Decision support-tools for early detection of infection in older people (aged> 65 years): a scoping review.

BACKGROUND: Infection is more frequent, and serious in people aged > 65 as they experience non-specific signs and symptoms delaying diagnosis and prompt treatment. Monitoring signs and symptoms using decision support tools (DST) is one approach that could help improve early detection ensuring timely treatment and effective care. OBJECTIVE: To identify and analyse decision support tools available to support detection of infection in older people (> 65 years). METHODS: A scoping review of the literature 2010-2021 following Arksey and O'Malley (2005) framework and PRISMA-ScR guidelines. A search of MEDLINE, Cochrane, EMBASE, PubMed, CINAHL, Scopus and PsycINFO using terms to identify decision support tools for detection of infection in people > 65 years was conducted, supplemented with manual searches. RESULTS: Seventeen papers, reporting varying stages of development of different DSTs were analysed. DSTs largely focussed on specific types of infection i.e. urine, respiratory, sepsis and were frequently hospital based (n = 9) for use by physicians. Four DSTs had been developed in nursing homes and one a care home, two of which explored detection of non- specific infection. CONCLUSIONS: DSTs provide an opportunity to ensure a consistent approach to early detection of infection supporting prompt action and treatment, thus avoiding emergency hospital admissions. A lack of consideration regarding their implementation in practice means that any attempt to create an optimal validated and tested DST for infection detection will be impeded. This absence may ultimately affect the ability of the workforce to provide more effective and timely care, particularly during the current covid-19 pandemic.

What are the most effective interventions to improve physical performance in pre-frail and frail adults? A systematic review of randomised control trials.

BACKGROUND: With life expectancy continuing to rise in the United Kingdom there is an increasing public health focus on the maintenance of physical independence among all older adults. Identifying interventions that improve physical outcomes in pre-frail and frail older adults is imperative. METHODS: A systematic review of the literature 2000 to 2017 following PRISMA guidelines and registered with PROSPERO (no. CRD42016045325). RESULTS: Ten RCT trials fulfilled selection criteria and quality appraisal. The study quality was moderate to good. Interventions included physical activity; nutrition, physical activity combined with nutrition. Interventions that incorporated one or more physical activity components significantly improved physical outcomes in pre-frail and/or frail older adults. CONCLUSIONS: Physical activity interventions are key to maintaining independence in pre-frail and frail older adults. A lack of consensus regarding the definition of frailty, and an absence of core measures to assess this means any attempt to create an optimal intervention will be impeded. This absence may ultimately impact on the ability of older and frail adults to live well and for longer in the community.

Elevated levels of CRP and IL-8 are related to reduce survival time: 1-year follow-up measurements of different analytes in frail elderly nursing home residents.

There are only few studies with specific focus on predictors of survival in nursing home residents (NHRs). The aim was to study whether 1-year changes in complete blood count (including hemoglobin, red blood cells, erythrocyte volume fraction, mean corpuscular volume, mean corpuscular hemoglobin concentration, white blood cells count and platelet count), C-reactive protein and interleukin-1ß (IL-1ß), IL-1Ra, IL-6, IL-8 and IL-10, are associated with 8-year survival in elderly NHRs, aged ≥ 80 years. Complete blood count, C-reactive protein and interleukins were measured at baseline, after 6 and 12 months from 167 NHRs aged 80-101 years, mean age 88 ± 4.5 years, 75% of whom were women. Dates of death were collected from the National Death Register 8 years after baseline. Levels of hemoglobin, red blood cells and mean corpuscular hemoglobin concentration were lower after 1-year, but higher for mean corpuscular volume and IL-1ß, compared to baseline or 6 month follow-up. In the Cox regression model with a time-dependent covariate, raised levels of C-reactive protein and IL-8 were associated with reduced survival time. Elevated levels of C-reactive protein and IL-8 during 1-year follow-up were related to reduce lengths of survival in elderly NHRs.

Differences in levels of albumin, ALT, AST, γ-GT and creatinine in frail, moderately healthy and healthy elderly individuals.

