The minimum data set depression quality indicator: does it reflect differences in care processes?

PURPOSE

The objective of this work was to determine if nursing homes that score differently on prevalence of depression, according to the Minimum Data Set (MDS) quality indicator, also provide different processes of care related to depression.

DESIGN AND METHODS

A cross-sectional study with 396 long-term residents in 14 skilled nursing facilities was conducted: 10 homes in the lower (25th percentile: low prevalence 0-2%) quartile and 4 homes in the upper (75th percentile: high prevalence 12-14%) quartile on the MDS depression quality indicator. Ten care processes related to depression were defined and operationalized into clinical indicators. Measurement of nursing home staff implementation of each care process and the assessment of depressive symptoms were conducted by trained research staff during 3 consecutive 12-hr days (7 a.m. to 7 p.m.), which included resident interviews (Geriatric Depression Scale), direct observations, and medical record review using standardized protocols.

RESULTS

The prevalence of depressive symptoms according to independent assessments was significantly higher than prevalence based on the MDS quality indicator and comparable between homes reporting low versus high rates of depression (46% and 41%, respectively). Documentation of depressive symptoms was significantly more common in homes reporting a high prevalence rate; however, documentation of symptoms on the MDS did not result in better treatment or management of depression according to any care-process measure. Psychosocial prevention and intervention efforts, such as resident participation in organized social group activities, were not widely used within either group of homes.

IMPLICATIONS

The MDS depression quality indicator underestimates the prevalence of depressive symptoms in all homes but, in particular, among those reporting low or nonexistent rates. The indicator may be more reflective of measurement processes related to detection of symptoms than of prevention, intervention, or management of depression outcomes. A depression quality indicator should not be eliminated from MDS reports because of the importance and prevalence of the condition. However, efforts to improve nursing home staff detection of depressive symptoms should be initiated prior to the use of any MDS-based depression indicator for improvement purposes. Homes that report a low prevalence of depression according to the nationally publicized MDS quality indicator should not be regarded as providing better care.

Improving food intake in nursing home residents with feeding assistance: a staffing analysis

BACKGROUND

Recommendations have been made to increase the number of nursing home (NH) staff available to provide feeding assistance during mealtime. There are, however, no specific data related to two critical variables necessary to estimate mealtime staffing needs: (1) How many residents are responsive to feeding assistance? (2) How much staff time is required to provide feeding assistance to these residents? The purpose of this study was to collect preliminary data relevant to these two issues.

METHODS

Seventy-four residents in three NHs received a 2-day, or six-meal, trial of one-on-one feeding assistance. Total percentage (0% to 100%) of food and fluid consumed during mealtime was estimated across 3 days during usual NH care and 2 days during the intervention. The amount of time that staff spent providing assistance and type of assistance (i.e., frequency of verbal and physical prompts) was measured under each condition.

RESULTS

One half (50%) of the participants significantly increased their oral food and fluid intake during mealtime. The intervention required significantly more staff time to implement (average of 38 minutes per resident/meal vs 9 minutes rendered by NH staff).

CONCLUSIONS

The time required to implement the feeding assistance intervention greatly exceeded the time the nursing staff spent assisting residents in usual mealtime care conditions. These data suggest that it will almost certainly be necessary to both increase staffing levels and to organize staff better to produce higher quality feeding assistance during mealtimes.

Health care utilization by old-old long-term care facility residents: how do Medicare fee-for-service and capitation rates compare?

OBJECTIVE

To describe the healthcare utilization of a long-term care population receiving primary and specialty care in a closed system and to compare Medicare fee-for-service (FFS) reimbursement with the amount that would have been paid under capitation for these services.

SETTING

A life care community in California composed of two facilities, both having residential care and nursing facility (NF) beds.

PARTICIPANTS

Residents (n = 700) living in the community between September 1995 and February 1996.

METHODS

Data on Medicare Part A and Part B reimbursements were gathered from billing records for hospitalizations, based on diagnostic related group payments, primary and specialty care visits, various procedures, diagnostic tests, and therapeutic services. These data were compared with what the facility, in collaboration with the providers and an affiliated hospital, would have received under Medicare capitated rates at that time.

