Effect of Cranberry Capsules on Bacteriuria Plus Pyuria Among Older Women in Nursing Homes: A Randomized Clinical Trial.

Importance: Bacteriuria plus pyuria is highly prevalent among older women living in nursing homes. Cranberry capsules are an understudied, nonantimicrobial prevention strategy used in this population. Objective: To test the effect of 2 oral cranberry capsules once a day on presence of bacteriuria plus pyuria among women residing in nursing homes. Design, Setting, and Participants: Double-blind, randomized, placebo-controlled efficacy trial with stratification by nursing home and involving 185 English-speaking women aged 65 years or older, with or without bacteriuria plus pyuria at baseline, residing in 21 nursing homes located within 50 miles (80 km) of New Haven, Connecticut (August 24, 2012-October 26, 2015). Interventions: Two oral cranberry capsules, each capsule containing 36 mg of the active ingredient proanthocyanidin (ie, 72 mg total, equivalent to 20 ounces of cranberry juice) vs placebo administered once a day in 92 treatment and 93 control group participants. Main Outcomes and Measures: Presence of bacteriuria (ie, at least 105 colony-forming units [CFUs] per milliliter of 1 or 2 microorganisms in urine culture) plus pyuria (ie, any number of white blood cells on urinalysis) assessed every 2 months over the 1-year study surveillance; any positive finding was considered to meet the primary outcome. Secondary outcomes were symptomatic urinary tract infection (UTI), all-cause death, all-cause hospitalization, all multidrug antibiotic-resistant organisms, antibiotics administered for suspected UTI, and total antimicrobial administration. Results: Of the 185 randomized study participants (mean age, 86.4 years [SD, 8.2], 90.3% white, 31.4% with bacteriuria plus pyuria at baseline), 147 completed the study. Overall adherence was 80.1%. Unadjusted results showed the presence of bacteriuria plus pyuria in 25.5% (95% CI, 18.6%-33.9%) of the treatment group and in 29.5% (95% CI, 22.2%-37.9%) of the control group. The adjusted generalized estimating equations model that accounted for missing data and covariates showed no significant difference in the presence of bacteriuria plus pyuria between the treatment group vs the control group (29.1% vs 29.0%; OR, 1.01; 95% CI, 0.61-1.66; P = .98). There were no significant differences in number of symptomatic UTIs (10 episodes in the treatment group vs 12 in the control group), rates of death (17 vs 16 deaths; 20.4 vs 19.1 deaths/100 person-years; rate ratio [RR], 1.07; 95% CI, 0.54-2.12), hospitalization (33 vs 50 admissions; 39.7 vs 59.6 hospitalizations/100 person-years; RR, 0.67; 95% CI, 0.32-1.40), bacteriuria associated with multidrug-resistant gram-negative bacilli (9 vs 24 episodes; 10.8 vs 28.6 episodes/100 person-years; RR, 0.38; 95% CI, 0.10-1.46), antibiotics administered for suspected UTIs (692 vs 909 antibiotic days; 8.3 vs 10.8 antibiotic days/person-year; RR, 0.77; 95% CI, 0.44-1.33), or total antimicrobial utilization (1415 vs 1883 antimicrobial days; 17.0 vs 22.4 antimicrobial days/person-year; RR, 0.76; 95% CI, 0.46-1.25). Conclusions and Relevance: Among older women residing in nursing homes, administration of cranberry capsules vs placebo resulted in no significant difference in presence of bacteriuria plus pyuria over 1 year. Trial Registration: clinicaltrials.gov Identifier: NCT01691430.

Optimizing Retention in a Pragmatic Trial of Community-Living Older Persons: The STRIDE Study.

