Sebastiana Zimba Kalula

Does multidisciplinary stroke care improve outcome in a secondary-level hospital in South Africa?

Background and Purpose The improved outcome (survival and function) of stroke patients admitted to multidisciplinary stroke units (SU) in developed countries has not been replicated in developing countries in sub-Saharan Africa. This study documents the outcome of patients admitted to the first multidisciplinary SU opened at a secondary hospital in Cape Town, South Africa. Methods Patient outcomes including in-hospital mortality, resource utilization (length of hospital stay, CT brain scans performed, and tertiary hospital referral), and access to inpatient rehabilitation were recorded for all patients admitted to the hospital for 3 months before initiating multidisciplinary stroke care and for 3 months after implementing multidisciplinary stroke care. Results One hundred and ninety-five patients were studied; 101 of these were managed in the SU. Inpatient mortality decreased from 33% to 16% after initiating multidisciplinary stroke care (P = 0·005). The length of hospital stay increased from a mean (SD, 95% CI) of 5·1 (6·5, 3·8–6·4) days to 6·8 (4·5, 5·9–7·6) days (P = 0·01). Referral to inpatient rehabilitation increased from 5% to 19% (P = 0·04) for those who survived to discharge. The number of CT brain scans performed and the number of referrals to the tertiary academic hospital did not increase significantly. Conclusions Multidisciplinary stroke care was successfully implemented in a resource-constrained secondary-level hospital in South Africa and despite the limitations of the study, the significant reduction in inpatient mortality and increase in referral for inpatient rehabilitation would suggest an improvement in stroke care. Resource utilization in terms of length of hospital stay increased by a mean of 2 days but the number of CT brain scans performed and referral to a tertiary hospital did not increase significantly.

Chronic noncommunicable diseases in 6 low- and middle-income countries: Findings from wave 1 of the world health organization's Study on Global Ageing and Adult Health (SAGE)

In this paper, we examine patterns of self-reported diagnosis of noncommunicable diseases (NCDs) and prevalences of algorithm/measured test-based, undiagnosed, and untreated NCDs in China, Ghana, India, Mexico, Russia, and South Africa. Nationally representative samples of older adults aged ≥50 years were analyzed from wave 1 of the World Health Organizations Study on Global Ageing and Adult Health (2007-2010; n = 34,149). Analyses focused on 6 conditions: angina, arthritis, asthma, chronic lung disease, depression, and hypertension. Outcomes for these NCDs were: 1) self-reported disease, 2) algorithm/measured test-based disease, 3) undiagnosed disease, and 4) untreated disease. Algorithm/measured test-based prevalence of NCDs was much higher than self-reported prevalence in all 6 countries, indicating underestimation of NCD prevalence in low- and middle-income countries. Undiagnosed prevalence of NCDs was highest for hypertension, ranging from 19.7% (95% confidence interval (CI): 18.1, 21.3) in India to 49.6% (95% CI: 46.2, 53.0) in South Africa. The proportion untreated among all diseases was highest for depression, ranging from 69.5% (95% CI: 57.1, 81.9) in South Africa to 93.2% (95% CI: 90.1, 95.7) in India. Higher levels of education and wealth significantly reduced the odds of an undiagnosed condition and untreated morbidity. A high prevalence of undiagnosed NCDs and an even higher proportion of untreated NCDs highlights the inadequacies in diagnosis and management of NCDs in local health-care systems.

Management of older patients presenting after a fall − an accident and emergency department audit

BACKGROUND It is common for older patients to present to accident and emergency (AE) departments after a fall. Management should include assessment and treatment of the injuries and assessment and correction of underlying risk factors in order to prevent recurrent falls. OBJECTIVES To determine management of older patients presenting after a fall to the AE department of Groote Schuur Hospital in Cape Town, South Africa. METHOD Hospital records were reviewed for a random sample of 100 patients aged 65 years and older presenting to the AE department after a fall, between December 2001 and May 2002. RESULTS The mean age of the sample was 78.6 years (range 65-98 years); 72% of subjects were female. History of a previous fall, and history of drug or alcohol intake, were recorded in less than 20% of cases. Blood pressure and pulse rate were recorded in approximately 90% of cases, and pulse rhythm and postural blood pressure in 2%. Examination of the musculoskeletal system was done in 86% of cases and that of other systems in less than 50%; cognitive assessment was conducted in less than 30%. Radiological investigations were performed in 89% of cases, glucose and haemoglobin in 32%, renal profile and electrocardiogram in 5%, and urinalysis in 4%. Three-quarters of the patients were referred for further management: 52% to orthopaedic surgery, 12% to other surgical subspecialties, 6% to the general medical department, and 6% to other hospitals and clinics. No referrals were made to geriatric medicine, physiotherapy or occupational therapy. CONCLUSIONS In managing elderly patients after a fall, the AE department focused on injuries sustained. Little effort was made to establish and manage risk factors, hence to prevent recurrent falls. Guidelines are needed for the management of such patients in AE departments.

