JAGS Abstracts - June 2006
Septic Arthritis in Patients Aged 80 and Older: A Comparison with Younger Adults
Florence Gavet, MD, Anne Tournadre, MD, Martin Soubrier, MD, Jean Michel Ristori, PhD, and Jean Jacques Dubost, MD
Objectives: To compare the frequency and characteristics of septic arthritis in patients younger than 80 and aged 80 and older.
Design: Retrospective.
Setting: Single hospital center.
Participants: Patients admitted between 1979 and 2002 for septic arthritis.
Measurements: Age, sex, time to diagnosis, predisposing factors, joint, temperature, white blood cell count, microorganism, and short-term outcome.
Results: Of 335 patients, 206 (61.4%) were aged 60 and older, and 42 (12.5%) were 80 and older. The latter had an average age of 84 (range 80–97) and were mainly women (72%). Eighteen of the 42 had at least one risk factor. The mean time to diagnosis was 21 days (range 1 day to 3 months). Twenty patients (47%) had knee involvement, six (14%) shoulder involvement, ten (23.8%) a prosthetic infection, and five (12%) polyarticular infection. Ten (23%) were afebrile. In half of the cases, there was no increase in white blood cell count. The microorganisms isolated were Staphylococcus aureus (n=16, 38%), coagulase negative staphylococci (n=8, 19%), streptococci (n=12, 28%), and gram-negative bacilli (n=6, 14%). The mortality rate increased with age: 0.7% of patients younger than 60, 4.8% of those aged 60 to 79, and 9.5% of those aged 80 and older.
Conclusion: Advanced age is a risk factor for septic arthritis and poor outcome. J Am Geriatr Soc 2005;53(7):1210-1213.
___________________________________________________________________________________________________________________
Atypical Antipsychotic Medications and Risk of Falls in Residents of Aged Care Facilities
Le T. T. Hien, BS, Robert G. Cumming, MB, BS, MPH, PhD, Ian D. Cameron, MB, BS, PhD, Jian S. Chen, MD, Stephen R. Lord, PhD, Lyn M. March, MB, BS, PhD, Jennifer Schwarz, RN, David G. Le Couteur, MB, BS, PhD, and Philip N. Sambrook, MD
Objectives: To determine whether use of atypical antipsychotics (olanzapine and risperidone) is associated with lower risk of falls than use of typical antipsychotics.
Design: Prospective cohort study with 1-month follow-up.
Setting: Residential aged care facilities in Sydney, Australia.
Participants: Two thousand five people aged 65 to 104 (mean age 86).
Measurements: Medication use at baseline was collected from medical records. Data on potential confounders were collected at interview and physical examination and from medical records. The outcome was accidental falls (one or more).
Results: One thousand one hundred seven subjects (55%) used at least one type of psychotropic medication, with 289 (14%) using an antipsychotic. There were 82 olanzapine users, 38 risperidone users, and 181 users of typical antipsychotics. Eleven percent of subjects (n=226) had at least one fall during follow-up. After adjusting for a comprehensive range of falls risk factors, hazard ratios (HRs) for falls were 1.35 (95% confidence interval (CI)=0.87–2.09) for typical antipsychotics, 1.32 (95% CI=0.57–3.06) for risperidone, and 1.74 (95% CI=1.04–2.90) for olanzapine. Antidepressants were also associated with falls (adjusted HR=1.45, 95% CI=1.09–1.93).
Conclusion: Despite fewer extrapyramidal side effects, atypical antipsychotic medications are not associated with fewer falls than the older, more-established antipsychotics. J Am Geriatr Soc 2005;53(8):1290-1295.
_________________________________________________________________________________________________________________
Obesity in Nursing Homes: An Escalating Problem
Kate L. Lapane, PhD, and Linda Resnik, PhD, PT, OCS
Objectives: To estimate trends in the prevalence of obesity in nursing homes, to characterize the obese nursing home population, and to evaluate the extent to which estimates of the prevalence of obesity varied by facility and geographic location.
Design: Cross-sectional.
Setting: One thousand six hundred twenty-five nursing homes in Kansas, Maine, Mississippi, New York, and South Dakota from 1992 to 2002; 16,110 nursing homes in the United States in 2002.
Participants: Newly admitted residents between 1992 and 2002 (n=847,601) in selected states and 1,448,046 residents newly admitted to a U.S. nursing home in 2002 with height and weight documented on the Minimum Data Set (MDS) assessment.
Measurements: Data were from the Systematic Assessment of Geriatric Drug Use via Epidemiology database. Residents were classified as having a body mass index of less than 18.5 kg/m2, 18.5 to 24.9 kg/m2, 25.0 to 29.9 kg/m2, 30 to 34.9 kg/m2, or 35.0 kg/m2 or greater.
Results: Adjusting for sociodemographics, in Kansas, Maine, Mississippi, New York, and South Dakota, fewer than 15% of newly admitted residents were obese in 1992, rising to more than 25% in 2002. In U.S. nursing homes, the distribution of obese residents is not shared equally across facilities. Nearly 30% of residents with a BMI of 35 kg/m2 or greater are younger than 65, and a disproportionate percentage of obese residents are non-Hispanic black. Residents identified as obese had a higher likelihood of comorbid conditions (e.g., diabetes mellitus, arthritis, hypertension, depression, and allergies).
