Effect of influenza vaccination of nursing home staff on mortality of residents: a cluster-randomized trial.

OBJECTIVES: To evaluate the effect of staff influenza vaccination on all-cause mortality in nursing home residents. DESIGN: Pair-matched cluster-randomized trial. SETTING: Forty nursing homes matched for size, staff vaccination coverage during the previous season, and resident disability index. PARTICIPANTS: All persons aged 60 and older residing in the nursing homes. INTERVENTION: Influenza vaccine was administered to volunteer staff after a face-to-face interview. No intervention took place in control nursing homes. MEASUREMENTS: The primary endpoint was total mortality rate in residents from 2 weeks before to 2 weeks after the influenza epidemic in the community. Secondary endpoints were rates of hospitalization and influenza-like illness (ILI) in residents and sick leave from work in staff. RESULTS: Staff influenza vaccination rates were 69.9% in the vaccination arm versus 31.8% in the control arm. Primary unadjusted analysis did not show significantly lower mortality in residents in the vaccination arm (odds ratio=0.86, P=.08), although multivariate-adjusted analysis showed 20% lower mortality (P=.02), and a strong correlation was observed between staff vaccination coverage and all-cause mortality in residents (correlation coefficient=-0.42, P=.007). In the vaccination arm, significantly lower resident hospitalization rates were not observed, but ILI in residents was 31% lower (P=.007), and sick leave from work in staff was 42% lower (P=.03). CONCLUSION: These results support influenza vaccination of staff caring for institutionalized elderly people.

Interobserver and intraobserver reliability of detecting age-related macular degeneration using a nonmydriatic digital camera.

PURPOSE: To evaluate the interobserver and intraobserver reliability of detecting early and late age-related macular degeneration (AMD) using a nonmydriatic digital camera in two distinct groups of older people. DESIGN: Prospective study. METHODS: The two groups consisted of a series of patients older than 70 years hospitalized in a geriatric unit and a younger series of people older than 55 years. In both groups, nonmydriatic color fundus photographs were obtained and graded independently by two ophthalmologists (V.L. and M.S.). No ophthalmic examination was performed. Main outcome measures were frequencies of early and late AMD and interobserver and intraobserver agreement. RESULTS: Among 233 patients in group 1 (mean age, 84.6 years), only 119 patients (51%) could undergo photography because of associated multiple morbidities. Mean age of group 2 was 63.8 years. In group 1, 35 (14.5%) of 238 pictures were ungradable. In series 2, 65 (9.1%) of 716 pictures were ungradable. Frequencies of early and late AMD were 30.3% and 5.9% vs 12.6% and 2.6% in series 1 and 2, respectively. Interobserver and intraobserver agreement was good or excellent (kappa > 0.6) in both groups. CONCLUSIONS: In the entire geriatric cohort, 43% of the patients had gradable pictures allowing a diagnosis. These patients would otherwise have had no access to any form of funduscopy. In the younger population, nonmydriatic pictures permitted a diagnosis in 90% of the individuals. Detection of AMD with a nonmydriatic digital camera may lead to large-scale screening and specific management.

Medical information and surrogate designation: results of a prospective study in elderly hospitalised patients.

OBJECTIVES: To determine the preferences of French elderly inpatients concerning medical information and surrogate designation in life-threatening situations. METHODS: Intention-to-act questionnaire was completed by two geriatricians during a patient interview in the week following admission in three geriatric units in France. The participants were elderly patients (> or =70 years) with adequate cognitive performance for decision making as assessed by the Mini Mental State Examination. The impact of socio-demographic factors, level of confidence in medical care, cognitive or physical disability on surrogate designation and amount of medical information expected were measured. MEASUREMENTS: Impact of socio-demographic factors, level of confidence in medical care, cognitive or physical disability on surrogate designation and amount of medical information expected. RESULTS: 426 consecutive elderly patients were recruited. 32.6% wanted to receive complete information about their care and 77% declared they would want to be informed if they were in a life-threatening situation. 4.5% reported they would not want any medical information. A family member was designated as surrogate by 73% of the patients. In 28%, a second surrogate was also designated, usually the family physician (22%) or a member of the hospital medical staff (10%). Polytomous logistic regression analysis was used to assess determinants of the amount of information expected and social and medical parameters. MMSE score, the presence of physical disability, a low level of confidence in medicine and the presence of children were identified as independent determinants of a high level of information expectation. CONCLUSION: Elderly hospitalised patients expressed a strong desire to receive extensive information and were willing to designate a surrogate in a life-threatening situation. The surrogate was usually a family member alone or with another person, usually a practitioner.

Relations between undernutrition and nosocomial infections in elderly patients.

BACKGROUND: Hospital-acquired infections and malnutrition are of major concern in public health in elderly patients. However, the interactions between these two entities are not well established. OBJECTIVES: To determine the incidence of nosocomial infections (NI) and its association with malnutrition. SUBJECTS: 185 hospitalised older adults aged 81.6+/-0.6 years old were nutritionally assessed on admission by measurement of anthropometric variables, serum nutritional proteins and evaluation of dietary intake. During hospitalisation, patients' progress was closely monitored, particularly for the detection of nosocomial infections. RESULTS: The incidence rate of NI was 59% and the global infection rate was 7.6/1,000 bed days. The most common infection site was the urinary tract (n=63). The nutritional status of the population was studied by comparing three groups defined according to the absence (group I, n=116), presence of one infection (group II, n=38) or presence of more than one infection (group III, n=31). All but one anthropometric parameters varied among the three groups. Total energy intake also varied among the three groups. The group I had higher daily nutrient intake than the other two groups (respectively P=0.004 and P<0.0001). Albumin, transthyretin, and C-reactive protein levels differed significantly among the three groups (respectively P<0.0001, P<0.0001 and P=0.0003). Age, energy intake, length of hospital stay and the presence of a urinary catheter were independent risk factors of nosocomial infection. CONCLUSION: Our findings show that patients with multiple NI were older, showed an altered nutritional status, a prolonged recovery, more frequently had urinary catheters and more discharge placement.