Still WALKing-FOR: 2-year sustainability of the 'WALK FOR' intervention.

BACKGROUND: low mobility of hospitalised older adults is associated with adverse outcomes and imposes a significant burden on healthcare and welfare systems. Various interventions have been developed to reduce this problem; at present, however, their methodologies and outcomes vary and information is lacking about their long-term sustainability. This study aimed to evaluate the 2-year sustainability of the WALK-FOR (walking for better outcomes and recovery) intervention implemented by teams in acute care medical units. METHODS: a quasi-experimental three-group comparative design (N = 366): pre-implementation, i.e. control group (n = 150), immediate post-implementation (n = 144) and 2-year post-implementation (n = 72). RESULTS: mean participant age was 77.6 years (± 6 standard deviation [SD]) and 45.3% were females. We conducted an analysis of variance test to evaluate the differences in primary outcomes: number of daily steps and self-reported mobility. Levels of mobility improved significantly from the pre-implementation (control) group to the immediate and 2-year post-implementation groups. Daily step count: pre-implementation (median: 1,081, mean: 1,530 SD = 1,506), immediate post-implementation (median: 2,225, mean: 2,724. SD = 1,827) and 2-year post-implementation (median: 1,439, mean: 2,582, SD = 2,390) F = 15.778 P < 0.01. Self-reported mobility: pre-implementation (mean:10.9, SD = 3.5), immediate post-implementation (mean: 12.4, SD = 2.2), 2-year post-implementation (mean: 12.7, SD = 2.2), F = 16.250, P < 0.01. CONCLUSIONS: the WALK-FOR intervention demonstrates 2-year sustainability. The theory-driven adaptation and reliance on local personnel produce an effective infrastructure for long-lasting intervention. Future studies should evaluate sustainability from a wider perspective to inform further in-hospital intervention development and implementation.

Shared and distinct factors underlying in-hospital mobility of older adults in Israel and Denmark (97/100).

BACKGROUND: Low in-hospital mobility is widely acknowledged as a major risk factor in acquiring hospital-associated disabilities. Various predictors of in-hospital low mobility have been suggested, among them older age, disabling admission diagnosis, poor cognitive and physical functioning, and pre-hospitalization mobility. However, the universalism of the phenomena is not well studied, as similar risk factors to low in-hospital mobility have not been tested. METHODS: The study was a secondary analysis of data on in-hospital mobility that investigated the relationship between in-hospital mobility and a set of similar risk factors in independently mobile prior to hospitalization older adults, hospitalized in acute care settings in Israel (N = 206) and Denmark (N = 113). In Israel, mobility was measured via ActiGraph GT9X and in Denmark by ActivPal3 for up to seven hospital days. RESULTS: Parallel multivariate analyses revealed that a higher level of community mobility prior to hospitalization and higher mobility ability status on admission were common predictors of a higher number of in-hospital steps, whereas the longer length of hospital stay was significantly correlated with a lower number of steps in both samples. The risk of malnutrition on admission was associated with a lower number of steps, but only in the Israeli sample. CONCLUSIONS: Despite different assessment methods, older adults' low in-hospital mobility has similar risk factors in Israel and Denmark. Pre-hospitalization and admission mobility ability are robust and constant risk factors across the two studies. This information can encourage the development of both international standard risk evaluations and tailored country-based approaches.

Participation in daily activities after acute illness hospitalization among high-functioning older adults: a qualitative study.

