Rapid Detection of Influenza Outbreaks in Long-Term Care Facilities Reduces Emergency Room Visits and Hospitalization: A Randomized Trial.

OBJECTIVES: To assess whether the use of rapid influenza diagnostic tests (RIDTs) for long-term care facility (LTCF) residents with acute respiratory infection is associated with increased antiviral use and decreased health care utilization. DESIGN: Nonblinded, pragmatic, randomized controlled trial evaluating a 2-part intervention with modified case identification criteria and nursing staff-initiated collection of nasal swab specimen for on-site RIDT. SETTING AND PARTICIPANTS: Residents of 20 LTCFs in Wisconsin matched by bed capacity and geographic location and then randomized. METHODS: Primary outcome measures, expressed as events per 1000 resident-weeks, included antiviral treatment courses, antiviral prophylaxis courses, total emergency department (ED) visits, ED visits for respiratory illness, total hospitalizations, hospitalizations for respiratory illness, hospital length of stay, total deaths, and deaths due to respiratory illness over 3 influenza seasons. RESULTS: Oseltamivir use for prophylaxis was higher at intervention LTCFs [2.6 vs 1.9 courses per 1000 person-weeks; rate ratio (RR) 1.38, 95% CI 1.24-1.54; P < .001]; rates of oseltamivir use for influenza treatment were not different. Rates of total ED visits (7.6 vs 9.8/1000 person-weeks; RR 0.78, 95% CI 0.64-0.92; P = .004), total hospitalizations (8.6 vs 11.0/1000 person-weeks; RR 0.79, 95% CI 0.67-0.93; P = .004), and hospital length of stay (35.6 days vs 55.5 days/1000 person-weeks; RR 0.64, 95% CI 0.0.59-0.69; P < .001) were lower at intervention as compared to control LTCFs. No significant differences were noted for respiratory-related ED visits or hospitalizations or in rates for all-cause or respiratory-associated mortality. CONCLUSIONS AND IMPLICATIONS: The use of low threshold criteria to trigger nursing staff-initiated testing for influenza with RIDT resulted in increased prophylactic use of oseltamivir. There were significant reductions in the rates of all-cause ED visits (22% decline), hospitalizations (21% decline), and hospital length of stay (36% decline) across 3 combined influenza seasons. No significant differences were noted in respiratory-associated and all-cause deaths between intervention and control sites.

Rapid Detection of Influenza Outbreaks in Long Term Care Facilities Reduces Emergency Room Visits and Hospitalization.

Context: Influenza is a significant respiratory pathogen for residents of long-term care facilities (LTCFs). Rapid influenza detection tests (RIDT) may enable early outbreak detection allowing a timely response. Objective: We assessed whether RIDT for LTCF residents with acute respiratory infection is associated with increased antiviral use and decreased healthcare utilization. Study Design and Analysis: Non-blinded, pragmatic, randomized controlled trial (clinicaltrials.gov: NCT0296487). Setting: Wisconsin LTCFs. Population Studied: Residents of 20 LTCFs matched by bed capacity and geographic location. Intervention: (1) modified case identification criteria and (2) nursing-staff initiated collection of nasal swab specimen for on-site RIDT. Outcome Measures: Primary outcome measures, expressed as events per 1000 resident-weeks, included antiviral treatment courses, aniviral prophylaxis courses, total emergency department (ED) visits, ED visits for respiratory illness, total hospitalization, hospitalization for respiratory illness, hospital length of stay, total deaths, and deaths due to respiratory illness over three influenza seasons. Results: Oseltamivir use for prophylaxis was higher at intervention LTCFs (2.6 vs 1.9 courses per 1000 person-weeks; rate ratio: 1.38; 95%CI: 1.24-1.54; p<0.001); rates of oseltamivir use for treatment were not different. Rates of total ED visits (7.6 vs 9.8/1000 person-weeks; RR=0.78; 95%CI: 0.64-0.92; p=0.004), total hospitalizations (8.6 vs 11.0/1000 person-weeks; RR=0.79; 95%CI: 0.67-0.93; p=0.004), and hospital length of stay (35.6 days vs 55.5 days/1000 person-weeks; RR=0.64; 95%CI: 0.0.59-0.69; p<0.001) were lower at intervention as compared to control LTCFs. No significant differences were noted for respiratory-related ED visits or hospitalizations or in rates for all-cause or respiratory-associated mortality. Conclusions: The use of low threshold criteria to trigger nursing staff-initiated testing for influenza with RIDT resulted in increased prophylactic use of oseltamivir. There were significant reductions in the rates of all-cause ED visits (22% decline), hospitalizations (21% decline), and hospital length of stay (36% decline) across three combined influenza seasons. No significant differences were noted in respiratory-associated and all-cause deaths between intervention and control sites. This feasible, and low-cost intervention may provide significant benefit and should be further tested in other settings.

