Marnie Graco

An enhanced exercise and cognitive programme does not appear to reduce incident delirium in hospitalised patients: a randomised controlled trial

Objective To determine if a programme of progressive resistance exercise, mobilisation and orientation, in addition to usual care, was superior to usual care alone in the prevention of incident delirium in older hospitalised patients. Design A randomised controlled trial. Setting The study was performed at a secondary referral hospital in Melbourne, Australia between May 2005 and December 2007. Participants 648 consecutive medical inpatients aged 65 years or older who had been in hospital for less than 48 h and who did not have delirium. Intervention Participants were randomly allocated to a twice-daily programme of progressive resistance exercise tailored to individual ability, mobilisation and orientation in addition to usual care or to usual care alone. Measurements Delirium was measured using the Confusion Assessment Method at baseline and every 48 h until discharge. Secondary outcome measures were severity and duration of delirium, discharge destination and length of stay. Results Delirium occurred in 4.9% (95% CI 2.3% to 7.3%) of the intervention group (15/305) and in 5.9% (20/339; 95% CI 3.8% to 9.2%) of the group receiving usual care. No difference was observed between groups (χ2; p=0.5). The intervention had no effect on delirium duration, severity, discharge destination or length of stay. Conclusion A programme of progressive resistance exercise and orientation was not effective in reducing incident delirium in hospitalised elderly patients.

Validation of the hospital outcome prediction equation (HOPE) model for monitoring clinical performance

Background: The aim of this study was to validate a risk‐adjusted hospital outcome prediction equation (HOPE) using a statewide administrative dataset.

Glycemic outcome not predicted by baseline psychological measures in a diabetes management program.

The Northern Health Diabetes Hospital Admission Risk Program is a chronic disease management program that aims to improve the glycemic management of patients with diabetes. The aim of this project was to determine if there was any relationship between psychological characteristics and glycemic outcome in a diabetes management program. A prospective study of patients attending the diabetes management program investigated validated measures of cognition, stage of change, locus of control, self-efficacy, depression and anxiety, and quality of life. The study investigated 86 type 2 diabetes patients (mean age 59 years, 49% female). Glycemic control (HbA1c) was measured at baseline and after 12 months in the program. Glycemic control was poor on admission to the service with a mean HbA1c of 8.9%. The measures of cognition, self-efficacy, locus of control, mental health, and quality of life were not associated with improvements in HbA1c. Those participants with shorter duration of disease and more contacts with the service were significantly more likely to experience improvements in HbA1c. Psychometric data were not predictive of glycemic outcome. Rather, in this chronic disease management program, glycemia improved more in patients who were seen earlier in their disease course and managed more intensively, regardless of their psychometric status.

Neuropsychological function in patients with acute tetraplegia and sleep disordered breathing

&NA; Sleep disordered breathing is highly prevalent following spinal cord injury and likely caused by the injury. Beyond the devastating physical consequences of spinal cord injury, neuropsychological dysfunction is also common. In both the able‐bodied and chronic spinal cord injury patients, sleep disordered breathing impairs many areas of neuropsychological function. However, this has not been investigated in patients with acute injury. Study objectives: To investigate the relationship between apnea severity and neuropsychological function in patients with acute‐onset tetraplegia and sleep disordered breathing. Methods: Polysomnography and neuropsychological testing were performed on 104 participants (age M = 45.60, SD = 16.38; 10 female) across 11 international sites, 2 months postinjury (M = 60.70 days, SD = 39.48). Neuropsychological tests assessed attention, information processing, executive function, memory, learning, mood, and quality of life. Results: More severe sleep apnea was associated with poorer attention, information processing, and immediate recall. Deficits did not extend to memory. Higher preinjury intelligence and being younger reduced the associations with sleep disordered breathing; however, these protective factors were insufficient to counter the damage to attention, immediate recall, and information processing associated with sleep disordered breathing. Conclusions: These data suggest that new spinal cord injury may function as a model of “acute sleep apnea” and that more widespread sleep apnea‐related deficits, including memory, may only be seen with longer exposure to apnea. These findings have important implications for functioning and skill acquisition during rehabilitation and, as such, highlight the importance of sleep health following tetraplegia.

Depression is greater in non-English speaking hospital outpatients with type 2 diabetes.

This study aimed to compare the prevalence of depression and anxiety in English (ES) and non-English speaking (NES) hospital outpatients with type 2 diabetes. Overall, depression and/or anxiety were present in 31% of patients. The prevalence of depression was significantly higher in NES than ES patients (p=0.03).

Subjective sleep disturbances and quality of life in chronic tetraplegia

Study design:This is a cross-sectional survey.Objectives:The objective of this study was to evaluate the subjective sleep disturbances and quality of life in chronic tetraplegia.Setting:This study was conducted in a community sample from Victoria, Australia.Methods:People with tetraplegia were mailed a survey battery including the following: demographic questions; Karolinska Sleepiness Scale (KSS); Basic Nordic Sleepiness Questionnaire; Functional Outcomes of Sleep Questionnaire (FOSQ); Multivariate Apnoea Prediction Index and Assessment of Quality of Life (AQoL) Questionnaire. Scores were compared with the best available normative data.Results:A total of 163 of 424 (38%) surveys were returned (77% male; 39% sensory and motor complete; mean age±s.d.=46±14 years; mean years since injury=11±8 years). The AQoL health utility score (0.31±0.29) was significantly lower than published population norms. FOSQ total (17.55±2.57) and KSS (3.93±2.27) scores were no different from the best available population data. People with tetraplegia reported worse sleep habits, symptoms and quality than a normal population, as indicated on 17 of 21 questions on the Basic Nordic Sleep Questionnaire. Multivariate analysis found that greater injury severity (coefficient (95% CI)=0.14 (0.10, 0.18)), increasing age (−0.004 (−0.008, −0.001)) and worse sleep symptoms (−0.005 (−0.009, −0.0003)) were all significantly associated with reduced quality of life.Conclusion:People with chronic tetraplegia experience more subjective sleep problems and worse quality of life than their able-bodied counterparts. Quality of life is related to injury severity, age and sleep symptoms. Treating the sleep disorders experienced by people living with tetraplegia has the potential to improve their health and well-being.

