Hospital Careful Hand Feeding Program Reduced Feeding Tube Use in Patients with Advanced Dementia

OBJECTIVES

Tube feeding is prevalent among patients with advanced dementia despite empirical data that suggest its lack of benefit. To provide an alternative to tube feeding for end-of-life patients, a careful hand feeding program was launched in a Hong Kong geriatric convalescent hospital in February 2017. We aim to compare the rates of feeding tube insertion before and after program implementation and determine risk factors for feeding tube insertion. For patients on careful hand feeding, we evaluated their sustainability on oral feeding and the rates of hospital readmissions compared with tube feeding patients over the next 12 months.

DESIGN

Retrospective cohort study.

SETTING AND PARTICIPANTS

Advanced dementia patients ≥60 years with indication for tube feeding due to feeding problems admitted from January 2015-June 2019.

METHODS

Data was collected on demographic and clinical variables, initial feeding mode (careful hand feeding vs. tube feeding), subsequent feeding mode changes, and hospital admissions over the next 12 months. Rates of feeding tube insertion, sustainability on oral feeding, and hospital readmissions were compared using Chi-square test. Risk factors for feeding tube insertion were assessed using logistic regression models.

RESULTS

Among 616 advanced dementia patients admitted with feeding problems, feeding tube insertion rate declined significantly after careful hand feeding program implementation (72% vs 51% p<.001). Independent risk factors for feeding tube insertion were admission prior to program implementation, presence of dysphagia alone, dysphagia combined with poor intake, and lack of advance care planning. Among patients on careful hand feeding, 91% were sustained on oral feeding over the next twelve months and did not differ significantly before or after careful hand feeding program implementation (p=.67). There was no significant difference in hospital readmission rates between careful hand feeding patients and tube feeding patients before (83% vs 86%, p=.55) and after careful hand feeding program implementation (87% vs 85%, p=.63).

CONCLUSIONS AND IMPLICATIONS

A hospital careful hand feeding program significantly reduced the feeding tube insertion rate among advanced dementia patients with feeding problems. The vast majority of patients on careful hand feeding were sustained on oral feeding over the next 12 months but their rate of hospital readmissions remained similarly high after program implementation.

Frailty and sarcopenia-from theory to practice

Frailty and sarcopenia have emerged as important syndromes in geriatrics. Their impact is far reaching and are associated with many poor outcomes in older adults. Assessment of frailty and sarcopenia should form part of the assessment in older adults at all encounters between healthcare staff and older adults, coupled with comprehensive geriatric assessment. Early interventions are warranted based on existing consensus guideline recommendations. Recently, strict lockdown measures to protect at-risk groups during the coronavirus disease 2019 pandemic may have led to worsening of frailty and sarcopenia among older adults, owing to social isolation, reduced access to care, and physical inactivity. Assessment and prevention of frailty and sarcopenia are of particular importance during pandemics. Further study is warranted to find the best strategies for managing frailty and sarcopenia.

Effectiveness of Partially Hydrolyzed Guar Gum in Reducing Constipation in Long Term Care Facility Residents: A Randomized Single-Blinded Placebo-Controlled Trial

OBJECTIVES

To assess the effectiveness of partially hydrolyzed guar gum (PHGG) in improving constipation and reducing the use of laxatives among long term care facility (LTCF) residents.

DESIGN

A single-center, prospective, randomized, placebo-controlled, single-blinded parallel-group trial from September 2021 to November 2021.

SETTING

Four LTCF in Hong Kong.

PARTICIPANTS

Fifty-two LTCF residents with chronic constipation (mean age: 83.9±7.6 years, male 38%).

INTERVENTION

5g PHGG mixed with 200ml water per day for 4 weeks was given to intervention group participants. Control group received 200ml water for 4 weeks. Participants continued their usual as-needed laxative (lactulose, senna or dulcolax) on their own initiative.