The burden and risk factors for adverse drug events in older patients - a prospective cross-sectional study

OBJECTIVE To determine the burden and risk factors for adverse drug events (ADEs) in older patients. Design. A prospective cross-sectional study. METHODS Patients (65 years and older) presenting to the tertiary Emergency Unit of Groote Schuur Hospital, Cape Town, between February and May 2005, were assessed for well established ADEs, as defined by the South African Medicines Formulary. Logistic regression models were fitted to determine drugs and other factors associated with the likelihood of developing ADEs. RESULTS ADEs were identified in 104 of the 517 (20%) presentations. The most frequently involved drug classes were cardiovascular (34%), anticoagulant (27%), analgesic (19%) and antidiabetic (9%). Patients who developed ADEs were more likely to have five or more prescription drugs (p < 0.0001), more than three clinical problems (p = 0.001), require admission (p = 0.04), and report compliance with medication (p = 0.02) than those who did not. Drugs shown to independently confer increased risk of ADEs were angiotensin-converting enzyme inhibitors (RR = 2.6, 95% CI: 1.3 - 5.2, p = 0.009), non-steroidal anti-inflammatory drugs (RR = 4.1, 95% CI: 2.1 - 8.0, p < 0.0001) and warfarin (RR = 3.1, 95% CI: 1.6 - 6.3, p = 0.0014). CONCLUSION ADEs contribute significantly to the burden of elderly care in the Emergency Unit. In a setting such as ours, increased pill burden and certain drug classes are likely to result in increased risk of ADEs in the older population group.

Prevalence of and factors associated with frailty and disability in older adults from China, Ghana, India, Mexico, Russia and South Africa

BACKGROUND The severe burden imposed by frailty and disability in old age is a major challenge for healthcare systems in low- and middle-income countries alike. The current study aimed to provide estimates of the prevalence of frailty and disability in older adult populations and to examine their relationship with socioeconomic factors in six countries. METHODS Focusing on adults aged 50+ years, a frailty index was constructed as the proportion of deficits in 40 variables, and disability was assessed using the World Health Organization Disability Assessment Schedule (WHODAS 2.0), as part of the Study on global AGEing and adult health (SAGE) Wave 1 in China, Ghana, India, Mexico, Russia and South Africa. RESULTS This study included a total of 34,123 respondents. China had the lowest percentages of older adults with frailty (13.1%) and with disability (69.6%), whereas India had the highest percentages (55.5% and 93.3%, respectively). Both frailty and disability increased with age for all countries, and were more frequent in women, although the sex gap varied across countries. Lower levels of both frailty and disability were observed at higher levels of education and wealth. Both education and income were protective factors for frailty and disability in China, India and Russia, whereas only income was protective in Mexico, and only education in South Africa. CONCLUSIONS Age-related frailty and disability are increasing concerns for older adult populations in low- and middle-income countries. The results indicate that lower levels of frailty and disability can be achieved for older people, and the study highlights the need for targeted preventive approaches and support programs.

Falls and fall prevention programmes in developing countries: Environmental scan for the adaptation of the Canadian Falls prevention curriculum for developing countries

PROBLEM Falls in older persons in developing countries are poorly understood, and falls prevention and health promotion programmes for this population are largely lacking. METHODS A systematic review was carried out of relevant literature on falls and prevention programmes, and falls prevention education, and a scan undertaken of health promotion programmes for older persons in a representative country - South Africa. RESULTS Studies on the risk and prevalence of falls are largely retrospective and hospital-based, with varied methodology, including study period, sampling method and sample size. Falls prevalence is based largely on self-reports in studies on general trauma in all age groups. Falls incidence varies from 10.1% to 54%. No reports could be traced on sustained falls prevention or health promotion programmes. CONCLUSION Scant research has been conducted and little preventive education offered on falls in older persons. Adaptation of the Canadian Falls Prevention Curriculum for developing countries will help to fill gaps in knowledge and practice. IMPACT ON INDUSTRY With rapid increase in the populations of older persons in developing countries, research on age related disorders such as falls is required to guide policy and management of falls.

Profile and management of patients at a memory clinic

Increasing longevity and a growing older population are being accompanied by a higher prevalence of dementia and concomitant demand for care. In this connection, the University of Cape Town/Groote Schuur Hospital (UCT/GSH) Memory Clinic provides a valuable service to patients, families and health professionals. High levels of behavioural and psychological symptoms of dementia need expert tertiary level assessment and management. Public education on dementia, early referral for assessment by primary care health professionals, and advanced training of health professionals are needed to encourage early recognition and appropriate management. Community-based care services too are needed to support caregivers of cognitively impaired older individuals.

