Prospective Validation of Cessation of Contact Precautions for Extended-Spectrum ß-Lactamase-Producing Escherichia coli(1).

After contact precautions were discontinued, we determined nosocomial transmission of extended-spectrum ß-lactamase (ESBL)-producing Escherichia coli by screening hospital patients who shared rooms with ESBL-producing E. coli-infected or -colonized patients. Transmission rates were 2.6% and 8.8% at an acute-care and a geriatric/rehabilitation hospital, respectively. Prolonged contact was associated with increased transmission.

Prediction of discharge destination after neurological rehabilitation in stroke patients.

BACKGROUND/AIMS: Returning home is one of the most important aims of stroke patients when admitted to rehabilitation. METHODS: A single-center prospectively ascertained database study was conducted. RESULTS: Among 1,332 eligible patients (median age = 76.5 years), 828 (62.2%) returned home. Multiple logistic regression revealed 5 independent predictors: independent sitting balance, higher motor and social-cognitive functional independence measure subscores (all on admission to rehabilitation), living with a partner and younger age. The area under the curve (AUC) of this model was 0.86 (95% confidence interval (CI) 0.84-0.88). When age was excluded from the model, the AUC remained virtually the same (AUC = 0.85, 95% CI = 0.83-0.87). CONCLUSION: The discharge destination could be predicted in a majority of patients with easily available parameters. Availability of a partner as well as parameters linked to severity of the neurological and functional deficit were both important. Age alone adds very little to the predictive power of these variables, therefore access to rehabilitation should not be denied on grounds of age.

Safety of pharmacological augmentation of stroke rehabilitation.

BACKGROUND: Based on experimental studies, pharmacological augmentation (PA) of stroke rehabilitation might be reasonable. Whether PA is beneficial in clinical practice is unclear. METHODS: We performed an observational study on the use of PA in addition to regular rehabilitative therapies in a stroke rehabilitation unit. Over 20 months, we systematically observed (1) the utilization rate of PA, (2) possible adverse events, and (3) the functional outcome of patients with versus without PA (non-PA). The primary outcome variable was the increase in abilities in activities of daily living during in-hospital rehabilitation as quantified by the delta 'functional independence measure' (FIM). RESULTS: Ninety-seven of 249 (39%) patients had PA. L-Dopa was used in 63 (65%), acetylcholinesterase inhibitors in 33 (34%), and selective serotonin reuptake inhibitors in 31 (32%) PA patients. In 11 (11%) patients, PA was associated with delirium (n = 4), gastrointestinal symptoms (n = 4), electrolyte disorders (n = 2), or incontinence (n = 1). All adverse events were temporary. PA patients did not differ from non-PA patients in age (74 vs. 73 years; p = 0.62), gender ratio, and stroke type (ischemia 85 vs. 82%; p = 0.49). However, compared with non-PA patients, PA patients were more severely affected (median NIH Stroke Scale Score 7 vs. 4; p < 0.001; median FIM 58 vs. 85; p = 0.01). At discharge, the PA group had a higher median ΔFIM compared with non-PA patients (16 vs. 9; p = 0.01). None of the PA patients but 5 (3.3%) of the non-PA patients had died. CONCLUSION: PA of stroke rehabilitation was used frequently. The absence of safety concerns suggests that there is scope for benefit from PA in stroke rehabilitation. A large randomized controlled trial seems feasible and ethically justified.

[Vitamin D Level in Employees of a Swiss University Geriatric Hospital]. / Vitamin-D-Status bei Mitarbeitenden eines universitären Schweizer Geriatriespitals.

Vitamin D Level in Employees of a Swiss University Geriatric Hospital Abstract. Vitamin D plays an important role in health. The aim of this study was to determine the vitamin D level in hospital employees from different age, sex and occupational groups. 281 employees took part in the investigation. Vitamin D (25-OH) was determined by serum sample analysis, the mean value was 59.5 nmol/l. 43.1 % of participants showed a vitamin D deficiency (<50 nmol/l). Low vitamin D levels significantly correlated with increased BMI. Women, physically active employees and those in occupations with medical content had significantly higher vitamin D levels. Sports activity and substitution were independent predictors of vitamin D level. The study illustrated that increased sun exposure and/or vitamin D supplementation are needed.

