Cardiopulmonary resuscitation: capacity, discussion and documentation.

BACKGROUND: End-of-life care decisions, including treatment such as cardiopulmonary resuscitation (CPR), are complex issues requiring a patient to have the capacity for effective decision-making. AIM: To assess the prevalence and documentation of CPR decisions in our hospital in patients aged > 65 years. DESIGN: Prospective audit. METHODS: Review of patient notes and resuscitation forms within our acute Trust on Elderly Care and General Medicine wards, including the decisions made, involvement of patient and/or family members and whether an assessment of capacity was made. RESULTS: On the Elderly Care wards, 37 CPR decisions were made on 104 patients, and nearly all of these were clearly documented. On the General Medical wards, only one decision out of 40 patients was made. Geriatricians incorporated patient views in one quarter of decisions; all but one of these patients wanted CPR. Of those patients 'not for CPR', family members were informed in only one third of cases, according to the documentation. Capacity was documented on only four occasions. DISCUSSION: Geriatricians make significantly more CPR decisions than general physicians do, but still involve patient and family views in only a minority of cases, and an assessment of capacity is rarely explicitly documented. We suggest a three-step approach to clinical decision making, to increase both the volume and the quality of CPR decisions, which may be improved further by the use of information leaflets for patients and their families.

Effect of upper airway obstruction in acute stroke on functional outcome at 6 months.

BACKGROUND: The aim of this study was to determine whether upper airway obstruction occurring within the first 24 hours of stroke onset has an effect on outcome following stroke at 6 months. Traditional definitions used for obstructive sleep apnoea (OSA) are arbitrary and may not apply in the acute stroke setting, so a further aim of the study was to redefine respiratory events and to assess their impact on outcome. METHODS: 120 patients with acute stroke underwent a sleep study within 24 hours of onset to determine the severity of upper airway obstruction (respiratory disturbance index, RDI-total study). Stroke severity (Scandinavian Stroke Scale, SSS) and disability (Barthel score) were also recorded. Each patient was subsequently followed up at 6 months to determine morbidity and mortality. RESULTS: Death was independently associated with SSS (OR (95% CI) 0.92 (0.88 to 0.95), p<0.00001) and RDI-total study (OR (95% CI) 1.07 (1.03 to 1.12), p<0.01). The Barthel index was independently predicted by SSS (p = 0.0001; r = 0.259; 95% CI 0.191 to 0.327) and minimum oxygen saturation during the night (p = 0.037; r = 0.16; 95% CI 0.006 to 0.184). The mean length of the respiratory event most significantly associated with death at 6 months was 15 seconds (sensitivity 0.625, specificity 0.525) using ROC curve analysis. CONCLUSION: The severity of upper airway obstruction appears to be associated with a worse functional outcome following stroke, increasing the likelihood of death and dependency. Longer respiratory events appear to have a greater effect. These data suggest that long term outcome might be improved by reducing upper airway obstruction in acute stroke.

Effects of incremental levels of continuous positive airway pressure on cerebral blood flow velocity in healthy adult humans.

Sleep disordered breathing is common in patients with cerebrovascular disease, and could exacerbate the cerebral damage in acute stroke. Data about the effects of continuous positive airway pressure (CPAP) upon cerebral perfusion are conflicting. We investigated whether increasing levels of CPAP may affect cerebral haemodynamics, assessed by transcranial Doppler (TCD) in normal humans. A group of 25 healthy young volunteers were evaluated before (CPAP0-pre), during (CPAP5, CPAP10 and CPAP15, denoting CPAP at 5, 10 and 15 cmH(2)O respectively) and after (CPAP0-post) application of incremental levels of CPAP delivered through a mouthpiece. The mean cerebral blood flow velocity (CBFV) and the pulsatility index (PI; an indirect measure of cerebrovascular resistance) in the middle cerebral artery were measured with TCD. Respiratory rate, heart rate, end-tidal carbon dioxide pressure (PETCO(2)), transcutaneous haemoglobin oxygen saturation (SpO(2)), mean arterial blood pressure and anxiety score were also recorded. Compared with CPAP0-pre, CBFV was significantly decreased as higher levels of CPAP were applied (P <0.0001). CPAP15 increased PI (P <0.05), ETCO(2) was reduced by CPAP10 and CPAP15 (P <0.0001), and anxiety score and SpO(2) increased at all levels of CPAP (P <0.05). Heart rate, respiratory rate and mean arterial pressure did not change. The decrease in CBFV was correlated with the fall in P ETCO(2) (CPAP15) and the increase in PI (CPAP10, CPAP15) (P <0.05). In conclusion, even low levels of CPAP delivered through a mouthpiece in awake, young volunteers led to a decrease in CBFV, measured by TCD. This fall in CBFV was associated with hypocapnia and with an increase in both cerebrovascular resistance and anxiety due to breathing against positive pressure. As the negative consequences of a fall in CBFV may outweigh the therapeutic effects of CPAP in the post-stroke setting, further studies of the cerebrovascular effects of CPAP with different interfaces in elderly patients with and without stroke are needed before intervention trials can be performed safely.

