Epidemiologic features of pet evacuation failure in a rapid-onset disaster.

OBJECTIVE: To describe epidemiologic features of pet evacuation failure after a hazardous chemical spill in which residents had no warning and only a few hours notice to evacuate. DESIGN: Cross-sectional study. SAMPLE POPULATION: Pet-owning households that evacuated from a hazardous chemical spill with (n = 119) or without (122) their pets. Procedures-Evacuees were surveyed by mail. RESULTS: 261 of 433 (60.3%) dogs and cats in 241 households were not evacuated. Of the 241 households, 119 (49.4%) evacuated with their pets, 98 (40.7%) evacuated without them but later attempted to rescue them, and 24 (10.0%) neither evacuated their pets nor attempted to rescue them. Pet evacuation failure was most common in households that thought the evacuated area was safe for pets. Risk of pet evacuation failure increased in households with many animals, low pet attachment and commitment scores, and low levels of preparedness. Cat evacuation failure was associated with not having cat carriers. Nearly 80% of households that evacuated with their pets found accommodation with friends and family. CONCLUSIONS AND CLINICAL RELEVANCE: Pet evacuation failure was common and jeopardized pets' health and well-being. Logistical challenges to transporting pets were substantial contributors to pet evacuation failure, whereas not knowing where to house a pet was only a minor concern. Most pet owners seemed self-reliant and acted appropriately towards their pets. Such self-reliant behavior by pet owners should be encouraged prior to disasters as part of an evacuation plan for households.

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

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

Iron status in atrophic glossitis: a pilot study.

We studied the relationship between laboratory markers of iron status and atrophic glossitis diagnosed clinically and documented with photographs. Nine subjects with glossitis underwent determination of CBC, ferritin, iron, and iron binding capacity. Five of the subjects had laboratory evidence suggesting iron deficiency.

Poor positive predictive value of low sensitive thyrotropin assay levels for hyperthyroidism in nursing home residents.

We assessed the positive predictive value of a low thyrotropin (TSH) level on sensitive TSH (STSH) assay as an indicator of hyperthyroidism. In 742 determinations on nursing home residents who were not taking thyroid hormone, we identified 15 with low TSH levels. None of the residents had a completely suppressed (undetectable) TSH level upon initial testing or an elevated total triiodothyronine (T3) or thyroxine (T4) level. Half the patients in whom total T3 was measured had low levels. Of 11 surviving residents, four subsequently had a normal TSH level and six others had a normal free T4 level. Only one patient had a slight elevation of the free T4 level. None of the residents were diagnosed as having hyperthyroidism.

Low serum folic acid levels in a nursing home population: a clinical experience.

Four hundred fifty-five residents of the Wisconsin Veterans Home had fasting serum specimens obtained for folic acid as part of standard practice. Twenty-nine percent were taking folic acid supplements. Six percent (n = 28) were taking phenytoin, a folate antagonist. No resident receiving a folate supplement (400 mcg/day) had a low serum folic acid level. This finding may be important for practitioners selecting a dose of folic acid for nursing home patients. Of the 325 residents not receiving a folate supplement, nine (3%) had low folic acid levels (< 2.5 ng/mL). Two of the nine were receiving phenytoin. Five were characterized by staff as eating well. As low serum levels are preventable with a multivitamin, we believe that supplementation with a multivitamin containing 400 mcg folic acid/day should be considered in nursing home residents.

Obtaining a durable power of attorney for health care from nursing home residents.

BACKGROUND: A durable power of attorney for health care (DPA) allows a person to appoint a surrogate decision-maker for any future period of mental incapacity. The absence of advance directives can lead to confusion and the expenditure of resources while trying to exert a substituted judgment. METHODS: The Wisconsin DPA was presented with an organized pilot program to 150 residents who had been judged by their social workers to have the capacity to make informed decisions regarding medical care. The reasons residents gave for accepting or rejecting a DPA were analyzed. RESULTS: Seventy-nine percent prepared a DPA. Reasons for signing included allowing the resident to decide who would make medical decisions and assuring that specific wishes would be carried out. Twenty-one percent did not execute a DPA. Reasons were categorized as confusion and misunderstanding regarding the legal system, mistrust, or social isolation. CONCLUSIONS: The high rate (79%) of DPA completion is probably related to individually counseling residents. However, competent residents who despite counseling do not choose to execute a DPA can have detailed advance directives ("living wills") prepared without appointing a decision-maker.

Nutritional correlates of atrophic glossitis: possible role of vitamin E in papillary atrophy.

Atrophy of the filiform papillae of the tongue is a sign of malnutrition. However, papillary atrophy has not been correlated with laboratory indices of nutritional status. We studied photographs of tongues from 30 elderly subjects and determined the percentage of normal papillary development (%NPD) relative to a reference photograph. We also determined 16 nutritional blood levels and used stepwise multiple linear regression to examine their relationship to %NPD. We found that %NPD correlated significantly (p < 0.0031) with levels of vitamin E and prealbumin, but not with 14 other laboratory indices. Subjects with overt atrophic glossitis (%NPD < 50%) tended to have multiple nutritional deficiencies. The high correlation of plasma vitamin E levels with %NPD may be related to its role as an antioxidant and in the maintenance of cellular membrane integrity.

Lack of association between free testosterone and bone density separate from age in elderly males.

It is unclear what proportion of the variance in bone density in elderly males is accounted for by testosterone status. We studied 112 ambulatory, elderly volunteers (mean age 71.7 years) and determined free testosterone (FT), as well as bone density measurements by photon absorptiometry at multiple sites. Our studies of 35 of these subjects 4 years later included morning FT and dual energy X-ray absorptiometry. There were no significant correlations between FT and bone density at multiple scanning sites with the effects of age partialed out. We suspect that our inability to detect a significant effect of FT on bone density was related to the relative strength of other determinants of bone density, as well as to the fact that FT values are far more dynamic than bone density.

Self-reported hearing difficulty and audiometric thresholds in nursing home residents.

BACKGROUND: Nursing home practitioners usually assess the general health and functional abilities of each resident at the time of admission. If audiometric screening is not routinely available, assessment of the resident's hearing status will probably consist only of asking questions about hearing difficulty. In this study we explored which questions, when answered positively, were most strongly associated with moderate or severe hearing impairment. METHODS: A total of 198 newly admitted nursing home residents answered questions regarding their hearing in common listening situations, and then underwent audiometric assessment. RESULTS: Fifty-four percent of the residents had a pure tone average hearing level of > 25 dB at 500, 1000, and 2000 Hz and were therefore considered impaired. A single general question regarding hearing had a sensitivity of 69% in determining the presence of such impairment. Three specific questions which assessed hearing--in a group, while watching television, and while on the telephone--had a collective sensitivity of 83%. Asking the three questions was significantly (P = .003) more effective than asking only the general question. CONCLUSIONS: A set of specific questions significantly improved the identification of residents whose hearing loss affected their daily living activities compared with the use of a single hearing loss question.

Follow-up of mild hypothyroidism in a nursing home.

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

Hearing loss in the nursing home. An institutional issue.

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

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

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