instrument in the ED.

Investigation and diagnostic formulation in patients admitted with transient loss of consciousness.

Several commonly completed tests have low diagnostic yield in the setting of transient loss of consciousness (T-LOC). We estimated the use and cost of inappropriate investigations in patients admitted with T-LOC and assessed if these patients were given a definitive diagnosis for their presentation. We identified 80 consecutive patients admitted with T-LOC to a university teaching hospital. Eighty-eight percent (70/80) had a computerized topography (CT) brain scan and 49% (34/70) of these scans were inappropriate based on standard guidelines. Almost half (17/80) of electroencephalograms (EEG) and 82% (9/11) of carotid doppler ultrasound performed were not based on clinical evidence of seizure or stroke respectively. Forty-four percent (35/80) of patients had no formal diagnosis documented for their presentation. Inappropriate investigation in T-LOC is very prevalent in the acute hospital, increasing cost of patient care. In addition, there is poor diagnostic formulation for T-LOC making recurrent events more likely in the absence of definitive diagnoses.

Towards a building typology and terminology for Irish hospitals.

BACKGROUND: The physical form of the hospital environment shapes the care setting and influences the relationship of the hospital to the community. Due to ongoing demographic change, evolving public health needs, and advancing medical practice, typical hospitals are frequently redeveloped, retrofitted, or expanded. It is argued that multi-disciplinary and multi-stakeholder approaches are required to ensure that hospital design matches these increasingly complex needs. To facilitate such a conversation across different disciplines, experts, and community stakeholders, it is helpful to establish a hospital typology and associated terminology as part of any collaborative process. AIMS: Examine the literature around hospital design, and review the layout and overall form of a range of typical Irish acute public hospitals, to outline an associated building typology, and to establish the terminology associated with the planning and design of these hospitals in Ireland. METHODS: Searches in 'Academic Search Complete', 'Compendex', 'Google', 'Google Scholar', 'JSTOR', 'PADDI', 'Science Direct', 'Scopus', 'Web of Science', and Trinity College Dublin Library. The search terms included: 'hospital design history'; 'hospital typology'; 'hospital design terminology'; and 'hospital design Ireland'. RESULTS: Typical hospitals are composed of different layouts due to development over time; however, various discrete building typologies can still be determined within many hospitals. This paper presents a typology illustrating distinct layout, circulation, and physical form characteristics, along with a hospital planning and design terminology of key terms and definitions. CONCLUSION: This typology and terminology define the main components of Irish hospital building design to create a shared understanding around design, and support stakeholder engagement, as part of any collaborative design process.

Dementia in the acute hospital: the prevalence and clinical outcomes of acutely unwell patients with dementia.

BACKGROUND: Studies have demonstrated that a significant minority of older persons presenting to acute hospital services are cognitively impaired; however, the impact of dementia on long-term outcomes is less clear. AIM: To evaluate the prevalence of dementia, both formally diagnosed and hitherto unrecognised in a cohort of acutely unwell older adults, as well as its impact on both immediate outcomes (length of stay and in-hospital mortality) and 12-month outcomes including readmission, institutionalisation and death. DESIGN: Prospective observational study. METHODS: 190 patients aged 70 years and over, presenting to acute hospital services underwent a detailed health assessment including cognitive assessment (standardised Mini Mental State Examination, AD8 and Confusion Assessment Method for the Intensive Care Unit). Patients or informants were contacted directly 12 months later to compile 1-year outcome data. Dementia was defined as a score of 2 or more on the AD8 screening test. RESULTS: Dementia was present in over one-third of patients (73/190). Of these patients, 36% (26/73) had a prior documented diagnosis of dementia with the remaining undiagnosed before presentation. The composite outcome of death or readmission to hospital within the following 12 months was more likely to occur in patients with dementia (73% (53/73) vs. 58% (68/117), P = 0.043). This finding persisted after controlling for age, gender, frailty status and medical comorbidities, including stroke and heart disease. CONCLUSION: A diagnosis of dementia confers an increased risk of either death or further admission within the following 12 months, highlighting the need for better cognitive screening in the acute setting, as well as targeted intervention such as comprehensive geriatric assessment.

