James George

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.

Postacute care for older people in community hospitals: a multicenter randomized, controlled trial.

OBJECTIVES: To compare the effects of community hospital care on independence for older people needing rehabilitation with that of general hospital care.

Systematic approaches to the prevention and management of patiens with delirium

Delirium is a common complication of acute illness in older people. Earlier and more reliable detection could be achieved by greater routine cognitive testing in older people. Research evidence suggests that episodes of delirium and duration of delirium could be reduced by about one third if systems of care that prioritized delirium risk factor amelioration were comprehensively adopted. Specialist delirium units have a place in leading and disseminating best practices. Health service regulators should consider monitoring delirium as an adverse health care outcome.

Family-led rehabilitation after stroke in India (ATTEND): a randomised controlled trial

Summary Background Most people with stroke in India have no access to organised rehabilitation services. The effectiveness of training family members to provide stroke rehabilitation is uncertain. Our primary objective was to determine whether family-led stroke rehabilitation, initiated in hospital and continued at home, would be superior to usual care in a low-resource setting. Methods The Family-led Rehabilitation after Stroke in India (ATTEND) trial was a prospectively randomised open trial with blinded endpoint done across 14 hospitals in India. Patients aged 18 years or older who had had a stroke within the past month, had residual disability and reasonable expectation of survival, and who had an informal family-nominated caregiver were randomly assigned to intervention or usual care by site coordinators using a secure web-based system with minimisation by site and stroke severity. The family members of participants in the intervention group received additional structured rehabilitation training—including information provision, joint goal setting, carer training, and task-specific training—that was started in hospital and continued at home for up to 2 months. The primary outcome was death or dependency at 6 months, defined by scores 3–6 on the modified Rankin scale (range, 0 [no symptoms] to 6 [death]) as assessed by masked observers. Analyses were by intention to treat. This trial is registered with Clinical Trials Registry-India (CTRI/2013/04/003557), Australian New Zealand Clinical Trials Registry (ACTRN12613000078752), and Universal Trial Number (U1111-1138-6707). Findings Between Jan 13, 2014, and Feb 12, 2016, 1250 patients were randomly assigned to intervention (n=623) or control (n=627) groups. 33 patients were lost to follow-up (14 intervention, 19 control) and five patients withdrew (two intervention, three control). At 6 months, 285 (47%) of 607 patients in the intervention group and 287 (47%) of 605 controls were dead or dependent (odds ratio 0·98, 95% CI 0·78–1·23, p=0·87). 72 (12%) patients in the intervention group and 86 (14%) in the control group died (p=0·27), and we observed no difference in rehospitalisation (89 [14%]patients in the intervention group vs 82 [13%] in the control group; p=0·56). We also found no difference in total non-fatal events (112 events in 82 [13%] intervention patients vs 110 events in 79 [13%] control patients; p=0·80). Interpretation Although task shifting is an attractive solution for health-care sustainability, our results do not support investment in new stroke rehabilitation services that shift tasks to family caregivers, unless new evidence emerges. A future avenue of research should be to investigate the effects of task shifting to health-care assistants or team-based community care. Funding The National Health and Medical Research Council of Australia.BACKGROUND Most people with stroke in India have no access to organised rehabilitation services. The effectiveness of training family members to provide stroke rehabilitation is uncertain. Our primary objective was to determine whether family-led stroke rehabilitation, initiated in hospital and continued at home, would be superior to usual care in a low-resource setting. METHODS The Family-led Rehabilitation after Stroke in India (ATTEND) trial was a prospectively randomised open trial with blinded endpoint done across 14 hospitals in India. Patients aged 18 years or older who had had a stroke within the past month, had residual disability and reasonable expectation of survival, and who had an informal family-nominated caregiver were randomly assigned to intervention or usual care by site coordinators using a secure web-based system with minimisation by site and stroke severity. The family members of participants in the intervention group received additional structured rehabilitation training-including information provision, joint goal setting, carer training, and task-specific training-that was started in hospital and continued at home for up to 2 months. The primary outcome was death or dependency at 6 months, defined by scores 3-6 on the modified Rankin scale (range, 0 [no symptoms] to 6 [death]) as assessed by masked observers. Analyses were by intention to treat. This trial is registered with Clinical Trials Registry-India (CTRI/2013/04/003557), Australian New Zealand Clinical Trials Registry (ACTRN12613000078752), and Universal Trial Number (U1111-1138-6707). FINDINGS Between Jan 13, 2014, and Feb 12, 2016, 1250 patients were randomly assigned to intervention (n=623) or control (n=627) groups. 33 patients were lost to follow-up (14 intervention, 19 control) and five patients withdrew (two intervention, three control). At 6 months, 285 (47%) of 607 patients in the intervention group and 287 (47%) of 605 controls were dead or dependent (odds ratio 0·98, 95% CI 0·78-1·23, p=0·87). 72 (12%) patients in the intervention group and 86 (14%) in the control group died (p=0·27), and we observed no difference in rehospitalisation (89 [14%]patients in the intervention group vs 82 [13%] in the control group; p=0·56). We also found no difference in total non-fatal events (112 events in 82 [13%] intervention patients vs 110 events in 79 [13%] control patients; p=0·80). INTERPRETATION Although task shifting is an attractive solution for health-care sustainability, our results do not support investment in new stroke rehabilitation services that shift tasks to family caregivers, unless new evidence emerges. A future avenue of research should be to investigate the effects of task shifting to health-care assistants or team-based community care. FUNDING The National Health and Medical Research Council of Australia.

