Sep-06
Occurrence and Treatment of Suspected Pneumonia in Long-Term Care Residents Dying with Advanced Dementia
Jen-Hau Chen, MD, MPH, Jennifer L. Lamberg, MD, Yen-Ching Chen, ScD, Dan K. Kiely, MPH, MA, John H. Page, MBBS, MSc, ScD, Carmel J. Person, MD, RN, and Susan L. Mitchell, MD, MPH
Objectives: To describe the occurrence and management of suspected pneumonia in end-stage dementia and to identify factors associated with aggressiveness of antibiotic treatment.
Design: Retrospective cohort study.
Setting: A 675-bed long-term-care facility in Boston, Massachusetts.
Participants: Two hundred forty subjects aged 65 and older who died with advanced dementia between January 2001 and December 2003. Subjects who had suspected pneumonia during the last 6 months of life were identified.
Measurements: Independent variables included subject characteristics and features of suspected pneumonia episodes. These variables were obtained from medical records. Antibiotic treatment for each episode was determined. Multivariate analysis was used to identify independent variables associated with aggressiveness of treatment.
Results: One hundred fifty-four (64%) subjects with advanced dementia experienced 229 suspected pneumonia episodes during the last 6 months of life. Within 30 days of death, 53% of subjects had suspected pneumonia. Antibiotic treatment for the 229 episodes was as follows: none, 9%; oral only, 37%; intramuscular, 25%; and intravenous, 29%. Factors independently associated with more-invasive therapy were lack of a do-not-hospitalize order (adjusted odds ratio (AOR)= 3.24, 95% confidence interval (CI)=2.02–5.22), aspiration (AOR=2.75, 95% CI=1.44– 5.26), primary language not English (AOR=2.21, 95% CI= 1.17–4.15), and unstable vital signs (AOR=2.02, 95% CI= 1.10–3.72).
Conclusion: Pneumonia is a common terminal event in advanced dementia for which many patients receive parenteral antibiotics. The aggressiveness of treatment is most strongly determined by advance care planning, the patient’s cultural background, and clinical features of the suspected pneumonia episode. J Am Geriatr Soc 2006;54(2):290-295.
___________________________________________________________________________________________________________________
A Systematic Review of the Efficacy and Safety of Atypical Antipsychotics in Patients with Psychological and Behavioral Symptoms of Dementia
Susan Carson, MPH, Marian S. McDonagh, PharmD, and Kim Peterson, MS
Although the Food and Drug Administration (FDA) has not approved atypical antipsychotics for use in patients with dementia, they are commonly prescribed in this population. Recent concerns about increased risk of cerebrovascular events and mortality have led to warnings. A systematic review was conducted to assess the benefits and harms of atypical antipsychotics when used in patients with behavioral and psychological symptoms of dementia. Electronic searches (through March 2005) of the Cochrane Library, Medline, Embase, and PsycINFO were supplemented with hand searches of reference lists, dossiers submitted by pharmaceutical companies, and a review of the FDA Website and industry-sponsored results database. Using predetermined criteria, each study was assessed for inclusion, and data about study design, population, interventions, and outcomes were abstracted. An overall quality rating (good, fair, or poor) was assigned based on internal validity.
The evidence for olanzapine and risperidone supports their effectiveness compared with placebo. Short-term adverse events were similar to placebo. Risperidone had no advantage over haloperidol on efficacy measures in the better-quality studies. Risperidone had an advantage over haloperidol on some measures of extrapyramidal symptoms. Evidence for the other atypical antipsychotics is too limited to assess efficacy and safety. Trials were short term and conducted in highly selected populations.
The potential for increased risk of cerebrovascular adverse events and mortality is a serious concern. To make judgments about when the benefits of atypical antipsychotics outweigh the potential harms, clinicians need more information. Additional data from existing trials and more-complete reporting of trial results could provide this information. J Am Geriatr Soc 2006; 54(2): 354-361.
______________________________________________________________________________________________________________________
Can High-Risk Older Drivers Be Identified Through Performance-Based Measures in a Department of Motor Vehicles Setting?
Karlene K. Ball, PhD, Daniel L. Roenker, PhD, Virginia G. Wadley, PhD, Jerri D. Edwards, PhD, David L. Roth, PhD, Gerald McGwin, Jr., PhD, Robert Raleigh, MD, John J. Joyce, JD, Gayla M. Cissell, MA, and Tina Dube, MS
Objectives: To evaluate the relationship between performance-based risk factors and subsequent at-fault motor vehicle collision (MVC) involvement in a cohort of older drivers.
