Editorial: Diagnostic Testing for SARS-Coronavirus-2 in the Nursing Facility: Recommendations of a Delphi Panel of Long-Term Care Clinicians.

With the COVID-19 pandemic progressing, guidance on strategies to mitigate its devastating effects in nursing facilities (NFs) is critical to preventing additional tragic outcomes. Asymptomatic spread of COVID-19 from nursing facility staff and residents is a major accelerator of infection. Facility-wide point-prevalence testing is an emerging strategy in disease mitigation. Because time is not available to await the results of randomized controlled trials before implementing strategies in this high-risk setting, an expert Delphi panel composed of experienced long-term care medicine professionals has now met to provide testing guidance for SARS-Coronavirus-2 to NFs. After many email and telephone discussions, the panel responded to a questionnaire that included six different scenarios, based on varying availability of Polymerase Chain Reaction (RT-PCR) testing and personal protective equipment (PPE). The panel endorsed facility-wide testing of staff and residents without dissent when diagnostic RT-PCR was available. While the panel recognized the limitations of RT-PCR testing, it strongly recommended this testing for both staff and residents in NFs that were either COVID-19 naive or had limited outbreaks. There was also consensus on testing residents with atypical symptoms in a scenario of limited testing capability. The panel favored testing every 1 to 2 weeks if testing was readily available, reducing the frequency to every month as community prevalence declined or as the collection of additional data further informed clinical critical thinking and decision-making. The panel recognized that frequent testing would have consequences in terms of potential staff shortages due to quarantine after positive tests and increased PPE use. However, the panel felt that not testing would allow new clusters of infection to form. The resulting high mortality rate would outweigh the potential negative consequences of testing. The panel also recognized the pandemic as a rapidly evolving crisis, and that new science and increasing experience might require an updating of its recommendations. The panel hopes that its recommendations will be of value to the long-term care industry and to policy makers as we work together to manage through this challenging and stressful time.

Health care decisions among elderly long-term care residents and their potential proxies.

Seventy residents of the residential care section of a long-term care facility were asked to make health decisions after being presented four clinical vignettes. Two vignettes involved high-risk procedures (aortic valve replacement and carotid endarterectomy) and two were low risk (flu vaccination and psychotropic medication). Comparisons were made between decisions made by the elderly participants and predictions of those decisions by potential proxies, including the participant's closest relative and a nurse, a social worker, and a physician in the facility. There was a low rate of agreement between decisions made by the elderly participant and the decisions the potential proxies thought they would make. The highest agreement was found between the participants' actual decision and the decision predicted by their relatives. The lowest agreement occurred between what the physician thought the participant would choose for the two high-risk vignettes and what the participant actually chose. The quality of the elderly participant's decisions was also rated on a four-point scale by the potential proxy, as well as by a researcher. Highest ratings of the quality of the elderly person's decision-making ability were assigned by the relative. A significant negative correlation was obtained between the elderly person's age and the decision-making rating assigned by the physician, and significant positive correlations were obtained between mental status and decision-making ratings by the other raters. These data have important implications for designing and implementing strategies to maximize the ability of elderly people in long-term care settings to participate in decisions about their health care.

Explicit criteria for determining inappropriate medication use in nursing home residents. UCLA Division of Geriatric Medicine.

Increasing attention is being paid to inappropriate medication use in nursing homes. However, criteria defining the appropriate or inappropriate use of medication in this setting are not readily available and are not uniform. We used a two-round survey, based on Delphi methods, with 13 nationally recognized experts to reach consensus on explicit criteria defining the inappropriate use of medications in a nursing home population. The criteria were designed to use pharmacy data with minimal additional clinical data so that they could be applied to chart review or computerized data sets. The 30 factors agreed on by this method identify inappropriate use of such commonly used categories of medications as sedative-hypnotics, antidepressants, antipsychotics, antihypertensives, nonsteroidal anti-inflammatory agents, oral hypoglycemics, analgesics, dementia treatments, platelet inhibitors, histamine2 blockers, antibiotics, decongestants, iron supplements, muscle relaxants, gastrointestinal antispasmodics, and antiemetics. These criteria may be useful for quality assurance review, health services research, and clinical practice guidelines. The method used to establish these criteria can be used to update and expand the guidelines in the future.

An accurate method to obtain urine for culture in men with external catheters.

Results of urine cultures from 26 male nursing home patients wearing external catheters, collected by a simple standardized technique, were compared with culture results from the same patients obtained by sterile in-and-out catheterization. The culture results were the same in 22 (85%) of the matched specimens, and specimens collected by the standardized technique were 100% sensitive and 94% specific in detecting significant growth of pathogenic organisms. In contrast, 13 (57%) of 23 specimens collected from patients with external catheters by the nursing home staff using their routine technique yielded three or more organisms and were considered contaminated. These results suggest that it is possible to obtain a urine specimen that reflects bladder urine in the vast majority of patients with external catheters, and thus potentially avoid the need for in-and-out catheterization when diagnosing and planning treatment for urinary tract infections in this population.

