Accuracy of rapid urine screening tests among incontinent nursing home residents with asymptomatic bacteriuria.

OBJECTIVE: To determine the accuracy of rapid urine screening tests in detecting bacteriuria among incontinent nursing home residents. SETTING: Six nursing homes. PARTICIPANTS: 214 chronically incontinent, but otherwise asymptomatic, nursing home residents who were enrolled in a clinical intervention trial for urinary incontinence. MEASUREMENTS: 684 urine specimens were collected, the majority (76%) by a clean catch technique and the remainder by in-and-out catheterization. Each specimen underwent dipstick testing for nitrite and leukocyte esterase, a rapid, enzyme-based screening test for bacteriuria, and a quantitative urine culture using standard laboratory techniques. RESULTS: No one screening test or combination of tests had adequate sensitivity and specificity for clinical purposes. However, using all three tests, the sensitivity increases to 97% in females and 92% in males when any one of the tests is positive, and the specificity increases to 95% in females and 97% in males when all three tests are negative. Among nursing home residents suspected of having a symptomatic urinary tract infection, the prevalence of bacteriuria is probably higher than in our study population (e.g., 60-70%, compared with 32%). At these prevalence rates, the positive predictive value of any of the three tests being positive is 93% and higher, and the negative predictive value of all three tests being negative is 80 to 90%. CONCLUSIONS: Our data must be interpreted cautiously because of the specimen collection methods, the definitions we used, and the fact that we studied a population who did not have symptoms of an acute urinary tract infection. In addition, we did not examine the absolute accuracy of the screening tests, but their accuracy as a clinician might use them in a nursing home. Despite these caveats, our data suggest that a combination of these screening tests could be useful in the initial assessment of nursing home residents for bacteriuria, and result in considerable cost savings. Studies are needed to replicate our findings among nursing home residents with symptomatic urinary tract infections.

Pyuria among chronically incontinent but otherwise asymptomatic nursing home residents.

OBJECTIVE: To determine the prevalence of pyuria and its relationship to bacteriuria in a representative sample of chronically incontinent nursing home residents. DESIGN: Prospective, descriptive case series. SETTING: Six nursing homes. PARTICIPANTS: Two hundred fourteen chronically incontinent, but otherwise asymptomatic, nursing home residents who were enrolled in a clinical intervention trial for urinary incontinence. MEASURES: Two hundred fourteen urine specimens were collected by a validated clean catch technique. Each specimen underwent dipstick testing for leukocyte esterase, microscopic urinalysis to determine the number of white blood cells per high power field of centrifuged urine, and quantitative urine culture using standard laboratory techniques. RESULTS: The overall prevalence of pyuria was 45%, as defined by > 10 white blood cells per high field of spun urine, and the overall prevalence of bacteriuria was 43%, as defined by the growth of > 100,000 colony forming units of a urinary pathogen. Fifty-nine percent of the specimens with bacteriuria and 34% of the specimens without bacteriuria had pyuria. Of specimens with pyuria, 56% had bacteriuria, and of specimens without pyuria, 31% had bacteriuria. When any colon change on the leukocyte esterase pad was considered positive, this finding had a sensitivity of 83% and a specificity of 52% for pyuria on microscopic urinalysis. CONCLUSIONS: Pyuria is common among chronically incontinent nursing home residents, both in the presence and absence of bacteriuria. Clinicians must therefore be cautious in interpreting the presence of pyuria to indicate symptomatic infection in this population. Using pyuria to determine the need for antimicrobial treatment could result in unnecessary expense and morbidity as well as contribute to the development of resistant organisms in nursing homes. Research is needed to define pyuria better, to determine its prevalence and relationship to bacteriuria among nursing home residents with symptoms of acute urinary tract infection, and to elucidate the etiology and significance of sterile pyuria in this population.

Effects of prompted voiding on fecal continence among nursing home residents.

