Mobility and safety issues in drivers with dementia

ABSTRACTAlthough automobiles remain the mobility method of choice for older adults, late-life cognitive impairment and progressive dementia will eventually impair the ability to meet transport needs of many. There is, however, no commonly utilized method of assessing dementia severity in relation to driving, no consensus on the specific types of assessments that should be applied to older drivers with cognitive impairment, and no gold standard for determining driving fitness or approaching loss of mobility and subsequent counseling. Yet, clinicians are often called upon by patients, their families, health professionals, and driver licensing authorities to assess their patients’ fitness-to-drive and to make recommendations about driving privileges. We summarize the literature on dementia and driving, discuss evidenced-based assessments of fitness-to-drive, and outline the important ethical and legal concerns. We address the role of physician assessment, referral to neuropsychology, functional screens, dementia severity tools, driving evaluation clinics, and driver licensing authority referrals that may assist clinicians with an evaluation. Finally, we discuss mobility counseling (e.g. exploration of transportation alternatives) since health professionals need to address this important issue for older adults who lose the ability to drive. The application of a comprehensive, interdisciplinary approach to the older driver with cognitive impairment will have the best opportunity to enhance our patients’ social connectedness and quality of life, while meeting their psychological and medical needs and maintaining personal and public safety.</jats:p

Long term outcome of stroke: Stroke is a chronic disease with acute events.

Long term outcome of stroke: Stroke is a chronic disease with acute events

Irish Heart Foundation National Audit of Stroke Care

Stroke is the third leading cause of death and disability worldwide. It constitutes a formidable burden of disability for patients, their families, health professionals and the wider community. It combines aspects of both acute and chronic disease, and there is increasing evidence that those affected by stroke can benefit to a very significant extent from organised stroke care throughout the course of the illness. Delivering this care requires a unique combination of skills, drawing on neurosciences, cardiovascular medicine, general medicine, the science of ageing, rehabilitation, vascular surgery, and public health. Local and timely evidence on the service performance is essential to assess quality of care and to improve services. This has not been available to date in Ireland. The aim of this project was to conduct a national audit of stroke care in hospital and the community in the Republic of Ireland. This was achieved by completing six separate surveys and by drawing conclusions based on complementary information across the studies. The six surveys are described next. Where possible, audit systems used in the UK’s Sentinel audit were used to provide an opportunity for comparison of relative, as well as absolute, levels of achievement of recommended standards of care

Community-based post-stroke service provision and challenges: a national survey of managers and inter-disciplinary healthcare staff in Ireland.

ABSTRACT: BACKGROUND: The extent of stroke-related disability typically becomes most apparent after patient discharge to the community. Maximising rehabilitation input at this point can minimise the impact of disability. As part of the Irish National Audit of Stroke Care (INASC), a national survey of community-based allied health professionals and public health nurses was conducted. The aim was to document the challenges to service availability for patients with stroke in the community and to identify priorities for service improvement. METHODS: The study was a cross-sectional tailored interview survey with key managerial and service delivery staff. As comprehensive listings of community-based health professionals involved in stroke care were not available, a cascade approach to information gathering was adopted. Representative regional managers for services incorporating stroke care (N=7) and disciplinary allied health professional and public health nurse managers (N=25) were interviewed (94% response rate). RESULTS: Results indicated a lack of formal, structured community-based services for stroke, with no designated clinical posts for stroke care across disciplines nationally. There was significant regional variation in availability of allied health professionals. Considerable inequity was identified in patient access to stroke services, with greater access, where available, for older patients (\u3e65 years). The absence of a stroke strategy and stroke prevalence statistics were identified as significant impediments to service planning, alongside organisational barriers limiting the recruitment of additional allied health professional staff, and lack of sharing of discipline-specific information on patients. CONCLUSIONS: This study highlighted major gaps in the provision of inter-disciplinary team community-based services for people with stroke in one country. Where services existed, they were generic in nature, rarely inter-disciplinary in function and deficient in input from salient disciplines. Challenges to optimal care included the need for strategic planning; increased funding of healthcare staff; increased team resources and teamwork; and removal of service provision barriers based on age. There were notably many challenges beyond funding. Similar evaluations in other healthcare systems would serve to provide comparative lessons to serve to tackle this underserved aspect of care for patients with stroke and their families

Gait Characteristics and Cognitive Function in Middle-Aged Adults With and Without Type 2 Diabetes Mellitus: Data from ENBIND

