Peter Gonski

Case-Controlled Study of Nursing Home Residents Referred for Treatment of Vocally Disruptive Behavior

The aim of this study was to identify factors associated with vocally disruptive behavior (VDB) in nursing home patients referred to aged care services for treatment, using a case-control methodology. Characteristics of the VDB, reasons for referral, perceived causal factors, and psychotropic use were noted. Twenty-five subjects and controls were examined with the Screaming Behavior Mapping Instrument, the Cornell Scale for Depression in Dementia, the Dementia Behavior Disturbance Scale, and measures of cognition, functional capacity, social activities, and emotional reactions of nursing staff. VDB was associated with other disturbed behaviors, depression, anxiety, severe dementia, functional impairment, communication difficulties, use of psychotropic medication, social isolation, and emotional distress in the nursing staff. Reasons for referral may relate more to the stress experienced by nursing home staff in managing VDB than to specific attributes of the VDB itself.

The management of patients with hip fractures who are taking Clopidogrel.

Aim:  To assess the outcomes of patients with acute proximal hip fractures who were taking Clopidogrel.

A Critical Review of Admission and Discharge Medications in an Elderly Australian Population

SummaryMedications were examined on admission to and discharge from hospital in an elderly population. Polypharmacy was documented. Patients were discharged on more medications (4.7) than they were taking prior to admission (4.1). This was statistically significant in men (p < 0.001) but not women. Multiple medication changes were undertaken. Admission drug regimens perceived by patient, admitting hospital doctor and general practitioner were also compared, Of 64 patients who were able to name their medications, only 64% described the same list as admitting doctors and only 43% described the same list as general practitioners. Hospital doctor and general practitioner lists were the same in only 37% of cases. Communication between these 3 groups needs to be optimised.

Time to diagnosis in young-onset dementia and its determinants: the INSPIRED study

The objective of this study is to identify factors determining the time to diagnosis for young‐onset dementia (YOD), defined as dementia with symptom onset before age 65 years, by mapping the diagnostic pathways.

Medium term effects of including manual therapy in a pulmonary rehabilitation program for chronic obstructive pulmonary disease (COPD): a randomized controlled pilot trial.

Study design: Randomized clinical trial. Objective: To investigate the effect of including manual therapy (MT) in a pulmonary rehabilitation program for patients with chronic obstructive pulmonary disease (COPD). Background: The primary source of exercise limitation in people with COPD is dyspnea. The dyspnea is partly caused by changes in chest wall mechanics, with an increase in chest wall rigidity (CWR) contributing to a decrease in lung function. As MT is known to increase joint mobility, administering MT to people with COPD carries with it the potential to influence CWR and lung function. Methods: Thirty-three participants with COPD, aged between 55 and 70 years (mean = 65·5±4 years), were randomly assigned to three groups: pulmonary rehabilitation (PR) only, soft tissue therapy (ST) and PR, and ST, spinal manipulative therapy (SM), and PR. Outcome measures including forced expiratory volume in the 1st second (FEV1), forced vital capacity (FVC), 6-minute walking test (6MWT), St. Georges respiratory questionnaire (SGRQ), and the hospital anxiety and depression (HAD) scale were recorded at 0, 8, 16, and 24 weeks. Results: There was a significant difference in FVC between the three groups at 24 weeks (P = 0·04). For the ST+SM+PR group versus PR only the increase was 0·40 l (CI: 0·02, 0·79; P = 0·03). No major or moderate adverse events (AE) were reported following the administration of 131 ST and 272 SM interventions. Discussion: The increase in FVC is a unique finding. Although the underlying mechanisms responsible for this outcome are not yet understood, the most likely explanation is the synergistic effect resulting from the combination of interventions. These results support the call for a larger clinical trial in the use of MT for COPD.

