Routine testing of folate levels in geriatric assessment for dementia

Infections in nursing homes: assessing quality of care

BACKGROUND

Each year more than 25% of nursing home patients are taken to the hospital emergency room or hospitalized for the evaluation and treatment of infections. These transfers may have an adverse impact on the quality and the cost of patient care.

METHODS

Using both Medicare and Medicaid records from a sample of dually eligible elderly people in Ohio, we identified patients receiving antibiotic prescriptions in the nursing home and measured the frequency of nursing home physician visits and the hospital transfer rate.

RESULTS

Among the study sample (N = 1306), two thirds experienced a total of 3685 episodes of infections. Just under 5% of the sample were hospitalized as a result of the infection. In one third of the episodes, physicians saw the resident in person within 5 days (before or after) of the initiation of the medication. The hospital transfer rate was slightly higher (7% vs 3.5%) for those patients directly evaluated by a physician before receiving the prescription.

CONCLUSIONS

A majority of prescriptions were written without direct physician examination, raising key questions about practice patterns and the effect on patient care and costs.

Reversible dementias

With so many conditions that can manifest in dementia, the question arises as to how extensive an evaluation need be done on the individual patient presenting with dementia. Thorough physical, neurologic, and psychiatric examinations are the cornerstones of the work-up, with special attention paid to the history, use of medications, and mental status of the patient. Laboratory tests recommended by the National Institutes of Health Consensus Conference on Differential Diagnosis of Dementing Diseases include a complete blood count, electrolyte and metabolic screen, thyroid panel, vitamin B12 and folate levels, syphilis serology, urinalysis, chest radiograph and electrocardiogram, and head CT scan. These evaluations are sufficient to diagnose the majority of treatable dementias. Other evaluations including magnetic resonance imaging, electroencephalography, cerebrospinal fluid examination, cerebral blood flow and metabolism measures (rate of cerebral blood flow, single photon emission computed tomography, and positron-emission tomography), and brain biopsy all can be of additional assistance in diagnosing the cause of the dementia when justified by the clinical setting. When the appropriate diagnosis is made, therapy is directed at the primary disorder. Successful treatment of the primary condition may result in stabilization or partial or complete reversal of the cognitive disturbance. In some instances, judicious pharmacologic management of the accompanying behavioral disturbance may be required.