EP.FRI.57 Audit of Medical Records on Structure and Content of T&O Documentation

The aim of the audit was to assess if Trauma & Orthopaedic admission documentation and record-keeping met the national standards. Standards used included the ‘Royal College of Physicians-Generic Record Keeping Standards 2, 4, 6, 10’ and ‘Professional Records Standards Body, Section 2 Admission Record’. Seventeen admission criteria and eight documentation criteria where audited from the respective standards. Retrospective data were collected using A&E clerking documents, GP referral letters, admission clerking proformas and continuation notes from hospital admission. Initial data showed that only 41% of pages of documentation had appropriate patient identification details listed. Of the 17 admission criteria audited, only 7 criteria scored above 90%. The major downfalls were in vital signs (38%) and assessment scales i.e. Abbreviated Mental Test Score (18%) and venous thromboembolism assessment (32%). With regards to subsequent separate entries, the main failure was entries not listed in chronological order (48%), with only two criteria scoring above 90% (entries dated and legibility). Following the implementation of an updated admission proforma and education on documentation; only 5 of the 17 admission criteria scored 90% or above. However, 46% of pages had the correct patient identification details on admission. On subsequent ward entries, 7 out of the 8 sections had improved, with 62% of notes in chronological order. Furthermore, 4 out of the 8 documentation criteria scored above 90%. Informing staff on correct documentation helped improve doctors’ entries in patients’ notes. Improvements in the admission proforma need to be made to help meet record-keeping standards.

Underrecognition and undertreatment of thirst among hospitalized patients with restricted oral feeding and drinking

Thirst is distressing but overlooked by healthcare professionals. Patients experience thirst due to comorbidities, physical or cognitive limitations, and iatrogenesis. Nasogastric tube (NGT) use and nil-by-mouth(NBM) orders are common practices that can lead to thirst. However, thirst in these populations has never been formally studied. We aim to examine prevalence of recognition and treatment of thirst among NGT + NBM and NBM patients. Our descriptive study was conducted intermittently over 25 weeks, across 1.5 years, in 12 adult general medicine wards of a tertiary hospital. Cognitively intact NGT + NBM or NBM inpatients, defined as Abbreviated Mental Test score ≥ 8, were studied. One-time questionnaire was administered. Variables included: demography, co-morbidities, clinical condition, feeding route, thirst defined by thirst distress and/or intensity ≥ 3, pain, hunger and volume status. 88 NGT + NBM and NBM patients were studied. 69.3% suffered from thirst. Thirsty patients experienced significant thirst-related distress (mean score ± SD: 5.7 ± 2.5). Subjects with previous stroke and who were euvolemic tended towards thirst. 13.6% were asked about thirst by doctors or nurses. Thirst was a major source of patient distress in our study. We suggest that thirst needs to be actively identified and targeted to achieve person-centred care.

PENURUNAN INDEKS MASSA TUBUH (IMT) BERHUBUNGAN STATUS KOGNISI BURUK PADA LANSIA

Salah satu masalah yang dialami pada lansia adalah Terganggunya kapasitas intelektual yang berhubungan dengan fungsi kognitif pada lansia. Faktor nutrisi adalah faktor yang dapat menentukan keadaan kognitif lansia dan untuk mencegah potensi penurunan kognitif pada lansia. Tujuan penelitian ini untuk mengetahui adanya hubungan antara indeks massa tubuh dengan status kognisi pada lansia. Penelitian ini merupakan penelitian analitik dengan rancangan penelitian studi cross-sectional. Penelitian dilaksanakan di Panti Sosial Tresna Werda Wana Seraya, Denpasar. Penghitungan Indeks Massa Tubuh (IMT) yang dilakukan pada lansia dengan pengukuran berat badan dan tinggi badan berdasarkan tinggi lutut dan Status kognisi ditentukan dengan menggunakan kuisioner abbreviated mental test (AMT). Data yang diperoleh di analisis secara univariat dan bivariat dengan uji korelasi Rank Spearman. Terdapat 22 responden termasuk dalam penelitian ini dengan rerata umur 76,5±4,56 tahun. Prevalensi penurunan fungsi kognitif lansia diperoleh 77,3%. Dari 17 lansia dengan penurunan fungsi kognitif, sebanyak 58,8% mengalami gizi kurang, 35,3% mengalami gizi baik dan 5,9% mengalami gizi lebih. Berdasarkan uji korelasi diperoleh hubungan yang cukup kuat antara indeks massa tubuh dengan status kognisi (r = 0,436; p=0,043). Dengan demikian, dapat disimpulkan bahwa terdapat hubungan yang cukup kuat antara IMT dengan status kognitif pada lansia.