Why aren't people with young onset dementia and their supporters using formal services? Results from the INSPIRED study

Background/Aims Despite reporting high levels of burden, supporters of people with young onset dementia (YOD) underuse formal community services. Previous quantitative studies in YOD are of limited utility in guiding service design because they did not consider important contextual barriers to service use. The aim of this study was to identify all relevant barriers and describe the service features considered most important to improving uptake by people with YOD and their supporters. Methods Eighty-six people with consensus-confirmed YOD (mean onset age 55.3 years) and/or their primary supporter participated in quantitative interviews, and 50 also participated in one of seven qualitative focus groups. Interview participants reported levels of community service use and reasons for non-use, functional impairment, behavioural and psychological symptoms, supporter burden, social network, and informal care provision. Focus group participants expanded on reasons for non-use and aspects of an ideal service. Results Although at least one community service was recommended to most participants (96.8%), 66.7% chose not to use one or more of these. Few of the clinical or demographic factors included here were related to service use. Qualitative analyses identified that lack of perceived need, availability, and YOD-specific barriers (including ineligibility, unaffordability, lack of security, lack of childcare) were commonly reported. Five aspects of an ideal service were noted: unique, flexibile, affordable, tailored, and promoting meaningful engagement. Conclusion People with YOD and their families report that formal community services do not meet their personal and psychological needs. Researchers can provide ongoing assessment of program feasibility, suitability, and generalisability.

Southcare Geriatric Flying Squad: an innovative Australian model providing acute care in residential aged care facilities

This study reviews the outcomes of a model developed to improve the quality of care of residents living within residential aged care facilities (RACF). The Southcare Geriatric Flying Squad saw a total of 640 acutely unwell RACF residents over an 18‐month period. Of these, 578 (90.3%) were managed in the RACF avoiding emergency department. Only 35 (5.5%) patients required emergency department transfer and 27 (4.2%) were directly admitted to a medical ward. The service may have reduced emergency presentations by offering rapid assessment and management, choice in place of treatment and level of interventions.

Diagnosis and management of hyponatraemia in the older patient

Hyponatraemia (serum sodium concentration below 135 mmol/L) is the most common electrolyte disturbance and occurs commonly in older people. The causes can be complex to diagnose and treat and many published guidelines do not focus on the issues in an older patient group. Here, we are principally concerned with diagnosis and management of euvolaemic and hypervolaemic hyponatraemia in hospitalised patients over 70 years old. We also aim to increase awareness of hyponatraemia in residential aged care facilities and the community. Hyponatraemia can have many causes; in older people, chronic hyponatraemia can often be the result of medications used to treat chronic disease, particularly thiazide or thiazide‐like drugs (such as indapamide) or drugs acting on the central nervous system. Where a reversible trigger (such as drug‐induced hyponatraemia) can be identified, hyponatraemia may be treated relatively simply. Chronic hyponatraemia due to an irreversible cause will require ongoing treatment. Fluid restriction can be an effective therapy in dilutional hyponatraemia, although poor compliance and the burdensome nature of the restrictions are important considerations. Tolvaptan is an oral vasopressin receptor antagonist that can increase serum sodium concentrations by increasing electrolyte‐free water excretion. Tolvaptan use is supported by clinical trial evidence in patients with hypervolaemic or euvolaemic hyponatraemia below 125 mmol/L. Clinical trial evidence also supports its use after a trial of fluid restriction in patients with symptomatic hyponatraemia above 125 mmol/L. The use of tolvaptan is affected by regulatory restriction of chronic therapy due to safety concern and the non‐subsidised cost of treatment.

