Comprehensive geriatric assessment of a patient with complex needs.

This is the third in a short series that presents case study examples of the application of comprehensive geriatric assessment (CGA) in different clinical settings. CGA is a holistic assessment model, which is designed to determine a frail older person's medical and mental health status, as well as functional, social and environmental issues. When undertaken by nurses, it can enable individualised care planning. The case study presented explores the application of CGA with an 89-year-old patient with complex health and social care needs. It demonstrates how a hospital admission was avoided and the patient's health outcomes improved, by using a nurse-led systematic approach to assessment and by careful consideration of CGA domains.

The relationship between malnutrition risk and clinical outcomes in a cohort of frail older hospital patients.

BACKGROUND & AIMS: Malnutrition has an adverse effect on clinical outcomes and frail older people may be at greater risk of malnutrition. The purpose and aims of this study was to investigate the relationship between markers of malnutrition risk and clinical outcomes in a cohort of frail older hospital patients. METHODS: 78 frail older hospital patients had the following measurements recorded; length of stay (LOS), time to medical fitness for discharge (TMFFD), body mass index (BMI), malnutrition universal screening tool (MUST) and mini-nutritional assessment short-form (MNA-SF) scores, blood urea, C-reactive protein (CRP), albumin, CRP-albumin ratio; and bioelectrical impedance assessment (BIA) measurements (n = 66). Patients were grouped by mortality status 12 months post hospital admission. Grouping by albumin classification was performed (n = 66) whereby, <30 g/l indicated severe malnutrition, 30-34.9, moderate and >35, low. Receiver-operating characteristic (ROC) curve analysis was performed on variables as potential predictors of mortality. RESULTS: After 12 months, 31% (n = 24) of patients died. LOS was significantly greater in this group (25.0 ± 22.9 vs 15.4 ± 12.7d, P < 0.05). BMI (23.8 ± 4.9 vs 26.4 ± 5.5 kg/m2); fat mass (FM) (17.2 ± 9.9 vs 25.5 ± 10.5 kg), fat mass index (FMI) (9.3 ± 4.1 vs 17.9 ± 2.4 kg/m2); and MNA-SF score (6.6 ± 2.4 vs 8.6 ± 2.7) were significantly lower (P < 0.05), and urea significantly higher (11.4 ± 8.7 vs 8.8 ± 4.4 mmol/l, P = 0.05). Albumin was typically low across the entire group (30.5 ± 5.9 g/l) and a potential relationship was identified between albumin and MNA-SF score. MNA-SF, FM, and FMI were significant predictors of mortality outcome by ROC curve analysis, whereas MUST was a poor predictor. CONCLUSION: This study highlights a potential relationship between indicators of malnutrition risk and clinical outcomes in frail older hospital patients which should be studied in larger cohorts with an aim to improve patient care.

A comparison of the malnutrition screening tools, MUST, MNA and bioelectrical impedance assessment in frail older hospital patients.

BACKGROUND & AIMS: This cohort study aimed to investigate and compare the ability to predict malnutrition in a group of frail older hospital patients in the United Kingdom using the nutritional risk screening tools, MUST (malnutrition universal screening tool), MNA-SF(®) (mini nutritional assessment-short form) and bioelectrical impedance assessment (BIA) of body composition. METHODS: MUST and MNA-SF was performed on 78 patients (49 males and 29 females, age: 82 y ± 7.9, body mass index (BMI): 25.5 kg/m(2) ± 5.4), categorised by nutritional risk, and statistical comparison and test reliability performed. BIA was performed in 66 patients and fat free mass (FFM), fat mass (FM) and body cell mass (BCM) and index values (kg/m(2)) calculated and compared against reference values. RESULTS: MUST scored 77% patients 'low risk', 9% 'medium risk' and 14% 'high risk', compared to MNA-SF categorisation: 9%, 46% and 45%, respectively (P < 0.000001). Reliability assessment found poor reliability between the screening tools (coefficient, r = 0.4). Significant positive correlations were found between most variables (P < 0.05-<0.001); although females exhibited greater variation. FFM index analysis found 40% of males low/depleted, 21% borderline/at risk with 96% categorised by MNA-SF as either malnourished or at risk (MUST-35%). 29% males had low FM index and all appropriately classified by MNA-SF. 30% females had low FFM index or borderline, MNA-SF screening appropriately categorised 86% (compared to MUST-29%). CONCLUSIONS: This preliminary data may have significant clinical implications and highlights the potential ability of the MNA-SF and BIA to accurately assess malnutrition risk over MUST in frail older hospital patients.

A critical literature review exploring the challenges of delivering effective palliative care to older people with dementia.

AIM: This paper considers the challenges of delivering effective palliative care to older people with dementia and the possible strategies to overcome barriers to end-of-life care in these patients. BACKGROUND: In UK alone, approximately 100,000 people with dementia die each year and as the number of older people increases, dementia is set to become even more prevalent. Dementia is a progressive terminal illness for which there is currently no cure. Patients dying with dementia have significant health-care needs and in recent years it has been recognised that palliative care should be made available to everyone regardless of diagnosis, as this improves comfort and quality of life. Despite this, patients dying with dementia are often still not given access to palliative care services. METHOD: A review of English language literature published after 1996 to the present day relating to older people with dementia during the terminal phase of their illness. RESULTS: Twenty-nine articles met inclusion criteria for the review. Most originated from North America and UK and were mostly quantitative in nature. Four key themes were identified: difficulties associated with diagnosing the terminal phase of the illness (prognostication); issues relating to communication; medical interventions; and the appropriateness of palliative care intervention. CONCLUSIONS: This review reinforces the importance of providing appropriate palliative care to individuals suffering from end-stage dementia and identifies some of the barriers to extending such specialist palliative care provision. RELEVANCE TO PRACTICE: There is an urgent need to improve palliative care provision for older people with end-stage dementia and, in addition, more research is required on the needs of patients entering the terminal phase of dementia to assist the allocation of appropriate resources and training to ensure quality and equality in the provision of end-of-life care.