S.T. O’Keeffe

Changing attitudes to cardiopulmonary resuscitation in older people: a 15-year follow-up study

BACKGROUND while it is well established that individual patient preferences regarding cardiopulmonary resuscitation (CPR) may change with time, the stability of population preferences, especially during periods of social and economic change, has received little attention. OBJECTIVE to elicit the resuscitation preferences of older Irish inpatients and to compare the results with an identical study conducted 15 years earlier. METHODS one hundred and fifty older medical inpatients awaiting discharge in a university teaching hospital or a district general hospital subjects were asked about resuscitation preferences. Results were compared to those elicited from a hundred subjects in 1992. RESULTS most patients (94%) felt it was a good idea for doctors to discuss CPR routinely with patients, compared with 39% in 1992. In their current health, 6% in 2007 and 76% in 1992 would refuse CPR. The independent predictors of refusal of CPR in current health on logistic regression were age and year of assessment. In the final model, those aged 75-84 years [OR 2.77 (95% CI 1.25-6.13), P = 0.02] and 85 years or more [OR 15.19 (4.26-54.15), P < 0.0001] were more likely than those aged 65-74 years (reference group) to refuse CPR. Those questioned in 2007 [OR 0.04 (0.02-0.81), P < 0.0001] were less likely than those questioned in 1992 (reference group) to refuse CPR. CONCLUSIONS there has been a significant shift in the attitudes of older Irish inpatients over 15 years towards favouring greater patient participation in decision making and an increased desire for resuscitation.

Jollity and the “Santa Claus” effect: bah humbug?

Dear Editor, I greatly enjoyed reading Brendan Kelly’s study of jollity in Europe (Kelly, 2017). However, I must protest his entirely one-sided portrait of Santa Claus and his comment on the ‘ubiquity of jollity at Christmas’. Santa may well be ‘‘very, very jolly’’ but this is on the back of his mistreatment and exploitation of elves and reindeers. Christmas generally leads to a decline in mood and in life satisfaction (Mutz, 2016; Sansone & Sansone, 2011). Furthermore, a quick Google search for jollity (5 September 2017) produces ‘‘about 1,270,000 results’’, many of them indeed referring to Christmas. However, the results total plummets to 438,000 when the search is repeated after excluding sites that also have the words ‘‘forced’’, ‘‘fake’’ or ‘‘false’’. The study’s (rejected) hypothesis was that countries close to where Santa Claus lives would have the highest level of jollity. Santa Claus is often believed to reside in the north of Finland (although I find it hard to believe that such a socially progressive country would tolerate his running a virtual sweatshop). Repeating the searches with the Finnish words (from Google Translate – I didn’t have a Finn to hand) for jollity (iloisuus and ilonpito) and for forced (pakko), false (väärä) and fake (väärennös) led to an even more dramatic decline from about 94 800 to 17 500 results. Without wanting to appear Scrooge-like, (and noting that that I am personally even jollier than a rich, healthy, young Swiss male, whatever the season), I suggest that the ‘‘Santa Claus’’ effect on true jollity is a negative one and that this is unsurprising if one is likely to be accosted by a disturbing character given to using the downright sinister ‘‘Ho! Ho! Ho!’’ as a greeting who plans to enter your home without permission in a most unorthodox way (Davis, 2012).

Challenge of diagnosing non-convulsive status epilepticus presenting as delirium

PurposeNonconvulsive status epilepticus (NCSE) is relatively common in older people. Although NCSE is a known cause of delirium, diagnosis is often delayed or missed.MethodsWe report three cases where NCSE was identified as the cause of delirium in older people that illustrate the challenge of diagnosis.ResultsThe cases illustrate that clinical manifestations such as slight twitching of the eyelids or periorally, eye signs, automatisms and disorders of speech and language are often very subtle. Electroencephalography (EEG), and monitoring the clinical and EEG effects of intravenous anticonvulsants, are crucial to diagnosis. Increased availability of portable EEG machines will facilitate early diagnosis. In situations where an EEG is not easily available, a trial of treatment is warranted. Hypoactive delirium is the main variant seen in NCSE but psychosis may also occur.ConclusionsClinicians should maintain a high index of suspicion for NCSE in patients with delirium especially when no other obvious cause is identified.

