Predictors for falls among hospital inpatients with impaired mobility

Gait and balance disturbances have been shown to predispose to falls in hospital. We aimed to investigate the patient characteristics associated with an unsafe gait and to determine what features predispose to falling in this group of hospital inpatients. In a prospective open observational study we studied 825 patients admitted for rehabilitation following acute medical illness or a surgical procedure. The patient's gait was assessed with the 'get up and go' test and classified into one of four categories-normal; abnormal but safe with or without mobility aids; unsafe; or unable. 72.6% of patients were assessed as having an unsafe gait. The factors independently associated with an unsafe gait were confusion, abnormal lower limbs, hearing defects and the use of tranquillizers. Patients with an unsafe gait who fell were more likely than the non-fallers within the group to have had falls in the past (85.3% versus 73.8%) and to be confused (66.2% versus 34.1%). Patients with both these characteristics had a 37.5% chance of falling compared with 15.4% in patients with one and 11.2% in patients with none of these characteristics. The presence of confusion and a history of falls identifies those patients who are at greatest risk of falls. Such patients might be the focus of special efforts at falls prevention.     

Nutritional status on admission and hospital mortality of under-five year old children with infectious diseases in Ouagadougou,Burkina Faso

BACKGROUND: It is known that malnutrition in childhood interacting with infectious diseases contributes to increase mortality. In Burkina Faso, infectious pathologies and malnutrition are public health problems. We examined the impact of malnutrition status, using the Weight-for-age (WA) index, on mortality of children hospitalized for infectious diseases. METHODS: This retrospective study uses a systematic sample derived from the year 1999 hospital register. In total data of 1573 children from 0 to 59 months were analyzed. The association between mortality and dependent variables was measured by relative risks (RR) in univariate analysis. A logistic regression was realized and attributable risk percent (etiologic fraction among exposed) of death was calculated. RESULTS: The total intra-hospital lethality amounted to 15.3%. Age, diagnosis, type of care recourse and malnutrition (low WA index) on admission were associated to mortality. The logistic regression model confirmed the high risks of deaths for young children (0-11m), children in malnutrition (low WA index) and those with severe malaria. The attributable risk percent of death indicates that, 87% of deaths are statically attributable to severe malnutrition (WA Z-score<=-3) and 64.3% of deaths are statically attributable to moderate malnutrition (WA Z-score]-3, -2]). CONCLUSION: Nutritional status evaluation would allow to select children at risk and reduce mortality by including nutritional intervention in standard treatment of children hospitalized for infectious diseases.     

Nutritional status at submission for dietetic services and screening for malnutrition at admission to hospital.

This paper presents two studies in a quality management project that aims to diminish malnutrition among hospitalized patients. The objective of study 1 was to investigate what information was available on the nutritional status of patients submitted for dietetic services for reasons other than obesity (n= 167) and of study 2 to evaluate a nine-question screening sheet for malnutrition in patients (n= 115) within 48 h of admission to the hospital. In study 1 sufficient data to evaluate nutritional status was found for 17% of the patients submitted for dietetic services. In study 2 the screening sheet identified 21% of the patients as malnourished and a full nutritional assessment of seven anthropometrical and biochemical measurements 20%. The screening sheet could be simplified to six questions and then had a sensitivity of 0.69, a specificity of 0.91 and a positive predictive value of 0.65. It is concluded that evaluation of nutritional status in hospitalized patients has been disregarded and a simple screening sheet can be used to identify patients in need of further nutritional assessment and treatment.     

Nutritional frailty, sarcopenia and falls in the elderly

PURPOSE OF REVIEW: There is currently intense interest in understanding why certain elderly individuals become frail and disabled with age whereas others do not. Is frailty the result of an acceleration of normal aging processes or is it the result of chronic medical conditions that are superimposed on the conventional mechanisms of aging? The clinical problem of falls has long been recognized as a threat to some elderly individuals, but too often is not considered worthy of objective study. The factors underlying falls are now being investigated as part of the increasing attention being paid to the evolution of frailty in the elderly. RECENT FINDINGS: Frailty in the elderly has been given many names, but increasing efforts are now being made to define frailty in a standardized way that would allow more objective study. The frail elderly patient usually shows loss of both neurological and muscle function. Falls in the elderly are an example in which deterioration may be present in both functions. Methods are being developed to separate the loss of muscle capacity from the associated loss of central and peripheral neurological function involved in gait and balance. SUMMARY: The definition of frailty has been centered around the onset of accelerated weight loss with an associated decrease of mass and strength of skeletal muscle. New studies are discussed that extend this definition. Methods for a more detailed analysis of the physiological and metabolic deficits leading to falls in the elderly may provide a better understanding of frailty in general.     

