Epidemic Norwegian scabies in a geriatric unit

Norwegian scabies is highly contagious and presents with a psoriasiform dermatosis. It afflicts particularly the elderly and patients with immunosuppression. Two weeks after the admission of an index case of Norwegian scabies to a geriatric ward, 13 and 25 patients and 6 of 18 ward nurses developed scabies. Despite comprehensive treatment, the ward epidemic recurred 6 weeks later probably as a result of inadequate treatment of the index case. This diagnosis should be considered when patients from high-risk groups present with an undiagnosed rash.     

A geriatric rehabilitation and assessment unit in a community hospital

This report describes functional status at admission, discharge, and six months later for 100 elderly persons treated at a community hospital assessment and rehabilitation unit. The goal of the unit is to prevent institutionalization of frail elderly persons considered at risk for nursing home placement. Characteristics of the first 100 admissions include the following: average age, 79 years; female, 77 per cent; length of stay, 23 days; average number of admitting diagnoses, 3.4. Ninety-one new diagnoses of treatable conditions were made. On admission, 81 per cent of patients were confined to bed or chair or needed assistance with ambulation, compared with 27 per cent at discharge and 22 per cent at six months. Activities showing significant improvement include dressing, housekeeping, use of toilet, and ambulation. At six months, 15 per cent had died, 67 per cent were living in the community, and 19 per cent were institutionalized. It is concluded that care at the geriatric unit probably resulted in improved function and decreased nursing home placement.     

A geriatric neuropsychiatric inpatient unit

Geriatric neuropsychiatry units have been developed in hospitals in various parts of the United States to provide an intensive diagnostic and treatment program for geriatric patients who have behavioral problems or the early signs of dementia. The Geriatric Neuropsychiatry Unit at the Boston City Hospital is described as a model unit. The process of patient selection and admissions criteria are outlined. Diagnostic interventions and the full evaluative process are then presented, followed by a summary of the therapeutic interventions. These interventions include pharmacologic, psychotherapeutic, behavioral, and milieu therapies. The communications process essential for effective multidisciplinary team function is also reviewed. Discharge planning procedures are presented, along with a summary of patient outcomes.     

Comparison of a geriatric unit with a general ward in Mexican elders

There is evidence that geriatric services may be more effective in handling problems of the elderly in acute care. We therefore studied a cohort of matched triplets (age, gender and admission diagnosis), to assess the effect of a geriatric service on elderly problems (falls, pressure ulcers, delirium and functional decline). This is a follow up study; comparing a geriatric unit with an internal medicine unit at two hospitals of the Mexican Institute of Social Security (IMSS) in Mexico City. Socio-demographic characteristics, functionality, emotional state, cognitive status, delirium, co-morbidities, diagnosis, number of medications, presence of pressure ulcers and falls, were assessed. We developed a composite variable as a global end-point, including: delirium, falls, mortality, pressure sores and functional decline. 70 patients were included in the geriatric services and 140 in the internal medicine unit. Mean age =72.5±7 years (±S.D.), and 52.9% were women. At baseline, only illiteracy, quality of life and the number of medications were statistically different between each group. Fully adjusted multiple logistic conditional regression model found an odds ratio of 0.27 (95% CI 0.1-0.7) for the presence of the composite variable, favoring the geriatric unit. Geriatric units in acute care may be beneficial in different frequent end points in elderly.     

Auditing the process of care in a new geriatric unit.

To assess whether the objectives of a new Extended Care Unit were reflected in the care of the patients and in the outcome of that care, an audit of the patients' records was performed. The audit sample involved 101 geriatric patients who had been admitted to the Unit for rehabilitation therapy, and then discharged. The study included assessment of the records for compliance with individual audit criteria, examination of the records in terms of a composite audit score, and analysis of the relationship between these scores and three outcome indices. Although the audit did not show a significant correlation between recorded care processes and treatment outcomes, it did reveal the extent to which the Unit's goals were reflected in the care process.     

Immune profile of elderly patients admitted in a geriatric short care unit

Introduction

Immunosenescence embraces the whole of age-induced changes observed in the immunomodulatory functions of a living organism, and is mostly characterized by a decrease in cell-mediated immunity and important modifications of the immunological repertoire. The impact of the pathology on ageing immunity is poorly understood and few data are available on the immunological status of old polypathological patients.

Methods

We report the results of a prospective study aiming at characterizing several established immunological parameters in patients of 75 years old or more, and admitted for diverse pathologies in a unit of acute geriatric ward.

Results

Among the 51 included patients (35 women and 16 men), 90% displayed poly-pathologies. We found a prevalence of 86% of immunological abnormalities, with lymphopenia among 41% of the patients (<1500/mm³) and abnormal lymphocytes phenotypes among 95% of the oldest patients (>85 years). A strong skewing towards memory T lymphocytes (CD45RO+) over naive T lymphocytes (CD45RA+) was found in 80% of the cases and inverted CD4/CD8 T cells ratio was observed in 12% of our patients. Vitamin D insufficiency (<30 ng/ml), which is frequent among the patients (94%), is a predictive factor for T and B cell lymphopenia.

Conclusion

Immunological abnormalities are frequent in this frail population and lymphopenia, in particular, could constitute a reinforcing factor of fragility. Vitamin D deficiency could also affect elderly patients’ immunity.     

Relevance of readmission of elderly patients discharged from a geriatric unit

Eight percent of the elderly patients discharged from a geriatric unit in one year were readmitted within three months. Forty-six percent had been living alone and nearly all of these had received full community support at the time of discharge. Recurrent problems were the reason for readmission in 59% of cases, mainly due to falls, incontinence, and confusion. Only 54% of the readmitted patients were discharged home again--those with new additional problems tended to die in hospital, whereas those with recurrent problems often required institutional long-term care. It is concluded that even with careful discharge planning, a proportion of patients will require readmission, some of which will also require long-term institutional care. This number is quite small in terms of the total number of patients discharged from a geriatric unit and should not be a reason for seeking nursing home care at an early stage.     

