Background Hospital inpatients experience substantial sleep problems that have been linked with worse health outcomes, poor quality of life and the post-hospital syndrome. However, little is known about assessing sleep issues in older hospitalised patients. Objective To conduct an in-depth investigation on hospitalised older adults’ sleep challenges and methods of sleep assessment. Design Cross-sectional observational study. Setting Public hospital inpatientunit. Subjects Long-stay hospitalised older adults. Methods Data were collected using validated sleep questionnaires, actigraphy devices and qualitative interviews. Quantitative data were analysed with descriptive statistics, multiple logistic regression and Cohen’s Kappa. Qualitative data were analysed with qualitative content analysis; findings compared to the quantitative assessments. Results We collected data on 33 older long-stay hospital inpatients, who were mean (SD) 80.2(7.4) years old, 57.6% female and were hospitalised following stroke, medical illness and orthopaedic fracture. Mean (SD) total sleep time and actigraphic sleep efficiency were 480.6(73.6) minutes and 81.5(11.2)%, respectively. About, 57.6% were poor sleepers (Pittsburgh Sleep Quality Index [PSQI]) and 30.8% had indicators of clinical depression/low quality of life (WHO-5 well-being index). Three main themes were identified: “sleep assessment”; “factors that affect sleep”; “expectations of sleep”. Bad sleepers were more likely to feel a lack of control over their sleep, while good sleepers spoke about the ability to adjust and accept their circumstances. Conclusions We found high levels of sleep problems and identified substantial discrepancies between the validated sleep questionnaire and qualitative response data. Our findings indicate that standard assessment tools, such as PSQI, may not be suitable to assess sleep in hospitalised older adults and call for further investigations to build more appropriate methods. Further exploring psychological factors and expectations could potentially lead to novel interventions to improve sleep in this setting.
The phrase ‘not safe for discharge home’ is often heard in relation to an older person in hospital, commonly due to functional limitations or risk of falls. But it remains unclear how such a standard of safety should be set in this context, or who should set it. In addition, labelling someone ‘unsafe’ to return to their own home has significant practical and ethical implications. After briefly exploring these issues, this Commentary suggests that a holistic approach and shared decision-making is required in this setting. Instead of simply declaring someone safe or unsafe for discharge home, specific ‘safety concerns’ (or ‘hazards’) should be identified and addressed as able. Ongoing specific concerns can then be discussed in conjunction with a patient’s values and perceived benefits of returning home, in comparison with potential pros and cons of other discharge options. Overall, this paper suggests that paying attention to our words and values can enhance discharge planning and person-centred care.
Decision-making capacity is a vital concept in law, ethics, and clinical practice. Two legal cases where capacity literally had life and death significance are NHS Trust v Ms T [2004] and Kings College Hospital v C [2015]. These cases share another feature: unusual beliefs. This essay will critically assess the concept of capacity, particularly in relation to the unusual beliefs in these cases. Firstly, the interface between capacity and unusual beliefs will be examined. This will show that the "using and weighing of information" is the pivotal element in assessment. Next, this essay will explore the relationship between capacity assessment and a decision's "rationality." Then, in light of these findings, the essay will appraise the judgments in NHS v T and Kings v C, and consider these judgments' implications. More broadly, this essay asks: Does capacity assessment examine only the decision-making process (as the law states), or is it also influenced by a decision's rationality? If influenced by rationality, capacity assessment has the potential to become "a search and disable policy aimed at those who are differently orientated in the human life-world" (Gillett 2012, 233). In contentious cases like these, this potential deserves attention.
The discharge of older people from hospital at night is a topical and emotive issue that has recently gained media attention in New Zealand and the United Kingdom, including calls to prevent it occurring. With growing pressures on hospital capacity and ageing populations, normative aspects of hospital discharge are increasingly relevant. This paper therefore addresses the question: Should older people (say, over eighty years old) ever be discharged home from hospital during the night? Or given safety concerns, should regulation against the night-time discharge of older people be put in place? Employing a principlist lens to bioethics, this paper considers key principles or values involved, including discharge safety concerns, personal preference and consent, the risk of remaining in hospital, and broader considerations around discharge policy. These points act as a possible framework for further research and discussion of normative aspects of hospital discharge. Overall, this paper argues that while discharge safety concerns must be properly acknowledged and addressed, it can still sometimes be appropriate for an older person to leave hospital at night. The option of night-time discharge should therefore remain open to people of all ages.
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