Impaired Inpatients Research Articles

Interactions that support older inpatients with cognitive impairments to engage with falls prevention in hospitals: An ethnographic study.

To explore the nature of interactions that enable older inpatients with cognitive impairments to engage with hospital staff on falls prevention. Ethnographic study. Ethnographic observations on orthopaedic and older person wards in English hospitals (251.25 h) and semi-structured qualitative interviews with 50 staff, 28 patients and three carers. Findings were analysed using a framework approach. Interactions were often informal and personalised. Staff qualities that supported engagement in falls prevention included the ability to empathise and negotiate, taking patient perspectives into account. Although registered nurses had limited time for this, families/carers and other staff, including engagement workers, did so and passed information to nurses. Some older inpatients with cognitive impairments engaged with staff on falls prevention. Engagement enabled them to express their needs and collaborate, to an extent, on falls prevention activities. To support this, we recommend wider adoption in hospitals of engagement workers and developing the relational skills that underpin engagement in training programmes for patient-facing staff. Interactions that support cognitively impaired inpatients to engage in falls prevention can involve not only nurses, but also families/carers and non-nursing staff, with potential to reduce pressures on busy nurses and improve patient safety. The paper adheres to EQUATOR guidelines, Standards for Reporting Qualitative Research. Patient/public contributors were involved in study design, evaluation and data analysis. They co-authored this manuscript.

Video-based fall prevention education for cognitively impaired inpatients: a pilot study

Video-based fall prevention education for cognitively impaired inpatients: a pilot study

FALSE-POSITIVE FDG-PET DIAGNOSIS OF AD IN GERIATRIC INPATIENTS WITH NEWLY MANIFESTED COGNITIVE IMPAIRMENT AND CEREBROVASCULAR DISEASE

In a study on the accuracy of the etiological diagnosis of newly manifested, clinically uncertain cognitive impairment in elderly geriatric inpatients (WHO Trials Registry DRKS00005041) the most probable etiological diagnosis made by an interdisciplinary academic expert team integrating all available data (clinical, laboratory, neuropsychological, structural MRI, and FDG PET) was Alzheimer's disease (AD) in 14 patients and mixed disease (MD), i.e., AD plus cerebrovascular disease (CVD), in 16 patients. The presence of an AD-typical reduction pattern in FDG PET was required for both AD and MD etiological diagnosis. Clinical follow-up including detailed neuropsychological testing after 15.7±3.1 months confirmed progressive neurodegeneration in all AD cases whereas the etiological diagnosis of MD was adjusted to CVD in 3 of the 16 cases. This suggests an increased risk of false positive FDG PET in cognitively impaired inpatients with CVD. Aim of this study was to provide some evidence for this hypothesis. The 3 patients in whom the etiological diagnosis of MD was adjusted by the follow-up to CVD only (MD-to-CVD converters) were compared to the 13 patients in whom the MD diagnosis was confirmed (MD-stables) with respect to various variables including total volume of white matter hyperintensities (WMH) estimated from FLAIR MRI using the lesion segmentation toolbox for SPM8, local and global grey matter volume estimated from MPRAGE MRI using a fully-automated atlas-based method, pons-scaled FDG-uptake in an AD meta-ROI, specific FDG dose, blood glucose concentration at the time of PET, duration of follow-up, and age. Unexpectedly, the total WMH volume was significantly smaller (not larger) in MD-to-CVD converters compared to MD-stable patients (20.6 vs. 40.1 ml, Mann-Whitney U-test p = 0.031). Grey matter volume in the right occipital lobe trended towards lower values in MD-to-CVD converters (14.8 vs. 19.2 ml, p = 0.070). None of the other variables showed an effect. These findings provide some evidence that false positive FDG PET with respect to the diagnosis of AD in cognitively impaired geriatric inpatients might be secondary to partial volume effects caused by occipital atrophy. They do not provide evidence for an association with white matter disease.

