Hypocholesterolemia as a predictor of death: a prospective study of 224 nursing home residents

The relationship of cholesterol, albumin, hemoglobin and glucose levels, and anthropometric variables to risk of death was examined in all residents of a nursing home. Risk of death was a "U-shaped" function of the cholesterol levels. A tenfold increase in relative risk was associated with cholesterol less than 3.4 mmol/l, and the least risk was associated with the middle tertile of cholesterol levels (4.0-5.0 mmol/l). For any level of plasma cholesterol, risk was constant with time for at least 6 months. Low albumin, low hemoglobin, and high fasting glucose levels were also associated with increased mortality; cholesterol levels were nonlinearly related to levels of these risk factors. Proportional hazards models showed that immobility, presence of decubitus ulcers of at least stage II, and use of enteral feeding were also risk factors for death. Because hypocholesterolemia correlated significantly (p less than .05) with the presence of decubiti, elevated white blood cell count, and use of enteral feeding, the association between hypocholesterolemia and risk of death was most likely due to its association with malnutrition and infection.     

Telemedicine: a pilot study in nursing home residents

BACKGROUND: Telemedicine has been applied successfully in various fields of medicine. This mode of health care delivery may potentially be useful in supporting frail nursing home residents who require multidisciplinary geriatric services. OBJECTIVE: To assess the feasibility of telemedicine in providing geriatric services to nursing home residents, and whether this mode of care resulted in increased productivity and savings. METHODS: A local 200-bed nursing home supported by the Community Geriatric Assessment Team (CGAT) was recruited. Over a 1-year period, teleconferencing was used to replace conventional geriatric outreach services. The feasibility of telemedicine was evaluated by participating specialists. Productivity gains, consumption of hospital services and user satisfaction were measured. RESULTS: Telemedicine was adequate for service delivery in up to 99% of cases, depending on the specialty. A greater number of clients were served and follow-up intervals were shortened. The service was cheaper than conventional outreach or clinic activities, and acceptable to users and clients. In particular, savings were made through a 9% reduction in visits to the Accidents and Emergency Department and in 11% fewer admissions to acute hospital wards. CONCLUSION: telemedicine is a feasible means of delivering multidisciplinary care to frail nursing home residents, and may result in increased productivity and significant savings.     

Pneumonia versus aspiration pneumonitis in nursing home residents: prospective application of a clinical algorithm

OBJECTIVES: To prospectively evaluate a clinical algorithm for the diagnosis of pneumonitis and pneumonia in nursing home residents. DESIGN: Prospective cohort study. SETTING: Inpatient geriatrics unit. PARTICIPANTS: Nursing home residents admitted to the hospital with suspected pneumonia. MEASUREMENTS: Identification of pneumonitis and pneumonia using the algorithm; medical record review and abstraction of clinical data; hospital outcome and length of stay. RESULTS: One hundred seventy episodes of suspected pneumonia were screened with the algorithm and classified into four groups: 25% pneumonia, 28% aspiration pneumonitis of 24 hours or less duration, 12% aspiration pneumonitis of more than 24 hours' duration, and 35% an aspiration event without pneumonitis. Presenting symptoms and signs, laboratory tests, severity of illness measures, or serum C-reactive protein levels did not distinguish between the four groups. Those with an aspiration event without pneumonitis tended to be treated less often with antibiotic therapy after admission (P=.004) and after discharge (P=.01). Of those who survived, there was no significant difference in mean hospital length of stay between the four groups. There was no significant difference in the percentage of case fatality between the four groups, but those with aspiration pneumonitis of 24 hours or less duration and with an aspiration event without pneumonitis had a lower mortality than the other two groups. CONCLUSION: Distribution of episodes of suspected pneumonia by clinical category as determined using the algorithm was similar to that of the derivation study, as were case fatality rates in each category. These findings suggest that the algorithm may be useful for making the distinction between pneumonitis and pneumonia in nursing home residents; further studies are warranted.     

