Peteris Darzins

Predicting Driving Performance in Older Adults: We Are Not There Yet!

Objective. We set up this study to determine the predictive value of approaches for which a statistical association with driving performance has been documented. Methods. We determined the statistical association (magnitude of association and probability of occurrence by chance alone) between four different predictors (the Mini-Mental State Examination, Trails A test, Useful Field of View [UFOV], and a composite measure of past driving incidents) and driving performance. We then explored the predictive value of these measures with receiver operating characteristic (ROC) curves and various cutoff values. Results. We identified associations between the predictors and driving performance well beyond the play of chance (p < .01). Nonetheless, the predictors had limited predictive value with areas under the curve ranging from .51 to .82. Conclusions. Statistical associations are not sufficient to infer adequate predictive value, especially when crucial decisions such as whether one can continue driving are at stake. The predictors we examined have limited predictive value if used as stand-alone screening tests.

Can this patient go home? Assessment of decision-making capacity

Occupational therapists can make important contributions to decisions about whether inpatients can return to their own homes after the diagnostic or therapeutic aspects of the conditions that required hospitalisation have been addressed. Where necessary, occupational therapists suggest physical environmental modifications or the provision of support from families, friends or community services to accommodate activity limitations the patients may have, so that they would have little personal care participation restrictions.1 When the assessments reveal potentially harmful personal care participation restrictions that cannot be solved by environmental

Interrater reliability of the Personal Care Participation Assessment and Resource Tool (PC-PART) in a rehabilitation setting.

BACKGROUND The Personal Care Participation Assessment and Resource Tool (PC-PART), formerly the Handicap Assessment and Resource Tool (HART), assesses the domains of clothing, hygiene, nutrition, mobility, safety, residence and supports. AIM To examine the interrater reliability of the PC-PART in a rehabilitation setting. METHODS Assessments made by the researcher were compared to the interdisciplinary rehabilitation team. The research and standard assessments occurred within three working days. Raters were blind to each others scores. Sample participants were a consecutive case-series of rehabilitation clients with varied diagnoses, activity limitations and participation restrictions. Of 66 consecutive patients seen during the a priori determined enrolment period, 25 were included in the study (nine males and 16 females, aged 44-85 years). The remaining 41 patients did not meet the inclusion criteria. CONCLUSION The PC-PART has good interrater reliability. Clinicians, administrators and researchers can be reassured about this aspect of the validity of the tool.

On-road driving assessment and route design for drivers with dementia

Introduction Dementia causes the progressive loss of cognitive capacities and thus impairs social and daily living skills. Dementia, to varying degrees, influences driver performance and safety. Eventually drivers affected by dementia must stop driving so they do not harm themselves or others. However, having to stop driving can result in loss of mobility and social connections. Therefore, assessing drivers with dementia is important. Driving assessment is susceptible to possible biases, including unreliable driving performance measures or driving routes that are inconsistent in the levels of difficulty of the driving tasks and manoeuvres. The aim of the study was to determine what measures of driving performance could optimally be applied to occupational therapy on-road driving assessments. Method All drivers with dementia underwent a 60 minute, set route on-road driving assessment that consisted of 110 pre-programmed observation points. Results The study identified 80 sufficiently challenging driving tasks and described the relationship of driving error to that task, for example, critical errors at unguided intersections. Conclusion The results of the task-demand by error type analysis identified a list of task items that can be applied to assessment route design to increase consistency of on-road assessment for people with dementia.

Use of the sensory nerve stimulator to accelerate healing of a venous leg ulcer with sensory nerve dysfunction: a case study.

A new therapy using sensory nerve stimulation [International Patent Application Number PCT/AU2004/001079: ‘nerve function and tissue healing’ (Khalil, Z)] has been developed in our vascular physiology laboratory. This treatment has been found to improve the deficient sensory nerve function and associated deficient wound healing of older persons to levels seen in young people. An 82‐year‐old man with a small but persistent venous leg ulcer for 18 months, despite apparently appropriate wound dressings and compression therapy, was seen in a specialist wound management service. The patients sensory and microvascular function was assessed in great detail using the vascular physiology laboratory techniques, and he was provided the sensory nerve stimulation therapy in addition to conventional therapy. His wound healed after 4 weeks. We report the case here. Prior to nerve stimulation therapy, cutaneous sensation, microvascular blood flow and oxygen tension were found to be reduced near the ulcer when compared with the opposite, non ulcerated leg. After therapy, oxygen tension and microvascular blood flow had improved. This case provides further evidence that sensory nerve stimulation therapy at the stipulated parameters improves wound healing. The observation that sensory nerve function improved provides support for the notion that improvement in healing is mediated by improved nerve function.

