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.

Meeting Complex Needs Through Community Collaboration: a Case Study.

This case study focuses on complex trauma in a refugee family. It explores the barriers faced while supporting a family presenting with complex and multifaceted needs. It reviews the roles, processes and participation of practitioners from Service Coordination (case management) and Treatment (therapeutic intervention) perspectives. This case study also examines the gaps in existing services for new immigrant and refugee populations within a community and provides recommendations for closing these gaps.

Home, please: A conjoint analysis of patient preferences after a bad hip fracture.

AIM: An Australian study of older, community-dwelling women found that 80% would rather be dead than experience loss of independence and nursing home admission after a bad hip fracture. We re-examined this issue using a conjoint analysis approach. METHODS: We asked older hospital patients with a history of falls, fracture or osteoporosis to imagine they had a hip fracture resulting in significant residual disability. Subjects were asked to rank in order of preference an orthogonal array of nine out of 36 potential outcome scenarios reporting risk of falls, life expectancy, discharge home with support or to a nursing home and family agreement or disagreement with discharge location. RESULTS: Of 192 patients satisfying inclusion criteria, 183 agreed to participate and 97 completed the study. Those who failed to complete the study were older and had lower Mini-Mental State Examination scores than those who completed the study. For the group as a whole, averaged importance scores were: discharge residence 31.3%, length of life 27%, fall risk 26.4% and family preference 15.5%. On average, subjects would be willing to sacrifice approximately 9 months of life in order to return home rather than go to a nursing home. CONCLUSIONS: In the present study, older people at high risk for fracture judged that after a bad hip fracture their main priority would be to remain at home.

Preferences of older people for early diagnosis and disclosure of Alzheimer's disease (AD) before and after considering potential risks and benefits.

Studies suggest that most people support screening for and disclosure of dementia, but it is not clear whether respondents have reflected on the benefits and risks of diagnosis. In this study, preferences, rated on a 7-point Likert scale, for diagnosis, disclosure and screening for AD were measured before and after discussion of the potential benefits and hazards of diagnosis in 132 hospital and community subjects in Galway, Ireland. At baseline the percentages with a positive attitude (Likert rating of 5-7) were 79.6% for diagnosis, 85.7% for disclosure and 59.3% for screening. On follow-up, there was no significant change in disclosure responses (12 more positive, 18 more negative, 102 unchanged (p=0.2), 78.1% positive attitude) while there were significant declines in ratings for diagnosis (11 more positive, 27 more negative, 94 unchanged (p=0.03), 69.1% with positive attitude) and screening (10 more positive, 35 more negative, 87 unchanged (p<0.0001), 42.1% positive attitude). In conclusion, although most people want to 'know' if they have AD, there is a diminishing degree of support from disclosure to diagnostic assessment to screening. Preferences for diagnosis and screening decline when respondents have the opportunity to consider the consequences of their decision.

Prevalence and predictors of bedrail use in an acute hospital.

OBJECTIVE: to determine the prevalence and predictors of bedrail use in an acute hospital. DESIGN AND SETTING: overnight survey in a University teaching hospital. SUBJECTS: Three-hundred and twenty-seven beds and patients in 14 wards. METHODS: data were collected on bedrail use and on the bed system, ward and patient characteristics. Medical, nursing and physical therapy notes were examined and the night and day nurses and, if necessary, the doctors and therapists caring for the patient interviewed to determine patients' diagnoses, functional and cognitive status. RESULTS: there were 133 (40.7%) beds with one or more raised rails. Independent predictors of bedrail use were use of electric profiling beds, confusion, reduced alertness and any difficulty with transferring from bed. The most common reported indication for bedrail use was 'to prevent rolling out of bed' (59%); 'to prevent getting out of bed' was recorded in 11% of cases. Use of bedrails was judged inappropriate in 27/133 (20.3%) patients and in 14/43 (32.6%) patients with abnormal mental status; misuse was particularly common in those with confusion or agitation [13/34 (38.2%)]. Failure to use bedrails was potentially inappropriate in 32/194 (16.5%) of those without bedrails. CONCLUSION: this study using individual patient data shows that the use of electric profiling beds, abnormal mental states and difficulty transferring from bed are the main predictors of bedrail use in acute hospitals. Inappropriate use of bedrails is common in those with cognitive impairment or with agitation.