Paul Varghese

Pragmatic, Cluster Randomized Trial of a Policy to Introduce Low‐Low Beds to Hospital Wards for the Prevention of Falls and Fall Injuries

OBJECTIVES: To evaluate the efficacy of a policy to introduce low‐low beds for the prevention of falls and fall injuries on wards that had not previously accessed low‐low beds.

The Diagnostic Accuracy of Telegeriatrics for the Diagnosis of Dementia via Video Conferencing

INTRODUCTION The suitability of video conferencing (VC) technology for clinical purposes relevant to geriatric medicine is still being established. This project aimed to determine the validity of the diagnosis of dementia via VC. METHODS This was a multisite, noninferiority, prospective cohort study. Patients, aged 50 years and older, referred by their primary care physician for cognitive assessment, were assessed at 4 memory disorder clinics. All patients were assessed independently by 2 specialist physicians. They were allocated one face-to-face (FTF) assessment (Reference standard--usual clinical practice) and an additional assessment (either usual FTF assessment or a VC assessment) on the same day. Each specialist physician had access to the patient chart and the results of a battery of standardized cognitive assessments administered FTF by the clinic nurse. Percentage agreement (P(0)) and the weighted kappa statistic with linear weight (K(w)) were used to assess inter-rater reliability across the 2 study groups on the diagnosis of dementia (cognition normal, impaired, or demented). RESULTS The 205 patients were allocated to group: Videoconference (n = 100) or Standard practice (n = 105); 106 were men. The average age was 76 (SD 9, 51-95) and the average Standardized Mini-Mental State Examination Score was 23.9 (SD 4.7, 9-30). Agreement for the Videoconference group (P(0)= 0.71; K(w) = 0.52; P < .0001) and agreement for the Standard Practice group (P(0)= 0.70; K(w) = 0.50; P < .0001) were both statistically significant (P < .05). The summary kappa statistic of 0.51 (P = .84) indicated that VC was not inferior to FTF assessment. CONCLUSIONS Previous studies have shown that preliminary standardized assessment tools can be reliably administered and scored via VC. This study focused on the geriatric assessment component of the interview (interpretation of standardized assessments, taking a history and formulating a diagnosis by medical specialist) and identified high levels of agreement for diagnosing dementia. A model of service incorporating either local or remote administered standardized assessments, and remote specialist assessment, is a reliable process for enabling the diagnosis of dementia for isolated older adults.

Documentation of in-hospital falls on incident reports: Qualitative investigation of an imperfect process

BackgroundIncident reporting is the prevailing approach to gathering data on accidental falls in hospitals for both research and quality assurance purposes, though is of questionable quality as staff time pressures, perception of blame and other factors are thought to contribute to under-reporting.MethodsThis research aimed to identify contextual factors influencing recording of in-hospital falls on incident reports. A qualitative multi-centre investigation using an open written response questionnaire was undertaken. Participants were asked to describe any factors that made them feel more or less likely to record a fall on an incident report. 212 hospital staff from 30 wards in 7 hospitals in Queensland, Australia provided a response. A framework approach was employed to identify and understand inter-relationships between emergent categories.ResultsThree main categories were developed. The first, determinants of reporting, describes a hierarchical structure of primary (principle of reporting), secondary (patient injury), and tertiary determinants that influenced the likelihood that an in-hospital fall would be recorded on an incident report. The tertiary determinants frequently had an inconsistent effect. The second and third main categories described environmental/cultural facilitators and barriers respectively which form a background upon which the determinants of reporting exists.ConclusionA distinctive framework with clear differences to recording of other types of adverse events on incident reports was apparent. Providing information to hospital staff regarding the purpose of incident reporting and the usefulness of incident reporting for preventing future falls may improve incident reporting practices.

