603 CHALLENGES IN THE MANAGEMENT OF SEVERE ORTHOSTATIC HYPOTENSION ASSOCIATED WITH SUPINE HYPERTENSION IN A PATIENT WITH AUTONOMIC DYSFUNCTION ON BACKGROUND OF NASOPHARYNGEAL CARCINOMA AND TYPE II DIABETES MELLITUS

Introduction

Combined chemotherapy and radiotherapy increases long term survival in patients with nasopharyngeal carcinoma. However, radiotherapy of the carotid sinus or brain stem can evolve labile hypertension and orthostatic intolerance from chronic baroreflex failure. Diabetes would also cause this neuropathy. Management of patients with Supine hypertension-Orthostatic hypotension can be very challenging.

Methods

A case report was done on a 71-year-old man with metastatic nasopharyngeal carcinoma status post radiation therapy who was admitted with severe supine hypertension-orthostatic hypotension. Patient was managed with both non-pharmacological and pharmacological methods, and monitored for postural symptoms, complications of severe supine hypertension—which has been linked to left ventricular hypertrophy and kidney dysfunction, and placed on 24 hour ambulatory blood pressure monitoring to aid in management so as to prevent hypertension induced organ damage.

Results

This review outlines the pathophysiology of Supine hypertension-Orthostatic hypotension, treatment complications and potential management strategies recommendations for this group of patients. It revealed the benefit of having a 24 hour ambulatory blood pressure monitoring, which provides insight on the timing and magnitude of an individual’s blood pressure fluctuations throughout the day so as to further guide management.

Conclusion

Chronic baroreflex failure is a late sequela of neck irradiation for naso-pharyngeal carcinoma due to accelerated atherosclerosis in the region of the carotid sinus baroreceptor. Treatment goal is achieved with adequate control of pre-syncopal symptoms and prevention of long term complications. Non-pharmacological interventions remain the first line of therapy, followed by pharmacological interventions as necessary. Nonetheless, management of blood pressure in these elderly patients with baroreflex dysfunction remains challenging and should be individualized. Moving forward, a prospective study on the incidence of late onset, iatrogenic baroreflex failure as a late complication of neck irradiation and its particular relationship to carotid arterial rigidity should be conducted to increase awareness, timely diagnosis and management of the condition among physicians.

Factors Causing Delay in Discharge of Elderly Patients in an Acute Care Hospital

Introduction: Prolonged hospitalisation not only increases cost, it is also associated with other complications. Length of stay (LOS) is one of the indicators that reflect total cost of care during hospitalisation. So, it is of paramount importance to find out why elderly patients overstay in acute care hospitals and address these issues proactively. Since no local data is available, a study was planned to ascertain reasons why the discharging of elderly patients from hospital is delayed and whether these reasons are avoidable. Materials and Methods: Long-stay patients were defined as those whose LOS had notably exceeded the average LOS for the Diagnosis Related Group (DRG), based on principal admitting diagnosis. A separate analysis showed that the specialty-specific long-stay marker for geriatric medicine was 28 days, so casenote review was done for all patients with LOS of more than 28 days who were discharged from geriatric medicine service of an acute care hospital during a 1-year study period. Information was collected on demographic profile, functional and cognitive status, past medical and social history, admitting medical diagnoses, discharge limiting and delaying factors. Results: During the study period, 150 patients stayed over 28 days and 137 casenotes were available for review. The mean age of the patients was 84 years, 55.5% were female, 77.4% were Chinese, mean abbreviated mental test (AMT) score was 3 and mean modified Barthel’s score was 11. The commonest primary diagnosis was sepsis followed by neurological problems, falls-related complication and cardiovascular diseases. The 2 most common discharge limiting factors (the final event which resulted in delay in discharge) were social issues (54, 39.4%) and sepsis (47, 34.3%). Of 47 patients with sepsis, 37 (78.7%) were nosocomial infection. Urinary tract infection and pneumonia were the 2 most common nosocomial infections. The 4 most common factors contributing to delayed discharge (various problems that surfaced throughout the hospital stay) were sepsis (94, 68.6%), decondi- tioning (65, 47.4%), social issues (52, 38.0%) and cardiovascular disorders (37, 27.0%). Conclusion: Elderly patients are more prone to hospitalisation-related complications like nosocomial infection and deconditioning leading to prolonged hospital stay. Early interventions can reduce these complications. Early identification of social issues and prompt discharge planning should be done to avoid delay in discharge. Key words: Deconditioning, Discharge planning, Nosocomial infections, Social

Factors causing delay in discharge of elderly patients in an acute care hospital

INTRODUCTION

Prolonged hospitalisation not only increases cost, it is also associated with other complications. Length of stay (LOS) is one of the indicators that reflect total cost of care during hospitalisation. So, it is of paramount importance to find out why elderly patients overstay in acute care hospitals and address these issues proactively. Since no local data is available, a study was planned to ascertain reasons why the discharging of elderly patients from hospital is delayed and whether these reasons are avoidable.

