A community study of the prevalence of restless legs.
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Adult↗
Biomedical subjects
S T O'Keeffe
Publications and source records attributed to S T O'Keeffe.
Nocturnal leg cramps in older people.
Nocturnal leg cramps are common in older people. Such cramps are associated with many common diseases and medications. Physiological methods may be useful for preventing cramps in some people, but there have been no controlled trials of these approaches. Quinine is moderately effective in preventing nocturnal leg cramps. However, there are concerns about the risk/benefit ratio with this drug. In patients with severe symptoms, a trial of 4-6 weeks' treatment with quinine is probably still justified, but the efficacy of treatment should be monitored, for example using a sleep and cramp diary.
Aged↗
Development and implementation of resuscitation guidelines: a personal experience.
OBJECTIVES: to develop and implement guidelines on the appropriate use of cardiopulmonary resuscitation, which would ensure patient involvement in decision-making about cardiopulmonary resuscitation whenever possible but without offering illusory choices where resuscitation was unlikely to succeed. DESIGN: quantitative guidelines were developed after a review of the literature on survival after cardiopulmonary resuscitation. Patients were classified according to their estimated likelihood of survival to discharge after resuscitation: < 1%, group A; 1-10%, group B; and > 10%, group C. Qualitative guidelines were developed after consideration of the legal and ethical principles of cardiopulmonary resuscitation. It was decided to inform competent patients in group A that cardiopulmonary resuscitation would be inappropriate, and to seek the preferences of competent patients in group B. The operation of the guidelines was examined in patients aged 65 years or more admitted under a single consultant in an acute community hospital. RESULTS: 147 patients were studied: 39 in group A, 26 in group B and 82 in group C. Of 36 patients in groups A and B judged competent, cardiopulmonary resuscitation discussions were only undertaken in 17, usually because acute distress or anxiety precluded effective communication. Of the 23 patients or family members from whom cardiopulmonary resuscitation preferences were sought, four opted for full cardiopulmonary resuscitation and six for limited cardiopulmonary resuscitation (usually witnessed-arrest only and no ventilation). CONCLUSION: it is difficult to involve acutely ill elderly patients in cardiopulmonary resuscitation decision-making. Limited cardiopulmonary resuscitation is a useful option for patients, relatives and doctors.
Aged↗
Autonomy vs welfare? Anatomy of a risky discharge.
Questions about competence are often encountered when considering whether an elderly person with disability or cognitive impairment should return to their own home. This paper discusses the issues raised by one such case. It is argued that autonomy is a good in itself, whether or not it advances welfare. Hence, unless incompetence is clearcut, patients who wish to go home must go home, regardless of whether or not health care professionals view this as the best or safest choice.
Accidents, Home↗
Thiamine deficiency in elderly people.
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Aging↗
Development and validation of a brief observer-rated screening scale for depression in elderly medical patients.
OBJECTIVE: to develop a depression screening scale that does not rely on verbal communication. SETTING: an acute geriatric unit in a teaching hospital. SUBJECTS: 96 patients (mean age 81 years, range 68-92, 59 women); 40% of the initial study group of 50 and 22% of the validation group of 46 were diagnosed as depressed. METHODS: we devised a scale using nine items which could be rated by an observer; we determined inter-rater reliability, sensitivity, specificity and predictive values for each item compared with a Geriatric Mental State-AGECAT diagnosis of depression; we validated a final scale of six items. RESULTS: inter-rater reliability was poor for two items (irritability and sleep disturbance) while two items (sleep disturbance and night sedation) had poor sensitivity; we omitted these items in a revised scale. Re-analysis of data from the initial study showed that a cut-off of > or = 3 on the revised scale gave a sensitivity of 83%, a specificity of 95%, a positive predictive value of 0.89 and a negative predictive value of 0.90. Spearman's correlation coefficient between the six-item questionnaire and the Hamilton rating scale was 0.79. In the validation study, the cut-off score of > or = 3 on the revised six-item scale had a sensitivity of 90%, specificity of 72%, a positive predictive value of 0.69 and a negative predictive value of 0.96. CONCLUSIONS: this simple, short, observation-based screening scale completed by nurses is sensitive and specific in identifying depression in elderly medically ill patients, and may be a useful addition to clinical practice.
Aged↗
Telling the truth about cancer: views of elderly patients and their relatives.
The aim of this study was to compare the attitudes of elderly patients and their relatives towards telling the truth about cancer. 120 patients were asked if they would wish to be told about bad news, such as cancer, which might emerge during the admission. Matched relatives were asked if such information should be disclosed to the patient. Of the 120 patients, 99 (83%) wanted to be told the truth; 66 relatives (55%) relatives wanted their next of kin informed. There was agreement in 73 (61%) pairs. The kappa statistic was 0.16 (95% confidence interval -0.03 to 0.35), which indicates poor agreement. We conclude that most elderly people wish to be informed of a diagnosis of cancer. Patient preferences cannot be predicted by talking to relatives.
Age Factors↗
Clinical significance of delirium subtypes in older people.
