"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.

Frailty in an Adult Acute Hospital Population: Predictors, Prevalence, and Outcomes.

Frailty is common among older hospital inpatients. While studies describe frailty prevalence in acute hospitals, it is usually based upon retrospective hospital-coded data or brief screening on admission rather than comprehensive geriatric assessment (CGA). Further, little is known about differences between pre-admission and current frailty status. Given this, we investigated the prevalence of pre-frailty and frailty among adult inpatients in a large university hospital after CGA. Of the 410 inpatients available, 398 were included in the study, with a median age of 70 years; 56% were male. The median length of stay (LOS) at review was 8 days. The point prevalence of frailty was 30% versus 14% for pre-frailty. The median Clinical Frailty Scale score pre-admission was 3/9, which was significantly lower than at review, which was 4/9 (p < 0.001). After adjusting for age and sex, frailty was associated with greater odds of prolonged LOS (odds ratio [OR] 1.7, p = 0.045), one-year mortality (OR 2.1, p = 0.006), and one-year institutionalisation (OR 9, p < 0.001) but not re-admission. Frailty was most prevalent on medical and orthopaedic wards. In conclusion, CGA is an important risk assessment for hospitalised patients. Frailty was highly prevalent and associated with poor healthcare outcomes. Frailty status appears to worsen significantly during admission, likely reflecting acute illness, and it may not reflect a patient's true frailty level. The development of frailty clinical care pathways is recommended in order to address the poor prognosis associated with a diagnosis of frailty in this setting.

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.

Alterations and Preservations: Practices and Perspectives of Speech-Language Pathologists Regarding the Intervention of Thickened Liquids for Swallowing Problems.

PURPOSE: The intervention of thickened liquids (TL) is commonly used to reduce aspiration in people with dysphagia. Speech-language pathologists (SLPs) have traditionally believed it is an effective intervention. Recent articles highlight limited evidence, poor acceptance, and a variety of unintended consequences. This study explores if current debates have been reflected in SLP practices and perspectives. METHOD: An e-survey was developed. Participants were recruited via professional associations in Australia, New Zealand, Ireland, the United Kingdom, and the United States. Descriptive and inferential statistics were used to explore the data. Principal component analysis was used to summarize SLP practices and perspectives. RESULTS: The 370 respondents represented mainly experienced, confident, hospital-based clinicians. While 20% of respondents frequently recommend TL, 61% believe it to be a burdensome treatment. "Best treatment" and "It works" beliefs continue to underpin decision making. Those who recommend TL most often are most influenced by penetration, coughing, and their own clinical experience. They are more likely to believe TL is evidence based and effective, reduces aspiration, and improves hydration. Person-centeredness is important among all respondents, although significant numbers would implement TL against patient wishes. Improvements in aspiration status and quality of life rank highly as reasons to discontinue TL. CONCLUSIONS: The results of this study suggest that fewer respondents are regularly using TL. Divergent groups are evident with those frequently employing and believing in the efficacy of TL and those who do not. While current debates are influencing practice, there clearly remains a significant number of SLPs continuing to recommend TL. This study's findings highlight both alterations and preservations in the discipline's approach to TL and calls for SLPs to reframe our thinking regarding this intervention as well as consider alternative options in this treatment space. SUPPLEMENTAL MATERIAL: https://doi.org/10.23641/asha.24317110.

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.

Developing a guidance resource for managing delirium in patients with COVID-19.

As the COVID-19 pandemic escalates worldwide, it is apparent that many patients with more severe illness will also experience delirium. These patients pose a particular challenge in the application of optimal care due to issues with infectious risk, respiratory compromise and potential interactions between medications that can be used to manage delirium with antiviral and other treatments used for COVID-19. We describe a guidance resource adapted from existing guidelines for delirium management that has been tailored to the specific challenge of managing delirium in patients with COVID-19 infection. Issues around the assessment and treatment of these patients are examined and distilled into a simple (one-paged guidance resource that can assist clinicians in managing suspected delirium.

Mainstreaming medical humanities in continuing professional development and postgraduate training.

Although the medical humanities are increasingly well established in terms of scholarly research and undergraduate medical education, a notable deficit has been its low profile in postgraduate training and continuing professional development (CPD).We undertook to develop a programme in the medical humanities to address the deficit in CPD and specialist training, working with colleagues in a range of colleges and disciplines in Ireland. We describe the first element, a masterclass embedded in a series devoted to more traditionally recognised clinical aspects of CPD, webcast live to a range of hospitals across Ireland, whose focus was an introduction to the medical humanities by a panel of clinician scholars each of whom had published in peer-reviewed journals on the topic.Postgraduate colleges of medicine can play an important role in developing medical humanities strands in their postgraduate training and CPD activities. Given the relative novelty of developing postgraduate training and CPD in medical humanities, it may be worthwhile developing an intercollegiate platform among the wider range of medical colleges in the British Isles to jointly develop the most effective mechanisms to further propagate medical humanities and leverage the expertise of a larger pool of faculty in medical humanities.

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.

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.

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.

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.