Thyrotoxicosis induced by topical iodine application.

We describe an elderly man who was admitted with congestive cardiac failure and found to have thyrotoxicosis. He did not have goiter, and he had normal radioiodine uptake in his neck. Serum iodine levels were elevated, explaining the lack of increase in radioiodine uptake in the thyroid gland. He had multiple pressure sores, which were treated with povidone-iodine (Betadine) soaks. Biochemical data were consistent with Graves' disease unmasked by topical iodine application. Povidone-iodine soaks are commonly used in decubitus ulcer care and warrant special attention in patients with preexisting thyroid disorders. We have reviewed the literature on this unusual complication.

Coping with diagnosis related groups. The changing role of the nursing home.

In an attempt to document the changing role of a specific nursing home in the delivery of medical care since the initiation of diagnosis related groups (DRGs), we studied 100 consecutive patients initially admitted to the Veterans Administration Medical Center-Milwaukee Nursing Home Care Unit (NHCU) during the first 23 weeks of 1986 (post-DRGs). Patient characteristics, reason for NHCU admission, and patients' final disposition were determined and compared with those of consecutive patients admitted to the same facility during an identical time period in 1983 (pre-DRGs). More than seven times as many patients were admitted in 1986, and prior to NHCU admission the acute care hospital stay was significantly shorter in 1986 (22 vs 60 days). Whereas in 1983, most patients (94%) were admitted to the NHCU for long-term care placement, in 1986, the majority of patients (64%) were admitted for continuation of therapy started in the acute care hospital. In 1983 only two patients (9%) required hospital readmission within ten days of NHCU admission, compared with 22 (22%) of the patients in 1986. At the termination of the study period, none of the 31 patients admitted to the NHCU in 1983 had been discharged; in comparison, 33% of the patients in 1986 were discharged home. We conclude that in 1986 certain nursing homes drastically changed their role in the delivery of medical care, and are now functioning as extensions of acute care hospitals. Such a role is advantageous in allowing patients to be quickly discharged from the acute care hospital; however, the changing role presents new problems and challenges.

Clinical characteristics of patients in the persistent vegetative state.

Little is known concerning the specific clinical characteristics of patients in persistent vegetative states (PVS). Fifty-one patients from four nursing homes, approximately 3% of the total patients, were identified as being in a PVS. The mean age of the patients was 64.8 +/- 3.2 years (range, 19 to 96 years) and the mean duration of the PVS was 3.3 +/- 5.0 years (range, 1 to 16.8 years), with 13 patients' PVS being longer than 5 years. Cerebrovascular accidents and dementia were the most common causes of the PVS, accounting for 32 of the cases (63%). In the younger patients cerebral trauma secondary to motor vehicle accidents was the most common cause. All 51 patients were fed via tube feeding and 35 patients had urinary catheters (75%). All patients were receiving daily medications, with greater than 50% taking daily vitamins. Over 30% were taking digitalis and/or diuretics and over 32% were taking H2 blockers. Transfer of patients to an acute care hospital was not uncommon, with 31 patients (61%) requiring 63 acute care hospitalizations during their stay in the nursing home. As expected, infections were the most common reason for acute care hospitalization, although 15 of the patients were hospitalized for surgical procedures. Another common problem encountered by the patients was pressure sores, with 78% of patients requiring specific therapy for at least one pressure sore. Surprisingly, only 27 (53%) of 51 patients had a specific resuscitation status designation in the medical chart, and neither presence of a chart designation nor specific resuscitation order was related to the patient's age or the cause or duration of PVS. From these data it would appear that clinical characteristics of patients in PVS are variable. Some patients are young, others are old. The cause varies from cerebrovascular accidents to cerebral trauma. Survival may be prolonged; complications are not uncommon, with some patients requiring acute care hospitalization.

Outcomes of cardiopulmonary resuscitation in nursing homes: can we predict who will benefit?