OBJECTIVE: to examine the relative frequency and outcome of clinical subtypes of delirium in older hospital patients. DESIGN: prospective observational study. SETTING: acute geriatric unit in a teaching hospital. SUBJECTS: 94 patients with delirium from a prospective study of 225 admissions. MEASUREMENTS: clinical subtypes of delirium were determined according to predefined criteria. Characteristics examined in these subgroups included illness severity on admission, prior cognitive impairment, mortality, duration of hospital stay and hospital-acquired complications. RESULTS: of the 94 patients, 20 (21%) had a hyperactive delirium, 27 (29%) had a hypoactive delirium, 40 (43%) had a mixed hypoactive-hyperactive psychomotor pattern and seven (7%) had no psychomotor disturbance. There were significant differences between the four groups in illness severity (P < 0.05), length of hospital stay (P < 0.005) and frequency of falls (P < 0.05). Patients with hypoactive delirium were sicker on admission, had the longest hospital stay and were most likely to develop pressure sores. Patients with hyperactive delirium were most likely to fall in hospital. There were no differences in aetiological factors between the groups. CONCLUSION: outcomes of hospitalization differ in different clinical subtypes of delirium.
Aged↗
Drug-induced cognitive impairment in the elderly.
Elderly people are more likely than younger patients to develop cognitive impairment as a result of taking medications. This reflects age- and disease-associated changes in brain neurochemistry and drug handling. Delirium (acute confusional state) is the cognitive disturbance most clearly associated with drug toxicity, but dementia has also been reported. The aetiology of cognitive impairment is commonly multifactorial, and it may be difficult to firmly establish a causal role for an individual medication. In studies of elderly hospital patients, drugs have been reported as the cause of delirium in 11 to 30% of cases. Medication toxicity occurs in 2 to 12% of patients presenting with suspected dementia. In some cases CNS toxicity occurs in a dose-dependent manner, often as a result of interference with neurotransmitter function. Drug-induced delirium can also occur as an idiosyncratic complication. Finally, delirium may occur secondary to iatrogenic complications of drug use. Almost any drug can cause delirium, especially in a vulnerable patient. Impaired cholinergic neurotransmission has been implicated in the pathogenesis of delirium and of Alzheimer's disease. Anticholinergic medications are important causes of acute and chronic confusional states. Nevertheless, polypharmacy with anticholinergic compounds is common, especially in nursing home residents. Recent studies have suggested that the total burden of anticholinergic drugs may determine development of delirium rather than any single agent. Also, anticholinergic effects have been identified in many drugs other than those classically thought of as having major anticholinergic effects. Psychoactive drugs are important causes of delirium. Narcotic agents are among the most important causes of delirium in postoperative patients. Long-acting benzodiazepines are the commonest drugs to cause or exacerbate dementia. Delirium was a major complication of treatment with tricyclic antidepressants but seems less common with newer agents. Anticonvulsants can cause delirium and dementia. Drug-induced confusion with nonpsychoactive drugs is often idiosyncratic in nature, and the diagnosis is easily missed unless clinicians maintain a high index of suspicion. Histamine H2 receptor antagonists, cardiac medications such as digoxin and beta-blockers, corticosteroids, non-steroidal anti-inflammatory agents and antibiotics can all cause acute, and, less commonly, chronic confusion. Drug-induced confusion can be prevented by avoiding polypharmacy and adhering to the saying 'start low and go slow'. Special care is needed when prescribing for people with cognitive impairment. Early diagnosis of drug-induced confusion, and withdrawal of the offending agent or agents is essential.
Aged↗
Reproducibility and responsiveness of quality of life assessment and six minute walk test in elderly heart failure patients.
OBJECTIVE: To examine the reproducibility and responsiveness to change of a six minute walk test and a quality of life measure in elderly patients with heart failure. DESIGN: Longitudinal within patient study. SUBJECTS: 60 patients with heart failure (mean age 82 years) attending a geriatric outpatient clinic, 45 of whom underwent a repeat assessment three to eight weeks later. MAIN OUTCOME MEASURES: Subjects underwent a standardised six minute walk test and completed the chronic heart failure questionnaire (CHQ), a heart failure specific quality of life questionnaire. Intraclass correlation coefficients (ICC) were calculated using a random effects one way analysis of variance as a measure of reproducibility. Guyatt's responsiveness coefficient and effect sizes were calculated as measures of responsiveness to change. RESULTS: 24 patients reported no major change in cardiac status, while seven had deteriorated and 14 had improved between the two clinic visits. Reproducibility was satisfactory (ICC > 0.75) for the six minute walk test, for the total CHQ score, and for the dyspnoea, fatigue, and emotion domains of the CHQ. Effect sizes for all measures were large (> 0.8), and responsiveness coefficients were very satisfactory (> 0.7). Effect sizes for detecting deterioration were greater than those for detecting improvement. CONCLUSIONS: Quality of life assessment and a six minute walk test are reproducible and responsive measures of cardiac status in frail, very elderly patients with heart failure.
