Hyperthyroidism as a cause of atrial fibrillation in long-term care.

BACKGROUND: We measured sensitive thyrotropin-stimulating hormone (sTSH) in 50 consecutive nursing home patients (39 men) with atrial fibrillation to determine the frequency of hyperthyroidism. METHODS: Patients were identified in a long-term care facility by an electrocardiogram demonstrating atrial fibrillation. The sensitive thyrotropin-stimulating hormone assay had a detection limit of less than or equal to 0.02 mU/L (normal range, 0.46 to 3.60 mU/L). RESULTS: No subject had a suppressed sensitive thyrotropin-stimulating hormone. CONCLUSIONS: Hyperthyroidism is not a common cause of atrial fibrillation in male nursing home residents.

Duration of antiviral prophylaxis during nursing home outbreaks of influenza A: a comparison of 2 protocols.

BACKGROUND: We performed a randomized trial of 2 protocols guiding the duration of antiviral chemoprophylaxis during outbreaks of influenza A in a rural, 700-bed nursing home for veterans and their spouses with 14 nursing units in 4 buildings. METHODS: Half of all residents volunteered to participate. Nursing units were randomized, and the effectiveness of short-term (minimum, 14 days and 7 days without the onset of a case in the building) vs long-term (minimum, 21 days and 7 days without the onset of a case in the 4-building facility) prophylaxis was compared using amantadine hydrochloride in the influenza seasons of 1991-1992 and 1993-1994 and rimantadine hydrochloride in the influenza season of 1994-1995. A "case" is defined as an incident of a respiratory tract illness and the isolation of an influenza virus organism. We compared the number of cases after the discontinuation of short- vs long-term chemoprophylaxis. Prospective surveillance identified residents with new respiratory tract symptoms, and specimens for viral cultures were obtained even in the absence of temperature elevation. RESULTS: We documented influenza A virus activity during 3 seasons (32, 68, and 12 patients, respectively). During the 1991-1992, 1993-1994, and 1994-1995 influenza seasons, the patients on 11 floors were assigned to receive short-term chemoprophylaxis and those on 10 floors were assigned to long-term chemoprophylaxis. Only in 1993-1994 did chemoprophylaxis extend beyond 14 or 21 days when new cases continued beyond 14 days. Amantadine-resistant strains were circulating at that time. None of the participants in the prospective, controlled study had influenza develop after the termination of short- or long-term chemoprophylaxis. CONCLUSION: Antiviral chemoprophylaxis can be administered for the longer duration of 14 days or, in the absence of new culture-confirmed illness in the nursing building, for 7 days.

Influence of age and body weight on spine and femur bone mineral density in U.S. white men.

Bone mineral density (BMD) was measured in normal white males using 153 Gd dual-photon absorptiometry. Measurements were made on the lumbar spine (n = 315) and on the proximal femur (n = 282) utilizing three regions of interest. There was a small but significant age-related decrease in spinal BMD (r = -0.11; -0.001 g/cm2 per year) and trochanteric BMD (r = 0.27; -0.002 g/cm2 per year). The BMD of the other femoral sites decreased more rapidly; the femoral neck (r = -0.58; -0.005 g/cm2 per year) and Ward's triangle (r = -0.69; -0.007 g/cm2 per year) declined by about 21 and 34%, respectively, from age 20 to age 70. These femoral BMD decreases were three to four times greater than those usually seen in the peripheral skeleton in males but less than the decreases of 25-30 and 40% in the femoral neck and Ward's triangle of white females. This pattern of aging bone loss may partially explain the paucity of spine fractures and the lower incidence of hip fractures in males versus females.

Effects of iodinated glycerol on thyroid function studies in elderly nursing home residents.

Iodinated glycerol is used as a mucolytic expectorant in the treatment of respiratory disorders. Iodine can inhibit the biosynthesis of thyroid hormone and induce hypothyroidism, particularly in patients with a history of thyroid disease. Such effects have not been reported in individuals without known thyroid disease who are being treated with organically bound iodine in the form of iodinated glycerol. In the course of a thyroid screening program for nursing home residents, eight subjects were identified who were being treated with iodinated glycerol. Five of these were found to have thyrotropin elevations; one showed a low serum thyroxine level and a decreased free thyroxine index. None of these residents had a history of thyroid disease. Abnormalities of thyroid function improved or resolved after discontinuation of therapy. Elderly nursing home residents without known thyroid disease are at risk of thyroid suppression when given iodinated glycerol.

