Trauma in Auckland: an overview

Data are presented on all 569 subjects who, as a result of trauma, either died or were admitted to hospital in Auckland over a four week period. Median age was 23 with an overall 3:2 male:female ratio. Median injury severity score (ISS) was five with 9% of subjects having an ISS of 16 or more (major trauma). Blunt trauma accounted for 84% of all injuries. Life threatening injuries were most commonly to the head, thorax and abdomen while the largest number of less severe injuries were to the extremities. Eight subjects died before admission to hospital and a further six in hospital. Definitive care was given to 98% of patients at Middlemore and Auckland hospitals (including the onsite Princess Mary paediatric facility) but 26% had presented first to other hospitals and 43% of all patients were transferred from one hospital to another. The 561 patients used 6380 hospital days (including 314 intensive care days) and the following services--operating room 63%, orthopaedic ward 45%, plastic surgical ward 17%, paediatric ward 15%, neurosurgical ward 10%, general surgical ward 5%, intensive care 5% and CT scanner 4%. Only one hospital death was judged potentially preventable. This study reveals areas where trauma care could be improved, demonstrates the large amount of hospital resources required to treat trauma and particularly highlights the urgent need for studies into strategies for trauma prevention in New Zealand.     

The effect of admission to a geriatric ward on medication use: 2002 versus 1985

PURPOSE: To investigate the changes in pharmacotherapy of patients during and after admission to a geriatric ward in 2002 and to investigate if this goes along with reduction of drugs. To describe the differences of the admitted patients and their medication in 2002 compared to 1985. METHODS: Included patients were admitted to the geriatric ward of a general hospital in the Netherlands during 2002 (n = 258, mean age 84.2 years). Medication at admission, during admission and at discharge were described after retrospective reviewing of medical charts. A comparable study was performed at the same ward in 1985. RESULTS: In 2002, most frequently used medication at admission was acetylsalicylic acid (30.2%). Pantoprazole was during admission used in 38.8% of patients and at discharge in 31.8%. Folic acid that was at admission used by 11.6% of patients was at discharge increased to 23.4%. At discharge, vitamin D was used in 21.5% of patients, whereas lisinopril was used in 17.8% of patients. Both in 1985 and 2002 vitamins were added and use of antibiotics was increased during admission. A mean addition of 1.0 drug in 1985 and of 0.7 drugs in 2002 was observed. CONCLUSIONS: Geriatric hospital admission resulted both in 1985 and 2002 in addition of medication. In both periods reductions in medication were nullified by addition of medication for reason of therapy optimisation. Compared to 1985 admitted patients receive more medication resulting from new insights into pharmacotherapy and more use of preventive medicine.     

Frequency and profile of objective cognitive deficits in hospitalized patients recovering from COVID-19

Early reports and case series suggest cognitive deficits occurs in some patients with COVID-19. We evaluated the frequency, severity, and profile of cognitive dysfunction in patients recovering from prolonged COVID-19 hospitalization who required acute inpatient rehabilitation prior to discharge. We analyzed cross-sectional scores from the Brief Memory and Executive Test (BMET) in a cohort of N = 57 COVID-19 patients undergoing inpatient rehabilitation, calculating the frequency of impairment based on neuropsychologist diagnosis and by age-normed BMET subtests. In total, 43 patients (75%) were male, 35 (61%) were non-white, and mean age was 64.5 (SD = 13.9) years. In total, 48 (84%) were previously living at home independently. Two patients had documented preexisting cognitive dysfunction; none had known dementia. Patients were evaluated at a mean of 43.2 (SD = 19.2) days after initial admission. In total, 50 patients (88%) had documented hypoxemic respiratory failure and 44 (77%) required intubation.  Forty-six patients (81%) had cognitive impairment, ranging from mild to severe. Deficits were common in working memory (26/47 [55%] of patients), set-shifting (21/44 [47%]), divided attention (18/39 [46%]), and processing speed (14/35 [40%]). Executive dysfunction was not significantly associated with intubation length or the time from extubation to assessment, psychiatric diagnosis, or preexisting cardiovascular/metabolic disease. Attention and executive functions are frequently impaired in COVID-19 patients who require acute rehabilitation prior to discharge. Though interpretation is limited by lack of a comparator group, these results provide an early benchmark for identifying and characterizing cognitive difficulties after COVID-19. Given the frequency and pattern of impairment, easy-to-disseminate interventions that target attention and executive dysfunctions may be beneficial to this population.Subject terms: Human behaviour, Outcomes research     

Is cognitive impairment a risk factor for poor compliance among Japanese elderly in the community?