Introducing alcohol-based hand rub for hand hygiene: the critical need for training.

BACKGROUND: Use of an alcohol-based hand rub for hand hygiene has recently been recommended by the Centers for Disease Control and Prevention. However, the proper technique for using hand rub has not been well described and is not routinely taught in hospitals. OBJECTIVE: To evaluate the impact of training on proper technique as outlined by the European Standard for testing alcohol-based hand rubs (European Norm 1500) in a clinical study. DESIGN, SETTING, AND PATIENTS: Prospective study including 180 healthcare workers (HCWs) in a 450-bed, university-affiliated geriatric hospital where alcohol-based hand rub was introduced in the late 1970s. INTERVENTION: Structured training program in hand hygiene with alcohol-based hand rub. Technique for using hand rub was tested by the addition of a fluorescent dye to the disinfectant and the number of areas missed was quantified by a validated visual assessment method. In addition, the number of bacteria eradicated was estimated by calculating the difference between the log(10) number of colony-forming units (cfu) of bacteria on the fingertips before and after the procedure, and reported as reduction factor (RF). MAIN OUTCOME MEASURE: Log(10) cfu bacterial counts on fingertips before and after training in the appropriate technique for using hand rub. RESULTS: At baseline, only 31% of HCWs used proper technique, yielding a low RF of 1.4 log(10) cfu bacterial count. Training improved HCW compliance to 74% and increased the RF to 2.2 log(10) cfu bacterial count, an increase of almost 50% (P<.001). Several factors, such as applying the proper amount of hand rub, were significantly associated with the increased RF. CONCLUSION: These results demonstrate that education on the proper technique for using hand rub, as outlined in EN 1500, can significantly increase the degree of bacterial killing.

[How to Manage Polypharmacy in the Elderly]. / Polypharmazie: Arznei-Cocktail im Alter, was macht Sinn?

Polypharmacy is accentuated in our fast-growing population. Polypharmacy is associated with adverse drug reactions, interactions, non-compliance, and increased risk of geriatric syndroms (falls, incontinence, malnutrition, cognitive impairment, delirium). There is a dilemma between clinical practice guidelines and pragmatism in the treatment of elderly patients in the last ten years of life. Reducing polypharmacy is a challenge and we present some instruments for reducing polypharmacy.

Effects of vitamin D and calcium supplementation on falls: a randomized controlled trial.

Specific receptors for vitamin D have been identified in human muscle tissue. Cross-sectional studies show that elderly persons with higher vitamin D serum levels have increased muscle strength and a lower number of falls. We hypothesized that vitamin D and calcium supplementation would improve musculoskeletal function and decrease falls. In a double-blind randomized controlled trial, we studied 122 elderly women (mean age, 85.3 years; range, 63-99 years) in long-stay geriatric care. Participants received 1200 mg calcium plus 800 IU cholecalciferol (Cal+D-group; n = 62) or 1200 mg calcium (Cal-group; n = 60) per day over a 12-week treatment period. The number of falls per person (0, 1, 2-5, 6-7, >7 falls) was compared between the treatment groups. In an intention to treat analysis, a Poisson regression model was used to compare falls after controlling for age, number of falls in a 6-week pretreatment period, and baseline 25-hydroxyvitamin D and 1,25-dihydroxyvitamin D serum concentrations. Among fallers in the treatment period, crude excessive fall rate (treatment - pretreatment falls) was compared between treatment groups. Change in musculoskeletal function (summed score of knee flexor and extensor strength, grip strength, and the timed up&go test) was measured as a secondary outcome. Among subjects in the Cal+D-group, there were significant increases in median serum 25-hydroxyvitamin D (+71%) and 1,25-dihydroxyvitamin D (+8%). Before treatment, mean observed number of falls per person per week was 0.059 in the Cal+D-group and 0.056 in the Cal-group. In the 12-week treatment period, mean number of falls per person per week was 0.034 in the Cal+D-group and 0.076 in the Cal-group. After adjustment, Cal+D-treatment accounted for a 49% reduction of falls (95% CI, 14-71%; p < 0.01) based on the fall categories stated above. Among fallers of the treatment period, the crude average number of excessive falls was significantly higher in the Cal-group (p = 0.045). Musculoskeletal function improved significantly in the Cal+D-group (p = 0.0094). A single intervention with vitamin D plus calcium over a 3-month period reduced the risk of falling by 49% compared with calcium alone. Over this short-term intervention, recurrent fallers seem to benefit most by the treatment. The impact of vitamin D on falls might be explained by the observed improvement in musculoskeletal function.

