G. S. Rai

An evaluation of risk factors for in-patient falls in acute and rehabilitation elderly care wards.

Falls occurring in elderly in-patients during periods of hospitalization are common, and attempts have been made to predict and prevent them based on risk factor analysis. These have not looked extensively at specific elderly care wards. We have investigated in-patient falls in mixed acute and rehabilitation elderly care wards in a case-controlled study. Fifty fallers were paired with fifty non-fallers, and their risk factors for falling evaluated. Only three risk factors were significantly more common in the fallers. These were: a previous history of falls; the presence of confusion/disorientation, and needing help to toilet/incontinence/diarrhoea. Prediction of falls based on the presence of the first two of these risk factors gives a sensitivity of 68% and a specificity of 88%. A risk factor approach to the prediction of falls in an in-patient elderly care setting seems to be less practical than was previously hoped.

Medication-related admissions in older people: a cross-sectional, observational study.

AbstractBackground: Medication-related admissions are an important cause of hospital admissions in older people. The scope for prevention is less clear. Objectives: To characterize medication-related hospital admissions in older people and assess their preventability. Methods: This was a cross-sectional, observational study conducted over 3 months. A pharmacist based in the medical admissions ward of a north London hospital screened all patients aged ≥65 years. A specialist physician assembled additional information, which was presented to a multi-professional panel to confirm attribution and preventability. A total of 409 patients were screened, of whom 14% (95% CI 10.6, 17.4) had medication-related problems, 6.4% (95% CI 4.0, 8.8) were admitted because of medication-related problems and 3.9% (95% CI 2.0, 5.8) were considered to have preventable medication-related problems. Medicines to prevent or treat cardiovascular disease were implicated in 69% (18/26) of the medication-related admissions and 69% (11/16) of preventable medication-related admissions. Amongst hospitalized patients, admission attributed to adverse drug reaction was more likely as the number of medications being taken increased, and admission attributed to undertreatment was more likely as the number of pre-existing conditions increased. Conclusion: Medication-related admissions are common in older people and over half are preventable. Morbidity associated with medicines used for cardiovascular disease is important. There is a difficult balance to be struck between avoiding iatrogenic illness in older people and ensuring they benefit from medications for pre-existing conditions. Opportunities exist for improving the delivery of care to reduce adverse outcomes.

Clinical brain proton magnetic resonance spectroscopy for management of Alzheimer's and sub-cortical ischemic vascular dementia in older people

This study examined the clinical usefulness of magnetic resonance spectroscopy (MRS) performed using an automated single voxel technique at 1.0 T field strength in a district general hospital magnetic resonance (MR) scanner in the assessment of older people referred to a memory clinic with suspected dementia. Of 50 elderly subjects (M:F 20:30) examined and followed-up clinically over more than 2 years, 20 had clinical Alzheimers disease (AD), 18 had clinical vascular dementia, six had mixed features and three were normal. Three normal volunteers were also studied. MRS was performed at the same time as structural magnetic resonance imaging (MRI), added <15 min to the examination and was well-tolerated in all patients studied. Patients with AD had significantly higher myoinositol/creatine (MI/Cr) ratios (mean +/- S.D.: 0.82 +/- 0.04) compared to those with vascular dementia (mean +/-S. D.: 0.71 +/- 0.07, P<0.00001) and normal subjects (mean +/- S.D.: 0.72 +/- 0.036, P<0.0002); there was little overlap between the AD and vascular groups. The mixed dementia group also had significantly higher MI/Cr ratios (mean +/- S.D.: 0.80 +/- 0.05) than vascular dementia (P<0.01) and normal (P<0.03) groups, but with considerable overlap. No significant differences were shown for N-acetyl aspartate or choline/creatine ratios between the different clinical groups. These data suggest that MI/Cr ratios can distinguish patients with AD from normal subjects and those with sub-cortical ischemic vascular dementia and that MRS will be useful to clinicians managing persons with AD in a district general hospital setting.

Falls Handicap Inventory (FHI)--an instrument to measure handicaps associated with repeated falls

moperitoneum secondary to barotrauma described in the literature are young persons aged 20 to 40 years. This is probably because intensive treatment (including mechanical ventilation) has traditionally been given to young patients suffering from ventilatory failure resulting from asthma. In recent years, however, such treatment has also become available to older patients, yielding cases of barotrauma and pneumoperitoneum among this group of patients. As we expect to see more older patients diagnosed as having pneumoperitoneum, it is of great importance that, once the possibility of life-threatening perforation has been eliminated, unnecessary invasive procedures be avoided and conservative treatment be administered to these high-risk patients.