OBJECTIVE: To determine the effects of prompted voiding on fecal continence in nursing home residents. DESIGN: Prospective, uncontrolled trial of prompted voiding for urinary incontinence. PARTICIPANTS: One hundred sixty-five nursing home residents who completed a 9 to 10-week trial. MEASUREMENTS: Trained research aides performed physical checks for urinary and fecal incontinence hourly from 8 AM to 6 PM for 3 days (total of 33 checks) at baseline, for the last 3 days of a 1-week trial of prompted voiding, and after 9 to 10 weeks of prompted voiding. RESULTS: After 9 to 10 weeks of prompted voiding, there was no significant change in the frequency of incontinent bowel movements per resident (1.1 [95% CI.83, 1.4] to .87 [95% CI.67, 1.1]; P = 0.140). There was a significant increase in the number of continent bowel movements per resident (.17 [95% CI.10, .24] to .62 [95% CI.45, .80]; P = .000). This increase occurred in residents whose urinary incontinence responded well to prompted voiding as well as those whose urinary incontinence did no respond. The percentage of bowel movements that were continent also increased significantly from 18% (95% CI 8,29) at baseline to 45% (95% CI 32,57) after 9 to 10 weeks of intervention (P = .000). In addition to these findings, we noted a marked increase in the total frequency of bowel movements after the first week of prompted voiding. This may have resulted from the relief of fecal impactions caused by the increased toileting, mobility, and fluid intake that occurred with prompted voiding. CONCLUSION: Prompted voiding did not change the frequency of incontinent bowel movements significantly in this sample of nursing home residents. However, the number of continent bowel movements and the percentage of bowel movements that were continent did increase. Our data must be interpreted cautiously because our study was designed primarily as an intervention for urinary, not fecal, incontinence and the design was neither blinded nor controlled. Trials of systematic toileting schedules specifically directed at fecal incontinence, with attention to fecal impaction, diet, fluid intake and laxative use, should be conducted.

Characteristics and quality of prescribing by doctors practicing in nursing homes.

OBJECTIVES: To describe the professional characteristics of doctors practicing in nursing homes and to determine whether those characteristics correlate with quality of prescribing. DESIGN: A prospective, cohort study. PARTICIPANTS: 306 physicians practicing in 12 nursing homes in greater Los Angeles. MEASUREMENTS: We surveyed doctors about their age, sex, education, credentials, and NH practice. We also determined medication orders for a 1-month period and evaluated them using explicit criteria for appropriateness developed by an expert panel. RESULTS: We obtained data from 72% of MDs. Respondents had a mean age of 53 years (29-78) and were 94% male. Fifty-seven percent trained in internal medicine, 20% graduated outside the US or Canada, 67% were board certified in their declared specialty, and 5% had a certificate of added qualification in geriatrics (CAQ). Sixteen percent spent > 10% of their professional time in NHs, and 46% had NH practices that were > 20% Medicaid; most did not consult psychiatrists when prescribing psychoactive drugs. Forty percent of residents had at least one inappropriate prescription. The characteristics of doctors associated with the best prescribing quartile were female sex, CAQ, no board certification, and frequent consultation with psychiatrists. The characteristics of doctors in the most inappropriate quartile were older age, graduation from medical school before 1965, graduation from US medical school, small NH practice, and infrequent consultation with psychiatrists. CONCLUSIONS: Although the quality of prescribing in nursing homes is related to some physician characteristics, the relationships are not those most commonly stated.

Use of a portable ultrasound device to measure post-void residual volume among incontinent nursing home residents.

OBJECTIVE: To determine the accuracy of a portable ultrasound device for the assessment of post-void residual (PVR) volume among incontinent nursing home (NH) residents. DESIGN: Prospective, clinical series. SETTING: Seven community-based nursing homes. STUDY POPULATION: Two hundred one consecutively assessed incontinent NH residents who were participating in a larger clinical trial. MEASUREMENTS: PVR volumes measured by trained research associates using a portable ultrasound device and by in-and-out catheterization were compared. The accuracy of the ultrasound was calculated using the volume obtained by catheterization as the gold standard. RESULTS: The ultrasound demonstrated excellent test-retest and interrater reliability. For low PVRs, the device was highly sensitive (.90) for PVR < 50 mL and .95 for PVR < 100 mL) and moderately specific (.71 for PVR < 50 mL and .63 for PVR < 100 mL). For PVRs of more than 200 mL (n = 26), the ultrasound had a sensitivity of .69 and a specificity of .99. CONCLUSION: The portable ultrasound we used was reliable and reasonably accurate for assessing PVR in a representative sample of incontinent NH residents. Because the sensitivity for clinically significant urinary retention (PVR > 200 mL) was only .69, repeated measurements may be necessary to exclude high PVR in individual NH residents. Recent changes in ultrasound design should improve its ease of use and accuracy. Although measuring PVR by ultrasound is much easier and more comfortable than catheterization for both NH residents and staff, the cost of the device may be a barrier to its widespread use in the NH setting.

