RESUMO
Often, the provisional diagnosis for an elderly patient who arrives at the hospital with confusion is presumed to be delirium stemming from confusion usually caused by an infectious cause. The famous mnemonic PINCH ME signifies the ruling out of pain, infection (that usually has a urinary cause), constipation, dehydration, medication (particularly narcotics), and the environment (factors triggering confusion in a patient with a background of dementia). However, we report a rare case of sudden confusion in an elderly male with no previous history of cognitive impairment. This is the first ever reported case to the best of our knowledge of a patient that presented with sudden confusion, impaired extraocular mobility, and spontaneous cranial hemorrhage that was ultimately determined to be due to a hypothalamic and/or a pituitary cause. It signifies a need for prompt evaluation to arrive at an early diagnosis. Additionally, we hope this case report would serve as a guide to look beyond the current mnemonic of PINCH ME and instead to a new mnemonic of 'PINCH ME HOT' where the latter most mnemonic connotes the need to look at a hypothalamic/pituitary, ocular, or traumatic origin for the delirium.
RESUMO
Medically led, patient-centred, future care planning for patients predicted to be in their last year of life is possible on the complex care ward of an acute hospital, where patients often wait for social care placement into a nursing home. When the patient lacks the mental capacity to engage in the planning discussions themselves, meetings can take place between the multidisciplinary geriatric team and either those close to the patient or an independent mental capacity advocate. Participants in the meeting should use any existing advance care planning information, as appropriate, to develop 'best interests advice' (which can be referred to at a later date when a best interests decision needs to be made for the patient). Any future medical care plan should be reviewed for applicability and validity if the person's condition changes (improves or deteriorates), if the patient or those close to the patient request it, or 6-12 months after the initial plan is made. Education, training and support must be provided to ensure acceptance and understanding of the PEACE (PErsonalised Advisory CarE) process and general end of life care in the community. Specialist palliative care services are often best placed to provide this.
RESUMO
There is a large evidence base for nutritional intervention in acutely ill and post-operative hospitalised patients, but the evidence base for nursing home (NH) residents is small. The prevalence of poor nutrition in NHs is high and baseline nutrition appears to be an important determinant of response to nutritional intervention. Residents with mininutritional assessment (MNA) scores above 23.5 tend to show less response than those with lower scores. This relates in part to failure to increase intake in the better nourished as well as to actual response to increased intake. At the low end of the MNA spectrum, the increasing prevalence of multiple pathologies tends to result in a reduced response, but randomised controlled studies in this group is probably not ethical. Most studies have tended to investigate the intermediate group with MNA scores of 17-23.5 or equivalent using other scales. Interventions have usually resulted in increased intake of calories and micronutrients. Other end points have variously shown responses including weight, immunological measures, infection rates, decubitus ulcers, falls and fracture rates. Many studies have been too small to demonstrate benefit and some are likely to have suffered from type l errors - showing benefit by chance. Poorly quantifiable variables likely to be of importance include the local environment and catering as well as pathophysiological variability.