Risk factors in geriatric drug prescribing. A practical guide to avoiding problems.

Although the use of medication has helped to cure and control disease, it has also led to serious iatrogenic illness. Toxicity is most common and severe in the elderly. Confusion, falls, depression, sedation, deterioration of function, and urinary incontinence and retention are frequently the manifestation of that toxicity. Normal ageing places older patients at risk because of changes in metabolism, distribution, and excretion of drugs, and sensitivity to drug effects is often greater in the elderly. Disease and the interactions of other drugs can increase the incidence and severity of side effects. Certain drugs should be avoided in the elderly. Those that are long acting and require hepatic metabolism, those with strong anticholinergic properties, and those that are highly sedating tend to cause the most problems. In every case, physicians must weigh the potential benefit of prescribing against the potential risk.

Sleep hygiene in physically dependent nursing home residents: behavioral and environmental intervention implications.

The purpose of this report is to summarize data from a sample of 230 residents in eight nursing homes (NHs) that are relevant to the development of environmental and behavioral interventions for sleep. Four conclusions can be drawn: (1) there is strong evidence that the nighttime sleep of these residents was adversely affected by environmental noise and light; (2) residents appear to spend substantial time in bed and sleeping during the day; (3) there are significant differences between some homes in the amount of time that residents spend in bed and sleeping during the day, as well as the frequency of nighttime awakenings associated with environmental events; and (4) residents' preference and nighttime noise source data suggest that a multifaceted intervention to improve sleep hygiene could successfully implemented in the NH setting. An intervention addressing these issues may result in improved sleep and overall well-being for a substantial portion of the NH population.

Change in self-reported functioning in older persons entering a residential care facility.

We evaluated the responsiveness of measures of function in admissions to a long-term care facility. Between baseline and follow-up assessment, one-fifth or more of the subjects either worsened or improved in most aspects of reported function. We compared two measures of self-reported function (COOP charts and a short-form survey). Convergent validity was observed for changes in pain, social health, and mental health (r = 0.39-0.74), but not for physical functioning. Although the short-form physical function measure discriminated worsening on several performance-based external criteria of physical functioning (area under ROC curves up to 0.82), the COOP and other measures of physical functioning were less likely to do so. All physical function measures were less responsive for detecting improvement. Clinicians and investigators intending to monitor change in function must consider the responsiveness of their measures.

Management of urinary incontinence in Veterans Administration nursing homes.

Nursing Home Care Units in Veterans Administration Medical Centers across the country were surveyed to determine methods of management of urinary incontinence (UI) in the nursing home (NH) setting. Information was obtained from 90 of the VA NHs on demographic aspects of the NH population, prevalence and severity of urinary and fecal incontinence, common problems encountered, and specific strategies and techniques. Written guidelines for bladder training and catheter care from many of the NHs were analyzed. The results of the survey reinforce the need for research designed to improve the care of the incontinent NH patient.

Urine specimen collection from incontinent female nursing home residents.

OBJECTIVE: To determine if a clean catch technique can accurately diagnose bacteriuria among incontinent female nursing home residents. DESIGN: Cultures and dipstick screening test results from paired urine specimens, one collected by a clean catch technique and the other collected by sterile in-and-out catheterization, were compared. PARTICIPANTS: A total of 101 incontinent female nursing home residents who were being assessed for participation in a larger clinical intervention trial for incontinence. MEASUREMENTS: Each urine was tested by a dipstick method for leukocyte esterase and nitrite and sent to a bioclinical laboratory for quantitative culture. RESULTS: Positive and negative culture results matched in 92 of the 101 paired specimens. Using the catheter specimen as a gold standard, the clean catch had a sensitivity of 90%, specificity of 92%, positive predictive value of 81%, and a negative predictive value of 95%. In a population with symptoms suggestive of infection, among whom the prevalence of bacteriuria would likely be higher than in the asymptomatic residents we studied (e.g., 60% vs 30%), the positive predictive value would increase to 95%, but the negative predictive value would decrease to 86%. The concordance of the results of the urine screening tests was not as good, except for the detection of a positive leukocyte esterase test and a negative nitrite test. CONCLUSION: Incontinent female nursing home residents do not necessarily have to be catheterized in order to obtain an accurate quantitative urine culture. Our results using a careful clean catch technique are comparable to those previously reported using urine obtained from a urine-soiled diaper as well as those using a condom catheter technique in men.

External catheter use and urinary tract infections among incontinent male nursing home patients.