MATERIALS AND METHODS

Long-stay patients were defined as those whose LOS had notably exceeded the average LOS for the Diagnosis Related Group (DRG), based on principal admitting diagnosis. A separate analysis showed that the specialty-specific long-stay marker for geriatric medicine was 28 days, so casenote review was done for all patients with LOS of more than 28 days who were discharged from geriatric medicine service of an acute care hospital during a 1-year study period. Information was collected on demographic profile, functional and cognitive status, past medical and social history, admitting medical diagnoses, discharge limiting and delaying factors.

RESULTS

During the study period, 150 patients stayed over 28 days and 137 casenotes were available for review. The mean age of the patients was 84 years, 55.5% were female, 77.4% were Chinese, mean abbreviated mental test (AMT) score was 3 and mean modified Barthel's score was 11. The commonest primary diagnosis was sepsis followed by neurological problems, falls-related complication and cardiovascular diseases. The 2 most common discharge limiting factors (the final event which resulted in delay in discharge) were social issues (54, 39.4%) and sepsis (47, 34.3%). Of 47 patients with sepsis, 37 (78.7%) were nosocomial infection. Urinary tract infection and pneumonia were the 2 most common nosocomial infections. The 4 most common factors contributing to delayed discharge (various problems that surfaced throughout the hospital stay) were sepsis (94, 68.6%), deconditioning (65, 47.4%), social issues (52, 38.0%) and cardiovascular disorders (37, 27.0%).

CONCLUSION

Elderly patients are more prone to hospitalisation-related complications like nosocomial infection and deconditioning leading to prolonged hospital stay. Early interventions can reduce these complications. Early identification of social issues and prompt discharge planning should be done to avoid delay in discharge.

Role of nasogastric tube in preventing aspiration pneumonia in patients with dysphagia

INTRODUCTION

Every year, a large number of patients with dysphagia are placed on feeding tubes to prevent aspiration pneumonia. This prospective study was planned to compare the incidence of aspiration pneumonia and death in patients with dysphagia who were either fed orally or through a nasogastric tube.

METHODS

All patients aged 65 years or older, at the point of discharge from the geriatric medicine ward of a hospital, were recruited over a six-month period with a two-month follow-up. Patients diagnosed with dysphagia by the speech therapist were recommended to have either oral feeding with modified diet or nasogastric tube feeding. The incidence of aspiration pneumonia and death among patients on oral feeding, nasogastric tube feeding and patients who refused nasogastric tube feeding were compared.

RESULTS

A total of 122 patients completed the study. The rate of aspiration pneumonia and death were, respectively, 31.2 percent in nasogastric tube-fed patients and 10.3 percent in orally-fed patients (Fisher's exact test, p-value equals 0.007). Multivariate analysis showed that the mode of feeding predicted outcome (p-value equals 0.03). The rate of aspiration pneumonia and death were 31.2 percent in nasogastric tube-fed patients and 11.5 percent in those who refused nasogastric tube feeding (Fisher's exact test, p-value equals 0.064). Nasogastric tube-fed patients were more cognitively- and functionally-impaired compared to those on oral feeding.

CONCLUSION

In our study, patients on nasogastric tube feeding did not have a better outcome against aspiration pneumonia and mortality when compared to those who were on oral feeding. The poorer outcome of nasogastric tube-fed patients could be attributed to their worse cognitive and functional statuses. Larger studies are needed to refute or confirm the usefulness of nasogastric tube in elderly patients with dysphagia.

Use of physical restraints in nursing homes: current practice in Singapore

INTRODUCTION

One of the indicators of quality care in nursing homes is the proper use of physical restraints. Restraints have been associated with multiple complications, such as pressure ulcers, incontinence and immobility. The aim of our study was to assess the indication, use and complications related to physical restraints in Singapore nursing homes.

