Stephen C. Allen

What determines whether an elderly patient can use a metered dose inhaler correctly

The metered dose inhaler (MDI) technique of 30 elderly patients (mean age 79.9 years) was assessed. Sixty per cent were competent, though only 10% had an ideal technique; 40% were incompetent. Inadequate timing of actuation and inhalation was the most frequent error made. Competence was significantly related to mental status questionnaire (MSQ) scores of 7/10 or more. Patients who were first prescribed an MDI in hospital were significantly more likely to be competent than those prescribed an MDI by the general practitioner. Competence was not related to age, underlying diagnosis or duration of MDI therapy. Elderly patients requiring MDI therapy should be carefully selected and properly instructed by the prescribing doctor.

A Comparative Study of the Use of Four Fall Risk Assessment Tools on Acute Medical Wards

Objectives: To compare the effectiveness of four falls risk assessment tools (STRATIFY, Downton, Tullamore, and Tinetti) by using them simultaneously in the same environment. Design: Prospective, open, observational study. Setting: Two acute medical wards admitting predominantly older patients. Participants: One hundred thirty-five patients, 86 female, mean age±standard deviation 83.8±8.01 (range 56–100). Measurements: A single clinician prospectively completed the four falls risk assessment tools. The extent of completion and time to complete each tool was recorded. Patients were followed until discharge, noting the occurrence of falls. The sensitivity, specificity, negative predictive accuracy, positive predictive accuracy, and total predictive accuracy were calculated. Results: The number of patients that the STRATIFY correctly identified (n=90) was significantly higher than the Downton (n=46; P<.001), Tullamore (n=66; P=.005), or Tinetti (n=52; P<.001) tools, but the STRATIFY had the poorest sensitivity (68.2%). The STRATIFY was also the only tool that could be fully completed in all patients (n=135), compared with the Downton (n=130; P=.06), Tullamore (n=130; P=.06), and Tinetti (n=17; P<.001). The time required to complete the STRATIFY tool (average 3.85 minutes) was significantly less than for the Downton (6.34 minutes; P<.001), Tinetti (7.4 minutes; P<.001), and Tullamore (6.25 minutes; P<.001). The Kaplan-Meier test showed that the STRATIFY (log rank P=.001) and Tullamore tools (log rank P<.001) were effective at predicting falls over the first week of admission. The Downton (log rank P=.46) and Tinetti tools (log rank P=.41) did not demonstrate this characteristic. Conclusion: Significant differences were identified in the performance and complexity between the four risk assessment tools studied. The STRATIFY tool was the shortest and easiest to complete and had the highest predictive value but the lowest sensitivity.Objectives: To compare the effectiveness of four falls risk assessment tools (STRATIFY, Downton, Tullamore, and Tinetti) by using them simultaneously in the same environment.

Fall risk-assessment tools compared with clinical judgment: an evaluation in a rehabilitation ward

OBJECTIVES to compare the use of two falls risk-identification tools (Downton and STRATIFY) with clinical judgment (based upon the observation of wandering behaviour) in predicting falls of medically stable patients in a rehabilitation ward for older people. METHODS in a prospective observational study, with blinded end-point evaluation, 200 patients admitted to a geriatric rehabilitation hospital had a STRATIFY and Downton Fall Risk assessment and were observed for wandering behaviour. RESULTS wandering had a predictive accuracy of 78%. A total of 157/200 were identified correctly compared to 100/200 using the Downton score (P < 0.0001 95%, CI 0.18-0.42), or 93/200 using STRATIFY (P < 0.0001; 95% CI 0.15-0.37). The Downton and STRATIFY tools demonstrated predictive accuracies of 50% and 46.5%, respectively, with no statistical significance between the two (P = 0.55; 95% CI 0.77-1.71). Sensitivity for predicting falls using wandering was 43.1% (22/51). This was significantly worse than Downton 92.2% (47/51: P < 0.001) and STRATIFY 82.3% (42/51: P < 0.001). CONCLUSIONS this study showed that clinical observation had a higher accuracy than two used falls risk-assessment tools. However it was significantly less sensitive implying that fewer patients who fell were correctly identified as being at risk.

