Critically ill elderly who require mechanical ventilation: the effects of age on survival outcomes and resource utilisation in the medical intensive care unit of a general hospital.

INTRODUCTION: Advanced age has been a criterion for denying admission to the medical intensive care unit (MICU) due to the perceived poorer outcome and increased resource utilisation. We studied the relationship between age and outcome of the critically ill mechanically-ventilated patients admitted to the MICU. MATERIALS AND METHODS: This prospective study included patients admitted to the MICU for mechanical ventilation between 1994 and 1998. These were divided into 2 cohorts, with 206 patients aged 65 and above and 159 below 65 years. Outcome measures were MICU and hospital mortality and length of stay (LOS) in the MICU and hospital. Logistic and linear regression analyses were performed to determine the association between age and MICU and hospital mortality, as well as MICU and hospital LOS. Factors adjusted for included gender, smoking history, pre-hospitalisation functional status, ambulatory status, use of inotropes and APACHE II (m) scores (APACHE II scores were modified to exclude age points). RESULTS: Multivariate analysis revealed no statistically significant relationship between age and MICU or hospital mortality and LOS. However, APACHE IIM scores were significantly related to both MICU and hospital mortality (OR, 1.1; CI, 1.07-1.14 and OR, 1.1; CI, 1.09-1.18 respectively), but did not predict MICU or hospital LOS. CONCLUSION: Severity of acute illness and chronic co-morbidities, but not age, are predictors of MICU and hospital mortality in elderly ventilated patients.

A palliative care approach to end-stage neurodegenerative conditions.

INTRODUCTION: Neurodegenerative conditions, such as Alzheimer's disease, Parkinson's disease and motor neurone disease, are progressive and incurable conditions that ultimately lead to a state of total functional incapacitation and death. These conditions are "terminal" and, therefore, should be managed with a palliative care approach. This article highlights some of the issues in caring for patients with end-stage neurodegenerative conditions from a palliative perspective. METHODS: This review is based on evidence from pre-existing medical literature on the above subject and the authors' personal experiences and observations. CONCLUSION: Patients with end-stage neurodegenerative conditions have needs similar to that of advanced cancer patients. Therefore, the principles and practice of palliative care should be applied to such patients. This may also mean that palliative care training should be undertaken in nursing homes, where a large number of such patients are located.

Early unplanned readmission of elderly in Singapore: a retrospective study.

STUDY OBJECTIVE: To study the incidence and profile of elderly patients requiring early unplanned readmission within 15 days of discharge from a regional hospital and the predictive factors for readmission. PATIENTS: All patients (n = 150) aged 65 years old and above who were readmitted within 15 days into the hospital's geriatric unit in the western region of Singapore over a period of 10 months were retrospectively studied. METHODOLOGY: Demographic data, information on patients' medical problems and social environment were gathered from the patients' medical, nursing and therapist records. A control group (n = 103) consisting of patients not readmitted over 15 days were gathered over the same period. RESULTS: The percentage of readmission over the period between 1 January 1999 and 31 October 1999 was (150/1632) 9.2% (95% CI, 7.8% to 10.7%). There were a total of 150 patients with an equal number of male and female patients. The patients had a mean of 4 medical problems. Cardiovascular disease was noted in 73% (95% CI, 65.5% to 80.2%) of the patients during the index admissions. They were noted to be ambulatory and were staying with their own families. Half of the patients were discharged from the index admission with no adjustment to their previous care system. The majority of patients (68.7%; 95% CI, 59.9% to 75.4%) required readmission because of medical problems. Fifty per cent of the patients admitted for a new medical complaint were secondary to sepsis. Thirty per cent (95% CI, 22.8% to 38.0%) of the study population had both medical and social issues. The main predictive factors noted when compared to a control group of 103 patients (using a stepwise logistic regression model) were number of medical problems (P = 0.0128; OR = 1.4; 95% CI, 1.1 to 1.9) and number of previous admissions (P = 0.005; OR = 1.6; 95% CI, 1.2 to 2.3). CONCLUSION: Unplanned readmissions are relatively common in elderly patients. They cannot be entirely prevented in view of multiple chronic illnesses. Further studies, looking at early detection of medical problems and prevention of nosocomial infections are warranted to decrease the problem of readmissions for this group of elderly.

Premature discharge in a community hospital.