Predictors of nursing home placement in Parkinson's disease: a population-based, prospective study

OBJECTIVES: To examine the rate and predictors of nursing home placement in patients with Parkinson's disease. DESIGN: Four-year prospective study. SETTING: A population-based study in western Norway PARTICIPANTS: 178 community-dwelling subjects with Parkinson's disease. MEASUREMENTS: Main outcome measure was the time from baseline to nursing home admission. Baseline evaluation of motor symptoms (Unified Parkinson's Disease Rating Scale, UPDRS), cognition (clinical dementia interview, Gottfries, Brane & Steen dementia scale, and Mini-Mental State Examination), depression (clinical interview and the Montgomery & Asberg Depression Rating Scale), and psychotic symptoms (UPDRS Thought Disorder item) were performed. RESULTS: Forty-seven patients (26.4%) were admitted to a nursing home during the 4-year study period. Institutionalized patients were older, had more advanced Parkinson's disease with more severe motor symptoms and impairment of activities of daily living, were cognitively more impaired, were more often living alone, and had more hallucinations than those who continued to live at home. Duration of disease, levodopa dose, and gender distribution did not differ between the two groups. A Cox proportional hazards linear regression analysis showed that old age, functional impairment, dementia, and hallucinations were independent predictors of nursing home admission. CONCLUSIONS: Both motor and neuropsychiatric symptoms contributed to institutionalization, but the presence of hallucinations was the strongest predictor. This finding indicates it is possible that effective treatment of hallucinations may reduce the need for institutionalization in patients with Parkinson's disease.     

Positive tuberculin skin tests in nursing home residents in Southern Taiwan

In Taiwan, the tuberculin skin test (TST) is not recommended as a screening test for Mycobacterium tuberculosis (TB) infections. The aim of this study is to determine the prevalence and predictors of positive tuberculin reactivity and its association with TB infections among nursing home residents in Taiwan. A cross-sectional study and review of medical records were conducted at four nursing homes in Tainan City. A one-stage TST was performed by study nurses using two tuberculin units of purified protein derivative (PPD) of the RT23 strain. An induration ≥10 mm at 72 h was considered to be a positive reaction. Chest radiographs, acid-fast stains and mycobacterial cultures of three sputum samples were performed for those with a positive TST result. Of 115 residents (66.5% participation, mean age 73.1 years) who underwent a TST, 26 (22.6%) had a positive reaction. One woman was microbiologically diagnosed to have pulmonary TB. On multivariate analysis, a Bacille Calmette-Guérin (BCG) scar and a history of myocardial infarction were significantly associated with a positive TST. In conclusions, this study shows a considerable rate of positive TST among nursing home residents in southern Taiwan. A BCG scar and a history of myocardial infarction were associated with a positive TST.     

Oral health of Adelaide nursing home residents: longitudinal study

Objective: The Adelaide Dental Study of Nursing Homes aimed to quantify oral disease experience, incidence and increments in Adelaide nursing home residents. Methods: Questionnaires and dental inspections were completed at baseline and at 1‐year for residents from randomly selected Adelaide nursing homes. Results: The residents were very functionally dependent, cognitively impaired and behaviourally difficult older adults with complex oral problems and dental treatment needs. The prevalence of edentulism (total tooth loss) (63%) decreased and more residents were retaining natural teeth. Existing residents had a mean of 10.8 teeth present and new residents had a mean of 12.7 teeth present. Residents’ previous experiences of caries (decay) were high – existing residents had a mean of 1.2 decayed teeth and new residents had a mean of 0.8 decayed teeth. Residents’ caries increments (new decay) over the 1‐year period were high (coronal = 2.5 surfaces; root = 1.0 surfaces), especially in those who had lost weight and who could eat fewer food types. These levels of caries were many times greater than had been reported for community‐dwelling older adults. Large accumulations of plaque, calculus and debris (food) were evident on residents’ natural teeth and dentures, especially those with dementia. Up to 25% of residents owned dentures that were not worn. Residents with dementia gave their carers complex and challenging oral hygiene care problems. Existing and new residents had similar general health and oral health characteristics, with the exceptions that new residents had significantly more filled tooth surfaces, and fewer decayed retained roots. Conclusion: New residents were being admitted to the nursing homes with a compromised oral health status or developed severe oral diseases and conditions within several months of their admittance. Residents’ oral diseases, especially coronal and root caries, rapidly progressed during their stay in residential care.     