Type 2 Diabetes Mellitus (T2DM) in midlife is associated with a greater risk of dementia in later life. Both gait speed and spatiotemporal gait characteristics have been associated with later cognitive decline in community-dwelling older adults. Thus, the assessment of gait characteristics in uncomplicated midlife T2DM may be important in selecting-out those with T2DM at greatest risk of later cognitive decline. We assessed the relationship between Inertial Motion Unit (IMUs)- derived gait characteristics and cognitive function assessed via Montreal Cognitive Assessment (MOCA)/detailed neuropsychological assessment battery (CANTAB) in middle-aged adults with and without uncomplicated T2DM using both multivariate linear regression and a neural network approach. Gait was assessed under (i) normal walking, (ii) fast (maximal) walking and (iii) cognitive dual-task walking (reciting alternate letters of the alphabet) conditions. Overall, 138 individuals were recruited (n = 94 with T2DM; 53% female, 52.8 8.3 years; n = 44 healthy controls, 43% female, 51.9 8.1 years). Midlife T2DM was associated with significantly slower gait velocity on both slow and fast walks (both p \u3c 0.01) in addition to a longer stride time and greater gait complexity during normal walk (both p \u3c 0.05). Findings persisted following covariate adjustment. In analyzing cognitive performance, the strongest association was observed between gait velocity and global cognitive function (MOCA). Significant associations were also observed between immediate/delayed memory performance and gait velocity. Analysis using a neural network approach did not outperform multivariate linear regression in predicting cognitive function (MOCA) from gait velocity. Our study demonstrates the impact of uncomplicated T2DM on gait speed and gait characteristics in midlife, in addition to the striking relationship between gait characteristics and global cognitive function/memory performance in midlife. Further studies are needed to evaluate the longitudinal relationship between midlife gait characteristics and later cognitive decline, which may aid in selecting-out those with T2DM at greatest-risk for preventative interventions

Stroke and Nursing Home Care: a national survey of nursing homes.

BACKGROUND: Although stroke is recognised as a major factor in admission to nursing home care, data is lacking on the extent and nature of the disabilities and dependency in nursing homes arising from stroke. A national study conducted in nursing homes can quantify the number of residents with stroke in nursing homes, their disability and levels of dependency. METHODS: A cross-sectional survey research design was used. A total of 572 public and private nursing homes were identified nationally and a stratified random selection of 60 nursing homes with 3,239 residents was made. In half of the nursing homes (n = 30) efforts were made to interview all residents with stroke Survey instruments were used to collect data from residents with stroke and nursing home managers on demography, patient disability, and treatment. RESULTS: Across all nursing homes (n = 60), 18% (n = 570) of the residents had previously had a stroke. In homes (n = 30), where interviews with residents with stroke (n = 257), only 7% (n = 18) residents were capable of answering for themselves and were interviewed. Data on the remaining 93% (n = 239) residents were provided by the nursing home manager. Nurse Managers reported that 73% of residents with stroke had a high level of dependency. One in two residents with stroke was prescribed antidepressants or sedative medication. Only 21% of stroke residents were prescribed anticoagulants, 42% antiplatelets, and 36% cholesterol lowering medications. Stroke rehabilitation guidelines were lacking and 68% reported that there was no formal review process in place. CONCLUSIONS: This study provides seminal findings on stroke and nursing home services in Ireland. We now know that one in six nursing home residents in a national survey are residents with a stroke, and have a wide range of disabilities. There is currently little or no structured care (beyond generic care) for stroke survivors who reside in nursing homes in Ireland

2012 - That was the year that was

Geriatric medicine has an encyclopaedic sweep, reflecting the complexity of both the ageing process and of our patient group. Keeping up with, and making sense of, the relevant scientific literature is challenging, especially as ageing has increased in prominence as a focus of research across many branches of the sciences and the humanities. This review of research published in 2012 in generalist, geriatric medicine and gerontology journals has been compiled with a view to extracting those aspects of research into ageing which could be considered relevant not only to the practice of geriatric medicine, but also to our understanding of the ageing process and the relationship of geriatric medicine to other medical specialties and public health. The research discussed includes new insights into global ageing and the compression of morbidity; nosological, clinical and therapeutic aspects of dementia; an innovative study on the microbiome and ageing; epidemiological perspectives into multi-morbidity; an overview of the impact of the first waves of Baby Boomers; fresh thinking on geriatric syndromes such as orthostatic hypotension, kyphosis, urinary incontinence after stroke, frailty and elder abuse; an update of the Beers criteria and the first stirrings of recognition of the longevity dividend in the biomedical literature