Hospital discharge instructions: comprehension and compliance among older adults

BACKGROUND

Little is known regarding the prevalence or risk factors for non-comprehension and non-compliance with discharge instructions among older adults.

OBJECTIVE

To quantify the prevalence of non-comprehension and non-compliance with discharge instructions and to identify associated patient characteristics.

RESEARCH DESIGN

Prospective cohort study.

SUBJECTS

Four hundred and fifty adults aged ≥ 65 admitted to medical and surgical units of a tertiary care facility and meeting inclusion criteria.

MEASURES

We collected information on demographics, psycho-social factors, discharge diagnoses, and medications using surveys and patient medical records. Domains within discharge instructions included medications, follow-up appointments, diet, and exercise. At 5 days post-discharge, we assessed comprehension by asking patients about their discharge instructions, and compared responses to written instructions from medical charts. We assessed compliance among patients who understood their instructions.

RESULTS

Prevalence of non-comprehension was 5 % for follow-up appointments, 27 % for medications, 48 % for exercise and 50 % for diet recommendations. Age was associated with non-comprehension of medication [odds ratio (OR) 1.07; 95 % confidence interval (CI) 1.04, 1.12] and follow-up appointment (OR 1.08; 95 % CI 1.00, 1.17) instructions. Male sex was associated with non-comprehension of diet instructions (OR 1.91; 95 % CI 1.10, 3.31). Social isolation was associated with non-comprehension of exercise instructions (OR 9.42; 95 % CI 1.50, 59.11) Depression was associated with non-compliance with medication (OR 2.29; 95 % CI 1.02, 5.10) and diet instructions (OR 3.30; 95 % CI 1.24, 8.83).

CONCLUSIONS

Non-comprehension of discharge instructions among older adults is prevalent, multi-factorial, and varies by domain.

The minimally conscious state: definition and diagnostic criteria

OBJECTIVE

To establish consensus recommendations among health care specialties for defining and establishing diagnostic criteria for the minimally conscious state (MCS).

BACKGROUND

There is a subgroup of patients with severe alteration in consciousness who do not meet diagnostic criteria for coma or the vegetative state (VS). These patients demonstrate inconsistent but discernible evidence of consciousness. It is important to distinguish patients in MCS from those in coma and VS because preliminary findings suggest that there are meaningful differences in outcome.

METHODS

An evidence-based literature review of disorders of consciousness was completed to define MCS, develop diagnostic criteria for entry into MCS, and identify markers for emergence to higher levels of cognitive function.

RESULTS

There were insufficient data to establish evidence-based guidelines for diagnosis, prognosis, and management of MCS. Therefore, a consensus-based case definition with behaviorally referenced diagnostic criteria was formulated to facilitate future empirical investigation.

CONCLUSIONS

MCS is characterized by inconsistent but clearly discernible behavioral evidence of consciousness and can be distinguished from coma and VS by documenting the presence of specific behavioral features not found in either of these conditions. Patients may evolve to MCS from coma or VS after acute brain injury. MCS may also result from degenerative or congenital nervous system disorders. This condition is often transient but may also exist as a permanent outcome. Defining MCS should promote further research on its epidemiology, neuropathology, natural history, and management.

Efficacy and safety of modafinil (Provigil) for the treatment of fatigue in multiple sclerosis: a two centre phase 2 study

OBJECTIVE

To assess the efficacy and safety of modafinil for the treatment of fatigue in multiple sclerosis (MS).

METHODS

Patients aged 18-65 years with a diagnosis of MS, a stable disability level < or =6 on the Kurtzke extended disability status scale (EDSS), and a mean score >4 on the fatigue severity scale (FSS) were eligible for the 9 week, single blind, phase 2, two centre study. Exclusion criteria included a diagnosis of narcolepsy, sleep apnoea, or clinically significant major systemic disease and recent use of medications affecting fatigue. All patients, who remained blinded for the treatment regimen, received placebo during weeks 1-2, 200 mg/day modafinil during weeks 3-4, 400 mg/day modafinil during weeks 5-6, and placebo during weeks 7-9. Safety was evaluated by unblinded investigators. Efficacy was evaluated by self rating scales, using the FSS, the modified fatigue impact scale (MFIS), a visual analogue scale for fatigue (VAS-F), and the Epworth sleepiness scale (ESS). Adverse events were recorded.

RESULTS

Seventy two patients (MS type: 74% relapsing-remitting; 7% primary progressive; 19% secondary progressive) received treatment. After treatment with 200 mg/day modafinil for 2 weeks, a significant improvement in fatigue versus placebo run in was demonstrated. Mean scores after treatment with 200 mg/day modafinil were: FSS, 4.7 versus 5.5 for placebo (p<0.001); MFIS, 37.7 versus 44.7 (p<0.001); and VAS-F, 5.4 versus 4.5 (p=0.003). Fatigue scores for 400 mg/day modafinil were not significantly improved versus placebo run in. Mean ESS scores were significantly improved (p<0.001) with 200 mg/day modafinil (7.2) and 400 mg/day (7.0) versus the score at baseline (9.5). Serious adverse events were not found at either dose. The most common adverse events were headache, nausea, and aesthenia. Sixty five patients (90%) completed the study.

CONCLUSIONS

These data suggest that 200 mg/day modafinil significantly improves fatigue and is well tolerated in patients with MS.

The development of guidelines for the management of concussion in sports

Concussion in sports has caught the attention of the news media in recent years, primarily due to the high profile of certain athletes who have sustained traumatic brain injuries. Even though the management of concussion remains somewhat controversial, certain principles of neuroscience regarding mental status alterations and other symptoms resulting from concussion are well accepted by medical experts. Several authors have previously published management strategies for sports-related concussion based on their own experiences, but this article will describe the formal process of developing guidelines for the diagnosis and management of concussion in sports. The processes of literature review, evidence-based analysis, and consensus building are described. This article includes the grading scale, sideline evaluation, and management strategy adopted as a practice parameter by the American Academy of Neurology. Emphasis is placed on the need to detect mild forms of concussion through detailed observation and examination of athletes.

Lead poisoning from hair spray ingestion

A 37-year-old alcoholic woman was poisoned by lead from drinking hair spray mixed with water. Laboratory and pathologic findings showed changes due to lead poisoning. Further analysis by Scanning Electron Microscopy (SEM) and Energy Dispersive X-Ray Analysis (EDXA) confirmed the presence of lead in both the tissues and the hair spray. The significance of these findings is discussed.

Granulomatous giant cell angiitis of the central nervous system

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