Objectives: Advances in the field of clinical nutrition have introduced a wide range of formulations to the market. Today physicians are faced with a bewildering choice of formulations. Increasingly, patients are being discharged to the community from the restructured hospitals with enteral tube feeding. It is important for the family physician to be familiar with the types of formulations and the different enteral tubes. These tubes need to be changed on a regular basis and the family physician in the community will likely be called upon to provide such services. The enteral route is always preferable to parenteral provided there are no contraindications such as ileus, gastrointestinal ischaemia, or bilious and persistent vomiting. Enteral tubes are easy to insert and cheap, and the insertion can be done at the bedside. It is important to confirm the correct placement of the tube in the stomach before initiating feeding as the tube may be coiled, twisted or malpositioned in the respiratory tract. This can be done by aspiration of the stomach contents and testing it with pH paper. In the case of an unconscious patient, this can be done with a chest X-ray.

Sleep disturbance is common in the elderly and is frequently undiagnosed. It has been estimated that 75% of adults >65 years of age has sleep disturbance and 30% of them has insomnia. The classification of insomnia has less significance in the older adults as the subtypes demonstrate significant overlap and usually treatment of the underlying disorder does not solve the problem or cure it. The elderly has multiple comorbidities and polypharmacy with a myriad of cause for insomnia. A comprehensive medical and psychiatric history together with a complete physical examination and mental state examination should be done in the evaluation of the older patient. Behavioural therapy with sleep hygiene education should be the initial treatment together with the treatment of the contributing physical and psychiatric conditions. Referral to an expert for cognitive behavioural therapy or multicomponent therapy may be necessary if the initial therapy failed to produce any improvement. If medications are needed it can be combined with behavioural therapy. Medication used should be the lowest effective dose and prescribed for short-term use of not more than 4 weeks. Medications used need to be discontinued gradually and one needs to be mindful of rebound insomnia upon withdrawal. Wherever possible, it will be ideal to avoid benzodiazepines and other sedative hypnotics as first choice for insomnia. Over the counter sleep aids which usually contain antihistamines may not be good choices as they carry significant risk of adverse events and drug interactions. Currently the safest medications for use in the elderly includes the Z-drugs (zolpidem, zopiclone), melatonin and low dose tricyclic antidepressant Doxepin.

Community resources are limited. Most are run by Voluntary Welfare Organisations that depend on subsidies from the government and funds raised from donations and activities. The out-of-pocket payment from patients depends on per capita household means testing. Patients are matched to the type of services based on their functional statuses. The tools used for functional assessments are the RAF forms and Modified Bartel Index. Applications for most of the community services are done online through the Agency of Integrated Care. Essentially, there are three types of community resources, namely financial, psychosocial, and care resources to help patients in need. To navigate this social maze, Family Physicians will need to familiarise themselves with the type of resources available, the means testing procedure, as well as the referral system. After assessing the patient’s needs and functional status, family physicians will have to match the services that can best serve their patient’s needs.

Singapore has a rapidly ageing population with an increasingly complex chronic disease burden. The number of seniors living alone has also tripled in the last 15 years. Primary care physicians will have to change the way that we delivery primary care. Patients have multi-comorbidities and are sicker. Family Physician Practice has to enhance the coordination of medical and social care and the provision of comprehensive care across the entire cycle of care. This can be achieved by being connected to the health system and resources, making additional efforts in providing care coordination to navigate the health system, and optimising clinical social care around the patient’s needs with a multi-disciplinary team (MDT). There has been an increase in the number of services in the community but gaps still exist, especially in the coordination of healthcare and psychosocial care services. The team will need to tap on all available services to ensure patients’ medical and social needs are taken care of and they are enabled to age gracefully in place.