Transitioning from insulin to dipeptidyl-peptidase 4 (DPP-4) inhibitors for type 2 diabetes.

Insulin administration is time intensive and costly in facility staffing. When we started nursing home patients with type 2 diabetes (T2D) on DPP-4 inhibitors, we tapered insulin when finger stick blood sugar levels dropped to <200 mg/dL. Of 34 patients we were able to stop mealtime insulin in 28 (82%) and stop all insulin in 20 (59%). On average, hemoglobin A1c (HbA1c) decreased 0.5% and weight by 2.8 pounds. Among the 20 who stopped all insulin, HbA1c improved in 11 on average 1% (p=0.02), and weight decreased in 11 on average 4.1 pounds (p=0.66). 12 patients were switched in one day because of a low insulin dose or low HbA1c Tapering duration in the other 8 ranged from 10-727 days with an insulin dose of 28 to 84 units daily. Larger studies are needed to confirm our findings, develop a protocol for tapering insulin, and measure hypoglycemia, comfort and cost.

Association Between Dehydration and Falls.

OBJECTIVE: To determine whether there is an association between dehydration and falls in adults 65 years and older. PATIENTS AND METHODS: We used University of Wisconsin Health electronic health records from October 1, 2011 to September 30, 2015 to conduct a retrospective cohort study of Midwestern patients 65 years and older and examined the association between dehydration at baseline (defined as serum urea nitrogen to creatinine ratio > 20, sodium level > 145 mg/dL, urine specific gravity > 1.030, or serum osmolality > 295 mOsm/kg) and falls within 3 years after baseline while accounting for prescriptions of loop diuretic, antidepression, anticholinergic, antipsychotic, and benzodiazepine/hypnotic medications and demographic characteristics, using logistic regression. RESULTS: Of 30,634 patients, 37.9% (n=11,622) were dehydrated, 11.4% (n=3483) had a fall during follow-up, and 11.7% (n=3572) died during the follow-up period. We found a positive association of dehydration with falls alone (odds ratio [OR], 1.13; P=.002). For the outcome of falls or death, dehydration was positively associated (OR, 1.13; P=.001), along with loop diuretics (OR, 1.26; P<.001) and antipsychotic medications (OR, 1.52; P<.001). CONCLUSION: More than one-third of older adults in this cohort were dehydrated, with a strong association between dehydration and falls. Understanding and addressing the risks associated with dehydration, including falls, has potential for improving quality of life for patients as they age.

Yoga's effect on falls in rural, older adults.

BACKGROUND: Unintentional falls affect 30% of people over age 65 years. Yoga has been shown to improve balance. We designed this study to examine if yoga reduces falls. METHODS: We conducted 16 sessions of Hatha yoga over 8 weeks. Participants were randomly assigned to practice 10min of yoga daily at home in addition to 5-min relaxation exercises or relaxation exercises only (control group). RESULTS: Of the 38 participants completing the intervention, 15 participants reported a total of 27 falls in the 6-months before the study, compared to 13 participants sustaining 14 falls in the 6 months from the start of the study (p<0.047), without difference between yoga home-exercise and home relaxation-only groups. Compared to baseline scores, all participants improved on the Berg Balance Scale (53-54 out of 56, p=0.002), the Functional Gait Assessment (22.9-25.8 out of 30 points, p<0.001), and the Dynamic Gait Index (20.6-22.4 out of 24 points, p<0.001). Right leg stand time improved from a mean of 13.3s to 17.1s (p=0.020) and standing forward reach distance from 26.0cm to 29.6cm (p<0.001). Without difference between groups. Confidence, with the Activities-specific Balance Confidence Scale, increased in the yoga home-exercise group (88%-93%, p=0.037) compared to 90% unchanged from pre-intervention in the home relaxation-only group. CONCLUSION: Yoga classes reduce self-reported falls and improve balance measures. The addition of home yoga exercises did not enhance benefit over relaxation exercise only.