MEASUREMENTS

Baseline measurements included age, gender, Charlson comorbidity index, Roackwood's Clinical Frailty Scale, body mass index and daily dietary fiber intake. Outcome measures were fecal characteristics assessed by Bristol Stool Form Scale, bowel opening frequency and laxative use frequency at baseline, first, second, third and fourth week of trial. Adverse events were measured. The study was registered on ClinicalTrial.gov; identifier: NCT05037565.

RESULTS

There was no significant difference in bowel frequency and stool characteristics between the treatment group and control group. However, there was a significantly lower frequency of lactulose, senna, and total laxative use in the treatment group compared with controls in the third and fourth week. There was no significant difference in adverse effects between the two groups.

CONCLUSION

This study showed that daily dietary fibre supplementation by using PHGG for 4 weeks in LTCF residents results in significantly less laxative use than placebo. It may be an effective way to reduce laxative dependence among older people living in LTCFs.

Reduced Pneumonia Risk in Advanced Dementia Patients on Careful Hand Feeding Compared With Nasogastric Tube Feeding

OBJECTIVES

To compare survival and pneumonia risk among hospitalized patients with advanced dementia on nasogastric tube feeding (NGF) vs careful hand feeding (CHF) and to examine outcomes by feeding problem type.

DESIGN

Retrospective cohort study.

SETTING AND PARTICIPANTS

Advanced dementia patients aged ≥60 years with indication for tube feeding admitted to 2 geriatric convalescent hospitals between January 1, 2015, and June 30, 2019.

METHODS

Comparison on the effect of NGF and CHF on survival and pneumonia risk using Kaplan Meier survival analysis and Cox proportional hazards models.

RESULTS

Of the 764 patients (mean age 89 years, 61% female, 74% residential care home residents), 464 (61%) were initiated on NGF and 300 (39%) on CHF. The primary feeding problem types were dysphagia (50%), behavioral feeding problem (33%), or both (17%). There was no difference in 1-year survival rate between NGF and CHF groups (36% vs 37%, P = .71) and survival did not differ by feeding problem type. Nasogastric tube feeding was not a significant predictor for survival (adjusted hazard ratio 1.15, 95% CI 0.94-1.39). Among 577 (76%) patients who survived to discharge, pneumonia rates were lower in the CHF group (48% vs 60%, P = .004). After adjusting for cofounders, NGF was a significant risk factor for pneumonia (adjusted hazard ratio 1.41, 95% CI 1.08-1.85). In subgroup analyses, NGF was associated with increased pneumonia risk for patients with both dysphagia and behavioral feeding problem (P = .01) but not in patients with behavioral feeding problem alone (P = .24) or dysphagia alone (P = .30).

CONCLUSIONS AND IMPLICATIONS

For advanced dementia patients with feeding problems, there is no difference in survival between NGF and CHF. However, NGF is associated with a higher pneumonia risk, particularly for patients with both dysphagia and behavioral feeding problem. Further research on how the feeding problem type impacts pneumonia risk for patients on NGF is needed.

Rapid Estimate of Inadequate Health Literacy (REIHL): development and validation of a practitioner-friendly health literacy screening tool for older adults

INTRODUCTION

This study aimed to develop and validate a brief practitioner-friendly health literacy screening tool, called Rapid Estimate of Inadequate Health Literacy (REIHL), that estimates patients' health literacy inadequacy in demanding clinical settings.

METHODS

This is a methodological study of 304 community-dwelling older adults recruited from one community health centre and five district elderly community centres. Logistic regression models were used to identify the coefficients of the REIHL score's significant factors. Receiver operating characteristic (ROC) curve analysis was then used to assess the REIHL's sensitivity and specificity. Path analysis was employed to examine the REIHL's criterion validity with the Chinese Health Literacy Scale for Chronic Care and concurrent validity with self-rated health scale and the Geriatric Depression Scale-15.