OBJECTIVE: The association between cognitive impairment and compliance with prescribed medications was investigated among functionally independent Japanese elderly in the community. SUBJECTS: The subjects of this study were 220 elderly persons aged 60 years and over, who lived in the community. All participants were taking a regimen of one or more prescribed drugs. We included elderly with mild to moderate cognitive impairment. Medication use was observed by pharmacist-conducted interviews during home visits. Compliance was estimated by the pill count method. The Mini-Mental State Examination (MMSE) was used to estimate cognitive function. RESULTS: The mean age (SD) of the subjects was 75.7 (6.9) years. Of the subjects, 58 (26.4%) were cognitively impaired (MMSE < or = 23), and 76 (34.6%) exhibited poor compliance (rate of compliance< 80%). Poor compliance was associated with the subjects who had a lower education level, had lower MMSE scores, had concern about taking drugs, who intentionally self-selected (intentional noncompliance) prescribed drugs, had a poor relationship with a physician, who did not have one dose package, and those who did not use a medical calendar. In multiple logistic regression analyses, intentional noncompliance (OR 19.65, 95%, CI 9.22-41.92; OR, odds ratio; CI, confidence interval), cognitive impairment (MMSE < or = 23; OR 2.94, 95%, CI 1.32-6.58), and a poor relationship with a physician (OR 6.24. 95%, CI 1.55-25.20) were independent predictors of poor compliance for elderly in the community. CONCLUSION: We found that cognitive impairment was one of the predictors for poor compliance among the elderly who are functionally independent in the community. Intentional noncompliance was the strongest predictor for poor compliance, which was influenced by the relationship between patient and physician. Physicians should establish good communication with their elderly patients and provide some support to compensate for cognitive impairment.     

Blocked beds.

In a cross-sectional survey of 325 surgical and orthopaedic beds 43 (16%) of the 265 occupied beds were filled by patients who had no medical need to be in an acute ward. They had been in hospital for a median time of 40 weeks up to the survey date. Of the 43 patients, 11 were awaiting transfer to a geriatric ward; 13 to community residential care; and seven to their homes. There was no plan for discharge or transfer for the remaining 12 (28%). Those "at risk" of becoming long-stay patients for social reasons on these wards were women, over 75, living alone or with one relative, who had been admitted to hospital in emergency with a fractured femur, head injury, or other trauma. Action necessary to reduce the number of social long-stay patients includes (a) changing attitudes to the solving of social case problems; (b) revising procedures of assessment and planning of future care; (c) improving teamwork and record keeping within the hospital and the community services; (d) providing a better balance of acute, medium and long-stay hospital beds; and (e) putting more resources into rehabilitation.     

Influence of a ward-based pharmacist on the medication quality of geriatric inpatients: a before–after study

Background Despite several international studies demonstrating that ward-based pharmacists improve medication quality, ward pharmacists are not generally established in German hospitals. Aim We assessed the effect of a ward-based clinical pharmacist on the medication quality of geriatric inpatients in a German university hospital. Method The before-after study with a historic control group was conducted on the geriatric ward. During the control phase, patients received standard care without the involvement of a pharmacist. The intervention consisted of a clinical pharmacist providing pharmaceutical care from admission to discharge. Medication quality was measured on admission and discharge using the Medication Appropriateness Index (MAI). A linear regression analysis was conducted to calculate the influence of the intervention on the MAI. Results Patients in the intervention group (n?=?152, mean 83 years) were older and took more drugs at admission compared to the control group (n?=?159, 81 years). For both groups, the MAI per patient improved significantly from admission to discharge. Although the intervention did not influence the summated MAI score per patient, the intervention significantly reduced the MAI criteria Dosage (p?=?0.006), Correct Directions (p?=?0.016) and Practical Directions (p?=?0.004) as well as the proportion of overall inappropriate MAI ratings (at least 1 of 9 criteria inappropriate) (p?=?0.015). Conclusion Although medication quality was already high in the control group, a ward-based clinical pharmacist could contribute meaningfully to the medication quality on an acute geriatric ward.

