Suboptimal management of hypernatraemia in acute medical admissions.

BACKGROUND: Hypernatraemia arises commonly in acute general medical admissions. Affected patients have a guarded prognosis with high rates of morbidity and mortality. Age-related physiology and physical/cognitive barriers to accessing water predispose older patients to developing hypernatraemia. This study sought to perform a descriptive retrospective review of hypernatraemic patients admitted under acute general medicine teams. METHODS: A retrospective cross-sectional study of a sample of acute medical in-patients with serum[sodium]>145 mmol/L was conducted. Patients were exclusively older(>69 years) and admitted from Nursing homes (NH)(41%) and non-NH pathways(59%). A comparison of management of NH /non-NH patients including clinical presentation, comorbidities, laboratory values, [sodium] monitoring, intravenous fluid regimes and patient outcomes was performed. RESULTS: In total, 102 consecutive patients (males, n=69(67.6%)) were included. Dementia and reduced mobility were more common in NH residents and admission serum [Sodium] higher (148 vs 142 mmol/L/p=0.003). Monitoring was inadequate: no routine bloods within the first 12h in >80% of patients in both groups. No patient had calculated free water deficit documented. More NH patients received correct fluid management (60% vs 33%/p%0.015). Incorrect fluid regimes occurred in both groups (38% vs 58%/p=0.070). Length of stay in discharged patients was lower in NH, (8(4-20) vs 20.5(9.8-49.3 days)/p=0.003). Time to death for NH residents was shorter (9(5.5-11.5) vs 16 (10.25-23.5) days/p=0.011). CONCLUSION: This study highlights suboptimal management of hypernatraemia. Implementation of hypernatraemia guidelines for general medical older inpatients are clearly required with mechanisms to confirm adherence. Health care workers require further education on diagnostic challenges of dehydration in older people and the importance of maintaining adequate hydration.

Preventative strategies and interventions to improve outcomes during heatwaves.

Extreme weather events including recently experienced prolonged heatwaves are predicted to increase in frequency and intensity as a result of climate change. Vulnerable groups, and particularly older persons, are at increased risk of heat-related illness and mortality. Multimodal interventions that incorporate community, primary and secondary care programmes are required. Social programmes such as early warning systems, regional heat plans and community-led initiatives that specifically target the isolated, dependent older person are protective. Establishing clear and effective communication on health promotion and preventative measures is the key. Energy-efficient building design and eco-city planning are vital to reduce the impact of heatwaves at both a population and individual level. Anticipatory strategies should be adopted to ensure ample access to fluids, target barriers to increase oral intake and allow early identification of intercurrent illness, along with regular medication reviews. Prompt management of risk factors for the development of heat-related illness and treatment of complications such as heat stroke and cardiovascular events are keys to reducing the negative health impact of extreme heat in at-risk populations. Morbidity and mortality in heatwaves should be preventable. Evidence-based interventions are available to mitigate and prevent the negative health impact of extreme heat and should be implemented in all residential settings.

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.

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.

A review of nocturnal leg cramps in older people.

Nocturnal leg cramps are common and troublesome, especially in later life, and have a significant impact on quality of life, particularly sleep quality. This article reviews the current state of knowledge regarding the diagnosis, frequency, pathophysiology and management of cramps. Recent evidence suggests that diuretic and long-acting beta-agonist therapy predispose to leg cramps. There is conflicting evidence regarding the efficacy of prophylactic stretching exercises in preventing cramps. Quinine remains the only medication proven to reduce the frequency and intensity of leg cramps. However, the degree of benefit from quinine is modest and the risks include rare but serious immune-mediated reactions and, especially in older people, dose-related side effects. Quinine treatment should be restricted to those with severe symptoms, should be subject to regular review and requires discussion of the risks and benefits with patients.

A randomised trial of the effect of different fluid consistencies used in the management of dysphagia on quality of life: a time trade-off study.

BACKGROUND: thickened fluids are commonly advised to minimise the risk of aspiration in people with dysphagia, although many do not comply with this treatment. In health economics, utilities are values that reflect an individual's preferences for different health states. We examined the healthcare utilities, elicited using a time trade-off approach (TTO), from healthcare professionals and non-dysphagic patients, associated with long-term use of thickened fluids. METHODS: the risk of aspiration with thin fluids was explained to consecutive hospital patients without dysphagia (n = 76) and to a convenience sample of healthcare professionals (n = 75) who were then randomly allocated to drink as much as possible of 200 ml of pre-prepared water of Grade 1 (very mildly thick) or Grade 2 (mildly thick) consistency. A standardised script with a ping-pong approach was then used to elicit TTO utilities for use of thickened fluids using a 10-year horizon. RESULTS: median (inter-quartile range) utilities were 0.7 (0.5-0.9) for those receiving Grade 1 and 0.5 (0.3-0.7) for those receiving Grade 2 consistency fluid (Mann-Whitney test, P = 0.001). Thus, for example, on average those allocated to Grade 2 fluid would be willing to sacrifice 5 years of a 10-year lifespan not to be restricted to fluid of that consistency. There were no significant differences between patient and professional values. CONCLUSION: patients and professionals judge that long-term use of thickened fluids would significantly impair quality of life. Utilities associated with more viscous fluids are particularly low.