OPTIMISING INDEPENDENCE OF OLDER PERSONS WITH COGNITIVE AND FUNCTIONAL DECLINE: INTERDISCIPLINARY HOME-BASED REABLEMENT PROGRAM (I-HARP) — A PARALLEL-GROUP PILOT RCT

Background:Dysphagia, or swallowing dysfunction, commonly occurs in patients with dementia and leads to serious health consequences, including impaired oral intake, caregiver burden, decreased quality of life, and aspiration pneumonia. There are currently no evidence-based approaches to treat dysphagia in dementia. Patients with dementia experience increased difficulties with swallowing that begin in the mild phase and worsen with disease progression. However, the prevalence of dysphagia in dementia remains unclear with prior research limited by use of assessment methods other than the gold standard videofluoroscopic swallow study (VFSS). The purpose of this study was to determine the prevalence and severity of dysphagia in inpatients with diagnosed dementia referred for swallowing evaluation at a large, university hospital. Methods:Billing data were used to identify inpatients with a clinical bedside evaluation (CPT code= 92610) in calendar year 2014. In-depth abstractions of 2035 electronic health records were performed using a standardized data instrument. Given that most patients diagnosed with dementia by their primary care providers are correctly diagnosed(1), pre-existing dementia diagnoses were identified through review of past medical history, problem lists, and medications. Dysphagia severity ratings were derived from videofluoroscopic swallow study (VFSS) clinical reports. Results:355 patients (17%) were diagnosed with dementia; 47% of these received a VFSS (n=167). The majority of patients with dementia who underwent VFSS were diagnosed with mild or moderate dysphagia (89%). 48% of those with dysphagia on VFSS were male and 42% were female. 47 (27.8%) patients with dementia who underwent VFSS had pneumonia; 94% (44) of these patients were found to have dysphagia. Conclusions:Mild-moderate dysphagia is extremely common amongst inpatients with dementia referred for swallowing evaluation. Identification of dysphagia with gold-standard videofluoroscopy in inpatients with dementia is feasible and will allow for timely intervention to prevent dysphagiarelated health consequences. These data suggest that a significant potential subject pool is available for clinical trial recruitment to test efficacy of novel interventions for dysphagia in dementia. References: (1)Bradford A, Kunik ME, Schulz P, Williams SP, Singh H. Missed and delayed diagnosis of dementia in primary care: prevalence and contributing factors. Alzheimer Dis Assoc Disord. 2009;23(4):306-314.

The effect of combining manual therapy with exercise for mild chronic obstructive pulmonary disease: study protocol for a randomised controlled trial

BackgroundChronic obstructive pulmonary disease (COPD) is a major cause of disability and hospital admission. Current management strategies have not been successful in altering the loss of lung function typically seen as the disease progresses. A recent systematic review into the use of spinal manipulative therapy (SMT) in the management of COPD concluded that there was low level evidence to support the view that a combination of SMT and exercise had the potential to improve lung function more than exercise alone in people with moderate to severe COPD.The aim of this study is to investigate whether the combination of exercise and manual therapy (MT) that includes SMT produces sustainable improvements in lung function and exercise capacity in people with mild COPD.Methods/designThe study is a randomised controlled trial of 202 people with stable mild COPD. The cohort will be divided into two equal groups matched at baseline. The first group will receive a standardised exercise program. The second group will receive MT that includes SMT plus the same standardised exercise program. Exercise will be administered a total of 36 times over an 18-week period, while MT will be administered in conjunction with exercise a total of 15 times over a 6-week period. The primary outcome measure is lung function (forced expiratory volume in the 1st second: FEV1 and forced vital capacity: FVC). The secondary outcome measures are the 6-minute walking test (6MWT), quality of life questionnaire (St George’s Respiratory Questionnaire: SGRQ), anxiety and depression levels (Hospital Anxiety and Depression Scale: HADS), frequency of exacerbations, chest wall expansion measurements (tape measurements) and systemic inflammatory biomarker levels. Outcome measurements will be taken by blinded assessors on seven occasions over a 48-week period. Adverse event data will also be gathered at the beginning of each intervention session.DiscussionThis randomised controlled trial is designed to investigate whether the combination of MT and exercise delivers any additional benefits to people with mild COPD compared to exercise alone. The study is designed in response to recommendations from a recent systematic review calling for more research into the effect of MT in the management of COPD.Trial registrationANZCTRN, 12614000766617. Registered on 18 July 2014.