Are older drivers’ on-road driving error rates related to functional performance and/or self-reported driving experiences?

• Older drivers’ on-road driving behavior was observed on two occasions approximately 12 months apart (Times 1 and 2) to determine whether the self-selected driving routes changed over time or whether their driving behavior changed over time.

Neurovascular changes after four-layer compression bandaging in people with chronic venous leg ulcers.

Objectives : Venous leg ulcers represent a major clinical problem, with poor rates of healing. Ideal treatment is compression bandaging. The effect of compression on neurovascular tissues involved in wound repair is unclear. This study aims to assess the effect of four-layer compression therapy (40 mmHg) on neurovascular function and wound healing in people with chronic venous leg ulcers – 15 people (55 years or older) with venous leg ulcers for more than six weeks. Methods : Basal microvascular perfusion measurement (MPM), oxygen tension (tcpO2) measured at sensor temperatures of 39°C and 44°C and sensory nerve function using electrical cutaneous perception thresholds (ECPT) at 5, 250 and 2000 Hz (corresponding to C, Aδ and Aβ fibres) were assessed adjacent to the ulcer site, and at a mirror location on the non-ulcerated limb. Testing was undertaken before and after therapy for 5–12 weeks of four-layer compression bandaging. Results : There was significant improvement in tcpO2 at 44°C and ECPT at 2000 Hz (P<0.05) compared with pre-intervention. Changes in basal MPM, tcpO2 at 39°C and ECPT at 5 and 250 Hz after compression therapy did not reach statistical significance. Conclusion : Four-layer compression bandaging in people with venous leg ulcers improved some components of neurovascularture in people with chronic venous leg ulcers. Whether this improvement has contributed to wound healing in this study requires further investigation.

Ethical and Practical Dimensions of Prescribing for Older People as Quality of Life Decreases

Prescribing medicines for older people always presents difficulties, never more so than when quality of life decreases or the process of dying begins. The problem confronting doctors, and others caring for older patients, is the option of intervening or not intervening. The principles of bioethics can be used to assist those making decisions regarding the medical management of older people. Decisions that are made must consider the likely benefit and associated harms that may accrue from continuing or commencing treatment. Respect for individuals and their wishes must be maintained even when the patients decision‐making capacity is impaired and others need to make decisions for them. Management dilemmas include when to stop or reduce prescribing as the end‐of‐life approaches, the use of medication to manage behavioural disturbance, multiple medication use increasing the risk for harm and the use of drugs for which the evidence of benefit is not available for older patients or for which there is evidence of increased adverse effects that may impair quality of life. Those caring for older people must consider a wide range of options and can be assisted by asking key questions to help guide appropriate decision making.

Assessment of insomnia in high level residential aged care facility residents

Insomnia is common in nursing home settings but assessment and management of sleep disturbance is often suboptimal. New assessment procedures that target potentially remediable clinical causes of insomnia were implemented and evaluated at two high level residential aged care Facilities (HLRACFs) (formerly called nursing homes), in Melbourne, Australia. Fifty‐eight of 147 residents (39%) who complained of insomnia, or were nominated by nursing staff as having disturbed sleep, and had confirmation of sleep disturbance on overnight sleep log, were provided with a structured assessment protocol. A multidisciplinary team then considered the causes of each residents insomnia. A potentially remediable medical or psychiatric cause was identified in 66% of residents with insomnia. More than one such factor was identified in 34%. Pain was a likely factor in 39%. Depression was a likely factor in 30%. Insomnia, depression and pain were significantly correlated.

Hospital discharge data under-reports delirium occurrence. Results from a point prevalence survey of delirium in a major Australian health service: Clinical audit highlights reporting gap

Delirium in hospitalised patients is common, and a risk factor for adverse outcomes. Health services require accurate delirium data to monitor the impact of initiatives designed to improve detection and prevention of delirium.