Measuring quality of life of cognitively impaired elderly inpatients in palliative care: psychometric properties of the QUALID and CILQ scales

ABSTRACTObjectives: The study aimed to assess the psychometric properties of the Czech versions of the Quality of Life in Late-Stage Dementia (QUALID) and the Cognitively Impaired Life Quality (CILQ) scales for use in the palliative care setting in terminally ill patients with cognitive impairment.Methods: The sample comprised 306 cognitively impaired inpatients with advanced cancer and non-cancer conditions. In this cross-sectional study, two Quality of Life (QoL) measurements were performed at baseline and after five days. The dimensionality of the QUALID and CILQ scales was evaluated using a principal component analysis with Varimax rotation. Reliability was assessed using Cronbach's alpha; inter-rater reliability was evaluated with Kappa index. Test–retest stability was calculated using the intraclass correlation coefficients (ICCs) comparing scores from baseline and 3–5 days post-baseline. The construct validity of the QUALID and CILQ scale was established by Spearman's correlation coefficients with the Symptom Management at the End-of-Life in Dementia (SM-EOLD).Results: Both scales were shown to have adequate validity and reliability (Cronbach's α = 0.812 for QUALID, and α = 0.73 for CILQ), good inter-rater agreement (QUALID: κ = 0.760; CILQ: κ = 0.801) as well as test–retest reliability (QUALID: ICC = 0.847; CILQ: ICC = 0.925).Conclusion: The Czech versions of the QUALID and CILQ scales may be recommended for use in the Czech Republic in the area of palliative care.

Direct inpatient burden caused by foot-related conditions: a multisite point-prevalence study

ObjectiveThe aims of this point-prevalence study were to investigate a representative inpatient population to determine the prevalence of people admitted to hospital for the reason of a foot-related condition, and...

The safety and effectiveness of earwax removal by nurse in cognitive impaired inpatients.

難聴は認知機能低下のリスクであるが，高齢の認知症患者では耳垢栓塞の頻度が高い．我々は認知症病棟において看護師による外耳道の観察および耳垢水・耳洗浄処置を行った．耳鏡を用いた外耳道の観察を行いえた98名中32名（33％）に鼓膜の全くみえない耳垢を認めた．看護師による耳処置について同意の得られた22名中14名では耳垢水・耳洗浄のみで鼓膜確認可能となったが，8名は耳鼻咽喉科医による除去が必要であった．

A decision aid regarding long-term tube feeding targeting substitute decision makers for cognitively impaired older persons in Japan: A small-scale before-and-after study

BackgroundIn Japan, there is no decision-making guide regarding long-term tube feeding that specifically targets individuals making decisions on behalf of cognitively impaired older persons (substitute decision makers). The objective of this study was to describe the development and evaluation of such a decision aid.MethodsIn this before-and-after study, participants comprised substitute decision makers for 13 cognitively impaired inpatients aged 65 years and older who were being considered for placement of a percutaneous endoscopic gastrostomy tube in acute care hospitals and mixed-care hospitals in Japan. Questionnaires were used to compare substitute decision makers’ knowledge, decisional conflict, and predisposition regarding feeding tube placement before and after exposure to a decision aid. The acceptability of the decision aid was also assessed. Paired t-tests were used to compare participants’ knowledge and decisional conflict scores before and after using the decision aid.ResultsSubstitute decision makers showed significantly increased knowledge (P < .001) and decreased decisional conflict (P < .01) regarding long-term tube feeding after using the decision aid. All substitute decision makers found the decision aid helpful and acceptable.ConclusionsThe decision aid facilitated the decision-making process of substitute decision makers by decreasing decisional conflict and increasing knowledge.

Cognitive Impairment in Elderly Renal Inpatients: An Under-Identified Phenomenon

Background/Aims: Cognitive impairment is a common but under-recognised problem in patients with chronic kidney disease, and is likely to become more significant as this patient population ages. Methods: This cross-sectional study focussed on inpatients aged ≥65 years at a tertiary renal unit, and consisted of two parts. Part 1 (n = 25) considered whether cognitively impaired inpatients were being identified and being referred to memory services. In Part 2 (n = 105) two different cognitive function tests were attempted (6-CIT, MMSE). Results: In Part 1, cognitive function tests were attempted in only 4 patients at admission and 1 patient subsequently. No patients were referred to memory services. In Part 2, 6-CIT was abnormal (score ≥8) in 61.4%, and MMSE was abnormal (score <27) in 79.5% (score 21-26: 28.9%, 15-20: 28.9%, 10-14: 13.3%, <10: 8.4%). There was a close correlation between MMSE and 6-CIT (R² = 0.735). Only 7.2% of those assessed had a documented cognitive deficit prior to admission. Conclusion: This is the first study looking at cognition in elderly inpatients with chronic kidney disease. There appears to be a much higher rate of cognitive impairment than expected and this is largely unidentified. These deficits are likely to have a major impact on both inpatient and outpatient management.