Polymorphic CAG repeat length in the androgen receptor gene and association with neurodegeneration in a heterozygous female carrier of Kennedy's disease

Abstract.Kennedy’s disease (spinobulbar muscular atrophy) is an X-linked form of motor neuron disease affecting adult males carrying a CAG trinucleotide repeat expansion within the androgen receptor gene. While expression of Kennedy’s disease is thought to be confined to males carrying the causative mutation, subclinical manifestations have been reported in a few female carriers of the disease. The reasons that females are protected from the disease are not clear, especially given that all other diseases caused by CAG expansions display dominant expression. In the current study, we report the identification of a heterozygote female carrying the Kennedy’s disease mutation who was clinically diagnosed with motor neuron disease. We describe analysis of CAG repeat number in this individual as well as 33 relatives within the pedigree, including two male carriers of the Kennedy’s mutation. The female heterozygote carried one expanded allele of the androgen receptor gene with CAG repeats numbering in the Kennedy’s disease range (44 CAGs),with the normal allele numbering in the uppernormal range (28 CAGs). The subject has two sons, one of whom carries the mutant allele of the gene and has been clinically diagnosed with Kennedy’s disease, whilst the other son carries the second allele of the gene with CAGs numbering in the upper normal range and displays a normal phenotype. This coexistence of motor neuron disease and the presence of one expanded allele and one allele at the upper limit of the normal range may be a coincidence. However, we hypothesize that the expression of the Kennedy’s disease mutation combined with a second allele with a large but normal CAG repeat sequence may have contributed to the motor neuron degeneration displayed in the heterozygote female and discuss the possible reasons for phenotypic expression in particular individuals.

Length of Stay, Discharge Destination, and Functional Improvement Utility of the Australian National Subacute and Nonacute Patient Casemix Classification

Background and Purpose— Although implemented in 1998, no research has examined how well the Australian National Subacute and Nonacute Patient (AN-SNAP) Casemix Classification predicts length of stay (LOS), discharge destination, and functional improvement in public hospital stroke rehabilitation units in Australia. Methods— 406 consecutive admissions to 3 stroke rehabilitation units in Queensland, Australia were studied. Sociodemographic, clinical, and functional data were collected. General linear modeling and logistic regression were used to assess the ability of AN-SNAP to predict outcomes. Results— AN-SNAP significantly predicted each outcome. There were clear relationships between the outcomes of longer LOS, poorer functional improvement and discharge into care, and the AN-SNAP classes that reflected poorer functional ability and older age. Other predictors included living situation, acute LOS, comorbidity, and stroke type. Conclusions— AN-SNAP is a consistent predictor of LOS, functional change and discharge destination, and has utility in assisting clinicians to set rehabilitation goals and plan discharge.

Successes and failures in assessing cognitive function in older adults using video consultation

We investigated the level of agreement between specialists conducting a cognitive assessment via videoconference compared with a face-to-face assessment. The patient and doctor were linked via a videoconference system which was located within the same hospital. To assess inter-rater reliability, paired face-to-face assessments were also carried out. There were 42 subjects, who were aged over 50 years and who had not attended a memory disorder clinic in the previous 12 months. A battery of standardized cognitive assessments was performed by a trained clinic nurse, prior to the two assessments by separate specialists. The weighted kappa score for face-to-face inter-rater reliability was 0.53. The agreement between face-to-face and videoconferencing assessment was 0.63. The present study shows that the use of videoconferencing for cognitive assessment results in assessment outcomes similar to those from face-to-face assessment.

Physical examination and diagnosis of dementia for video consultation

ditions were performed with Wilcoxon matched-pairs signed-ranks tests. Given the directional hypothesis, onesided Po.05 was considered statistically significant. There was no significant difference between stride time before and after galantamine treatment within walking conditions (P 5.09 for single tasking and P 5.77 for dualtasking). Stride time was significantly longer under dualtasking than walking alone before treatment (P 5.01) but not after (P 5.09). There were no significant gait changes at all in the no-treatment control group (P 5.74). MMSE scores of subjects with AD were significantly lower (P 5.02). Mean number of enumerated digits during the backward-counting task did not differ significantly between singleand dual-tasking conditions or between the treatment and no-treatment groups (P 5.50 for control group and P 5.62 and P 5 1.00 before and after galantamine, respectively, for the group with AD) (Table 1). These results confirm that subjects with AD and no galantamine treatment showed a significant increase in stride time under dual-task conditions. This change in gait parameters is a marker of an inability to appropriately adapt allocation of attention between gait and a walking-associated attention-demanding task with a resulting greater risk of falling. In addition, this report is, to our knowledge, the first to demonstrate improvement in gait performance after treatment with galantamine. The absence of a significant increase in stride time while dual-tasking in subjects with AD treated with galantamine suggests a galantamine-associated enhancement of the ability to adapt gait patterns to unexpected situations. If these open-label data can be reproduced and confirmed in a prospective, double-blind, placebo-controlled study design, patients with AD with greater falls risk might benefit from galantamine treatment.

