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May-08
From the Journal of the American Geriatrics Society
Physician Communication with Family Caregivers of Long-Term Care Residents at the End of Life
Holly Biola, MD, MPH, Philip D. Sloane, MD, MPH, Christianna S. Williams, PhD, Timothy P. Daaleman, DO, MPH, Sharon W. Williams, PhD, and Sheryl Zimmerman, PhD
OBJECTIVES: To assess family perceptions of communication between physicians and family caregivers of individuals who spent their last month of life in long-term care (LTC) and to identify associations between characteristics of the family caregiver, LTC resident, facility, and physician care with these perceptions.
DESIGN: Retrospective study of family caregivers of persons who died in LTC.
SETTING: Thirty-one nursing homes (NHs) and 94 residential care/assisted living (RC/AL) facilities.
PARTICIPANTS: One family caregiver for each of 440 LTC residents who died (response rate 66.0%) was interviewed 6 weeks to 6 months after the death.
MEASUREMENTS: Demographic and facility characteristics and seven items rating the perception of family caregivers regarding physician–family caregiver communication at the end of life, aggregated into a summary scale, Family Perception of Physician-Family caregiver Communication (FPPFC) (Cronbach alpha=0.96).
RESULTS: Almost half of respondents disagreed that they were kept informed (39.9%), received information about what to expect (49.8%), or understood the doctor (43.1%); the mean FPPFC score (1.73 on a scale from 0 to 3) was slightly above neutral. Linear mixed models showed that family caregivers reporting better FPPFC scores were more likely to have met the physician face to face and to have understood that death was imminent. Daughters and daughters-in-law tended to report poorer communication than other relatives, as did family caregivers of persons who died in NHs than of those who died in RC/AL facilities.
CONCLUSION: Efforts to improve physician communication with families of LTC residents may be promoted using face-to-face meetings between the physician and family caregivers, explanation of the patient's prognosis, and timely conveyance of information about health status changes, especially when a patient is actively dying. J Am Geriatr Soc 2007;55(6):846-856.
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Emergence of Rimantadine-Resistant Virus Within 6 Days of Starting Rimantadine Prophylaxis with Oseltamivir Treatment of Symptomatic Cases
Paul J. Drinka, MD, CMD, and Tom Haupt, MS
OBJECTIVES: To report on the detection of rimantadine resistance within 6 days of starting rimantadine prophylaxis.
DESIGN: Observational prospective study.
SETTING: Fifty-bed nursing unit during the 2004/05 influenza season.
PARTICIPANTS: All residents.
INTERVENTION: Clinical monitoring for new onset of respiratory illness followed by collection of nasopharyngeal swabs for Directigen AB testing and influenza culture. After outbreak identification, rimantadine was administered as prophylaxis, whereas oseltamivir was used to treat symptomatic cases. Laboratory monitoring for the emergence of rimantadine resistance was reinitiated on the fifth day of rimantadine prophylaxis.
MEASUREMENTS: Tabulation of respiratory illnesses, rapid tests and cultures yielding influenza A, and rimantadine sensitivity determination in five index isolates.
RESULTS: A total of 15 symptomatic cases were identified over 8 days. Amantadine sensitivity was determined in five cases. Three initial cases were sensitive to rimantadine, whereas two cases identified after 6 days of rimantadine prophylaxis were resistant to rimantadine.
CONCLUSION: The Centers for Disease Control and Prevention reported that 91% of isolates collected early the following season (2005/06) were resistant to rimantadine. Rimantadine treatment is no longer recommended. This experience anticipated the new recommendations. If reemergence of sensitivity follows discontinuation of rimantadine use, using rimantadine as prophylaxis and oseltamivir for treatment of symptomatic cases might be efficacious and economical on a national scale. J Am Geriatr Soc 2007;55(6):923-926.
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BRIEF REPORTS A Higher Dose of Vitamin D Reduces the Risk of Falls in Nursing Home Residents: A Randomized, Multiple-Dose Study
Kerry E. Broe, MPH, Tai C. Chen, PhD, Janice Weinberg, ScD, Heike A. Bischoff-Ferrari, MD, MPH, Michael F. Holick, and Douglas P. Kiel, MD, MPH
OBJECTIVES: To determine the effect of four vitamin D supplement doses on falls risk in elderly nursing home residents.
DESIGN: Secondary data analysis of a previously conducted randomized clinical trial.
SETTING: Seven hundred twenty-five-bed long-term care facility.
PARTICIPANTS: One hundred twenty-four nursing home residents (average age 89).
INTERVENTION: Participants were randomly assigned to receive one of four vitamin D supplement doses (200 IU, 400 IU, 600 IU, or 800 IU) or placebo daily for 5 months.
MEASUREMENTS: Number of fallers and number of falls assessed using facility incident tracking database.
RESULTS: Over the 5-month study period, the proportion of participants with falls was 44% in the placebo group (11/25), 58% (15/26) in the 200 IU group, 60% (15/25) in the 400 IU group, 60% (15/25) in the 600 IU group, and 20% (5/23) in the 800 IU group. Participants in the 800 IU group had a 72% lower adjusted-incidence rate ratio of falls than those taking placebo over the 5 months (rate ratio=0.28; 95% confidence interval=0.11–0.75). No significant differences were observed for the adjusted fall rates compared to placebo in any of the other supplement groups.
