Analysis of Adverse Effects during Amantadine Prophylaxis in a Nursing Home Population

Objective:

To evaluate adverse reactions during amantadine prophylaxis in a nursing home population, and to identify baseline characteristics that were associated with their development.

Design:

A retrospective chart review.

Setting:

A 233-bed teaching nursing home.

Main Results:

Amantadine prophylaxis was given to 199 of 210 residents (95 percent), 19 of whom died during the one-month period of amantadine prophylaxis. None of the deaths were attributed to amantadine. Of the surviving residents, 26 percent developed adverse effects after an average of two weeks of amantadine prophylaxis. The majority of adverse effects involved the central nervous system, including change in mental status in 40 percent, agitation or disruptive behavior in 34 percent, hallucinations in 19 percent, and mood changes in 19 percent. All adverse effects resolved. Baseline characteristics regarding age, gender, serum creatinine, number of medications, and dosage of amantadine of the residents who experienced adverse effects were similar to those of patients who did not. Adverse effects tended to occur less often in patients with an underlying cardiovascular illness than in those without (odds ratio = 0.52; confidence interval = 0.27–1.0). There was no obvious explanation for this association, which approached statistical significance. Patients with an underlying psychiatric disorder tended to develop adverse effects almost twice as often as those without, but this trend was also not statistically significant (odds ratio = 1.9; confidence interval = 0.93–3.8).

Conclusions:

Amantadine prophylaxis was associated with reversible adverse effects in 26 percent of these nursing home residents. Earlier identification of adverse effects (and subsequent dose reduction) with a prospective surveillance checklist might have lessened the severity and duration of adverse effects.

The incidence of attempted CPR in nursing homes

We studied the frequency with which cardiopulmonary resuscitation (CPR) is attempted on residents of American nursing homes. Each author (all members of the Clinical Practice Committee of the American Geriatrics Society) completed a questionnaire in 1989 about policy and practice regarding CPR during 1988 in each of three to seven nursing homes, by questioning the medical or nursing director or the administrator. Because of the vagaries of nursing home record-keeping, data from some homes were allowed when they were "accurate to within 10%." Data from 58 nursing homes, totalling 10,836 bed-years were available. In 33 of these homes, accounting for 5,425 bed-years, CPR was never attempted. CPR was more likely to be foregone in nursing homes with religious affiliation than in nursing homes without (13 of 17 vs 18 of 38; chi 2 = 4.0; P less than 0.05). Religious affiliation was unknown for three nursing homes. Academic affiliation (10 of 16 vs 20 of 37 in non-affiliated nursing homes) and non-profit status (14 of 19 vs 16 of 23 in for-profit nursing homes) did not significantly affect the likelihood that CPR would never be used. In 31 of 54 nursing homes with explicit do not resuscitate (DNR) policies, CPR was never performed, compared to 2 of 4 homes without such policies. For nursing homes with complete data, there were 1,196 deaths in 32 facilities where CPR was never attempted compared to 1,294 deaths for 24 nursing homes with CPR. For 22 nursing homes without CPR, there were 2,172 emergency room transfers compared to 1,363 emergency room transfers in 18 nursing homes where CPR was attempted.(ABSTRACT TRUNCATED AT 250 WORDS)

The outcome of CPR initiated in nursing homes

To determine outcomes following attempted cardiopulmonary resuscitation initiated in nursing homes, we retrospectively reviewed ambulance and hospital records for all 705 people aged 65 or over who underwent attempted resuscitation by ambulance crews in 1987 in Baltimore City and Baltimore County. From medic unit encounter forms we noted whether or not the address of origin was a nursing home and to what hospital the person was taken. Hospital records were then examined to determine outcomes: death in the emergency room, death during consequent hospitalization, or live discharge. Complete information was obtained for all 117 nursing-home residents and for 580 of 588 nonresidents. When attempted resuscitation was begun in a nursing home, only two patients survived to hospital discharge, whereas 61 nonresidents (11%) survived after a mean stay of 14 days. Of the 115 nursing-home residents who did not survive to hospital discharge, 102 (89%) were pronounced dead in the emergency room, two (2%) more died within 24 hours of admission, and the remaining 11 (9%) died after an average stay of five days. Of the 519 nonresidents who died before discharge, 433 (83%) were pronounced dead in the emergency room, 16 (3%) died in the first 24 hours, and 70 (14%) lived an average of nine days. One of the two nursing-home residents who survived was an 87-year-old woman who spent 30 days in the hospital and died eight months after returning to the nursing home, demented, cachectic, with a large sacral pressure sore.(ABSTRACT TRUNCATED AT 250 WORDS)