BACKGROUND: Reference intervals are widely used as decision tools, providing the physician with information about whether the analyte values indicate ongoing disease process. Reference intervals are generally based on individuals without diagnosed diseases or use of medication, which often excludes elderly. The aim of the study was to assess levels of albumin, alanine aminotransferase (ALT), aspartate aminotransferase (AST), creatinine and γ-glutamyl transferase (γ-GT) in frail, moderately healthy and healthy elderly indivuduals. METHODS: Blood samples were collected from individuals >80 years old, nursing home residents, in the Elderly in Linköping Screening Assessment and Nordic Reference Interval Project, a total of 569 individuals. They were divided into three cohorts: frail, moderately healthy and healthy, depending on cognitive and physical function. Albumin, ALT, AST, creatinine and γ-GT were analyzed using routine methods. RESULTS: Linear regression predicted factors for 34% of the variance in albumin were activities of daily living (ADL), gender, stroke and cancer. ADLs, gender and weight explained 15% of changes in ALT. For AST levels, ADLs, cancer and analgesics explained 5% of changes. Kidney disease, gender, Mini Mental State Examination (MMSE) and chronic obstructive pulmonary disease explained 25% of the variation in creatinine levels and MMSE explained three per cent of γ-GT variation. CONCLUSIONS: Because a group of people are at the same age, they should not be assessed the same way. To interpret results of laboratory tests in elderly is a complex task, where reference intervals are one part, but far from the only one, to take into consideration.

Assessment of body temperature measurement options.

Assessment of body temperature is important for decisions in nursing care, medical diagnosis, treatment and the need of laboratory tests. The definition of normal body temperature as 37°C was established in the middle of the 19th century. Since then the technical design and the accuracy of thermometers has been much improved. Knowledge of physical influence on the individual body temperature, such as thermoregulation and hormones, are still not taken into consideration in body temperature assessment. It is time for a change; the unadjusted mode should be used, without adjusting to another site and the same site of measurement should be used as far as possible. Peripheral sites, such as the axillary and the forehead site, are not recommended as an assessment of core body temperature in adults. Frail elderly individuals might have a low normal body temperature and therefore be at risk of being assessed as non-febrile. As the ear site is close to the hypothalamus and quickly responds to changes in the set point temperature, it is a preferable and recommendable site for measurement of body temperature.

Clinical decision-making process for early nonspecific signs of infection in institutionalised elderly persons: experience of nursing assistants.

AIM: To illuminate nursing assistant's experiences of the clinical decision-making process when they suspect that a resident has an infection and how their process relates to other professions. BACKGROUND: The assessment of possible infection in elderly individuals is difficult and contributes to a delayed diagnosis and treatment, worsening the goal of good care. Recently we explored that nursing assistants have a keen observational ability to detect early signs and symptoms that might help to confirm suspected infections early on. To our knowledge there are no published papers exploring how nursing assistants take part in the clinical decision-making process. DESIGN: Explorative, qualitative study. SETTING: Community care for elderly people. PARTICIPANTS: Twenty-one nursing assistants, 22-61 years. METHODS: Focus groups with verbatim transcription. The interviews were subjected to qualitative content analysis for manifest and latent content with no preconceived categories. FINDINGS: The findings are described as a decision-making model consisting of assessing why a resident feels unwell, divided into recognition and formulation and strategies for gathering and evaluating information, influenced by personal experiences and preconceptions and external support system and, secondly, as taking action, consisting of reason for choice of action and action, influenced by feedback from the nurse and physician. CONCLUSION: Nursing assistant's assessment is based on knowing the resident, personal experiences and ideas about ageing. Nurses and physician's response to the nursing assistant's observations had a great impact on the latter's further action. A true inter-professional partnership in the clinical decision-making process would enhance the possibility to detect suspected infection early on, and thereby minimize the risk of delayed diagnosis and treatment and hence unnecessary suffering for the individual. RELEVANCE TO CLINICAL PRACTICE: In order to improve the clinical evaluation of the individual, and thereby optimise patient safety, it is important to involve nursing assistants in the decision-making process.

Evidence-based practice in a multiprofessional context.

BACKGROUND: Healthcare today is a complex system with increasing needs of specific knowledge of evaluation of research and implementation into clinical practice. A critical issue is that we all apply evidence-based practice (EBP) with standardised methods and continuing and systematic improvements. EBP includes both scientific and critical assessed experience-based knowledge. For the individual, this means applying evidence-based knowledge to a specific situation, and for the organisation, it means catering for a systematic critical review and evaluation and compiling research into guidelines and programmes. In 2009, the County Council of Jönköping had approximately 335,000 inhabitants and the healthcare organisation had more than 10,000 employees. As the County Council actively promotes clinical improvement, it is interesting to explore how healthcare employees think about and act upon EBP. The aim of this survey was therefore to describe factors that facilitate or hinder the application of EBP in the clinical context. METHOD: A quantitative study was performed with a questionnaire to healthcare staff employed in the County Council of Jönköping in 2009. The questionnaire consisted of questions concerning which factors are experienced to affect the development of evidence-based healthcare. There were 59 open and closed questions, divided into the following areas: • Sources of knowledge used in practice • Barriers to finding and evaluating research reports and guidelines • Barriers to changing practice on the basis of best evidence • Facilitating factors for changing practice on the basis of best evidence • Experience in finding, evaluating and using different sources of evidence. The participants were selected using the county council's staff database and included medical, caring and rehabilitative staff within hospitals, primary care, dentistry and laboratory medicine. The inclusion criteria were permanent employment and clinical work. Invitations were sent to 5787 persons to participate in the study and 1445 persons answered the questionnaire. RESULTS: Knowledge used in daily clinical practice was mainly based on information about the patient, personal experience and local guidelines. Twenty per cent answered that they worked 'in the way they always had', and 11% responded that they used evidence from research as a basis for change. The participants experienced that EBP was not used enough in clinical healthcare and explained this with practical and structural barriers, which they thought should be better monitored by the organisation and directors. CONCLUSION: Overall, the results indicate that the scientific evidence for healthcare is not used sufficiently as a base for decisions in daily practice as well as for changing practice. This is more prominent among assistant staff. As a consequence, this might affect the care of the patients in a negative way. Increased awareness of EBP and a stronger evidence-based approach are keys in the ongoing improvement work in the county. Local guidelines seem to be a way to implement knowledge. But, as the arena of activities is complex and the employees have diverse education levels, different strategies to facilitate and promote EBP are necessary.