RESULTS

Annually, residents averaged 16.3 primary care visits, 7.7 specialist visits, and 3453 hospital days per thousand. Nursing facility residents received significantly more primary care than did those in residential care. Total Medicare Part A and B payments per resident per month averaged $558. The monthly capitation rate in effect at the time for this population was substantially higher at $1085, generating an annual "risk pool" of $9.1 million. Care provided in the two facilities varied greatly. Hospitalization rates, clinic-based primary care and specialist visits, and therapy sessions were greater in facility one. Overall expenditures were lower for residents at facility two, where the majority of care was provided by trained geriatricians in collaboration with physician extenders and without sophisticated clinical pathways and utilization controls.

CONCLUSIONS

Our data support other studies that suggest that teams of geriatricians and physician extenders can reduce hospitalization rates and overall expenditures. Capitated rates for the frail, geriatric population warrant careful study. These rates must balance fiscal responsibility with the need for adequate, risk-adjusted payments that create incentives for providers to produce high quality as well as cost-effective care.

Barriers to effective communication in skilled nursing facilities: differences in perception between nurses and physicians

BACKGROUND

Effective communication between nurses and physicians is central to the clinical care of nursing home residents. Anecdotal evidence suggests that communication between the groups is unsatisfactory, but no empirical data exist with which to validate assumptions. The purpose of this pilot study was to compare perceptions of potential communication barriers among nurses and physicians in four California nursing homes.

METHODS

Registered nurses (n = 59), and physicians (n = 47) involved in the direct clinical care of nursing home residents completed a 12-item questionnaire designed to elicit perceptions about potential communication barriers. Five specific categories of barriers were identified. These included nurse competence, time burden of calls, necessity of calls, professional respect, and language comprehension. Responses were compared using t test analysis.

RESULTS

Significant differences in perceived communication barriers were identified. Physicians, but not nurses, perceive nursing competence to be a significant barrier. Nurses perceive physicians to be unpleasant. Both physicians and nurses perceive that physicians do not value nurses' opinions. Neither group perceived language expression, language comprehension, or time burden of phone calls to be barriers to communication.

CONCLUSIONS

Issues related to the perceived competency of nurses by physicians is consistent with existing data from other clinical settings. Differences in awareness about scope of practice and regulatory requirements between the groups may offer a partial explanation for the discordant perceptions. Perceptions by nurses (but not physicians) of unpleasantness and/or disrespect during telephone encounters may reflect the broader ongoing differences in professional culture, social status, and gender inequality between the two groups. Further clarification of the causes of barriers to effective communication is essential in order to plan appropriate interventions.

Falls and fall prevention in the nursing home

The mean incidence of falls in nursing homes is 1.5 falls per bed per year (range 0.2-3.6). The most common precipitating causes include gait and balance disorders, weakness, dizziness, environmental hazards, confusion, visual impairment, and postural hypotension. The most important underlying risk factors for falls and injuries include some of these same items as well as others: leg weakness, gait and balance instability, poor vision, cognitive and functional impairment, and sedating and psychoactive medications. A focused history and physical examination after a fall can usually determine the immediate underlying cause(s) of the fall and contributory risk factors. Many strategies for fall prevention have been tried with mixed success. The most successful take into account the multifactorial causes of falls, and include interventions to improve strength and functional status, reduce environmental hazards, and allow staff to identify and monitor high-risk residents. Regular evaluations in the nursing home can help identify patients at high risk who can then be targeted for specific treatment and prevention strategies. Strategies that reduce mobility through use of restraints have been shown to be more harmful than beneficial and should be avoided. A number of promising fall prevention strategies, involving both specific quality assurance programs and technologic devices, are being evaluated currently.

Perioperative care in the elderly urologic patient

This article summarizes the preoperative evaluation and postoperative care recommended for elderly patients undergoing urologic procedures. Most of the common issues faced during the perioperative period are discussed, but many other topics require reference to other sources or consultation with specialists. A thorough preoperative evaluation is needed, and meticulous attention to postoperative care is mandatory. The most important common problem is assessment of cardiovascular risk in patients and a general approach is suggested by the authors. Surgical risk in elderly patients is increased, but most of this excess risk is because of associated comorbid conditions. Effective pre- and postoperative assessment and care can minimize this risk and maximize the chances of a successful outcome.

