Yew Yoong Ding

Geriatric assessment and intervention in an emergency department observation unit reduced re‐attendance and hospitalisation rates

Aim:  To determine the efficacy of geriatric assessment and intervention in an emergency department observation unit (EDOU).

Noninvasive urodynamic evaluation of bladder outlet obstruction using Doppler ultrasonography

OBJECTIVES Previously we had developed a new method of noninvasive urodynamics using color Doppler ultrasound. Using this technique, we attempted to identify parameters that would diagnose bladder outlet obstruction (BOO). METHODS Twenty-two men who underwent pressure-flow urodynamic studies were included. Color scale transperineal ultrasound and uroflowmetry data were analyzed by custom-made software. The maximum flow velocities in the entire prostatic urethra (V(0)), in the distal prostatic urethra just proximal to the external urethral sphincter (V(1)), and in the membranous urethra (V(2)) were obtained. Corresponding functional cross-sectional areas of the urethra at these three sites (A(0), A(1), and A(2)) were calculated as Qmax/V. The velocity ratio (VR), which was equal to V(1)/V(2), was also calculated as a parameter. All these parameters obtained by the velocity-flow urodynamics were compared with the Abrams-Griffiths number (AG). RESULTS From the x-y plots obtained, VR correlated best with AG, with Spearmans rho of 0. 728. A(0) and A(1) had rho values of -0.461 and -0.708 against AG, respectively. All men with VR exceeding 1.6 had obstruction, whereas those with VR less than 1.1 did not. CONCLUSIONS The VR was found to be the best parameter for diagnosing BOO. When prostatic urethral obstruction was present, the velocity in the prostatic urethra would be high but the velocity slows down to 62.5% or greater immediately below the sphincter. We believe that noninvasive pressure-flow-like urodynamic evaluation based on Doppler ultrasound has clear potential for diagnosing BOO.

A comparison of comorbidities obtained from hospital administrative data and medical charts in older patients with pneumonia

BackgroundThe use of comorbidities in risk adjustment for health outcomes research is frequently necessary to explain some of the observed variations. Medical charts reviews to obtain information on comorbidities is laborious. Increasingly, electronic health care databases have provided an alternative for health services researchers to obtain comorbidity information. However, the rates obtained from databases may be either over- or under-reported. This study aims to (a) quantify the agreement between administrative data and medical charts review across a set of comorbidities; and (b) examine the factors associated with under- or over-reporting of comorbidities by administrative data.MethodsThis is a retrospective cross-sectional study of patients aged 55 years and above, hospitalized for pneumonia at 3 acute care hospitals. Information on comorbidities were obtained from an electronic administrative database and compared with information from medical charts review. Logistic regression was performed to identify factors that were associated with under- or over-reporting of comorbidities by administrative data.ResultsThe prevalence of almost all comorbidities obtained from administrative data was lower than that obtained from medical charts review. Agreement between comorbidities obtained from medical charts and administrative data ranged from poor to very strong (kappa 0.01 to 0.78). Factors associated with over-reporting of comorbidities were increased length of hospital stay, disease severity, and death in hospital. In contrast, those associated with under-reporting were number of comorbidities, age, and hospital admission in the previous 90 days.ConclusionsThe validity of using secondary diagnoses from administrative data as an alternative to medical charts for identification of comorbidities varies with the specific condition in question, and is influenced by factors such as age, number of comorbidities, hospital admission in the previous 90 days, severity of illness, length of hospitalization, and whether inhospital death occurred. These factors need to be taken into account when relying on administrative data for comorbidity information.