Ability to learn inhaler technique in relation to cognitive scores and tests of praxis in old age

Clinical observations have shown that some older patients are unable to learn to use a metered dose inhaler (MDI) despite having a normal abbreviated mental test (AMT) score, possibly because of dyspraxia or unrecognised cognitive impairment. Thirty inhaler-naive inpatients (age 76–94) with an AMT score of 8–10 (normal) were studied. Standard MDI training was given and the level of competence reached was scored (inhalation score). A separate observer performed the minimental test (MMT), Barthel index, geriatric depression score (GDS), ideational dyspraxia test (IDT), and ideomotor dyspraxia test (IMD). No correlative or threshold relationship was found between inhalation score and Barthel index, GDS, or IDT. However, a significant correlation was found between inhalation score and IMD (r = 0.45, p = 0.039) and MMT (r = 0.48, p = 0.032) and threshold effects emerged in that no subject with a MMT score of less than 23/30 had an inhalation score of 5/10 or more (adequate technique requires 6/10 or more), and all 17/18 with an inhalation score of 6/10 or more had an IMD of 14/20 or more. The three patients with a MMT >22 and inhalation score <6 had abnormal IMD scores. Inability to learn an adequate inhaler technique in subjects with a normal AMT score appears to be due to unrecognised cognitive impairment or dyspraxia. The MMT is probably a more useful screening test than the AMT score in this context.

Low dose diamorphine reduces breathlessness without causing a fall in oxygen saturation in elderly patients with end-stage idiopathic pulmonary fibrosis

There is very little evidence regarding the safety and efficacy of opioids for the control of dyspnoea in the terminal stages of idiopathic pulmonary fibrosis (IPF). We conducted an open case series study of 11 elderly opioid-naive patients referred for management of severe breathlessness before and after their first injection of 2.5 mg diamorphine subcutaneously. Subjective breathlessness, measured by a 100 mm visual analogue scale, fell by a mean of 47 mm in the first 15 min (PB 0.0001) and the mean heart rate fell by 12/min (P-0.007). There were small non-significant falls in the mean respiratory rate (2/min), systolic blood pressure (6 mmHg) and oxygen saturation (1%). These changes were maintained at 30 min. Follow up treatment with oral morphine remained effective in reducing the symptom of breathlessness and no patient showed signs of respiratory depression. Low dose opioids are effective and safe in the palliative management of IPF in frail elderly patients.

Characteristics of Single Fallers and Recurrent Fallers among Hospital In-Patients

Background: Recurrent fallers constitute a minority of patients who fall but contribute considerably to the total number of falls recorded. Objective: To study the characteristics of recurrent fallers in a hospital setting. Methods: In a prospective observational study we investigated the characteristics of 1,025 patients admitted to a geriatric non-acute hospital. Patients were followed until discharge and were classified as non-fallers, single fallers or recurrent fallers. Results: We identified 824 non-fallers, 136 single fallers and 65 recurrent fallers contributing 175 falls. Compared to non-fallers, recurrent fallers were more likely to have pre-admission falls (p = 0.004), confusion (p < 0.0001), an unsafe gait (p = 0.0001) and be on tranquillisers (p = 0.018) and antidepressants (p = 0.006). They had longer stays in hospital (p < 0.0001) and more nursing home discharges (p = 0.0001). There was considerable overlap with risk factors for single fallers but compared to this group they were more likely to be confused (p = 0.027), and on antidepressant medication (p = 0.009). They also had a longer length of stay (p < 0.001) and more nursing home discharges (p = 0.03). Confusion (p = 0.0001), unsafe gait (p = 0.0006) and antidepressants (p = 0.018) were independently associated with recurrent falls. Conclusions: It is important to recognise the risk factors that prospectively identify a recurrent faller because of the significant contribution to total falls by a relatively small number of patients. This may be useful not only in trying to reduce total falls but also in trying to reduce injury.

