Mary Hofmann

Practice Guidelines for the Treatment of Patients With Delirium

In general, the treatment of delirium is broken down into three parts—psychiatric management, environmental and supportive interventions, and somatic interventions. In the broadest terms, the underlying cause of the delirium should be sought and treated if possible. Behavioral and environmental intervention should be optimized and instituted first. If necessary, to prevent patient distress or harm, pharmacological interventions should be instituted, the mainstay of which is haloperidol therapy.

Home-Based Leg-Strengthening Exercise Improves Function 1 Year After Hip Fracture: A Randomized Controlled Study

OBJECTIVES: To compare the effectiveness of a short‐term leg‐strengthening exercise program with that of attentional control on improving strength, walking abilities, and function 1 year after hip fracture.

Alimentary tract surgery in the nonagenarian: elective vs. emergent operations.

The objective of this study was to compare elective with emergent surgery in patients over the age of 90 years. We retrospectively reviewed the records of patients over 90 years of age who underwent alimentary tract surgery between1994 and2002 at acommunity teaching hospital.Of100 patients(mean age 92 years; range 90 to 98 years), 82 were women and 18 were men. Seventy-three percent were admitted from private homes or assisted-living facilities, and 27% came from a skilled-nursing facility (SNF). Major comorbid conditions existed in 93%. Procedures included right hemicolectomy (22%), adhesiolysis and/or small bowel resection (19%), cholecystectomy (14%), left-sided or sigmoid colectomy (11%), and perineal proctectomy (8%). Overall morbidity and mortality were 36% and 15%, respectively. Postoperative complications included respiratory failure and pneumonia (11%), arrhythmias (9%), delirium (7%), congestive heart failure and myocardial infarction (6%), and urinary complications (4%). Twentyeight percent of the operations were elective, and 72% were emergent. Morbidity and mortality were higher in the emergent group (41% and 19%, respectively) than in the elective group (26% and 4%, respectively; P = 0.04), especially for patients with an emergent surgical problem who came from a nursing home (22%). Average length of stay was 12 ±10 days (range 2 to 69 days) with little difference between elective and emergent cases. Sixty-four percent of patients were discharged to skilled-nursing facilities. Alimentary tract surgery can be performed safely in nonagenarians, and they should not be denied surgical care solely because of age.

Decreasing the Incidence of Falls in the Nursing Home in a Cost-Conscious Environment: A Pilot Study

OBJECTIVE To evaluate the prevalence of falls and determine the effectiveness of three simple interventions in decreasing the number of falls in a frail nursing home population. METHODS Charts and records were reviewed to determine the prevalence of falls. Falls were tracked according to severity and time and place of occurrence. Interventions were made in three areas: (1) Environmental: Room furniture was repositioned. (2) Staffing: One additional staff member was added (by schedule change) at the time when the incidence of falls was highest. (3) Restorative activity program: A program was added at the time when the incidence of falls was high. Falls data were again collected after the intervention. RESULTS Before intervention, there were 479 falls resulting in 16 fractures; 221 (46%) of the falls occurred during the 3-11 shift and resulted in 63% (n = 10) of the fractures. After intervention, there were a total of 299 falls and 8 fractures. This represents a statistically significant 38% reduction in the total number of falls and a 50% reduction in the total number of fractures during this period. Additionally, falls on the evening and night shifts were significantly reduced from 221 to 115 falls and 91 to 29 falls, respectively. CONCLUSION Our interventions may have contributed to a decrease in the overall number of falls and resultant fractures. Our data suggest these simple, practical, and easy to implement methods may positively impact the number of falls in other institutions as well.

Laparoscopic Colectomy In Octogenarians and Nonagenarians: A Preferable Option to Open Surgery?

OBJECTIVES To determine if laparoscopic colectomy is safer and more effective than open colectomy in patients older than 80 years of age. METHODS An operating room database of all colectomies performed on patients >or=80 years, from January 2002 to September 2007, was analyzed retrospectively. Data reviewed included type of operation, type of resection, length of procedure, length of stay (LOS), estimated blood loss, American Society of Anesthesiologists (ASA) grade, diagnosis, complications, mortality rates, and discharge destination, with p-values <0.05 considered significant. RESULTS One hundred thirty-nine patients underwent open procedures (Open group) during the study period versus 150 patients who underwent laparoscopic procedures (Lap group). Of the Lap group, 15 patients were converted to open cases. Forty-four patients from the Open group were excluded from the analysis as they were treated emergently, leaving 95 patients in the Open group. The mortality for open procedures was significantly higher at 9/95 (9.4%), compared with 3/150 (2%) following laparoscopic procedures (p = 0.0132). LOS was significantly longer for open procedures (11.16 days) versus laparoscopic procedures (7.11 days), p = 0.0001. Open procedures were associated with an increased risk of postoperative ileus (p < 0.02). The Open group had a higher likelihood of discharge to a nursing facility (43/87) than the Lap group (33/147), p < 0.0001. There were no significant differences in the length of procedure, estimated blood loss and postoperative complications. CONCLUSIONS Laparoscopic colectomy is a safer option that offers an improved outcome compared with open colectomy in elderly patients. Significant improvements in LOS, mortality rates, and discharge destination were observed.