Antipsychotic prescription amongst hospitalized patients with dementia.

BACKGROUND: Antipsychotic drugs are used to treat behavioural and psychological symptoms of dementia, despite significant safety concerns regarding increased risk of stroke and mortality. The numbers of patients with dementia and related behavioural symptoms being treated in acute hospitals is increasing. AIM: (i) to determine pre-admission and in-hospital prevalence of antipsychotic use in a national sample of patients with dementia and acute illness; (ii) identify reasons for antipsychotic use; (iii) assess features of the ward environment which impact on patients with dementia; (iv) determine availability of dementia-specific policies, training, appraisal and mentorship programs which influence service delivery. DESIGN AND METHODS: Four-part standardized audit in 35 public acute hospitals comprising (i) retrospective healthcare record review (n = 660); (ii) prospective assessment of ward environment (n = 77); (iii) ward organization interview with clinical managers (n = 77); (iv) hospital organisation interview with senior managers (n = 35). RESULTS: Antipsychotic drugs were prescribed to 29% of patients with dementia before hospitalization and to 41% during hospitalization; one quarter received new or additional prescriptions. Assessments for delirium (45%), dementia symptoms (39%), mood (26%), mental state (64%) and distress-provoking factors (3%) were suboptimal. Drug indications were documented in 78%. Non-pharmacological interventions were not documented. Most wards lacked environmental cues to promote orientation. Dementia-specific care pathways existed in 2 of 35 hospitals. Staff support and training programmes were suboptimal. 12% of patients were discharged with new antipsychotic prescriptions. CONCLUSION: Antipsychotic medications are commonly prescribed for hospitalized patients with dementia in Ireland. Ward environments and dementia-related governance structures are suboptimal.

Acute hospital care: how much activity is attributable to caring for patients with dementia?

BACKGROUND: People with dementia are among the most frequent service users in the acute hospital. Despite this, the acute hospital is not organized in a manner that best addresses their needs. METHODS: We examined acute dementia care over a 3-year period from 2010 to 2012 in a 600-bed university hospital, to clarify the service activity and costs attributable to acute dementia care. RESULTS: Nine hundred and twenty-nine patients with dementia were admitted during the study period, accounting for 1433/69 718 (2%) of all inpatient episodes, comprising 44 449/454 169 (10%) of total bed days. The average length of stay was 31.0 days in the dementia group and 14.1 days in those >65 years without dementia. The average hospital care cost was almost three times more (€13 832) per patient with dementia, compared with (€5404) non-dementia patients, accounting for 5% (almost €20 000 000) of the total hospital casemix budget for the period. DISCUSSION: Service activity attributable to dementia care in the acute hospital is considerable. Moreover, given the fact that a significant minority of cognitive impairment goes unrecognized after acute admissions, it is likely that this is under-representative of the full impact of dementia in acute care. Although the money currently being spent on acute dementia care is considerable, it is being used to provide a service that does not meet its user needs adequately. It is clear that acute hospitals need to provide a more 'dementia friendly' service for acutely unwell older persons.

Clinical Consensus Guidelines on the Application of Cerebrospinal Fluid Biomarkers for Alzheimer's Disease Diagnosis: Recommendations of the Irish Network for Biomarkers in Neurodegeneration.

It is accepted that a lumbar puncture (LP) and cerebrospinal fluid (CSF) biomarker analysis support the routine diagnostic work-up for the differential diagnosis of dementia due to Alzheimer's disease (AD) within certain patient cohorts1. These tests, which measure CSF protein concentrations of amyloid-ß42 (Aß42), total tau (t-tau) and phospho tau (p-tau), were recently validated, accredited and made available clinically for the first time in Ireland. A working group, comprising Irish clinical and scientific researchers, met to review a) the validation results; b) international consensus opinions, and c) research and clinical evidence as to the clinical utility of CSF biomarker analysis for AD dementia diagnosis. The outcome of this meeting was the formulation of a consensus statement paper for the benefit of health care professionals involved in the diagnosis and management of dementia to ensure appropriate use of these biomarker tests in clinical settings in Ireland.