PURPOSE: To determine the benefits of cardiopulmonary resuscitation (CPR) in nursing home patients and assess possible prearrest and arrest predictors of survival. PATIENTS AND METHODS: During a 4-year period (1986 to 1989), consecutive nursing home patients from Milwaukee, Wisconsin, who sustained cardiac arrest and received CPR by paramedics were studied. The patients' prearrest clinical characteristics were determined including age, length of stay in nursing home, medical diagnoses, medications, circumstances surrounding the arrest, laboratory studies, and baseline functional status. Cardiac arrest data were obtained from a paramedic computer data base and included whether the arrest was witnessed, initial cardiac rhythm, and success of CPR. Survival was defined as the discharge of the patient alive from the hospital, and the patient's pre- and post-arrest functional status was compared. Possible predictors of survival were analyzed from the patient's prearrest characteristics and arrest characteristics. RESULTS: Of the total 196 patients who received CPR, 37 (19%) were successfully resuscitated and hospitalized, and 10 (5%) survived to be discharged. However, 27% of patients survived whose arrests were witnessed and who demonstrated ventricular fibrillation at the time of the arrest. In comparison, only 2.3% of all other nursing home patients who received CPR survived (p < 0.0002). Age, mental or functional status, hematocrit, renal dysfunction, pulmonary disease, cancer, and cardiovascular disease were not significant predictors of survival. At the time of hospital discharge, the functional status of the majority (80%) of the survivors was comparable to their prearrest status and 40% of the survivors lived for greater than 12 months. CONCLUSION: We conclude that only a small percentage of nursing home patients who sustain cardiac arrest will benefit from CPR. However, greater than 25% of nursing home patients whose arrest is witnessed and who demonstrate ventricular fibrillation will survive. This is comparable to the survival rate of elderly community-dwelling persons who sustain cardiac arrest. Our data suggest that CPR should be initiated only in nursing home patients whose cardiac arrest is witnessed and should only be continued in patients whose initial documented cardiac rhythm is ventricular fibrillation or ventricular tachycardia.

Anterior pituitary function and growth hormone use in the elderly.

Age-related changes in GH and IGF-I secretion occur in both men and women and may partially contribute to the body compositional changes of decreased lean body mass, increased adiposity, alterations in bone density, and increased cardiovascular risk, all of which can affect adversely on functional capacity. hGH, GHRH, GHRP and other trophic factors hold promise as therapeutic strategies to improve the functional status of frail elderly subjects. In addition, there is potential for hGH use in elderly patients in various catabolic states because of its anabolic effects with nitrogen retention. However, careful long-term clinical trials are necessary with development of specific targeting criteria before conclusions regarding efficacy and benefits can be decided.

Comparison of methods for calculation and depiction of incidence infection rates in long-term care facilities.

Assessment of changes in endemic infections in health care facilities are often based on comparison of infection rates over time. This study compared two methods for calculating and depicting infection data at a hospital-based nursing home care unit. Prospective incidence surveillance of nursing home acquired infections was conducted over a 12-month period, during which time denominator information on census and patient care days was also collected. Monthly infection rates were calculated based on (a) census (number infections per month/average monthly census), and (b) care duration (number infections per month/average monthly resident stay days). Results showed average monthly infection incidence of 27.4 episodes, (range 19-37), with average monthly census of 166.2 (range 160.0-180.0) and average monthly patient days of 5056 (range 4631-5583). The average census based monthly infection rate was 16.5 (range 11.9-22.4); average care duration based monthly infection rate was 5.4 (range 3.8-7.2) episodes per 1000 patient care days. Results indicate care duration based rates demonstrate less marked rate fluctuation than census based findings, and that duration based rates are more similar to values observed in acute care hospital nosocomial infection rates, thus are less likely to be misunderstood or misinterpreted by staff. Institutions should consider analyzing their methods for depicting infection data to provide consistency and clarity in data reporting.

Evaluation of the systolic murmur in the elderly.

A common clinical entity in the elderly population is the systolic murmur detected during cardiac auscultation. Although it can occur in patients of any age group, the approach to diagnosis differs in the elderly. Two cases are presented which illustrate different pathologic processes that can result in the development of a systolic murmur. The prevalence of this entity in the elderly is highlighted, and a strategy for diagnosis is outlined.

Importance of resident placement within a skilled nursing facility.