The medical director in hospital-based transitional care units

This article begins with a brief overview of what subacute care is and why it is growing exponentially. It then discusses the characteristics of patients appropriate for treatment in a transitional care unit (TCU) and the evolving role of physicians in their care. The process of care in a typical hospital-based TCU from admission to discharge is discussed with an emphasis on documentation and an interdisciplinary approach. The role of the medical director is emphasized. The article closes with strategies the authors feel are useful for improving care in hospital-based TCUs.

Cost-effectiveness of low-air-loss beds for treatment of pressure ulcers

BACKGROUND

Cost-effectiveness of low-air-loss beds for the healing of pressure ulcers was analyzed in the nursing home setting. A statistical model of pressure ulcer healing was used to estimate cost-effectiveness based on patient and ulcer characteristics.

METHODS

Results of a previous randomized trial (84 patients from three nursing homes in Los Angeles) were reanalyzed and combined with estimates of costs to calculate the cost-effectiveness in dollars per added day free of pressure ulcers achieved by the use of low-air-loss beds compared to conventional foam mattresses.

RESULTS

The cost-effectiveness of the low-air-loss bed was $26 per added day free of ulcers for our standard patient. Results were sensitive to low-air-loss bed lease costs and patient and wound healing characteristics. Results were less sensitive to expected mortality, daily wound care costs, and time-frame of consideration. Low-air-loss beds were more cost-effective for patients with good healing characteristics and mild ulcers.

CONCLUSIONS

Findings support the expanded use of this technology for patients with mild pressure ulcers and good healing characteristics. For these patients, the cost-effectiveness of low-air-loss beds is comparable to other accepted health treatments. For patients with severe ulcers and poor healing characteristics, low-air-loss bed cost-effectiveness compares poorly with other accepted health treatments unless the lease cost can be substantially reduced, or unless life with a pressure ulcer is valued close to death.

Predictors of skilled nursing placement in a multilevel long-term-care facility

OBJECTIVE

To determine if cognitive and functional data gathered before admission to residential care (i.e., board and care) placement can predict nursing home placement.

DESIGN

Retrospective study using Cox proportional hazards analysis and pairwise assessment of adjusted relative risk factors to determine which independent variables predicted skilled nursing placement. Subjects were followed for an average of 23.7 months (SD = 18.6 months).

SETTING

Multilevel 1,735-bed long-term care facility, Jewish Home for the Aging, Reseda, California.

PARTICIPANTS

Of the 248 consecutive residential care admissions studied, 80% were women. Subject's mean age was 84.8 years (SD = 5.0); 67% had no significant cognitive impairment.

INDEPENDENT VARIABLES

Categorical variables were classifications with respect to dementia status, incontinence, hearing, and ambulation. Interval variables were number of medications, Katz ADL, and five neuropsychological tests. Demographic variables were gender, age, language of origin, and education.

OUTCOME VARIABLE

Time between preadmission testing and the move up to skilled nursing placement.

RESULTS

Pairwise assessment of adjusted potential risk factors indicated that cognitive dysfunction, less than perfect Katz ADL performance, and hearing loss were the most important independent risk factors for nursing placement.

CONCLUSIONS

The findings remind us to pay careful attention to residents exhibiting even relatively mild cognitive deficits upon admission because these residents are likely to need increased environmental support.

Cognitive function in old and very old residents of a residential facility: relationship to age, education, and dementia

OBJECTIVE

To determine if age, education, and dementia status affect neuropsychological performance in old and very old frail residential care subjects.

DESIGN

Descriptive study of performance at the time of preadmission assessment.

SETTING

Jewish Home for the Aging, Reseda, California.

PARTICIPANTS

201 applicants to the Jewish Home for the Aging residential care setting. Mean age was 84.7 years; SD was 5.6. Ninety-five subjects were 84 years of age or younger, while 106 were age 85 and older. There were 141 nondemented, 21 demented, and 39 were possibly demented applicants. Levels of education were as follows: 0-4 years: n = 25; 5-8: n = 69; 9-12: n = 77; and, 13-20: n = 23.

MEASUREMENTS

Independent variables were age, education, and dementia status. Outcome measures were Folstein MMSE, Inglis P-A Learning Test, Digit Span, Cube Copying, selected Boston Diagnostic Aphasia Exam subtests.