Health expenditure and catastrophic spending among older adults living with HIV

ABSTRACT Introduction: The burden of HIV is increasing among adults aged over 50, who generally experience increased risk of cormorbid illnesses and poorer financial protection. We compared patterns of health utilisation and expenditure among HIV-positive and HIV-negative adults over 50. Methods: Data were drawn from the Study on global AGEing and adult health in South Africa with analysis focusing on individual and household-level data of 147 HIV-positive and 2725 HIV-negative respondents. Results: HIV-positive respondents reported lower utilisation of private health-care facilities (11.8%) than HIV-negative respondents (25.0%) (p = .03) and generally had more negative attitudes towards health system responsiveness than HIV-negative counterparts. Less than 10% of HIV-positive and HIV-negative respondents experienced catastrophic health expenditure (CHE). Women (OR 1.8; p < .001) and respondents from rural settings (OR 2.9; p < .01) had higher odds of CHE than men or respondents in urban settings. Over half the respondents in both groups indicated that they had received free health care. Conclusions: These findings suggest that although HIV-positive and HIV-negative older adults in South Africa are protected to some extent from CHE, inequalities still exist in access to and quality of care available at health-care services – which can inform South Africa’s development of a national health insurance scheme.

Effectiveness of community-based peer-led diabetes self-management programmes (COMP-DSMP) for improving clinical outcomes and quality of life of adults with diabetes in primary care settings in low and middle-income countries (LMIC): a systematic review and meta-analysis

Introduction Globally, an estimated 380 million people live with diabetes today—80% in low-income and middle-income countries. The Middle East, Western Pacific, Sub-Saharan Africa and South-East Asia remain the most affected regions where economic development has transformed lifestyles, people live longer and there is an increase in the adult population. Although peer support has been used in different conditions with varied results, yet there is limited evidence to date supporting its effectiveness, particularly for individuals with diabetes. In this review, we will focus on community-based peer-led diabetes self-management programmes (COMP-DSMP) and examine the implementation strategies and diabetes-related health outcomes associated with them in LMIC primary healthcare settings. Methods and analysis In accordance with reporting equity-focused systematic reviews PRISMA-P (preferred reporting items for systematic review and meta-analysis protocols 2015 checklist) guidelines, a systematic review with meta-analysis of randomised controlled trials (RCTs), non-randomised controlled trials, quasi-randomised controlled trials (CCTs) that involve contact with an individual or group of peers (paid or voluntary). Electronic searches will be performed in The Cochrane Library, MEDLINE, PubMed, SCOUPS, CINAHL and PsycINFO Database for the period January up to July 2000 along with manual searches in the reference lists of relevant papers. The analyses will be performed based on baseline data from RCTs, CCTs and preintervention and postintervention means or proportions will be reported for both intervention and control groups, and the absolute change from baseline will be calculated, together with 95% CIs. For dichotomous outcomes, the relative risk of the outcome will be presented compared to the control group. The risk difference will be calculated, which is the absolute difference in the proportions in each treatment group. Ethics and dissemination Ethics is not required for this study, given that this is a protocol for a systematic review, which utilises published data. The findings of this study will be widely disseminated through peer-reviewed publications and conference presentations. Trial registration number PROSPERO (2014:CRD42014007531).

Use of physical restraint in hospital patients: A descriptive study in a tertiary hospital in South Africa

Background The use of physical restraint in patient management is a common and emotive issue, and has legal and ethical dimensions. Objective To document the prevalence of physical restraint use, patient characteristics associated with physical restraint use, and nurses’ and doctors’ knowledge and perceptions towards the practice. Methods A cross-sectional study of 572 patients, of whom 132 were physically restrained, was conducted in acute wards of a tertiary hospital. Data were collected on the 132 physically restrained patients. Fifty-nine doctors and 159 nurses completed a specially constructed questionnaire. Descriptive statistics were derived and expressed as numbers and percentages. Results Prevalence of restraint use was 23% (132/572). The distribution in acute wards was: medical 54.5%; surgical 44.7%; maternity 0.8%; psychiatry none. Mean age (SD) of the restrained patients was 49 years (20.5); 53.8% were male. The commonest types of restraints used were bed rails 93% and wrist belts 12%. Restraints were used largely to protect medical devices and as protection from harm. Less than 15% of the nurses reported having received training and 36% of the doctors reported having received some guidance on the use of restraints. Only a minority of nurses and doctors knew of a hospital policy on restraint use. Documentation on the prescription and indication for the use of restraint was poor. Conclusion Prevalence of restraint use is high and poorly coordinated. A policy on the use of restraint and comprehensive guidelines should be developed to guide health care practitioners in the management of patients where restraint cannot be avoided.