Low-impact (compliant) flooring and staff injuries.

INTRODUCTION: Low impact flooring (LIF) has shown potential for reducing fall-related injuries for older people in residential care or hospital environments. However, the increased rolling resistance when moving equipment on these floors has raised concerns that staff injuries may increase. METHODS: LIF was trialled on one Older Persons Health ward for 2.5 years. Reported staff injuries were monitored during and following the trial. Numbers of staff injured on the LIF ward were compared with three other similar and adjacent OPH wards without LIF for the duration of the trial ('concurrent control' evaluation). At the trial conclusion the LIF ward moved to a different hospital that had standard flooring. This enabled a further 'during and after' evaluation where numbers of staff injured from the LIF ward during the trial were compared with those reported afterwards by the same ward staff without LIF. RESULTS: There was no difference in the numbers of staff injured in the LIF ward compared with the concurrent control wards (28 LIF vs 30 control; p = 0.44). The number of staff with injuries in the LIF ward also did not significantly alter when those staff moved to a new ward without LIF (45 after vs 28 before; p = 0.11). CONCLUSION: There was no change in the numbers of staff with injuries during the LIF trial in an Older Persons Health ward. This small study suggests LIF appears safe for both patients and staff.Implications for rehabilitationFalls in hospital are common with patient injuries occurring in approximately 20-30% of falls.Low impact (compliant) flooring may reduce fall-related injuries in hospitals and residential care.Low impact flooring has an increased rolling resistance, which has the potential to increase staff injuries when moving equipment.This study found no change in the number of staff injured during a low impact flooring trial providing some reassurance that these floors are safe for staff.

Warfarin-related intracerebral haemorrhage: better outcomes when reversal includes prothrombin complex concentrates.

BACKGROUND: Warfarin-related intracerebral haemorrhage (WRICH) has high mortality. Haematoma expansion is prolonged in WRICH and independently predicts worse outcomes. Guidelines recommend prompt reversal of the warfarin coagulopathy, but evidence of benefit is lacking. AIMS: To determine whether the introduction of a WRICH reversal protocol (late 2008), which includes prothrombin complex concentrates (PCC), improves outcomes METHODS: All patients presenting with WRICH between January 2004 and July 2010 were included. Retrospective case note and radiology review was performed, collecting data on intracerebral haemorrhage (ICH) severity, degree and timeliness of reversal, and patient outcomes. Cox's proportional hazards analysis was used to compare outcomes associated with and without PCC after controlling for ICH severity. RESULTS: Eighty-eight patients were included (27 treated palliatively). Mean international normalised ratio was 2.9. Vitamin K, PCC and fresh frozen plasma were given alone or in combination to 68, 23 and 44 patients, and mean time from computed tomography scanning to administration was 2.2, 3.3 and 3.1 h respectively. Four patients received PCC pre-protocol (none before 2007), two during development and seventeen patients post-protocol. Those who received PCC had improved survival (P < 0.001). After controlling for ICH score, hazard ratio for death was 0.27 (P < 0.01) for use of PCC. Survival tended to be greater with earlier administration of PCC (P = 0.053). Despite improved survival, discharge domicile and function were not significantly worse. CONCLUSIONS: PCC reversal was associated with improved survival without worsened disability. Delays in administration may have reduced the potential benefits.

Stroke discharges from a rehabilitation unit: 1-year and 5-year domicile outcomes. Function is important.

BACKGROUND: Stroke units save lives, reduce disability and increase the chances of the person returning to their own home. Following the introduction of a stroke rehabilitation unit, we assessed the durability of stroke discharges over a 1-year period and predictors of early 'failed' home discharges. Stability of discharge domicile and survival over 5 years was also reviewed. METHODS: A 6-month cohort of all discharges was followed for 5 years. Changes in domicile, including entry into institutional care, were recorded out to 5 years or until death. Predictors of early (3 months) and later (1 year) discharge stability were assessed. RESULTS: There were 142 discharges. Fifty-eight (76%) of those who returned home were still at home 12 months later. In contrast, there was a high mortality of dependent patients who were discharged to high dependency care (9 (29%) and 13 (42%) at 3 and 12 months, respectively). The chance of an early failed discharge was associated with lower functional ability on discharge (P= 0.012). Lower function on discharge was also independently associated with death in the next 12 months (P < 0.0001). At 5 years the mortality for the whole sample was 55% (78 of 141) and 38 (61%) of the survivors still lived in the community whereas 24 (39%) resided in institutional care. CONCLUSION: Functional ability on discharge is a key predictor of ability to remain at home as well as survival and therefore every effort should be made to maximize function.