OBJECTIVES: The Strategies to Reduce Injuries and Develop Confidence in Elders (STRIDE) study is testing the effectiveness of a multifactorial intervention to prevent serious fall injuries. Our aim was to describe procedures that were implemented to optimize participant retention; report retention yields by age, sex, clinical site, and follow-up time; provide reasons for study withdrawals; and highlight the successes and lessons learned from the STRIDE retention efforts. DESIGN: Pragmatic cluster randomized trial. SETTING: A total of 86 primary care practices within 10 US healthcare systems. PARTICIPANTS: A total of 5451 community-living persons, 70 years of age or older, at high risk for serious fall injuries. MEASUREMENTS: Study outcomes were collected every 4 months by a central call center. Reconsent was required to extend follow-up beyond the originally planned 36 months. RESULTS: Over a median follow-up of 3.2 years (interquartile range = 2.8-3.7 y), 439 (8.1%) participants died and 600 (11.0%) withdrew their consent or did not reconsent to extend follow-up beyond 36 months, yielding rates (per 100 person-years) of deaths and withdrawals of 2.6 and 3.6, respectively. The withdrawal rate increased with advancing age, was comparable for men and women, and did not differ much by clinical site. The most common reasons for withdrawal were illness and unable to contact for reconsent at 36 months. Completion of the follow-up interviews was greater than 93% at each time point. Most participants completed all (71.8%) or all but one (9.2%) of the follow-up interviews. The most common reason for not completing a follow-up interview was unable to contact, with rates ranging from 2.8% at 40 months to 4.6% at 20 months. CONCLUSION: Completion of the thrice-yearly follow-up interviews in STRIDE was high, and retention of participants over 44 months exceeded the original projections. The procedures used in STRIDE, together with lessons learned, should assist other investigators who are planning or conducting large pragmatic trials of vulnerable older persons. J Am Geriatr Soc 68:1242-1249, 2020.

Frequency of Infection during Fever Episodes among Long-Term Care Residents.

BACKGROUND: Empirical data regarding the frequency of infection during fever episodes among women in long-term care facilities are lacking. METHODS: We conducted a case-series analysis of women long-term care residents enrolled in a randomized trial evaluating cranberry capsules to reduce bacteriuria plus pyuria across twenty-one long-term care facilities in CT, USA. Fever episodes identified during adverse event surveillance were assessed using established guidelines for older adults. Among fever episodes, infections were classified using standardized infection surveillance definitions in long-term care residents. RESULTS: We identified 123 fever episodes among 80 women long-term care residents. Median age was 88 years (range, 65-101), and 81% (N=65) had dementia. Among 123 fever episodes, 79 (64%) met criteria for 86 total infections (lower respiratory tract, N=43; pneumonia, N=27; gastroenteritis, N=9; urinary tract, N=7). CONCLUSION: Data from this study suggest that approximately two-thirds of fever episodes involve infection among women in long-term care facilities. These data may guide provider assessments of fever in older adult women in long-term care facilities.

Increased Fluoroquinolone-Susceptibility and Preserved Nitrofurantoin-Susceptibility among Escherichia coli Urine Isolates from Women Long-Term Care Residents: A Brief Report.

Suspected urinary tract infection is a common indication for antimicrobial therapy in long-term care residents. We sought to characterize antimicrobial susceptibilities among urine isolates collected from women long-term care residents enrolled in a clinical trial across 21 long-term care facilities in Connecticut, United States of America between August 2012 and October 2015. Among 967 urine cultures collected from 175 women long-term care residents with and without suspected urinary tract infection, we identified 456 bacterial isolates. Escherichia coli (55.3%), Klebsiella (13.8%) and Enterococcus (8.3%) species were the predominant organisms identified. Among all 456 urine isolates, 68.1% were ciprofloxacin-susceptible, 77.2% were trimethoprim/sulfamethoxazole-susceptible, 86.3% were cefazolin-susceptible, and 72.6% were nitrofurantoin-susceptible. Among 252 Escherichia coli urine isolates, 60.2% were ciprofloxacin-susceptible, 73.7% were trimethoprim/ sulfamethoxazole-susceptible, 84.5% were cefazolin-susceptible, and 86.5% were nitrofurantoin-susceptible. These findings suggest that trimethoprim/sulfamethoxazole may be favorable empiric therapy while the urinary isolate is unknown, and nitrofurantoin may be optimal therapy for uncomplicated urinary tract infection due to Escherichia coli in women long-term care residents.

Step by step: integrating evidence-based fall-risk management into senior centers.

PURPOSE: Our purpose in this project was to conceptualize and implement evidence-based fall-prevention programming into senior centers. We present challenges to this process and strategies to overcome them. DESIGN AND METHODS: We carried out a dissemination project in nine diverse senior centers in Connecticut. Participants included investigators from the Connecticut Collaboration for Fall Prevention (CCFP), senior center administrators, and trained staff interventionists implementing a program of fall prevention based on the Yale Frailty and Injury Cooperative Studies of Intervention Trials (known as the Yale FICSIT). Using CCFP materials that were based on the stages of change, senior center staff developed methods to integrate fall-prevention programming into their centers. We extracted implementation challenges, and the strategies that senior center staff developed to overcome them, from the minutes of monthly work-group meetings. Monthly counts of individual assessments were also a source of data. RESULTS: Challenges included staffing and the delineation of authority, structural issues, engaging senior center membership, cultural issues, and the modification of existing practices. Each senior center devised site-specific methods to overcome these challenges when CCFP investigators convened work-group meetings. We developed creative strategies to inform senior center membership about fall prevention, and in the first 18 months, 4% of members scheduled individual assessments. IMPLICATIONS: The challenges of integrating evidence-based fall-prevention programming into existing senior center services can be negotiated by collaboration among senior center administrators, health providers, the center membership, and researchers. This experience suggests that senior centers may be important venues to reach older adults with fall-prevention programming.