Screaming in nursing home residents

This article reports the results of two studies of screaming in the nursing home. The first was a survey study of 408 nursing home residents, which revealed that 25% of the residents screamed at least four times a week. Screaming was associated with cognitive impairment, depressed affect, social networks of poor quality, and severe impairment in the performance of activities of daily living. The second study was an in-depth observational study of five residents who screamed frequently. Residents screamed more often when they were alone in their rooms during the evening hours, suggesting that screaming may arise as a response to social isolation.     

Staphylococcus aureus colonization among nursing home residents in a large Finnish nursing home

We studied colonization with methicillin-resistant and -sensitive Staphylococcus aureus (MRSA, MSSA) in the second largest nursing home in Finland, in which the residents volunteered had their nostrils, throats, perineums, skin lesions, and catheter exit sites swabbed, and catheter urines cultured. The specimens were cultured onto non-selective and selective agar, with or without enrichment in salt-containing trypticase soy broth (TSB). S. aureus was identified by routine methods, methicillin resistance was detected by oxacillin and cefoxitin disk diffusion and MIC E-tests, and GenoType MRSA -test was used for mecA gene confirmation. A total of 663 cultures were obtained from 213 residents. Of those, 165 specimens (25%) from 94 residents (44%) were positive for S. aureus, and 3 specimens (0.4%) from 2 (0.9%) residents were positive for MRSA. Of the 165 S. aureus isolates, 31 (19%) from 25 (27%) residents were found only from sites other than nostrils (30 MSSA and 1 MRSA). TSB enrichment detected additional 33 (5%) S. aureus isolates (32 MSSA and 1 MRSA), resulting in 8 (5%) additional residents. None of the MRSA strains would have been found if only nostrils and throat had been screened, and no enrichment broth had been used.     

Dressing of cognitively impaired nursing home residents: description and analysis

PURPOSE: Getting dressed is an activity that is of particular difficulty for many persons with dementia, given the need for hand-eye coordination, fine motor skills, and overall planning skills. Despite several studies concerning interventions to improve dressing behavior, very little is known about the dressing process as it is currently performed. The purpose of this study is to characterize the dressing activity of daily living (ADL) of nursing home residents suffering from dementia and thereby identify ways to improve the dressing process. DESIGN AND METHODS: We analyzed videotapes of dressing of 20 special care unit residents to describe the dressing process and the interaction between residents and staff members. RESULTS: Staff members completely dressed the residents in the majority of cases. Interaction between the staff members and the residents was considered insufficient in most sessions. IMPLICATIONS: The study identified possible intervention techniques, assistive devices, organizational routines, and environmental changes that may improve the dressing process. The results have implications that nursing homes may consider in their policies, care activities, staff training, and environment to facilitate safety, comfort, and satisfaction during the dressing process.     

Psychiatric disease and social isolation in elderly nursing home residents: a comparative study

As part of a population-based morbidity survey, a sample of over-65-year-old residents of geriatric nursing homes and old people's homes (N = 153) in the city of Mannheim, F.R.G. (Popn. 308,000) was investigated with regard to mental and physical impairment, as well as to the frequency and quality of their family and social contacts. Corresponding data from the investigation of a community sample (N = 350) served as a basis for a direct comparison of old people in residential care and those living in the community. The findings point to a large relative excess both of mental impairments--especially organic brain syndromes--and of physical disabilities among the nursing-home residents. Those in old people's homes, in marked contrast, do not differ in these respects from persons of the same age living in the community. The home residents have on average far fewer social contacts, and derive less help and support from their social relationships, than do their contemporaries who live in private households. From this point of view, there appears to be little difference between those in nursing homes and those in old people's homes. The observed disparities between the home and community samples remained significant following statistical correction of the data for differences in the sample distributions by age and by marital status. The implications of these findings for further research and for geriatric service-planning are discussed.     

