Symposia / European Geriatric Medicine 5S1 (2014) S17–S43 S37

history alone. Previous clinical trials on unexplained falls have

highlighted the benefit of pacemaker insertion in elderly patients

who have cardiogenic causes for their falls.

Conventional cardiac event monitors as well as ambulatory blood

pressure monitors allow patients to have their cardiac rhythms

and blood pressure monitored in a non-invasive way. Their utility

is limited by the length of time they can remain on a patient

(usually up to one week). The use of implantable loop recorder (ILR)

technology has made it easier to monitor patients for an extended

period of time. This technology allows for continued ambulatory

monitoring of a patient’s cardiac rhythm for up to three years. A

pilot study is currently being undertaken in St. James Hospital called

the Falls and Unexplained Syncope in the Elderly Trial (FUSE). It has

found that between 35–40% of patients in the trial had a cardiac

abnormality detected by the loop recorder and 20% of the group

had syncopal events detected which required a pacemaker within

the first six months alone. In addition it has allowed patients to

transmit this information remotely through a telephone line. This

and other medical technologies offer powerful new investigations

in the diagnosis of syncope in unexplained falls.

Atrial fibrillation: an underestimated risk factor for falls and

syncope

(S. Jansen):

Background: Atrial fibrillation (AF) is the most common cardiac

arrhythmia, but little evidence regarding the association between

AF and falls and syncope exists.

Methods: Within the Irish Longitudinal Study on Ageing (TILDA),

cross-sectional analyses within a population sample of people

aged 50 and over was performed. Ten-minute electrocardiogram

recordings (n = 4885) were analysed to detect AF. Information

on falls and/or syncope in the past year was gathered

through computer aided personal interviews (CAPI). Self-reported

comorbidities, subjective and objective health measures and

medications were also recorded. Multivariate logistic regression

was performed to study associations between atrial fibrillation and

falls and/or syncope. Mean age was 62 years (SD ±8.4), 54% was

male.

Results: Prevalence of AF was 3% with a marked age gradient to

1:5 men of 80 years and over. Of participants, 23% experienced

falls and/or syncope in the past year (87% falls, 20% syncope).

Overall, AF was associated with one or more falls and/or syncope

after adjustment for potential confounders (OR 1.6 [95%CI 1.0–2.4]).

After stratification for age group, AF was significantly associated

with falls in participants aged 65–74 years (OR 2.0 [1.0–3.9]), and

with syncope in participants aged 50–64 years (OR 4.7 [1.7–12.8]).

Conclusion: AF is associated with falls and syncope in a cohort of

community dwelling older persons in Ireland. Early recognition of

AF could potentially decrease fall and syncope risk, and prevent

stroke and other AF related cardiovascular events.

Cerebral perfusion in (unexplained) falls and syncope

(J.A.H.R. Claassen):

This presentation will explain the physiology of blood pressure and

blood pressure regulation, and of cerebral autoregulation, using

examples from physiological measurements in elderly subjects

(aging controls, geriatric patients who visit the falls clinic). It will

illustrate how these mechanisms can be separated from each other

and how they work together to minimize cerebral hypoperfusion,

e.g. during changes in posture. Finally, this presentation will

explain how cerebral autoregulation can explain the inter-

individual and intra-individual difference in symptomatology for

similar reductions in blood pressure. A common clinical example

is that some patients have presyncope with orthostatic blood

pressure drop of 25mmHg, whereas others withstand reductions

of 60mmHg apparently without symptoms. Recordings of blood

pressure and cerebral blood flow, obtained from geriatric falls

patients, will be used to illustrate these points.

This presentation will contribute towards the fourth learning

objective.

SS7.02

Using clinical research to change clinical practice – closing

the “know–do” gap

J.R. Gladman4, A.H. Ranhoff2, A.L. Gordon1, S.P. Conroy3

1University of Nottingham, Nottingham, United Kingdom; 2Kavli

Research Center for Ageing and Dementia, Bergen, Norway;3Nottingham University Hospitals NHS Trust, Nottingham, United

Kingdom; 4University of Leicester, Leicester, United Kingdom

Medical research is a process that begins with findings from

fundamental research and ends with impact on wider society. Two

‘translational gaps’ have been identified. The first translational gap –

“from bench to patient” – describes moving findings of potential

clinical value from genetic, cellular or organ studies to practical

application in humans. The second translational gap refers to what

is sometimes called the “know–do” gap, or “implementation gap”.

This describes a failure to put research showing proven benefits

into clinical practice. This symposium will describe experience

gained by four researchers in medicine of older people about the

“know–do” gap – how research can be used to modify clinical

practice.