AIM: To determine the size of the problem of premature discharge in a community hospital (CH) and to ascertain the reasons for it. METHOD: A retrospective review of all admissions in year 2000 which resulted in premature discharge i.e. discharge within one week of admission, was conducted in a community hospital, St Luke's Hospital for the Elderly. Information collected on the selected cases included biodata, reason for CH stay, admitting diagnosis, source of admission, duration of stay and reason for terminating stay prematurely. For cases which required acute hospital transfer or ended in death in the CH, the type and day of onset of the respective medical problems were documented. RESULTS: Out of 924 admissions in year 2000, 12% resulted in premature discharge. Within this category of patients, 54% were discharged within the first three days and median duration of stay was three days. Majority of the admissions were for rehabilitation (83%) and respite care (15%). Neurological (60%) and orthopaedic (18%) problems constituted the bulk of the admitting diagnoses. The main reason for premature discharge was acute hospital transfer (90%) for medically unstable patients and those with unresolved medical problems. CONCLUSION: Premature discharge in the CH is an important issue and the greater cause lies in the need to transfer medically unstable patients or patients with unresolved medical problems back to the acute hospital. Stricter enforcement of admission criteria into CHs, increased vigilance on the part of acute hospitals and implementation of subacute care in CH can be solutions to the problem.

Wegener's granulomatosis in the elderly.

Wegener's granulomatosis classically involves the upper respiratory tract, lungs and kidneys. Rarely, it also affects the skin and heart. Cardiac involvement is uncommon in Wegener's granulomatosis and myocardial infarction is seldom highlighted. It can be a difficult diagnosis to make in the elderly who often have multiple co-existing illnesses. We present a case of a 75-year-old Chinese woman with interesting cardiac and dermatological manifestations of Wegener's granulomatosis.

Is euthanasia compatible with palliative care?

There has been a gradual shift in the attitude of the medical community as well as the lay public towards greater acceptance of euthanasia as an option for care of the terminally ill and dying. There have also been calls by certain groups to actually legalize voluntary euthanasia and physician-assisted suicide for patients who meet certain conditions, some of which are as follows: that the patient be of a sound mind, suffering from an incurable or terminal illness, experiencing unbearable suffering and uncontrollable pain. The rationale for legalizing euthanasia is based on the principle of the patient's right of self-determination and the duty of doctors to relieve pain and suffering at all times. A few within the medical community quickly saw certain similarities in terms of goals and aims between euthanasia and palliative care and, thus, proposed that euthanasia be an option or choice for difficult palliative care cases. Some even went as far as to suggest that euthanasia and palliative care be part of the continuum of care for terminally ill patients. When palliative medicine fails to fully control pain and suffering for the patient, euthanasia can be the logical next step in the continuum of care. This article seeks to discuss why the rationale for legalizing euthanasia is flawed, why euthanasia goes against the fundamental principles of Medicine in general and why it is incompatible with the practice of palliative medicine.

Functional status of the elderly in Singapore.

BACKGROUND: This study was done to look at prevalence and factors affecting functional dependence. The data in this paper were part of the 'Community Study on State of Health, Function, Cognitive and Social State of Elderly People in Singapore' conducted in Singapore between September 1992 and December 1993. PATIENTS: Four hundred and one elderly, aged 60 years and above were studied. Sixty-eight subjects (17%) were dependent in at least one function of Activities of Daily Living (ADL) as measured by the Barthel's Index (BI). RESULTS: The most common problem identified using this index was urinary incontinence. Forty subjects (10.4%) were dependent in at least one Instrumental Activities of Daily Living (IADL) function. The most common mode of transportation was by public transport, of which travelling by bus was the most common (59.9%) and mass rapid transit (MRT) was the least common (4%). Female gender and age > or = 75 were significant factors associated with dependence measured on Barthel's index but not on IADL. CONCLUSION: Results of this study were also compared with two previous surveys done in Singapore. Discrepancies in results noted could be attributed to different definitions in which the functions were assessed. We should aim to standardise the definition and measures of function in the local context in order to measure changes in the elderly population.

Self-perception of health among elderly community dwellers in Singapore.