Predictors of discharge stability in the first year following hospital admission for a frail elderly population.

The frail elderly are a group of patients who are at high risk of institutionalization and death. Specialist older person's health care aims to maximize function and independence. However, there is little published work on the long-term outcomes following hospitalization in a frail elderly population. This study examines the outcomes in the first year after hospitalization for this group. We find that 62% are able to remain in their own homes and that functional status is the strongest predictor of outcome, with age and living arrangements also significant.

The risk of recurrent stroke after intracerebral haemorrhage.

BACKGROUND AND AIM: The risks of recurrent intracerebral haemorrhage (ICH) vary widely (0-24%). Patients with ICH also have risk factors for ischaemic stroke (IS) and a proportion of ICH survivors re-present with an IS. This dilemma has implications for prophylactic treatment. This study aims to determine the risk of recurrent stroke events (both ICH and IS) following an index bleed and whether ICH recurrence risk varies according to location of index bleed. PATIENTS AND METHODS: All patients diagnosed with an acute ICH presenting over an 8.5 year period were identified. Each ICH was confirmed by reviewing all of the radiology results and, where necessary, the clinical case notes or post-mortem data. Recurrent stroke events (ICH and IS) were identified by reappearance of these patients in our stroke database. Coronal post-mortem results for the same period were also reviewed. Each recurrent event was reviewed to confirm the diagnosis and location of the stroke. RESULTS: Of the 7686 stroke events recorded, 768 (10%) were ICH. In the follow-up period, there were 19 recurrent ICH and 17 new IS in the 464 patients who survived beyond the index hospital stay. Recurrence rate for ICH was 2.1/100 in the first year but 1.2/100/year overall. This compares with 1.3/100/year overall for IS. Most recurrences were "lobar-lobar" type. CONCLUSION: The cumulative risk of recurrent ICH in this population is similar to that of IS after the first year.

Secondary prevention of fractures in older people: evaluation of a protocol for the investigation and treatment of osteoporosis.

It has been found previously that the investigation and treatment of osteoporosis following a fracture is poor, with only 9% of older people after a fracture being on effective osteoporosis treatment. To improve this aspect of post-fracture care in older people, a protocol has been instituted on an orthogeriatric rehabilitation ward in Christchurch, New Zealand. An audit was performed to assess the efficacy of this protocol in improving the investigation and treatment of osteoporosis (n = 193). Compliance with the investigation protocol was assessed and the pharmacological therapy initiated was requested from the general practitioner. All recommended blood-test investigations were requested in 62.8% of cases. Compared to a pre-protocol population, there was a marked increase in the measurement of bone mineral density (BMD; 93 vs 11%, P < 0.01) and vitamin D (95 vs 12%, P < 0.01). Vitamin D levels were low/-borderline in 95.6% of cases. BMD was performed in 77.7% of cases and showed osteoporosis and osteopenia to be present in 78.6 and 14.0%, respectively. For the 60 patients with BMD-confirmed osteoporosis whose therapy was obtained, 13.3% had no pharmacological therapy prescribed. Calcium, vitamin D or both were prescribed in 85.0%, bisphosphonates in 50.0% and hormone replacement therapy in 1.7% of patients. Vitamin D deficiency and osteoporosis on the basis of the BMD result are very common. The institution of a protocol has shown a significant improvement in the management of osteoporosis following a fracture. Some of the multifactorial barriers to full implementation of the guidelines are described.

A randomized controlled trial of strapping to prevent post-stroke shoulder pain.