     

The pharmacokinetics of pioglitazone in patients with impaired renal function

AIMS: To evaluate the effect of renal impairment on the pharmacokinetics and safety of pioglitazone and its metabolites M-III and M-IV with impaired renal function and normal renal function. METHODS: In a phase-I, open-label, parallel-group study, six healthy subjects with normal renal function (creatinine clearance> 80 ml min-1), nine patients with moderate renal impairment (creatinine clearance 30-60 ml min-1) and 12 patients with severe renal impairment (creatinine clearance < 30 ml min-1) received single and multiple oral doses of pioglitazone 45 mg. The serum pharmacokinetic profiles of pioglitazone and its metabolites M-III and M-IV were assessed for the first and last dose administered (day 1 and day 12, respectively). RESULTS: Pharmacokinetic data revealed no significant accumulation of pioglitazone or its metabolites M-III and M-IV in patients with renal impairment. There was no significant difference in the pharmacokinetic profile of pioglitazone in subjects with normal and with moderately impaired renal function. After single oral doses, mean area under the concentration-time curve (AUC) values were decreased in patients with severe renal impairment compared with healthy subjects with normal renal function for pioglitazone (13 476 vs 17 387, P = 0.371; -23%; confidence interval (CI) -57, 38), M-III metabolite (13 394 vs 15 071, P = 0.841; -11%; CI -74, 194) and M-IV metabolite (27 991 vs 49 856, P = 0.006; -44%; CI -62, -17). After repeated oral doses of pioglitazone, mean AUC values (microg.h l-1) were decreased in patients with severe renal impairment compared with healthy subjects with normal renal function for pioglitazone (8744 vs 14,565, P = 0.004; -40%; CI -57, -16), M-III (3991 vs 7,289, P = 0.0009; -45%; CI -60, -25) and M-IV (21 080 vs 25 706, P = 0.181; -18%; CI 39, 10). The tolerability and safety profile of pioglitazone was comparable between groups. CONCLUSIONS: Pioglitazone was well tolerated in patients with varying degrees of renal impairment. Although mean serum concentrations of pioglitazone and its metabolites are increased in patients with severe renal impairment, adjustment of starting and maintenance doses in these patients is probably unwarranted.     

Analysis of the activities of a geriatric assessment and rehabilitation unit

In a four month period 228 patients were admitted to the Wakari assessment and rehabilitation unit in Dunedin, New Zealand. One hundred and seventy subjects came from the community, 35 were transferred from the local public hospital, and 23 were readmitted. Median lengths of stay were 13, 26 and 10 days respectively. Assessment of activities of daily living (ADL) dependency on admission and discharge showed a significant improvement in ability by discharge, which correlated closely with place to which subjects were discharged, and with survival. There was 5% inpatients death rate which cumulated to 18%, 23%, 34%, 39% and 46% by six weeks, three months, six months, nine months and one year respectively. High discharge dependency was closely related to poor survival after discharge. Use of domiciliary services did not change because the savings from those who moved into institutions were cancelled out by those who were discharged back to the community being in need of increased social support.     

Stress in caregivers of elderly patients: the effect of an admission to a rehabilitation unit

OBJECT: to study stress in caregivers of elderly dependent persons after admission to a geriatric assessment and rehabilitation unit. METHOD: in 1986-7 we studied patients admitted to a geriatric assessment and rehabilitation unit in Dunedin to establish the relationship between caregiver stress, their psychological health and social functioning, and patient variables such as physical dependency. RESULTS: of the 64 patients who were admitted from the community and who had a caregiver, 42 were discharged back to the community, and 30 remained there until six weeks. On admission caregiver stress was increased by problems perceived in social function (lack of companionship, excessive responsibilities and financial problems) and decreased when the caregiver had a high sense of psychological wellbeing. It was not associated with high patient dependency or the level of social support. Caregiver stress one week after discharge was lower among those with high emotional support and those with an internal locus of control. If caregiver stress one week after discharge was high there was an increased rate of readmission. CONCLUSION: rehabilitation should include interventions directed towards the psychological health and social function of the caregiver as well as the physical independence of the patient. Improved financial support and the provision of companionship through community support groups may result in reduced caregiver stress, which should help dependent elderly people to continue to live in the community.     