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.

Confusion: delirium and dementia - a smartphone app to improve cognitive assessment

Abstract Older patients with dementia and delirium are more prone to adverse events in hospital, but formal cognitive assessment to identify these vulnerable patients on admission is often not carried out by junior doctors. A smartphone app was created and provided on hospital wards to facilitate the use of standard cognitive assessments for delirium and dementia. Before the introduction of the app, 36% of patients over 75 years old were assessed cognitively. After the app, the percentage of cognitive assessments improved to 63%. Improvements in cognitive assessments were most marked after individual teaching of the doctors on the wards in the use of the app and on making the app available on the ward tablets. The results of the study suggest that the introduction of a smartphone app for junior doctors can improve performance in cognitive assessment of older people.

Frailty–a clinical overview

Frailty as a concept has been around in medical practice for many years but has only relatively recently been established as a medical syndrome. Although frailty is not synonymous with chronological age, it is recognized to be more common as people get older. Frailty is independently associated with increasing dependency, hospital admissions and morbidity and mortality. As populations age, frailty will become more of a challenge to health care systems. It is important that health care professionals, especially geriatricians, are aware of this emerging syndrome and its potential adverse outcomes, as well as measures to reverse and slow its progress. The aim of this review is to discuss the definition, identification and potential treatment options for frailty, most relevant to the practising clinician.

Improving quality and value in healthcare for frail older people

This article reports an important multi‐centre practice‐based review that identifies good practice and an ideal pathway for the healthcare of frail older people, which, if replicated nationally, could result in improved quality of care and better value for money for the NHS. Data on healthcare resource groups (HRGs) in England were examined as a marker for the management of elderly people through the healthcare system. Care pathways in several different NHS trusts were explored via staff interviews. A high variation in treatment outcomes across centres was found. Principles of best practice were identified and include: comprehensive geriatric assessment; the availability of specialist geriatric teams and wards; and shared assessment and co‐ordination between care agencies.

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.

Medical morbidity and mortality conferences: past, present and future

Morbidity and mortality conferences (MMCs) have three potential aims—to improve patient safety by reducing adverse events and preventable deaths, to improve overall quality of care as part of the hospital governance structure and as educational learning events. At present, medical MMCs vary widely in format and attendance from hospital to hospital. The evidence for MMCs actually reducing adverse events and preventing avoidable deaths is disappointing. There is better evidence for their educational role. The majority of medical deaths in hospitals are frail older people with poor life expectancy in whom inadequate care is more likely to be due to errors of omission rather than commission. Medical MMCs should be multidisciplinary and led by a senior clinician to encourage discussion and reflection in a ‘blame-free’ environment. They should be learning events for both clinicians and the organisation as a whole with a structure to support this.