Factors associated with early demise in nursing home residents: a case control study

A case-control study was performed to identify factors differentiating nursing home residents who die within 12 months of admission (decedents) and those who survive for at least four years (survivors). Using Tennessee Medicaid data, 49 decedent/survival pairs admitted during the same year were matched for age, race, sex, nursing home, and diagnosis. There were no significant differences between the decedent and survivor groups in demographic factors, sensory impairments, physical handicaps, or number of drugs prescribed. Assessments of the ability to perform activities of daily living were found to be strongly associated with survival, providing a valuable prognostic tool. The authors suggest that personnel providing care for patients of advanced age would benefit from instruction in making such assessments.     

Osteoporosis and living of residents in a nursing home

Residents in a nursing home can become bedridden following fracture caused by osteoporosis or falls. To prevent fall and fracture is important, and conceived to reflect quality of caregiving in individual facilities. The incidence of falling is around 35% in all nursing homes related to our facility. Incidents of falling occur mostly during walking among ambulatory residents, and during performing transfers among residents using wheelchairs. Dementia is suggested to be a factor influencing the incidence of falling. In order to prevent fracture resulting from falling and osteoporosis in nursing homes, it is important that all working members in each facility examine prevention measures comprehensively, while considering characteristics of an environment of their facility and residents therein. All working members should thereby activity interven in the QOL (quality of life) of residents, and assist them to lead a healthy and joyful life n their nursing home.     

Depression in nursing home residents.

Although their extent remains unclear, major and minor depressions are widespread in the nursing home population. This statement appears intuitively to be correct when consideration is given to the inactivity, decline in functional competence, loss of personal autonomy, and unavoidable confrontation with the process of death and dying that are associated with nursing home placement. In addition, some nursing home residents have had previous episodes of depression or are admitted to the facility already dysthymic or with other chronic forms of the illness. Such circumstances provide a favorable culture for the development and persistence of depressive illness. When the high frequency of other psychiatric disorders among nursing home residents is factored in, it is not surprising that long-term health care facilities have come to be regarded as de facto psychiatric hospitals. Nursing homes largely lack the treatment resources of psychiatric hospitals, however. Nursing home physicians are often unprepared to make psychiatric diagnoses, and a perfunctory annual psychiatric evaluation is insufficient to manage the complex depression syndromes of nursing home residents. Because nursing home psychiatrists typically work on a consultation basis, recommendations are not necessarily acted upon by the primary physicians. The consequences of undiagnosed and untreated depression are substantial. From the psychiatric perspective, the possibility that depression increases the risk for eventual development of permanent dementia highlights the importance of early identification for cases of reversible dementia. From the rehabilitation point of view, persistent depression among individuals with physical dependency following a catastrophic illness is associated with failure to improve in physical functioning. Depression can probably be linked to increased medical morbidity in nursing home residents, a relationship that also has been suggested for elderly medical inpatients. If so, the use of nursing time and other health-care facility services would be greater for depressed than nondepressed residents, and financial costs would be higher as well. Finally, recent data point to increased mortality in nursing home residents with major depressive disorder. It is apparent that depression in long-term care facilities is a condition with doubtful prognosis and negative medical, social, and financial consequences. The highest costs of all may be paid by nursing home residents who experience the unrelieved suffering of depressive illness. Only epidemiologic research using standard diagnostic criteria and direct resident assessment will adequately establish the magnitude of the need for intervention among depressed residents in long-term care.(ABSTRACT TRUNCATED AT 400 WORDS)     

Anergy testing in nursing home residents

Delayed cutaneous hypersensitivity (DCH) testing is commonly used to determine exposure to Mycobacterium tuberculosis and in the evaluation of cellular-mediated immunity. Many reports indicate that anergy to ubiquitous antigens is common in the elderly. Recent studies suggest that anergy in the aged is not common when five or more antigens are used. Because it is often difficult to purchase singularly or apply a larger number of quality DCH antigens, we investigated the usefulness of the Multitest CMI in 29 nursing home residents with chronic diseases. This device simultaneously applies seven skin test antigens and a negative control. Ten young healthy subjects served as controls. DCH reactions were scored based on the sum of induration and total number of positive responses. Although elderly subjects had significantly lower scores than the young subjects, only 7% of elderly subjects were anergic. Our data indicate that the Multitest CMI is a highly effective device to test for DCH in geriatric subjects with chronic diseases. Although skin test responses in these subjects were blunted, in most residents cellular-mediated immunity remained intact.