Cognitive screening assessment in Thai older adults: a prospective study of the reliability and validity of the Abbreviated Mental Test

PurposeThe purpose of this paper is to examine the reliability and validity of the Abbreviated Mental Test (AMT) and the agreement with the Mini-Mental State Examination (MMSE).Design/methodology/approachThis cross-sectional study included 446 older adults who were recruited by cluster sampling from 200,481 adults aged more than 60 years. For each participant, the AMT was administered by village health volunteers and, on a separate day, by a trained professional who also administered the MMSE. Descriptive statistics, Bland and Altman levels of agreement, and Receiver Operator Curves (ROCs) were used to analyze data.FindingsAdministration of the AMT by village health volunteers during the annual health screening found cognitive impairment in only 1.12% of the sample. When the AMT was given to these same individuals by trained professionals, the rate of cognitive impairment was almost 24 times greater. Two items in the Thai AMT may require modification due to markedly elevated failure rates. At the cut score of 8, the sensitivity and specificity of the AMT relative to the MMSE were moderate (78.83 and 66.67%, respectively). The degree of agreement between AMT and MMSE was 0.49 (p < 0.001) and the correlation between the difference scores and the mean is exceptionally low (0.048).Originality/valueReliable and valid cognitive screening assessment requires the administrator to be well trained and the tools to be appropriate for the population. Although AMT is short and easy for a nonprofessional to administer, some items were not suitable due to construct validity and contextual issues.

The Abbreviated Mental Test Score; Is There a Need for a Contemporaneous Update?

Introduction: Designed in 1972 the Abbreviated Mental Test Score (AMTS) is widely used to assess a cognition on hospital admission. The Nottingham Hip Fracture Score uses this in predicting morbidity/mortality in neck of femur fracture. The consequences of misappropriating cognitive impairment could have lasting implications. Questions about the monarchy or World War One and Two may be inappropriate for today’s diverse society. Materials and Methods: 100 patients were questioned during routine fracture clinic appointments. Patients were asked: In what year did WWII start? Who is the current monarch? Please state a memorable event in your lifetime that you would not expect another person of the same age to forget. Two-tailed Z-tests were performed between the observed proportions and those from the original AMTS validation study. Results: Only 47% (n = 47) were able to correctly answer the year in which WW2 started. A statistically significant difference when compared to the upper and lower limits from the original study (z = -4.191, p < .001.). Significance was not seen in the second question, with 97% (n-97) identifying the monarch correctly. 51% (n = 51) of participants suggested the terrorist attack on the World Trade Centre in New York as an alternative memorable event. Discussion: Some hospitals now use the 4 “A”s Test (4-AT) as a screening tool for delirium. Without amendments to the Nottingham Hip Fracture Score, AMTS use is likely to continue in orthogeriatric patients. Over time there will be a need for the AMTS to be reviewed so that it remains a true assessment of cognition. Its limitations regarding language and culture is widely acknowledged and several validated variants have been published in the literaure. Conclusions: We highlight a potential future issue with the AMTS and raise considerations for the development of an alternative question to better meet the needs of the orthogeriatric population.

Path analysis reveals the direct effect of PCB28 on cognitive dysfunction in older Chinese females

Background Current findings support the hypothesis that the exposure of dioxin-like polychlorinated biphenyls (dl-PCBs) has adverse cognitive effects even at levels that are generally considered to pose low or no risk. However, the effect of non-dioxin-like PCBs (ndl-PCBs) on neurobehavior of aging people is largely unknown. Therefore, this study aimed toinvestigate the association of ndl-PCBs burden with the cognition functions among elderly adults. Methods Using samples and data from Weitang Geriatric Diseases study (2014–2015), 6 indicator-PCBs were detected in plasma by GC-MS and cognitive dysfunction (CoD) were measured by the Abbreviated Mental Test in 266 participants (age: 61–90). Sequential logistic regression was used to analyze the effects of PCBs on cognition functions. Then the female aged less than and equal to 80 years was selected, and path analysis was used to determine the direct or indirect impacts of co-exposure PCBs on COD by Structural Equation Modeling. Results After sequential adjusting for potential confounder, no association of PCBs 52, 101, 138, 153, 180, LPCBs, HPCBs, and ∑PCBs with the risk of COD was observed; however, the exposure of PCB28 was significantly associated with COD ((Model 3: OR = 3.12, 95% CI = 1.19–8.11, p = 0.020). The final path model also fits that only exposure to PCB28 had a direct effect on COD (β = 0.696, SE = 1.14; p = 0.036). Conclusions After controlling the co-exposures and confounders, the exposure to PCB28 can directly increase the risk of cognitive impairment in older Chinese females.

