The specialty of geriatric medicine in Malta : at a crossroads

Till 1991, the practice of geriatric medicine as a specialty in Malta was associated solely with long-stay care at St. Vincent de Paule Hospital. Then Zammit Clapp Hospital started providing a specialised geriatric service, by catering for elderly people with acute medical problems requiring urgent care and rehabilitation which normally would be referred to St. Luke’s Hospital.peer-reviewe

Monitoring thyroid function status in elderly patients on amiodarone

Objectives: To evaluate whether elderly patients on amiodarone were having their thyroid function status monitored as recommended in the literature and to identify the frequency and type of thyroid function test abnormalities noted. Methods: Patients on amiodarone were identified by examining the prescription charts and medical files of consecutive admissions into Zammit Clapp Hospital (ZCH) and residents at St Vincent de Paul Residence (SVPR). Data was obtained on whether thyroid function tests had been checked at the start of the medication and every six months; the results of such tests carried out over the previous year; the clinical indication to prescribe the medication; and the course of action followed when results were abnormal. Results: 1334 prescription charts were examined. 69 patients (5.2%) were on amiodarone. The most common clinical indication for the medication was atrial fibrillation (68.1%). As regards thyroid status, 39.1% of subjects had blood tests checked at the start of the medication but only 2.9% every 6 months. Although 75.4% had had their thyroid status checked over the previous year, 8.7% never had any thyroid function tests carried out whilst they were on the medication. In all 27.5% of subjects had thyroid gland dysfunction of which 13% had subclinical hypothyroidism, 11.6% clinical hypothyroidism and 2.9% clinical hyperthyroidism. All patients with abnormal results had been kept on amiodarone even when the arrhythmia had abated. Conclusions: Thyroid dysfunction is a common side effect of amiodarone medication. The regular measurement of thyroid function tests, as recommended, should be adhered to in a stricter manner.peer-reviewe

Depressive illness in institutionalised older people in Malta

Depression in older persons is associated with being placed in a nursing home. Depression is linked to increased medical morbidity in nursing home residents. 150 patients living in two nursing homes in Malta were included in the study. The geriatric depression scale was used to identify depression. Data for risk factors for depression and management of residents for this pathology was also collected. 67.3% (p value <0.01) were found to be depressed. 12% of the total population had major depression while 55.3% had minor depression. Only 40% of those diagnosed with depression in this study had been so diagnosed prior to the study. Significant associations included low Barthel scores, loneliness, being currently in pain, taking several medications, being widowed and having osteoarthritis. The study also showed that those residents already diagnosed with depression were being treated inappropriately with low prescription levels of antidepressants (40.6%). : Results show that depression in nursing home residents is highly prevalent and under diagnosed. There is also a lack of proper treatment in those identified with depression. There is a need for further research to develop intervention and management strategies for depression that is specifically tailored to meet the needs of the frail nursing home population.peer-reviewe

Pre-admission assessment of elderly applicants to long-term care

Aim: to identify whether pre-admission assessment of elderly applicants could be an effective means of identifying actual need for long term care Methods: 105 applicants to long term care were assessed at source for suitability for admission. Assessment instruments used were OARS and CAPE. All subjects were followed up after 3 months to assess actual outcome. Findings: Assessment findings showed that of the study group (n=105), 22% could remain in the community, 21% could benefit from hospital care / rehabilitation and 57% required institutionalisation. Unmet need was identified in applicants in the community (n=40) for home help, day care, social worker, physiotherapy, occupational therapy and community nursing. Conclusion: Pre-admission assessment appropriately identifies the actual needs of applicants to long-term care and prevents inappropriate admission.peer-reviewe

Rethinking care for the sick elderly

It is well established that Geriatrics and Gerontology are specialties in their own right meriting separate tertiary and primary care training.1 Health Care for the elderly also forms a newly added subject to the field of biomedical ethics.2 Demographic studies are consistently predicting the increasing proportion of "aged" members in our global population.3 Positive conceptions of 'healthy aging' are rightly displacing negative ageist perceptions that indiscriminately cast the elderly as weak, vulnerable, or incapable of self-determination.4 When, through the natural course of aging or due to illness or injury, body or mind begin to fail, a legitimate need for intervention - and care - will arise. In this article we discuss what is morally justified for the elderly population and recommend changes necessary in Malta especially in view of the established postwar rise in the elderly population. 5 to which Malta has been no exception. The President of the Malta College of Family Doctors is of the opinion that, "As medical technology continues to develop and new treatments and health care costs escalate, governments all over the world must devise more morally explicit principles whereby health care resources are allocated". He also points out that there exist dilemmas at sectorial levels where different groups of people, with different special needs, may feel disadvantaged. The elderly, for example, he says have less priority than the young in getting `life-saving cardiac treatment', whilst benefiting from other services helping them to remain active members of society.6 No one doubts that the institutions that were available in Malta for the elderly until a few years ago left much to be desired. The phrase "Tax-Xjuh" for the elderly was associated with either "tal-Frankuni" (Mount Carmel Hospital) for the psychiatrically ill or with "L-Imgieret" (St. Vincent De Paul Residence) and many were the elderly who shied away from wanting to spend the last few years of their life in such institutions. Although changes have been recently implemented to improve the quality of care and the quality of the environment in these institutions, much still needs to be done.peer-reviewe