RESULTS

Subjects with 0 to 4 years of education scored more poorly on cognitive tests than other subjects. The very old tended to score more poorly than the old. Neuropsychological tests discriminated between those with normal cognitive function, possible dementia, and established dementia. About one-third of nondemented elderly scored below the traditional impairment cut-off of 24 points on the Mini-Mental State Exam.

CONCLUSIONS

Questions are raised about how to interpret the poorer cognitive performance of very old and often frail subjects, especially in long-term-care settings where there are fewer demands upon residents whose impairments might otherwise cause them more functional difficulty.

Physician evaluation and management of nursing home residents

The diverse goals of nursing home care, the heterogeneity of nursing home residents, and the varied circumstances under which physicians care for them make their evaluation and care complex and challenging. When evaluating and caring for nursing home residents, physicians must address many issues besides treatment of multiple chronic diseases (including impairments in cognitive and physical functioning, sensory deficits, depression, and behavioral disorders associated with dementia) and concerns of family members. The physician should be integrated with an interdisciplinary team composed of nurses, rehabilitation therapists, social workers, and others. Recently implemented federal rules for nursing home care, which include the Minimum Data Set and Resident Assessment Protocols, provide a useful framework for interdisciplinary assessment and care planning and should improve the care nursing home residents receive. Better data are needed on the most cost-effective strategies for evaluating and caring for nursing home residents. Reimbursement for physician services, availability of nurse practitioners and physician assistants, and overall quality of nursing home care must be improved so physicians can better achieve the recommendations outlined.

Total quality management: administrative and clinical applications in nursing homes

OBJECTIVE

Describe the application of the Total Quality Management (TQM) model to the unique work force, resident population, and regulatory issues that characterize long term care settings.

DESIGN

The key differences between TQM and current management and training practices in nursing homes are described. A specific data-based example is provided of a successful TQM application to health care involving clinical work processes related to incontinence care.

CONCLUSION

Significant organizational and clinical obstacles must be overcome if TQM is to improve the quality of life and satisfaction of nursing home residents and their families as it has improved the efficiency and product quality in hospital and non-health-care settings.

Change in self-reported functioning in older persons entering a residential care facility

We evaluated the responsiveness of measures of function in admissions to a long-term care facility. Between baseline and follow-up assessment, one-fifth or more of the subjects either worsened or improved in most aspects of reported function. We compared two measures of self-reported function (COOP charts and a short-form survey). Convergent validity was observed for changes in pain, social health, and mental health (r = 0.39-0.74), but not for physical functioning. Although the short-form physical function measure discriminated worsening on several performance-based external criteria of physical functioning (area under ROC curves up to 0.82), the COOP and other measures of physical functioning were less likely to do so. All physical function measures were less responsive for detecting improvement. Clinicians and investigators intending to monitor change in function must consider the responsiveness of their measures.

Using multidimensional health measures in older persons to identify risk of hospitalization and skilled nursing placement

We examine the relationship between multidimensional measures of function and outcomes in a cohort of older persons admitted to the residential care level of a multi-level long-term care facility. We collected self-reported measures of various aspects of health using the Medical Outcome Study Short-form Health Survey (SF-20) and the Dartmouth COOP charts, as well as performance-based measures of physical and cognitive function. Subjects (mean age 84.3 years) were followed for a median of 557 days. In multivariate analyses, emotional function (measured by either the SF-20 or COOP method) was a predictor of placement in skilled care. Self-reported overall health (measured by either the SF-20 or COOP method) and timed manual performance were predictive of hospitalization. Change on the functional status measures between 2 points in time was not associated with later placement in skilled care except in the case of timed manual performance. In an older population at risk for frequent and numerous health events, this study shows that two popularized self-report methods for assessing function yield results that predict future outcomes of great importance to older persons. However, measures that predict use of long-term care may not predict use of the hospital and vice versa.

A randomized trial of low-air-loss beds for treatment of pressure ulcers

OBJECTIVE

To assess the effectiveness of low-air-loss beds for the treatment of pressure ulcers in nursing homes.

DESIGN

Prospective, randomized, clinical trial.

SETTING

Three teaching nursing homes in Los Angeles, Calif.

SUBJECTS

Eighty-four nursing home residents with trunk or trochanter pressure ulcers (Shea stage > or = 2).