A serious outbreak of parainfluenza type 3 on a nursing unit.

OBJECTIVE: To report a serious outbreak of respiratory illness in a nursing home, with isolation of parainfluenza type 3 in four cases. DESIGN: Viral respiratory cultures from a sample of symptomatic residents, and retrospective chart review. SETTING: A 50-bed nursing unit/floor in a skilled nursing facility. PARTICIPANTS: All residents of the nursing unit. MEASUREMENTS: Respiratory viral cultures and clinical chart review. RESULTS: Twenty-five of 49 residents developed new respiratory symptoms between September 2 and September 25, 1999. Ten cases (40%) had a tympanic temperature of 100 degrees F or greater. Eighteen (72%) had a chest X-ray with 11 (44%) new infiltrates. Sixteen (64%) were treated with antibiotics. Three cases were hospitalized and four died (16%) within 1 to 9 days after onset of symptoms. Four of 10 viral cultures yielded parainfluenza type 3. CONCLUSIONS: Parainfluenza type 3 may cause outbreaks complicated by pneumonia and fatal outcome. Clinicians should consider uniform secretion precautions to contain all viral URIs in nursing homes.

Low circulating levels of insulin-like growth factors and testosterone in chronically institutionalized elderly men.

OBJECTIVE: To determine the prevalences of and the associations between hyposomatomedinemia and hypogonadism in healthy young men, healthy old men, and chronically institutionalized old men. DESIGN: Survey with serial blood tests. SETTING: Veterans Affairs nursing home and young and old men living in the community. SUBJECTS: Three groups were studied: healthy young men (20-29 years old, n = 32), healthy old men (59-98 years old, n = 30), and chronically institutionalized old men (59-95 years old, n = 112). MEASUREMENTS: Plasma insulin-like growth factor-I (IGF-I), total testosterone (TT), free testosterone (FT), and plasma insulin-like growth factor-II (IGF-II) were measured. In subjects with low testosterone level, serum luteinizing hormone (LH) was also determined. In a subset of chronically institutionalized old men with low IGF-I, the serum growth hormone (GH) level was analyzed during the first 4 hours of sleep. RESULTS: A low IGF-I level (defined as a value below the lower 2.5 percentile of the comparison group) occurred in 85% of the healthy old men when compared with healthy young men (P < 0.001), in 90% of the chronically institutionalized old men when compared with healthy young men (P < 0.001), and in 26% of the chronically institutionalized old men when compared with healthy old men (P < 0.001). In chronically institutionalized old men with low IGF-I compared with healthy young men, nocturnal peaks of serum GH were < 2 ng/mL in most cases. Low TT (defined as a value below the lower 2.5 percentile of the comparison group) occurred in 86% of the healthy old men when compared with healthy young men (P < 0.001), in 88% of the chronically institutionalized old men when compared with healthy young men (P < 0.001), and in 28% of the chronically institutionalized old men when compared with healthy old men (P < 0.001). The results of FT were similar. In 80% of the institutionalized old men with low TT and FT, the serum LH level was low (< 20 mU/mL). In 53% of the institutionalized old men, the IGF-II level was below the lower 2.5 percentile of the healthy old men (P < 0.001). In both healthy and institutionalized old men, IGF-I and IGF-II levels were significantly correlated to each other (r = 0.6), but neither was significantly correlated to TT or FT. In the institutionalized old men, IGF-I was inversely correlated with age and with a diagnosis of dementia; TT and FT were inversely correlated with age and with the degree of dependency in ADL's. CONCLUSIONS: Compared with healthy young men, most healthy old men have low serum IGF-I, TT, and FT levels. The geriatric hyposomatomedinemia and hypogonadism are more severe in institutionalized old men. In the latter group, both endocrine deficiencies are usually of central origin, but their occurrences are not significantly associated. Healthy old men usually have a low level of IGF-I compared with healthy young men, but a similar level of IGF-II; institutionalized old men are usually low in both values.

Correlates of depression and burden for informal caregivers of patients in a geriatrics referral clinic.