Prevalence and predictors of upper airway obstruction in the first 24 hours after acute stroke.

BACKGROUND AND PURPOSE: The prevalence of sleep-disordered breathing after stroke has been reported to be between 32% and 71%. However, the first 24-hour period, when upper airway obstruction may have a critical effect on the cerebral circulation because of hemodynamic fluctuations and repetitive hypoxia, has not been studied. Furthermore, data on prediction of upper airway obstruction after stroke are limited. This study sought to assess the prevalence of upper airway obstruction in the first 24 hours of stroke and to ascertain whether its occurrence could be predicted. METHODS: One hundred twenty patients with acute stroke underwent a respiratory variable-only sleep study, started within 24 hours of onset of neurological symptoms. Sleep history and stroke characteristics were recorded on admission. RESULTS: We found that 79%, 61%, and 45% of the patients had a respiratory disturbance index greater than 5, 10, and 15 events per hour, respectively. Patients had a significantly higher respiratory disturbance index when nursed in the supine (29 events per hour), supine left (29 events per hour), and supine right (24 events per hour) positions than in any other position (P<0.0001). On logistic regression analysis, BMI (P=0.025), neck circumference (P=0.026), and limb weakness (P=0.025) independently predicted the occurrence of upper airway obstruction in the first 24 hours after acute stroke. CONCLUSIONS: Upper airway obstruction is common in the first 24 hours after stroke, especially if patients are nursed in the supine position, and typical obstructive sleep apnea risk factors (body mass index and neck circumference) appear to be the best predictors of its occurrence. Stroke characteristics (severity, clinical subtype, and clinically assessed pharyngeal function) are not independently associated with upper airway obstruction after stroke.

Slowing the rate of acute medical admissions.

We studied the effectiveness of a dedicated medical receiving room (MRR) with senior registrar (SR) assessment of GP requests for medical admission. In the first of three 16-week study periods, patients were assessed by senior house officers or registrars. In the second period, patients were assessed by a single SR. In the third period, nine SRs manned the MRR on a rota. Outcome measures included same-day discharge rate, use of specialist beds and 28-day readmission rate. A questionnaire was sent to general practitioners (GPs) of patients discharged in period three to assess their satisfaction with the service. The same-day discharge rate increased from 3.6% in period one to 29% in period two (p < 0.001) and 15% in period three (p < 0.001). The use of specialist and off-site beds also increased from 1.2 per week in period one to 2.9 in period two and 3.1 in period three. The 28-day readmission rate was 13.3% in period one, 6.9% in period two and 6% in period three. The GPs were satisfied with the service provided by the MRR and all felt that the discharge was appropriate. Assessment of GP referrals for acute medical admission by SRs in a MRR allows more patients to be safely discharged on the same day than if the assessment is carried out by a more junior doctor. SRs also direct more patients to the relevant specialty, so improving patient care and effective use of available beds.

Hemiplegic shoulder pain (HSP): natural history and investigation of associated features.

The prevalence of hemiplegic shoulder pain (HSP) and associated factors was studied in patients with a stroke followed for 6 months after discharge from hospital. A questionnaire was used to evaluate shoulder symptoms and an examination of the shoulder and arm was carried out three times over 6 months. A total of 108 patients were studied with a mean age of 71 years. Sixty-nine patients (63.8%) developed HSP at some time during the study period. The number with HSP was 39 at discharge from hospital, 59 at 8 weeks post-discharge and 36 at 6 months. Nine carers reported lifting the patient by pulling on the hemiplegic arm, even though six of them had received advice about correct lifting techniques. Reduced shoulder shrug was associated with HSP at all times and reduced pinch grip was also associated with HSP at discharge from hospital. Patients who required help with transfers were more likely to suffer with HSP. There was no difference in the prevalence of HSP in patients treated at the day hospital compared to those who received domiciliary physiotherapy. It is concluded that HSP is common after a stroke and the prevalence increases in the first weeks after discharge from hospital. Stroke patients and their carers need advice about correct handling of the hemiplegic arm, and more work is required to ensure that correct handling occurs after discharge in patients at high risk of this unpleasant complication.

Homes and housing for elderly people.

Most elderly people in Britain live independently in their own homes. Moving to alternative accommodation may be necessary for some people but requires careful consideration. A multidisciplinary assessment should be performed when a person plans to move into residential care; this should include the input of a doctor trained in geriatric medicine. A range of housing options is open to elderly people and these options are discussed here.

Outcome in patients who require a gastrostomy after stroke.