INTERVENTIONS

Subjects were randomly assigned to use either a low-air-loss bed (n = 43) or a 10-cm corrugated foam mattress (n = 41) throughout the healing of their ulcers.

OUTCOME MEASURES

Ulcers were assessed twice weekly using surface area and two observational scales (median follow-up, 37.5 days; range, 4 to 571 days).

RESULTS

Groups were similar with respect to demographics, medical variables, wound care, and early dropouts. Results indicate more than a threefold improvement in median rate of healing for low-air-loss beds compared with foam mattresses (9.0 vs 2.5 mm2/d; P = .0002). This finding was true for deep as well as superficial ulcers (deep ulcers, 9.9 vs 0.7 mm2/d; P = .02; superficial ulcers, 9.0 vs 3.2 mm2/d; P = .004). Cox regression models revealed that the bed, ulcer depth, and fecal continence had independent effects on healing. After controlling for fecal continence, the deep and superficial subgroups using low-air-loss beds remained 2.5 times more likely to heal in a given length of time compared with those using foam mattresses (combined cure probability ratio, 2.66; 95% confidence interval, 1.34 to 5.17; P < .004).

CONCLUSION

Low-air-loss beds provide substantial improvement compared with foam mattresses despite other factors in pressure ulcer healing.

Cognitive function in non-demented older adults with hypothyroidism

PURPOSE

(1) to evaluate objectively changes in cognitive function and electrophysiologic characteristics associated with hypothyroidism of varying severity and duration in primarily older persons; (2) to determine whether these changes are reversible when a euthyroid state has been attained after treatment with thyroid hormone.

SUBJECTS AND METHODS

We enrolled 54 non-demented hypothyroid patients (31-99, mean 68.6 +/- 16.4 years) with biochemical evidence of hypothyroidism (38 had overt and 14 had minimal hypothyroidism) and 30 euthyroid controls (31-96, mean 63.7 +/- 18.4 years) screened for good general health. We evaluated attention, orientation, memory, learning, visual-spatial abilities, calculation, language, visual scanning, and motor speed using standardized neuropsychological tests. Electrophysiological measures of neurocognitive function included the P300 latency component of the auditory Event-Related Potentials (ERP) and conduction speed from eye to cortex, the P100 latency component of the Patterned Visual-Evoked Potential (PVEP). All patients were studied when hypothyroid. A subset of patients with minimal initial test abnormalities were available to be retested when euthyroid, 5 and 9 months after onset of thyroid replacement therapy.

RESULTS

Hypothyroid patients showed significantly lower scores on the Mini-Mental Status Test (MMS) and on five of 14 neuropsychological tests as compared to controls. The neuropsychological tests affected were copying a cube (visual-spatial function), the Inglis Paired Associates Learning Test-Low and Medium association items (memory and learning), Animal Naming (word fluency/production), and the Trail Making A test (attention, visual scanning and psychomotor function. Hypothyroidism also was associated with longer P100 latencies of PVEPs to 20' checks, but showed no significant differences in PVEP P100 latency to 50' checks, nor in the latency of the auditory ERP component P300. There was a statistically significant correlation between a laboratory index of the severity of hypothyroidism (serum T4) and the Inglis Medium Association items and Animal Naming. There was a statistically significant improvement after 5 months of treatment on three of the timed performance tests that previous studies have shown to be most sensitive to brain dysfunction.

CONCLUSION

Hypothyroidism in non-demented older adults is associated with impairments in learning, word fluency, visual-spatial abilities, and some aspect of attention, visual scanning, and motor speed. The MMS by itself was sensitive in differentiating hypothyroid patients with cognitive deficits from controls, while electrophysiological measures did not generally differentiate the hypothyroid patients from normal controls. The MMS was not sensitive to treatment effects, but treatment was associated with significant improvements in three of the most sensitive measures of cognitive dysfunction.

Detectable serum levels of tumor necrosis factor alpha may predict early mortality in elderly institutionalized patients

OBJECTIVE

To determine if detectable serum tumor necrosis factor alpha (TNF) levels are associated with higher mortality in nursing home residents.

SUBJECTS AND METHODS

The basal serum concentrations of TNF and interleukin-1 alpha (IL-1) were measured in 129 elderly nursing home patients (mean age of 89 years), and survival in the cohort was monitored over a 13-month period.