Caregiver burden has been associated with patient dementia. In this study we tested the hypothesis that caregiver burden and depression are related to patient cognitive impairment. We analyzed records of 127 elderly male patients from a Veterans hospital geriatrics referral clinic. The patients and their informal caregivers had been referred to the clinic because the complexity and multiplicity of their problems were beyond the treatment capability of other clinics. There was a high prevalence of dementia (73%) and depression (69%) in these patients according to Diagnostic and Statistical Manual (DSM-III) criteria. Quantitative measures of patient dementia and dependency in activities of daily living were not statistically associated with measures of caregiver depression or burden. In contrast, measures of patient depression were significantly correlated with measures of caregiver depression and burden. We hypothesize that caregivers of chronically ill, elderly men cope better with physical and cognitive incapacity than with affective symptoms. Because caregiver support is the most important factor in maintaining a disabled elder in the community, we suggest evaluating patients and caregivers for depression as part of standard practice in geriatric clinical settings.

Thyroid stimulating hormone elevation without antithyroid antibody elevation in nursing home patients.

OBJECTIVES: To investigate the relationship between antithyroid antibody elevation and thyrotropin (TSH) elevation. SETTING: Large state veterans home. METHODS: Seven hundred seventy-six residents were screened for TSH elevation. Seventy-two residents with TSH elevation and no history of thyroid disease or recent iodine exposure later had determinations of antithyroglobulin and antimicrosomal antibodies. The relationship between TSH levels and antibody titers was explored. RESULTS: Eleven percent of the residents had TSH elevation. Thirty-two percent of men and 64% of women with TSH elevation had elevation of antithyroid antibodies. Those residents with the highest antithyroid antibody titers had significantly greater TSH elevation. CONCLUSION: Previous investigators have found similar percentages of individuals with TSH elevation who lack antithyroid antibody elevation. We hypothesize that TSH elevation without elevated antibody titers may be the result of a previously described involutional histologic lesion of the thyroid.

Mortality following isolation of various respiratory viruses in nursing home residents.

OBJECTIVE: To compare mortality following isolation of influenza A to mortality following isolation of other respiratory viruses in a nursing home. SETTING: The Wisconsin Veterans Home, a 688-bed skilled nursing facility for veterans and their spouses. PARTICIPANTS: All residents with respiratory viral isolates obtained between 1988 and 1999. DESIGN: Thirty-day mortality was determined following each culture-proven illness. RESULTS: Thirty-day mortality following isolation of viral respiratory pathogens was 4.7% (15/322) for influenza A; 5.4% (7/129) for influenza B; 6.1% (3/49) for parainfluenza type 1; 0% (0/26) for parainfluenza types 2, 3, and 4; 0% (0/26) for respiratory syncytial virus (RSV); and 1.6% (1/61) for rhinovirus. CONCLUSIONS: Mortality following isolation of certain other respiratory viruses may be comparable to that following influenza A (although influenza A mortality might be higher without vaccination and antiviral agents). The use of uniform secretion precautions for all viral respiratory illness deserves consideration in nursing homes.

Hearing loss in the nursing home. An institutional issue.

One hundred ninety-eight nursing home admissions underwent audiometric assessment and answered questions regarding hearing difficulty in common listening situations. Twenty-four percent demonstrated normal thresholds (0-25 dB) in the speech frequencies with only mild losses at 4000 Hz. Fifty-four percent had normal thresholds through the speech frequencies with moderate to profound losses at higher frequencies, or mild losses (26-40 dB) in the speech frequencies. Such persons would be at risk in daily listening situations. Twenty-two percent had moderate or greater losses (greater than 40 dB) through the entire frequency range. Sixteen percent of this significantly impaired group were not identified as having a hearing loss by either the admitting RN or physician. Sixty percent of residents reported trouble in a group if they could not see the speaker's face, when watching television, and/or when using the telephone. The data indicate that a systematic hearing screening program is the most reliable means of identifying hearing loss and functional hearing handicap on an individual basis. The high prevalence of hearing problems suggests that this handicap also needs to be addressed from the perspective of institutional policy. Staff training and environmental modification should be undertaken to give hearing support to the entire nursing home population.

Follow-up of mild hypothyroidism in a nursing home.