Impact of hospitalisation in an acute medical geriatric unit on potentially inappropriate medication use

BACKGROUND AND OBJECTIVE: Potentially inappropriate medication use is a major safety issue in the elderly and may cause a substantial proportion of drug-related hospital admissions. Hospitalisation could result in a change in the quantity and type of drugs, but its effect on potentially inappropriate drug use is still unknown. The aim of this study was to estimate the potentially inappropriate medication prevalence in patients > or =70 years of age at admission to and at discharge from an acute medical geriatric unit, and to identify the factors associated with no longer being a potentially inappropriate drug user at hospital discharge. METHODS: A prospective drug surveillance study was undertaken in 2018 elderly patients (> or =70 years of age) admitted to an acute medical geriatric unit in Limoges University Hospital, France. Prescribing patterns were established at admission and at discharge. Potentially inappropriate medication use was evaluated according to a list derived from the Beers criteria and adapted to French practice. "To be no longer a potentially inappropriate drug user at discharge" was defined as using at least one potentially inappropriate medication at admission and not using it at discharge. RESULTS: The numbers of drugs used at admission/discharge were 6.2 +/- 3.1/5.4 +/- 2.5. The prevalence of potentially inappropriate medication use decreased from 66% (95% CI 63.8, 68.0) at admission to 43.6% (95% CI 41.3, 45.9) at discharge. At discharge, 535 subjects were no longer potentially inappropriate medication users. Multivariate analysis showed that no longer being a potentially inappropriate medication user was associated with the number of drugs used (4-6 drugs vs < or =3 odds ratio [OR] 1.20; 95% CI 0.86, 1.68; 7-9 drugs vs < or =3 OR 1.37; 95% CI 0.97, 1.93; > or =10 drugs vs < or =3 OR 1.64; 95% CI 1.10, 2.44), age (80-89 years vs 70-79 years OR 1.38; 95% CI 1.03, 1.85; > or =90 years vs 70-79 years OR 1.69; 95% CI 1.22, 2.83), cerebral vasodilator use (OR 2.87; 95% CI 2.31, 3.57), analgesic use (OR 1.54; 95% CI 1.06, 2.25) and concomitant use of psychotropic drugs of the same therapeutic class (OR 1.94; 95% CI 1.29, 2.92). CONCLUSION: Hospitalisation in geriatric services results in a reduction in potentially inappropriate medication use. Improved pharmacological education of practitioners, especially with regard to drug adverse effects, is desirable to improve management of geriatric patients.     

The impact of a pharmacist on post-take ward round prescribing and medication appropriateness

Background Medication communication and prescribing on the post-take ward round following patient admission to hospital can be suboptimal leading to worse patient outcomes. Objective To evaluate the impact of clinical pharmacist participation on the post-take ward round on the appropriateness of medication prescribing, medication communication, and overall patient health care outcomes. Setting Tertiary referral teaching hospital, Brisbane, Australia. Method A pre-post intervention study was undertaken that compared the addition of a senior clinical pharmacist attending the post-take ward was compared to usual wardbase pharmacist service, with no pharmacist present of the post-take ward round. We assessed the proportion of patients with an improvement in medication appropriateness from admission to discharge, using the START/STOPP checklists. Medication communication was assessed by the mean number of brief and in-depth discussions, with health care outcomes measured by comparing length of stay and 28-day readmission rates. Main outcome measures: Medication appropriateness according to the START/STOPP list, number and type of discussions with team members and length of stay and readmission rate. Results Two hundred and sixty patients were recruited (130 pre- and 130-post-intervention), across 23 and 20 post-take ward rounds, respectively. Post-intervention, there was increase in the proportion of patients who had an improvement medication appropriateness (pre-intervention 25.4%, post-intervention 36.9%; p?=?0.004), the number of in-depth discussions about patients’ medication (1.9?±?1.7 per patient pre-intervention, 2.7?±?1.7 per patient post-, p?<?0.001), and the number relating to high-risk medications (0.71?±?1.1 per patient pre-intervention, to 1.2?±?1.2 per patient post-, p?<?0.05). Length of stay and 28-day mortality were unchanged. Conclusion Clinical pharmacist participation on the post-take ward round leads to improved medication-related communication and improved medication appropriateness but did not significantly improve health care outcomes.