AIMS AND OBJECTIVES: To describe high-functioning older adults' experiences of participation in daily activities and perceived barriers and facilitators to participation one- and 3-months post-acute hospitalization. BACKGROUND: Older adults discharged after acute illness hospitalization are at risk for functional decline and adverse health outcomes. Yet, little is known about the subjective experience of resuming participation in meaningful activities beyond the immediate post-discharge period among high-functioning older adults, a mostly overlooked sub-sample. DESIGN: Qualitative descriptive longitudinal study adhering to the COREQ guidelines. METHODS: Forty two participants ages ≥65 years (mean age 75, SD ± 7.9) were recruited from internal medicine wards. Semi-structured interviews were conducted at participants' homes one-month post-discharge, followed by a telephone interview 3-months after. Data were analyzed using thematic analysis. RESULTS: Participants perceived the hospitalization as a disruption of healthy and meaningful routines. This first key theme had unique expressions over time and included two sub-themes. At one month: (1) reduced life spaces and sedentary routines. At 3 months: (2) a matter of quality not quantity - giving up even one meaningful activity can make a difference. The second key theme was described as a combination of physical and psychological barriers to participation over time. These themes demonstrated the profound impact of the hospitalization on behavior (participation) and feelings (e.g., symptoms). The third key theme was described as a dyad of intrinsic and extrinsic facilitators to participation. CONCLUSIONS: Acute illness hospitalization may lead to subtle decreases in participation in meaningful health-promoting activities, even among high-functioning older adults. These changes may impact overall well-being and possibly mark the beginning of functional decline. RELEVANCE TO CLINICAL PRACTICE: This study highlights the need for a more comprehensive assessment of participation, relevant for high-functioning older adults, to enable person-centered care. Intervention programs should address the modifiable barriers and facilitators identified in this study.

The contribution of functional cognition screening during acute illness hospitalization of older adults in predicting participation in daily life after discharge.

BACKGROUND: Cognitive assessment in acutely hospitalized older adults is mainly limited to neuropsychological screening measures of global cognition. Performance-based assessments of functional cognition better indicate functioning in real-life situations. However, their predictive validity has been less studied in acute hospital settings. The aim of this study was to explore the unique contribution of functional cognition screening during acute illness hospitalization in predicting participation of older adults one and three months after discharge beyond traditional neuropsychological measures. METHODS: This prospective longitudinal study included 84 older adults ≥ 65 years hospitalized in internal medicine wards due to acute illness, followed by home visits at one month and telephone interviews at three months (n = 77). Participation in instrumental activities of daily living, social and leisure activities was measured by the Activity Card Sort. In-hospital factors included cognitive status (telephone version of the Mini-Mental State Examination, Color Trails Test), functional cognition screening (medication sorting task from the alternative Executive Function Performance Test), emotional status (Hospital Anxiety and Depression scale), functional decline during hospitalization (modified Barthel index), length of hospital stay, the severity of the acute illness, symptoms severity and comorbidities. RESULTS: Functional cognition outperformed the neuropsychological measures in predicting participation declines in a sample of relatively high-functioning older adults. According to a hierarchical multiple linear regression analysis, the overall model explained 28.4% of the variance in participation after one month and 19.5% after three months. Age and gender explained 18.6% of the variance after one month and 13.5% after three months. The medication sorting task explained an additional 5.5% of the variance of participation after one month and 5.1% after three months, beyond age and gender. Length of stay and the Color Trails Test were not significant contributors to the change in participation. CONCLUSIONS: By incorporating functional cognition into acute settings, healthcare professionals would be able to better detect older adults with mild executive dysfunctions who are at risk for participation declines. Early identification of executive dysfunctions can improve continuity of care and planning of tailored post-discharge rehabilitation services, especially for high-functioning older adults, a mostly overlooked population in acute settings. The results support the use of functional cognition screening measure of medication management ability in acute settings.

The effect of co-dependent (thinking in motion [TIM]) versus single-modality (CogniFit) interventions on cognition and gait among community-dwelling older adults with cognitive impairment: a randomized controlled study.

BACKGROUND: Cognition and motor skills are interrelated throughout the aging process and often show simultaneous deterioration among older adults with cognitive impairment. Co-dependent training has the potential to ameliorate both domains; however, its effect on the gait and cognition of older adults with cognitive impairment has yet to be explored. The aim of this study is to compare the effects of the well-established single-modality cognitive computerized training program, CogniFit, with "Thinking in Motion (TIM)," a co-dependent group intervention, among community-dwelling older adults with cognitive impairment. METHODS: Employing a single-blind randomized control trial design, 47 community-dwelling older adults with cognitive impairment were randomly assigned to 8 weeks of thrice-weekly trainings of TIM or CogniFit. Pre- and post-intervention assessments included cognitive performance, evaluated by a CogniFit battery, as a primary outcome; and gait, under single- and dual-task conditions, as a secondary outcome. RESULTS: CogniFit total Z scores significantly improved from baseline to post-intervention for both groups. There was a significant main effect for time [F (1, 44) = 17.43, p < .001, ηp2 = .283] but not for group [F (1, 44) = 0.001, p = .970]. No time X group interaction [F (1, 44) = 1.29, p = .261] was found. No changes in gait performance under single and dual-task performance were observed in both groups. CONCLUSIONS: The findings show that single-modality (CogniFit) and co-dependent (TIM) trainings improve cognition but not gait in older adults with cognitive impairment. Such investigations should be extended to include various populations and a broader set of outcome measurements. TRIAL REGISTRATION: ACTRN12616001543471. Date: 08/11/2016.