RESULTS

At 4 months follow-up, seven out of 33 patients with detectable serum TNF levels had died (21.2%), and only three out of 96 patients with undetectable serum TNF levels had died (3.1%) (P less than 0.001). The difference in mortality remained significant up to 13 months of follow-up (P less than 0.05). Those with detectable serum TNF levels and those with undetectable levels were comparable in age, body mass index, hematocrit, lymphocyte counts, and serum level of albumin, prealbumin, and retinol-binding protein. When patients with detectable serum IL-1 levels were compared to those with undetectable levels, there were no significant differences in mortality over a 13-month period.

CONCLUSION

Detectable serum TNF levels in elderly nursing home patients may be a predictor of early mortality.

Decreased serum triiodothyronine is associated with increased concentrations of tumor necrosis factor

Previous studies in laboratory animals have shown that tumor necrosis factor-alpha (TNF) may alter thyroid function tests. To determine whether elevated serum TNF levels are associated with altered serum concentrations of T4, T3, free T4, rT3, and TSH, we measured these parameters in 29 nursing home residents with detectable serum TNF levels and compared the levels to those found in 36 patients with undetectable serum TNF levels. The 2 groups were matched for age, sex, clinical problems, use of medications, and nutritional status. Patients with detectable serum TNF levels had significantly lower serum T3 concentrations compared to those with undetectable levels [1.072 +/- 0.588 vs. 1.621 +/- 0.594 nmol/L (mean +/- SD); P less than 0.01]. Differences in other tests did not achieve statistical significance. Thyroid function tests were not significantly different when patients with detectable interleukin-1 alpha levels, another cytokine secreted during endotoxemia, were compared to those with undetectable levels. These observations taken together with the previous findings in laboratory animals suggest that some of the alterations in thyroid hormone levels seen in nonthyroidal illness are associated with elevated serum concentrations of TNF.

The value of assessing falls in an elderly population. A randomized clinical trial

OBJECTIVE

To measure the effects of a specialized postfall assessment intended to detect causes and underlying risk factors for falls, and to recommend preventive and therapeutic interventions.

DESIGN

Randomized, controlled trial.

SETTING

A long-term residential care facility for elderly persons.

SUBJECTS

Within 7 days of a fall, 160 ambulatory subjects (mean age, 87 years) were randomly assigned to receive either a comprehensive postfall assessment (intervention group, n = 79) or usual care (control group, n = 81).

INTERVENTION

The postfall assessment included a detailed physical examination and environmental assessment by a nurse practitioner; laboratory tests; electrocardiogram; and 24-hour Holter monitoring. Probable cause or causes for the fall, identified risk factors, and therapeutic recommendations were given to the patient's primary physician.

MEASUREMENTS AND MAIN RESULTS

Through use of the assessment, many remediable problems (for example, weakness, environmental hazards, orthostatic hypotension, drug side effects, gait dysfunction) were detected. At the end of the 2-year follow-up period, the intervention group had 26% fewer hospitalizations (P less than 0.05) and a 52% reduction in hospital days (P less than 0.01) compared with controls. Patients in the intervention group had 9% fewer falls and 17% fewer deaths than controls by 2 years, but these trends were not statistically significant.

CONCLUSIONS

Our study suggests that falls are a marker of underlying disorders easily identifiable by a careful postfall assessment, which in turn can reduce disability and costs.

An outbreak of an influenza-like illness in a nursing home

As part of an ongoing infection surveillance program, data were collected on an outbreak of respiratory illness affecting 29% of residents in a 231-bed long-term care facility. Viral titers could be collected on 60% of the ill residents and respiratory syncytial virus (RSV) was established in 14 of the symptomatic patients and was thought to be the probable cause of the outbreak. Compared with previously reported long-term institutional outbreaks of RSV, there were significantly fewer cases of pneumonia (5% vs. 14% to 55%) and deaths (2% vs. 6% to 20%). However, morbidity was substantial in this outbreak, with 46% of patients suffering prolonged malaise and anorexia; the mean duration of symptoms was four weeks. Respiratory syncytial virus may be an important cause of respiratory illness in nursing homes and may be unappreciated if specific diagnostic methods are not employed. The recent availability of rapid diagnostic tests and specific antiviral therapy for RSV warrant further clinical studies to develop management strategies for this infection.

