Prevalence of vision loss among hospital in-patients; a risk factor for falls?

PURPOSE: Despite poor vision being a risk factor for falls, current hospital policies and practices often do not include a vision assessment at patient admission or in the hospital's incident reporting system when a fall occurs. Our purpose was to document the prevalence of vision loss in hospital general medicine units to increase awareness of poor vision as a potential risk factor for falls that occur within the hospital, and inform future preventative practice. METHODS: This cross-sectional study took place in medicine units of an acute care hospital. Participants were adult in-patients. Visual acuity (VA), contrast sensitivity and stereoacuity were measured, and patients were screened for field loss, extinction and neglect. RESULTS: 115 participants took part (average age 67 ± 17, 48% female). Overall, 89% had a visual impairment defined as being outside the age-norms for one or more vision measure, 62% had low vision, and 36% had vision loss equivalent to legal blindness [VA equal to or poorer than 1.0 logMAR (6/60, 20/200) or ≥10x below age-norms]. There was a considerable discrepancy between the prevalence of low vision and the percentage of patients who reported an ocular diagnosis that would result in visual loss (30%). Ten patients fell during the study period, and of these 100% had visual impairment, 90% had low vision and 60% had vision loss equivalent to legal blindness, which compares to 58%, 22% and 9% for non-fallers. Similar high prevalences were found in those whose reason for admission to the hospital was a fall (92%, 63% and 33% respectively). CONCLUSIONS: Vision loss has a high prevalence among patients in hospital medicine units, and is higher still among those who fall. Since vision loss may be a contributing factor to falls that occur in hospitals, implementing an assessment of vision at hospital admission would be useful to alert staff to those patients who are at risk for falls due to poor vision, so that preventative measures can be applied.

Melatonin decreases delirium in elderly patients: a randomized, placebo-controlled trial.

BACKGROUND: Disturbance in the metabolism of tryptophan and tryptophan-derived compounds (e.g., melatonin) may have a role in the pathogenesis of delirium. OBJECTIVE: To evaluate the efficacy of low dose exogenous melatonin in decreasing delirium. DESIGN: A randomized, double-blinded, placebo-controlled study. SETTING: An Internal Medicine service in a tertiary care centre in London, Ontario, Canada. PARTICIPANTS: 145 individuals aged 65 years or over admitted through the emergency department to a medical unit in a tertiary care hospital. INTERVENTION: Patients were randomized to receive either 0.5 mg of melatonin or placebo every night for 14 days or until discharge. MEASUREMENTS: The primary outcome was the occurrence of delirium as determined by Confusion Assessment Method (CAM) criteria. RESULTS: Of a total of 145 individuals (mean age (standard deviation): 84.5 (6.1) years) 72 were randomly assigned to the melatonin group and 73 to the placebo group. Melatonin was associated with a lower risk of delirium (12.0% vs. 31.0%, p = 0.014), with an odds ratio (OR), adjusted for dementia and co-morbidities of 0.19 (95% confidence intervals (CI): 0.06-0.62). Results were not different when patients with prevalent delirium were excluded. LIMITATION: An intention to treat analysis was not possible due to loss to follow-up. CONCLUSION: Exogenous low dose melatonin administered nightly to elderly patients admitted to acute care may represent a potential protective agent against delirium.

A novel clinical pharmacy experience for third-year medical students.

A novel, clinical curriculum was developed to teach third-year medical students the principles of prescribing for elderly people. The experience involved a didactic session with a community pharmacist and a home visit to assess a senior citizen volunteer who was over age 75 years and was prescribed more than five medications. The medical students completed pre- and postexperience questionnaires to assess knowledge and opinions. Statistical analysis used paired t tests to compare pre- and postknowledge. The percentage agreeing or disagreeing were calculated for Likert opinion responses by using mean summary scores. Pre- and postexperience results were compared using paired t tests. Students showed improved knowledge scores on recognizing drug-drug (P=0.029) and drug-disease interactions (P=0.012). Knowledge on true/false prescribing questions was improved (P=0.005). Students felt that their current curriculum gave insufficient time to prescribing issues, and wanted more education about the use of medications and appropriate prescribing. The majority of students felt that they learned new things (81%), the experience was enjoyable (65%), important topics were covered (71.4%) and they would be more likely to confer with a community pharmacist because of the experience (75%). The novel curriculum described appears to be effective and warrants further evaluation.