The outcome of elderly patients following removal of indwelling urinary catheter

The objectives of this study were to examine the documented indications for the insertion of the indwelling urinary catheter in elderly patients before admission to Zammit Clapp Hospital, St. Julians and St Vincent de Paule Residence, Luqa and to study the outcome after attempting removal of the indwelling urinary catheter. 64 patients from Zammit Clapp Hospital and 61 patients from St. Vincent de Paule Residence were studied. In 34 patients (24%), no clear reason for catheterisation prior to admission could be identified. In 46 patients (32 %) catheterisation was performed for severe uncontrollable incontinence. In all, 66 patients had their indwelling urinary catheter removed at some stage. Of these a total of 49 patients were continent 15 days after the removal of the catheter, 33 patients were still continent after 3 months and 29 patients remained continent after one year. With regards’ to continence rate, a poorer outcome was noted in patients with a mental score of less than 5/10, when compared to patients with a mental score of more than 5/10. Continence rates were better in patients from Zammit Clapp Hospital than in patients from St. Vincent de Paule residence. In conclusion, attempts should be made to use long term indwelling urinary catheterisation only if other measures fail. This can be achieved by proper multi-disciplinary team assessment and education of the patient or his carers. Full support from social services and provision and advice about the use of continence aids is necessary.peer-reviewe

Tuberculosis in Malta : comparisons between the young and elderly in a low incidence country

Background: Malta has one of the lowest reported incidence rates of tuberculosis in Western Europe, and was approaching the elimination phase. It was observed that a disproportionate number of cases were occurring among persons of advanced age. Objective: To investigate the epidemiology of tuberculosis in the elderly Malta-born population. Methods: A retrospective review of national TB surveillance data from 1995 to 2005 with estimation of 11-year means. Age stratified comparisons between the general, the younger, and the elderly Malta-born populations were made. Results: One hundred and seventeen Malta-born patients were included in the study; 99% of all notified cases. The mean stratified incidence rates of TB among the general population, those less than 65 years of age, and the elderly (65 years and over) were 2.8, 1.6, amd 10.6 per 100,000 person-years respectively. When the study sample was stratified wnto 15-year age groups, their mean TB incidence showed an exponential increase. All major age groups showed a fall in incidence, with the elderly group featuring the steepest decline od about 5% per year. The stratified incidence ratio of males to females, and pulmonary to extra-pulmonary TB was greatest in the elderly. Relapse occurred more commonly amongst elderly males. Conclusion: Contrasting age-stratified differences in incidence, gender, site, relapse, and mortality rates were discovered between the two major age groups, with the elderly forming a sub-population with distinct TB-related characteristics. Thus, the elderly, even when living in very low TB-incidence regions, should receive particular consideration.peer-reviewe

Predictors and consequences of presenteeism: a study of nurses in Maltese geriatric settings

Background: Most commonly conceptualised as attending work whilst ill, sickness presenteeism (SP) contrasts with sickness absence (SA), which involves avoiding work when ill. Due to shortcomings in SP research and theory, its predictors and consequences remain unclear. The healthcare sector experiences a particularly high prevalence of SP. Despite this, SP and its consequences have not been studied in a healthcare setting in Malta. Aims: To explore the factors that foster SP, SA and their consequences in ward-based nurses working with older adults in Malta. Methods: An exploratory mixed-methods study was conducted at two medical facilities which catered for older adults in Malta. Data were collected from nurses in two phases. During Phase I, recorded semi-structured qualitative interviews (N=18) investigated the predictors and consequences of SP and SA. These were analysed thematically, and the emerging themes guided the development of a quantitative questionnaire that was distributed cross-sectionally (Phase II). The obtained data (N=270) were analysed in three sets of analyses to identify; (i) the correlates of SP and SA frequency and propensity (ii) explore how illness perceptions vary between SP and SA episodes; and (iii) identify correlates of the main consequences of SP and SA, namely performance loss and illness outcomes Results: SP and SA were found to be common, with SP associated with negative illness outcomes and poor levels of work performance. SA was believed to be salutogenic. Four categories of factors were associated with SP and SA and their consequences: (i) illness perceptions, which referred to participants’ experiences and views of their illness episodes; (ii) work attitudes, which included feelings and behaviours towards different aspects of occupational life; (iii) organisational factors, which included workplace factors and administrative measures; and (iv) personal factors, including illness behaviour preference and personal life. The perceived consequences of attending work and staying home when ill also appeared to influence SP and SA decisions. Implications: Interventions that foster primary, secondary and tertiary prevention may benefit nurses’ health and reduce SP and SA frequency. The investigation’s findings also led to the development of a model of SP and SA decisions. Conclusion: Illness perceptions, work attitudes, organisational factors and personal factors all appeared to play a role in SP and SA decisions and their consequences. In-view of the findings, suggestions were made regarding future SP research, theory and practical implications

Continuous k-to-1 functions between complete graphs of even order

A function between graphs is k-to-1 if each point in the co-domain has precisely k pre-images in the domain. Given two graphs, G and H, and an integer k ≥ 1, and considering G and H as subsets of R 3, there may or may not be a k-to-1 continuous function (i.e. a k-to-1 map in the usual topological sense) from G onto H. In this paper we review and complete the determination of whether there are finitely discontinuous, or just infinitely discontinuous k-to-1 functions between two intervals, each of which is one of the following: ]0, 1[, [0, 1[and [0, 1]. We also show that for k even and 1 ≤ r < 2s, (r, s) 6= (1, 1) and (r, s) 6= (3, 2), there is a k-to-1 map from K2r onto K2s if and only if k ≥ 2s.peer-reviewe