Autopsy study of the elderly institutionalized patient. Review of 234 autopsies.

Autopsies are performed much less frequently in the elderly than in younger patients. Little information exists as to causes of death in the institutionalized elderly. The clinical diagnostic error rate documented by autopsy studies ranges from 6% to 68%. We analyzed the clinical and autopsy records of 234 patients who died during a 14 1/2-year period at our chronic care institution to determine the accuracy of clinical cause of death in addition to the pathologic cause of death. The most common causes of death included bronchopneumonia (33%), congestive heart failure (15%), metastatic carcinoma (14%), pulmonary embolism (8%), myocardial infarction (7%), cerebrovascular accident (6%), unknown cause of death (8%), and a miscellaneous group (9%). The highest diagnostic error rate was in the underdiagnosis of pulmonary embolism (39% antemortem accuracy rate). The most accurately diagnosed condition was cerebrovascular accident (92% antemortem accuracy rate). Pneumonia was correctly diagnosed antemortem in 73% of the patients studied. These data suggest that serious and potentially treatable illnesses are underdiagnosed in the elderly institutionalized patient and that there is valuable information to be learned by performing autopsies in the elderly population.

Obscuring urinary incontinence. Diapering of the elderly.

To assess the prevalence, evaluation, and treatment of urinary incontinence in an institutionalized elderly population, the charts of 511 residents in a New York City nursing home were reviewed. Whereas the nurses' notes documented urinary incontinence in 62.4% of the total resident population, the physicians' notes listed this as a problem in only 10% of the residents. Most (90.3%) of the cases of incontinence were not classified as to etiology or pattern. Treatment emphasized the use of diapers in 78.2% of the cases, which was combined with bladder conditioning in most instances. This treatment approach had been initiated, administered, and monitored by the nursing staff. Indwelling catheters were used in 4.0% of the situations, and pharmacologic therapy was used in 2.5% of the cases. It is suggested that adult diapers may not be the optimal treatment for urinary incontinence since they treat the symptom instead of the cause. There should be a systematic approach to the classification and treatment of urinary incontinence prior to the long-term utilization of diapers.

Nosocomial urinary-tract infections in a skilled nursing facility.

Fifty-five documented infections reported from an admission unit of a large skilled nursing facility (SNF) during a five-month period were analyzed. Of these, 45 (82 percent) were urinary-tract infections (UTIs), chiefly asymptomatic bacteriuria. Sixty-three percent of the UTIs were acquired in the SNF, and the remainder were acquired during the preceding stay in a general hospital. Statistically, Proteus species infections were more common among the SNF-acquired UTIs, whereas Pseudomonas aeruginosa infections were the most common among the hospital-acquired UTIs. The following recommendations are made: 1) for previously hospitalized elderly patients in whom urinary-tract sepsis develops soon after admission to an SNF, treatment should start with an antibiotic active against Pseudomonas aeruginosa while the results of cultures are pending; 2) symptomatic lower urinary-tract infections caused by SNF-acquired Proteus species should be treated with nalidixic acid or trimethoprimsulfamethoxazole; 3) the term "nosocomial infection" should be broadened to include infections acquired in long-term care institutions; and 4) infection surveillance should be started in selected long-term care institutions for the elderly as part of an expanded National Nosocomial Infections Survey.

Obtaining informed consent in the teaching nursing home.

The authors observed attempts to obtain informed consent for clinical research at the Jewish Institute for Geriatric Care. One study entailed the use of venipuncture, urine collections, urethral catheterizations, and antibiotic therapy. The other required that venipunctures and lumbar punctures be performed on dementia patients. Patients and families were observed to be unwilling to consent to any procedure more invasive than venipuncture. Poor recall and other physical and psychologic factors impaired comprehension of the protocols, and some patients requested second opinions from trusted "others." Written consent could be refused despite verbal consent. Furthermore, incompetent patients could refuse to participate in protocols for which family members had given consent. The implications of these observations are discussed. Despite concerns, which are enumerated, it is concluded that informed consent can be obtained in the teaching nursing home.

Can physically restrained nursing-home residents be untied safely? Intervention and evaluation design.

OBJECTIVE: To develop an intervention that will enable nursing home personnel to remove physical restraints from nursing-home residents safely and cost effectively. DESIGN: A multicenter prospective pre-post study. SETTING: Sixteen high-restraint-use nursing homes, four each from California, Michigan, New York, and North Carolina. The 16 facilities have 2075 beds. INTERVENTION: A 2-year educational demonstration study, including a 2-day workshop, specially prepared written and video materials, and telephone and on-site clinical consultations. Each nursing home designated a nurse to be the clinical coordinator and to lead a multidisciplinary team in conducting a restraint assessment and devising interventions for removal. OUTCOME MEASURES: We compared pre- and post-study aggregate and individual facility rates of restraint use, incidents and accidents, family attitudes, financial impact, serious injuries, and staff attitudes and work patterns. CONCLUSION: Preliminary data suggest that this intervention was well received and appears to be effective in achieving restraint-free care.