Comparison of three interventions in the treatment of malnutrition in hospitalised older adults: A clinical trial

Aim: The objective of the present study was to determine the most effective method for providing oral nutrition support to hospitalised older adult patients with malnutrition using clinical and patient-centred measures. Methods: The present study involved consecutive assignment of 98 inpatients assessed as malnourished (Subjective Global Assessment B or C) to conventional commercial supplements (traditional, n = 33), MedPass (n = 32, 2cal/mL supplement delivered 60mL four times a day at medication rounds) or mid-meal trolley (n = 33, selective snack trolley offered between meals) for two weeks. Weight change, supplement compliance, energy and protein intake (3-day food records), quality of life (EQ-5D), patient satisfaction and cost were evaluated. Results: Weight change was similar across the three interventions (mean ± SD): 0.4 ± 3.8% traditional; 1.5 ± 5.8% MedPass; 1.0 ± 3.1% mid-meal (P = 0.53). Energy and protein intakes (% of requirements) were more often achieved with traditional (107 ± 26, 128 ± 35%) and MedPass (110 ± 28, 126 ± 38%) compared with mid-meal (85 ± 25, 88 ± 25%) interventions (P = < 0.01). Overall quality-of-life ratings (scale 0-100) improved significantly with MedPass (mean change, 12.4 ± 20.9) and mid-meal (21.1 ± 19.7) interventions, however, did not change with traditional intervention (1.5 ± 18.1) (P = 0.05). Patient satisfaction including sensory qualities (taste, look, temperature, size) and perceived benefit (improved health and recovery) was rated highest for mid-meal trolley (all P < 0.05). Conclusions: Patients achieved recommended intake with supplements (MedPass or traditional), and despite lower cost, higher satisfaction and quality of life with selective mid-meal trolley did not achieve recommended energy and protein intake. Future research is warranted for implementing a combination of strategies in providing oral nutrition support.

The Rowland Universal Dementia Assessment Scale (RUDAS) as a reliable screening tool for dementia when administered via videoconferencing in elderly post-acute hospital patients.

The Rowland Universal Dementia Assessment Scale (RUDAS) is a six-domain screening tool for dementia. We measured the practicality and reliability of administering the RUDAS in a telemedicine setting. Inpatients were recruited from a Geriatric and Rehabilitation Unit. Each patient was administered the RUDAS both face-to-face (FTF) and via videoconferencing (VC). The assessment format (FTF or VC) and the allocation of doctor (Doctor 1 or Doctor 2) to format were randomized. Scores from each assessment format were compared. The outcome of no difference was decided based on a difference in mean of no more than ± one point. Percentage agreement (agreement being ±2 points) was calculated on individual test scores. Forty-two patients (average age 75 years) completed the two assessments. Their mean Mini-Mental State Examination (MMSE) score was 24.7 (range 10–30). The mean RUDAS score for both FTF and VC assessment was 24.9 (difference between the means 0.04), i.e. there was no significant difference. The results suggest that the RUDAS can be reliably administered via VC in post acute patients as an alternative to FTF administration.

Reliability of online geriatric consultation triage decisions: A pilot study

Peninsula Health’s Older Wiser Lifestyles (OWL) program is Australia’s first older adult-specific alcohol and other drugs service. We were pleased to see McLaughlin et al.’s [1] recommendation for national guidelines for non-hazardous alcohol consumption by older Australians. This recommendation was based on evidence indicating that changes in physiology associated with the natural ageing process affect the pharmacokinetics of alcohol [2,3], as well as McLaughlin et al.’s findings regarding sex differences and the benefits of alcohol-free days [1].