Many Paths to Recovery: Comparing Basic Function and Participation in High-Functioning Older Adults After Acute Hospitalization.

Function after acute hospitalization is mostly operationalized by Basic Activities of Daily Living (BADL), a limited concept that overshadows a wide range of instrumental, social, and recreational activities, otherwise referred to as participation. Participation is important for patients' health and quality of life after hospitalization. This study focuses on high-functioning older adults, examining functional recovery after hospitalization by comparing BADL assessment with assessment of participation at one and three months following discharge relative to pre-hospitalization. Quantitative data were collected from 72 participants divided into two age groups of hospitalized older adults (age 65-74, n = 38; age ≥75, n = 34), followed by home visits after 1 month and telephone interviews 3 months after discharge. Both groups experienced a significantly greater decline in participation, compared with BADL, which were mostly preserved. A comprehensive assessment of participation better captures functional changes in high-functioning older adults. Early identification of participation withdrawal is crucial for preventing disability.

"Behind the Scenes" of Accelerometer Use to Quantify In-Hospital Mobility of Older Adults.

Measuring in-hospital mobility of older adults with accelerometers is becoming more common practice. However, neither the unique challenges surrounding accelerometer use within acute hospital settings nor the potential solutions to these challenges have been well documented. The aim of this article is to present and discuss what occurs "behind the scenes" when using accelerometers to quantify in-hospital mobility among older adults in acute hospital wards. The article identifies the challenges related to accelerometer use that emerged over the course of daily data collection for 2 large-scale studies, including matters of recruitment, daily use, technical and methodological issues, loss of devices, missing data, and troubleshooting. The article details the tasks and the strategies we developed for overcoming these challenges and how we implemented them within the acute wards. Finally, the article provides recommendations for researchers and clinicians on how to improve future use of accelerometers or other devices aimed to enhance in- hospital mobility of older adults.

A bridge to cross: Tube feeding and the barriers to implementation of palliative care for the advanced dementia patient.

AIMS AND OBJECTIVES: To elucidate the attitudes and knowledge of nursing home (NH) staff involved in the decision-making process surrounding tube feeding for people with advanced dementia, and regarding palliative care and eating difficulties in this population. BACKGROUND: Dementia's final stage is associated with eating difficulties. "Comfort feeding" is the approach endorsed by the American Geriatrics Society for those with advanced dementia and eating difficulties. Despite this, tube feeding remains a persisting practice in NHs in Israel. DESIGN: A qualitative descriptive study. METHODS: Twenty-seven NH employees from different sectors employed by seven NHs in northern Israel underwent semi-structured, face-to-face interviews. The COREQ checklist was used to aid with reporting and analysis of results. RESULTS: In Israel, there is an emerging palliative care discourse in caring for people with advanced dementia living in the NH setting. However, many interviewed did not demonstrate an accurate understanding of this term or of the term "comfort feeding." Several barriers towards implementation of palliative care were identified and include a lack of formal education regarding nutrition in advanced dementia, socio-economic factors and their association with the two types of NHs operating in Israel (those with exclusively private funding and those reimbursed by the Ministry of Health). CONCLUSIONS: Interviews with NH staff regarding eating difficulties in advanced dementia shed light on the palliative care discourse, which is in a liminal stage in many countries. The themes that emerged may help inform future recommendations regarding palliative care in general and more specifically in NH residents with advanced dementia, in countries where policy is still being developed and refined. RELEVANCE TO CLINICAL PRACTICE: Understanding barriers towards implementation of a palliative approach and comfort feeding specifically could improve the care for people with advanced dementia in the NH setting.

The relationships between step count and hospitalisation-associated outcomes in acutely hospitalised older adults - A systematic review.