RESULTS

The REIHL has scores ranging from 0 to 23. It had 76.9% agreement with the Chinese Health Literacy Scale for Chronic Care. The area under the ROC curve for predicting health literacy inadequacy was 0.82 (95% confidence interval=0.78-0.87, P<0.001). The ROC curve of the REIHL showed that scores ≥11 had a sensitivity of 77.8% and specificity of 75.6% for predicting health literacy inadequacy. The path analysis model showed excellent fit (Chi squared [2, 304] 0.16, P=0.92, comparative fit index 1.00, root mean square error of approximation <0.001, 90% confidence interval=0.00-0.04), indicating that the REIHL has good criterion and concurrent validity.

CONCLUSION

The newly developed REIHL is a practical tool for estimating older adults' inadequate health literacy in clinical care settings.

Assessment and diagnosis of dementia: a review for primary healthcare professionals

Dementia is one of the most costly, disabling diseases associated with ageing, yet it remains underdiagnosed in primary care. In this article, we present the comprehensive approach illustrated with a classical case for diagnosing dementia which can be applied by healthcare professionals in primary care. This diagnostic approach includes history taking and physical examination, cognitive testing, informant interviews, neuropsychological testing, neuroimaging, and the utility of cerebrospinal fluid biomarkers. For the differential diagnosis of cognitive impairment, the differences and similarities among normal ageing, mild cognitive impairment, depression, and delirium are highlighted. As primary care physicians are playing an increasingly prominent role in the caring of elderly patients in an ageing population, their role in the diagnosis of dementia should be strengthened in order to provide a quality care for patients with dementia.

End-of-life care for advanced dementia patients in residential care home-a Hong Kong perspective

Dementia will become more common as the population ages. Advanced dementia should be considered as a terminal illnesses and end-of-life (EOL) care is very much needed for this disease group. Currently, the EOL services provided to this vulnerable group in Hong Kong, especially those living in residential care homes, is limited. The usual practice of residential care homes is to send older residents with advanced dementia to acute hospitals when they are sick, irrespective of their wish, premorbid status, diagnoses and prognosis. This may not accord with what the patients perceive to be a "good death". There are many barriers for older people to die in place, both at home and at the residential care home. In the community, to enhance EOL care to residential care home for the elderly (RCHE) residents, pilot EOL program had been carried out by some Community Geriatric Assessment Teams. Since 2015, the Hospital Authority funded program "Enhance Community Geriatric Assessment Team Support to End-of-life Patients in Residential Care Homes for the Elderly" has been started. In the program, advance care planning (ACP), Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) (non-hospitalized) order will be established and the program will be expected to cover all clusters in Hong Kong by 2018/2019. In hospital setting, EOL clinical plan and EOL ward in geriatric step-down hospitals may be able to improve the quality of death of older patients. In Sep 2015, the Hospital Authority Guidelines on Life-Sustaining Treatment in the Terminally Ill was updated. Amongst other key EOL issues, careful (comfort) hand feeding was mentioned in the guideline. Other new developments include the possible establishment of enduring power of attorney for health care decision and enhancement of careful hand feeding amongst advanced dementia patients in RCHEs.

Effectiveness of a discharge planning and community support programme in preventing readmission of high-risk older patients

OBJECTIVE

To examine the effectiveness of Integrated Care and Discharge Support for elderly patients in reducing accident and emergency department attendance, acute hospital admissions, and hospital bed days after discharge. Factors that compromise its effectiveness were investigated and cost analysis was performed.

DESIGN

Cohort prospective study.

SETTING

Integrated Care and Discharge Support for elderly patients in Hong Kong West Cluster.

PARTICIPANTS

Home-dwelling patients recruited between April 2012 and March 2013 into Integrated Care and Discharge Support for elderly patients in Hong Kong West Cluster.