The prevalence and one-year outcome of limb arterial obstructive disease in a nursing home population.

To assess the utility of bedside diagnostic measures to detect prognostically significant peripheral vascular disease, we examined 60 nursing home residents by physical examination, Doppler sphygmomamometry and pneumatic oscillometry, and recorded the clinical history. Eighty-eight percent of the cases had tibial/brachial arterial systolic pressure indices below 0.95, the lower limit traditionally considered normal. Yet, no more than 5% of the patients carried a previous diagnosis of peripheral vascular disease or had intermittent claudication, leg ulcers or gangrene. Approximately half of the patients had tibial/brachial pressure indices less than 0.7, and one year later in these cases, there was significantly greater morbidity and nearly twice the mortality of patients with less severe disease. We conclude that simple bedside diagnostic tests of arterial disease used in this study discloses a high prevalence of disease in institutionalized elderly patients and identifies a group at particular risk for morbid complications.

Pernicious anemia in the demented patient without anemia or macrocytosis. A case for early recognition.

It is well known that the neurologic manifestations of vitamin B12 deficiency can occur in the absence of anemia. The authors recently observed two elderly patients who presented to a chronic care institution with the diagnosis of dementia, and in both individuals low serum B12 levels were found in conjunction with abnormal Schilling tests. In neither of these two patients was there anemia or macrocytosis. After receiving parenteral B12 injections there was improvement noted in cognitive functions as well as in activities of daily living. The authors are reporting these patients to alert clinicians to the fact that pernicious anemia in the elderly can first present with low serum B12 levels and neurologic abnormalities in the absence of anemia or macrocytosis.

Assessing life expectancies of older nursing home residents.

OBJECTIVE: Care of nursing home (NH) residents is often based on the usual survival of the home's residents. In order to improve our understanding of this population, and, thus, ultimately facilitate individualization of their care, we developed a mathematical model that predicts their survival. SETTING: The Jewish Home and Hospital (JHH), a nursing home. PARTICIPANTS: 1145 older residents who were at the JHH from January 1, 1986, through July 1, 1986. MEASUREMENTS: Information abstracted from medical records and JHH computerized data: clinical, demographic, and dependencies in activities of daily living (ADLs). MAIN OUTCOME MEASURE: survival from July 1, 1986. DESIGN: Retrospective cohort study via medical chart review. The study period covered admission to JHH through January 17, 1996. Accelerated failure time (AFT) models generated the life expectancy model derived from 50% of the study group and were validated on the remaining sample. We computed predicted AFT and proportional hazards (PH) life expectancies. RESULTS: Significant, independent predictors of decreased survival were male gender, increased age, increase in summary ADL index, and impairment of cardiac, respiratory, neurological, and endocrine/metabolic systems. The interaction between gender and respiratory system impairment was significant. The Spearman correlation coefficients between the observed survivals and those predicted by the Phase I model are 0.49 for Phase I residents and 0.42 for Phase II residents. Our sample life table includes NH residents with different risk profiles and their associated survival estimates as well as interquartile ranges. AFT and PH survivals were similar. CONCLUSION: This first comprehensive model that predicts survival of NH residents can help formulate public health policies and identify appropriate NH residents for clinical trials. The model is a promising step toward improving the health care of NH residents.

Sequential outbreak of influenza A and B in a nursing home: efficacy of vaccine and amantadine.

OBJECTIVE: To describe the sequential occurrence of influenza A and B in a nursing home, and to determine the efficacy of influenza vaccine and/or amantadine treatment with respect to incidence and sequelae. SETTING: The Jewish Home and Hospital for Aged, a skilled-care nursing facility. PARTICIPANTS: Of 499 frail older nursing home residents, 139 contracted influenza during the study period (mean age 87.5 years; SD = 6.7). The residents were followed from February through April 1988. INTERVENTION: Influenza vaccine and/or amantadine. MEASUREMENTS: Episodes of influenza and their sequelae, i.e., pneumonia, hospitalization, and death. RESULTS: The vaccine had no effect on the incidence of influenza-like illness, length of illness, or the associated death rate. It reduced the rate of pneumonia secondary to influenza A and B (relative risk = .57; 95% CI: .37 to .89; P = .023). Amantadine did not affect the attack rate of influenza nor the rate of pneumonia secondary to influenza. It was associated with decreased mortality (relative risk = 0; P = .001), and shorter length of influenza A illness (PWilcoxon = .082). Although the combination of amantadine and vaccine did not affect length of influenza (A or B) illness, it was associated with a significantly lower rate of sequelae (relative risk = .58; 95% CI: .36 to .95; P = .024). CONCLUSION: In this epidemic, the combination of amantadine and vaccine was most effective in reducing the rate of influenza-associated sequelae. The possibility of a "biphasic" epidemic prompts consideration of vaccinating nonimmunized nursing home residents, even though it may be late in the influenza season.