In order to examine the relative frequency of urinary tract infection (UTI) and bacteriuria among male nursing home patients managed with and without external catheters (EC), we prospectively followed four cohorts of patients (EC worn continuously, N = 30; EC worn at night only, N = 19; incontinent without catheter, N = 13; and continent, N = 30) for a total of 497 patient months at risk. The proportion of patients with EC worn continuously who had at least one episode of bacteriuria (87%) and at least one UTI (40%), and the incidence of UTI (0.08 episodes per patient-month at risk) was significantly higher than among continent or incontinent patients without EC. Patients with EC at night only had an intermediate frequency of these findings. Differences in clinical and functional status characteristics among the four cohorts, in addition to the use of EC, could have contributed to the higher frequencies of bacteriuria and UTI. None of the clinical characteristics we examined were associated with the development of UTI among patients with EC. Further studies are necessary to identify factors associated with UTI among patients who are managed by EC so that effective preventive strategies can be developed and targeted to patients at high risk.

Informing the elderly. A comparison of four methods.

Providing elderly persons with understandable information with which they can make informed health care decisions is a difficult, yet critical, task. Four methods of enhancing understanding of the Resident's Bill of Rights were evaluated in residents of the board and care section of a long-term care facility. The methods included the use of large print and simplified language, a storybook, and a videotape. There was no significant improvement for performance on the comprehension test after any of the methods of presentation of the Bill of Rights. A number of subjects were found to be very deficient in short term memory or in verbal knowledge. When these subjects were eliminated from the analyses, significant improvement was demonstrated with the simplified version of the Bill of Rights yielding the most improvement. These findings indicate that many elderly people can benefit from an informed consent procedure that provides information clearly and simply. Furthermore, with relatively simple cognitive screening procedures, it should be possible to identify those unable to process the information necessary to participate in common health care decisions.

Habit training and oxybutynin for incontinence in nursing home patients: a placebo-controlled trial.

In order to determine if a bladder-relaxant drug could enhance the effectiveness of a toileting program for incontinence among functionally impaired nursing home patients, 15 patients with detrusor hyperreflexia were enrolled in a 6-week trial during which they were put on a habit training protocol alone for 2 weeks, habit training (HT) and a placebo for 2 weeks, and then HT and oxybutynin for 2 weeks (2.5 mg three times daily for 1 week, then 5 mg three times daily for 1 week). Bacteriuria, which was present without other symptoms in 11 of the 13 patients who completed the trial, was treated before HT began. Eradication of the bacteriuria resulted in a small, statistically significant increase in cystometric bladder capacity (44 mL; 95% confidence interval 16 to 72 mL), but the detrusor hyperreflexia and frequent episodes of incontinence persisted. HT alone reduced the mean percentage of every-two-hour checks which were wet from 43% to 32% (95% confidence interval of the difference -1% to -21%; P = .04 by a paired t test); addition of placebo and active drug did not result in any further reduction. Cystometric bladder capacity had not changed significantly by the end of the trial (measured while patients were still on active drug), and there was no consistent relationship between changes in bladder capacity and changes in wet checks. Although our sample size is small, the data are consistent with other studies in similar populations. The relatively practical and inexpensive interventions we employed in this study will need to be modified or intensified in order to substantially reduce the frequency of incontinence among functionally disabled nursing home patients.

Development and testing of an incontinence monitoring record.

Bladder records can play an important role in the assessment and treatment of incontinence. Many records currently used in long-term care settings are difficult to read and interpret, and they do not provide for the recording of information that can be of value in the assessment and treatment process. Two versions of an incontinence monitoring record (IMR), one using black and white symbols and the other using colored circles, were developed and tested in a quasiexperimental design in three proprietary nonacademically affiliated nursing homes. The IMRs were well accepted by the nursing staff in these homes. Recordings were made more frequently and interrater reliability was highest with the color version of the IMR. Results of this initial study are promising and suggest that the IMR, or a similarly designed record, will be helpful in nursing homes to assess the bladder and bowel status of new admissions, determine patterns of and factors associated with incontinence, design individualized bladder training programs, and monitor the results of these programs and other treatment modalities. In addition, the IMR can provide an opportunity for nurses' aides to meaningfully participate in the assessment and treatment of a condition they manage on a daily basis.

Genitourinary dysfunction in a geriatric outpatient population.

Clinical and urodynamic findings in 167 women and 96 men, aged 65 years and older evaluated consecutively during a four-year period in an outpatient urodynamic laboratory, are presented and compared with findings from other studies of geriatric populations. Seventy-three percent of the patients (81% of the women and 60% of the men) presented with symptoms of incontinence, most commonly of the mixed type. Although pathological lesions such as tumors and stones were rare, urodynamic abnormalities were common. Urodynamic evidence of sphincter weakness in women and detrusor motor instability were the most common urodynamic findings among patients who presented with incontinence. Close to 20% of patients who presented without incontinence also had one or more of these findings. Approximately one-third of patients had multiple urodynamic findings, emphasizing the complexity of the pathophysiology, diagnosis, and treatment of genitourinary dysfunction in many geriatric patients. Despite the long duration of symptoms in most patients, the majority were substantially improved after diagnosis and treatment of the specific genitourinary and urodynamic abnormalities detected.