RESULTS

A total of 1090 older patients were studied. The Integrated Care and Discharge Support for elderly patients programme reduced accident and emergency department attendance by 40% (P<0.001), acute hospital admissions by 47% (P<0.001), and hospital bed days by 31% (P<0.001) at 6 months after implementation. Improvements in Barthel Index 20 (P<0.001) and Modified Functional Ambulation Category scale (P<0.001) were observed. Of the patients, 85 (7.8%) died within 6 months of initiation of the programme. Only 26 (2.4%) older patients required institutionalisation in residential care homes within 6 months after the programme. Increasing age (P=0.025) and high Charlson Comorbidity Index score (P=0.001) were positive predictors for accident and emergency department attendance. A high albumin level (P=0.001) and living alone (P=0.033) were negative predictors for accident and emergency department attendance. Of the patients, 310 (28.4%) had no reduction in bed days after the programme. Increasing age (P=0.025) and number of medications (P=0.003) were positive predictors for no reduction in bed days; while higher haemoglobin level (P=0.034) was a negative predictor. There was a potential annual cost-saving of HK$22.5 million (approximately US$2.9 million).

CONCLUSION

The Integrated Care and Discharge Support for elderly patients programme reduced accident and emergency department attendance, acute hospital admissions and hospital bed days, and was potentially cost-saving. Age, Charlson Comorbidity Index, albumin level, and living alone were factors associated with accident and emergency department attendance. Age, number of medications, and haemoglobin level were associated with no reduction in bed days. Further study of the cost-effectiveness of such programme is warranted.

Falls prevention in the elderly: translating evidence into practice

Falls are a common problem in the elderly. A common error in their management is that injury from the fall is treated, without finding its cause. Thus a proactive approach is important to screen for the likelihood of fall in the elderly. Fall assessment usually includes a focused history and a targeted examination. Timed up-and-go test can be performed quickly and is able to predict the likelihood of fall. Evidence-based fall prevention interventions include multi-component group or home-based exercises, participation in Tai Chi, environmental modifications, medication review, management of foot and footwear problems, vitamin D supplementation, and management of cardiovascular problems. If possible, these are best implemented in the form of multifactorial intervention. Bone health enhancement for residential care home residents and appropriate community patients, and prescription of hip protectors for residential care home residents are also recommended. Multifactorial intervention may also be useful in a hospital and residential care home setting. Use of physical restraints is not recommended for fall prevention.

Dignified Palliative Long-Term Care: An Interpretive Systemic Framework of End-of-Life Integrated Care Pathway for Terminally Ill Chinese Older Adults

PURPOSE

To critically examine the system dynamics necessary for successfully implementing a novel end-of-life integrated care pathway (EoL-ICP) program in promoting dignity and quality of life among terminally-ill Chinese nursing home residents.

METHODS

Thirty stakeholders were recruited to participate in 4 interpretive-systemic focus groups.

RESULTS

Framework analysis revealed 10 themes, organized into 3 categories, namely, (1) Regulatory Empowerment (interdisciplinary teamwork, resource allocation, culture building, collaborative policy making), (2) Family-Centered Care (continuity of care, family care conference, partnership in care), and (3) Collective Compassion (devotion in care, empathic understanding, compassionate actions).

CONCLUSIONS

These findings highlight the importance of organizational structure, social discourse, and shared meaning in the provision of EoL-ICP in Chinese societies, underscoring the significant triangulation between political, cultural, and spiritual contexts embodied in the experience of dignity.

Preventing aspiration pneumonia in older people: do we have the 'know-how'?

Aspiration pneumonia is common in older people. To reduce the risk of aspiration pneumonia, maintenance of good oral hygiene is important and medications affecting salivary flow or causing sedation are best avoided, if possible. The use of H2 blockers and proton-pump inhibitors should be minimised. Different compensatory and facilitation techniques can be applied during oral feeding. Hand feeding should be tried before consideration of tube feeding. The use of tube feeding is the last resort and is mainly for improving nutrition and hydration. Prevention of aspiration pneumonia and increasing survival rates should not be the rationales for tube feeding. Feeding via both gastrostomy and nasogastric tube has similar risks for aspiration pneumonia, and continuous pump feeding is not better than intermittent feeding. Jejunal feeding might decrease the chance of aspiration pneumonia in selected high-risk patients. If older patients are on angiotensin-converting enzyme inhibitors without intolerable cough, continuing the drug may be beneficial. Folate deficiency, if present, needs to be promptly corrected. Further better-designed studies are warranted to find the best ways for prevention of aspiration pneumonia.