The course of untreated mild hypothyroidism was followed in 67 nursing home residents (mean age 78 years). The diagnosis was based on a normal free thyroxine index (FTI) and elevated thyrotropin concentration (TSH 4.6 to 15.0 microIU/mL, nl less than or equal to 4.5 microIU/mL. FTI and FSH were measured in follow-up 42-378 (mean 161) days after the diagnosis of mild hypothyroidism had been made. In 45 patients initial TSH was less than 6.8 microIU/mL; in 23 of these subjects TSH returned to normal during the observation period, whereas in 22 TSH remained elevated. In all 22 residents whose initial TSH was greater than 6.8 microIU/mL, TSH remained elevated at follow-up. In 4 subjects whose initial TSH concentrations ranged from 5.0 to 9.6 microIU/mL, FTI fell below normal 91-141 days after the diagnosis of mild hypothyroidism was made. Clinical progression of the signs or symptoms of hypothyroidism was not detected in the 4 patients who developed hypothyroxinemia. Three demonstrated positive thyroid antibody titers, and 1 had myasthenia gravis. These observations suggest a need for replacement therapy in debilitated patients with mild hypothyroidism and evidence of thyroid autoimmunity.

Reintroduction of influenza A to a nursing building.

We report an outbreak of influenza A from a four-building veterans' facility in King, Wisconsin. Influenza was isolated in 154 of 721 residents over a 121-day period. Building A had 2 cases, no isolates for 40 days, followed by 27 cases. Building B had 25 cases, no isolates for 75 days, followed by 4 cases. Building C had 23 cases, no isolates for 14 days, followed by 17 cases. Influenza A may be reintroduced to a nursing building. Surveillance with contingency plans for restarting of prophylaxis must continue for the duration of influenza in the community.

Report of an outbreak: nursing home architecture and influenza-A attack rates.

OBJECTIVE: To determine factors that might account for a significantly lower attack rate in a newly constructed nursing building during an epidemic of type A influenza. SETTING: A four-building, long-term care facility for veterans and their spouses, with an average daily census of 690. DESIGN: Prospective surveillance with retrospective analysis. PARTICIPANTS: Symptomatic residents submitting to viral culture. MEASUREMENTS: Number of respiratory illnesses and influenza cultures in consenting symptomatic residents. Building characteristics. RESULTS: An influenza A (H3N2) outbreak was culture-confirmed in 68 nursing home residents. Influenza A was isolated in 3/184 (2%) residents in Building A, 31/196 (16%) in Building B, 18/194 (9%) in Building C, and 16/116 (14%) in Building D. Denominators are average daily census during the outbreak. Building A had significantly fewer culture-confirmed cases than the other buildings (P < .001). Fewer residents in Building A, 47% compared with 61% in Buildings B, C, and D, were participants in a formal study of influenza. Eight of 15 respiratory illnesses identified during the outbreak that were not cultured occurred in Building A. These factors could not account for the difference in attack rates. Building A has a unique ventilation system, more square feet of public space per resident, and does not contain office space that serves the entire four-building facility. CONCLUSION: Our retrospective observation suggests that architectural design may influence the attack rate of influenza A in nursing homes.

Low TSH levels in nursing home residents not taking thyroid hormone.

BACKGROUND: Many practitioners perform a thyroid stimulating hormone (TSH) assay as a screening test in older patients. The introduction of sensitive TSH assays with lower normal limits has created a laboratory abnormality that is often of uncertain significance. Mechanisms include autonomous overproduction of thyroid hormone, nonthyroidal illness including medication effects, and hypothalamic/pituitary dysfunction. OBJECTIVE: To characterize the clinical status and course of nursing home residents with low TSH and normal total T4 levels in the absence of treatment with thyroid hormone. DESIGN: Retrospective chart review was performed to determine participants status at the time of low TSH level, with additional recording of follow-up thyroid hormone levels, cardiac rhythm, and mortality. Mortality was compared with that of a control group matched for age and sex. SETTING: A nursing home for veterans and their spouses. MAIN RESULTS: Forty subjects with low TSH and initially normal total T4 were identified. Only three subjects were subsequently diagnosed as hyperthyroid. TSH levels of 18 subjects subsequently normalized, and four additional subjects had low total T3 levels suggesting a nonthyroidal mechanism. Seven subjects died during the first 4 months of follow-up compared with three in a control group (P < .001). Nine of the 40 subjects had a history of or current atrial fibrillation. No new atrial fibrillation was documented during 388 months of EKG follow-up. CONCLUSIONS: Low total T3 levels, TSH normalization, and excess mortality suggest that nonthyroidal illness plays a role in the pathogenesis of low TSH determinants in the nursing home. Autonomous production of thyroid hormone also plays a role. We believe that the term "subclinical hyperthyroidism" should be used only if the clinician believes that autonomous overproduction of thyroid hormone is the cause of a low TSH level. If subsequent research shows correctable adverse consequences associated with subclinical hyperthyroidism from autonomous overproduction of thyroid hormone, a more aggressive diagnostic approach will be needed to define the mechanism of a low TSH level at the time of its discovery.