Restraint reduction reduces serious injuries among nursing home residents.

OBJECTIVES: To describe how removing physical restraints affected injuries in nursing home settings. DESIGN: A 2-year prospective study of an educational intervention for physical restraint reduction. SETTING: Sixteen diverse nursing homes with 2075 beds in California, Michigan, New York, and North Carolina. PARTICIPANTS: Study A: 859 residents who were physically restrained at the onset of the intervention on October 1, 1991. Study B: all residents who occupied the 2075 beds in the 16 facilities 3 months before the intervention and 3 months after its completion. INTERVENTION: Educational program for nursing home staff followed by quarterly site consultations to participating nursing homes. MAIN OUTCOME MEASURES: Rate of physical restraint use and injuries. RESULTS: Study A: Serious injuries declined significantly among the 859 residents restrained initially when restraint orders were discontinued (X2 = 6.2, P = .013). Study B: During the intervention period, physical restraint use among the 2075 residents decreased from 41% to 4%, a 90% reduction. The decrease in the percentage of injuries of moderate to serious severity was significant (i.e., 7.5% vs 4.4%, P2-tail = .0004) as was the rate of moderate and serious injuries combined (Rate Ratio = 1.580, P2-tail = .0033). CONCLUSIONS: A substantial decrease in restraint use occurred without an increase in serious injuries. Although minor injuries and falls increased, restraint-free care is safe when a comprehensive assessment is done and restraint alternatives are used.

Ethics rounds at the nursing home: an alternative to an ethics committee.

The increased attention in US medicine to medical ethics reflects in large part the "new" demography of a growing elderly population and the conflict of whether decisions regarding medical care should be based on cost-effectiveness or "human-effectiveness." Currently, about 40 percent of the nation's elderly end up in nursing homes where they confront ethical and legal dilemmas that would not arise in their own homes. In the nursing home, difficult medical-ethical decisions generally rely on two approaches: the often used but frequently invalid concept of informed consent and little used ethics committees. At The Jewish Home and Hospital for Aged in New York City we have developed a program of "ethics rounds" as an alternative to ethics committees. We conduct the rounds in the open style of a forum or clinical conference rather than with the aura of a decision-making group. We encourage the participation of patients and family and seek to educate the staff, any one of whom may choose to attend. The rounds consist of a multidisciplinary case presentation, an interview of patient and/or family, a discussion by the staff, and an overview by an ethicist. Staff response to the educational and interdisciplinary aspects of the rounds has been remarkably positive.

Relationships of sex hormone levels to dependence in activities of daily living in the frail elderly.

OBJECTIVES: We undertook this nursing home study in order to determine the relationships between dependency in activities of daily living (ADL) and blood levels of estrone, testosterone, androstenedione, and dehydroepiandrosterone (DHEA). Little is known about this issue. METHODS: cross-sectional study of 370 nursing home residents. Hormone levels in blood specimens drawn in 1997 and 1998 were correlated with degree of ADL dependency recorded in medical charts. RESULTS: Because of multiple comparisons associations were deemed significant for P-values < or =0.017 for males and < or =0.0125 for females. In males, the following were inversely related: testosterone levels with dependency in transferring and eating; estrone with eating and a summary ADL index; and androstenedione with toileting and a summary ADL index (in all cases, r=-0.4; P=0.007-0.015). Inverse trends existed between testosterone levels and dependency in mobility and a summary ADL index; and androstenedione and eating (in all cases r=-0.3; P=0.030-0.055). Among females the following were directly related: estrone levels with dependence in mobility, toileting, transferring, and a summary ADL index; and DHEA with transferring and a summary ADL index (r=0.2-0.3, P=0.0001-0.01). Trends existed between estrone and eating, and DHEA and toileting (r=0.1-0.2, P=0.04). CONCLUSION: In male residents, higher sex hormone levels are associated with better ADL performance. Among females the opposite is true. While further studies are needed to elucidate these relationships, our results and recent findings of others suggest sex hormone actions in older women differ from those in younger populations. A possible stress-related mechanism is also presented.

A teaching nursing home: ten years of partnership between the Jewish Home and Hospital for Aged and the Mount Sinai School of Medicine.

The JHHA is moving forward into new areas of pursuit within long-term care, including studies of the pneumonia vaccine; the cause of Alzheimer's disease; the difference between the brain of the Alzheimer's patient and the normal aging brain; new patterns and approaches in pharmacy and pharmacology; and the new nursing home of the 21st century in a changing health care environment. Students and graduate physicians will continue to strengthen their clinical identity by virtue of this exposure, and those of all ages will benefit from the research and advances in patient care coming out of this program.

