Influenza vaccine and pneumonia mortality in a nursing home population

The effectiveness of immunization against influenza in elderly persons is uncertain. A retrospective cohort study in a New York City nursing home examined the occurrence of pneumonia and its related mortality over three consecutive influenza seasons (Nov 1 through April 30, 1979 to 1980, 1980 to 1981, and 1981 to 1982). Nearly one half of approximately 450 residents (mean age, 84 years) accepted immunization each year. The vaccinated and unvaccinated groups were similar. The attack rate of pneumonia did not differ significantly between the vaccinated and unvaccinated groups in any of the three influenza seasons. When influenza was occurring in the community (1979 to 1980 and 1980 to 1981), however, the risk of death from pneumonia in the unvaccinated group was three-fold higher than in the vaccinated group (60% vs 18% and 73% vs 25%, respectively). In a year when influenza was specifically sought and not found in the facility (1981 to 1982), however, vaccination did not affect pneumonia-related mortality. This study also suggests that estimates of mortality due to pneumonia should include deaths that occur up to 60 days after onset of pneumonia; shorter follow-up may overestimate the protective effect of vaccination.     

Decisional control in moving to a nursing home: postadmission adjustment and well-being.

Five hundred and two skilled nursing facility residents were measured with a multidimensional assessment instrument within 4 weeks of admission, and then at 3 and 12 months following baseline, to determine the impact of deciding and wanting to make the move on well-being and adjustment. Dependent variables included measures of physical, social, and psychological functioning, social interaction, activity, satisfaction with services, and discharge. Regression analyses suggest an interactive effect on ADL change at 3 months.     

Urinary tract infections. How to manage nursing home patients with or without chronic catheterization

Urinary tract infections (UTIs)--including cystitis, pyelonephritis, and catheter-associated infections--are among the most common nursing home-acquired infections. Asymptomatic bacteriuria can be identified in 20 to 50% of nursing home residents who do not have bladder catheters and in 100% of those who do. Diagnostic tests for nursing home patients with suspected UTI include urinalysis, urine culture, and sensitivity testing. Treatment of cystitis can usually be managed in the nursing home with oral antibiotics. Initial therapy with a parenteral agent is often recommended in nursing home-acquired pyelonephritis.     

Coping effectiveness in nursing home residents. The role of control

The purpose of this study was to investigate the role of perceived control in the selection and effectiveness of coping strategies used by nursing home residents. A path analysis of a model of coping effectiveness was conducted using a cluster sample of 100 nursing home residents. Respondents were assisted in completing the Importance, Locus, and Range of Activities Checklist, the Jalowiec Coping Scale, two self-anchoring ladders measuring coping effectiveness, and an item measuring perceived health. Mental status was measured with the Pfeiffer Short Portable Mental Status Questionnaire. Results demonstrated that mental status and functional ability were positively related to perceived control (p < .01). Perceived health and the use of secondary control (e.g., prayer, getting help from family, and depending on others) were the only two variables positively influencing coping effectiveness (p < .01 and p < .05, respectively). Longitudinal studies are recommended to investigate these relationships as they evolve.     

Antivirals and the control of influenza outbreaks.

During annual influenza epidemics, outbreaks of influenza in closed institutions are common. Among healthy children or young adults, such outbreaks are uncommonly associated with serious morbidity or mortality; however, in hospitals and nursing homes, attack rates as high as 60% and case-fatality rates as high as 50% have been reported. Annual influenza vaccination of both patients or residents and hospital and nursing home staff has had a substantial impact on mortality and has reduced the number of outbreaks. Nonpharmacologic interventions (e.g., handwashing and contact isolation of case patients) may reduce the spread of influenza, although evidence for their efficacy is lacking. Nonetheless, long-term care facilities for the elderly population with high vaccination rates and better-than-average infection-control programs have a 25%-50% chance of experiencing an influenza outbreak each year, with an expected resident attack rate of 35%-40%. Thus, antiviral drugs have been increasingly used to mitigate the impact of influenza outbreaks. There are 2 classes of antiviral drugs that are active against influenza: adamantanes and neuraminidase inhibitors. Drugs of the 2 classes appear to be equally effective for the treatment and prophylaxis of susceptible influenza A virus strains. However, adamantanes are not active against influenza B virus, and an increasing proportion of influenza A isolates are resistant to adamantanes. Adamantanes are associated with higher rates of adverse events than are neuraminidase inhibitors. There is substantial evidence that antiviral prophylaxis is effective in terminating outbreaks of seasonal influenza in closed institutions. If stockpiles are adequate, antiviral drugs are likely to be even more important in mitigating the impact of influenza transmission in health care institutions during the next influenza pandemic.     