Reliability of color Doppler ultrasound urodynamics in the evaluation of bladder outlet obstruction

OBJECTIVES To analyze the intrarater and interrater reliability of a newly developed noninvasive urodynamic technique based on color Doppler ultrasound for the evaluation of bladder outlet obstruction. We previously demonstrated the feasibility of this new technique. METHODS Color Doppler ultrasound urodynamic evaluations were performed on 31 men with and without bladder outlet obstruction. An ultrasound image-directed Doppler system with a 3.75-MHz probe operated by a remote control robotic manipulator was used to obtain color scale data using the transperineal approach in men during voiding. We measured the flow velocities in the distal prostatic (V1) and membranous urethra (V2) and used them to obtain the velocity ratio (VR = V1/V2). Combining this information with simultaneous uroflowmetry, the functional cross-sectional area of the distal prostatic urethra (A1) was calculated. These parameters were independently reinterpreted by an inexperienced investigator using the color image data stored in a personal computer. The intrarater and interrater reliability for VR were assessed using a classification based on cutoff values previously shown to indicate the presence or absence of obstruction. RESULTS The retest correlation using Spearmans rho for VR in terms of intrarater and interrater reliability was 0.95 and 0.57, respectively; that for A1 was 0.97 and 0.64, respectively. Using a VR of less than 1.1 (to indicate the absence of obstruction) and a VR greater than 1.6 (to indicate the presence of obstruction) for classification, intrarater and interrater agreement occurred in 93.6% to 96.8% and 77.4% to 83. 9% of cases, respectively. CONCLUSIONS The color Doppler ultrasound urodynamic technique for noninvasive evaluation of bladder outlet obstruction can be performed with reasonable reliability.

Outcomes of an innovative model of acute delirium care: the Geriatric Monitoring Unit (GMU)

Objective Delirium is associated with poor outcomes following acute hospitalization. The Geriatric Monitoring Unit (GMU) is a specialized five-bedded unit for acute delirium care. It is modeled after the Delirium Room program, with adoption of core interventions from the Hospital Elder Life Program and use of evening light therapy to consolidate circadian rhythms and improve sleep in older inpatients. This study examined whether the GMU program improved outcomes in delirious patients. Method A total of 320 patients, including 47 pre-GMU, 234 GMU, and 39 concurrent control subjects, were studied. Clinical characteristics, cognitive status, functional status (Modified Barthel Index [MBI]), and chemical restraint-use data were obtained. We also looked at in-hospital complications of falls, pressure ulcers, nosocomial infection rate, and discharge destination. Secondary outcomes of family satisfaction (for the GMU subjects) were collected. Results There were no significant demographic differences between the three groups. Pre-GMU subjects had longer duration of delirium and length of stay. MBI improvement was most evident in the GMU compared with pre-GMU and control subjects (19.2±18.3, 7.5±11.2, 15.1±18.0, respectively) (P<0.05). The GMU subjects had a zero restraint rate, and pre-GMU subjects had higher antipsychotic dosages. This translated to lower pressure ulcer and nosocomial infection rate in the GMU (4.1% and 10.7%, respectively) and control (1.3% and 7.7%, respectively) subjects compared with the pre-GMU (9.1% and 23.4%, respectively) subjects (P<0.05). No differences were observed in mortality or discharge destination among the three groups. Caregivers of GMU subjects felt the multicomponent intervention to be useful, with scheduled activities voted the most beneficial in patient’s recovery from the delirium episode. Conclusion This study shows the benefits of a specialized delirium management unit for older persons. The GMU model is thus a relevant system of care for rapidly “graying” nations with high rates of frail elderly hospital admissions, which can be easily transposed across acute care settings.

Monocyte chemoattractant protein-1: a proinflammatory cytokine elevated in sarcopenic obesity

Objective Sarcopenic obesity (SO) is associated with poorer physical outcomes and functional status in the older adult. A proinflammatory milieu associated with central obesity is postulated to enhance muscle catabolism. We set out to examine associations of the chemokine monocyte chemoattractant protein-1 (MCP-1) in groups of older adults, with sarcopenia, obesity, and the SO phenotypes. Methods A total of 143 community dwelling, well, older adults were recruited. Cross-sectional clinical data, physical performance, and muscle mass measurements were collected. Obesity and sarcopenia were defined using revised National Cholesterol Education Program (NCEP) obesity guidelines and those of the Asian Working Group for Sarcopenia. Serum levels of MCP-1 were measured by enzyme-linked immunosorbent assay (ELISA). Results In all, 25.2% of subjects were normal, 15.4% sarcopenic, 48.3% obese, and 11.2% were SO. The SO groups had the lowest appendicular lean mass, highest percentage body fat, and lowest performance scores on the Short Physical Performance Battery and grip strength. The MCP-1 levels were significantly different, with the highest levels found in SO participants (P<0.05). Conclusion Significantly raised MCP-1 levels in obese and SO subjects support the theory of chronic inflammation due to excess adiposity. Longitudinal studies will reveal whether SO represents a continuum of obesity causing accelerated sarcopenia and cardiovascular events, or the coexistence of two separate conditions with synergistic effects affecting functional performance.