Non-influenza respiratory viruses may overlap and obscure influenza activity.

OBJECTIVE: To report the number and timing of influenza A isolates, as well as overlapping respiratory viruses. Co-circulating respiratory viruses may obscure the determination of influenza activity. DESIGN: Prospective clinical surveillance for the new onset of respiratory illness followed by viral cultures during seven separate influenza seasons. SETTING: The Wisconsin Veterans Home, a skilled nursing facility for veterans and their spouses. RESULTS: Influenza A isolates were encountered in greater numbers than non-influenza A isolates during three seasons. Seasonal variability is striking. In December 1992, we identified a large outbreak of respiratory illness. Influenza type B was cultured from 102 residents. In December 1995, influenza A was cultured from 285 people in Wisconsin. At that time, we identified outbreaks of respiratory illness in two of our four buildings. Based on statewide data, we suspected an influenza outbreak; however, 26 isolates of parainfluenza virus type 1 were cultured with no influenza. The potential importance of culturing at the end of the season was demonstrated in 1991-1992 when an outbreak of respiratory syncytial virus (RSV) overlapped and extended beyond influenza A activity. CONCLUSIONS: When interpreting new clinical respiratory illnesses as a basis for declaring an outbreak of influenza A, clinicians should realize that co-circulating respiratory viruses can account for clinical illnesses. Clinicians might utilize healthcare dollars efficiently by performing cultures to focus the timing of influenza A chemoprophylaxis. Cultures could be performed when clinical outbreak criteria are approached to confirm an outbreak. Culturing of new respiratory illness could begin again before the anticipated discontinuation of prophylaxis (approximately 2 weeks).

Risk factors for bacteriuria in men.

OBJECTIVE: To identify risk factors for bacteriuria in a selected group of institutionalized men. METHODS: A total of 99 men, mean age seventy-one years, range forty-eight to one hundred four years, living in a nursing home were evaluated for diagnoses of benign prostatic hyperplasia (BPH) and diabetes mellitus (DM), symptoms of bladder outlet obstruction, and postvoid residual urine volume (PVR). At the time of evaluation urine cultures were performed for all subjects. Urinalyses had been performed in all men within the two years prior to initiation of the study. Residents unable to give informed consent, with a history of cancer of the prostate or bladder, previous urethral or prostate surgery, or inability to void in the standing position were excluded. RESULTS: Prior to or during the study 30 residents had bacteriuria, which was not correlated with age, PVR, previous diagnoses of BPH or DM, or with obstructive or irritative urinary symptoms consistent with bladder outlet obstruction. CONCLUSIONS: Competent, institutionalized residents with higher functional levels meeting the inclusion criteria were not at a high risk of bacteriuria. The concept that increased PVR per se predisposes to bacteriuria cannot be substantiated.

Position-related changes in voiding dynamics in men.

OBJECTIVES: To investigate by urodynamic study position-related changes in uroflowmetry and postvoid residual urine volume (PVR) in men because altered bladder function in the supine position may be a predisposing factor for urinary tract infections in the institutionalized elderly. METHODS: Two healthy men, 34 and 59 years of age and living at home, and 53 nursing home residents (mean age 71.8 years, range 46 to 92) were evaluated with uroflowmetry in the standing and recumbent positions (lying on the left or right side); corresponding PVRs were measured by transabdominal ultrasonic bladder scanning. The two healthy men were monitored longitudinally with multiple recordings in both voiding positions, and the nursing home residents were subjected to two observations: one measurement of the variable parameters in either position. Differences were considered to be significant at P < 0.05. RESULTS: The 34-year-old man performed 51 3 flows (368 standing and 145 recumbent). The mean of all the peak flow rates in the upright (28.2 +/- 4.2 mL/s) versus the recumbent (16.8 +/- 4.1 mL/s) position revealed a highly significant difference (P = 0.0001). Sixteen urinary flows and corresponding PVRs were completed by this subject in either voiding position. The difference between PVRs in the standing (13.1 +/- 14.7 mL) versus recumbent (15.3 +/- 17.5 mL) position was not statistically significant. The 59-year-old man completed 156 flows (128 standing and 28 recumbent). A highly significant difference was noted between the mean of all peak flows in the upright (18.9 +/- 4.1 mL/s) versus recumbent (12.6 +/- 2.0 mL/s) position (P = 0.0001). Thirty-seven urinary flows and corresponding PVRs were completed by this individual (10 PVRs were determined after voiding in the standing and 27 after voiding in the recumbent position). No significant difference was noted between PVRs in the standing (24.6 +/- 34.4 mL) versus recumbent (16.5 +/- 60.0 mL) position. In the nursing home residents, the difference between the mean peak flow rates in the standing (14.5 +/- 8.6 mL/s) versus recumbent (12.4 +/- 6.7 mL/s) position also reached statistical significance (P = 0.0084). The difference between PVRs in the standing (60.5 +/- 125.6 mL) versus recumbent (84.8 +/- 186.2 mL) position barely reached statistical significance (P = 0.0497). CONCLUSIONS: The urinary flow rate decreases in the recumbent position. Bedridden residents may be predisposed to urinary tract infections because of alterations in voiding dynamics in the supine position. This area needs further study.