How to prevent low back pain

This chapter summarizes the European Guidelines for Prevention in Low Back Pain, which consider the evidence in respect of the general population, workers and children. There is limited scope for preventing the incidence (first-time onset) of back pain and, overall, there is limited robust evidence for numerous aspects of prevention in back pain. Nevertheless, there is evidence suggesting that prevention of various consequences of back pain is feasible. However, for those interventions where there is acceptable evidence, the effect sizes are rather modest. The most promising approaches seem to involve physical activity/exercise and appropriate (biopsychosocial) education, at least for adults. Owing to its multidimensional nature, no single intervention is likely to be effective at preventing the overall problem of back pain, although there is likely to be benefit from getting all the players onside. However, innovative studies are required to better understand the mechanisms and delivery of prevention in low back pain.     

How to prevent steroid induced osteoporosis

The first choice for prevention of corticosteroid osteoporosis is a potent oral bisphosphonate-for example, alendronate or risedronate. Intravenous bisphosphonates should be considered for patients intolerant of the oral route. For patients receiving chronic low dose corticosteroids treatment with calcium and vitamin D may prevent further bone loss. Use of parathyroid hormone is promising.     

Pain in the nursing home.

The treatment of pain in the nursing home setting continues to present several unique and challenging problems. Increasingly, studies are focusing on the large number of elderly with important pain problems in long-term care. The inclusion of pain as an area of clinical focus in the Minimum Data Set has fueled interest in this problem and will provide solid data for future study. Researchers are attempting to establish reliable and valid data using standardized assessment tools previously validated in younger adults and are attempting use of traditional and cutting-edge assessment tools in cognitively impaired patients. Assessment is being linked to innovative interventions in noncommunicative, cognitively impaired residents using primary care nurses who best know these patients to decipher "normal" from "abnormal" behavior. The application of available pharmacologic interventions are more challenging because of the higher incidence of side effects in the elderly; part of this problem is the result of the decreased hepatic metabolism and renal clearance present in older patients. The nursing home environment has limited resources that can create logistical concerns in terms of diagnosis and treatment but also can positively limit overly invasive modalities. This article explores these issues and offers suggestions for the appropriate assessment and management of pain in long-term care residents.     

Home-and community-based alternatives to nursing homes: services and costs to maintain nursing home eligible individuals at home

This study analyzes home- and community-based services (HCBS) use patterns and determines the costs of purchasing in-home services comparable to those offered by SCAN(R), a Social HMO. METHODS. Administrative data on 8,229 nursing home certifiable members were used to profile use patterns; a telephone survey gathered data on the market value of these services. RESULTS. Frail Social HMO members used a variety of HCBS to remain independent at home. These individuals would spend an average of $4,900 out of pocket per year to purchase equivalent HCBS, if they were not enrolled in the Social HMO. DISCUSSION. Findings suggest that the costs of maintaining a Social HMO member at home are modest and affordable, yet offer a substantial benefit, particularly to low- and moderate-income older people. With the aging of the population, an integrated medical and social program, such as the Social HMO, offers a viable policy solution.     

Depression in nursing home residents.

Although their extent remains unclear, major and minor depressions are widespread in the nursing home population. This statement appears intuitively to be correct when consideration is given to the inactivity, decline in functional competence, loss of personal autonomy, and unavoidable confrontation with the process of death and dying that are associated with nursing home placement. In addition, some nursing home residents have had previous episodes of depression or are admitted to the facility already dysthymic or with other chronic forms of the illness. Such circumstances provide a favorable culture for the development and persistence of depressive illness. When the high frequency of other psychiatric disorders among nursing home residents is factored in, it is not surprising that long-term health care facilities have come to be regarded as de facto psychiatric hospitals. Nursing homes largely lack the treatment resources of psychiatric hospitals, however. Nursing home physicians are often unprepared to make psychiatric diagnoses, and a perfunctory annual psychiatric evaluation is insufficient to manage the complex depression syndromes of nursing home residents. Because nursing home psychiatrists typically work on a consultation basis, recommendations are not necessarily acted upon by the primary physicians. The consequences of undiagnosed and untreated depression are substantial. From the psychiatric perspective, the possibility that depression increases the risk for eventual development of permanent dementia highlights the importance of early identification for cases of reversible dementia. From the rehabilitation point of view, persistent depression among individuals with physical dependency following a catastrophic illness is associated with failure to improve in physical functioning. Depression can probably be linked to increased medical morbidity in nursing home residents, a relationship that also has been suggested for elderly medical inpatients. If so, the use of nursing time and other health-care facility services would be greater for depressed than nondepressed residents, and financial costs would be higher as well. Finally, recent data point to increased mortality in nursing home residents with major depressive disorder. It is apparent that depression in long-term care facilities is a condition with doubtful prognosis and negative medical, social, and financial consequences. The highest costs of all may be paid by nursing home residents who experience the unrelieved suffering of depressive illness. Only epidemiologic research using standard diagnostic criteria and direct resident assessment will adequately establish the magnitude of the need for intervention among depressed residents in long-term care.(ABSTRACT TRUNCATED AT 400 WORDS)     

Infections in the nursing home.

Infections are a common cause of morbidity and mortality in nursing home patients. A variety of factors predispose these patients to infections. Infections commonly encountered among these patients include pneumonia, urinary tract infections, tuberculosis, and gastrointestinal and skin infections. Preventive measures and infection control techniques offer protection to both patients and employees.