What is the evidence base for the assessment and evaluation of body temperature?

Measurement and management of body temperature is often based on traditionand personal ideas and beliefs rather than evidence based knowledge. This article summarises the literature to provide a guide to evidence based assessment and evaluation of body temperature in clinical practice.

Early nonspecific signs and symptoms of infection in institutionalized elderly persons: perceptions of nursing assistants.

AIM: To explore early nonspecific signs and symptoms of infection in elderly institutionalized individuals as described by nursing assistants. BACKGROUND: Nonspecific signs and symptoms and lack of specific ones are common in connection with infection in institutionalized elderly persons and contribute to a delayed diagnosis and treatment. In clinical care, the nurse makes notes on the individual status of the patient on a daily basis and decides whether to contact the physician or not. However, in Sweden nursing assistants provide most of the daily care and therefore have many opportunities to observe subtle changes that may be early signs of infection. METHOD: Data were collected in 2006 from focus interviews with 21 female nursing assistants. The interviews were verbatim transcripted and analysed with qualitative content analysis for manifest content with no preconceived categories. FINDINGS: Nursing assistants' descriptions of nonspecific signs and symptoms of infection comprised two exclusive categories. Is not as usual described general signs and symptoms of discomfort related to possible infection, such as discomfort, unrestrained behaviour, aggressiveness, restlessness, confusion, tiredness and feebleness, and decreased eating. Seems to be ill was more distinctly related to signs and symptoms of established infection in general terms of fever and pain or more specifically related to pneumonia, urinary tract infection, skin infection, cold and eye infection. CONCLUSION: Nursing assistants have a keen observational ability to detect early signs that might help to confirm suspected infections in elderly nursing home residents early on. Whether or not the cited categories are actual early signs and symptoms of infectious disease needs to be further investigated.

Time for a change to assess and evaluate body temperature in clinical practice.

The definition of normal body temperature as 37 degrees C still is considered the norm worldwide, but in practice there is a widespread confusion of the evaluation of body temperature, especially in elderly individuals. In this paper, we discuss the relevance of normal body temperature as 37 degrees C and consequences in clinical practice. Our conclusion is that body temperature should be evaluated in relation to the individual variability and that the best approach is to use the same site, and an unadjusted mode without adjustments to other sites. If the baseline value is not known, it is important to notice that frail elderly individuals are at risk of a low body temperature. In addition, what should be regarded as fever is closely related to what is considered as normal body temperature. That is, as normal body temperature shows individual variations, it is reasonable that the same should hold true for the febrile range.

Gender differences in predictors of survival in elderly nursing-home residents: a 3-year follow up.

This study focus on predicting factors of survival possible to modify by nursing care, and the incidence and mortality rate of nursing-home-acquired pneumonia, allocated to 1, 2 and 3 years of follow ups. The residents consisted of 156 women and 78 men living in special housing for the elderly. Data on chronic disease and medication were obtained at baseline, and activities of daily living (ADL) status, nutritional status and body temperature were assessed. The incidence of pneumonia was noted prospectively for 1 year and retrospectively for the following 2 years. Predictive factors for survival were explored by Cox hazard regression analysis. The results showed that age, functional and cognitive impairment were predictors of mortality irrespective of gender, while poor nutritional status in women and chronic obstructive pulmonary disease, heart disease and medication with sedatives in men were gender-specific predictors. ADL correlated positively with dementia and negatively with S-albumin irrespective of gender, while malnutrition correlated positively with ADL in women and positively with chronic obstructive pulmonary disease in men. To promote the quality of daily living in elderly individuals, it is of importance to improve the capabilities in daily functions and nutritional status, especially in women with functional impairment, and to prevent anxiety particularly in men. The findings also clarify that pneumonia is as common as cerebral vascular insult and heart failure as cause of death in this population.