Tetanus immunisation in geriatric patients with accidental wounds: how much is needed?

OBJECTIVE: In the industrialised world, the elderly carry the highest risk for tetanus. This prospective serological study was performed to evaluate the reliability of tetanus immunisation histories and the antibody response to tetanus vaccinations in the elderly. METHODS: 40 individuals >65 years with a bleeding trauma were included in the study. Their tetanus vaccination histories were investigated, and accordingly a single booster (group A, n = 7), or a three dose basic immunisation against tetanus (group B, n = 33) was provided. In addition, tetanus antitoxin levels were determined. RESULTS: Age varied between 67 and 95 years. Inconsistencies regarding the vaccination history were found between patients and their physicians in 30% (12/40), between patient statements and vaccination documents in 57.1% (8/14) and between physicians' records and vaccination documents in 35.7% (5/14). Antitoxin titres >0.15 IU/ ml were considered protective, giving a seroprevalence of 92.5%. Sensitivities and negative predictive values for tetanus immunity were 30.6% and 10.7% based on patient histories and 2.8% and 7.9% based on physicians' records. In group A, after the single booster immunisation the median titre rose from 1.2 to 14.2 IU/ml, in group B from 0.9 to 5.3 IU/ml after the first, and to 9.6 IU/ml after the third tetanus toxoid dose (p <0.001 using Friedman's test). CONCLUSIONS: In Switzerland, elderly patients with a tetanus prone wound provide an unreliable vaccination history but their seroprotection against tetanus is high. A single booster for secondary immunisation is therefore sufficient. It is not necessary to take the largely unreliable vaccination history into account.

[Assessment of patient satisfaction in geriatric hospitals: a methodological pilot study]. / Erhebung der Patientenzufriedenheit in der Geriatrie: Eine methodologische Pilotstudie.

UNLABELLED: The assessment of patient satisfaction using mailed questionnaires is an established method of quality management in acute care hospitals in our health care system. The needs of aged patients and the inter-professional approach of geriatric medicine are, however, not taken into account by such surveys. To date, validated German instruments to assess patient opinions in geriatric in-hospital care are rare. We report the results of a multi-center feasibility study of a questionnaire developed especially for such needs. We examined 1918 patients with a median age of 82 years and a mean Mini- Mental Score (MMS) of 25 points in 3 Swiss geriatric hospitals. We examined the results of all completed written questionnaires for their psychometric properties. In parallel, we assessed the satisfaction of the patient's spouses or family members applying the same instrument. The return rate was 32% when the instrument was applied as a questionnaire and 60% when applied as an interview. In questionnaires, the return rate was dependent on cognition with lower return in patients with low MMS scores. The return rate of questionnaires mailed to family members was 35%. The theoretical construct patient satisfaction was reliable and valid. The Cronbach-Alpha values in different item areas ranked between 0.67 (hotel services, room quality) and 0.92 (physicians). We were not able to assess the quality of medical therapies and of pain treatment due to low answer frequencies. Overall, patients were satisfied with all medical services in the participating hospitals. In contrast, satisfaction was low in family members regarding the quality of information flow between family members and physicians or nurses. CONCLUSIONS: An instrument to assess patient opinions can easily be introduced into a geriatric hospital. Such an instrument can provide important information for the improvement of quality in different areas of geriatric care such as medical, nursing care or guest services.

