A Salih

Rehabilitation of the older vascular amputee: A review of the literature

The aim was to review the literature on factors affecting prosthetic rehabilitation of older vascular lower extremity amputees. A search of the literature was carried out using the MEDLINE, EMBASE and CINAHL databases up to September 2010. Only original English language articles were accepted. Relevant studies were reviewed and selected based on prespecified inclusion criteria namely: age more than 65 years; vascular cause for the amputation; amputation level of below knee, through‐the‐knee or above knee; and discussed factors affecting rehabilitation. Age alone is not an absolute contraindication to prosthetic limb prescription; however, it does influence the potential success of gait retraining. Other factors influencing prosthetic fitting and use include comorbidities, premorbid function, level of amputation, status of the remaining limb and patient motivation. Prosthetic gait retraining is not possible in every older dysvascular amputee; however, almost all amputees will benefit from a rehabilitation program to increase independence in transfers and learn wheelchair skills. The MESH key words were: “aged” “diabetes complications” “peripheral vascular diseases” “amputees” “amputation” “rehabilitation” and “artificial limbs”. Geriatr Gerontol Int 2013; 13: 264–273.

Screening for delirium within the interrai acute care assessment system

To develop and validate a screening strategy for delirium within the inter RAI Acute Care comprehensive assessment system. Prospective validation cohort study. Acute general medical wards in two acute care metropolitan hospitals in Brisbane, Australia. Two hundreds thirty-nine subjects with and without delirium, aged 70 and older. Trained research nurses assessed subjects within 36 hours of hospital admission using the inter-RAI acute care (AC) system which includes four observational delirium items: Acute change mental status from baseline (ACMS), mental function varies over the course of the day (MFV), episode of disorganised speech (EDS), and easily distracted (ED). Geriatricians assessed subjects face to face within 4 hours of nurses’ assessment using the Diagnostic and Statistical Manual of Mental Disorders (DSM IV) criteria and clinical judgement to determine delirium presence. Based on the performance of each delirium feature and to achieve highest predictive accuracy, a combination algorithm of either ACMS or MFV was developed and compared with the reference standard diagnosis determined by geriatricians. Geriatricians diagnosed delirium in 52 of 239 (21.7%) subjects aged 70–102 years. The area under the receiver operator characteristics (AUC) for interRAI-AC delirium screener algorithm was 0.87 (95% CI; 0.80, 0.93), sensitivity 82%, specificity 91%, positive and negative predictive value of 0.72% and 95%, and likelihood ratio of 9.6 achieving the highest predictive accuracy of all possible combination of 4 delirium features. Underlying pre-morbid cognitive impairment did not undermine validity of the screening strategy, AUC 0.85 (95% CI; 0.74,0.95), sensitivity 90% and specificity 69%. The interRAI AC delirium screening strategy is a valid measure of delirium in older subjects in acute medical wards.

Promoting walking amongst older patients in rehabilitation: Are accelerometers the answer?

The role of physical activity amongst older people in inpatient rehabilitation settings has been little studied. Walking has a number of potential benefits for older people in rehabilitation but it is not known whether increased walking improves outcomes in this population. Until now mobility monitoring has not been possible in routine practice. Recently tri-axial accelerometers have been validated for ambulatory activity monitoring in older adults. Accelerometry has the potential to explore the role of walking in older patients in rehabilitation. Providing data regarding activity levels may improve patient motivation and assist clinicians with activity prescription. Future research could determine the relationship between activity levels and patient outcomes.

The validity of video clips in the diagnosis of gait disorder.

We investigated the accuracy and validity of clinical gait assessment, performed by experienced geriatricians viewing video clips of 10 s duration. Nineteen patients with normal or characteristic abnormal gait patterns were studied. The treating physicians diagnosis served as the gold standard. Another live assessment was then performed by a geriatrician blinded to the medical record to establish inter-rater reliability of live assessments. Subsequently, each gait video clip was examined by two independent geriatricians without any background clinical documentation. Diagnostic accuracy was tested at two levels – whether the gait was abnormal, and the specific gait diagnosis. The agreement of the video clip examination with the gold standard to identify abnormal gait from normal gait ranged from substantial to excellent among assessors (κ = 0.68–0.85), although low agreement with the gold standard was achieved in the detection of specific gait diagnosis (average agreement between both viewing geriatricians 50%). The technique appears to be a valid screening procedure for detecting gait abnormalities (average sensitivity 100%, specificity 70%).