Assessment of nutritional status on hospital admission: nutritional scores

Malnutrition is still a largely unrecognized problem in hospitals. Malnutrition in hospitalized patients is generally related to increasing morbidity and mortality, and costs and length of stay. The aim of this study was to assess the nutritional status of patients on admission to a general hospital using different nutritional scores and to test the sensitivity and specificity of these scores. Sample population included 60 patients (55% male; 45% female) selected (aged 65.6+/-15.9 y) at random by using a computer software program. The nutritional state assessment was performed within 48 h of admission, using different nutritional indices (Subjective Global Assessment (SGA), Nutritional Risk Index (NRI), Gassull classification, Instant Nutritional Assessment (INA) and a combined index). About 78.3% of patients were found to be malnourished on admission. The frequency of malnutrition degree varied from 63.3% as assessed by the SGA to 90% with the NRI. Malnutrition severity was not related to the diagnosis. However, an elderly population was associated with a higher prevalence of malnutrition. INA was the best single score to identify patients who are malnourished or at risk of malnutrition and who may benefit from nutrition support.     

PPARgamma, energy balance, and associations with colon and rectal cancer

Peroxisome proliferator-activated receptor-gamma (PPARgamma) has been hypothesized as being involved in colorectal cancer given its role in adipocyte development and insulin resistance. In this study we evaluated the association between the Pro12Ala (P12A) PPARgamma polymorphism and body mass index (BMI), waist-to-hip ratio (WHR), physical activity level, and energy intake and risk of colorectal cancer using data from a population-based, case-control study of colon cancer (1,577 cases and 1,971 controls) and rectal cancer (794 cases and 1,001 controls). We further evaluated how the P12A PPARgamma polymorphism is associated with obesity and fat pattern in the control population. The odd ratio for PPARgamma PA or AA genotype relative to the PP genotype for colon cancer was 0.9 (95% confidence interval, CI=0.8-1.0) and for rectal cancer was 1.2 (95% CI=1.0-1.5) adjusting for race, age, and sex. P12A PPARgamma did not significantly interact with BMI, WHR, energy intake, and energy expenditure to alter risk of colon or rectal cancer. Furthermore, the P12A PPARgamma polymorphism was not associated with obesity or WHR in the control population; it did not interact with energy intake or energy expenditure to alter risk of obesity or large WHR. These data do not support the hypothesis that the P12A PPARgamma polymorphism is associated with colon or rectal cancer through regulation of energy balance.     

The thiamin, riboflavin and pyridoxine status of patients on emergency admission to hospital.

The aim of this study was to assess the prevalence of thiamin, riboflavin and pyridoxine deficiencies at admission to an acute hospital. One hundred and twenty adult patients were selected at random from those admitted via the Accident and Emergency department over 3 days. Comparisons were made with a group of 80 healthy blood donors sequentially attending a local transfusion centre. The alcohol intake of 500 patients admitted sequentially via the same Accident and Emergency department was also assessed. Erythrocyte transketolase (ETK), glutathione reductase (EGR) and aspartate aminotransferase (EAA) coenzyme activation assays were used to determine thiamin, riboflavin and pyridoxine deficiencies. The prevalences of deficiency states in the inpatient group were 21, 2.7 and 32% for thiamin, riboflavin and pyridoxine deficiencies respectively with 49.2% being deficient in one or more vitamin. The mean alcohol intake in the group of patients in whom this was assessed was 9.7 units per week compared with 10 units per week amongst blood donors.     

Nutritional parameters at hospital admission as predictors of pressure ulcer development in elective surgery

Nutritional parameters obtained at hospital admission were studied to determine whether they would predict which surgical patients would develop pressure ulcers during a period of up to three weeks of hospitalization. Nutrition parameters were serum albumin, total protein, lymphocyte count, mid-arm muscle circumference, triceps skin fold, and weight change. Lymphocyte count was significant (p = 0.007, adjusted r2 = 0.019) in predicting the development of a pressure ulcer during hospitalization. Because lymphocyte count accounted for less than 2% of the variance, it is not a clinically significant predictor. When nonnutritional pressure ulcer risk factors were controlled for in the regression, no nutritional factors were predictive of ulcer development.     