Are geriatric medicine fellows prepared for the important skills of hospice and palliative care?

Many geriatricians care for terminally ill and dying patients, but it is unclear whether the current geriatric medicine fellows receive sufficient training in hospice and palliative care (H&PC). A national cross-sectional survey was conducted between March and June 2011 to determine fellows' experience and perceived competency with H&PC. Fellows (143 of 298, 48%) and program directors (PDs; 69 of 150, 46%) answered the surveys on paper or online. Three-fourths of the fellows planned to practice H&PC; however, only 35% fellows versus 42% PDs believed that fellows were well prepared in this area. Factors associated with fellows' self-reported better preparation included completion of an H&PC rotation, experiences with an inpatient hospice facility, inpatient palliative care consulting service, and the presence of a formal H&PC curriculum.

Treatment of osteoporosis: current state of the art.

Osteoporosis can be treated with medications and lifestyle changes, including avoiding a sedentary lifestyle, alcohol, and smoking. We will identify medications that protect against hip fractures in addition to vertebral fractures, and explore new evidence of adverse effects and risks. Bisphosphonates are used as first-line treatment. We will discuss the latest osteoporosis medications, drug interactions, potential bone protective effects of other drug classes, and the evidence of exercise and kyphoplasty.

Perioperative management of delirium and dementia in the geriatric surgical patient.

BACKGROUND: Older adults undergo operations as our population ages. Increasing life expectancy and disease burden, along with decreased functional status and organ reserve, place the elderly surgical patient at higher general risk in the perioperative state. In particular, these patients have more diseases including dementia and medications that put them specifically at higher risk of delirium. PURPOSE: This overview describes the diagnosis, pathophysiology, and treatment of delirium and its interface with depression and dementia, and explains aging changes based on the picture of perioperative management in surgical interventions. CONCLUSIONS: Today, surgeons must be equipped to attend the geriatric patient's needs. Early recognition of comorbidities such as dementia and delirium as well as speedy and competent therapeutic treatment can limit consequences and impact.

Use of days of the week in a modified mini-mental state exam (M-MMSE) for detecting geriatric cognitive impairment.

PURPOSE: The purpose of this study was to compare a modified version of the Mini-Mental State Examination (MMSE) with the standard MMSE and the Mini-Cog in patients ≥65 years old, stratified by education and literacy level. METHOD: This cross-sectional exploratory study enrolled a convenience sample of 219 patients with a complaint of memory loss or a diagnosis of dementia from a geriatric outpatient clinic, nursing home, senior center, and university hospital. The MMSE was administered, and in addition to spelling and serial 7s backward, patients were asked to recite the days of the week backward with the intent to reduce educational bias. Scores on the modified MMSE were compared with scores of the MMSE and the Mini-Cog. RESULTS: Of the 219 patients, 157 were identified with cognitive impairment by the Mini-Cog. Using a cutoff of ≤23, the MMSE identified 118 patients and the modified MMSE identified 91 patients with cognitive impairment, and with a cutoff of ≤27 the MMSE identified 168 and the modified MMSE 149 patients. All cognitively intact subjects correctly recited the days of the week backward. Specificity of the modified MMSE was higher than the MMSE for most groups. The highest sensitivity and specificity (94% and 88%, respectively) as well as positive and negative predictive values (96% and 81%, respectively) were in patients with low levels of education for the modified MMSE using a cut off of ≤27. CONCLUSION: Using the days of the week in the MMSE among illiterate and semiliterate participants and with education less than high school, and using a cutoff of 27 of 30, correlates better with Mini-Cog for dementia screening, with fewer false positives.