Salmonella outbreak in a nursing home

We performed a retrospective review of an outbreak of Salmonella gastroenteritis that occurred in a community nursing home in 1987. Forty-four of 199 residents had a diarrheal illness; Salmonella heidelberg was isolated from the stool in 19 cases. Although the distribution of cases suggested a common source for the outbreak, no common source of infection could be demonstrated, despite extensive investigation. The clinical presentation of symptomatic individuals ranged from mild diarrhea to a severe gastrointestinal illness, and 26% of symptomatic, culture-positive patients required hospitalization. The median duration of pathogen excretion during convalescence in untreated residents was six weeks, but six patients who were treated with antibiotics shed S. heidelberg for a median duration of 14.5 weeks. We conclude that (1) the clinical spectrum of Salmonella gastroenteritis in nursing-home patients is variable, ranging from mild to severe illness; and (2) nursing-home Salmonella outbreaks impose a high economic burden because of expense of epidemiologic investigation, prolonged isolation measures, hospitalization for severely ill residents, and potential institutional closure.

Lack of an association between the presence of tumor necrosis factor or interleukin-1 alpha in the blood and weight loss among elderly patients

To determine the association between blood cytokine levels and body weight loss in elderly patients, serum levels of cachectin/tumor necrosis factor alpha (TNF) and interleukin-1 alpha (IL-1) were measured with specific and sensitive ELISA systems. Of the 19 healthy young subjects, two (10.5%) had detectable levels of serum TNF and one (5.3%) was positive for IL-1. In the healthy elderly group, two of the 12 subjects (16.7%) had measurable TNF levels and four (33.3%) had elevated IL-1 levels. Of the 61 ambulatory elderly patients, 31.1% had serum that contained TNF and 22.9% had IL-1. Similar proportions were found in 127 nursing home patients. None of the common diseases examined in this study nor any commonly used medications were associated with increased serum cytokine levels. Patients with weight loss of more than 5 lbs were less likely to have elevated serum TNF and IL-1 levels compared to the rest of the group. It is concluded that although elevated levels of TNF or IL-1 may occur more frequently in older groups, there is no evidence for a causal relationship between these circulating cytokines and clinically significant weight loss in the elderly.

Pain in the nursing home

Pain is an understudied problem in geriatric medicine and especially among nursing home residents. The focus of this study was to describe the scope of the problem of pain in a long-term care facility. Ninety-seven subjects from a 311-bed multilevel teaching nursing home were interviewed, and charts were reviewed for pain problems and management strategies. Functional status, depression, and cognitive impairment were also evaluated. Results indicate that 71% of residents had at least one pain complaint (range, 1-4). Of subjects with pain, 34% described constant (continuous) pain and 66% described intermittent pain. Of 43 subjects with intermittent pain, 51% described pain on a daily basis. Major sources of pain included low back pain (40%), arthritis of appendicular joints (24%), previous fracture sites (14%), and neuropathies (11%). Moderately strong correlations were found between pain and infrequent attendance at recreational and social activities (r = .50). However, little correlation was observed between pain and the Yesavage Depression Scale, the Folstein Mini-Mental State Scale, or basic ADLs measured by the Katz Scale. Pain-management strategies consisted of analgesic drugs, physical therapy, and heating pads. Only 15% of patients with pain had received medication within the previous 24 hours. The findings suggest that pain is a major problem in long-term care. Strategies for pain management appear to be limited in scope and application in this setting. Important barriers were identified that influence the reporting and management of pain in this setting.

The effect of dietary salt ingestion on blood pressure of old-old subjects. A double-blind, placebo-controlled, crossover trial

To study the effect of dietary salt restriction and supplementation on blood pressure of elderly subjects, we performed a randomized, placebo-controlled, double-blind, crossover trial. Seven healthy subjects living in a long-term care facility, with a mean age of 85 and normal to borderline-hypertensive blood pressures, completed a 16-week protocol. During the double-blind cycles, subjects consumed either a low sodium (43 mmol/day) or a high sodium diet (175 mmol/day) for four weeks supplemented with placebo or salt capsules, with crossover to the other diet. Sitting diastolic blood pressure was significantly lower during the low sodium diet (69.86 mmHg +/- 3.80 vs 78.71 mmHg +/- 3.99, P less than .01), with all subjects showing decreases. Supine plasma renin activity and plasma aldosterone were significantly lower during the high sodium diet. Both low and high sodium diets were well-tolerated by subjects. Symptomatic postural hypotension and hyponatremia were not observed. We conclude that old-old subjects with borderline hypertension demonstrate salt-dependent increases in blood pressure. Without additional supportive studies, however, these results should not be generalized to any specific cohort of elderly individuals.