IMPAIRED HEART RATE RECOVERY INDEX IN PATIENTS WITH SARCOIDOSIS

Background Sarcoidosis, an inflammatory granulomatous disease, is associated with various cardiac disorders, including threatening ventricular arrhythmias and sudden cardiac death. Heart rate recovery (HRR) after exercise is a function of vagal reactivation, and its impairment is an independent prognostic indicator for cardiovascular and all-cause mortality. The aim of our study was to evaluate HRR in patients with sarcoidosis. Methods The study population included 56 patients with sarcoidosis (23 men, mean age=47.3 ± 13.0 years, and mean disease duration=38.4 ± 9.7 months) and 54 healthy control subjects (20 men, mean age=46.5 ± 12.9 years). Basal ECG, echocardiography, and treadmill exercise testing were performed on all patients and control participants. The HRR index was defined as the reduction in the heart rate at peak exercise to the first-minute rate (HRR1), second-minute (HRR2), third-minute (HRR3), and fifth-minute (HRR5) after the cessation of exercise stress testing. Results There are significant differences in HRR1 and HRR2 indices between patients with sarcoidosis and the control group (25 ± 6 vs 34 ± 11; P Conclusions The HRR index was impaired in patients with sarcoidosis as compared with control subjects. When the prognostic significance of the HRR index is considered, these results may partially explain the increased occurrence of arrhythmias and sudden cardiac death in patients with sarcoidosis. Our findings suggest that the HRR index may be clinically helpful in identifying high-risk patients with sarcoidosis.

Falls in older hospital inpatients and the effect of cognitive impairment: a secondary analysis of prevalence studies

The objective of this study was to compare fall rates in older hospital inpatients with and without cognitive impairment. Relationships between age, gender, mobility, cognitive impairment, care dependency, urinary incontinence and medical disciplines were investigated. Falls are common in older people with cognitive impairment, but studies in the hospital setting are rare. A secondary analysis of three nationwide prevalence studies in German hospitals from the years 2005, 2006 and 2007 was conducted. Trained staff nurses used a standardised instrument to collect data about accidental falls within the last two weeks in their institutions and about other patient characteristics. Data from 9246 patients aged 65 years or older from 37 hospitals were analysed. The fall rate for cognitively impaired patients was 12·9%, while only 4·2% of older persons without cognitive impairment experienced a fall. Comparison between medical disciplines showed great differences concerning fall risk for confused and non-confused inpatients. In multivariate logistic regression analysis, the odds-ratio association of cognitive impairment and falls was 2·1 (CI 1·7-2·7). Higher age (OR 1·5, CI 1·2-1·9), greater care dependency (OR 1·6, CI 1·1-2·1), reduced mobility (OR 2·6, CI 1·9-3·7) and being a patient on a geriatric ward (OR 1·8, CI 1·1-2·9) were also statistically significant predictors in this model. Cognitively impaired older people constitute a high-risk group for accidental falls in hospitals. Fall prevention strategies in the hospital setting should address cognitively impaired inpatients as an important high-risk group.

565 IMPAIRED INNATE IMMUNE RESPONSES IN PATIENTS WITH EARLY ACUTE HBV INFECTION

565 IMPAIRED INNATE IMMUNE RESPONSES IN PATIENTS WITH EARLY ACUTE HBV INFECTION

Assessing client competence to participate in rehabilitation decision making1

Numerous persons receiving rehabilitation services demonstrate compromised judgmental or cognitive ability which occasionally casts doubt on the validity of their consent to, or refusal of, rehabilitation treatment. A 14-member panel of nationally recognized forensic and neurorehabilitation experts (recruited from physiatry, law and mental health) viewed 21 videotaped competency interviews of cognitively impaired inpatients in an acute care rehabilitation hospital. Each rater offered an opinion on whether the interviewee was competent or not based on background history and the interview format presented here. Their ratings are compared with those of the interviewees' treating professionals, who based their competency assessments on their day-to-day clinical interactions with the patients. Results showed similar judgments among the three groups of videotape raters but statistically significant differences between the ratings of the panel members and the patients' treatment team. Reasons for these discrepancies are explored with additional comments on the conceptual obstacles presented by competency assessments in general. This article also describes a brief evaluation of competence to consent to treatment developed during the research program with input from the panel of experts. Qualified rehabilitation providers might employ such techniques to assess competence to participate in medical decision making.

