Pandemic Influenza Planning in Nursing Homes: Are We Prepared?

Avian influenza or Influenza A (H5N1) is caused by a viral strain that occurs naturally in wild birds, but to which humans are immunologically naïve. If an influenza pandemic occurs, it is expected to have dire consequences, including millions of deaths, social disruption, and enormous economic consequences. The Department of Health and Human Resources plan, released in November 2005, clearly affirms the threat of a pandemic. Anticipating a disruption in many factions of society, every segment of the healthcare industry, including nursing homes, will be affected and will need to be self‐sufficient. Disruption of vaccine distribution during the seasonal influenza vaccine shortage during the 2004/05 influenza season is but one example of erratic emergency planning. Nursing homes will have to make vital decisions and provide care to older adults who will not be on the initial priority list for vaccine. At the same time, nursing homes will face an anticipated shortage of antiviral medications and be expected to provide surge capacity for overwhelmed hospitals. This article provides an overview of current recommendations for pandemic preparedness and the potential effect of a pandemic on the nursing home industry. It highlights the need for collaborative planning and dialogue between nursing homes and various stakeholders already heavily invested in pandemic preparedness.     

Are All Commonly Prescribed Antipsychotics Associated with Greater Mortality in Elderly Male Veterans with Dementia?

OBJECTIVES: To estimate mortality risk associated with individual commonly prescribed antipsychotics. DESIGN: Five‐year retrospective study. SETTING: Veterans national healthcare data. PARTICIPANTS: Predominantly male, aged 65 and older, with a diagnosis of dementia and no other indication for an antipsychotic. Subjects who received an antipsychotic were compared with randomly selected controls who did not. Exposed and control cohorts were matched according to their date of dementia diagnosis and time elapsed from diagnosis to the start of antipsychotic therapy. MEASUREMENTS: Mortality during incident antipsychotic use. RESULTS: Cohorts who were exposed to haloperidol (n=2,217), olanzapine (n=3,384), quetiapine (n=4,277), or risperidone (n=8,249) had more comorbidities than their control cohorts. During the first 30 days, there was a significant increase in mortality in subgroups prescribed a daily dose of haloperidol greater than 1 mg (hazard ratio (HR)=3.2, 95% confidence interval (CI)=2.2–4.5, P<.001), olanzapine greater than 2.5 mg (HR=1.5, 95% CI=1.1–2.0, P=.01), or risperidone greater than 1 mg (HR=1.6, 95% CI=1.1–2.2, P=.01) adjusted for demographic characteristics, comorbidities, and medication history using Cox regression analyses. Greater mortality was not seen when a daily dose of quetiapine greater than 50 mg (HR=1.2, 95% CI=0.7–1.8, P=.50) was prescribed, and there was no greater mortality associated with a dose less than 50 mg (HR=0.7, 95% CI=0.5–1.0, P=.03). No antipsychotic was associated with greater mortality after the first 30 days. CONCLUSION: Commonly prescribed doses of haloperidol, olanzapine, and risperidone, but not quetiapine, were associated with a short‐term increase in mortality. Further investigations are warranted to identify patient characteristics and antipsychotic dosage regimens that are not associated with a greater risk of mortality in elderly patients with dementia.     

Prompted Voiding for Nighttime Incontinence in Nursing Homes: Is it Effective?

OBJECTIVES: To determine whether prompted voiding (PV) is effective for nighttime urinary incontinence in nursing home (NH) residents and whether residents who respond well to daytime PV also respond well at night. DESIGN: Prospective case series. SETTING: Four community NHs. PARTICIPANTS: Sixty-one long-stay incontinent NH residents of mean age 88 years, 75% female. MEASUREMENTS: The percentage of hourly checks for wetness and the appropriate toileting rate (continent voids divided by total voids) were measured during 3 days (7 a.m.-7 p.m.) of PV, and for an average of 5 nights (7 p.m.-7 a.m.), during which a modified PV protocol, designed to be minimally disruptive to sleep, was carried out. RESULTS: Fourteen residents (23%) responded well to daytime PV, with average wetness and appropriate toileting rates of 5% and 73%, respectively. In the group as a whole, nighttime PV was not effective, with wetness and appropriate toileting rates of 49% and 18%, respectively. Among those who responded well to daytime PV, wetness rates during nighttime PV remained significantly higher than during the day (24% vs. 5%; P = .000), and nighttime appropriate toileting rates were significantly lower (39% vs. 73%; P = .002). The poor response rate at night was primarily observed between 10 p.m. and 6 a.m. CONCLUSIONS: In this sample of incontinent NH residents, nighttime PV, even when carried out so as to minimize sleep disruption, was not an effective intervention. Although residents who responded well to daytime PV responded better to nighttime PV than those who did not respond to daytime PV, their wetness rates remained relatively high and their appropriate toileting rates were low. These data suggest that routine nighttime toileting programs should not be carried out for the majority of incontinent NH residents. Instead, individualized care based on resident's preferences, willingness to toilet at night, and sleep patterns should be emphasized.     

Hospice Care in Nursing Homes: Is Site of Care Associated with Visit Volume?