Specific attention to the placement of nursing-home residents within a skilled nursing facility is often neglected. a study was made of the effects on mental and emotional status, sensory perception, and capability for the needs of daily living when a mentally incompetent resident was placed as a room-mate with a competent resident. By means of a rating scale designed for this study, the mentally competent subjects were assessed before and after this type of placement. A significant change occurred in mental and emotional status (p less than 0.001) but there was no change in either sensory perception or the ability to perform the tasks of daily living. The data suggest that the placement of a mentally incompetent resident with one who is mentally competent may result in an alteration of mental and emotional status for the latter. It is important that placement conditions be considered in the initial processing of all nursing-home residents.

Patients in a persistent vegetative state attitudes and reactions of family members.

Patients in a persistent vegetative state (PVS) constituted approximately 3% of the population in four Milwaukee nursing homes. In order to understand family members' attitudes and reactions toward such patients, 33 (92%) of 36 family members of patients in PVS contacted were studied. The age of the patients ranged from 19 to 95 with a mean age of 73.4 +/- 17.2 years, and family members' ages ranged from 41 to 89 with a mean age of 61.8 +/- 3.3 years. The etiology of the PVS varied from dementia to cerebral trauma. The mean duration of the PVS was 54 +/- 8.4 months (range 12 to 204). Family members reported that they visited patients 260 times during the first year following the onset of the PVS and were still visiting at a rate of 209 visits yearly at the time of the interview. There was no significant correlation between the frequency of the family members visits and the duration of the PVS, the patient's or family member's age, or the family member's relationship to the patient. Ninety percent of patients were considered by family members to have some awareness of pain, light or darkness, environment, taste, verbal conversation, or the family member's presence. Most family members thought they understood the patient's medical condition, and the majority did not expect the patient to improve. Nevertheless, the majority of family members wanted the patient to undergo therapeutic interventions, including transfer to the acute hospital and surgery.(ABSTRACT TRUNCATED AT 250 WORDS)

Documentation and evaluation of fevers in hospital-based and community-based nursing homes.

We reviewed clinical evaluation practices and documentation of fever (greater than or equal to 100.2 degrees F) in all febrile patients over a two-month period in a hospital-based nursing home (HBNH) compared with a community-based nursing home (CBNH). Results showed 38 febrile (mean 101.9 degrees F) HBNH patients and 26 febrile (mean 101.5 degrees F) CBNH patients. Median time from fever onset to physician contact was 4 hours in HBNH and 12.5 hours in CBNH episodes (P less than 0.01). Laboratory studies were initially performed in 68% of HBNH and 31% of CBNH episodes (P less than 0.005), and diagnosis of fever source was documented in 76% of HBNH and 16% of CBNH episodes (P less than 0.005). Overall assessment stratification showed 81% febrile HBNH patients had both evaluation and therapy performed compared with 38% in CBNH (P less than 0.0001); 39% of febrile CBNH patients had no evaluation or therapy performed. Results indicate lack of documentation, and fever evaluation in CBNHs may preclude complete detection of nursing home-acquired infections and thereby hamper preventive responses to potential infection problems.

Prevalence survey of infections and their predisposing factors at a hospital-based nursing home care unit.

A prevalence survey was performed at a Veterans Administration nursing home care unit to detect the frequency, demographics, features, and potential risk factors associated with infections, compare different methods for calculating infection rates, and compare prevalence data with routine physician reporting of infections during a one-month period. In 176 evaluable residents, 22 nursing home-acquired infections were detected, with rates of 12.5% by infections per residents at risk, and 4.6% by infections per 1000 resident-days. Fifty percent of these infections (11 of 22) involved the urinary tract, seven of which were associated with indwelling catheters. Factors potentially associated with increased overall infection rates included immobility (P less than .02), acute-care hospitalization in the 28 days preceding the study (P less than .01) and antibiotics given preceding the infection (P less than .001). An indwelling urinary catheter (P less than .01) potentially was associated with an increased urinary tract infection rate. During the concurrent period, routine physician reporting of infection detected four of the 22 infections (18%) that were identified by the survey. These findings suggest that physician reporting of infection underestimates infection risk as compared with conventional surveillance practices, and that hospital-based care units may have infection problems more similar to acute-care hospitals than to community nursing homes. Identification of potential risk factors is critical in planning preventive practices based on institution-specific needs.

Association of dehydroepiandrosterone sulfate, body composition, and physical fitness in independent community-dwelling older men and women.