The know–do gap

(J.R. Gladman):

JG will talk about the know–do gap, drawing upon the principles

used by a UK organisation which has been developed to help

more research cross the gap – the Collaboration for Leadership and

Applied Health Research and Care (CLAHRC). He will illustrate these

principles by their application to his recently completed research

programme in frail older people. He will describe and critically

appraise a variety of knowledge transfer approaches used in the

closure of the know–do gap.

Closing the gap (1): Examples from hip fracture patients in

Norway

(A.H. Ranhoff):

AHR will present practical examples from the care of older hip

fracture patients in Norway. Despite Norway having the highest

incidence of hip fractures in the world, orthogeriatric services have

been difficult to organize. She will present the latest innovations in

research, the status of hip fracture care in Norway; with results from

a local quality database and the National Hip Fracture Registry. The

implementation of orthogeriatric care, and particularly integrated

medical and geriatric interdisciplinary care, will be described

and discussed step by step with local, regional and national

perspectives.

Closing the gap (2): Healthcare for care home residents in the

UK

(A.L. Gordon):

AG will present an example from community geriatrics using two

studies. The Care Home Outcome Study (CHOS) provided a rationale

for care which is multidisciplinary, iterative and uses expertise

in common geriatric syndromes. Staff Interviews in Care Homes

Study (STICH) described poor transfer of care documentation,

inadequate recognition of care homes’ role in care management

and difficulties responding to daily fluctuations in health. These

findings have supported new contracts for general practitioners,

models for comprehensive geriatric assessment prior to care home

admission, better transfer of care documentation and a leadership

programme for care home managers.

Closing the gap (3): Acute Medical unIt comprehensive Geriatric

assessment interventiOn Study

(S.P. Conroy):

SC will present an example from hospital-based care. He will

consider outputs from the Acute Medical unIt comprehensive

Geriatric assessment interventiOn Study (AMIGOS) – a randomised

S38 Symposia / European Geriatric Medicine 5S1 (2014) S17–S43

controlled trial to evaluate the effect of CGA in frail older

patients identified amongst acute medical admissions – and the

development of the Silver Book – a national guideline for the

effective management of acutely unwell older patients. He will

describe the journey from the research to implementation locally,

regionally and nationally and how acute care for frail older patients

is changing as a consequence of research findings.

SS8.01

Diagnostic decision making in patients with suspected venous

thromboembolism across hospital walls and age limits

G.J. Geersing, H.L. Koek, H.J. Schouten, J.J.M. Van Delden

UMC Utrecht, The Netherlands

How diagnosing VTE in older patients might differ from

diagnosing VTE in younger adult patients

(G.J. Geersing):

To correctly exclude the presence of VTE without need for further

diagnostic work-up, so-called diagnostic decision rules – based on a

weighed combination of signs and symptoms and the result of the

D-dimer test – have been developed. These strategies have been

derived and validated in both primary and secondary care patients

suspected of VTE. Notably frail older patients might benefit from

such a strategy provided that it can safely rule-out VTE in a substan-

tial proportion of them without needing to be referred for imaging

examination. Yet, the accuracy of these existing clinical decision

rules to rule-out VTE has never been tested in elderly populations.

Geert-Jan Geersing will discuss how diagnosing VTE in older

patients might differ from diagnosing VTE in younger adult patients.

The predictive performance of clinical decision rules is susceptible

to changes in patient populations and these rules might therefore

perform worse in older patients in whom the prevalence of both

VTE and co-morbidity are higher and the presentation of VTE might

be more obscure. Also, the translation of rules derived in hospital

setting to primary care or nursing-home setting might be problem-

atic. In addition, current available diagnostic strategies recommend

referral for further imaging examination for more than half of the

patients, whereas diagnostic decision strategies that would spare

higher proportions of older patients the possible hazardous referral

for imaging examination might better serve their needs.

Based on: Schouten HJ, Koek HL, Moons KG, van Delden JJ, Oudega R,

Geersing GJ. Eur J Gen Pract. 2013 Jun; 19(2): 123–7.

Validity of clinical decision rules to rule out VTE in older

ambulatory patients

(H.L. Koek):

Dineke Koek will present the results of the “Venous

thromboembolism in the elderly” study; a prospective validation

study on the accuracy of clinical decision rules to exclude venous

thromboembolism in frail older nursing home patients and primary

care patients (mean age 80 years) with clinically suspected deep

vein thrombosis or pulmonary embolism. VTE occurred in 29%

of the patients primarily suspected of pulmonary embolism and

in 47% of those primarily suspected of deep vein thrombosis. This

prevalence was much higher than in previous studies in populations

of younger adult patients (reporting a prevalence between 7% and

20%). This resulted in a higher failure rate (false negative rate) in

patients who had a low score on the clinical decision rule and a

normal D-dimer test (6% in our study versus below 2% in previous

studies). Dineke Koek will also discuss the potency of clinical

decision rules to rule in VTE in frail older patients (as opposed to

the current approach of ruling out VTE). A combined rule-out and

rule-in approach may enable clinicians’ decision-making for up to

58% of patients without the need for further diagnostic work-up.