Does oxybutynin add to the effectiveness of prompted voiding for urinary incontinence among nursing home residents? A placebo-controlled trial.

OBJECTIVE: To determine if oxybutynin, a bladder relaxant medication, adds to the effectiveness of prompted voiding (PV) in the management of urinary incontinence among nursing home residents. DESIGN: Randomized, placebo-controlled, double-blinded, dose-adjusted, crossover trial of oxybutynin added along with PV. SETTING: Seven nursing homes in Los Angeles County, California. PARTICIPANTS: Seventy-five nursing home residents with predominantly urge incontinence, whose incontinence did not respond well to a trial of PV. MAIN OUTCOME MEASURES: The frequency of incontinence, measured as the percentage of hourly (7 AM to 7 PM) physical checks over a 3-day period at which the resident was found wet. RESULTS: Sixty-three (84%) of the residents completed the study. Among those completing the trial, the percent of checks wet went from 26.5% to 23.7% on placebo to 20.2% on active drug. These changes were statistically significant but not clinically meaningful. A clinically significant decrease in the frequency of incontinence, which we defined as a relative reduction in the percent of checks wet of > 33%, occurred in 20 subjects (32%) while on active drug and in 12 subjects (19%) while on placebo (P = .48 by chi-square). Twenty-five subjects (40%) met our "continence criteria" of an average of one or less wet per day while on active drug, and 11 subjects (18%) achieved this goal on placebo (P = .005 by chi-square). CONCLUSION: Oxybutynin does not add to the clinical effectiveness of PV in the majority of nursing home residents with urge type urinary incontinence. Selected residents may, however, become more responsive to PV while on oxybutynin. Our data are consistent with other studies of bladder relaxant medications in functionally impaired populations. New drugs and/or other interventions are needed for the large number of incontinent nursing home residents who do not respond well to PV.

A computerized system for identifying and informing physicians about problematic drug use in nursing homes.

With growing concern over the quality of medication use in nursing homes, physicians, administrators, pharmacists, and regulators are looking for effective and efficient methods to improve it. Pharmacy consultation alone appears to be ineffective in controlling the use of inappropriate drugs. We describe here a computerized drug utilization review system designed for use in nursing homes. The system evaluates the appropriateness of medication use by criteria developed through the consensus of experts in geriatrics and specifically designed to address the pharmacological needs of elderly, nursing home residents. The program not only determines the frequency of inappropriate prescriptions, but produces written, educational statements to be given to prescribing physicians. These statements can also be given to nurses to educate them about issues in geriatrics pharmacology. Additionally, the system produces medication order forms that may help focus physicians' attention on the need to evaluate drugs individually.

Predictors of successful prompted voiding among incontinent nursing home residents.

OBJECTIVE: To develop a simple, noninvasive assessment strategy that will enable nursing home staff to identify incontinent residents who respond well to prompted voiding. DESIGN: Incontinent nursing home residents underwent an extensive clinical and functional assessment and then 7 days of prompted voiding. Data from the assessment and the first 3 days of prompted voiding were used to predict responsiveness to the intervention. SETTING: Seven nursing homes. PATIENTS: A cohort of 191 incontinent, long-stay nursing home residents who passed a simple behavioral screen (able to state their name or reliably point to one of two named objects). INTERVENTION: Prompted voiding was carried out by trained research nurse's aides from 7 AM to 7 PM for 7 days. The intervention was maintained in responsive residents 5 days per week for an additional 9 weeks. MAIN OUTCOME MEASURES: Physical checks for wetness were done by research staff hourly from 7 AM to 7 PM for 3 days in a baseline condition, during days 5 through 7 of the 7-day prompted voiding intervention, and for 3 days at the end of 9 weeks of prompted voiding in the responsive group. Outcome measures were percentage of checks wet and response to prompted voiding, with "responders" defined as residents with an average of one or fewer wet episode per day on days 5 through 7 of prompted voiding. RESULTS: Seventy-eight (41%) of the residents were responders. Their wet percentage went from 26.7% to 6.4% at the end of 1 week and was maintained at 9.6% after 9 weeks of prompted voiding. The best predictors of responsiveness were the wet percentage and the appropriate toileting percentage during the first 3 days of prompted voiding, the self-care subscale score of the Multidimensional Observational Scale for the Elderly, and the ability to ambulate without human assistance. The best sensitivity and specificity in identifying responders was achieved when either the wet percentage was lower than 20% or the appropriate toileting percentage was higher than 66% during the first 3 days of prompted voiding (sensitivity, 87%; specificity, 69%). Those residents falsely identified as responders by these criteria still had a 46% relative reduction in wetness. CONCLUSIONS: A substantial proportion of nursing home residents respond well to prompted voiding. The most responsive residents can be easily identified using data collected during a 3-day trial of the intervention. The assessment strategy is consistent with federal guidelines and could be used to facilitate quality control by assessing changes in percentage of wetness from the expected norm.