     

The use of the Hospital Anxiety and Depression Scale (HADS) in patients with chronic obstructive pulmonary disease: a pilot study.

AIMS: To investigate the use of the Hospital Anxiety and Depression Scale (HADS) with recuperating chronic obstructive pulmonary disease (COPD) patients. To study prevalence rates and changes in clinically relevant anxiety and depression during rehabilitation. METHODS: Consecutive patients admitted to a non acute respiratory ward over a twelve week period were asked to complete a HADS questionnaire on three occasions. Nurses recorded basic demographic information on admission. Additional demographic, medical and psychiatric data were obtained by retrospective review of medical records. RESULTS: Of 93 consecutive inpatients, 79 (85%) completed the admission HADS. 72 patients were eligible to complete the day three HADS and 60 the discharge HADS. Clinically relevant anxiety (HADS score of > or =8) was indicated in 39 patients (50%) and depression in 22 (28%). HADS anxiety (p=0.05) and total scores (anxiety+depression) (p=0.03) decreased between admission and discharge. A larger proportion of patients scored within the normal or mild psychopathology range by discharge. More severe COPD (FEV1% predicted) correlated with higher HADS anxiety scores (r=-0.39, p<0.001) and HADS depression scores (r=-0.34, p<0.005). Patients with a recorded history of anxiety (p<0.0001) and depression (p<0.02) had higher WADS scores. Females (n=37) when compared to males (n=42), recorded significantly higher HADS anxiety scores throughout (p<0.005). CONCLUSIONS: Clinically relevant anxiety, indicated by higher HADS scores, was more common in patients with severe COPD, a past history of anxiety or depression and females. Anxiety and total mood improved during inpatient rehabilitation. The use of this instrument with New Zealand COPD patients may improve identification and treatment of anxious and depressed patients.     

Pretreatment systolic orthostatic blood pressure (PSOP) and treatment response in elderly depressed inpatients

This study evaluated the utility of morning pretreatment systolic orthostatic blood pressure (PSOP) in predicting clinical response to treatment with nortriptyline (N = 11) or electroconvulsive therapy (N = 6) in 17 depressed geriatric inpatients (mean age, 70.4 +/- 5.1). Morning PSOP showed a significant inverse correlation with percent change in Hamilton depression ratings (rho = -0.59, p less than 0.01; r = -0.52, p less than 0.02). In nortriptyline-treated patients (N = 10, excluding one outlier), PSOP was significantly correlated with percent change in Hamilton ratings (rho = -0.55, p less than 0.05); a similar association was also found in the subsample of electroconvulsive therapy-treated patients (N = 6, rho = -0.77, p less than 0.05). Patients with PSOP less than or equal to 10 mm Hg averaged 83% improvement in Hamilton depression ratings versus 64% improvement in patients with PSOP less than or equal to 10 mm Hg (p less than 0.05). In an age-equated contrast group of 15 inpatients with mixed clinical pictures of depression and cognitive impairment (11 with primary degenerative dementia with depressive features and four with major depressive disorder with cognitive impairment), no relation between PSOP and treatment response (as measured by Hamilton ratings) was found. The current findings extend earlier work in medically healthy, nonsuicidal geriatric depressed outpatients and suggest that PSOP may also be useful in predicting treatment response in older, cognitively intact depressed inpatients (many with concurrent medical illness and/or suicidal) but not in mixed depression-dementia.     