MATERIALS AND METHODS

All residents aged >65 years old from 3 nursing homes were included in the study. A geriatrician reviewed the medical records of all elderly residents on restraints. Nursing staff interviews were also done to assess their knowledge regarding restraint use. A brief medical record review was also done for the elderly residents without restraints.

RESULTS

Out of 390 elderly residents, 91 were on physical restraints. The mean age of these residents were 80.1 years; 67% were female, 90.1% were Chinese and 82.4% belonged to functional category IV. Both urinary and faecal incontinence were observed in 97.8% of residents. Forty-six (50.5%) residents had no documented indication for restraints. It was noted that 20 (22%) residents were restrained to prevent dislodgement of the feeding tube, 17 (18.7%) were restrained to prevent falls and 8 (8.8%) were restrained for agitation. There were documented trials of removal of restraints for only 21 (23.1%) residents. Alternative approaches, such as diversion technique, were used for 31 (34.1%) residents to avoid restraint use.

CONCLUSION

Our study revealed a high rate of restraint use in the nursing homes. A restraint protocol should be available in every nursing home, requiring physician approval for the long-term application of physical restraints and intermittent reviews by physicians to assess the continued need for restraints.

Polypharmacy and inappropriate medication use in Singapore nursing homes

INTRODUCTION

At present, 7.2% of the population in Singapore is in the geriatric age group, which will increase to 18.4% in the year 2030. The frailest segment of the geriatric population live in nursing homes. They suffer from multiple co-morbidities requiring multiple medication use. Polypharmacy and inappropriate medication use have been considered as quality indicators for nursing home care. As no data of these indicators are available in Singapore, this study was planned to assess the prevalence of polypharmacy and inappropriate medication use in Singapore nursing homes.

MATERIALS AND METHODS

A total of 454 residents in the geriatric age group residing in 3 randomly selected nursing homes were involved in the study. Case notes were reviewed for demographic information, clinical history and medication use. The data were analysed for polypharmacy (5 or more medication orders) and inappropriate medication use (based on established criteria).

RESULTS

Residents were on an average of 5.32 medications. Polypharmacy and inappropriate medication use were seen in 266 (58.6%) and 318 (70.0%) residents, respectively. There was significant association between polypharmacy and inappropriate medication use [P < 0.001, chi2 = 82.56 at 95% confidence interval (CI)]. The most common medication-related problems were the use of medication without proper indication (n = 302), significant potential for adverse drug reactions (n = 281) and drug interactions (n = 141).

CONCLUSION

The prevalence of polypharmacy and inappropriate medication use is high in Singapore nursing homes. Current practice of medication use in the nursing homes may lead to significant adverse drug reactions and drug interactions. A multidisciplinary approach involving geriatricians, nursing home physicians, nurses and pharmacists may potentially reduce polypharmacy and inappropriate medication use in Singapore nursing homes.

Prescribing psychoactive medications in nursing homes: current practice in Singapore

AIM

To assess the prescribing practice, use and potential adverse effects of psychoactive medications in Singapore nursing homes.

METHOD

From a list of existing 24 voluntary welfare organisation (VWO) run nursing homes, four homes with the largest bed capacity were selected from the eastern zone of Singapore. When contacted, two homes agreed to participate in the study. Medical records of all residents aged 65 years and above were reviewed to obtain demographic information, clinical diagnoses and medication orders. Two geriatricians and one psychogeriatrician reviewed the psychoactive medications used in these nursing homes.

RESULT

A Total of 384 residents were enrolled in the study. Mean age of the participants was 79.1 years (65-107); 60.7% were female and 92.4% were Chinese. Dementia was documented for 131 (34.1%) residents, depression for 50 (13%) residents. Residents were on an average of 5.2 (0-14) medications. A total of 309 psychoactive medications were prescribed for the residents. Fifty-nine (63%) antipsychotics, 42 (65%) Benzodiazepines, 65 (61%) antidepressants, 10 (77%) others sedatives and 31 (100%) anticonvulsants were deemed inappropriate. Lack of documented indication, potential adverse drug reaction, drug-drug interaction and therapeutic duplication were the most common medication related problems observed in this study.

CONCLUSION

Majority of the nursing home residents were on psychoactive medications. Residents with dementia were more likely to be on psychoactive medications. Statistically significant association was observed between the use of inappropriate psychoactive medications and the diagnosis of dementia. Better documentation of clinical diagnoses and indications, and regular medication review for potential adverse drug reactions would improve the quality of care in Singapore nursing homes.