Aged↗
Assessing attentiveness in older hospital patients: global assessment versus tests of attention.
OBJECTIVES: Impairment of attentiveness is a cardinal symptom of delirium. We examined the relationship between bedside tests of attention and a global rating of attentiveness in older hospital patients and sought to identify cut-off points on the tests of attention that might be helpful in the diagnosis of delirium. SETTING AND PARTICIPANTS: Subjects were 110 patients admitted to an acute geriatric unit. MEASUREMENTS: Subjects were assessed by two physicians. One physician rated global attentiveness on a 10-cm visual analog scale following general conversation with the patient. The second physician determined whether patients met DSM-3 criteria for delirium or dementia and administered four tests of attentiveness: Digit Span Forwards (DSF), Digit Span Backwards (DSB), Vigilance "A' test (VAT), and a timed Digit Cancellation Test (DCT). MAIN RESULTS: Of the 87 patients who completed the study, 18 were delirious and 17 demented. There was no difference between demented and delirious patients on the VAT, DSF, or MMSE tests; other comparisons between demented and delirious patients and between delirious patients and those with neither delirium nor dementia were significant. All tests of attention except DSF were significantly correlated with the global rating. CONCLUSION: Simple bedside tests of attention can aid identification of delirium.
Aged↗
The neuropathogenesis of delirium.
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Brain↗
DNR orders in acute stroke.
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Acute Disease↗
Restless legs syndrome. A review.
Restless legs syndrome is characterized by unpleasant, deep-seated paresthesias in the legs and sometimes the arms. These sensations occur at rest and are relieved by movement. Sleep disturbance is common. Many patients also have periodic movements of sleep. Mild symptoms of restless legs occur in up to 5% of the population. Restless legs syndrome is idiopathic in most patients, but it may be the presenting feature of iron deficiency and is also common in uremia, pregnancy, diabetes mellitus, rheumatoid arthritis, and polyneuropathy. Treatment of the underlying cause, when possible, usually relieves the symptoms. For patients with severe symptoms, levodopa, bromocriptine mesylate, opioids, carbamazepine, clonazepam, and clonidine hydrochloride have proved to be effective.
Diagnosis, Differential↗
Gait disturbance in Alzheimer's disease: a clinical study.
Gait disturbance is common in patients with Alzheimer's disease (AD). The aim of this study was to analyse the clinical gait syndromes of patients with AD using Nutt's classification. Fifty-five patients who satisfied the NINCDS-ADRDA criteria for probable AD and 55 controls were recruited from a geriatric and a psychogeriatric unit. Patients with classical musculoskeletal or neurological syndromes causing gait disturbance were excluded. A standardized neurological examination was carried out in all subjects. Twenty-two (40%) patients and ten (18%) controls had a higher level gait disorder (p < 0.01). The pattern of gait disturbance in AD patients varied according to the stage of the disease. Cautious gait was the commonest gait disorder in AD patients with mild dementia, while frontal gait disorder was the commonest disturbance in patients with severe dementia. The prevalence of frontal release signs (gegenhalten or any primitive reflex) was highest among patients with frontal gait disorder.
Activities of Daily Living↗
Predicting delirium in elderly patients: development and validation of a risk-stratification model.
Delirium is a common and serious complication of acute illness in elderly patients. The aim of this study was to develop and validate a model for predicting development of delirium in elderly medical inpatients who did not have delirium on admission. Consecutive admissions to an acute geriatric unit underwent standardized cognitive assessment every 48 hours. Delirium was diagnosed according to DSM-3 criteria. Independent predictors of delirium in a derivation group of 100 patients were determined using stepwise logistic regression analysis; the predictive model comprised dementia, severe illness and elevated serum urea. This model performed well in a validation group of 84 patients. We conclude that elderly medical patients can be stratified according to their risk for developing delirium using a simple clinical model.
Aged↗
Subcutaneous fluids in elderly hospital patients with cognitive impairment.
Sixty patients (mean age 80 years) with cognitive impairment who required parenteral fluids for at least 48 h were randomized to receive either intravenous (i.v.) or subcutaneous (s.c.) fluids. There was no significant difference in the mean volume of fluid prescribed over 48 h in the two groups (s.c. 3.3 litres vs. i.v. 3.6 litres) or in the proportion of prescribed fluids actually administered (s.c. 0.82 vs. i.v. 0.76). After adjusting for baseline differences, there was no difference between serum urea or creatinine levels in the two groups at 48 h. Agitation related to the infusion was reported in 11 (37%) patients receiving s.c. fluids and 24 (80%) patients receiving i.v. fluids (p < 0.005). The cost of the cannulae used during the study was 6.80 pounds for the s.c. group and 28.70 pounds for the i.v. group. Local oedema was noted in 2 patients in the s.c. group and led to re-siting of the infusion in 1 patient. No other complication was noted. These results suggest that s.c. fluid therapy is the treatment of choice in nonurgent situations for confused patients who require parenteral fluids.
Aged↗