A geriatric assessment and intervention team for hospital inpatients awaiting transfer to a geriatric unit: A randomized trial

The objective of this study, designed as a randomized controlled trial, was to decrease the length-of-stay (LOS) of hospitalized patients on a waiting list for admission to an inpatient geriatric assessment unit (GAU), and to optimize use of the GAU and other hospital services. The participants included 108 elderly, functionally impaired inpatients referred for geriatric consultation, and appropriate for GAU admission, stratified into high and low ADL functioning groups. They were admitted to a 354-bed acute hospital, with a 31-bed long-stay ward and a 15-bed GAU; a 25-30 day delay occurred between screening and admission of inpatients to the GAU. Experimental subjects (N = 25) received the consultative services of a geriatric assessment and intervention team (GAIT) immediately after being qualified for GAU admission, in place of waiting for GAU services. Controls (N = 52) received usual hospital care until admitted to the GAU. While high-function patients randomized to the GAIT had significantly shorter hospital LOS than comparable controls (41.4 vs 56.5 days; p = 0.03), LOS reduction was even greater in the low-function stratum (44.5 vs 74.5 days; p = 0.001). Further, significantly more GAIT than control patients were discharged home (28% vs 11%; p = 0.044). A trend toward reduced mortality in the GAIT group was non-significant. We conclude that for Canadian hospitals in which extensive stays of frail elderly patients, "bed blockage", and thus access to unit-based geriatric services are common problems, the GAIT can efficiently decrease hospital LOS, increase home placement, and may improve outcomes.

Rehabilitation inpatient screening of early cognitive recovery.

A neuropsychologic bedside screening instrument has been developed for use with recovering, cognitively impaired inpatients. Its purpose is to help clarify the nature and extent of cognitive impairments and to quantify change during recovery. The Barry Rehabilitation Inpatient Screening of Cognition (BRISC) represents an extension downward into the broad range of below-normal functioning. Reliability and validity data, based on 20 head-injured inpatients, and normative data, based on 52 nonpatients are presented. These data indicate that the BRISC is an appropriate instrument for use with its target population.

Levels of adaptation and narcissistic psychopathology.

Why, one might reasonably query, do some narcissistic characters serve time as seemingly successful presidents of corporations while others serve time as seemingly impaired inpatients on psychiatric units? I will offer some observations on this unusual clinical phenomenon and suggest that it is useful to distinguish between two clinical presentations of narcissistic character psychopathology, which I will call, for the sake of expedience, Level 1 and Level 2. I will then examine 1) how an understanding of the dimensions of empathic abilities, paranoia, levels of depression, grandiosity, and defensive uses of denial and disavowal can lend a broad explanatory range to the understanding of these levels, and 2) how we can assess both successful and unsuccessful adaptation to the outer world and the inner world in narcissistic disorders. Moreover, it is important to distinguish between being well adapted and being emotionally healthy, which are quite different in meaning and intent. I use the term Level 1 to refer to the more poorly adapted presentation, and the term Level 2 to refer to the more successfully adapted narcissistic presentation. Characteristics of Level 1 narcissistic pathology dispose a patient to an adaptation that is similar to the description of the narcissistic patient who is often described as borderline; characteristics of Level 2 narcissistic pathology dispose a patient to a high-flying and superficially successful adaptation in which the patient can competently navigate the occupational and social demands of an external world despite the presence of severe object relational impairments. While a difference in adaptation is highlighted, emotional well-being is not within the exclusive province of either's characteristic adaptive skills.

The effects of a token economy program on self-care behaviors of neurologically impaired inpatients

This study examined the effectiveness of a ward-wide token economy program for improving the self-care skills of neurologically impaired patients. The three-month program focused on bed-making, putting pajamas away, dressing, shaving, and tooth-brushing. In addition, the performance of the brain damaged group was compared with that of schizophrenic subjects who participated in the same program. The performance of the twenty subjects—seven with organic brain damage and thirteen with schizophrenia—was analyzed using a least squares analysis of variance. It was found that regardless of disability, the token program was a significantly effective method of improving self-care skills on four of the five tasks.