Recent changes in stroke history, mobility status and life expectancy at admission among nursing home residents in Japan

We investigated changes in the condition of elderly people at admission to nursing homes, their prognosis after admission and recent changes of mortality risk factors among the residents. We then examine the possible relationship between the changes identified and discuss the possible effects of changes in social policy. A retrospective cohort study using survival analysis was conducted among 407 residents of three nursing homes in Toyama, Japan who were admitted between 1976 and 1990. By reviewing medical and care notes, we abstracted the admission date, gender, age at admission, stroke history, physical activity and date of discharge or death for each subject. Positive stroke history was defined as medical certification of thromboembolic or haemorrhagic stroke before admission. The level of physical activity at admission was classified as either mobile or immobile, according to whether it was possible to get out of bed without assistance from another person. Data were compared for subjects admitted during the two periods of 1976–82 and 1983–90. The latter period includes the year, 1985, when the Medical Service Law in Japan was amended for the purpose of effective allocation of medical resources. In comparison with that for the first admission period, the mean age at admission for the second period was significantly higher in both males and females. The age- and gender-adjusted odds ratio of stroke history to immobile status decreased from 4.7 for the first admission period to 2.2 for the second. The 5-year survival rate decreased, from 51 to 30% (P≤ 0.0001). In multivariate analysis, the relative hazard (RH) of mortality of the subjects in the later admission period to those in the earlier period was 2.0 [95% confidence interval (CI): 1.4–2.8], while the RH was not significant for either gender or age. Immobile status without stroke history showed the highest RH. The RH of the interaction of mobile status with stroke history and late admission period was significantly lower than 1.0. The study indicates that: the relative importance of stroke history in immobile status has decreased among the nursing home population, stroke history among the mobile subjects has become less predictive of poor prognosis after admission, the life expectancy after admission has declined, and the increased mortality is related to factors other than physical activity status and may be attributable to the recent reorganization of medical resources.     

Nutritional assessment: lean body mass depletion at hospital admission is associated with an increased length of stay

BACKGROUND: Low fat-free mass may be an independent risk factor for malnutrition that results in an increased length of hospital stay (LOS). OBJECTIVES: The objectives were to compare differences in fat-free mass and fat mass at hospital admission between patients and healthy control subjects and to determine the association between these differences and the LOS. DESIGN: Patients (525 men, 470 women) were prospectively recruited at hospital admission. Height-corrected fat-free mass and fat mass (fat-free-mass index or fat-mass index; in kg/m2) were determined in patients at admission by bioelectrical impedance analysis and were compared with values for sex-, age-, and height-matched control subjects. Patients were classified as well-nourished, moderately depleted, or severely depleted on the basis of a Subjective Global Assessment questionnaire and a body mass index (in kg/m2) < or > 20. RESULTS: Low fat-free mass was noted in 37% and 55.6% of patients hospitalized 1-2 d and > 12 d, respectively. The odds ratios were significant for fat-free-mass index and were higher in patients with a LOS of > 12 d [men (odds ratio: 5.6; 95% CI: 3.1, 10.4), women (4.4; 2.3, 8.7)] than in those with a LOS of 1-2 d [men (3.3; 2.2, 5.0), women (2.2; 1.6, 3.1)]. Severe nutritional depletion was significantly associated only with a LOS > 12 d. CONCLUSION: Fat-free mass and fat-free-mass index were significantly lower in patients than in control subjects. Because the fat-free-mass index is significantly associated with an increased LOS, provides nutritional assessment information that complements that from a Subjective Global Assessment questionnaire, and is a more sensitive determinant of the association of fat-free mass with LOS than is a weight loss > 10% or a body mass index < 20, it should be used to evaluate nutritional status.     

Psychological health status of mothers and the admission of children to hospital for gastroenteritis

The prevalence of psychological distress was measured by the 30-item general health questionnaire in two populations of mothers: those who had children hospitalized for gastroenteritis and those who cared for children with gastroenteritis at home. Significant differences emerged, with mothers of hospitalized children reporting higher levels of psychological distress. There were no differences in severity of the children's illness between the two groups as indicated by blind ratings of symptomatology from six infectious diseases hospital doctors. Thus hospitalization of children for gastroenteritis was not contingent on medical symptomatology. Instead the evidence indicates that the psychological status of mothers may influence doctors' management decisions on childhood gastroenteritis. Significant positive associations between poor psychological status and poor social resources illustrate the social context in which maternal vulnerability may influence child health care generally. The impact of maternal psychological status on decisions about paediatric care is discussed.     