Underestimation of Cognitive Impairment in Older Inpatients by the Abbreviated Mental Test Score versus the Montreal Cognitive Assessment: Cross-Sectional Observational Study

<b><i>Background/Aims:</i></b> Cognitive impairment is prevalent in older inpatients but may be unrecognized. Screening to identify cognitive deficits is therefore important to optimize care. The 10-point Abbreviated Mental Test Score (AMTS) is widely used in acute hospital settings but its reliability for mild versus more severe cognitive impairment is unknown. We therefore studied the AMTS versus the 30-point Montreal Cognitive Assessment (MoCA) in older (≥75 years) inpatients. <b><i>Methods:</i></b> The AMTS and MoCA were administered to consecutive hospitalized patients at ≥72 h after admission in a prospective observational study. MoCA testing time was recorded. Reliability of the AMTS for the reference standard defined as mild (MoCA &#x3c;26) or moderate/severe (MoCA &#x3c;18) cognitive impairment was assessed using the area under the receiver-operating curve (AUC). Sensitivity, specificity, positive and negative predictive values of low AMTS (&#x3c;8) for cognitive impairment were determined. <b><i>Results:</i></b> Among 205 patients (mean/SD age = 84.9/6.3 years, 96 (46.8%) male, 74 (36.1%) dementia/delirium), mean/SD AMTS was 7.2/2.3, and mean/SD MoCA was 16.1/6.2 with mean/SD testing time = 17.9/7.2 min. 96/205 (46.8%) had low AMTS whereas 174/185 (94%) had low MoCA: 74/185 (40.0%) had mild and 100 ( 54.0%) had moderate/severe impairment. Moderate/severe cognitive impairment was more prevalent in the low versus the normal AMTS group: 74/83 (90%) versus 25/102 (25%, <i>p</i> &#x3c; 0.0001). AUC of the AMTS for mild and moderate/severe impairment were 0.86 (95% CI = 0.80–0.93) and 0.88 (0.82–0.93), respectively. Specificity of AMTS &#x3c;8 for both mild and moderate/severe cognitive impairment was high (100%, 71.5–100, and 92.7%, 84.8–97.3) but sensitivity was lower (44.8%, 37.0–52.8, and 72.8%, 62.6–81.6, respectively). The negative predictive value of AMTS &#x3c;8 was therefore low for mild impairment (10.9%, 5.6–18.7) but much higher for moderate/severe impairment (75.2%, 65.7–83.3). All MoCA subtests discriminated between low and normal AMTS groups (all <i>p</i> &#x3c; 0.0001, except <i>p</i> = 0.002 for repetition) but deficits in delayed recall, verbal fluency and visuo-executive function were prevalent even in the normal AMTS group. <b><i>Conclusion:</i></b> The AMTS is highly specific but relatively insensitive for cognitive impairment: a quarter of those with normal AMTS had moderate/severe impairment on the MoCA with widespread deficits. The AMTS cannot therefore be used as a “rule-out” test, and more detailed cognitive assessment will be required in selected patients.

Dementia Community Screening Program in District Health Area 11: Phase 1

To estimate the prevalence of dementia among Thai elderly in the upper Southern region of Thailand, we performed a cross-sectional screening of all Thai older people from 2 areas of Nakhon Si Thammarat province: Tambon Baan Thungchon, Tha Sala district, and Moo 6 and 7 from Sichon district, from December 2016 to November 2017. Trained health volunteers identified the participants in their communities and collected data including age, gender, comorbidities, Timed Up and Go Test (TUGT) results, and Montreal Cognitive Assessment (MoCA) scores. Our sample comprised 773 participants, of which 605 (78.3 %) were from Baan Thungchon area, while 168 were from Moo 6 and Moo 7 of Sichon district. The majority of participants were female (431, 55.7 %). The mean age of the participants was 79 ± 9.1 years, with a minimum age of 60, and a maximum age of 95. Their comorbidities were hypertension (42.9 %), type II diabetic mellitus (33.2 %), dyslipidemia (37.5 %), and osteoarthritis of the knees (35.8 %). 35.1 % of them also had positive TUGT. Sixty-seven participants (8.7 %) scored 7 or lower in the Abbreviated Mental Test (AMT). Five participants (7.5 %) had a positive screening for dementia.

Thermal Sensation in Older People, with and without Dementia, Living in Residential Care: New Assessment Approaches Using Infrared Thermography

The temperature of the indoor environment is important for health and wellbeing especially at the extremes of age. The study aim was to undertsand the relationship between self-reported thermal sensation and extremity skin temperature in care home residents with and without dementia. The Abbreviated Mental Test (AMT) was used to discriminate residents to two categories, those with and those without dementia. After acclimatisation, measurements included: tympanic membrane temperature, thermal sensation rating followed by infrared thermal mapping of non-dominant hand and forearm. Sixty-nine afebrile adults (60-101 years of age) were studied in groups of two to five, in mean ambient temperatures of 21.4oC-26.6oC (median 23.6oC). Significant differences were observed between groups; thermal sensation rating (p=0.02), tympanic temperature (p=0.01), fingertip skin temperature (p=0.01) and temperature gradients; fingertip-wrist p=0.001 and fingertip-distal forearm, p=0.001.