Psychological depressive symptoms in grade II hypothyroidism in a nursing home.

In an effort to explore the relationship between Grade II hypothyroidism and depressive symptoms, 16 nursing home residents with normal free thyroxine index and elevated basal thyrotropin (thyroid-stimulating hormone; TSH) levels were matched for age, sex, nursing level of care, and certain medications with a control group who had normal basal TSH levels. The Geriatric Depression Scale (GDS) was administered to all participants. Basal TSH elevation was not associated with increased psychological depressive symptoms on the GDS.

Subclinical hypothyroidism in the elderly: to treat or not to treat?

Patients with subclinical hypothyroidism (SCH) have normal concentrations of thyroid hormone and elevated thyrotropin (TSH) levels. These individuals may experience mild symptoms of hypothyroidism. Such symptoms are nonspecific and also can be associated with aging or nonthyroidal illness. SCH is not uncommon in the elderly, particularly in females with positive thyroid antibodies and in those who have undergone partial thyroidectomy or I131 treatment for Graves' disease. Patients with SCH with markedly increased TSH levels or high-titer thyroid antibodies are at higher risk of progressing to overt hypothyroidism. Management options include observation only, with long-term follow up, or substitution with thyroid hormone. Replacement will prevent the development of overt hypothyroidism when reliable follow-up cannot be assured and may improve subtle, nonspecific symptoms of thyroid hormone deficiency. If a decision in favor of replacement therapy has been made, the dose of thyroid hormone should be increased gradually with the objective of returning the TSH level to normal without inappropriately elevating the serum thyroxine concentration. The patient should be carefully observed to see if hypothyroid symptoms, mental status or cardiac function improve with therapy. Continued administration of thyroid hormone would serve prophylactic purposes even if improvement did not occur.

Observations on nursing home residents with a history of hip fracture.

The authors evaluated nursing home residents with a prior history of hip fracture for osteopenia and its risk factors, and attempted to learn to what extent the residents' bone status had been considered by their primary care physicians. Thirty-one hip fracture residents in the Milwaukee VA nursing home were studied to determine their status with regard to bone mineral density of the proximal femur, and the following risk factors or predictors of osteopenia: history of smoking; history of fractures; calcium and vitamin D intake; underweight; immobility; hypogonadism; and administration of drugs that may accelerate bone demineralization. Data were also collected on the evaluation and management of the post hip fracture residents in three other nursing homes. In the Milwaukee nursing home, out of 31 hip fracture survivors, 74% had sustained a hip fracture before admission to the nursing home; 29% had a history of second fracture. In 84% of patients, there was no mention of osteopenia in the active medical problem list and, therefore, there was no intervention plan in place to improve or prevent further bone loss. Thirty-two percent were underweight, 36% were currently smoking, 55% were immobile, 64% were consuming at least one medication that might increase bone loss, calcium intake was less than 1,000 mg daily in 52%, and 66% were hypogonadal (serum testosterone level less than 300 ng/dL). Chart reviews of the hip fracture survivors at three other nursing homes revealed similar findings. Approximately 5-15% of nursing home residents are hip fracture survivors. They usually have severe osteopenia and multiple risk factors for further bone loss and future fractures.(ABSTRACT TRUNCATED AT 250 WORDS)