OBJECTIVES: To determine the association of dehydroepiandrosterone sulfate (DHEAS), body composition, and physical fitness in independent community-dwelling men and women aged 60 to 80 years. DESIGN: Cross sectional analysis. PARTICIPANTS: Independent men and women, 60 years of age and older, living in urban and suburban communities of Southeastern Wisconsin. MEASUREMENTS: History, physical examination, physical activity level, and anthropometrics were measured for every subject. Total adipose mass (TAM) and lean body mass were measured using dual energy X-ray absorptiometry. Dehydroepiandrosterone sulfate, insulin-like growth factor-1 (IGF-1), total testosterone (TT), and free testosterone (FT) were measured using radioimmunoassay. Physical fitness was measured as VO2max using exercise stress tests. Blood for lipids was analyzed using standard assays. RESULTS: In men, the DHEAS was significantly correlated to age (r = -.32), TAM (r = -.27), percent fat (r = -.30), HDL cholesterol (r = .34), TT (r = .30), VO2max (r = .23), and percent lean body mass (% LBM) (r = .33). In women, the DHEAS was not significantly correlated to any of the variables examined except body mass index (BMI) (r = .23). In men, after partialling out age, DHEAS was significantly correlated to HDL, % fat, TAM, % LBM, and TT. Multivariate analysis for men revealed that high density lipoprotein cholesterol (HDL) was the strongest predictor of serum DHEAS level, followed by % LBM, BMI, and age. The men in the highest quartile of serum DHEAS levels were different from those in the lowest quartile in terms of age, TT, FT, % fat, TAM, % LBM, HDL, and low density lipoprotein (LDL) cholesterol level. No such differences were found in the two groups of women. CONCLUSION: In this group of independent community-dwelling older men, several factors were found to be associated with the serum DHEAS concentration, whereas in a group of older women, no such associations were identified with the exception of BMI. Men in the highest quartile of serum DHEAS level, compared with those with a serum DHEAS level in the lowest quartile, were younger, leaner, more fit, had higher TT and FT levels, and had a favorable lipid profile. No such differences were identified between the women in the highest and the lowest quartiles of serum DHEAS level.

Efficacy of an influenza hemagglutinin-diphtheria toxoid conjugate vaccine in elderly nursing home subjects during an influenza outbreak.

OBJECTIVE: To compare the efficacy of an influenza hemagglutinin-diphtheria toxoid conjugate vaccine with the commercially available influenza hemagglutinin-subunit vaccine in preventing influenza in older adults living in a nursing home. DESIGN: A prospective, randomized, double-blind vaccine trial with 5 months of follow-up after vaccination. SETTING: Fourteen Wisconsin nursing homes. PARTICIPANTS: Nursing home residents at least 65 years old who were able to give informed consent and were free of malignancy and not receiving immunosuppressive therapy. INTERVENTIONS: Participants received, by intramuscular injection, 0.5 mL of a trivalent influenza vaccine containing 15 micrograms each of A/Leningrad/360/86 (H3N2), A/Taiwan/1/86 (H1N1), and B/Ann Arbor/1/86 (HA) or 0.5 mL of an influenza vaccine containing the same antigens conjugated to diphtheria toxoid (HA-D). MEASUREMENTS: Blood was obtained pre- and 1 month post-vaccination to assess for any vaccine-induced antibody titer change. Clinical surveillance for respiratory illness was performed twice weekly for 5 months. A record was kept of all signs and symptoms of new respiratory illness, and a viral culture and acute and convalescent sera were obtained. RESULTS: 204 participants received HA and 204 received HA-D. Both groups had similar baseline antibody levels to all influenza antigens. HA-D recipients seroconverted more frequently based on serum neutralizing activity (P < 0.05), had a greater increase in geometric mean titer (GMT), and sustained the increase in antibody titer longer than HA recipients. Vaccine hemagglutinin recall was greater in a subset of HA-D recipients as measured by lymphocyte proliferative assays (P < 0.05). During an outbreak of influenza A (H3N2 A/Shanghai/11/87-like and A/Victoria/7/87-like), fewer HA-D (29/195) than HA (43/204) recipients had laboratory-confirmed infection (P = 0.053), and, of these, fewer HA-D-treated subjects had lower respiratory tract involvement (5/29 HA-D and 17/43 HA) (P = 0.022). CONCLUSIONS: HA-D was more immunogenic in institutionalized elderly recipients and produced greater protection from influenza infection. Superior protection may be due to HA-D's ability to stimulate and recruit antigen-presenting cells, thus enabling the recipient to achieve and maintain functional antibody titers.