In-hospital and 6-month mortality rates after open elective vs open emergent colectomy in patients older than 80 years.

BACKGROUND: There are few reports of long-term outcomes in elderly patients after open colectomy. OBJECTIVE: This study aimed to determine the in-hospital and 6-month outcomes and identify the variables associated with mortality after colectomy in patients ≥80 years of age. DESIGN: The charts of patients ≥80 years of age, who underwent open colectomy, were analyzed. Data included indications for operation, underlying diagnoses, preoperative functional status, type of procedure, length of procedure, length of stay, ASA grade, complications, and in-hospital and 6-month mortality rates. Univariate and multivariate logistic regression analyses were conducted to ascertain risk factors for mortality. P values of <.05 were considered significant. MAIN OUTCOME MEASURES: The main outcome measures were in-hospital and 6-month mortality. RESULTS: One hundred sixty-two patients ≥80 years of age underwent colectomy: 99 patients emergently; 63, electively. Postoperative acute renal failure (3% vs 19%, P = .0032) and in-hospital deaths were significantly higher (4.7% vs 28%, P = .0002) among the patients undergoing emergent colectomies. The mortality rate among emergent cases rose from 28% in-hospital to 52% at 6 months. Mortality among the elective cases increased similarly from 4.7% to 28.5%. Admission from a nursing facility was associated with higher in-hospital mortality (47.6% vs 14.9%, P = .0005). Discharge to a skilled nursing facility was associated with a higher 6-month mortality rate compared with discharge to home (40% vs 17%). Length of procedure, postoperative complications, perioperative blood transfusion, and emergent indications for operation independently predicted in-hospital mortality. Postoperative complications and emergent diagnosis independently predicted 6-month mortality. The 6-month mortality rate varied according to the underlying diagnosis as follows: fulminant Clostridium difficile colitis (86%); ischemic colitis (60%); gastrointestinal bleeding (37%), and volvulus (40%). LIMITATIONS: This study was limited by its retrospective nature. CONCLUSIONS: Emergent open colectomy in elderly patients is associated with a high morbidity and mortality rate. The mortality rate rises by >20% in both elective and emergent cases at discharge to 6 months. Length of procedure, postoperative complications, and colectomy for emergent indications predicted mortality.

Aerobic training in a patient with nonsevere aplastic anemia: A case report

This case report examined whether a 26-year-old man with a 5-year history of nonsevere aplastic anemia could perform aerobic training and whether exercise was beneficial. Testing was performed at baseline and at 8 and 16 weeks and included complete blood tests, graded exercise tests with breath-by-breath gas analyses, and health status assessment with the Medical Outcomes Survey SF-12 health survey. Training consisted of treadmill walking for 25 minutes, 3 days a week for 16 weeks, at 75% of maximal heart rate. The patient successfully completed 16 weeks of training and had no adverse effects from testing or training. Training did not produce changes in disease-related measures (hematologic values) or impairment measures (cardiopulmonary measures of fitness). The mental component of the SF-12 improved from below 2 standard deviations from the population mean to within 1 standard deviation of the population mean. The benefits of aerobic training for this person with aplastic anemia were that he showed that he could participate in aerobic-type activities and that training appeared to improve his mental health.

Alimentary tract surgery in the nonagenarian: Elective versus urgent operations

The objective of this study was to compare elective with emergent surgery in patients over the age of 90 years. We retrospectively reviewed the records of patients over 90 years of age who underwent alimentary tract surgery between1994 and2002 at acommunity teaching hospital.Of100 patients(mean age 92 years; range 90 to 98 years), 82 were women and 18 were men. Seventy-three percent were admitted from private homes or assisted-living facilities, and 27% came from a skilled-nursing facility (SNF). Major comorbid conditions existed in 93%. Procedures included right hemicolectomy (22%), adhesiolysis and/or small bowel resection (19%), cholecystectomy (14%), left-sided or sigmoid colectomy (11%), and perineal proctectomy (8%). Overall morbidity and mortality were 36% and 15%, respectively. Postoperative complications included respiratory failure and pneumonia (11%), arrhythmias (9%), delirium (7%), congestive heart failure and myocardial infarction (6%), and urinary complications (4%). Twentyeight percent of the operations were elective, and 72% were emergent. Morbidity and mortality were higher in the emergent group (41% and 19%, respectively) than in the elective group (26% and 4%, respectively; P = 0.04), especially for patients with an emergent surgical problem who came from a nursing home (22%). Average length of stay was 12 ±10 days (range 2 to 69 days) with little difference between elective and emergent cases. Sixty-four percent of patients were discharged to skilled-nursing facilities. Alimentary tract surgery can be performed safely in nonagenarians, and they should not be denied surgical care solely because of age.