One-year incidence of hyperosmolar states and prognosis in a geriatric acute care unit

BACKGROUND: Hyperosmolar syndromes are associated with high mortality rates, yet little is known about their incidence and their prognosis. OBJECTIVE: To determine the 1-year incidence of hyperosmolar states and the prognostic factors for in-hospital and 1-year mortality. METHOD: A 6-month prospective cohort study was conducted in a 40-bed acute care geriatric unit and included all patients who developed plasma osmolarity of 320 mosm/l or greater. Age, sex and known cognitive impairment as possible risk factors of hyperosmolarity were assessed. In-hospital and 1-year mortality were calculated and risk factors for death among baseline patient characteristics were sought. RESULTS: 48 (11) of the 436 inpatients in the study were identified as hyperosmolar. Diabetic hyperosmolarity was found in 8 patients. Cognitive impairment was a risk factor for hyperosmolarity (relative risk 2.39, 95% confidence interval 2.18-3.33, p < 0.001), but not age or sex. Infections were accompanied by hyperosmolarity in 30 (62.5). Thirty-five patients (72.9) were bed- or chair-ridden. In-hospital mortality was higher in hyperosmolar patients (35.4) than in the others (16.7%, p = 0.003). Causes of death were infection in 5 (29.4), terminal cachexia in 5, thrombosis in 3, gastric bleeding in 1, renal failure in 2 and heart failure in 1. Functional dependency for mobility was a risk factor for in-hospital mortality but not the degree of hyperosmolarity. One-year mortality was 68.7%. Functional dependency and pressure ulcers were independent predictors of 1-year mortality (p = 0.005 and p = 0.044, respectively). CONCLUSION: Hyperosmolar states occurred in cognitively impaired and dependent patients and resulted in high mortality rates at short and at mid-term. Mortality was related to functional dependency rather than to hyperosmolarity.     

Delirium in an acute geriatric unit: clinical aspects

Delirium is a common event in geriatric hospitalized patients. A prospective study was performed in order to characterize predictors, features and outcome in an acute geriatric care unit in a general hospital in Israel. The tools used to detect delirium were the Confusion Assessment Method (CAM) and the Delirium Rating Scale (DRS), supported by clinical observation by an experienced geriatrician. Results showed an occurrence of 18%; risk factors were polypharmacy and poor nutritional status. Age, education, ethnic origin, pre-morbid cognition and ADL status did not show any statistical correlation with the occurrence of delirium. Delirious patients experienced longer hospital stays, more complications, high mortality rate, cognitive and functional decline. It is very difficult to prove the correlation between reduction of brain reserve and appearance of delirium, but as we have observed in other systems (cardiovascular, renal, etc.), it seems reasonable to presume that the same mechanism is involved in cognitive function. Our conclusions are that the diagnosis of delirium may be misleading by a psychiatric overwhelming presentation, and should be considered not as a transient event, but as a marker for cognitive and functional decline in the future, and therefore these patients should be looked after once discharged.     

A nosocomial outbreak of ampicillin-resistant Haemophilus influenzae type b in a geriatric unit

A nosocomial outbreak of Haemophilus influenzae type b (Hib) bronchitis occurred in a geriatric unit. The three infected patients were grouped together in an isolation unit and treated. A prevalence survey was done by obtaining pharyngeal cultures from patients and staff in the unit. One patient and a nurse were asymptomatic pharyngeal carriers of Hib. One infected patient was bedridden, and his only known Hib contact was the nurse. Geographic clustering was the only significant risk factor, as determined by a case-control study. Carriers were treated with rifampin. The isolates were characterized for strain relatedness by using three methods. All produced beta-lactamase and all were serotype b. Plasmid profiles and restriction endonuclease analysis of bacterial DNA were performed; chromosomes were digested with the restriction endonucleases HindIII and HaeIII. Strains were confirmed as identical by using these methods and were different from two Hib control strains producing beta-lactamase. This study documents nosocomial transmission of Hib, by using molecular typing methods.     

Prevention of delirium in an acute geriatric care unit

PURPOSE: Delirium is the most common complication of hospitalization in frail elderly. The prognosis is poor with increased mortality and morbidity. Confusion results from one or several precipitating factors in patients at risk. In a randomized study, a preventive multicomponent intervention reduced the incidence of delirium by 40%. The aim of our study was to evaluate the efficacy of such a preventive strategy, in the setting of an acute geriatric care unit. METHODS: The study was conducted in a French 26-bed geriatric acute care ward. The primary outcome was the comparison of the incidence of delirium among patients aged 75 years and older, before and after the implementation of a preventive strategy. The overall adherence of the ward staff to the prevention procedures was also determined. RESULTS: Before intervention, 367 patients were admitted (mean age: 80.6 years). The incidence of delirium was of 8.99%. In the subgroup of 123 demented patients, the incidence of delirium was of 15.4%. After intervention, 372 patients were admitted (mean age 84.9). The incidence of delirium was of 2.4% (relative risk reduction of 73%, P=0.001). In the subgroup of 133 demented patients, the incidence of delirium was 5.3% (relative risk reduction of 66%, P=0.01). The ward staff applied the prevention procedures in 96% of the 10 230 patients-day during the study period. CONCLUSION: This study shows that it is possible to apply the results of clinical research in clinical practice to prevent delirium in frail elderly hospitalized in an acute geriatric care unit. Such an easy preventive strategy could be applied in medical units admitting old patients at risk, in the context of a quality procedure.