Design: Prospective cohort study.
Setting: Motor Vehicle Administration (MVA) field sites in Maryland.
Participants: Of the 4,173 older drivers invited to participate in the study, 2,114 individuals aged 55 to 96 agreed to do so. These analyses focus on 1,910 individuals recruited through MVA field sites.
Measurements: Gross Impairment Screening Battery, which included Rapid Pace Walk, Head/Neck Rotation, Foot Tap, Arm Reach, Cued Recall, Symbol Scan, Visual Closure subtest of the Motor Free Visual Perception Test (MVPT), Delayed Recall, and Trail Making Test with an Abbreviated Part A and standard Part B; Useful Field of View (UFOV®) subtest 2; a Mobility Questionnaire; and MVC occurrence.
Results: In drivers aged 55 and older with intact vision (20/70 far visual acuity and 140° visual field), age, sex, history of falls, and poorer cognitive performance, as measured using Trails B, MVPT, and UFOV subtest 2, were predictive of future at-fault MVC involvement. After adjusting for annual mileage, participants aged 78 and older were 2.11 as more likely to be involved in an at-fault MVC, those who made four or more errors on the MVPT were 2.10 times as likely to crash, those who took 147 seconds or longer to complete Trails B were 2.01 times as likely to crash, and those who took 353 ms or longer on subtest 2 of the UFOV were 2.02 times as likely to incur an at-fault MVC. Older adults, men, and individuals with a history of falls were more likely to be involved in subsequent at-fault MVCs.
Conclusion: Performance-based cognitive measures are predictive of future at-fault MVCs in older adults. Cognitive performance, in particular, is a salient predictor of subsequent crash involvement in older adults. High-risk older drivers can be identified through brief, performance-based measures administered in a MVA setting. J Am Geriatr Soc 2006;54(1):77-84.
__________________________________________________________________________________________________________________________
Simvastatin Causes Changes in Affective Processes in Elderly Volunteers
Knashawn Morales, ScD, Marsha Wittink, MD, Catherine Datto, MD, Suzanne DiFilippo, RN, Mark Cary, PhD, Thomas TenHave, PhD, and Ira R. Katz, MD, PhD
Objectives: To test for simvastatin-induced changes in affect and affective processes in elderly volunteers.
Design: Randomized, clinical trial.
Setting: The Geriatric Behavioral Psychopharmacology Laboratory at the University of Pennsylvania.
Participants: Eighty older volunteers, average age 70, with high normal/mildly elevated serum cholesterol. Intervention: Simvastatin up to 20 mg/d or placebo for 15 weeks.
Measurements: Daily diary records of positive and negative affects and of events and biweekly measures of depressive symptoms. Affect ratings were obtained using the Lawton positive and negative affect scales; independent raters coded the valences of events.
Results: Thirty-one of 39 subjects assigned to placebo and 33 of 41 receiving simvastatin completed the study. During biweekly assessments, four subjects on simvastatin and one on placebo experienced depressive symptoms, as manifest by Center for Epidemiological Studies Depression scale scores greater than 16 (exact P=.36). Diary data demonstrated significant effects on affective processes. For positive affect, there was a significant medication-by-time interaction that reflected decreases in positive affect in subjects receiving simvastatin, greatest in those patients whose final total cholesterol levels were below 148 mg/dL. For negative affect, there were significant medication-by-event, and medication-by-event-by-time interactions, reflecting a time-limited increase in the apparent effect of negative events.
Conclusion: Simvastatin has statistically significant effects on affect and affective processes in elderly volunteers. The decrease in positive affect may be significant clinically and relevant to the quality of life of many patients. J Am Geriatr Soc 2006;54(1):70-76.
____________________________________________________________________________________________________________________________________
Therapeutic Exercise and Depressive Symptoms After Stroke
Sue-Min Lai, PhD, MS, MBA, Stephanie Studenski, MD, MPH, Lorie Richards, PhD, Subashan Perera, PhD, Dean Reker, PhD, Sally Rigler, MD, MPH, and Pamela W. Duncan, PhD, PT, FAPTA
Objectives: To examine the effect of exercise on depressive symptoms and the effect of baseline depressive symptoms on the benefits from exercise in stroke survivors who have completed acute rehabilitation.
Design: Planned secondary analysis of the data from a 9-month randomized, controlled trial.
Setting: Participant homes.
Participants: One hundred stroke survivors who had completed acute rehabilitation.