Dysphagia is common after a stroke and is associated with a poor outcome in terms of survival or functional recovery. Percutaneous gastrostomy (PG) provides reliable and safe nutrition for patients with neurological dysphagia in the short term but little is known about the the subsequent outcome in stroke patients. We reviewed the medical records of all stroke patients who had required a PG in four West Yorkshire hospitals over a 30-month period. All patients alive at the time of the study were contacted and functional status was recorded. Forty-one stroke patients had undergone PG and 37 records were obtained. There were 24 men and 13 women with a mean age of 74 years. Thirty-three patients had had a hemiplegia while four patients presented acutely with dysphagia but no hemiplegia (all had cerebral infarcts on CT scan). The timing of PG varied with a median time from stroke of 26 days (range 12-131). Complications include five chest infections ( < 1 week after PG), three local infections, two tubes pulled out and one perforation. Three patients died in the first 5 days after the PG. Thirty-one of the 37 patients had died at the time of the assessment, 21 during the original hospital admission. The median survival from the time of PG was 53 days (range 2-528) with only 12 patients surviving for more than 3 months. Six patients were alive at the time of the study and all but one were severely disabled (mean modified Barthel Index seven). There is no consensus about patients selection or timing of PG and our data should lead to more careful consideration of the risks and benefits of the procedure in stroke patients.

Prevalence and associated features of the cold hemiplegic arm.

BACKGROUND AND PURPOSE: Some stroke patients complain of an unpleasant sensation of coldness in the hemiplegic arm. This study aimed to determine the prevalence of this symptom and any associated features. METHODS: A questionnaire about symptoms in the arms was sent to patients at least 12 months after stroke. Reflex sympathetic dystrophy (RSD) was diagnosed if four typical symptoms were present in the arm. RESULTS: One hundred patients were recruited and 75 complete replies received. The mean age of the patients was 74 years, and the mean time since the stroke was 19 months. Forty patients (53%) experienced unilateral coldness in the hemiplegic arm. In 14 this sensation was constant, and 10 rated the symptom as troublesome. The symptom developed at a median time of 1 month after stroke, but only 13 patients (32%) sought advice from a doctor. Sensory symptoms and arm and shoulder pain were common, but the only symptoms associated with coldness were numbness (P < .001) and color change (P < .05). Fifteen patients fulfilled the diagnostic criteria for RSD, 13 of whom had coldness only in the hemiplegic arm. CONCLUSIONS: A sensation of coldness in the hemiplegic arm is common and distressing. It is associated with numbness and color changes in the arm. Some cases are caused by RSD, but other patients have coldness that may be due to other causes such as a vasomotor abnormality.

The cold hemiplegic arm.

BACKGROUND AND PURPOSE: Vasomotor changes occur in the arm after hemiplegic stroke. Previous studies have provided conflicting results, with most showing an increase in skin temperature of the hemiplegic arm. However, a number of patients complain of distressing coldness of the hemiplegic arm. METHODS: Eleven patients with symptomatic coldness and 10 patients with hemiplegia but no coldness were recruited. The severity of the symptom of coldness was compared by questionnaire with other common symptoms after stroke. A thermographic camera was used to record the finger skin temperature response to cold stress. Blood flow to both hands was also measured simultaneously by means of two plethysmographs. In all patients there were no symptoms in the unaffected arm, and this was used as a control. RESULTS: The symptom of coldness rated highly compared with other symptoms. In the symptomatic group the finger temperature on the hemiplegic side was lower at rest (median difference at rest, 0.65 degrees C; P < .0001) and at all times after cold stress. In the asymptomatic group the fingers on the hemiplegic side were colder at rest and after initial cooling (median temperature difference, 0.2 degrees C) but at no other time. Hand blood flow on the hemiplegic side was also decreased in the symptomatic group by 35%. This was not seen in the asymptomatic group. CONCLUSIONS: Coldness of the hand may be a severe and distressing symptom in some patients after hemiplegia. Symptomatic patients have lower finger skin temperatures at rest and after standard cold stress. These symptomatic patients also had reduced blood flow to the hemiplegic hand.

The effect of bed rest and intra-articular steroids on the acute phase response in rheumatoid arthritis.

The impact of therapeutic interventions on the disease process in patients with rheumatoid arthritis (RA) is complex. The effect on the acute phase response was studied in 25 in-patients on imposed bed rest, who were randomised to treatment with (n = 12) or without (n = 13) intra-articular steroids. C-reactive protein (CRP), ESR and IgA alpha-1 antitrypsin complex levels were measured on admission and on days 3 and 5. Levels at onset were not different between groups. At day 3 and day 5, a significant (p < 0.001) fall in CRP was seen only in the intra-articular steroid group. Other cytokine and disease parameter measures did not alter during the study period (although IL-6 and CRP correlated at onset in all 25 patients). The mean duration of the hospital stay was longer for the patients treated with bed rest only. Thus, bed rest when combined with intra-articular steroids produced a rapid systemic effect, while bed-rest alone did not have an effect on the acute phase response over this short time scale.