BACKGROUND AND PURPOSE: Although low ambulation among older adults has been linked to a broad range of adverse outcomes during and after acute hospitalisation, a systematic inquiry of the link between step count and these consequences is required. Therefore, the main purpose of this study is to systematically review the relationships between step count and hospitalisation-associated outcomes in acutely hospitalised older adults. METHODS: The electronic databases MEDLINE, CINAHL, and Embase were searched for studies including older adults (above age 65) hospitalised in acute internal wards. The search included the following key terms: 'accelerometer', 'step count', 'hospital', 'internal ward', and 'older adults'. Step count measurement linked to short- and/or long-term outcome(s) during and/or after hospitalisation. All types of articles (except reviews) in English from 1990 to May 2020 were considered. The Newcastle-Ottawa Scale was used to assess the quality of the included observational studies. Randomised controlled trials (RCT) were evaluated using the PEDro scale. The review protocol was registered with PROSPERO International Prospective Register of Systematic Reviews. PRISMA guidelines were followed and a PRISMA checklist for reporting systematic reviews completed. RESULTS: The search yielded 1340 articles, and of those, the inclusion criteria were met by 12 studies: eight prospective, three interventional (one randomised controlled trial), and one case-control. These studies included three major adverse hospitalisation outcomes associated with step count: functional decline, longer length of stay, and higher re-hospitalisation rate; however, the large heterogeneity in the studies' methodology makes meta-analysis impossible. CONCLUSIONS: Daily step count during hospitalisation of older adults is negatively associated with adverse outcomes, but causation cannot be inferred due to inconsistent outcomes and various methodological limitations. More studies are needed to illuminate causal pathways and mechanisms underlying these relationships, especially to differentiate between the relative contribution of personal versus environmental factors.

Early Detection and Intervention for Patients with Delirium Admitted to the Department of Internal Medicine: Lessons from a Pilot Initiative.

INTRODUCTION: Older patients who arrive to the emergency room with delirium have a worse prognosis than others. Early detection and treatment of this problem has been shown to improve outcome. We have launched a project at our hospital to improve the care of patients who arrive delirious to the medical emergency room. The present article describes lessons that can be learned from this pilot initiative. METHODS: All patients older than 70 years admitted to the department of internal medicine were screened for delirium in the emergency room using the 4AT screening tool. Data of patients with a 4AT score ≥5 (or with incomplete score) were transferred to the geriatric unit of the hospital. On the ward, the presence of delirium was confirmed by a geriatric nurse that validated that the patient could walk with support and ordered mobilization and physiotherapy (M&P). RESULTS: Over the 2 and a half years (10 quarters) allocated for the pilot project, 1,078 medical patients with delirium were included in this survey. In 59.3%, the diagnosis of delirium could be confirmed only after admission. Due to budgetary constraints, only 54.7% received the allocated specific intervention - early M&P. Since it was decided that randomization was not appropriate for our initiative, we found that patients who received M&P had lower (better) 4AT scores on admission, and lower mortality. No significant difference was found between the patients who received M&P and the others in length of hospitalization and discharge to nursing homes. Retrospective comparison of the two groups did not enable to determine whether M&P was given to the patients for whom it was most effective. CONCLUSIONS: It is often not possible to verify in the emergency room that the cognitive decline is indeed new, that is, is due to delirium, and measures must be taken to verify this point as soon as possible after admission. Due to numerous constraints, the availability of early M&P is often insufficient. Whenever resources are scarce and randomization is avoided, adequate criteria should be found for allocating existing dedicated staff to patients for whom early mobilization is likely to be most beneficial.

Why Do They Fall? The Impact of Insomnia on Gait of Older Adults: A Case-Control Study.