Copper and Zinc Levels in “Healthy” and “Sick” Elderly

Healthy elderly as a group have a wider range for serum copper, ceruloplasmin, and serum zinc than the adjusted ranges for the laboratory. In disease serum copper and/or ceruloplasmin act as acute‐phase reactants in vascular disease, inflammation, and malignancy. Serum zinc values likewise are affected by the presence of inflammation and malignancy. The reported low level of copper in patients with osteoporosis was not confirmed by the present study. Neither was there any evidence found for zinc deficiency in patients with dementia. J Am Geriatr Soc 33:847, 1985

Study to assess quality of life (morale and happiness) in two continuing care facilities — a comparative study in the UK and The Netherlands

The elderly in a nursing home in Nijmegen are less disabled and have higher morale and happiness scores than the elderly in a continuing care facility in London. These scores, however, do not correlate with physical or mental disabilities within each group. In Nijmegen, religion (practising and importance of) is associated with high happiness scores in the elderly, whereas use of sedatives lead to reduced happiness or low morale in both groups of elderly.

The Functional Autonomy Measurement System (SMAF): a measure of functional change with rehabilitation

The Functional Autonomy Measurement System (SMAF) is an instrument developed for the measurement of needs of the elderly and the handicapped. As this study shows, it can be used to demonstrate progress during rehabilitation. Of the 94 patients admitted and discharged from a 22 bed acute/rehabilitation ward for the elderly, 78 were discharged home or to their original accommodation, 7 died in hospital and 9 were transferred to a continuing care ward or a nursing home. The mean total score (admission vs. discharge: 18.06 vs. 9.18, P < 0.0001) as well as the score for subsections of Activities of Daily Living (ADL) (admission vs. discharge: 15.69 vs. 8.15, P < 0.0001), Communication (admission vs. discharge: 1.01 vs. 0.5, P < 0.0001) and Mental Function (admission vs. discharge: 1.29 vs. 0.64, P < 0.0001) showed significant improvement in the 78 patients who were discharged back to their original accommodation. Patients who died or required placement into a continuing care bed or nursing home showed no change in mean scores with treatment. The inter-observer agreement between two nurses and a doctor showed that the minor modifications to SMAF did not significantly affect the instrument.

Urinary incontinence handicap inventory.

Urinary incontinence is a common symptom encountered in the elderly. To measure the handicaps associated with urinary incontinence due to detrusor instability an instrument consisting of 17 questions (Urinary Incontinence Handicap Inventory (UIHI)) was developed and validated in thirty elderly women. The results show that the instrument has a high Cronbach alpha coefficient (0.87) and high test-to-retest reliability (0.99, P < 0.0001). The total score on the UIHI correlates significantly with the results on the visual analogue scales representing perception of distress felt by the individual (r = 0.91, P < 0.0001) and the severity of the symptom r = 0.78, P < 0.0001).

Medicines management support to older people: understanding the context of systems failure.

Objectives Changing demographics and pressures on the healthcare system mean that more older people with complex medical problems need to be supported in primary and community care settings. The challenge of managing medicines effectively in frail elderly patients is considerable. Our research investigates what can go wrong and why, and seeks insight into the context that might set the scene for system failure. Setting North London; a district general hospital and surrounding health authorities. Participants 7 patients who had been admitted to hospital and 16 informants involved in their care. Design Patients with preventable medication-related admissions were identified in an occurrence screening study. An accident investigation approach was used to create case studies from accounts of staff involved in each patients care prior to their admission. Structured analysis of case studies according to the accident investigation approach was complemented by a separate analysis of interviews using open coding with constant comparison to identify and illustrate higher-level contextual themes. Outcomes The study sheds light on care management problems, their causes and the context in which care management problems and their causes have occurred. Results Care management problems were rooted in issues with decision-making, information support and communications among staff members and between staff, patients and carers. Poor judgement, slips and deviations from best practice were attributed to task overload and complexity. Within general practice, at the interface with community services and with hospitals, we identified disruption to traditional intraprofessional and interprofessional roles, assumptions, channels and media of communication which together created conditions that might compromise patient safety. Conclusions New ways of working driven by the ethos of productivity are disrupting traditional intraprofessional and interprofessional roles, assumptions, channels and media of communication. Concomitant improvements in communications technology, process and protocol are urgently required to offset potentially serious risks to patient safety.

A study of admissions and inpatients over the Christmas period using the appropriateness evaluation protocol (AEP)

The aim of the study was to examine appropriateness of admissions and inpatients over Christmas especially in the elderly. The study was a prospective audit of admissions and inpatients to the Whittington Hospital. The main outcome measures were appropriateness of admission or day of hospital residence using the Appropriateness Evaluation Protocol. The protocol was applied to admissions and inpatients over Christmas and control periods. The results showed that there was a significant difference in the number of elderly admissions between the control period and Christmas period, 94 (34%) vs. 104 (43%) (P=0.02). However there was no corresponding change in appropriateness of elderly admissions, ten (10.6%) vs. six (5.8%), (P=0.2). The inappropriateness of day of hospital residence increased from 10% on the control day to 20% on the study day (P=0.02). In conclusion elderly patients are not admitted more inappropriately over Christmas but their discharge at this time appears to be delayed resulting in inappropriate bed use.