Predictors of falls among elderly people. Results of two population-based studies

A study was performed to identify and rank risk factors for falling among populations of institutionalized (fallers, N = 79, nonfallers, N = 70) and noninstitutionalized (fallers, N = 34, nonfallers, N = 34) elderly persons. Fallers were matched by age, sex, and living location to nonfaller control subjects. A nurse practitioner performed a comprehensive physical assessment in all subjects using a standardized protocol and physician consultation. Fallers in both populations were significantly more physically and functionally impaired than control subjects. Logistic regression identified hip weakness, poor balance, and number of prescribed medications as factors most strongly associated with falling among institutionalized subjects. A fall prediction model was developed from these findings yielding 76% overall predictive accuracy (89% sensitivity, 60% specificity). Using the model, the predicted 1-year risk of falling ranged from 12% for persons with none of the three risk factors to 100% for persons with all three risk factors. Findings among noninstitutionalized subjects were similar. These data support the concept of performing focused fall risk assessments to identify elderly patients at high risk for falling.

Diabetes mellitus in elderly nursing home patients. A survey of clinical characteristics and management

The clinical features of 47 frail nursing home diabetic patients with a mean age of 81 +/- 1.6 years were compared to those of 61 nondiabetic nursing home residents with a mean age of 80.2 +/- 1.2 years. Diabetic patients had a higher prevalence of renal failure, proteinuria, retinopathy, neuropathy, and infections than did other nursing home residents. Macroangiopathic disease tended to be equally common in both age groups. Diabetic nursing home residents had higher body weights compared to nondiabetic nursing home residents. Surprisingly, however, 21% of nursing home diabetics were greater than 20% below average body weight (compared to 24.5% of other nursing home residents), suggesting that undernutrition is a major problem in diabetic patients in a nursing home setting. Overall, the diabetic nursing home patients had better blood glucose control than younger ambulatory diabetic patients (mean age 66.2 +/- 4.7 years). The glycosylated hemoglobin (HbA1) level in those on oral agents was 8.9% +/- 0.7% for nursing home patients compared to 11.8% +/- 0.7% in ambulatory patients (P less than 0.01). The HbA1 in insulin-treated patients was similarly lower in nursing home diabetics (9.6% +/- 0.4% vs 11.8% +/- 0.7, P less than 0.05). There were only two mild hypoglycemic episodes in nursing home patients over 6-month observation period, whereas 12 ambulatory patients reported hypoglycemic episodes during the same period of time. We conclude that although the diabetic nursing home patients are sicker than the ambulatory diabetics, it is possible to achieve a fair blood glucose control in nursing home patients without a significant risk of recurrent hypoglycemia.

[Aortic regurgitation and aortic stenosis associated with gastrointestinal bleeding. Report of a case (author's transl)]

A 67-year-old woman with a double atherosclerotic aortic valvulopathy and rheumatoid arthritis presented recurrent episodes of gastrointestinal bleeding. Selective arteriography of the superior mesenteric artery demonstrated the existence of vascular malformations with extravasation of the contrast. The physiopathology of this lesion is unknown, but its incidence in adulthood suggests a degenerative process. A selective angiogram of the superior mesenteric artery is mandatory in patients with gastrointestinal bleeding and double aortic valvulopathy in order to establish the etiological diagnosis of the hemorrhage.

Multiple acquired haemostatic defects. Case report and review of the literature

A 14-year-old girl presented with severe haemorrhagic diathesis. Her past history suggested a congenital bleeding disorder. Investigations disclosed severe deficiency of all four vitamin K-dependent factors and a functional defect of platelets. These were caused by simultaneous administration of vitamin K antagonists and anti-inflammatory drugs. A complete clinical and laboratory recovery took place following withdrawal of drugs. The severity of the haemorrhagic diathesis prompted us to describe the case in order to draw the attention of medical personnel to the dangerous potentiation effects of different drugs administered with vitamin K antagonists.