STUDY OBJECTIVES: To compare gait and cognitive performance conducted separately as a single- (ST) and simultaneously as a dual-task (DT), ie, when a cognitive task was added, among community-dwelling older adults with and without insomnia. METHODS: Participants included: 39 (28 females) community-dwelling older adults with insomnia, 34 (21 females) controls without insomnia. Subject groups were matched for age, gender, and education. Sleep quality was evaluated based on two-week actigraphy. Gait speed and cognition were assessed as ST and DT performance. DT costs (DTCs) were calculated for both tasks. Outcomes were compared via independent samples t-tests or Mann-Whitney U-tests. RESULTS: Older adults with insomnia demonstrated significantly slower gait speed during ST (1 ± 0.29 vs 1.27 ± 0.17 m/s, p<0.001) and DT (0.77 ± 0.26 vs 1.14 ± 0.20 m/s, p<0.001) and fewer correct responses in the cognitive task during ST (21 ± 7 vs 27 ± 11, p=0.009) and DT (19 ± 7 vs 23 ± 9, p=0.015) compared to control group. DTC for the gait task was higher among older adults with insomnia (18.32%, IQR: 9.48-30.93 vs 7.81% IQR: 4.43-14.82, p<0.001). However, no significant difference was observed in DTC for the cognitive task (14.71%, IQR: -0.89-38.84 vs 15%, IQR: -0.89-38.84%, p=0.599). CONCLUSION: Older adults with insomnia have lower gait speed and poorer cognitive performance during ST and DT and an inefficient pattern of task prioritization during walking, compared to counterparts without insomnia. These findings may explain the higher risk of falls among older adults with insomnia. Geriatric professionals should be aware of potential interrelationships between sleep and gait.

Relationship Between Changes in Sedative-Hypnotic Medications Burden and Cognitive Outcomes in Hospitalized Older Adults.

BACKGROUND: Sedative-hypnotic medications (SHMs) are frequently used in hospitalized older patients, despite undesirable effects on cognitive status. Although previous studies found a significant number of patients experience changes in SHM use during hospitalization, it is unclear which pattern of change leads to hospital-associated cognitive decline (HACD). This study tested the association between patterns of SHM change and HACD. METHODS: This secondary analysis study included 550 patients age 70+ who were cognitively intact at admission (Short Portable Mental Status Questionnaire [SPMSQ] ≥8). HACD was defined as at least 1-point decline in SPMSQ between admission and discharge. Changes in sedative burden (SB) before and during hospitalization (average SB of all hospitalization days) were coded using the Drug Burden Index sorting study participants into four groups: without SB (n = 254), without SB changes (n = 132), increased SB (n = 82), and decreased SB (n = 82). RESULTS: Incidence of HACD was 233/550 (42.4%). In multivariate logistic analysis controlling for demographic characteristics, length of stay, severity of acute illness, comorbidity, SB score at home, pain on admission and depression, the odds of HACD were 2.45 (95% CI: 1.16 to 5.13) among participants with increased SB, 2.10 (95% CI: 1.13 to 3.91) among participants without SB changes, compared with participants with decreased SB. CONCLUSION: Older patients whose SB is increased or does not change are at higher risk for acquired cognitive decline than are those whose SB is reduced. Identifying patients with a potential increase in SB and intervening to reduce it may help to fight HACD.

Walking for Better Outcomes and Recovery: The Effect of WALK-FOR in Preventing Hospital-Associated Functional Decline Among Older Adults.

BACKGROUND: In-hospital immobility of older adults is associated with hospital-associated functional decline (HAFD). This study examined the WALK-FOR program's effects on HAFD prevention. METHODS: A quasi-experimental pre-post two-group (intervention group [IG] n = 188, control group [CG] n = 189) design was applied in two hospital internal medical units. On admission, patients reported pre-hospitalization functional status, which was assessed again at discharge and 1-month follow-up. Primary outcome was decline in basic activities of daily living (BADL), using the Modified Barthel Index. Secondary outcomes were decline in instrumental ADL (Lawton's IADL scale) and community mobility (Yale Physical Activity Survey). All participants (75.1 ± 7 years old) were cognitively intact and ambulatory at admission. The WALK-FOR included a unit-tailored mobility program utilizing patient-and-staff education with a specific mobility goal (900 steps per day), measured by accelerometer. RESULTS: Decline in BADL occurred among 33% of the CG versus 23% of the IG (p = .02) at discharge, and among 43% of the CG versus 30% in the IG (p = .01) at 1-month follow-up. Similarly, 26% of the CG versus 15% of the IG declined in community mobility at 1-month follow-up (p = .01). Adjusted for major covariates, the intervention reduced the odds of decline in BADL by 41% (p = .05) at discharge and by 49% at 1-month follow-up (p = .01), and in community mobility by 63% (p = .02). There was no significant effect of the intervention on IADL decline (p = .19). CONCLUSIONS: The WALK-FOR intervention is effective in reducing HAFD.