Augmentation of influenza antibody response in elderly men by thymosin alpha one. A double-blind placebo-controlled clinical study.

Influenza remains a major cause of illness and death in elderly people despite current vaccination programs. One factor is an immunization failure rate in the elderly that may be as high as 50%. To test whether administration of thymosin alpha 1 would result in greater antibody production, we administered it (900 micrograms/m2 subcutaneously twice weekly for eight doses) in conjunction with the 1986 trivalent influenza vaccine. Ninety men (65-99 years old, mean age 77.3 years) were randomized double-blind to receive thymosin alpha 1 or placebo by the same schedule; the sera from 85 of these men were acceptable for analysis. The two groups were similar with respect to underlying disease, medications, and age. No toxicity was observed in either group. Antibody response rate was defined as a four-fold rise in antibody titer over 3-6 weeks following vaccination and was measured by an enzyme-linked immunosorbent assay (ELISA). Analysis was performed on treatment groups and subgroups divided by the mean age: the older group consisted of subjects aged 77 years and older, and the younger group those aged from 65-76 years. Baseline and change in absolute antibody levels were compared by t test and using age as a continuous variable by multiple regression analysis.(ABSTRACT TRUNCATED AT 250 WORDS)

Emergency detention of the elderly: demographics, diagnoses, and outcome.

Involuntary medical detention is an increasing problem in many large teaching hospitals. Forty-two elderly patients involuntarily admitted for protective service to the general medical wards were compared with an age-matched group of 25 elderly persons voluntarily seeking care in the same institution. The comparison showed that most of the involuntarily admitted patients were more than 70 years of age, and more of them lived alone. On admission they had more dementia and dehydration but less urinary-tract infection than did the controls. Their hospital stays were longer. There was no difference between the groups with respect to discharge dispositions.

Survey of nursing personnel attitudes toward infections and their control in the elderly.

To better understand nursing practice in geriatric care settings as it relates to infections, a survey of nursing attitudes about a variety of infection control issues was undertaken. Nurses were recruited from four settings: a university-affiliated, private nursing home (N = 46), a hospital-based nursing home (N = 33), a private nursing home (N = 20), and a home care agency (N = 26). The nurses appropriately recognized the importance of pneumonia and influenza as major threats to health in these settings and also reported some indifference regarding the notification of physicians about fevers under 38.9 degrees C (102.0 degrees F). Among the groups, similar attitudes about infection control principles were recorded, except that the ratings by the home care agency nurses were different from those of the institution-based nurses in the following areas: isolation as a means to prevent infection spread, proper waste disposal methods, and frequency of catheter change. Assessment of personnel attitudes and practices are important in detecting problems, guiding in-service programing, and revising care practices.

Elevated salivary cortisol in the evening in healthy elderly men and women: correlation with bone mineral density.

BACKGROUND: Aging is associated with a loss of bone mineral density (BMD) in men and women. Loss of BMD can also be caused by hypercortisolemia in men or women at any age. This study measured salivary cortisol at 2300 h and 0700 h as indices of cortisol secretory activity in 228 elderly, community-dwelling subjects. Salivary cortisol results were correlated with BMD. We hypothesized that salivary cortisol is elevated at 2300 h in elderly people, and that salivary cortisol will correlate negatively with BMD. METHODS: Saliva was sampled at 2300 h (nadir in circadian rhythm) and 0700 h (peak in circadian rhythm) in 130 men (70.7 +/- 0.4 years old) and 98 women (70.0 +/- 0.4 years old); approximately half of the women were receiving hormone replacement therapy (HRT). BMD was measured by dual energy x-ray absorptiometry. RESULTS: Salivary cortisol at 2300 h was significantly elevated in men (2.3 +/- 0.1 nmol/L) and women (2.1 +/- 0.1 nmol/L) as compared to 73 younger controls (1.2 +/- 0.1 nmol/L; 37 +/- 1 year old). Salivary cortisol at 0700 h was not different between older subjects and younger controls. There was a significant negative correlation of lumbar (L2-4) BMD and 2300 h salivary cortisol in older women (r = -0.20, p = .05; n = 98); this correlation was significant only in women not on HRT. There was a highly significant negative correlation of lumbar (L2-4) BMD and 0700 h salivary cortisol in older men (r = -0.31, p = .0003). CONCLUSIONS: Salivary cortisol is a simple, nonstressful method for assessing activity of the hypothalamic-pituitary-adrenal (HPA) axis in the elderly population. A major finding was an elevation in the late night nadir in cortisol secretion. We also suggest that elevated cortisol secretion in elderly people may contribute to the age-related loss in bone mineral density and that this effect is prevented by HRT.