Diagnostic accuracy of a two-stage model for detecting obstructive sleep apnoea in chronic tetraplegia

Background Obstructive sleep apnoea (OSA) is highly prevalent in people with spinal cord injury (SCI). Polysomnography (PSG) is the gold-standard diagnostic test for OSA, however PSG is expensive and frequently inaccessible, especially in SCI. A two-stage model, incorporating a questionnaire followed by oximetry, has been found to accurately detect moderate to severe OSA (MS-OSA) in a non-disabled primary care population. This study investigated the accuracy of the two-stage model in chronic tetraplegia using both the original model and a modified version for tetraplegia. Methods An existing data set of 78 people with tetraplegia was used to modify the original two-stage model. Multivariable analysis identified significant risk factors for inclusion in a new tetraplegia-specific questionnaire. Receiver operating characteristic (ROC) curve analyses of the questionnaires and oximetry established thresholds for diagnosing MS-OSA. The accuracy of both models in diagnosing MS-OSA was prospectively evaluated in 100 participants with chronic tetraplegia across four international SCI units. Results Injury completeness, sleepiness, self-reported snoring and apnoeas were included in the modified questionnaire, which was highly predictive of MS-OSA (ROC area under the curve 0.87 (95% CI 0.79 to 0.95)). The 3% oxygen desaturation index was also highly predictive (0.93 (0.87–0.98)). The two-stage model with modified questionnaire had a sensitivity and specificity of 83% (66–93) and 88% (75–94) in the development group, and 77% (65–87) and 81% (68–90) in the validation group. Similar results were demonstrated with the original model. Conclusion Implementation of this simple alternative to full PSG could substantially increase the detection of OSA in patients with tetraplegia and improve access to treatments. Trial registration number Results, ACTRN12615000896572 (The Australian and New Zealand Clinical Trials Registry) and pre-results, NCT02176928 (clinicaltrials.gov).

Long-term change in respiratory function following spinal cord injury.

Study design:Retrospective study.Objectives:To model the effect of time since injury on longitudinal respiratory function measures in spinal cord injured-individuals and to investigate the effect of patient characteristics.Setting:A total of 173 people who sustained a spinal cord injury between 1966 and April 2013 and who had previously participated in research or who underwent clinically indicated outpatient respiratory function tests at the Austin Hospital in Melbourne, Australia, were included in the study. At least two measurements over time were available for analysis in 59 patients.Methods:Longitudinal data analysis was performed using generalised linear regression models to determine changes in respiratory function following spinal cord injury from immediately post injury to many years later. Secondly, we explored whether injury severity, age, gender and body mass index (BMI) at injury altered the time-dependent change in respiratory function.Results:The generalised linear regression model showed no significant change (P=0.276) in respiratory function measured in (forced) vital capacity ((F)VC) after the spinal cord injury. However, significant (P<0.05) differences in respiratory function over time were found when categorising age and BMI.Conclusion:This clinical cohort with long-term, repeated measurements of respiratory function showed no significant overall change in respiratory function over 23 years. However, a decline in respiratory function over time was observed in subgroups of individuals older than 30 years at the onset of injury and in those with a BMI>30 kg m−2.

Validation of the Dutch clinical prediction rule for ambulation outcomes in an inpatient setting following traumatic spinal cord injury.

Study design:Retrospective study.Objectives:To determine the accuracy of a previously described Dutch clinical prediction rule for ambulation outcome in routine clinical practice.Setting:Adult (⩾18 years) patients who were admitted to the Austin Hospital with a traumatic spinal cord injury between January 2006 and August 2014.Methods:Data from medical records were extracted to determine the score of the Dutch clinical ambulation prediction rule proposed by van Middendorp et al. in 2011. A receiver-operating characteristics (ROC) curve was generated to investigate the performance of the prediction rule. Univariate analyses were performed to investigate which factors significantly influence ambulation after a traumatic spinal cord injury.Results:The area under the ROC curve (AUC) obtained during the current study (0.939, 95% confidence interval (CI) (0.892, 0.986)) was not significantly different from the AUC from the original Dutch clinical prediction model (0.956, 95% CI (0.936, 0.976)). Factors that were found to have a significant influence on ambulation outcome were time spent in the ICU, number of days hospitalised and injury severity. Age at injury initially showed a significant influence on ambulation however, this effect was not apparent after inclusion of the 24 patients who died due to the trauma (and therefore did not walk after their injuries).Conclusion:The Dutch ambulation prediction rule performed similarly in routine clinical practice as in the original, controlled study environment in which it was developed. The potential effect of survival bias in the original model requires further investigation.

Recent trends in Victorian risk‐adjusted in‐hospital mortality: 1999–2009

The background of the study is a comparison of risk‐adjusted mortality across hospitals from different jurisdictions is now common worldwide.