Vascular risk factors, cardiovascular disease and functional impairment in community-dwelling adults.

BACKGROUND: Older adults report preservation of functional independence as one of the most important constructs of successful ageing. Vascular risk factors may increase the risk of functional impairment due to clinical and subclinical vascular disease. OBJECTIVE: To describe the association between vascular risk factors and impaired ability to perform daily living activities, independent of established cardiovascular disease. METHODS: We conducted an analysis of the Clarity Cohort, which is a cross-sectional study of 9,816 community-dwelling Irish adults. Of the total cohort, 3,499 completed standardized self-reported health questionnaires, which included questions on activities of daily living. Functional impairment was defined as self-reported impairment in self-care, mobility or household tasks. Using logistic regression analyses, we determined the association between vascular risk factors and functional impairment, independent of demographics, prior coronary artery disease, stroke, congestive heart failure, and peripheral vascular disease. RESULTS: Functional impairment was reported in 40.4% (n = 1,413) of the cohort overall and in 23% of those with established cardiovascular disease. The mean age was 66.2 ± 10.3 years, 52% of the cohort were aged over 65 and 45.6% were male. Some difficulty with instrumental activities of daily living was reported by 35.4% (n = 1,240) while 29.4% (n = 1,029) reported some difficulty with basic activities of daily living. On multivariable analysis, older age [OR 1.03 (1.02, 1.04) per year], current smoking [OR 1.43 (1.08, 1.89)], atrial fibrillation [OR 1.68 (1.07, 2.65)], former alcohol use [OR 1.87 (1.36, 2.57)] and prior stroke [OR 1.91 (1.24, 2.93)] were associated with an increased risk of functional impairment. Older age leaving education [OR 0.96 (0.94, 0.99)], non-use of alcohol [OR 0.76 (0.61, 0.93)] and increased high-density lipoprotein levels [OR 0.70 (0.56, 0.88)] were associated with reduced risk of functional impairment. CONCLUSIONS: Independent of established cardiovascular disease, some vascular risk factors are associated with functional impairment. Modification of these risk factors is expected to have a large impact on preservation of functional independence through prevention of overt and covert vascular disease.

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.

Atypical presentation of Abiotrophia defectiva infective endocarditis in an octogenarian.

Blood cultures should be performed in non-specifically unwell older adults following nonspecific presentations. Prompt diagnosis and commencement of targeted antimicrobial therapy are essential in older patients with A. defectiva IE.

Higher risk of vitamin D insufficiency/deficiency for rural than urban dwellers.

There are many risk factors for Vitamin D deficiency. This study aimed to compare the Vitamin D status and serum 25(OH)D concentrations of adults living in an urban area to adults living in a rural area in the West of Ireland (latitude 53.27° North). A cross-sectional retrospective analysis of clinical records was performed. Following interrogation of the electronic laboratory information system, individuals who had serum 25(OH)D concentrations measured at Galway University Hospitals between January 2011 and December 2015 were identified. Clinical demographics, setting and date of sampling were recorded. In total, 17,590 patients (urban n = 4,824; rural n = 12,766) were eligible for inclusion. Serum 25(OH)D concentrations were lower among rural compared to urban dwellers irrespective of season (spring p < 0.001, summer p = 0.009, autumn p = 0.002, winter p < 0.001). There was a significant difference in Vitamin D status between urban and rural dwellers in three of the four seasons: spring- deficiency: 16%-v-23%, insufficiency: 39%-v-43%, sufficiency: 45%-v-35% (p < 0.001); autumn- deficiency: 11%-v-10%, insufficiency: 30%-v-35%, sufficiency: 59%-v-56% (p = 0.01); winter- deficiency: 23%-v-25%, insufficiency: 35%-v-42%, sufficiency: 41%-v-33% (p < 0.001). Serum 25(OH)D concentrations were higher and the prevalence of deficiency lower in urban/rural females compared to urban/rural males (p < 0.001). Serum 25(OH)D concentrations increased sequentially from the 18-39 year age group to the 60-69 year age group in both urban (p < 0.001) and rural (p < 0.001) dwellers and then decreased progressively as age increased to ≥90 years. The odds of Vitamin D deficiency increased with age, lower daily sunshine hours, male gender, rural address and season.

Vitamin D Status of Adults in the Community, in Outpatient Clinics, in Hospital, and in Nursing Homes in the West of Ireland.