Conclusion: Increasing prevalence of obesity in nursing homes and substantial variation of obesity prevalence within facilities raise concerns about nursing home preparedness and access. J Am Geriatr Soc 2005;53(8):1386-1391.
__________________________________________________________________________________________________________________
Effect of Individualized Social Activity on Sleep in Nursing Home Residents with Dementia
Kathy Culpepper Richards, PhD, RN, Cornelia Beck, PhD, RN, Patricia S. O’Sullivan, Ed, and Valorie M. Shue, BA
Objectives: To test the efficacy of an individualized social activity intervention (ISAI) on decreasing daytime sleep, improving nighttime sleep, and lowering the day/night sleep ratio and to determine its cost.
Design: Pretest/posttest randomized with an experimental and control group.
Setting: Seven nursing homes. Participants: One hundred forty-seven residents with dementia.
Intervention: One to 2 hours of individualized social activities for 21 consecutive days.
Measurements: Twenty-four-hour sleep/wake patterns using an Actigraph.
Results: The ISAI group had significantly less daytime sleep (P=.001) and a lower day/night sleep ratio (P=.03) than the control group, after adjusting for baseline values. Because 40% of the sample slept 7 or more hours at night, a secondary analysis was conducted. When only those residents with a sleep efficiency of less than 50% (n=50) were included, the ISAI group (n=20) had less daytime sleep (P=.005), a lower day/night sleep ratio (P=.02), fell asleep faster (P=.03), and were awake less at night (P=.04) than the control group (n=30), after adjusting for baseline values. The weekly cost of the ISAI was roughly $70 per participant. Initial training and supply costs were $1,944.
Conclusion: The ISAI provides an alternative to medications, without side effects. J Am Geriatr Soc 2005;53(9):1510-1517.
___________________________________________________________________________________________________________________________
Underutilization of Environmental Adaptations for Bathing in Community-Living Older Persons
Aanand D. Naik, MD, and Thomas M. Gill, MD
Objectives: To determine the prevalence and utilization of environmental adaptations (home modifications and assistive devices) for bathing in community-living older persons with and without bathing disability.
Design: Cross-sectional study.
Setting: General community of greater New Haven, Connecticut.
Participants: Five hundred sixty-six community-living persons aged 73 and older.
Measurements: Trained research nurses performed a comprehensive assessment of bathing function, including an in-home evaluation of the bathing environment and self-reported utilization of environmental adaptations for bathing.
Results: The prevalence of most environmental adaptations for bathing was less than 50% and was only modestly greater in participants with bathing disability (range 6–54%) than in those without bathing disability (2–44%), although important differences in prevalence and utilization were observed according to the type of bathing disability. Participants who had difficulty (without dependence) with bathing were significantly less likely to have most of the environmental adaptations than participants who needed personal assistance (dependence) with bathing. These differences persisted in analyses that specifically evaluated the utilization of environmental adaptations for bathing transfers according to the type of disability with bathing transfers (59% of those with difficulty vs 88% of those with dependence, P<.001).
Conclusion: Potentially valuable environmental adaptations are absent from the homes of many older persons with bathing disability and may be particularly underused by older persons reporting difficulty with bathing. To ameliorate or delay the progression of disability in community-living older persons, assessment and remediation strategies should be better targeted to bathing function across the continuum of disability. J Am Geriatr Soc 2005;53(9):1497-1503.
_______________________________________________________________________________________________________________________________
Unnecessary Drug Use in Frail Older People at Hospital Discharge
Emily R. Hajjar, PharmD, Joseph T. Hanlon, PharmD, MS, Richard J. Sloane, MPH, Catherine I. Lindblad, PharmD, Carl F. Pieper, DrPH, Christine M. Ruby, PharmD, Laurence C. Branch, PhD, and Kenneth E. Schmader, MD
Objectives: To determine the prevalence and predictors of unnecessary drug use at hospital discharge in frail elderly patients.
Design: Cross-sectional.
Setting: Eleven Veterans Affairs Medical Centers.
Participants: Three hundred eighty-four frail older patients from the Geriatric Evaluation and Management Drug Study.
Measurements: Assessment of unnecessary drug use was determined by the consensus of a clinical pharmacist and physician pair applying the Medication Appropriateness Index to each regularly scheduled medication at hospital discharge. Those drugs that received an inappropriate rating for indication, efficacy, or therapeutic duplication were defined as unnecessary.
Results: Forty-four percent of patients had at least one unnecessary drug, with the most common reason being lack of indication. The most commonly prescribed unnecessary drug classes were gastrointestinal, central nervous system, and therapeutic nutrients/minerals. Factors associated (P<.05) with unnecessary drug use included hypertension (adjusted odds ratio (AOR)=0.61, 95% confidence interval (CI)= 0.38–0.96), multiple prescribers (AOR=3.35, 95% CI=1.16–9.68), and nine or more medications (AOR=2.24, 95% CI=1.25–3.99).
Conclusion: A high prevalence of unnecessary drug use at discharge was found in frail hospitalized elderly patients. Additional studies are needed to identify predictors and prevalence of unnecessary drug use in nonveteran populations so that interventions can be designed to reduce the problem. J Am Geriatr Soc 2005;53(9): 1518-1523.