Racial bias in presentation of cases

To investigate whether medical housestaff report race information differently during case presentations of black patients and white patients, a prospective observational study was performed. Without informing housestaff, a chief resident recorded data during consecutive case presentations over two months. For each presentation, the data included: 1) whether, where, and how often race was identified; 2) whether certain prospectively selected, "possibly unflattering characteristics" were mentioned; and 3) whether any "justifying" diagnoses were considered during presentation or subsequent discussion. Justifying diagnoses were those in which a patient's race was important in considering the likelihood of possible diagnoses. Twenty-three house officers presented 18 black and 35 white patients. A single East Indian patient was excluded from analysis. Race was specified more often during presentations of black than of white patients (16 of 18 for blacks vs. 19 of 36 for whites; p less than 0.01). For two black patients, a justifying diagnosis was considered, but excluding these patients did not change the results. Two other differences did not achieve statistical significance. Race was more often specified prominently and repeatedly during presentations of black patients. Among patients to whom "possibly unflattering" characteristics were attributed, race was more likely to be specified for blacks (10 of 10) than for whites (4 of 9). These case presentations appeared to show a subtle bias.

Deciding about resuscitation in a nursing home. Theory and practice

This study examines how plans about cardiopulmonary resuscitation (CPR) were made, what relevant orders were written, and what actual events occurred at the time of death in a nursing home. A chart review of 119 residents who died in a 233-bed nursing home in 1987 found one who underwent (unsuccessful) CPR. Nine records were unusable. The remaining 109 cases, none of which involved CPR, were studied. Documentation of discussions about CPR between physicians and residents or their surrogates was present in 90 charts. Of 85 residents with cognitive impairment, four were included in the CPR discussion and surrogates were consulted for 66. In 15, no discussion was documented. Of 24 residents without documented cognitive impairment, 11 were consulted. For nine others, surrogates were asked, and in four no discussion was recorded. One resident and three surrogates requested CPR. All others who were asked accepted a do-not-resuscitate (DNR) order. For 67 residents DNR orders were written. In six of these cases, physicians wrote the order without documenting consultation with resident or surrogate. For five residents orders to resuscitate (full code orders) were written. For 37 residents no order about CPR was recorded. Of the 42 residents who died without a DNR order, 37 were found dead by nursing staff, but in only one case was a physician contacted urgently. In this nursing home advance planning about CPR was frequently undertaken. Regardless of planning or the orders in the chart, CPR was a rare event.

Dialysis patients' attitudes about cardiopulmonary resuscitation and stopping dialysis

Dialysis patients are a unique population because of their chronic dependence on complex medical technology. Furthermore, their illness forces them to make critical decisions about medical care (mode of dialysis, renal transplantation, withdrawal from dialysis). The reasons dialysis patients discontinue therapy are not well understood, nor is it known whether they view dialysis therapy differently from other life-support interventions. We asked four groups of patients - in-center hemodialysis (HD), peritoneal dialysis (PD), renal transplant, and ambulatory elderly - questions about their wishes for (1) medical information, (2) participation in medical decision-making, (3) life-supporting therapy including cardiopulmonary resuscitation (CPR) and ventilatory support, and (4) stopping dialysis at the time of the study and in certain hypothetical situations. All groups wanted information and involvement in making medical decisions. Most patients desired CPR (96% of renal transplant, 76% of HD, 63% of PD, 82% of elderly), but PD patients chose CPR less often in all circumstances (at study, p = 0.004; in coma, p = 0.004; in permanent coma, p = 0.04), and they were less willing to undergo chronic ventilation (p = 0.001). PD patients were more likely to stop dialysis (p = 0.02) in coma than were HD patients. PD patients attended religious services more frequently and were less comfortable with machines, but these differences did not correlate with their decisions about life-support therapy. Dialysis patients have rarely considered stopping dialysis; they are similar to ambulatory elderly patients with regard to decisions about CPR and desire for involvement in medical decision-making. PD patients are a distinct subgroup worthy of further study.

Planning with elderly outpatients for contingencies of severe illness: a survey and clinical trial

The authors examined whether elderly patients would report positive or adverse emotional effects after their doctor, during a routine clinic visit, asked them to begin planning for future serious illness. Seventy-four patients, 65 years old or older, who were followed at a university hospital medical clinic were randomly allocated to an intervention or a control group. The intervention was a detailed discussion with the patient's physician of the patient's wishes about decision making and life support therapy in the event of extreme or incapacitating illness. A blinded interviewer then asked all consenting patients how they felt about the physician, the clinic visit, and their medical care. Intervention-group patients were questioned about their reactions to the physician and the discussion. Four important findings emerged: 1) Some emotional uncertainty was created when doctors raised these questions unexpectedly: one patient became visibly upset during the discussion, and three who gave consent to be interviewed afterward said that the discussion had made them wonder about their health. Nonetheless, all patients who received the intervention and completed the study were pleased that their doctor had asked. 2) Only 44% of all consenting patients reported having discussed these issues previously; only one had done so with a doctor. 3) 97% of patients who responded wanted to be kept informed by the doctor about their medical situations in times of serious illness. 4) Patients' replies to specific questions about life-sustaining therapy in the event of their own severe illnesses were quite variable. During routine clinic visits doctors can encourage most elderly patients to begin specific planning for potential severe illnesses.