BACKGROUND: Approximately 1 billion people worldwide have Vitamin D deficiency. The aim of this study was to compare Vitamin D status and serum 25-hydroxyvitamin D (25(OH)D) concentrations among adults sampled in the community, in outpatient clinics, as hospital inpatients and in nursing homes in the West of Ireland. The secondary aim was to determine the associations between length of hospital stay (inpatients) at the time of serum 25(OH)D sampling and Vitamin D status. METHODS: A cross-sectional study was carried out. Patients who had serum 25(OH)D analysis carried out in Galway University Hospitals (January 2011-December 2015) were identified following interrogation of the electronic laboratory data system. Baseline demographics, location, and date of sample collection were recorded. Vitamin D deficiency was defined as a serum 25(OH)D concentration <25 nmol/L. RESULTS: In total, 24,302 patient samples were eligible for inclusion: community 15,319; outpatient clinics 6,371; inpatients 2,339; and nursing home residents 273. Vitamin D deficiency was more common in nursing home residents than inpatients, or those sampled in outpatient clinics or in the community (42% vs 37% vs 17% vs 13%; p < .001). Inpatients sampled further into their hospital stay (≥3 days) had greater Vitamin D deficiency than inpatients sampled on 0-2 days (p = .007). Season (p < .001), sex (p < .001), and age (p < .001) were associated with 25(OH)D concentrations. Vitamin D deficiency was more common in Winter/Spring, in males, and in those aged ≥80 years. CONCLUSIONS: Nursing home residents and inpatients are at the highest risk for Vitamin D deficiency. Season, sex, age, and day of hospital stay on which serum 25(OH)D concentrations were sampled were associated with Vitamin D status.

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.

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'.

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.

Use of serial Mini-Mental State Examinations to diagnose and monitor delirium in elderly hospital patients.

OBJECTIVES: To determine the responsiveness of serial Mini-Mental State Examinations (MMSEs) for the diagnosis and monitoring of delirium in elderly hospital patients. DESIGN: Prospective study. SETTING: University teaching hospital. PARTICIPANTS: One hundred sixty-five people admitted to an acute geriatric service. MEASUREMENTS: Subjects were assessed using the MMSE and the Confusion Assessment Method on hospital Days 1 and 6. Changes in scores were compared between patients who remained free of delirium (n=124) and those who by Day 6 had developed delirium (n=14) or had resolution of delirium present on admission (n=22). RESULTS: A number of measures of responsiveness confirmed that serial MMSE scores were responsive to resolution and to development of delirium. A fall of 2 or more points on the MMSE was the best determinant for detecting development of delirium (93% sensitivity, 90% specificity, positive likelihood ratio (LR)=8.9 (95% confidence interval (CI)=5.2-15.1) and negative LR=0.08 95% CI=0.01-0.53)). A rise of 3 or more points was the best determinant for detecting resolution of delirium (77% sensitivity, 75% specificity, positive LR=3.1 (95% CI=2.1-4.5) and negative LR=0.30 (95% CI=0.14-0.66)). CONCLUSION: The MMSE is responsive to short-term changes in cognitive function in elderly patients. Serial MMSE tests should be helpful in monitoring the development and resolution of delirium in this population.

Does lowering blood pressure with antihypertensive therapy preserve independence in activities of daily living? A systematic review.

BACKGROUND: Hypertension is a major risk factor for functional impairment. Dependence is an important related outcome for older adults, but outcomes in hypertension trials appear to focus primarily on major vascular events. This systematic review had 2 objectives: (i) to determine the proportion of randomized controlled trials (RCTs) evaluating antihypertensive therapies that reported a measure of a person's ability to carry out activities of daily living (ADL) and (ii) to evaluate the effect of blood pressure (BP)-lowering therapies on ability to carry out ADL compared with control therapy. METHODS: We searched electronic databases, reference lists of relevant meta-analyses, and hypertension guidelines for clinical trials of adults with hypertension/prehypertension that were randomized to antihypertensive therapy or control for ≥1 year. RESULTS: Of 2,924 citations screened, there were 93 eligible RCTs. One (1%) reported ADL as a primary outcome measure. Nine (10%) reported ADL as a secondary outcome. Of these, 6 used validated ADL scales, whereas 4 measured ADL within quality-of-life scales. Six trials with duration of ≥1 year (n = 12,663) were amenable to meta-analysis, despite use of different ADL scales. The odds of having difficulty with ADL was reduced by BP-lowering therapy compared with control therapy (odds ratio = 0.84; 95% confidence interval = 0.77-0.92; I (2) = 0%). CONCLUSIONS: We identified few trials of antihypertensive therapy that reported ADL as an outcome measure, with heterogeneity in scales used. Antihypertensive therapy was associated with a lower risk of ADL impairment compared with control therapy. RCTs evaluating the effect of antihypertensive drugs on ADL in older adults with mild hypertension are required.