Prospective Observational Study of Delirium Recovery Trajectories and Associated Short-Term Outcomes in Older Adults Admitted to a Specialized Delirium Unit

To describe the recovery trajectories of delirium and to determine factors predicting the course of recovery and adverse outcome.

Predicting mortality among older adults hospitalized for community‐acquired pneumonia: An enhanced Confusion, Urea, Respiratory rate and Blood pressure score compared with Pneumonia Severity Index

Background and objective:  Pneumonia Severity Index (PSI) predicts mortality better than Confusion, Urea >7 mmol/L, Respiratory rate >30/min, low Blood pressure: diastolic blood pressure <60 mm Hg or systolic blood pressure <90 mm Hg, and age >65 years (CURB‐65) for community‐acquired pneumonia (CAP) but is more cumbersome. The objective was to determine whether CURB enhanced with a small number of additional variables can predict mortality with at least the same accuracy as PSI.

Impact of frailty and residual subsyndromal delirium on 1-year functional recovery: A prospective cohort study

To investigate the association between frailty and incomplete delirium recovery at discharge (residual subsyndromal delirium [RSSD]), and to examine the mediating role of RSSD in the relationship between frailty and functional recovery at 12 months post‐delirium.

The Case for Stage-Specific Frailty Interventions Spanning Community Aging to Cognitive Impairment

OBJECTIVES To explore factors associated with frailty across the continuum of healthy aging to cognitive impairment (mild cognitive impairment [MCI], mild and moderate Alzheimer disease [AD]). DESIGN Cross-sectional study. SETTING Senior activity centers and the outpatient memory clinic of a tertiary hospital. PARTICIPANTS Community-dwelling and functionally independent adults aged 50 years and older and older adults attending the memory clinic with MCI, and mild and moderate AD diagnoses. METHODS We recruited 299 participants comprising 200 cognitively healthy individuals, 16 with MCI, 68 with mild AD, and 15 with moderate AD. We collected measures of comorbidities, cognitive and functional performance, physical activity level, and anthropometric and nutritional status. Frailty was defined using Buchmann criteria, and sarcopenic obesity (SO) was defined using the Asian Working Group for Sarcopenia criteria and the revised National Cholesterol and Education Panel-obesity definition of waist circumference. Multiple logistic regression was performed to identify factors associated with frailty as a whole group and separately based on cognitive subgroups. RESULTS There were 16.7% of patients who met frailty criteria. Frailty prevalence was lowest in the well elderly (3.5%) and subsequently followed a U-shaped prevalence from MCI to mild and moderate AD, respectively. Specific univariate differences were noted in age, hypertension, ischemic heart disease, depressive symptoms, social differences, and functional scores. Multivariable logistic regression showed age, cognitive status, and SO to be significantly associated with frailty status. Subgroup analysis showed only SO to be significant (odds ratio [OR] 15.55, 95% confidence interval [CI] 1.63-148.42) in well elderly and only cognition to be associated with frailty (OR 0.89, 95% CI 0.80-0.99) among the cognitively impaired. CONCLUSION Our findings lend initial support to the case for stage-specific interventions for physical frailty with the focus on SO in healthy community-dwelling older persons and cognitive-based measures in older adults with cognitive impairment. The accurate clinical phenotyping would then set the stage for future potential investigative therapies along these specific lines, rather than an undifferentiated approach.