Ministry of health clinical practice guidelines: dementia.

The Ministry of Health (MOH) has updated the clinical practice guidelines on Dementia to provide doctors and patients in Singapore with evidence-based treatment for dementia. This article reproduces the introduction and executive summary (with recommendations from the guidelines) from the MOH clinical practice guidelines on Dementia, for the information of readers of the Singapore Medical Journal. Chapters and page numbers mentioned in the reproduced extract refer to the full text of the guidelines, which are available from the Ministry of Health website: http://www.moh.gov.sg/content/moh_web/healthprofessionalsportal/doctors/guidelines/cpg_medical/2013/cpgmed_dementia_revised.html. The recommendations should be used with reference to the full text of the guidelines. Following this article are multiple choice questions based on the full text of the guidelines.

Functional decline of the elderly in a nursing home.

INTRODUCTION: This study aims to determine if risk factors present on admission to the nursing home could be predictive of later functional decline and to determine the causes of decline. METHODS: This is a retrospective case-control study conducted in 2000 at a voluntary welfare nursing home. Functional decline was defined as deterioration in two or more of the five activities of daily living (ADLs), namely: mobility, toileting, bathing, dressing and feeding, from the time of admission to the study period. Potential risk factors for decline studied were: age, sex, marital status, number of medical diagnoses and medications, types of medical diagnoses, and the presence of dementia on admission to the home. Causes of decline were categorised as (A) Development of new illness, (B) Progression of chronic illness, or (C) Both of the above. RESULTS: 36 out of 103 residents had functional decline. On analysis, univariate and multivariable logistic regression models, adjusted for length of stay, yielded the same significant risk factors for decline, namely: age (p-value is 0.02) and dementia (p-value is 0.04). Majority of decline (78 percent) was due to progression of chronic illnesses, most commonly dementia (15 out of 36), eight percent were due to acute illness (stroke), and 14 percent were due to both. In January 2003, 18 out of the 36 residents who declined had died. CONCLUSIONS: Functional decline is common in the nursing home. More attention should be paid to the older residents and those with dementia, right from the point of admission.

Who are the residents of a nursing home in Singapore?

AIM OF STUDY: To describe the residents of a nursing home for the elderly in terms of their socio-demographic profile, mental and physical attributes, functional abilities and existing medical problems. METHOD: A random sample of 120 subjects was obtained from a total of 350 residents in a voluntary welfare nursing home. Two subjects were excluded as they did not satisfy inclusion criteria (age > or = 60 years). The subjects' biodata, social background, medical problems and functional status at the time of admission were obtained by a review of the case records. Each of the subjects was examined with attention to their general condition, hearing and vision, presence of postural hypotension, cognition and ability to perform basic activities of daily living (ADL). RESULTS: Results were available for 106 out of the 118 subjects as the rest were either discharged in the course of the study or had died. Single (36%), widowed (41%), female (71%) and age > or = 75 years (73%) consisted the majority. Most subjects (43%) were admitted because of both medical and social factors. Twenty-two percent appeared undernourished and of those who could be assessed, 14% had postural hypotension, 18% were hearing impaired and 53% had visual impairment. Fifty-two per cent suffered from mental problems while 46% and 40% had been diagnosed with hypertension and stroke respectively. Forty-eight percent had probable cognitive impairment (according to ECAQ scores) and 41% were very severely disabled (according to Barthel Index). Fifty-five percent were dependent in bathing, 50% dependent in dressing, 50% incontinent of urine (and requiring diapers), 48% were non-ambulant and 21% dependent in feeding. CONCLUSION: With a significant proportion of the population requiring nursing home care in the future, a closer review of the situation is needed. This study has identified malnutrition, urinary incontinence, falls, functional decline and impaired vision/hearing as issues that deserve greater attention and, where necessary, intervention. Whether implementing recognised effective interventions will truly benefit our nursing home residents would warrant more local studies.

Nursing home falls: a local perspective.