Does eradicating bacteriuria affect the severity of chronic urinary incontinence in nursing home residents?

OBJECTIVE: To determine the effects of eradicating otherwise asymptomatic bacteriuria on the severity of chronic urinary incontinence among nursing home residents. DESIGN: Residents were categorized as nonbacteriuric or bacteriuric on the basis of urine cultures. Bacteriuric residents were then randomly assigned to immediate and delayed treatment groups. The delayed treatment group was included to control for spontaneous changes in the severity of incontinence. The immediate treatment group received antimicrobial therapy for 7 days; after outcome measures had been repeated, the delayed treatment group was treated. SETTING: 6 community-based nursing homes. PATIENTS: Nursing home residents with chronic urinary incontinence. MEASUREMENTS: The frequency and volume of urinary incontinence were determined by physical checks for wetness by trained research aides hourly between 7 a.m. and 7 p.m. for 3 days in all patient groups (non-bacteriuric, bacteriuric with immediate treatment, and bacteriuric with delayed treatment) at baseline, after the immediate treatment group was treated, and again after the delayed treatment group was treated. RESULTS: 191 residents were enrolled, and 176 completed the study. Bacteriuria was eradicated by antimicrobial therapy in 71 residents (40%), and 17 residents (10%) had bacteriuria before and after therapy. The percentage of hourly checks at which the residents were found wet and other measures of incontinence severity remained essentially the same after bacteriuria was eradicated. In the nonbacteriuric group, the percentage of checks that were wet increased from 29% (95% CI, 26% to 32%) at baseline to 30% (CI, 27% to 34%) on repeated measurement. In the bacteriuric groups, the percentage increased from 34% (CI, 30% to 38%) before treatment to 35% (CI, 31% to 39%) after bacteriuria was eradicated. The presence of pyuria did not affect the results. CONCLUSION: Eradicating bacteriuria has no short-term effects on the severity of chronic urinary incontinence among nursing home residents. Our data support the practice of not treating asymptomatic bacteriuria in this population and validate the recommendations in the Health Care Financing Administration's Resident Assessment Protocol for urinary incontinence.

Inappropriate medication prescribing in skilled-nursing facilities.

OBJECTIVE: To quantify the appropriateness of medication prescriptions in nursing home residents. DESIGN: Prospective, cohort study. SETTING: Twelve nursing homes in the greater Los Angeles area. PARTICIPANTS: A total of 1106 nursing home residents. MAIN OUTCOME MEASURES: The appropriateness of medication prescriptions was evaluated using explicit criteria developed through consensus by 13 experts from the United States and Canada. These experts identified 19 drugs that should generally be avoided and 11 doses, frequencies, or durations of use of specific drugs that generally should not be exceeded. RESULTS: Based on the consensus criteria, 40% of residents received at least one inappropriate medication order, and 10% received two or more inappropriate medication orders concurrently; 7% of all prescriptions were inappropriate. Physicians prescribed a greater number of inappropriate medications for female residents. Regression analysis, corrected for clustering effects within facilities, showed that a greater number of inappropriate medication prescriptions were ordered in larger nursing homes. Inappropriate prescriptions were not related to the proportion of Medicaid (Medi-Cal) residents or the number of physicians practicing in the homes. CONCLUSIONS: Inappropriate medication prescribing in nursing homes is common. Female residents and residents of large nursing homes are at the greatest risk for receiving an inappropriate prescription.