"In Limbo"-use of, and alterations to, modified diets by nursing home staff in the absence of timely specialist support.

Background: Dysphagia is common in nursing home (NH) residents. Staff may not always be able to access speech and language therapist (SLT) assessments in a timely manner and there are some reports of nurses initiating or changing modified diets in these circumstances. Methods: A mixed quantitative and qualitative approach was used to analyse responses to an online anonymized survey of senior nurses working in Irish NHs. They were asked about their experience of delays accessing SLT services and whether they would ever initiate or change modified diets. Respondents were asked if they would give water to a thirsty resident, prescribed mildly thick liquids, who demanded it on a hot day because thickened fluid was not thirst quenching. Results: Of 77 nurses surveyed, 63 (82%) responded. Three quarters reported delays accessing SLT services sometimes or often. Thirty-four (54.0%) would not give the thirsty resident water. About 70% reported that thickened fluids or modified texture diets were started without SLT sometimes or often. A third of respondents would thicken fluids or modify food to a greater extent than previously recommended but very few would make a diet less restrictive. The main themes that emerged from the comments provided were related to the uncertainty and dilemmas created for staff, what mitigating actions they might take in those circumstances and the need for better guidance and better access to SLT services. Discussion: Delays accessing SLT services are common for Irish NHs, and staff may initiate or change modified diets themselves in these circumstances. The responses suggest a widespread, and unjustified, belief that thicker or more modified is better for those with dysphagia. Clear and accurate guidance, and a better SLT service, is needed for NH staff.

Informed consent for capacity assessment.

In this paper we examine the role of informed consent to capacity assessment, focussing primarily on the two jurisdictions of England and Wales, and Ireland. We argue that in both jurisdictions, a capacity assessment should be regarded as a distinct intervention, separate from the 'original' intervention at issue, and that specific informed consent to the assessment should generally be sought in advance. As part of this, we consider what information should be provided so as to ensure informed consent. Having established a baseline requirement for informed consent, we also recognise that informed consent to assessment will not always be possible, either because the person is unable to understand the information about assessment or because the person refuses to be assessed and so, in the final part of the article, we explore how to proceed when informed consent is either not possible or not forthcoming, including an analysis of the implications of the statutory presumption of capacity.

Informed or misinformed consent and use of modified texture diets in dysphagia.

BACKGROUND: Use of modified texture diets-thickening of liquids and modifying the texture of foods-in the hope of preventing aspiration, pneumonia and choking, has become central to the current management of dysphagia. The effectiveness of this intervention has been questioned. We examine requirements for a valid informed consent process for this approach and whether the need for informed consent for this treatment is always understood or applied by practitioners. MAIN TEXT: Valid informed consent requires provision of accurate and balanced information, and that agreement is given freely by someone who knows they have a choice. Current evidence, including surveys of practitioners and patients in different settings, suggests that practice in this area is often inadequate. This may be due to patients' communication difficulties but also poor communication-and no real attempt to obtain consent-by practitioners before people are 'put on' modified texture diets. Even where discussion occurs, recommendations may be influenced by professional misconceptions about the efficacy of this treatment, which in turn may poison the well for the informed consent process. Patients cannot make appropriate decisions for themselves if the information provided is flawed and unbalanced. The voluntariness of patients' decisions is also questionable if they are told 'you must', when 'you might consider' is more appropriate. Where the decision-making capacity of patients is in question, inappropriate judgements and recommendations may be made by substitute decision makers and courts unless based on accurate information. CONCLUSION: Research is required to examine the informed consent processes in different settings, but there is ample reason to suggest that current practice in this area is suboptimal. Staff need to reflect on their current practice regarding use of modified texture diets with an awareness of the current evidence and through the 'lens' of informed consent. Education is required for staff to clarify the importance of, and requirements for, valid informed consent and for decision making that reflects people's preferences and values.

Improved outcomes with delayed admission to post-acute care: results of a natural experiment.

