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Introduction Constipation has a high prevalence of 30-40% in those aged over 65. It can lead to complications including delirium, faecal impaction, stercoral ulceration, and bowel obstruction. Although stool charts are used in geriatric wards to monitor bowel movements to guide management of constipation, they are often inconsistently recorded. Similarly, regular laxatives are often not prescribed for constipated patients due to ward pressures or unawareness regarding their importance. Aims Our aims were to audit the rates of recording on stool charts and laxative prescription in a geriatrics department, and to assess whether a multifactorial intervention aimed at both doctors and nursing staff improved these rates. Methods Two independent assessors audited the recording of stool charts, and rates of constipating medications and laxative prescription in two geriatrics wards in a tertiary UK hospital. A multifactorial intervention was implemented, consisting of didactic sessions for doctors and nurses, healthcare assistant champions to promote the recording of stool charts, and consolidation of bowel movement recording onto a single paper stool chart by the bedside rather than multiple charts. After the intervention, the data was re-audited on the same wards. Descriptive statistics and frequency tabulation were used for data analysis. Results Data was collected from 33 patients. Pre-intervention, stool charts were recorded daily in 13 patients, 10 patients had no stool chart record, 20 patients were on at least one constipating medication, 12 patients were prescribed at least one laxative, and 5 out of 7 patients with opiates had laxatives co-prescribed. Post-intervention, stool charts were recorded daily in 21 patients, all patients had a stool chart record, 20 patients were on at least one constipating medication, 23 patients were prescribed at least one laxative, and 2 out of 4 patients with opiates had laxatives co-prescribed. Our intervention improved daily recording on stool charts by 24%, resulted in all patients having a current stool chart and improved prescription of regular laxatives by 34%. Conclusions A multifactorial intervention based on educational sessions, healthcare assistants acting as champions, and consolidation of recording of bowel movements into a single chart, improved stool chart recording and prescription of regular laxatives in a tertiary geriatrics department. Future auditing will extend the sample size and generalise the intervention to other hospital departments.

BACKGROUND: We determined the impact of a system-wide multicomponent intervention to improve recognition and documentation of cognitive frailty syndromes on hospital administrative coding for delirium. METHODS: A multicomponent intervention including introduction of structured patient assessment including cognitive/delirium screen, regular audit/feedback and educational seminars was undertaken (2012–17). Sensitivity and specificity of administrative International Classification of Diseases, 10th revision (ICD-10) delirium codes for the gold standard of prospectively clinically diagnosed delirium were calculated in consecutive patients admitted to acute medicine over five 8-week cycles (2010–18). RESULTS: Among 1,281 consecutive unselected admissions to acute medicine overall (mean / standard deviation age = 70.0/19.2 years; n=615 (48.0%) male), 320 had clinical delirium diagnosis (n=220 delirium only; n=100 delirium on dementia). Sensitivity of delirium coding increased from 12.8% (95% confidence interval (CI) 5.6–26.7) in 2010 to 60.2% (95% CI 50.1–69.7; p(trend)99% throughout. CONCLUSION: A multicomponent intervention increased sensitivity of hospital administrative diagnostic coding for delirium almost six-fold without increasing the false positive diagnosis rate.

We thank Cao et al. for their interest in our study.1 We acknowledge the importance of delayed scan time in DWI sensitivity and have previously highlighted this issue.2,3 Accordingly, there was a declining prevalence of DWI positivity with time, although 65% of our patients were scanned within 5 days.

Background and Purpose— Visit-to-visit variability in systolic blood pressure (SBP) is associated with an increased risk of stroke and was reduced in randomized trials by calcium channel blockers and diuretics but not by renin–angiotensin system inhibitors. However, time of day effects could not be determined. Day-to-day variability on home BP readings predicts stroke risk and potentially offers a practical method of monitoring response to variability-directed treatment. Methods— SBP mean, maximum, and variability (coefficient of variation=SD/mean) were determined in 500 consecutive transient ischemic attack or minor stroke patients on 1-month home BP monitoring (3 BPs, 3× daily). Hypertension was treated to a standard protocol. Differences in SBP variability from 3 to 10 days before to 8 to 15 days after starting or increasing calcium channel blockers/diuretics versus renin–angiotensin system inhibitors versus both were compared by general linear models, adjusted for risk factors and baseline BP. Results— Among 288 eligible interventions, variability in SBP was reduced after increased treatment with calcium channel blockers/diuretics versus both versus renin–angiotensin system inhibitors (−4.0 versus 6.9 versus 7.8%; P =0.015), primarily because of effects on maximum SBP (−4.6 versus −1.0 versus −1.0%; P =0.001), with no differences in effect on mean SBP. Class differences were greatest for early-morning SBP variability (3.6 versus 17.0 versus 38.3; P =0.002) and maximum (−4.8 versus −2.0 versus −0.7; P =0.001), with no effect on midmorning ( P =0.29), evening ( P =0.65), or diurnal variability ( P =0.92). Conclusions— After transient ischemic attack or minor stroke, calcium channel blockers and diuretics reduced variability and maximum home SBP, primarily because of effects on morning readings. Home BP readings enable monitoring of response to SBP variability-directed treatment in patients with recent cerebrovascular events.

Background In previous studies of treated hypertensives, nocturnal-BP was a stronger predictor than daytime-BP of residual risk of stroke and cardiovascular events (CVEs). However, it is unclear whether nocturnal hypertension (NH) explains residual risk of recurrent stroke after TIA/ischaemic stroke. Methods In a population-based study (Oxford Vascular Study), consecutive patients with TIA/non-disabling stroke had 24 hour ambulatory BP-monitoring (ABPM) at one-month follow-up. Mean daytime and mean night-time-BP were related to risk of recurrent stroke and cardiovascular events on follow-up after age/sex-adjustment. NH was defined as asleep mean SBP ≥120 mmHg and daytime-hypertension (DH) as awake mean SBP ≥140 mmHg. Results Among 1035 patients with ABPM (mean/SD age 68.67/12.74), 372 (36.4%) had residual NH and 190 (18.4%) had residual DH (p Conclusion Residual nocturnal hypertension was more common than daytime hypertension, but it was not a major risk factor for stroke or cardiovascular events.

Background and Purpose— Lack of reduced cognitive impairment with blood pressure (BP) lowering in trials may reflect use of the Mini-Mental State Examination (MMSE), which is insensitive to mild cognitive impairment after cerebrovascular events compared with the Montreal Cognitive Assessment. We determined relationships between impairment on MMSE versus Montreal Cognitive Assessment (MoCA) with the major physiological determinant of vascular cognitive impairment: hypertension and hypertensive arteriopathy. Methods— Cognitive impairment in consecutive patients 6 months after transient ischemic attack or minor stroke was defined as significant, mild, or none (MMSE Results— Of 463 patients, 45% versus 28% had at least mild cognitive impairment on the MoCA versus MMSE ( P Conclusions— The stronger relationship between impairment on the MoCA with hypertensive arteriopathy, independent of age, indicates a greater sensitivity for vascular-origin cognitive impairment. Use of MoCA should improve sensitivity for cognitive impairment and treatment effects in future studies.