An 80 year old man, who relied on a home based mealson-wheels service was admitted to hospital with nonspecific symptoms, but had clinical and biochemical evidence of scurvy. Subsequently, all new admissions (n=37) to the department over a three week period were assessed for evidence of undernutrition. It was found that 73% had hypovitaminosis C, with 30% having concentrations suggestive of scurvy. There were no significant associations between level of vitamin C and type of accommodation, food provision, or age. The commonest symptom associated with vitamin C deficiency was anorexia, but overall, there was a paucity of clinical signs associated with vitamin C deficiency. The possible associations of vitamin C deficiency in the elderly are discussed.A n 80 year old man presented with a gradual deterioration in his wellbeing over the past nine months, escalating to a point where he was bed bound. He also described an undetermined amount of weight loss associated with loss of appetite. His daughter had noticed that he had also developed mild short term memory loss, and he had been described by his general practitioner to have "dementia".His past medical history included bilateral total hip replacements, hypertension, iron deficiency anaemia in 1994 investigated with oesophagoduodenoscopy and colonoscopy (which were normal), and a label of folate deficiency from 1996. Current medications included ranitidine (150 mg twice a day) for indigestion, and nifedipine (10 mg twice a day) for hypertension.The patient was a widower and lived alone in his two bedroomed flat. He did not have home help, but did have daily meals-on-wheels. His daughter lived three miles away, visiting him every few days to help with shopping and cleaning.On examination, he was a thin elderly man whose body mass index was 19.8 kg/m 2 . He was not clinically anaemic and had no palpable lymphadenopathy, nor hepatosplenomegaly. There was marked superficial bruising and numerous "pigtail" hairs were present, mainly on his abdomen (fig 1). He was edentulous and had no stigmata suggestive of gingivitis. Minimental state examination (MMSE) score was 29/30. Further neurological examination was normal.Initial investigations including full blood count, folate, B12, clotting studies, electrolytes, and liver function and acute phase reactants were normal. Plasma vitamin C concentrations confirmed our clinical suspicion of scurvy (vitamin C <5, normal range 40-100 µmol/l). TREATMENT AND PROGRESSThe patient was referred to the dietitian for review. As previously noted, meals-on-wheels were provided, yet "he did not like the taste of the orange juice provided" and therefore did not drink any. He did not consume many of the vegetables, eating mainly meat. He was advised appropriate changes to his diet and received a 1 g supplement of vitamin C for a period of one month.At review, six weeks later, his bruising had disappeared, his weight had increased, and his appetite was improved. His MMSE was unchanged, but subjectively his short term memory had improved. STUDY...
This paper describes the experience of a cohort of elderly patients who were discharged after attending the accident and emergency department of a large Australian teaching hospital. Before‐and‐after comparisons of aspects of physical functioning revealed a considerable loss of independence in the period immediately after the visit to the hospital. Subsequent hospital admission or death was observed in 30 of the 90 patients studied. It is suggested that elderly patients discharged from the accident and emergency department are at risk and require special consideration and a high index of suspicion in terms of evaluation at the time of presentation. Before discharge, account should be taken of aspects of physical and mental function, social networks, and community supports available to each patient. A lowered threshold for admission is recommended on the basis of the high rate of return found in this study.
Balancing the interests of individual autonomy and protection is an escalating challenge confronting an ageing Australian society. One way this is manifested is in the current ad hoc and unsatisfactory way that capacity is assessed in the context of wills, enduring powers of attorney and advance health directives. The absence of nationally accepted assessment guidelines results in terminological and methodological miscommunication and misunderstanding between legal and medical professionals. Expectations between legal and medical professionals can be clarified to provide satisfactory capacity assessments based on the development of a sound assessment paradigm.
Assessing testamentary capacity in the terminal phase of an illness or at a person's deathbed is fraught with challenges for both doctors and lawyers. Numerous issues need to be considered when assessing capacity for a will. These issues are exacerbated when such an assessment needs to be undertaken at the bedside of a dying patient. The nature and severity of the illness, effects on cognition of the terminal illness, effects of medication, urgency, psychological and emotional factors, interactions with carers, family and lawyers, and a range of other issues confound and complicate the assessment of capacity. What is the doctor's role in properly assessing capacity in this context and how does this role intersect with the legal issues? Doctors will play an increasing role in assessing testamentary capacity in this setting. The ageing of society, more effective treatment of acute illness and, often, the prolongation of dying are only some of the factors leading to this increasing need. However, despite its importance and increasing prevalence, the literature addressing this challenging practical area is scarce and offers limited guidance. This paper examines these challenges and discusses some practical approaches.
Part 4: Health Care ISInternational audienceContemporary societies increasingly rely on complex and sophisticated information systems for a wide variety of tasks and, ultimately, knowledge about the world in which we live. Those systems are central to the kinds of problems our systems and sub-systems face such as health and medical diagnosis, treatment and care. While health information systems represent a continuously expanding field of knowledge production, we suggest that they carry forward significant limitations, particularly in their claims to represent human beings as living creatures and in their capacity to critically reflect on the social, cultural and political origins of many forms of data ‘representation’. In this paper we take these ideas and explore them in relation to the way we see healthcare information systems currently functioning. We offer some examples from our own experience in healthcare settings to illustrate how unexamined ideas about individuals, groups and social categories of people continue to influence health information systems and practices as well as their resulting knowledge production. We suggest some ideas for better understanding how and why this still happens and look to a future where the reflexivity of healthcare administration, the healthcare professions and the information sciences might better engage with these issues. There is no denying the role of health informatics in contemporary healthcare systems but their capacity to represent people in those datascapes has a long way to go if the categories they use to describe and analyse human beings are to produce meaningful knowledge about the social world and not simply to replicate past ideologies of those same categories
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