Nursing staff attitudes on the use of physical restraints in a teaching nursing home.

This study supports the importance of assessing the intrinsic and extrinsic attitudes and perceptions of staff on physical restraints. Any program developed to remove physical restraints in nursing homes should focus on safety issues and behavioral interventions that prevent injury to staff and resident. Environmental adaptations that would enhance residents' safety, such as alarms and wedge cushions, would be useful in a restraint reduction program. Educating staff about the risks of physical restraints and about safe alternative interventions might change their attitudes. By developing an educational program that focuses on a few residents at a time and by involving a multidisciplinary team, a truly individualized approach to restraint-free care for residents might be developed.

Acute myocardial infarction in a long-term care institution for the aged.

We reviewed the clinical characteristics and outcome of cases of acute myocardial infarction occurring from January 1, 1985, through December 31, 1987, in the population of a long-term care institution for the elderly. The total number of patients in the series was 43. Comparisons were made between those patients transferred to a general acute-care hospital and those who remained at the facility. The most common initial symptoms of acute myocardial infarction in 32 of 48 patients were, in order, dyspnea, dizziness or syncope, precordial pain, and abdominal pain. Nine (of 43) patients were asymptomatic. In the 14 (of 43) patients transferred to an acute-care hospital, cardiac failure, arrhythmias, and cardiogenic shock were much more frequent than among those retained in the long-term care facility. We concluded that a high index of suspicion for the diagnosis of acute myocardial infarction in the institutionalized elderly is indicated. Patients with mild infarction can be retained in long-term care institutions; resulting mortality from cardiac disorders should be low in adequately staffed and equipped long-term care institutions.

The clinical utility of a comprehensive periodic assessment form for the geriatric rehabilitation patient.

The Comprehensive Periodic Assessment Form is a new format used to document a patient's rehabilitation progress. It is a nonnarrative, semi-graphical form in which is digested on one page many sheets of progress notes from a variety of disciplines. Mobility, ADL, mental, and medical status overtime can be ascertained at a glance. The form has special utility for the aged patient experiencing rehabilitation treatment.

Retrain, don't restrain: the educational intervention of the National Nursing Home Restraint Removal Project.

This article describes an educational program that contributed to a 90% reduction in the use of physical restraints in 16 randomly selected nursing homes over a two-year period. The educational program advocated assessments by a multidisciplinary team to generate individualized, restraint-free interventions. The program consisted of a workshop, telephone and quarterly on-site consultations, regional meetings, a newsletter, and written and audio-visual materials. The workshop and site visits were powerful motivators, and participants also found the video very useful. Most nursing homes can easily adapt components of this project to create their own restraint-removal programs.

A center on ethics in long-term care.

Long-term care institutions are beginning to grapple with ethical issues on a regular basis. This has encouraged facilities to develop new mechanisms to deal with these issues. Described is a tripartite program that incorporates direct service, education, and research in ethics.

The measurement of residual urine in the evaluation of incontinent nursing home residents.

Seventy-six nursing home residents with urinary incontinence (59 females, 17 males, Mean age = 84 years) underwent an evaluation which included the measurement of residual urine and cystometric studies. Upon catheterization 18 subjects were found to have urine volumes greater than 100 ml. Only two subjects had urine volumes greater than 250 ml. Cystometry revealed detrusor instability in the majority (83%) of the 76 subjects. Although the measurement of the post-voiding residual urine is a simple method to assess for ineffective bladder emptying, at volumes less than 250 ml, it is not always possible to predict the type of bladder dysfunction without additional studies. There can be problems in obtaining an accurate measurement of the post-voiding residual urine in elderly institutionalized patients. Many of our subjects (36 subjects) experienced difficulty urinating prior to catheterization. The residual urine measurement should not be solely relied upon in the prediction of bladder dysfunction in the elderly. This measurement should be combined with other data to effectively investigate the etiology of urinary incontinence.

Tuberculosis surveillance in a long-term care facility.

The prevalence of tuberculous infection in residents of a large nursing facility in New York City was assessed. The population was predominantly female (80%) and white (86%), with almost one-half (49%) being foreign born. The mean age of the group was 86.1 years. Four hundred and fifty-five residents were given tuberculin skin tests using the two-step Mantoux test procedure. The prevalence of tuberculous infection was 27.5% with only slight differences being noted between the native-born (28.8%) and foreign-born (26.1%) residents. A 10% booster effect was noted. Tuberculous infection rates were higher in non-white than white residents. A progressive decline in the prevalence of tuberculous infection was noted with increasing age. No cases of tuberculosis were detected. Our study provides a model for collecting and evaluating epidemiologic data to assess infection prevalence and tuberculosis transmission in a long-term care facility.