Majority (90.5%) of the elderly living in the community in Singapore had a positive (satisfactory to good) perception of their health. This study found that age (70 years or older), recent hospitalisation, regular medical follow-up, hearing impairment, presence of chronic medical conditions (like musculo-skeletal problems, hypertension, ischaemic heart disease and chronic obstructive lung disease), impairment in activities of daily living, history of falls, those on regular medications and those with financial difficulties all adversely influenced perception of health. Those able to participate in regular outdoor leisure activities have a positive influence. Factors that did not significantly influence perception of health were gender, health-promoting activities, work, poor eyesight, cognitive impairment, urinary incontinence, diabetes, history of stroke and the ability to use public transport.

Preferred place of death--a local study of cancer patients and their relatives.

BACKGROUND: Knowing the preferred place of terminal care is helpful in the provision of services for the terminally ill. We carried out a survey of cancer in-patients and their relatives to determine the local preference for place of terminal care as well as the factors that affected their choice. METHODS: The study was conducted in the form of an interview survey on patients admitted to a general medical unit and a geriatric medicine unit. Relatives approached were the nearest kin (first degree relatives), or relatives living with the patients. Patients who were not aware of their diagnosis, who were unable to comprehend the questionnaire, or were too ill to participate were not interviewed. RESULTS: Fifty-two percent (23/44) of interviewed patients preferred to die at home if possible (compared to 34%, 15/44, who preferred the hospital). This is particularly so in the elderly and if there is assurance of domiciliary care. Relatives have an almost equal preference for the patient to be at home (45%, 35/77) or in the hospital (42%, 32/77) terminally. Given the support, more (37.5%, 12/32) of those who initially wanted their sick relatives to be in hospital would prefer them to spend their last days at home. CONCLUSION: There is a greater preference in cancer patients for terminal care at home. This is especially so for the elderly and if there is assurance of domiciliary care. This is an impetus for greater support of home care services.

A descriptive study of the demography, symptomology, management and outcome of the first 300 patients admitted to an independent hospice in Singapore.

The aims of this study were: 1) to describe the demography, symptomology, investigations conducted, non-pharmacological interventions and outcome of patients admitted to an inpatient hospice and 2) to identify the nursing and medical needs of terminally ill patients. Case-notes of the first 300 patients admitted to Dover Park Hospice were studied retrospectively. There were 159 men and 141 women making up 325 admissions. The racial distribution was: Chinese 95.0%, Malays 3.0%, Indians 1.3% and Others 0.6%. Two-thirds of the men (64.2%) had spouses while 44.7% of the women were widowed. The mean age was 64.7 years. The 3 most common cancers were lung (21.7%), colorectal (14.6%) and hepatobiliary (12.5%). A proportion of patients (39.5%) were not known to have any metastases. Most patients were referred from hospitals and the home-care based Hospice Care Association. The commonest reason for admission was for "terminal care" (57.2%). At admission, only 38% of the patients were aware of their diagnoses and prognosis while 30% did not know either. The average length of stay was 25 days with 7.7% of patients having more than one admission. The most common symptoms were pain, anorexia, breathlessness, insomnia, constipation and dry skin. Non-pharmacological interventions ranged from manual evacuation of the rectum to transfers to tertiary hospitals for surgery and other more invasive interventions. Many patients also attended day-care activities (23.1%). Outcome of the 325 admissions were as follows: went home 20%, died in the hospice 73.2%, went home to die 4.9% and others 1.8%.

Neuroimaging guidelines in cognitive impairment: lessons from 3 cases of meningiomas presenting as isolated dementia.

We report three cases of large intracranial meningiomas who presented with dementia alone and no accompanying focal neurological deficits. The meningiomas were detected solely as a result of a policy of routinely scanning the brains of patients presenting with early dementia. Dramatic improvements in the cognitive functions were noted following the excision of the tumours in two of the patients (the third passed away in the perioperative period). The implications of these cases with regard to deciding when to order a brain scan for patients presenting with isolated dementia are discussed in this article and a brief review of the relevant medical literature on this topic is also presented.

Epidemiology of falls among the elderly community dwellers in Singapore.