Wound healing is achieved through four coordinated and overlapping phases, 1) haemostasis, 2) inflammatory, 3) proliferative and 4) remodelling. This complex process can be disrupted by local or systemic risk factors, resulting in delayed healing and progression to a chronic wound. Chronic wounds interact closely with a patient’s comorbid illnesses, social circumstances and functional status. The Family Physician plays an important role to optimise patient and wound risk factors that impair wound healing. Strategies to enhance wound healing include optimising local wound care based on TIME principles, identification and optimising the underlying causes for poor wound healing and education to the patients and their caregivers in wound care, dressing changes and avoidance of risk factors to prevent recurrence. Complex chronic wound care may need a multi-disciplinary approach involving allied health members to provide additional nutritional, nursing and psychosocial support. There is a role for adjuvants such as hyperbaric oxygen therapy and platelet derived growth factor gels to enhance healing in certain wounds but stronger evidence is required to support its routine use.

Given the myriad of choices available on the market, selecting the appropriate wound dressing remains a challenge for most healthcare workers. It is important to exercise discretion and adopt a systematic approach in dressing selection following wound assessment, as this will directly impact on rates of wound healing, which in turns affects the patient’s quality of life and overall healthcare costs. This paper provides an overview of the common types of wound dressings in use currently and gives a brief synopsis of some of the latest advances in wound care technology and their applications in management of complex wounds. The consensus to date is for the use of hydrogels in the debridement stage, foams and low-adherence dressings in the granulation stage and hydrocolloids and low-adherence dressings for the epithelialization stage. Additional studies and research need to be undertaken to further evaluate the application of advanced wound technology in clinical practice.

Sleep disturbance is common in the elderly and is frequently undiagnosed. It has been estimated that 75 percent of adults >65 years of age has sleep disturbance and 30 percent of themhas insomnia. The classification of insomnia has less significance in the older adults as the subtypes demonstrate significantoverlap and usually treatment of the underlying disorder doesnot solve the problem or cure it. The elderly has multiplecomorbidities and poly pharmacy with a myriad of cause forinsomnia. A comprehensive medical and psychiatric historytogether with a complete physical examination and mentalstate examination should be done in the evaluation of the older patient. Behavioural therapy with sleep hygiene educationshould be the initial treatment together with the treatmentof the contributing physical and psychiatric conditions.Referral to an expert for cognitive behavioural therapy ormulticomponent therapy may be necessary if the initial therapy failed to produce any improvement. If medications are neededit can be combined with behavioural therapy. Medication usedshould be the lowest effective dose and prescribed for short-term use of not more than four weeks. Medications used needto be discontinued gradually and one needs to be mindfulof rebound insomnia upon withdrawal. Whenever possible,it will be ideal to avoid benzodiazepines and other sedativehypnotics as first choice for insomnia. Over the counter sleepaids which usually contain antihistamines may not be goodchoices as they carry significant risk of adverse events and druginteractions. Currently the safest medications for use in theelderly includes the Z-drugs (zolpidem, zopiclone), melatoninand low dose tricyclic antidepressant Doxepin.

INTRODUCTIONFrequent admitters to hospitals are high-cost patients who strain finite healthcare resources. However, the exact risk factors for frequent admissions, which can be used to guide risk stratification and design effective interventions locally, remain unknown. Our study aimed to identify the clinical and sociodemographic risk factors associated with frequent hospital admissions in Singapore.

METHODSAn observational study was conducted using retrospective 2014 data from the administrative database at Singapore General Hospital, Singapore. Variables were identified a priori and included patient demographics, comorbidities, prior healthcare utilisation, and clinical and laboratory variables during the index admission. Multivariate logistic regression analysis was used to identify independent risk factors for frequent admissions.

RESULTSA total of 16,306 unique patients were analysed and 1,640 (10.1%) patients were classified as frequent admitters. On multivariate logistic regression, 16 variables were independently associated with frequent hospital admissions, including age, cerebrovascular disease, history of malignancy, haemoglobin, serum creatinine, serum albumin, and number of specialist outpatient clinic visits, emergency department visits, admissions preceding index admission and medications dispensed at discharge. Patients staying in public rental housing had a 30% higher risk of being a frequent admitter after adjusting for demographics and clinical conditions.

CONCLUSIONOur study, the first in our knowledge to examine the clinical risk factors for frequent admissions in Singapore, validated the use of public rental housing as a sensitive indicator of area-level socioeconomic status in Singapore. These risk factors can be used to identify high-risk patients in the hospital so that they can receive interventions that reduce readmission risk.