No one size fits all-the development of a theory-driven intervention to increase in-hospital mobility: the "WALK-FOR" study.

BACKGROUND: There is growing evidence that mobility interventions can increase in-hospital mobility and prevent hospitalization-associated functional decline among older adults. However, implementing such interventions is challenging, mainly due to site-specific constraints and limited resources. The Systems Engineering Initiative for Patient Safety (SEIPS 2.0) model has the potential to guide a sustainable, site-tailored mobility intervention. Thus, the aim of the current study is to demonstrate an adaptation process guided by the SEIPS 2.0 model to articulate site-specific, culturally based interventions to improve in-hospital mobility among older adults. METHODS: Six consecutive phases addressed each of the model's elements in the research setting. Phase-1 aimed to determine a measurable outcome: steps/d, measured with accelerometers, associated with functional decline. Phase-2 included interviews with key persons in leadership positions in the hospital to explore organizational factors affecting in-hospital mobility. Phases-3 and 4 aimed to identify attitudes, knowledge, barriers, and current behaviors of medical staff (n = 116) and patients (n = 203) related to patient mobility. Phase-5 included four focus-groups with unit staff aimed at developing an action plan while adapting existing intervention strategies to site needs. Phase-6 relied on a steering committee that developed intervention-adaptation and implementation plans. RESULTS: Nine hundred steps/d was defined as the intervention outcome. 40% of patients walked fewer than 900 steps/d regardless of capability. Assessing or promoting mobility did not exist as a separate task and thus was routinely overlooked. Several barriers to patients' mobility were identified, specifically limited knowledge of practical aspects of mobility. Consequently, staff adopted practical steps to address them. Nurses were designated to assess mobility, and nursing assistants to support mobility. Mobility was defined as a quality indicator to be documented in electronic medical records and closely supervised by hospital and unit management. Preliminary analyses of the "Walk FOR" protocol demonstrates its' ability to reduce barriers, to re-shape staff attitudes and knowledge, and to increase in-hospital mobility of older adults. CONCLUSIONS: The SEIPS-2.0 model can serve as a useful guide for implementing a site-tailored comprehensive mobility intervention. This process, which relies on local resources, may promise sustainable practice change that may support early effective rehabilitation and recovery.

Dilemmas for guardians of advanced dementia patients regarding tube feeding.

Background: advanced dementia is an incurable illness, its last stage marked by inability to eat. Tube feeding was deemed a helpful solution at this stage, but in recent years its inefficiency has been proved, and it is no longer practiced in many countries around the world. In Israel, however, the procedure is still accepted. In the gastroenterology department at the Bnai Zion Medical Center, a serious interaction is ongoing with patients' legal guardians, where detailed information is given about the inefficiency of the tube procedure. Nevertheless, the great majority of guardians choose to have it performed. Purpose: to probe the considerations underlying the decision for gastrostomy, despite the data and the recommendations. Method: qualitative research, including participant observation at the clinic and in-depth interviews with guardians. Findings: the families of most patients did not discuss end-of-life issues with them. The overwhelming preference for using the technology was interpreted as life-saving, in contrast to comfort feeding, which was deemed euthanasia. The reasons given for the decision to tube feed were drawn from a range of outlooks: religion, the patient's earlier survival capacity, and pragmatic considerations involving relations with nursing home staff. Conclusion: study of the decision-making process of advanced dementia patients' guardians sheds light on the layers of meaning of the Israeli discourse regarding end-of-life issues.

Development and psychometric testing of a measure of older adult patients' attitudes towards mobility during hospitalization (ATM-H).

This paper describes the development and psychometric testing of a questionnaire evaluating attitudes towards mobility during hospitalization of older adults, an understudied phenomenon that lacks a valid and reliable measure. An instrument development procedure, followed by an empirical study, was conducted between December 2013 and June 2014. Instrument development included item generation and analysis of content validity, which was established by six experts. The validation study used a prospective within-patients design with a sample of 100 patients, age 70+, hospitalized in general medical units in a large medical center. Internal consistency, reliability, and divergent and predictive validity of the measure were tested. Reliability analysis revealed an acceptable estimate for the total score (0.76). Predictive validity was good. The divergent validity coefficient was in the expected direction. Preliminary psychometric properties of the measure showed acceptable results. The measure should be explored further in different cultural settings.