Integration of fall prevention into state policy in Connecticut.

PURPOSE OF STUDY: To describe the ongoing efforts of the Connecticut Collaboration for Fall Prevention (CCFP) to move evidence regarding fall prevention into clinical practice and state policy. METHODS: A university-based team developed methods of networking with existing statewide organizations to influence clinical practice and state policy. RESULTS: We describe steps taken that led to funding and legislation of fall prevention efforts in the state of Connecticut. We summarize CCFP's direct outreach by tabulating the educational sessions delivered and the numbers and types of clinical care providers that were trained. Community organizations that had sustained clinical practices incorporating evidence-based fall prevention were subsequently funded through mini-grants to develop innovative interventional activities. These mini-grants targeted specific subpopulations of older persons at high risk for falls. IMPLICATIONS: Building collaborative relationships with existing stakeholders and care providers throughout the state, CCFP continues to facilitate the integration of evidence-based fall prevention into clinical practice and state-funded policy using strategies that may be useful to others.

Development of a tool for eliciting patient priority from among competing cardiovascular disease, medication-symptoms, and fall injury outcomes.

OBJECTIVES: To develop a choice task for eliciting priorities in the face of competing cardiovascular disease (CVD) outcomes, medication-related symptoms, and fall injuries. DESIGN: Conjoint analysis. SETTING: Senior housing site. PARTICIPANTS: Convenience sample of 15 senior housing residents for the pretest, 13 residents for the pilot test. MEASUREMENTS: The final task included 11 sets of choices. In each, one option optimized the risk of one or two of the three outcomes at the expense of the other(s); the second option did the reverse. Relative importance scores for CVD, fall injury, and medication-symptom outcomes were calculated. Reliability was assessed for two administrations using intraclass correlations (ICCs). Wilcoxon rank sum tests were used to evaluate order effects. RESULTS: The ICCs between choice task administrations were 0.70 for fall injuries, 0.73 for medication symptoms, and 0.56 for CVD outcomes. The ICCs with removal of two outliers were 0.84, 0.72, and 0.84, respectively. Whether CVD or fall injuries appeared first had no effect on scores. CONCLUSION: Preliminary evidence of comprehensibility and reliability supports using the choice task to determine whether individuals' priorities differ in the face of competing outcomes.

Health outcome priorities among competing cardiovascular, fall injury, and medication-related symptom outcomes.

OBJECTIVES: To determine the priority that older adults with coexisting hypertension and fall risk give to optimizing cardiovascular outcomes versus fall- and medication symptom-related outcomes. DESIGN: Interview. SETTING: Community. PARTICIPANTS: One hundred twenty-three cognitively intact persons aged 70 and older with hypertension and fall risk. MEASUREMENTS: Discrete choice task was used to elicit the relative importance placed on reducing the risk of three outcomes: cardiovascular events, serious fall injuries, and medication symptoms. Risk estimates with and without antihypertensive medications were obtained from the literature. Participants chose between 11 pairs of options that displayed lower risks for one or two outcomes and a higher risk for the other outcome(s), versus the reverse. Results were used to calculate relative importance scores for the three outcomes. These scores, which sum to 100, reflect the relative priority participants placed on the difference between the risk estimates of each outcome. RESULTS: Sixty-two participants (50.4%) placed greater importance on reducing risk of cardiovascular events than reducing risk of the combination of fall injuries and medication symptoms; 61 participants did the converse. A lower percentage of participants with chronic obstructive pulmonary disease (P=.02), unsteadiness (P=.02), functional dependency (P=.04), lower cognition (P=.02) and depressive symptoms (P=.03) prioritized cardiovascular outcomes over fall injuries and medication symptoms than did participants without these characteristics. CONCLUSION: Interindividual variability in the face of competing outcomes supports individualizing decision-making to individual priorities. In the current example, this may mean forgoing antihypertensive medications or compromising on blood pressure reduction for some individuals.