Decisions about enteral tube feeding among the elderly.

OBJECTIVE: To determine choices about enteral tube feeding and factors associated with deciding to accept or forego this intervention in a group of ambulatory non-demented older individuals. DESIGN: Descriptive survey. SETTING AND PARTICIPANTS: Thirty four volunteers from a senior adult day center and 34 volunteers from the residential care section of a multilevel long-term care institution, mean age 77.8. INTERVENTION: Structured interview using a hypothetical clinical vignette in simplified language, story-book format depicting an irreversibly and severely impaired state of health. MEASUREMENT: Choice of whether to accept or forego enteral tube feeding based on the clinical vignette. RESULTS: Thirty four (50%) decided to accept and 34 (50%) chose to forego enteral tube feeding in the situation presented in the vignette. No demographic, cognitive, or affective factors were associated with the decision. Presentation of the vignette and associated questions were not anxiety-provoking or upsetting to the vast majority of participants. CONCLUSION: A hypothetical clinical vignette depicting a state of severely impaired health resulted in 34 (50%) of 68 ambulatory non-demented older individuals deciding to accept enteral tube feeding. No factors we examined were strongly associated with the decision. The vignette and discussion were not anxiety-provoking when presented in the format used in this study. Advance-directive discussions about enteral tube feeding and other health care decisions, using understandable hypothetical clinical vignettes that describe risks and benefits that might influence decisions, should be encouraged in the practice of geriatric medicine.

Total quality management: administrative and clinical applications in nursing homes.

OBJECTIVE: Describe the application of the Total Quality Management (TQM) model to the unique work force, resident population, and regulatory issues that characterize long term care settings. DESIGN: The key differences between TQM and current management and training practices in nursing homes are described. A specific data-based example is provided of a successful TQM application to health care involving clinical work processes related to incontinence care. CONCLUSION: Significant organizational and clinical obstacles must be overcome if TQM is to improve the quality of life and satisfaction of nursing home residents and their families as it has improved the efficiency and product quality in hospital and non-health-care settings.

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.

Use of primary care teams by HMOS for care of long-stay nursing home residents.

OBJECTIVE: To characterize the use of formal primary care programs by health maintenance organizations (HMOs) for their members who are long-stay residents of nursing homes. DESIGN: Using mail survey techniques, 34 Medicare risk-contracting HMOs with the largest Medicare beneficiary enrollments were asked to complete a written questionnaire. HMOs were asked how they evaluate care in nursing home settings and whether they operate a formal primary care program for members who are long-stay nursing home residents. Those reporting they had programs were asked about the program features, participation in the program, roles performed by clinical practitioners, and clinical caseloads. Surveys were completed by 21 (61.8%) of the HMOs. PARTICIPANTS: HMO management personnel who know the primary care programs the HMOs operate in affiliated nursing homes. MEASUREMENTS: Descriptive summaries of the HMOs' responses to the survey questions were generated. For HMOs with primary care programs, caseloads of physicians and nurse practitioners were estimated using survey data reported by the HMOs. RESULTS: Eight (38.1%) of the responding HMOs operate formal primary care programs in affiliated nursing homes. HMOs with programs consider more factors than non-program HMOs in evaluating care for nursing home residents. Reasons cited most frequently for not having a program are costs and too few nursing home residents. The most common primary care program features are designated physicians and use of physician extenders. CONCLUSIONS: Survey findings point to the potential importance of formal HMO primary care programs for long-term nursing home residents, which may expand with growth in the older population and Medicare-managed care. Program adoption, however, may depend on sufficient resident participation to be financially feasible.

Developing rehabilitative behavioral interventions for long-term care: technology transfer, acceptance, and maintenance issues.

Rehabilitative behavioral interventions that are documented in clinical trials to improve nursing home resident outcomes and are recommended by practice guidelines are often not adapted for daily use in nursing homes and other long-term care (LTC) facilities. Failure to evaluate issues other than clinical efficacy when developing interventions contributes to this gap between efficacy and effectiveness in practice. A potential solution is a research model that supplements traditional clinical intervention research with methodology designed specifically to evaluate the ability of LTC facilities to implement the interventions. This paper discusses several critical issues of intervention and implementation that should be addressed, including targeting interventions, advocacy, cost-effectiveness, training, and quality control. We also describe how clinical trials could be designed and staged to increase the probability that effective interventions will be implemented in the day-to-day care of frail older patients in LTC facilities.