Handling drug-related problems in rehabilitation patients: a randomized study

Background Drug-related problems (DRPs) have been found to be associated with increased morbidity, mortality, and health costs. Objective To investigate whether the inclusion of pharmacists in a rehabilitation team influences the handling of DRPs in the ward and whether an intervention in hospital affects drug use after discharge. Setting The rehabilitation ward of a general hospital in Oslo, Norway. Methods Patients were randomized into an intervention group (IG) or a usual care group (CG). The IG patients were followed prospectively by a pharmacist, who reviewed the patients?? drug therapies using information from their medical records and patient interviews. The pharmacist identified DRPs and suggested solutions during multidisciplinary team meetings. The IG patients received targeted drug counselling from the pharmacist before discharge. The drug therapy in the CG, for the period from study randomization to discharge, was assessed retrospectively by the pharmacist, who identified DRPs and recorded how they were acted upon. Three months after discharge, pharmacists who were blinded to the patient randomization, visited the patients at home and interviewed them about their medication. Main outcome measures: Types and frequencies of DRPs in the IG and CG were compared at hospital admission, at discharge, and 3?months after discharge. Results Of the 77 patients included, 40 belonged to the IG and 37 to the CG. Patient characteristics (IG vs CG) were as follows: age 73.5 versus 76.8?years; female 58 versus 68%; mean number of drugs at admission 8.3 versus 7.8; and mean number of drugs at discharge 8.5 versus 7.7. At admission, 4.4 DRPs per patient were recorded in the IG and 4.2 in the CG. Significantly more DRPs were acted upon and resolved in the IG; at discharge, the IG had 1.2 DRPs per patient and the CG had 4.0 (P?<?0.01). At the home visit, a significant difference between the groups was found: 1.63 versus 2.62 DRPs (P?=?0.02) for the IG and the CG, respectively. Conclusion Involvement of a pharmacist in drug-therapy management, including participation in multidisciplinary team discussions, markedly improved the identification and resolution of DRPs during a hospital stay. The benefit persisted after discharge.     

Does a delay in transfer to a rehabilitation unit for older people affect outcome after fracture of the proximal femur?

AIMS: To detemine the relationship between delay in transfer to rehabilitation wards and outcome for patients aged over 75 years with fracture of the proximal femur. METHODS: An observational study in a district general hospital of all patients admitted to hospital aged over 75 years with fracture of the proximal femur over 3 1/2 years. Outcome data collected included the number of patients discharged back to their usual residence and total hospital length of stay related to age, gender, usual residence and delay in transfer to a rehabilitation ward. RESULTS: 58% of 455 patients were transferred to a rehabilitation ward. For those patients who were transferred to a rehabilitation ward only age predicted discharge to a more dependent residence. The relative risk for discharge to a more dependent residence for people aged over 85 years compared to younger people was 1.47 (95% CI 1.15-1.88). Delay in transfer to rehabilitation was associated with a longer total hospital length of stay of 0.64 (95% CI 0.23-1.05) days per day of delay in transfer. CONCLUSIONS: Delay in transfer to a rehabilitation ward was associated with a disproportionate increase in total hospital length of stay for patients aged over 75 with fracture of the proximal femur.     

Psychotropic drug use and cognitive rehabilitation practice for elderly patients

Background Psychotropic drugs were associated with greater risks of adverse drug reactions, including lower the level of consciousness, cause cognitive dysfunction, relax muscles, cause hypotension and others. However, the effect of psychotropic drug use on rehabilitation outcomes is poorly documented in Japan. Objective To assess the association of increased psychotropic drugs during hospitalization with activities of daily living among elderly patients. Setting This study was conducted at the convalescent rehabilitation ward in the Hitachinaka General Hospital in Japan. Method This retrospective longitudinal cohort study included consecutive patients aged ≥?65 years between 2010 and 2016. Participants were divided based on presence or absence of increased psychotropic drugs including benzodiazepines, antidepressants, antipsychotics, and antiepileptic drugs during hospitalization. Functional recovery was assessed by the Functional Independence Measure (FIM). Multivariate analyses were performed, adjusting for confounding factors. Main outcome measures Cognitive gain in the Functional Independence Measure. Results We included 631 participants (227 males, 404 females) with a median age of 78 years (interquartile range 73–84 years). Multiple regression analysis revealed that change in psychotropic drug use, cognitive FIM at admission, and age were independently and negatively correlated with cognitive FIM gain. Multiple logistic regression analysis indicated that the “Comprehension” and “Memory” items of the cognitive FIM gain were independently and negatively associated with increased psychotropic drug use. Conclusion Increased psychotropic drug use during hospitalization may predict limited the improvement of cognitive activities of daily living in geriatric patients.