Lateral epicondylalgia: midlife crisis of a tendon

The pathogenesis and management of lateral epicondylalgia, or tennis elbow, a common ailment affecting middle-aged subjects of both genders continue to provoke controversy. Currently it is thought to be due to local tendon pathology, pain system changes, and motor system impairment. Its diagnosis is usually clinical, based on a classical history, as well as symptoms and signs. In selected cases, additional imaging (X-rays, ultrasound, and magnetic resonance imaging) can help to confirm the diagnosis. Different treatment modalities have been described, including the use of orthotics, non-steroidal anti-inflammatory drugs, steroid injections, topical glyceryl trinitrate, exercise therapy, manual therapy, ultrasound therapy, laser therapy, extracorporeal shockwave therapy, acupuncture, taping, platelet-rich plasma injections, hyaluronan gel injections, botulinum toxin injections, and surgery. Nevertheless, evidence to select the best treatment is lacking and the choice of therapy depends on the experience of the management team, availability of the equipment and expertise, and patient response. This article provides a snapshot of current medical practice for lateral epicondylalgia management.

Mortality and health services utilisation among older people with advanced cognitive impairment living in residential care homes

OBJECTIVES

To study the demography, clinical characteristics, service utilisation, mortality, and predictors of mortality in older residential care home residents with advanced cognitive impairment.

DESIGN

Cohort longitudinal study.

SETTING

Residential care homes for the elderly in Hong Kong West.

PARTICIPANTS

Residents of such homes aged 65 years or more with advanced cognitive impairment.

RESULTS

In all, 312 such residential care home residents (71 men and 241 women) were studied. Their mean age was 88 (standard deviation, 8) years and their mean Barthel Index 20 score was 1.5 (standard deviation, 2.0). In all, 164 (53%) were receiving enteral feeding. Nearly all of them had urinary and bowel incontinence. Apart from Community Geriatric Assessment Team clinics, 119 (38%) of the residents attended other clinics outside their residential care homes. In all, 107 (34%) died within 1 year; those who died within 1 year used significantly more emergency and hospital services (P<0.001), and utilised more services from community care nurses for wound care (P=0.001), enteral feeding tube care (P=0.018), and urinary catheter care (P<0.001). Independent risk factors for 1-year mortality were active pressure sores (P=0.0037), enteral feeding (P=0.008), having a urinary catheter (P=0.0036), and suffering from chronic obstructive pulmonary disease (P=0.011). A history of pneumococcal vaccination was protective with respect to 1-year mortality (P=0.004).

CONCLUSION

Residents of residential care homes for the elderly with advanced cognitive impairment were frail, exhibited multiple co-morbidities and high mortality. They were frequent users of out-patient, emergency, and in-patient services. The development of end-of-life care services in residential care homes for the elderly is an important need for this group of elderly.

Community end-of-life care among Chinese older adults living in nursing homes

AIM

The aim of the present study was to investigate the preference and willingness-to-pay (WTP) of older Chinese adults for community end-of-life care in a nursing home rather than a hospital.

METHODS

A total of 1540 older Chinese adults from 140 nursing homes were interviewed. Four hypothetical questions were asked to explore their preferences for end-of-life care. Using a discrete choice approach, specific questions explored acceptable trade-offs between three attributes: availability of doctors onsite, attitude of the care staff and additional cost of care per month.

RESULTS

Approximately 35% of respondents preferred end-of-life care in the nursing home, whereas 23% of them would consider it in a better nursing home. A good attitude of staff was the most important attribute of the care site. Respondents were willing to pay an extra cost of US$5 (HK$39) per month for more coverage of doctor's time, and US$49 (HK$379) for a better attitude of staff in the nursing home. The marginal WTP for both more coverage of doctor's time and better attitude of staff amounted to US$54 (HK$418). Respondents on government subsidy valued the cost attribute more highly, as expected, validating the hypothesis that those respondents would be less willing to pay an additional cost for end-of-life care.