Predictors of a nursing home placement from a non-acute geriatric hospital

Background: Identifying patients who need Nursing Home (NH) care following a hospital admission is important. Objective: To identify the factors that predispose to an NH discharge. Design: Prospective observational study with blinded end-point evaluation. Setting: A non-acute geriatric hospital. Subjects: Two hundred consecutive elderly patients who were admitted for rehabilitation following treatment for an acute illness. Main outcome measures: Discharge to an NH or home. Results: Thirty-five out of the 150 live discharges (23.3%) were to an NH. NH discharges had a longer length of stay (38.5 versus 19.8 days; p < 0001). They were more likely to have visual impairment (p = 0.0009), confusion (p < 0.0001), wandering behaviour (p = 0.003), incontinence (p < 0.0001 or unsafe gait (p = 0.0005), to be on tranquillizers (p = 0.003), to be at risk of falls (p = 0.02) and to have sustained a fall while in hospital (p = 0.001). Multiple logistic regression identified confusion (p = 0.001), incontinence (p = 0.02), falls in hospital (p = 0.01), gait abnormalities (p < 0.001), tranquillizers (p < 0.001), impaired distant vision (p = 0.01) and living alone (p < 0.001) as independently associated with the risk of an NH discharge. This risk proportionately increased with the number of risk factors present: 4.28% for 0–2 factors, 25.8% for 3–4 factors and 81.8% for 5–6 factors (p < 0.0001). Conclusion: These factors should be the target of specific rehabilitation in an attempt to reduce the risk of discharge to a nursing home and improve patient outcome.

Comparison of nebulized salbutamol with nebulized ipratropium bromide in acute asthma

Twelve patients admitted to hospital with an acute attack of bronchial asthma were studied. Six were treated initially with nebulized salbutamol solution by inhalation and 1 hour later by ipratropium bromide given in the same way; the other six were treated first with ipratropium bromide and 1 hour later by salbutamol. Ipratropium bromide was shown to be as effective as salbutamol when used as the initial bronchodilator but salbutamol produced significant further improvement when given 1 hour after ipratropium.

A four-helix bundle stores copper for methane oxidation

Methane-oxidizing bacteria (methanotrophs) require large quantities of copper for the membrane-bound (particulate) methane monooxygenase. Certain methanotrophs are also able to switch to using the iron-containing soluble methane monooxygenase to catalyse methane oxidation, with this switchover regulated by copper. Methane monooxygenases are nature’s primary biological mechanism for suppressing atmospheric levels of methane, a potent greenhouse gas. Furthermore, methanotrophs and methane monooxygenases have enormous potential in bioremediation and for biotransformations producing bulk and fine chemicals, and in bioenergy, particularly considering increased methane availability from renewable sources and hydraulic fracturing of shale rock. Here we discover and characterize a novel copper storage protein (Csp1) from the methanotroph Methylosinus trichosporium OB3b that is exported from the cytosol, and stores copper for particulate methane monooxygenase. Csp1 is a tetramer of four-helix bundles with each monomer binding up to 13 Cu(I) ions in a previously unseen manner via mainly Cys residues that point into the core of the bundle. Csp1 is the first example of a protein that stores a metal within an established protein-folding motif. This work provides a detailed insight into how methanotrophs accumulate copper for the oxidation of methane. Understanding this process is essential if the wide-ranging biotechnological applications of methanotrophs are to be realized. Cytosolic homologues of Csp1 are present in diverse bacteria, thus challenging the dogma that such organisms do not use copper in this location.

A comparison of four tests of cognition as predictors of inability to perform spirometry in old age

BACKGROUND previous studies have shown that a Mini Mental State Examination (MMSE) score of <24/30 and inability to copy intersecting pentagons (IP) predicts inability to perform spirometry. We hypothesised that clock drawing tests (CLOX 1 and 2), being validated tests of cognitive executive function, might predict spirometry performance with a higher sensitivity and specificity than the MMSE or IP. METHODS we studied 113 (84 females) spirometry-naïve inpatients, mean age of 84 years (range 74-97). All performed the MMSE, IP, CLOX 1 and 2 and then attempted to perform assisted spirometry to the American Thoracic Society/European Respiratory Society standard. RESULTS of 113, 49 met the criteria for adequate spirometry. Using normative thresholds for probable impairment, inability to perform spirometry was predicted by MMSE <24/30 with a sensitivity of 81% and specificity of 90% (P<0.0000); by inability to copy IP with a sensitivity of 92% and specificity of 100% (P<0.0000); by CLOX1 <10/15 with a sensitivity of 81% and specificity of 49% (P<0.001); and by CLOX2 <12/15 with a sensitivity of 63% and specificity of 65% (P<0.001). CONCLUSION CLOX tests did not perform better than MMSE and IP to identify subjects unlikely to be able to perform spirometry. Achieving assisted spirometry from the naïve state in old age might be more determined by global cognitive function and ideo-motor praxis than by executive control function.