CONCLUSION: Nursing home residents in the highest vitamin D group (800 IU) had a lower number of fallers and a lower incidence rate of falls over 5 months than those taking lower doses. Adequate vitamin D supplementation in elderly nursing home residents could reduce the number of falls experienced by the high falls risk group. J Am Geriatr Soc 2007;55(2):234-239.
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The Relationship of Indwelling Urinary Catheters to Death, Length of Hospital Stay, Functional Decline, and Nursing Home Admission in Hospitalized Older Medical Patients
Jayna M. Holroyd-Leduc, MD, Saunak Sen, PhD, Dan Bertenthal, MS, Laura P. Sands, PhD, Robert M. Palmer, MD, MPH, Denise M. Kresevic, PhD, Kenneth E. Covinsky, MD, MPH, and C. Seth Landefeld, MD
OBJECTIVES: To determine the association between indwelling urinary catheterization without a specific medical indication and adverse outcomes.
DESIGN: Prospective cohort.
SETTING: General medical inpatient services at a teaching hospital.
PARTICIPANTS: Five hundred thirty-five patients aged 70 and older admitted without a specific medical indication for urinary catheterization.
INTERVENTION: Indwelling urinary catheterization within 48 hours of admission.
MEASUREMENTS: Death, length of hospital stay, decline in ability to perform activities of daily living (ADLs), and new admission to a nursing home.
RESULTS: Indwelling urinary catheters were placed in 76 of the 535 (14%) patients without a specific medical indication. Catheterized patients were more likely to die in the hospital (6.6% vs 1.5% of those not catheterized, P=.006) and within 90 days of hospital discharge (25% vs 10.5%, P<.001); the greater risk of death with catheterization persisted in a propensity-matched analysis (hazard ratio (HR)=2.42, 95% confidence interval (CI)=1.04–5.65). Catheterized patients also had longer lengths of hospital stay (median, 6 days vs 4 days; P=.001); this association persisted in a propensity-matched analysis (HR=1.46, 95% CI=1.03–2.08). Catheterization was not associated (P>.05) with decline in ADL function or with admission to a nursing home.
CONCLUSION: In this cohort of older patients, urinary catheterization without a specific medical indication was associated with greater risk of death and longer hospital stay. J Am Geriatr Soc 2007;55(2):227-233.
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Age-Related Macular Degeneration: A Practical Approach to a Challenging Disease
Dan H. Bourla, MD and Tara A. Young, MD
Age-related macular degeneration (AMD) is the leading cause of blindness in older North Americans. The clinical spectrum, risk factors, pathophysiology, and potential therapeutic options for AMD warrant a careful review. Despite the growth in treatment options for this disease, there is no current curative therapy. Of critical importance is attention to modifiable risk factors—improvements in cardiovascular status, including smoking cessation, and routine ophthalmic monitoring for opportunities to provide early intervention. In addition, a low-vision assessment to investigate the potential use of visual assistive devices may be beneficial to any patient who has experienced a decrease in vision. Finally, education regarding the clinical course of age-related macular degeneration and accurate information with respect to the known benefits of available treatments will impart a better understanding of this disease to patients. J Am Geriatr Soc 2006;54(7):1130-1135.
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CLINICAL INVESTIGATIONS Exercise Program for Nursing Home Residents with Alzheimer's Disease: A 1-Year Randomized, Controlled Trial
Yves Rolland, MD, PhD, Fabien Pillard, MD, Adrian Klapouszczak, MD, Emma Reynish, MD, David Thomas, MD, Sandrine Andrieu, MD, PhD, Daniel Rivière, MD, and Bruno Vellas, MD, PhD
OBJECTIVES: To investigate the effectiveness of an exercise program in improving ability to perform activities of daily living (ADLs), physical performance, and nutritional status and decreasing behavioral disturbance and depression in patients with Alzheimer's disease (AD).
DESIGN: Randomized, controlled trial.
SETTING: Five nursing homes.
PARTICIPANTS: One hundred thirty-four ambulatory patients with mild to severe AD.
INTERVENTION: Collective exercise program (1 hour, twice weekly of walk, strength, balance, and flexibility training) or routine medical care for 12 months.
MEASUREMENTS: ADLs were assessed using the Katz Index of ADLs. Physical performance was evaluated using 6-meter walking speed, the get-up-and-go test, and the one-leg-balance test. Behavioral disturbance, depression, and nutritional status were evaluated using the Neuropsychiatric Inventory, the Montgomery and Asberg Depression Rating Scale, and the Mini-Nutritional Assessment. For each outcome measure, the mean change from baseline to 12 months was calculated using intention-to-treat analysis.
RESULTS: ADL mean change from baseline score for exercise program patients showed a slower decline than in patients receiving routine medical care (12-month mean treatment differences: ADL=0.39, P=.02). A significant difference between the groups in favor of the exercise program was observed for 6-meter walking speed at 12 months. No effect was observed for behavioral disturbance, depression, or nutritional assessment scores. In the intervention group, adherence to the program sessions in exploratory analysis predicted change in ability to perform ADLs. No adverse effects of exercise occurred.
CONCLUSION: A simple exercise program, 1 hour twice a week, led to significantly slower decline in ADL score in patients with AD living in a nursing home than routine medical care. J Am Geriatr Soc 2007;55(2):158-165.