CONCLUSIONS

Older Chinese adults living in nursing homes are willing to pay an additional fee for community end-of-life care services in nursing homes. Both the availability of the doctor and attitudes of nursing home staff are important, with the most important attribute being the staff attitudes. Geriatr Gerontol Int 2013; 14: 273-284.

Haemophagocytic lymphohistiocytosis: an uncommon clinical presentation of tuberculosis

Secondary haemophagocytic lymphohistiocytosis is a rare but fatal complication of tuberculosis. We describe two cases, and review the local and international experience on the management of this clinical entity. Prompt treatment with anti-tuberculous drugs forms the cornerstone of therapeutic success.

Rehabilitation in older people: know more, gain more

Functional decline is common among older patients during or even prior to hospitalisation, in spite of treatment of acute illnesses. An effective rehabilitation programme is vital to improve the motor and functional states of the older patients. Knowing factors affecting rehabilitation of older persons is important for their effective and efficient rehabilitation. This article, with special reference to local studies, examines age, gender, cognitive function, and serum albumin levels as to how they influence rehabilitation in the elderly. The conclusion is that we should not exclude patients of advanced age from rehabilitation programmes, based on poor cognitive function and low serum albumin levels as they can achieve similar gains in motor and functional outcomes. A nutritional programme to improve the albumin level of older persons could speed up the rehabilitation progress, rendering it more efficient. A gender-specific rehabilitation programme is needed to improve functional outcome in men and motor outcome in women. Moreover, knowing the factors influencing residential care home placement affords an opportunity to reduce reliance on institutionalisation after rehabilitation.

Lactobacillus rhamnosus hepatic abscess associated with Mirizzi syndrome: a case report and review of the literature

The clinical significance of Lactobacillus spp. isolated from clinical specimens has often been overlooked due to its low virulence. We report the first case of life-threatening bacteremic liver abscess due to Lactobacillus rhamnosus associated with Mirizzi syndrome in a 74-year-old Chinese man. Literature on sporadic reports of Lactobacillus liver abscess is reviewed.

Financial abuse in a mentally incapacitated old man

A mentally incapacitated 82-year-old man with no relatives was managed by a geriatrician-led multidisciplinary team when medical staff realised he was at risk of being exploited. They initiated a series of protective measures including an emergency guardianship application. The Guardianship Board appointed the Director of Social Welfare as his public guardian. This case illustrates that hospital staff should be alert to potential elder abuse to ensure timely protection of potential victims.

Does Age Predict Outcome in Stroke Rehabilitation? A Study of 878 Chinese Subjects

BACKGROUND

The predicting value of age on stroke rehabilitation has been controversial. There is a lack of large-scale studies in the Chinese population to examine the effect of age on stroke rehabilitation outcomes. This study examines the predictors of a good outcome after rehabilitation in Chinese stroke patients with special attention to age as a factor.

PATIENTS AND METHODS

This retrospective cohort study includes stroke patients receiving a standard inpatient multidisciplinary rehabilitation program in a neuro-rehabilitation ward of a convalescence hospital in Hong Kong from January 2000 to December 2003. Functional independence measure (FIM) >or=90 was used to define a good outcome. Multivariate regression analysis was used to assess the independent predictors of a good outcome.

RESULTS

There were important differences in clinical characteristics and complications of stroke among patients of three age groups: <65, >or=65 and <80, and >or=80 years. The total FIM scores both upon admission and at discharge were lower in the older age groups. No significant difference was observed in the changes in FIM scores across these age groups. Age was not an independent predictor for a good outcome. FIM upon admission was an independent predictor for a good outcome (discharge FIM >or=90) in all patients and in individual age groups. Having employment before stroke was a predictor for good outcome in all patients. Living at home prior to stroke was a predictor for the total population and the >or=65 and <80 years group. The length of stay predicted a good outcome in the group >or=80 years.