Use of Physical Restraints in a General Hospital: a Cross-Sectional Observational Study.

BACKGROUND: Physical restraints are a common, albeit controversial, tool used in the acute care setting. OBJECTIVES: To determine the prevalence of physical restraint use in an acute care hospital. Secondary objectives were to determine whether physical restraints are used more commonly in night shifts, identify patient risk factors for physical restraint use, and establish if staff-to-patient ratio correlated with physical restraint use. METHODS: An observational cross-sectional study was conducted over 3 months in 2013 in the medical, surgical and intensive care units in a mid-sized general hospital. All the physically restrained patients in each observation were added to the registry. At each observation one department was selected for comparison and all non-restrained patients were added to the registry. RESULTS: The study population comprised 2163 patients. Seventy-six were restrained and 205 were included as case-controls. The prevalence of physical restraint use was 3.51% (95% CI = 2.79-4.37%). Physical restraint use was more common in night shifts than day shifts: 4.40% vs. 2.56% (P = 0.03). Male gender, dependency, invasive ventilation, invasive tubes (nasogastric tube or urine catheter), and bedsores were all significantly correlated with restraint use. Staff-to-patient ratios were not significantly correlated with use of physical restraints. CONCLUSIONS: Physical restraints are relatively common in acute care wards. The use of physical restraints seems to correlate with certain patient characteristics but not with staff-to-patient ratios, and seems more common at night.

[Munchausen syndrome in an extreme form of factitious disorder].

Patients suffering from this disorder mimic symptoms of diseases and seek medical procedures and operations. We present a case of a patient who underwent a thorough investigation for unexplained persistent hypoglycemia. According to the algorithm approach to the non-diabetic patient, we measured insulin and c-peptide plasma levels while glucose levels were low and looked for sulphonylurea, blood and urine traces. Following the above, an endoscopic ultrasound demonstrated a small pancreatic lesion and an explorative laparotomy was performed to detect an insulinoma. This procedure was complicated by partial colectomy due to colonic gangrene. Following the patient's recovery, hypoglycemia recurred and the laboratory tests were repeated, revealing trace amounts of glipizide in her serum and urine. Studies which examined the prevalence of the phenomenon among cases of unexplained hypoglycemia, including patients who were operated for presumed insulinoma, were reviewed. No specific therapy for factitious disorder has been established. Management is based upon psychotherapy which is often not very effective. We recommend that one has to keep in mind that negative tests for sulphonylurea traces in serum and urine, do not contradict the diagnosis of factitious disorder, and it is recommended to repeat these tests several times.

Regional peptide uptake study in the rat intestinal mucosa: glatiramer acetate as a model drug.

PURPOSE: To identify regions of the rat intestine that are able to internalize from the lumen oligopeptides, using the model drug glatiramer acetate (GA). METHODS: GA was introduced into rat intestinal sacs and the integrity of GA during uptake was monitored using antibody detection. Sodium docecyl sulphate polyacrylamide gel electrophoresis (SDS-PAGE) and immunoblotting of intestinal homogenates that had been exposed to GA were performed to identify GA presence. An enzyme-linked immunosorbent assay (ELISA) protocol was adapted for GA quantification. Immunohistochemistry was undertaken to examine the rat colonic wall for GA uptake, and confocal microscopy was used to differentiate adsorbed and internalized peptide in cultured colorectal adenocarcinoma cells. RESULTS: The colon and the ileum, respectively, were identified to be the intestinal regions in which GA was maximally preserved during uptake from the lumen. GA was identified to cross the colonic wall from the epithelium to the serosa. Internalization of GA into cultured colonic epithelial cells was demonstrated. CONCLUSIONS: The rat colonic wall was identified to be less proteolytically active toward GA compared to the wall of the more proximal regions of the small intestine. GA has the capacity to penetrate from the lumen into the colonic wall. The maintenance of GA integrity within the wall of the colon offers the potential for local biological activity of the drug.