PURPOSE: To determine the effectiveness of a post-acute care scheme by exploiting a natural experiment. METHODS: We used a reduction in funding for an Irish PAC scheme based in private nursing homes as a natural experiment to explore the effectiveness of this scheme in a single large general hospital. RESULTS: Compared with an equivalent 3-month period in 2017 (pre-change, N = 169), those admitted to PAC in 2019 (post-change, N = 179), spent a median 6 days longer in acute care, although total duration spent in healthcare settings was the same. Compared with 2017, readmissions to hospital within 90 days of discharge (43/179 (24.0% v 58/169 (34.3%), p = 0.03) and discharge to long-term care from the PAC facility (3 (1.7%) v 14 (8.3%), p = 0.004) were significantly lower in 2019. CONCLUSION: Our results suggest that the longer stay in acute care and shorter stay in PAC was beneficial for patients and led to improved outcomes.

Talking about walking: lack of shared understanding of common mobility terms among different healthcare professional groups.

Australian studies suggest a lack of consensus in interpreting mobility recommendations, particularly affecting the terms "supervision" and "stand by assistance", was common and a contributing factor in patient falls. In a web-based survey, where responses were obtained from 102/150 (68%) therapists, 79/152 (52%) nurses and 97/132 (73%) doctors, we asked participants about their understanding of what requiring "supervision" or "stand-by assistance" when walking means. Responses to all questions differed significantly between the groups and the magnitude of the differences was greatest for the "supervision" questions. Asked if stand by assistance means the same as supervision, 71% of doctors, 35% of nurses and 14% of therapists said yes (p < 0.0001). There were also substantial within-group differences even among therapists. The widespread confusion regarding the interpretation of mobility terminology among and between different healthcare groups may impact on patient safety, and standardisation of mobility terminology is required.

Dehydration and renal failure in older persons during heatwaves-predictable, hard to identify but preventable?

Extremes of temperature are likely to increase in frequency associated with climate change. Older patients are particularly vulnerable to the effects of heat with excess mortality well documented in this population. Age-associated neurohormonal changes particularly affecting the renin angiotensin aldosterone system (RAAS), alterations in thermoregulatory mechanisms, changes in renal function and body composition render older persons vulnerable to dehydration, renal failure, heat stroke and increased mortality. Barriers to diagnosis and recognition of dehydration and renal failure include the absence of reliable clinical signs and cost-effective diagnostic tools. Regularly used medications also impact on physiological responses to excess heat as well as interfering with the recognition and management of dehydration during heat waves. In view of the above, anticipatory measures should be instituted ideally prior to the onset of heat waves to minimise morbidity and mortality for older people during periods of excess heat.

The perils of 'risk feeding'.

'Risk feeding' policies, for when people continue to eat and drink despite a perceived risk of choking or aspiration have become common in recent years. We argue that 'feeding' is demeaning language if referring to a person who is eating and drinking rather than to a healthcare technique and that 'risk-anything' is not how decisions are reached. It is true that patients with dysphagia are often unnecessarily designated nil-by-mouth (NBM), especially after a decision has been made that tube feeding is not indicated or is unwanted. However, risk-feeding policies may perpetuate common misperceptions that there is a straightforward relationship between aspiration and pneumonia and that interventions like NBM or tube feeding will reduce the risk of pneumonia. Such policies may reduce the potential for individualised and flexible decision making: many people's swallowing abilities and preferences fluctuate, sometimes from hour to hour, and staff need to have, and be encouraged to use, common sense, flexibility and judgement in these circumstances. There is also the potential for delays in providing food, fluid and medications if meetings must be held and risk-feeding paperwork completed and signed by someone with the necessary seniority and confidence. Further debate and discussion is required before risk-feeding policies become an established standard of care.

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.

Indications and outcomes of home visits by geriatricians.