OBJECTIVES: To determine factors associated with hospice visit volume and to examine whether visit volume differs by nursing home (NH) versus non-NH setting. DESIGN: Retrospective cohort study. SETTING: Twenty-one hospices across seven states under the ownership of one parent provider. PARTICIPANTS: Hospice patients from October 1998 through September 1999 in NH (n=9,460) and non-NH (n=15,484) settings. MEASUREMENTS: Data were from the provider's centralized information system. Average daily visit volume was the number of visits divided by the number of hospice routine home care days (days not in hospice inpatient or continuous home care). Multivariate logistic regression tested the association between site of care and an individual's probability of having average daily visits above the sample median. RESULTS: Average daily visits+/-standard deviation were 1.1+/-1.1 for NH and 1.2+/-1.3 for non-NH hospice patients. Site of care was not significantly associated with having an average daily visit volume above the sample median, but patients in NH settings had a lower probability of having a nurse average daily visit volume above the median (adjusted odds ratio (AOR)=0.59, 95% confidence interval (CI)=0.46-0.74) and a greater probability of having social worker (AOR=2.46, 95% CI=1.87-3.24), aide (AOR=1.97; 95% CI=1.11-3.48), and clergy (AOR=3.23, 95% CI=2.21-4.44) average daily visits above the median than those in non-NH settings. CONCLUSION: A different mix, not volume, of services appears to be used to address the physical, psychosocial, and spiritual needs of hospice patients/families who reside in NH settings than of those in non-NH settings.     

HIV and HCV Coinfection: Where Are We in 2010?

The epidemics of hepatitis C virus (HCV) and HIV are major causes of morbidity and mortality worldwide; the 33 million individuals who are coinfected with HCV and HIV face an increased risk of complications and death from liver disease in light of the accelerated progression of hepatitis C to fibrosis and cirrhosis in HIV coinfection. The mechanisms by which HIV accelerates the progression of HCV are thought to be related to alterations in the immunologic milieu, which collectively act to promote fibrogenesis. The progression of liver disease is in large part related to immunodeficiency, and, as with monoinfected individuals, optimal management of HIV infection with HAART may be important for prevention of hepatic morbidity. Treatment of HCV with pegylated interferon and ribavirin should be considered in eligible coinfected persons. Clinical trials in this population demonstrate sustained virologic response rates ranging from 17% to 35% in genotypes 1 and 4 and 44% to 73% in genotypes 2 and 3. However, given these limited response rates and high rates of intolerability, the impending introduction of directly acting antivirals against HCV holds particular promise for interruption of the insidious natural history of liver disease in HIV coinfected persons.     

Does Incorporating Medications in the Surveyors' Interpretive Guidelines Reduce the Use of Potentially Inappropriate Medications in Nursing Homes?

OBJECTIVES: To quantify the association between including specific medications deemed potentially inappropriate in the surveyors' interpretive guidelines for nursing homes and the prevalence of use. DESIGN: Quasi-experimental. SETTING: One thousand one hundred forty-one nursing homes in four U.S. states. PARTICIPANTS: Residents living in one of the included nursing homes in operation during 1997 (before Beers; n=130,250) and 2000 (after Beers; n=164,889). INTERVENTION: Inclusion of specific medications deemed potentially inappropriate in the surveyors' interpretive guidelines for nursing homes. MEASUREMENTS: Logistic regression models adjusting for clustering effects of residents residing in homes provided estimates of the relationship between the survey process and use of any medications targeted as potentially inappropriate as part of the survey process, as well as those deemed inappropriate but not included. RESULTS: The use of any potentially inappropriate medication decreased from 42.5% in 1997 to 39.8% in 2000. After adjustment for resident characteristics, residents were less likely to receive any potentially inappropriate medication (odds ratio (OR)=0.85, 95% confidence interval (95% CI)=0.84-0.87), those considered high-severity drugs (those with a high likelihood of a clinically significant adverse event) (OR=0.67, 95% CI=0.65-0.69), or Beers' medications not included in the surveyors' guidelines (OR=0.76, 95% CI=0.74-0.79) in 2000 than in 1997 after the changes to the drug regulations and interpretive guidelines. CONCLUSION: Targeting specific drugs in the surveyor's interpretive guidelines as a method to reduce potentially inappropriate medication use may not produce desired gains in medication-use quality improvement. Alternative strategies for nursing homes should be evaluated.     

Where Are we with Vitamin E?

Oxidative modification of low-density lipoproteins appears to significantly enhance their role in atherogenesis. Inhibition of this process with naturally occurring antioxidants has been proposed as a mechanism to retard the progression of coronary artery disease. Vitamin E has been among those natural antioxidants found to reduce atherosclerotic lesion formation in animal models. Further supported by a substantial accumulation of observational epidemiologic data demonstrating an association between antioxidant vitamin intake and reduced risk of cardiovascular mortality, vitamin E has been examined in a number of case-control and prospective cohort studies as a potential agent in the primary and secondary prevention of morbidity and mortality from coronary artery disease. These efforts have generated a large body of evidence suggesting a protective role, but conflict in the data remains. In addition, even with large, well-conducted prospective epidemiologic studies, the potential effects of residual confounding may be on the same order of magnitude as the reported benefit. The several small randomized interventional trials and two larger placebo-controlled studies that have been completed to date leave some key questions unanswered. Currently ongoing are several large randomized interventional trials that will serve to further clarify the role of this promising agent in the primary and secondary prevention of atherosclerotic coronary disease.