Identifying a cut-off point for normal mobility: a comparison of the timed 'up and go' test in community-dwelling and institutionalised elderly women.

BACKGROUND: physical mobility testing is an essential component of the geriatric assessment. The timed up and go test measures basic mobility skills including a sequence of functional manoeuvres used in everyday life. OBJECTIVES: to create a practical cut-off value to indicate normal versus below normal timed up and go test performance by comparing test performance of community-dwelling and institutionalised elderly women. SETTING AND PARTICIPANTS: 413 community-dwelling and 78 institutionalised mobile elderly women (age range 65-85 years) were enrolled in a cross-sectional study. MEASUREMENTS: timed up and go test duration, residential and mobility status, age, height, weight and body mass index were documented. RESULTS: 92% of community-dwelling elderly women performed the timed up and go test in less than 12 seconds and all community-dwelling women had times below 20 seconds. In contrast only 9% of institutionalised elderly women performed the timed up and go test in less than 12 seconds, 42% were below 20 seconds, 32% had results between 20 and 30 seconds and 26% were above 30 seconds. The 10(th)-90(th) percentiles for timed up and go test performance were 6.0-11.2 seconds for community-dwelling and 12.7-50.1 seconds for institutionalised elderly women. When stratifying participants according to mobility status, the timed up and go test duration increased significantly with decreasing mobility (Kruskall-Wallis-test: p<0.0001). Linear regression modelling identified residential status (p<0.0001) and physical mobility status (p<0.0001) as significant predictors of timed up and go performance. This model predicted 54% of total variation of timed up and go test performance. CONCLUSION: residential and mobility status were identified as the strongest predictors of timed up and go test performance. We recommend the timed up and go test as a screening tool to determine whether an in-depth mobility assessment and early intervention, such as prescription of a walking aid, home visit or physiotherapy, is necessary. Community-dwelling elderly women between 65 and 85 years of age should be able to perform the timed up and go test in 12 seconds or less.

Quantitative assessment of the stops walking while talking test in the elderly.

OBJECTIVE: To examine whether trunk sway and walking speed differ between elderly "stoppers" and "nonstoppers" during a shorter version of the stops walking while talking (SWWT) test-an observational assessment of impaired dual-task performance-and during a normal walking trial. DESIGN: The original SWWT test was administered on the way to the test room (over a distance of 150m). Then, subjects were asked to walk 2 trials of 8m while wearing a trunk sway measuring device strapped firmly to their lower back. For the first 8-m trial, no questions were asked (control trial). During the second 8-m trial, subjects were asked an easy question (What is your age?) after walking 2m. SETTING: Long-stay geriatric care unit in Switzerland. PARTICIPANTS: Seventeen institutionalized elderly (16 women, 1 man; mean age, 86.3y; range, 79-93y). Subjects had to be able to walk at least 150m and to understand simple questions. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: The amplitude of trunk sway angle and angular velocity in the forward-backward (pitch) and side-to-side (roll) directions and the duration of each trial were compared between the two 8-m walking trials with and without a question among subjects who did and did not come to a complete stop. RESULTS: In the original SWWT test, 4 persons stopped walking while talking, compared with 8 persons who stopped in the short (8-m) walking trial when a question was asked. Persons who stopped during the 8-m trial when a question was asked had significantly longer walking durations (by 19s) and larger trunk roll angular displacements (by 5.5 degrees ) during trials, both with and without a question. For both stoppers and nonstoppers, duration was longer during the trial when a question was asked. CONCLUSION: A fixed and brief walking distance, coupled with a single sudden question, provided an effective method of identifying subjects who stop walking while talking. These subjects are those who have slower walking speeds and more unstable trunk control in the roll plane even under normal walking conditions. Our findings support the predictive capabilities of a brief SWWT test for the unstable and fall-prone elderly, as well as the usefulness of objective trunk sway measures to identify gait instabilities.