PURPOSE: The value of the home (domiciliary) visit (HV) by geriatricians at the request of general practitioners has been questioned. We analysed HVs conducted by geriatricians in a west of Ireland hospital over a 14-year period. METHODS: From 2002 to 2016, a systematic record was maintained of all HVs conducted by a geriatrician. RESULTS: Consent to publication was obtained for 114 (81%) of 141 visits performed. A HV was requested in 47 (41%) cases because the person would not attend a clinic, most having a long history of refusing care, and in 40 (35%) cases because the person was severely immobile or too unwell to leave home. In 27 (24%) cases, assessment was best conducted in the home for other reasons including squalor. Of the referrals, only 40 (35%) sought specific medical advice and 15 (13%) sought advice regarding end-of-life planning. In many cases, general advice regarding management of self-neglect, unexplained decline, poor home circumstances and undue risk taking was sought. The commonest decision [45 (39%) participants] was that no major intervention would be appropriate or achievable in the person's circumstances and having regard to his or her own preferences. Twenty-three (20%) participants were persuaded to accept a major intervention they had previously declined. In 14 (12%) cases, a palliative care approach in the home was agreed. An application to court to determine what care the person should receive occurred in five (5%) cases. Many medications were stopped. CONCLUSIONS: Home visits by geriatricians remain a valuable option for selected older people.

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

BACKGROUND: Although 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. DISCUSSION: There 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. CONCLUSION: The 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.

Effectiveness of a multifaceted intervention to reduce night-time sedative use in a rehabilitation unit: a pre-post intervention study.

Background: night-time sedation prescribed during a hospital stay can result in long-term use of such medications in older people. We examined the effectiveness of a multifaceted intervention to reduce night time sedation in an inpatient rehabilitation unit. Methods: an initial retrospective survey of night-time sedative use was followed by prospective re-evaluation after a number of changes were made including education of staff and of patients regarding the potential hazards of sedative medications, measures to promote sleep hygiene and facilitate a 'quiet time' after 10 pm and development of a withdrawal protocol for patients on long-term night sedation. The primary outcome measures were the proportions of patients started on night sedation in the unit and the proportion of those using night sedation where a dose reduction was attempted before and after the intervention. Results: night sedation was prescribed for 22/68 (32.4%) subjects in the pre- and 23/169 (13.6%) subjects in the post-intervention surveys (P = 0.001); medication started while in the unit dropped from 10 (14.7%) to 1 (0.6%) (P < 0.0001). There was an improvement in the proportion of patients using night sedation where an attempt was made to reduce the dosage of or eliminate sedative drug use prior to discharge after the intervention was introduced (3/22 (13.6%) vs 14/23 (60.9%) (P = 0.001)). Conclusions: a multifaceted intervention, including ongoing education, audit and feedback and changes to unit practices to promote a 'quiet time' at night, leads to a substantial reduction in the use of night sedation in inpatients.

Will-making in Irish nursing homes: Staff perspectives on testamentary capacity and undue influence.

Allegations of lack of testamentary capacity or of undue influence are grounds for many disputed wills. Some people who make (or change an existing) will are resident in a nursing home. A substantial proportion of this population have cognitive or communication difficulties or are physically frail, and concerns regarding testamentary capacity or undue influence may be more likely to arise as a result. A questionnaire examining the experiences and views of staff regarding will-making by nursing home residents was posted to the Directors of Nursing of a random sample of 148 of the approximately 600 nursing homes in the Republic of Ireland and 81 responded. Over 10% of respondents reported seeing cases where they felt a resident who lacked capacity was visited by a solicitor or where a resident was placed under undue pressure to make or change a will or both. In most such cases, staff felt they could do little to intervene. In general, responses to the questionnaire suggested staff misunderstanding of the confidential nature of the relationship between a solicitor and a client and that respondents had an exaggerated view of the power and responsibility of doctors and of family members to influence residents' decisions and interactions with solicitors regarding will-making. This study suggests the need for improved Guidelines for staff regarding will-making in residential care including advice on how to proceed where concerns including undue pressure arise.

Challenge of diagnosing non-convulsive status epilepticus presenting as delirium.