Documenting the use of calcium supplements with oral bisphosphonates.

OBJECTIVE: Patients receiving an oral bisphosphonate for treatment of osteopenia or osteoporosis without adequate calcium intake are not optimally treated. Physicians prescribing bisphosphonates may not consistently document calcium supplementation recommendations. DESIGN: This is a retrospective chart review of osteoporotic or osteopenic outpatients with an active prescription for an oral bisphosphonate. This cross-sectional study was designed to determine the point prevalence of calcium supplementation recommendations by physicians. SETTING: Academic family medicine outpatient clinics. PATIENTS: Of the 1,229 patients with osteoporosis or osteopenia, 425 patients had an active prescription for an oral bisphosphonate and were included in the study. INTERVENTIONS: The active/inactive medication list and physician clinic notes in the electronic medical record were reviewed for documentation regarding calcium. MAIN OUTCOME MEASURES: The primary endpoint was the percentage of patients on bisphosphonates also receiving calcium. The secondary endpoint was the identification of demographic characteristics associated with lower use of calcium. RESULTS: The patient sample was 94% female, 69% white, with a mean body mass index of 27, and mean age of 72 years. Of the 425 patients, 387 (91.1%) were taking calcium or had a documented recommendation for calcium supplementation. Of the demographic characteristics evaluated, only age was statistically significantly different, with an average age of 76 years in the calcium group and 66 years of age in the noncalcium group. CONCLUSION: In this study, 91% of outpatients who were prescribed a bisphosphonate also were taking calcium or had it recommended to them. The only statistically significant difference between groups was greater age for those who received calcium.

Osteoporosis healthcare disparities in postmenopausal women.

BACKGROUND: Previous studies in referral populations have shown that fewer African American women complete dual-energy x-ray absorptiometry (DXA) screening and are prescribed medications for osteoporosis. This study examines if these disparities exist in primary care practices. METHODS: Of 4748 eligible women ≥60 years of age in primary care practices, we randomly selected 500 African American and 500 Caucasian women. We compared the DXA screening referral rate and results, follow-up rate, and medication prescribing for low bone mineral density (BMD) between African American and Caucasian women and analyzed provider demographics. We used logistic regression analysis to control confounding variables, such as age and BMI. RESULTS: Among the initial 1000 women, only 29.8% African American Women were referred to DXA compared to 38.4% Caucasian women (p<0.05), and 20.8% African American vs. 27.0% Caucasian (p<0.05) women completed the test. Among women with a diagnosis of osteoporosis, African Americans were less likely to receive medication (79.6% vs. 89.2%, p<0.05), without a difference in follow-up visit pattern between races. Female providers were more likely to refer women for DXA (27.7%) than male providers (21.7%) (p=0.035), and this gender difference in referral was more pronounced for African American patients. CONCLUSIONS: Not enough eligible women are being screened and treated for osteoporosis in primary care. Even fewer African American women receive DXA screenings and are treated for osteoporosis. Controlling for age and BMI attenuated but did not eliminate the difference. Female providers were more likely than male providers to refer women for DXA.

Reasons for bisphosphonate exclusion in patients treated for osteoporosis.