Education was associated with injuries requiring hospital admission

OBJECTIVES: We describe educational inequalities in the incidence of injuries resulting in hospital admission and explore the contribution of exposure variables and chronic diseases, alcohol consumption, and sedative use to the observed inequalities. STUDY DESIGN AND SETTING: Data from the Dutch prospective GLOBE study were linked to the National Hospital Discharge Register after 7 years of follow-up. RESULTS: Significantly higher hazard ratios (HRs) of traffic injuries in lower compared with higher educational groups were substantially reduced after adjustment for differences in the use of cars and mopeds between these groups. Significantly increased HRs in occupational, home, and sports (OHS) injuries in lower compared with higher educational groups were reduced after adjustment for higher prevalence rates of chronic diseases, very excessive alcohol consumption, and sedative use in lower educational groups. CONCLUSION: Exposure variables, chronic diseases, alcohol consumption, and sedative use contribute to educational inequalities in traffic and OHS injuries resulting in hospital admission.     

Nutritional status of mauritanian children during a drought emergency

Nutritional surveys were conducted in three regions of Mauritania between September and November, 1983, to assess the impact of a severe drought and to determine priorities for relief assistance. Survey sites and children were chosen at random using established Centers for Disease Control survey methodology. A total of 1,498 children between the ages of 6 months and 5 years were weighed, measured and examined for xerophthalmia and scurvy. Information on age, sex, diarrhea, measles immunization, diet and food aid was collected for each child. Levels of acute malnutrition (< 80 % of median weight‐for‐height) ranged from 8.2 to 17.2% in the 3 regions, and both xerophthalmia and scurvy were seen. The children between 1 to 3 years of age had the highest levels of malnutrition. Food aid deliveries were irregular and inadequate in the two regions with the highest rates of malnutrition. Implications for targeting and choice of relief efforts are discussed.     

Nutritional status, breastfeeding, and evolution of Infants with acute viral bronchiolitis

Acute viral bronchiolitis is a common respiratory infectious disease of infancy. A prospective study was carried out with 175 infants aged up to six months to evaluate their nutritional and breastfeeding status as possible risk factors for unfavourable evolution of previously-healthy infants from a care hospital. Immunofluorescence test for virus and anthropometric assessment were performed. Outcomes were length of oxygen-use, length of hospital stay, and type of hospital unit needed. Seventy-three percent of the infants were well-nourished, 6% undernourished, 8.6% at a nutritional risk, 10.9% overweight, and 1.7% obese. Eighty-one percent of the undernourished and nutritionally at-risk infants and 72% of the well-nourished, overweight, and obese infants did not receive exclusive breastfeeding. The median length of hospital stay was four days and of oxygen-use was 60 hours. The nutritional status did not affect the clinical course of previously-healthy infants with acute viral brochiolitis. The duration of exclusive breastfeeding, but not type of breastfeeding, was inversely related to the length of oxygen-use and the length of hospital stay. Shorter exclusive breastfeeding was observed in infants who were assigned to a paediatric ward or to an intensive care unit. In conclusion, longer duration of breastfeeding was associated with better clinical outcomes.     

0～5岁住院儿童营养状况及影响因素分析

目的分析西藏自治区昌都市人民医院5岁以下住院儿童营养不良和贫血状况及其影响因素,为制定儿童营养相关策略和政策提供科学依据。方法采用整群随机抽取法抽取1 208名住院儿童,用Z评分法和血红蛋白值评价儿童营养和贫血状况,用Logistic回归分析可能的影响因素,运用SPSS 13.0软件进行统计学分析。结果住院儿童的生长迟缓率为12.2%、低体重率为8.2%、消瘦率为6.8%、贫血率为20.2%,儿童生长迟缓率、低体重率、消瘦率和贫血率在各月龄组间差异均有统计学意义(P0.01),其中24~36月龄组生长迟缓率最高,低体重率、消瘦率和贫血率的患病高峰在6~12月龄,各月龄组性别间差异均无统计学意义(P0.05)。多因素分析结果表明,儿童生长迟缓的影响因素是出生体重(OR=1.001),低体重的影响因素有月龄(OR=1.018)、出生体重(OR=1.001),消瘦的影响因素有月龄(OR=1.052)和出生体重(OR=1.001),贫血的影响因素为月龄(OR=1.028)。结论西藏自治区昌都市人民医院5岁以下住院儿童营养不良和贫血状况仍然较为严重,应针对各年龄段儿童营养不良状况特点制定相应干预措施,从而改善当地儿童营养健康状况。