Errors in body temperature assessment related to individual variation, measuring technique and equipment.

Errors in body temperature measurement might seriously influence the evaluation of an individual's health condition. We studied individual variation, measurement technique and the equipment used when assessing body temperature. In the first part of the study, three volunteers performed repeated measurements for five mornings. In the second part, the morning rectal, oral, ear and axillary temperatures were measured once in 84 men and women (19-59 years). The repeated measurements showed a daily temperature difference of 0.1-0.4 degrees C in rectal and oral temperatures, 0.2 degrees C-1.7 degrees C in the ear and 0.1-0.9 degrees C in the axillary temperatures. In the sample of 84 subjects, men and postmenopausal women had a lower mean body temperature compared to premenopausal women. The mean deviation between rectal temperature, and oral, ear and axillary temperatures, respectively, was > 0.5 degrees C, with a large individual variation. In conclusion, in order to improve the evaluation of body temperature, the assessment should be based on the individual variation, the same site of measurement and no adjustment of oral, ear or axillary temperatures to the rectal site.

Morbidity, mortality and clinical presentation of nursing home-acquired pneumonia in a Swedish population.

Pneumonia has been estimated to be the second most common infection in nursing-home residents. However, to the authors' knowledge, no such Swedish data are available. Therefore, this study investigated the incidence, risk factors, and 30 d case-fatality rate and clinical presentation of nursing home-acquired pneumonia (NHAP) in 234 nursing-home residents aged 66-99 y. Activities of daily living (ADL status), malnutrition and body mass index were measured at baseline. The residents were then followed prospectively during 1 y for symptoms and signs of pneumonia. Pneumonia was verified clinically and/or radiologically in 32 residents, corresponding to a yearly incidence of 13.7%. The 30 d case-fatality rate was 28%. Cough and sputum production were the most specific, and fever > or = 38.0 degrees C rectally and cognitive decline were the most common non-specific presenting symptoms. Chronic obstructive pulmonary disease, ADL status > 5 and male gender were risk factors for acquiring pneumonia. In conclusion, NHAP is associated with high morbidity and mortality in Sweden. In order not to delay treatment, it is necessary to be aware that specific symptoms of pneumonia may be lacking in the clinical presentation in the nursing-home setting.

Normal oral, rectal, tympanic and axillary body temperature in adult men and women: a systematic literature review.

Normal oral, rectal, tympanic and axillary body temperature in adult men and women: a systematic literature review The purpose of this study was to investigate normal body temperature in adult men and women. A systematic review of data was performed. Searches were carried out in MEDLINE, CINAHL, and manually from identified articles reference lists. Studies from 1935 to 1999 were included. Articles were classified as (1) strong, (2) fairly strong and (3) weak evidence. When summarizing studies with strong or fairly strong evidence the range for oral temperature was 33.2-38.2 degrees C, rectal: 34.4-37.8 degrees C, tympanic: 35.4- 37.8 degrees C and axillary: 35.5-37.0 degrees C. The range in oral temperature for men and women, respectively, was 35.7-37.7 and 33.2-38.1 degrees C, in rectal 36.7-37.5 and 36.8-37.1 degrees C, and in tympanic 35.5-37.5 and 35.7-37.5 degrees C. The ranges of normal body temperature need to be adjusted, especially for the lower values. When assessing body temperature it is important to take place of measurement and gender into consideration. Studies with random samples are needed to confirm the range of normal body temperature with respect to gender and age.

The impact of ADL status, dementia and body mass index on normal body temperature in elderly nursing home residents.

A subset of seniors might demonstrate a lower body temperature compared with younger subjects. However, data on normal body temperature in seniors are sparse. The aim of the study was to study normal body temperature with a view of predicting factors of low body temperature in non-febrile seniors. Elderly women (n=159) and 78 men, aged > or =65 years, living in community resident homes were included in the study. Data on chronic diseases and medication were collected from medical records. Tympanic and rectal temperature was measured twice daily; once at 7-9 AM and then at 6-8 PM. In addition, body mass index (BMI), activities of daily living (ADL) status, as well as details regarding dementia and malnutrition were recorded. The variation in tympanic and rectal temperatures ranged from 33.8 to 38.4 degrees C and 35.6 to 38.0 degrees C, respectively. ADL status, dementia and BMI were significantly related to lower and analgesic to higher tympanic temperature. Dementia was significantly related to lower rectal temperature. Therefore, dementia, BMI, ADL status and analgesic shall not be overlooked when assessing temperature in seniors. More research is needed to further clarify the influence of these predictive factors, as well as the impact of BMI and malnutrition.