OBJECTIVE: Inadequate treatment is a concern in management of osteoporosis because of its negative impact on fracture risk, health care costs, and quality of life. Bisphosphonates are the most effective drug class at decreasing hip and spine fractures. The purpose of the study was to discover reasons for exclusion of bisphosphonates in the treatment of patients with osteoporosis. DESIGN: A cross-sectional study of electronic medical records. SETTING: Academic family medicine outpatient clinics. PATIENTS: Subset of patients older than 25 years of age who had a diagnosis of osteoporosis and were not on bisphosphonate treatment on December 31, 2007. OUTCOMES: The primary endpoint was the reason patients were not on bisphosphonate therapy. Secondary endpoints included the length of previous bisphosphonate therapy and the number of patients receiving other prescription treatments for osteoporosis. RESULTS: Of 698 patients with osteoporosis, 418 (60%) were not treated with a bisphosphonate. Patients were 91.6% female and 76.4% white, with a mean age of 77.5 ± 13.5 years. Of the random sample of 191 patients, 17 (8.9%) patients did not have an identifiable reason for bisphosphonate exclusion. The most common reasons were gastrointestinal (GI) diagnosis (28%), low functional status (24%), and poor renal function (12%). Almost half (44.5%) of patients were previously on a bisphosphonate, with an average use of 20.7 ± 17.7 months. Only 2.6% of patients received osteoporosis treatment other than a bisphosphonate. CONCLUSION: Even though 60% of patients were not prescribed a bisphosphonate, 91.1% had a reason for exclusion. With GI reasons most common, parenteral forms of bisphosphonates recently approved for osteoporosis may increase use.

Vitamin and mineral supplements.

Some vitamin and mineral supplements have proved to be clinically useful in preventing various diseases and health problems. Many widely used supplements, however, have shown no benefit when carefully studied. There are also several disease states and medications that should prompt the physician to recommend certain preventive supplements. This article gives an evidence-based look at the latest information in this area. Primary care physicians should be familiar with the latest research so they can be proactive in advising patients about proper use of vitamins and minerals.

Nursing home medication administration cost minimization analysis.

OBJECTIVES: To assess the time it takes nurses to administer medications in the nursing home setting, to calculate nursing cost of medication administration, and to determine whether using extended-release products are justified by decreasing nursing costs. DESIGN: Cost-minimization analysis using observational data from a time-motion analysis. SETTING: Two 150-bed nursing homes in rural eastern North Carolina. PARTICIPANTS: Nurses working during first and second shifts. MEASUREMENTS: Nurses were timed as they each administered medications to 12 patients. The mean time required to administer each dosage form was calculated. The cost of nursing time was based on the average nursing staff salary of $20.45 per hour as reported by the directors of nursing. Time and cost to dispense one more medication during an existing medication pass and an additional medication pass are calculated. RESULTS: The time to administer an additional dose of an oral medication to one patient was 45.01 seconds during an already scheduled medication pass and 63.05 seconds during a new medication pass. The cost of adding an oral medication once a day for a patient will cost $7.67 per month if administered at the same time as other medications or $10.74 per month if a new medication pass is required. The administration of other dosage forms, such as crushed, percutaneous enteroscopic gastrostomy, injection, and patch was more time involved and, thus, costlier. Formulas are provided to calculate medication administration cost based on local salary. CONCLUSIONS: Nursing time and costs for medication administration in the nursing home are great and should be considered when selecting a product. This may justify the selection of higher cost extended-release products.

Health care disparities in postmenopausal women referred for DXA screening.

BACKGROUND: Racial disparities have been identified in a number of areas in clinical medicine. Limited data are available on osteoporosis screening rates between races. We assessed the racial distribution in Dual Energy X-ray Absorptiometry (DXA) screening rates among African American and Caucasian women referred from our primary care clinics. METHODS: We obtained DXA results during the years 1998-2002 for all 546 women ages >50 years referred for bone mineral density (BMD) testing from a primary care population. We compared the DXA screening rates between African American and Caucasian women with the racial demographics of the referring primary care clinic population. RESULTS: African American women represented 45.9% and Caucasian women 51.7% of our primary care clinic population. Yet, only 14.5% (n=79) of the DXA screened women were African American, while 82.8% (n=452) were Caucasian. Age and recognized risk factors only explained a small portion of this difference. In women 65 years and older with universal screening recommendations, 19.4% (n=46) of the screened women were African American, and 80.6% (n=191) were Caucasian. The prevalence of osteoporosis was similar in both populations, 21.5% and 20.1% for African American and Caucasian women, respectively. CONCLUSIONS: Significantly fewer African American women had BMD screening even though national guidelines do not differentiate by race. The large disparity between the proportion of African American and Caucasian women screened calls for more equitable BMD screening among races.