CONCLUSIONS

Admission functional status, employment and living at home before stroke but not age per se are predictors of a good outcome following stroke rehabilitation. As older patients show comparable improvement during rehabilitation, intensive rehabilitation should not be withheld in stroke patients simply because of advanced age.

Herpetic shoulder paresis in a Chinese elderly patient

A patient with left shoulder girdle weakness secondary to herpetic myotomal paresis is reported. Needle electromyography revealed denervational discharge from the left supraspinatus, deltoid, and brachioradialis muscles, compatible with a radiculopathy that was relevant to his myotomes affected by zoster infection. The patient was managed with range-of-movement and strengthening exercises as well as pain relief for post-herpetic neuralgia. Further studies are required to determine whether antiviral treatment can limit the extent of motor deficit and hasten recovery. Zoster paresis should be one of the differential diagnoses of girdle muscle weakness.

Managing older patients with urinary retention in the Continence Clinic

OBJECTIVE

To evaluate the effectiveness of the Continence Clinic for managing retention of urine in older patients.

DESIGN

Retrospective study.

SETTING

Continence Clinic, Fung Yiu King Hospital, Hong Kong.

SUBJECTS AND METHODS

Case notes of 58 patients seen at the Fung Yiu King Hospital Continence Clinic from October 1997 to September 2001 were reviewed. The patients had retention of urine with post-void residual volume of more than 200 mL, retention of urine requiring catheterization, or had catheters for unknown reasons.

RESULTS

Urodynamic study performed for 22 (38%) patients showed that 12 had detrusor underactivity, six had detrusor hyperactivity with impaired contraction, and four had bladder outlet obstruction. Among the patients who were initially catheterized, the success rate for gradually stopping reliance on urinary catheterization was 84%. The success rate was higher among those who did not undergo urodynamic study than among those who had the study done (95% versus 67%; P=0.03). Reduction in post-void residual volume was observed at the last clinic visits (P<0.0001). Moreover, significant decreases in post-void residual volume were found both for patients who did and did not have urodynamic study.

CONCLUSION

Most of the older patients with urinary retention with or without indwelling catheters were treated successfully in the Continence Clinic by appropriate medical therapy. Urodynamic study can be performed for selected patients when managing urinary retention.

Total daily energy expenditure in wasted chronic obstructive pulmonary disease patients

OBJECTIVES

To investigate total daily energy expenditure in chronic obstructive pulmonary disease (COPD) patients during a rehabilitation programme.

DESIGN

Observational study involving a case and a control group.

SUBJECTS

Ten COPD patients (six with body mass index (BMI) <18.5 kg/m(2) and four with BMI >18.5 kg/m(2)) were evaluated for their energy expenditure profile. Four additional healthy age-matched volunteers were also included for methodology evaluation.

INTERVENTIONS

Measurements of total daily energy expenditure (TEE), resting energy expenditure (REE) and diet-induced thermogenesis (DIT) and energy intake were undertaken by indirect calorimetry and bicarbonate-urea methods and dietary records.

RESULTS

REE in COPD patients was not significantly different from that predicted by the Harris-Benedict equation. Before the exercise day the mean TEE was 1508 kcal/day and physical activity level (PAL as calculated by TEE/REE) was 1.52. On the exercise day the TEE increased to 1568 kcal/day and PAL was 1.60, but neither of these changes were significant. The energy cost of increased physical activity during rehabilitation exercise was estimated to be 191 kcal/day. No significant change was found in DIT between the two patient groups. However, overall energy balances were found to be negative (-363 kcal/day).

CONCLUSION

The rehabilitation programme did not cause a significant energy demand in COPD patients. TEE in COPD patients was not greater than in free-living healthy subjects. Patients, who were underweight, did not have a higher TEE than patients with normal weight. This suggested that malnutrition in COPD patients was not due to an increased energy expenditure. On the other hand, a significant negative energy balance due to insufficient energy intake was found in seven out of 10 patients.