Comprehensive geriatric assessment for the private hospital inpatient.

We examined the feasibility, cost and geriatrician satisfaction with this process through a small intervention–control pilot study. For controls, geriatricians completed consultations with no prior interRAI-AC assessment. Patients in the intervention group were assessed by a trained nurse using the interRAI-AC prior to geriatrician review. Geriatrician consultation costs were established using the Medicare item number 122 (A

Using the International Classification of Functioning, Disability and Health framework to categorise goals and assess goal attainment for transition care clients

161), and the nurse assessor cost was calculated by using the hourly rate of clinical nurse with medium experience level (A

Monitoring ambulation of patients in geriatric rehabilitation wards: the accuracy of clinicians' prediction of patients' walking time

42/hour).

Clinical utility of accelerometry in geriatric rehabilitation

To classify goals according to the International Classification of Functioning, Disability and Health (ICF) and to examine factors associated with goal attainment for transition care program (TCP) clients.

A pilot telegeriatrics service in rural Australia

The aim of this study is to determine whether clinicians’ estimates of patients’ walking time agree with those determined by accelerometer devices. The walking time was measured using a waist-mounted accelerometer device everyday during the patients’ waking hours. At each weekly meeting, clinicians estimated the patients’ average daily walking time in the previous week. Twenty-eight clinicians completed 176 estimates of the average daily walking time for 13 patients (78.5±6.6 years old) over 31 weeks. The average daily walking time measured by the accelerometers was 36.4±16.2 min and that estimated by clinicians was 61.3±38.4 min. Clinicians overestimated the amount of walking time by 24.8 min on average (mean% error=165.8%). Most estimates were between an hour less to 2 h more than the accelerometer measurements. Only 38.6% of the estimates agreed with the accelerometer measurements. Therefore, clinician assessment of the level of patient activity in a rehabilitation setting is highly inaccurate and unreliable.

Monitoring activity of inpatient lower limb prosthetic users in rehabilitation using accelerometry: Validation study

matically, but also her Karnofsky score increased to 80%, and she was discharged and followed by the outpatient clinics. In the literature, the causes of hypopituitarism in older persons are defined as pituitary adenomas, sequela of irradiation, or surgery for pituitary tumors, peripituitary tumors, vascular conditions, traumatic brain injury, infiltrative or granulomatous disease and infections. As none of these were shown to be the cause, and the pituitary fossa was also normal in size, we diagnosed idiopathic hypopituitarism in our elderly diabetic case. Furthermore, as a rule, hypopituitarism is clinically underestimated in the elderly, because typical symptoms that are less frequent than in younger patients and overlap with those of aging, severe hyponatremia and hypoglycemia are rare. In addition, hypoglycemia, one of the most common acute complications of diabetes mellitus, often occurs as a consequence of oral antidiabetics or insulin use in geriatric diabetic patients. In such cases, metabolic disorders facilitating the emergence of hypoglycemia should be taken into account when starting treatment. Thus, for each geriatric case, whether it is diabetes or not, it is important to evaluate the patient in terms of metabolic disorders and to assess the blood glucose level. In addition, diabetes and hypopituitarism together, as in the present case of an elderly patient with diabetes mellitus and hypopituitarism presenting with refractory hypoglycemia and acute renal failure under therapy with oral antidiabetic drugs, is an unusual situation. When the literature was reviewed, the coincidence of diabetes mellitus and hypopituitarism in older persons was reported only in case reports and idiopathic hypopituitarism in elderly diabetics, as in our case, is not a common clinic presentation in the elderly. Finally, although the most frequent cause of hypoglycaemia in geriatric diabetics is oral antidiabetic drugs, hypopituitarism should also be kept in mind for the differential diagnosis of hypoglycaemia in these cases.