OBJECTIVE: To determine whether strapping the shoulder in hemiplegic stroke patients: (1) prevents the development, or reduces the severity, of shoulder pain, (2) preserves range of movement in the shoulder, and (3) improves the functional outcomes for the arm and patient overall. DESIGN: A prospective, randomized, single-blind controlled trial of shoulder strapping versus no strapping. SETTING: Care of the elderly wards in a teaching hospital, Christchurch, New Zealand. SUBJECTS: All patients admitted with an acute hemiplegic stroke, who had persisting weakness of shoulder abduction. INTERVENTION: The treatment group had their affected shoulder strapped for six weeks from randomization in addition to standard physiotherapy. MAIN OUTCOME MEASURES: All subjects were assessed at entry (week 0), at end of the treatment phase (week 6) and two months later (week 14). A visual analogue scale (VAS) was used to assess shoulder pain severity whereas shoulder range of movement to the point of pain (SROMP) assessed passive range of movement and pain. Functional Independence Measure (FIM), Motor Assessment Scale (MAS) and Rankin Disability Index measured functional outcomes. RESULTS: Ninety-eight subjects participated (49 strapped, 49 controls). Intention to treat analysis showed no significant difference in pain, range of movement or functional outcomes after the intervention phase or at the final assessment. However there were trends for less pain at six weeks (VAS, p = 0.11) and better final upper limb function (MAS, p = 0.16) in strapped patients. Skin reactions were uncommon (6.1%). The presence of neglect or sensory loss, but not subluxation, at baseline was independently associated with poor outcome. Range of movement was lost early (mean difference SROMP between hemiplegic and contralateral shoulders at baseline = 15.2 degrees (95% CI 10.9-19.5)) and continued throughout the study. Shoulder strapping did not alter the rate at which range of movement was lost. CONCLUSIONS: No significant benefit with shoulder strapping was demonstrated and reasons for this are discussed. Range of movement in the hemiplegic shoulder is lost very early and any preventive treatments need to begin within the first 1-2 days after a stroke.

Stroke patients' views on stroke outcomes: death versus disability.

AIMS: To determine how elderly stroke patients perceive different stroke outcomes, including death, relative to each other and how these views compare with those of age/sex-matched controls. PARTICIPANTS AND SETTING: Twenty-eight elderly patients discharged from hospital with an acute stroke causing hemiplegia. Twenty-eight age/sex-matched control patients from the same hospital who had never had a stroke or transient ischaemic attack. METHODS: Patients and controls were asked to rank 11 clinical scenarios of potential stroke outcomes, from the most to the least desirable outcome. RESULTS: There was a striking bimodal distribution for sudden painless death in both groups. Painless death was preferred to even a minor stroke disability in over one-third of elderly individuals, whilst 20% would prefer severe disability rather than painless death. Sixty-nine per cent of stroke patients and 82% of controls ranked death as preferable to severe disability. Stroke patients may be more tolerant of disability (compared to death) than their controls (39% patients and 61% controls preferred death to any disability, p = 0.11). CONCLUSIONS: Our results suggest that many elderly individuals would rather die than be alive and severely disabled. This may have important implications for acute stroke treatments such as thrombolysis.

Is thiamine deficiency in elderly people related to age or co-morbidity?

OBJECTIVES: to compare erythrocyte thiamine pyrophosphate concentrations in elderly people with those in healthy younger people; to determine if any differences can be attributed to age or to co-morbidities. DESIGN: cross-sectional and 3-year longitudinal surveys. SETTING: primary care. PATIENTS: 100 volunteer blood donors and 222 elderly people from a general practice register. MEASUREMENTS: thiamine pyrophosphate concentrations using high performance liquid chromatography; physical examination, medical and medication history; grip strength, body mass index and plasma albumin. RESULTS: the mean [95% confidence interval (CI)] thiamine pyrophosphate concentration was 152 nmol/l (147-158) in the elderly group and 224 (213-235) nmol/l in the younger group (P < 0.001). Ninety-six (43.4%) of the elderly subjects had thiamine pyrophosphate concentrations below the fifth percentile of the younger subjects (140 nmol/l). Over 3 years thiamine pyrophosphate concentrations fell in the elderly cohort by 20% (95% CI: 14.5-24.5%; P < 0.01). Thiamine pyrophosphate concentrations in 39 healthy older people were no different from those in elderly people with co-morbidity but were significantly lower than those in the younger people. Elderly people with absent vibration sense in their feet had a lower thiamine pyrophosphate concentration than the rest of the group [129 (117-142)nmol/l compared with 156 (150-162)nmol/l; P < 0.01)]. Thiamine pyrophosphate concentrations were not related to prevalent diseases, common medications, body mass index, grip strength or plasma albumin. CONCLUSION: lower thiamine pyrophosphate concentrations in elderly people appear to be related more to age itself than to co-existent illnesses.

An analysis of falls in the hospital: can we do without bedrails?