Based on: Schouten HJ, Koek HL, Oudega R, Van Delden JJ, Moons KG,

Geersing GJ. Accuracy of decision strategies in diagnosing deep vein

thrombosis in frail older out-of-hospital patients – a validation study.

Submitted. And: Schouten HJ, Geersing GJ, Oudega R, Van Delden JJ,

Moons KG, Koek HL. Accuracy of the Wells-rule for pulmonary

embolism in older ambulatory patients. Submitted.

The diagnostic value of the D-dimer test using either

conventional or age-adjusted cut-off values in older patients

with suspected VTE

(H.J. Schouten):

A normal D-dimer test can rule out VTE in patients with a non-

high clinical probability according to a clinical decision rule. Since

D-dimer levels increase with age, D-dimer testing is less useful

to exclude VTE in older patients if the conventional cut-off value

(500mg/L) above which the test is considered abnormal is applied.

As potential solution of this problem, researchers proposed to use

an age-adjusted cut-off value (age·10mg/L) in patients >50 years. In

the third part of the symposium, Henrike Schouten will discuss the

results of a systematic review and bivariate random effects meta-

analysis on this topic. We included 13 cohorts that enrolled older

patients suspected of VTE in whom D-dimer testing (using both

conventional and age-adjusted cut-off values) and reference testing

were performed. Based on published data we reconstructed 2x2

tables, stratified by predefined age-categories and applied D-dimer

cut-off value. We found that the proportion of patients with a non-

high clinical probability (according to a clinical decision rule) in

whom D-dimer testing could exclude VTE was only 12.4% in those

aged more than 80 years. Therefore, D-dimer testing has limited

utility in older patients when the conventional cut-off value is

applied. Application of age-adjusted cut-off values increased the

specificity without modifying the sensitivity which remained >97%

in all age categories and would have resulted in correctly avoided

imaging examinations in 30–42% of patients over 60 years with a

non-high probability as compared to 12–33% when the conventional

cut-off value was applied.

Based on: Schouten HJ, Koek HL, Oudega R, Geersing GJ, Janssen KJ, van

Delden JJ, Moons KG. BMJ 2012 Jun 6; 344: e2985. And: Schouten HJ,

Geersing GJ, Koek HL, Zuithoff NP, Janssen KJ, Douma RA, van Delden JJ,

Moons KG, Reitsma JB. BMJ. 2013 May 3; 346: f2492.

Considerations in decisions to either refer for- or to withhold

additional diagnostic investigations in frail older patients

(J.J.M. van Delden):

Patients with a high risk of VTE require appropriate imaging

examination to confirm or refute the diagnosis. These imaging

modalities are mostly not available in primary care and nursing

home settings, necessitating patients in the high-risk category to

be referred to a hospital. Prior work has shown that frail older

patients are vulnerable for distress and complications resulting

from transitions to hospital-care. Hence, physicians might feel

reluctant to refer frail elderly patients for additional investigations.

Hans van Delden will set out the results of a study on physicians’

considerations in their decision-making to either refer for or to

withhold additional diagnostic investigations in nursing home

patients with suspected VTE. We applied both quantitative and

qualitative methods. In the quantitative part, patient outcomes

were related to the decision to withhold diagnostic investigations.

Referral for additional diagnostic investigations was withheld

in four out of ten nursing home patients for whom imaging

examination for suspected VTE was indicated. Patients in whom

diagnostic investigations were withheld had a higher mortality

rate than referred patients. For a better understanding of elderly

care physicians’ decisions, in-depth interviews were performed and

analysed using the grounded theory approach. In their decisions to

forgo diagnostic investigations, physicians incorporated the severity

of symptoms and estimated prognosis of the disease in the light

of the patients’ chronic condition, potential benefits of diagnostic

investigations and whether perfor-ming investigations agreed with

pre-established management goals in advance care planning.

Based on: Schouten HJ, van Ginkel S, Koek HL, Geersing GJ, Oudega R,

Moons KG, Van Delden JJ. J Am Med Dir Assoc. 2012 Oct; 13(8): 682–7.