Use of modified diets to prevent aspiration in oropharyngeal dysphagia: is current practice justified?

BackgroundAlthough modifying diets, by thickening liquids and modifying the texture of foods, to reduce the risk of aspiration has become central to the current management of dysphagia, the effectiveness of this intervention has been questioned. This narrative review examines, and discusses possible reasons for, the apparent discrepancy between the widespread use of modified diets in current clinical practice and the limited evidence base regarding the benefits and risks of this approach.DiscussionThere is no good evidence to date that thickening liquids reduces pneumonia in dysphagia and this intervention may be associated with reduced fluid intake. Texture-modified foods may contribute to undernutrition in those with dysphagia. Modified diets worsen the quality of life of those with dysphagia, and non-compliance is common. There is substantial variability in terminology and standards for modified diets, in the recommendations of individual therapists, and in the consistency of diets prepared by healthcare staff for consumption. Although use of modified diets might appear to have a rational pathophysiological basis in dysphagia, the relationship between aspiration and pneumonia is not clear-cut. Clinical experience may be a more important determinant of everyday practice than research evidence and patient preferences. There are situations in the management of dysphagia where common sense and the necessity of intervention will clearly outweigh any lack of evidence or when application of evidence-based principles can enable good decision making despite the absence of robust evidence. Nevertheless, there is a significant discrepancy between the paucity of the evidence base supporting use of modified diets and the beliefs and practices of practitioners.ConclusionThe disconnect between the limited evidence base and the widespread use of modified diets suggests the need for more careful consideration as to when modified diets might be recommended to patients. Patients (or their representatives) have a choice whether or not to accept a modified diet and must receive adequate information, about the potential risks and impact on quality of life as well as the possible benefits, to make that choice. There is an urgent need for better quality evidence regarding this intervention.

Accessory navicular syndrome as a cause of foot pain during stroke rehabilitation

Although usually asymptomatic, an accessory navicular bone can lead to medial foot pain, especially in younger people engaged in high impact sports. In many such cases, the tendon of posterior tibialis (which inverts and plantarflexes the foot) inserts onto the accessory bone resulting in greater strain on the tendon. In the present case, pain due to an accessory navicular bone first developed during stroke rehabilitation in a 69-year-old man. The relative overactivity of posterior tibialis in strokes involving the leg and overuse due to active rehabilitation were likely contributors. An accessory navicular syndrome should be considered as a cause of medial foot pain in patients following a stroke. As in our case, conservative management with rest, ice and elevation is usually successful.

115Non-Consultant Hospital Doctors’ Attitudes and Knowledge towards Sedative Prescription in an Acute Hospital

Background: Consumption of sedative medications is an independent risk factor for falls. These medications are known risk factors for the development of delirium and are known to reduce the alertness and concentration of older patients. Older patients are more vulnerable to adverse effects associated with these medications due to changes in pharmacokinetics and pharmacodynamics associated with ageing. Methods: We aimed to explore attitudes and knowledge of sedative prescriptions among doctors in a tertiary Irish hospital. A structured online questionnaire was distributed to 100 non consultant hospital doctors (NCHDs) including medical registrars, senior house officers and interns. Results: The overall response rate was 40% (n = 40). A total of 38 (95%) of respondents reported prescribing sedatives due to same medications recorded on community prescriptions of patients. 30 doctors (75%) selected that they prescribed these agents due to direct patient request with 32 (82%) citing pressure from patients and 9 (23%) pressure from nursing staff as an influencing factor in increased prescription of sedatives. Of those who took part, 5 (12%) admitted that they never assess background history of drug or alcohol dependency prior to prescribing. NCHDs accurately identified the adverse effects associated with benzodiazepines but one third were unsure regarding common adverse effects with Z drugs. The majority of participants (87.5%) were in favour of an educational session on non-pharmacologic approaches towards sleep hygiene. Conclusions: This survey reflects pressure to prescribe sedatives and hypnotics in the acute hospital setting with many not feeling adequately equipped to educate and encourage non pharmacologic approaches towards sleep hygiene. A multidisciplinary educational module is currently in development and will be integrated into the postgraduate education curriculum.