Henry Woodford

Diagnosis and management of urinary tract infection in hospitalized older people.

OBJECTIVES: To compare the diagnosis and management of urinary tract infection (UTI) in hospitalized older people with clinical criteria and therapeutic guidelines.OBJECTIVES: To compare the diagnosis and management of urinary tract infection (UTI) in hospitalized older people with clinical criteria and therapeutic guidelines. DESIGN: A retrospective case series of emergency hospital admissions collected over an 18-month period. SETTING: An acute general hospital in northwest England. PARTICIPANTS: Two hundred sixty-five patients aged 75 and older with a diagnosis of UTI at hospital discharge. MEASUREMENTS: Data relating to age, sex, presenting complaint, admission and discharge destinations, background comorbidities and medications, investigations performed, treatment given, length of stay, and complications were obtained using chart review. RESULTS: Of the 265 patients (mean age 85.4) the overdiagnosis of UTI was common, with 43.4% of patients not meeting criteria. Only 32.1% of patients overall had any urinary tract symptoms (48.7% in the UTI group). Of the non-UTI group, 12 (10.4%) had urinary tract symptoms with a negative urine culture, 43 (37.4%) had asymptomatic bacteriuria (ASB), and 60 (52.2%) had neither urinary tract symptoms nor bacteriuria. Treatment given varied greatly. The mortality rate was 6.0%, and the average length of stay was 29.9 days (median 17.0, range 1–192). Complications were frequent, including Clostridium difficile diarrhea (8%), falls (4%), methicillin-resistant Staphylococcus aureus infection (3%), and fracture (2%). CONCLUSION: More-reliable criteria are needed to aid the diagnosis of UTI in hospitalized older people. Better adherence to clinical management guidelines may improve outcomes.

Joint geriatric and psychiatric wards: a review of the literature

Joint geriatric/psychiatric wards are a potential solution to improving care of older patients with both psychiatric and medical illnesses in acute hospitals. A literature search using Medline, PsycINFO, Embase and CINAHL between 1980 and 2010 was carried out for information about joint wards for older people. Thirteen relevant papers were identified. These wards share common characteristics and there is evidence that they may reduce length of stay and be cost-effective, but there are no high-quality randomised controlled trials. Further research is needed, particularly regarding cost-effectiveness.

Non-convulsive status epilepticus: a practical approach to diagnosis in confused older people

Non-convulsive status epilepticus (NCSE) presents with minimal seizure activity clinically, but with evidence on EEG. It is a recognised cause of delirium in older people, but prevalence estimates vary widely. As delirium is a common presentation in older people and because NCSE is potentially reversible, an improved diagnostic ability in this group could be highly beneficial. EEG testing is required to make a definitive diagnosis, but this may be difficult due to access to testing, patient adherence and result interpretation. NCSE has two commonly recognised forms: complex partial status epilepticus (CPSE) and absence status epilepticus (ASE). Clinical features associated with NCSE in older people presenting with confusion include a reduction in level of arousal; aphasia or interrupted speech; myoclonus or subtle jerking; staring; automatisms; perseveration or echolalia; increased tone; nystagmus or eye deviation; emotional lability; disinhibition and anosagnosia. Risk factors include female sex, a history of epilepsy or a tonic–clonic seizure around the time of onset, and recent discontinuation of benzodiazepines. A practical approach to the diagnosis of NCSE in older people is suggested based upon the presence of clinical features suggestive of NCSE and local access to EEG testing.

Electromyographic Biofeedback for the Recovery of Motor Function After Stroke

Graeme J. Hankey MD, FRCP Section Editor: The specific objective of this review was to determine the efficacy of any form of electromyographic biofeedback (EMG-BFB) used after a stroke in order to aid motor function recovery. We searched the Cochrane Stroke Group Trials Register (last searched March 30, 2006), the Cochrane Central Register of Controlled Trials (CENTRAL; The Cochrane Library Issue 4, 2005), MEDLINE (1966 to November 2005), EMBASE (1980 to November 2005), CINAHL (1983 to November 2005), PsycINFO (1974 to November 2005) and First Search (1966 to November 2005). We …

Neurological and cognitive impairments detected in older people without a diagnosis of neurological or cognitive disease

Advanced age is associated with the finding of abnormalities on neurological and cognitive assessment. This review aims to identify studies that evaluated community samples of patients without a history of neurological disease and attempts to combine these data. While neurological signs were common, they were not universal and should not be considered an inevitable component of ageing. Additionally, they are associated with an increased risk of multiple adverse outcomes including functional decline and death. Therefore they should not be considered benign. Cognitive changes detected in studies that examined healthy older adults were only mild. More pronounced change suggests the development of dementia or mild cognitive impairment (a precursor to dementia). Changes in either neurological or cognitive examination in older adults should be considered abnormal and due to underlying disease. They should be investigated and treated in a similar way to abnormalities detected in younger individuals.

THE INVESTIGATION OF SYNCOPE IN OLDER PATIENTS

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