Mandibular and palatal tori, bone mineral density, and salivary cortisol in community-dwelling elderly men and women.

BACKGROUND: This investigation evaluated the relationship between the presence of tori and bone mineral density (BMD) and salivary cortisol levels. METHODS: A total of 230 healthy, community-dwelling elderly men (n = 129) and women (n = 101) aged 60 and older participated in this study. Forty-three women were on hormone replacement therapy (HRT). This was a component of a 5-year longitudinal study measuring subjects' body composition, hormone levels, physical activity, and diet every 6 months. Subjects were examined for the presence of tori by visual inspection and digital palpation. BMD at six sites was measured by dual-energy X-ray absorptiometry. Salivary cortisol levels were measured by radioimmunoassay. RESULTS: Twenty-three percent of all subjects had mandibular tori, 13% had palatal tori, and 12% had both mandibular and palatal tori. Mandibular tori were more common in men, and palatal tori were more common in women. The presence of mandibular tori was significantly correlated with BMD of the lumbar spine, femoral neck, trochanter, and Ward's triangle for all subjects, and with the femoral neck and trochanter of women not on HRT. Men with palatal tori had lower levels of salivary cortisol in the evening. CONCLUSIONS: This study documented the high prevalence of mandibular and palatal tori in a group of 230 elderly, community-dwelling subjects. Women not on HRT and all subjects taken as a group with mandibular tori had higher BMD. The presence of tori at young adulthood may be a marker of higher BMD in the future and of a lower risk for developing osteoporosis.

Falls.

Falls are a health hazard for the elderly patient. Annually, approximately 30 per cent or more of elderly patients will experience such a problem. Seventy per cent of deaths from falls occur in the elderly population. Morbidity from falls includes fractures, soft tissue trauma, anxiety about further falls, and loss of confidence. Falls are due to environmental factors; neurologic illness including dementia, drop attacks, and sensory loss; alcohol and drug use; orthostatis; cardiac arrhythmias; and acute illnesses such as infection, heart failure, and gastrointestinal bleeding. The physician who treats elderly patients needs to identify those patients at risk or those who already have the problem. Evaluation should not be limited to assessment for injury and must include establishing an etiology. Therapy depends upon determining the precise etiology for the fall and rectifying contributing factors.

Valuing educational scholarship at the Medical College of Wisconsin.

Since the late 1980s faculty and staff at the Medical College of Wisconsin (MCW) have actively sought to align their school's academic culture and promotional process with its mission of educational excellence and innovation. As one of the top 50 medical schools receiving NIH funds, MCW has well-established mechanisms to evaluate and recognize the scholarship of discovery. Understanding, evaluating, and recognizing the value of individuals engaged in the scholarship of teaching, however, required changes in individuals' beliefs and in the MCW's promotion processes and organizational infrastructure. Building on the successful introduction of the MCW's Educator's PortfolioCopyright, a tool for documenting educational scholarship, a multifaceted change strategy was implemented to influence underlying beliefs and values about clinician-educators. Retrospectively, this strategy was consistent with John Kotter's eight-step change model, which the authors apply as an organizing framework for this case report of educational evolution at the MCW. Through creating a guiding coalition, developing vision and strategy, generating short-term wins, and anchoring new approaches in the MCW's culture, the MCW has made substantive progress in recognizing and rewarding educational scholarship. Changing academic cultures to value education is itself an educational process, requiring persistence and the ability to teach others about educational scholarship and its associated criteria.