INTRODUCTION: This study aims to examine the demography of falls, factors that contribute to falls and fall risk factors in residents of a nursing home for the elderly in Singapore. MATERIALS AND METHODS: An 18-month follow-up study was carried out on 95 nursing home residents. Information on the subjects' potential risk factors for falls was obtained through a review of their casenotes and physical examination. At the end of the study period, the casenotes were reviewed for any documented fall, the circumstances surrounding each fall and whether complications resulted from the fall. The likely factors and events associated with each fall were categorised where possible. Logistic regression was performed to determine the risk factors for falls. Subjects who died or were discharged during the study were included in the analysis. RESULTS: Several subjects (72.6%) were > or = 75 years old, required assistance in activities of daily living (71.6%), cognitively impaired (52.6%), diagnosed with mental illness (49.5%) and non-ambulant (43.2%). A total of 63 falls contributed by 38 (40%) subjects were documented over 18 months, giving an incidence of 0.5 fall per bed year. Thirteen (20.6%) injuries resulted from the falls, of which 3 were fractures. Falls associated with both intrinsic and extrinsic factors were identified in 38.1% of falls. The most common intrinsic factors were gait disorders (31.7%) and confusion/difficult behaviour (31.7%). Contributory extrinsic factors include wheelchair/commode (22.2%) and bathroom-related (15.9%) incidents. Most falls occurred during ambulation (31.7%) and transfers (17.5%). On multivariate logistic regression, the only significant risk factors for falls were "need for ambulatory aids" (odds ratio, 24.4) and "cognitive impairment" (odds ratio, 8.1). CONCLUSION: The study confirms that falls are common amongst elderly in a local nursing home. Residents with gait instability and behavioural problems due to underlying dementia or mental illnesses are most at risk. Extrinsic factors, such as bathroom activities and the use of wheelchair/commodes, are contributory. Thus, falls reduction protocols in nursing homes should include behavioural measures, enhanced care practices and environmental modifications to be effective.

A three year review on surgical treatment of tubo-ovarian abscess.

The authors made a 3-year retrospective study of cases of tubo-ovarian abscess surgically treated in KK Women's and Children's Hospital. In the period studied (1998 through 2000), there were 36 such cases. A total of 11 patients underwent laparoscopic treatment while 25 patients underwent laparotomy. The study demonstrates the differences in the patient profile and the short term morbidity in each mode of surgical treatment and the changing trends in the surgical treatment of tubo-ovarian abscess.

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.

Hypodermoclysis or subcutaneous infusion revisited.

AIM OF STUDY: To review the use of hypodermoclysis in a local Hospice. METHOD: A review of all hypodermoclysis carried out over a six-month period was conducted. Special attention was paid to the reason for starting and stopping the drip, duration of the drip, complications, the type and amount of solution infused. RESULTS: Fifty-one (19%) out of 266 patients received hypodermoclysis during their stay. This constituted 5.9% of total patient-days in the study period. Vomiting and drowsiness were the main reasons for the use of drip. The commonest reason for stopping the drip was patient demise. Complications seen were drip site redness (16%), extravasation (15%) and bleeding (2.5%) There was no overt clinical sepsis in any of the patients. CONCLUSION: Hypodermoclysis is an easy and convenient means of providing hydration. The availability of a standard protocol with clearer guidelines on its use will help to reduce procedure-related complications and promote wider adoption of the practice.

Laparoscopy-guided percutaneous cholecystolithotomy: an evolving technique.

Gall-bladder conservation therapy has been evolving during the past decade. Popular techniques of conservative therapy are extracorporeal shock wave lithotripsy (ESWL) and medical dissolution therapy. The limitations of these procedures have prompted a search for alternative techniques, particularly in relation to percutaneous stone extraction. The cases of four patients with symptomatic gallstones who underwent percutaneous cholecystolithotomy under laparoscopic guidance are reported. The gall-bladder was punctured with a long needle and the tract dilated so that a nephroscope could be introduced. Three cases required stone fragmentation by an ultrasonic lithotripter before removal. Postoperative recovery was uneventful in all cases.