AIM: Falling is a serious medical problem for elderly persons. This study was done to look at prevalence and risk factors for falls in community dwelling elderly in Singapore. METHOD: A random sample of 3,000 persons aged 60 years and above was chosen from a database based on the 1990 population census. Letters were sent out to 2,582 subjects who had local and complete addresses. In the letter, they were informed about the purpose of the survey, and invited to participate in a questionnaire and clinical health screening at an appointed date at a polyclinic. Participants were reminded the day before their appointment by telephone, and a new appointment could be given at the subject's convenience. RESULTS: We found a prevalence rate of falls of 17.2%. Two-thirds of these had single falls, while one-third had recurrent falls, defined as having more than one fall within the previous one year. The following factors were found to be significantly associated with increase falling in the elderly: age > or = 75 years (O.R. = 1.82, 95% C.I. 0.95-3.50), female sex (O.R. = 2.5, 95% C.I. 1.40-4.48), Malay race (O.R. = 2.66, 95% C.I. 1.21-5.86), poor vision (O.R. = 1.7, 95% C.I. 0.99-2.90), Barthel's score of less than 20 (O.R. = 1.76, 95% C.I. 0.94-3.28), those taking 2 or more drugs daily (O.R. = 2.1, 95% C.I. 1.22-3.72) and the presence of hypertension (O.R. = 1.78, 95% C.I. 1.06-3.01). Fall rate is also twice as high in women as in men. At the same time, we found that women in the group we studied also tend to exercise less than the men. Fallers also had significantly more mobility and activities of daily living (ADL) disabilities (reflected by a lower Barthel's score) and this is consistent with other results. The only factor that reduced the risk of falling was regular exercise (O.R. = 1.64, 95% C.I. 0.93-2.93). CONCLUSION: In our study, we found differences between the group with single and recurrent falls. In the group with single falls, the fall tend to occur outdoors (O.R. = 2.97, 95% C.I. 1.03-8.60) and during the day (O.R. = 3.47, 95% C.I. 1.20-10.0), tend to be accidental (O.R. = 3.16, 95% C.I. 1.05-9.50) and tend to seek medical attention (O.R. = 3.68, 95% C.I. 1.23-11.0). Overall, 32 persons (46.4%) seek medical treatment after their falls, and of these, 65.6% were women. Risk factors for falls should be screened for all elderly.

Clinical utility of a portable ultrasound scanner in the measurement of residual urine volume.

BACKGROUND: Post-voiding residual urine volume is an important investigation in the management of voiding dysfunction. Catheterisation is widely regarded as the "gold" standard method of measurement. We investigated the performance of a portable ultrasound scanner (Bladder Scan BVI-2500), as an alternative method of measurement. METHODS: This study was prospective in nature. One hundred measurements of post-voiding residual urine volume by ultrasound were compared with measurements by catheterisation. RESULTS: The mean absolute error of the scanner was 52 mL. For volumes below 200 mL and 100 mL, this was 36 mL and 24 mL respectively. A decision regarding whether to decompress the bladder by catheterisation would have also been correct in 86% to 89% of instances, depending on the cut-off value of the residual volume used. In other words, the ultrasound measurement would have been correct in 9 out of 10 clinical cases. CONCLUSION: We recommend the routine use of portable ultrasound scanners of similar accuracy in the measurement of post-voiding residual urine volume.

Do-not-resuscitate orders: towards a policy in Singapore.

Despite the fact that the pioneers of cardio-pulmonary resuscitation (CPR) designed the techniques for victims who were meant to be "salvable", currently CPR is largely applied to anyone who collapses, regardless of their underlying illness. However, the central fact is that CPR (and all its related complex and expensive technology) has a very low success rate (in terms of eventual hospital discharge) and the most important determinant of survival has always been the nature and stage of the underlying illnesses. All these bespeak of a need to have do-not-resuscitate (DNR) orders which will incorporate the pertinent medical, ethical, socio-cultural and legal components. In this discussion paper some guidelines for DNR orders relevant to Singapore are proposed, the main rationale of the guidelines are explained and some challenges and needed changes associated with its implementation are addressed.

Dyspnoea in advanced malignancies: a palliative care approach.

The incidence of dyspnoea in advanced malignancies varies from 48-78.6% in different studies. A systematic approach enables the clinician to separate non-malignant causes from those due to complications of malignancy. Specific treatment should be considered for airway obstruction, secondary chest infection, pleural effusions and superior vena cava obstruction. Morphine remains the most effective drug and may be delivered either orally or by inhalation. Nebulised anaesthetics are alternatives, while the value of other drugs is uncertain. Oxygen therapy and treatment of anxiety are important components.