PURPOSE: Nonconvulsive status epilepticus (NCSE) is relatively common in older people. Although NCSE is a known cause of delirium, diagnosis is often delayed or missed. METHODS: We report three cases where NCSE was identified as the cause of delirium in older people that illustrate the challenge of diagnosis. RESULTS: The 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. CONCLUSIONS: Clinicians should maintain a high index of suspicion for NCSE in patients with delirium especially when no other obvious cause is identified.

The de-alzheimerisation of dementia? An analysis of internet searches.

PURPOSE: Alzheimer's disease is often seen by the public as synonymous with dementia but this may have changed in recent years. METHODS: We used Google Trends to examine the relative volume of internet searches from 2004 to July 2017 for the terms 'dementia' and 'Alzheimer' in English-speaking countries. For each country, a linear regression model was fitted for each search term and the slopes of the lines were compared. RESULTS: The slopes (standard error) for 'dementia' and 'Alzheimer', respectively, were: Australia-0.26 (0.02) and - 001 (0.002); Canada-0.23 (0.01) and 0.004 (0.01); Ireland: 0.33 (0.02) and - 0.04 (0.01); United Kingdom-0.36 (0.01) and 0.01 (0.001); and United States-0.23 (0.01) and - 0.01 (0.004). Differences between slopes were all significant at p < 0.001. CONCLUSIONS: In all countries, there was a large increase over time in relative search volumes for 'dementia' and a flat or negative trend in searches for 'Alzheimer'.

Summertime blues? A re-examination of the seasonality of web searches for restless legs and leg cramps.

OBJECTIVE: Studies that examined Internet searches for restless legs and leg cramps have found a strong seasonal effect with peaks in summer and troughs in winter months. The present study used an econometric approach to examine the seasonality of such searches in greater detail. METHODS: Monthly relative search volumes for 'restless legs' and 'leg cramps' from 2004 to March 2017 in the United Kingdom (UK) and Australia were obtained from Google Trends. Average percentage change from winter to summer months was examined. The TRAMO-SEATS procedure from the DEMETRA statistical software was used to decompose the data into trend, seasonal and noise components and to determine whether a combined seasonality test was positive. RESULTS: There were substantial percentage increases in Google Trends searches between winter and summer months regarding restless legs in the UK (median increase 46%) and Australia (33%) and regarding leg cramps in the UK (95%) and Australia (50%). However, the combined seasonality test was positive only for leg cramps and not for restless legs in both countries: although there was significant stable seasonality in restless legs searches, this was outweighed by substantial moving seasonality and noise components. CONCLUSIONS: Examination of average percentage increase in search volume from winter to summer exaggerates the degree of seasonality. Seasonal effects for restless legs searches are non-significant when the trend and noise components of the data are considered, although this does not exclude a clinical significance for the identified stable seasonality. Significant seasonality, with a summer peak, is present for leg cramps searches and suggests an increase in the incidence or severity of leg cramps in summer.

Deciding about nursing home care in dementia: A conjoint analysis of how older people balance competing goals.

AIM: "Don't put me in a home" is a common preference of older people, but so too is "I don't want to be a burden on my family." These and other goals often conflict with each other when people have worsening dementia and the issue of possible nursing home admission arises. METHODS: Community-dwelling older hospital patients were asked to imagine that they lived alone, had dementia and were experiencing increasing practical difficulties, and were presented with 11 possible "outcome packages." Conjoint analysis was used to investigate how participants ranked possible outcomes and traded-off between these factors: place of residence (home or nursing home), burden on their family, risk of harm and duration of life. RESULTS: Of 122 potential participants, 102 inpatients aged 65-80 years completed the study. Of these participants, 46 (46%) patients give the greatest weight to reducing the burden on their family, 39 (39%) to remaining at home, 11 (11%) to minimizing the risk of harm and five (5%) to maximizing the length of life. There were no significant clinical or demographic differences between these groups. There was a strong negative correlation (Spearman's rho -0.59, P < 0.0001) between importance scores for place of residence and for burden on family. CONCLUSIONS: There are important differences in how individual older people would balance the competing priorities of reducing the burden on their family and remaining at home in the event of developing dementia. Geriatr Gerontol Int 2017; 17: 2435-2440.