OBJECTIVES: To determine the effects of introduction of a bedrail policy, and an educational program, on patient falls and fall-related injuries. DESIGN: A prospective "Before and After" design. PARTICIPANTS AND SETTING: All patients admitted during 1 calendar year in an assessment, treatment, and rehabilitation unit for older people. INTERVENTION: A policy change for the use of bedrails (restricting their use) and an educational program about their effects. MEASUREMENTS: Patient fall rates -- all falls and around the bed falls -- and patient and staff injuries. RESULTS: There was a significant reduction in the number of beds with bedrails attached after the policy introduction (mean of 40/135 vs 18.5/135, respectively, P = .02), but the fall rate (either total or around the bed) did not change significantly. Serious injuries were significantly less common after the bedrail policy was introduced (P = .008), with fewer head injuries. CONCLUSIONS: Reducing the use of bedrails did not alter patient fall rates significantly, but it was associated with a reduction in serious injuries. Unless it can be shown that bedrails are beneficial, their continued use in older patients must be seriously questioned.

The prevalence of malnutrition in elderly hip fracture patients.

AIM: To determine the prevalence of protein and energy malnutrition in elderly patients with a fracture of the proximal femur, in New Zealand. METHODS: Consecutive elderly patients (65 years and over) admitted to Christchurch Hospital with a fracture of the proximal femur over a four-month period were recruited. Nutritional indices were measured within three days of admission. These included triceps skinfold thicknesses, mid upper arm circumference, serum albumin and pre-albumin. RESULTS: Forty-two per cent of patients had at least two, and nine per cent had three, indicators of protein and energy malnutrition present on admission. There was no significant difference in the prevalence of malnutrition between young old (<80 years) and old old (80 years and over) patients. Patients residing in an institution had lower mean protein reserves, as indicated by lower corrected arm muscle area (p=0.003) and pre-albumin levels (p=0.09), than those living in the community. A drink, rather than a pudding or biscuit, was the preferred protein and energy supplement form. Ensure Plus (lactose-free) and Fortisip (lactose-free) were the most preferred drink supplements. CONCLUSION: Protein and energy malnutrition is common in elderly New Zealanders who fracture their femur. The prevalence is comparable to overseas data. These patients prefer nutritional supplementation given as a drink.

What do patients and their carers want to know about stroke? A two-year follow-up study.

OBJECTIVE: To clarify what issues are important to stroke patients and their carers. To determine whether these issues change over time. DESIGN: Prospective study of consecutive patients admitted to hospital with a diagnosis of an acute stroke. Each participant had interviews at six and 24 months. In addition, a subgroup of these patients (consecutive discharges over a two-month period) were also seen at two weeks post discharge. SETTING AND SUBJECTS: Hospital-based cohort of stroke survivors. Interviewed in their own homes. MAIN OUTCOMES MEASURES: Documentation of the questions asked. RESULTS: At two weeks, six and 24 months, a median of three, two and three questions were asked by each patient respectively. Enquiries about basic aspects of stroke were common but diminished over time. Fear of recurrence was apparent at all three interview periods. Enquiries about the psychological sequelae of stroke became more prevalent at six and 24 months. At two years, 32% of respondents asked about concentration/memory difficulties with smaller numbers commenting on tiredness, depression and frustration. At two years, 18% of the sample were still uncertain of their chances of further recovery. CONCLUSIONS: Patients with stroke continue to have unanswered questions even two years after their stroke. The types of questions asked changed over time.

The response to treatment of subclinical thiamine deficiency in the elderly.

The significance of subclinical thiamine deficiency in the elderly was determined by assessing response to thiamine supplementation in a randomized double-blind, placebo-controlled trial. Thirty-five of 222 people aged > or = 65 y had two concentrations of erythrocyte thiamine pyrophosphate (TPP) < 140 nmol/L 3 mo apart and 41 other people had the first, but not the second, TPP concentration below this value. Both groups were randomly assigned in a double-blind trial to oral thiamine (10 mg/d) or a placebo. All subjects randomly assigned to receive thiamine showed increases in TPP concentrations compared with control subjects. Only the subjects with persistently low TPP concentrations showed subjective benefits from treatment with improvements in quality of life (measured on a visual analogue scale; P = 0.02) and decreases in systolic blood pressure (P = 0.05) and weight (P < 0.01) when compared with subjects given placebo. There was a trend toward benefits in sleep and energy (P = 0.07). We conclude that a low TPP concentration on two occasions is a better predictor of response to treatment than an isolated measurement. Quality of life was enhanced by providing thiamine supplements. Blood pressure and weight were lower after thiamine supplementation.