Intervention: A progressive, structured, 3-month physical exercise program.
Measurements: Demographics, stroke characteristics, impairments, functional limitations, the Geriatric Depression Scale, the Stroke Impact Scale, and the Medical Outcomes Study 36-Item Short Form.
Results: Baseline rates of depressive symptoms and other stroke sequelae were similar between the two arms. Ninety-three participants were assessed immediately after the intervention (3 months after enrollment), and 80 were assessed 9 months after enrollment. Six (14%) of the exercise group and 16 (35.6%) of the usual-care group had depressive symptoms at 3 months (P=.03). At 9 months, three (7.5%) of the exercisers had significant depressive symptoms compared with 10 (25%) who received usual care (P=.07). Participants with and without baseline depressive symptoms had equivalent treatment-related gains in impairments and functional limitations, but only participants with depressive symptoms had improved quality of life.
Conclusion: Exercise may help reduce poststroke depressive symptoms. Depressive symptoms do not limit gains in physical function due to exercise. Exercise may contribute to improved quality of life in those with poststroke depressive symptoms. J Am Geriatr Soc 2006;54(2):240-247.
_______________________________________________________________________________________________________________________________________
Two Outbreaks of Severe Respiratory Disease in Nursing Homes Associated with Rhinovirus
Lauri A. Hicks, DO, Colin W. Shepard, MD, Phyllis H. Britz, RN, Dean D. Erdman, DrPH, Marc Fischer, MD, Brendan L. Flannery, PhD, Angela J. Peck, MD, Xiaoyan Lu, MS, W. Lanier Thacker, MS, Robert F. Benson, MS, Maria L. Tondella, PhD, Mària E. Moll, MD, Cynthia G. Whitney, MD, MPH, Larry J. Anderson, MD, and Daniel R. Feikin, MD, MSPH
Objectives: To test a tool for screening the quality of nursing home (NH) pain medication prescribing.
Design: Validity and reliability of measurement tool developed for a pre/postintervention with untreated comparison group.
Setting: Six treatment NHs and six comparison NHs in rural and urban Colorado.
Participants: NH staff, physicians, and repeated 20% random sample of each home’s residents (N=2,031).
Intervention: Nurse and physician education; NH internal pain team to champion better pain management using a pain vital sign, consultations, and rounds. Measurements: An expert panel reviewed the Pain Medication Appropriateness Scale (PMAS) for content validity. Research assistants interviewed NH residents, assessed them for pain using standardized instruments, and reviewed their medical records for prescriptions and use of pain and adjuvant medication. Construct validity was assessed by comparing the PMAS of residents in pain with the PMAS of those not in pain and comparing scores in homes in which the intervention was more effective with those in which it was less effective, using the Fisher exact and Student t tests. Interrater and test-retest reliability were measured.
Results: The mean total PMAS was 64% of optimal. Fewer than half of residents with predictably recurrent pain were prescribed scheduled pain medication; 23% received at least one high-risk medication. PMAS scores were better for residents not in pain (68% vs 60%, P=.004) and in homes where nurses’ knowledge of pain assessment and management improved or stayed the same during the intervention (69% vs 61%, P=.03).
Conclusion: The PMAS is useful for assessing pain medication prescribing in NHs and elucidates why so many residents have poorly controlled pain. J Am Geriatr Soc 2006;54 (2): 231-239.
____________________________________________________________________________________________________________________________
Assessing the Appropriateness of Pain Medication Prescribing Practices in Nursing Homes
Evelyn Hutt, MD, Ginette A. Pepper, RN, PhD, FAAN, Carol Vojir, PhD, Regina Fink, RN, PhD, FAAN, AOCN, and Katherine R. Jones, RN, PhD, FAAN
Objectives: To test a tool for screening the quality of nursing home (NH) pain medication prescribing.
Design: Validity and reliability of measurement tool developed for a pre/postintervention with untreated comparison group.
Setting: Six treatment NHs and six comparison NHs in rural and urban Colorado.
Participants: NH staff, physicians, and repeated 20% random sample of each home’s residents (N=2,031).
Intervention: Nurse and physician education; NH internal pain team to champion better pain management using a pain vital sign, consultations, and rounds.
Measurements: An expert panel reviewed the Pain Medication Appropriateness Scale (PMAS) for content validity. Research assistants interviewed NH residents, assessed them for pain using standardized instruments, and reviewed their medical records for prescriptions and use of pain and adjuvant medication. Construct validity was assessed by comparing the PMAS of residents in pain with the PMAS of those not in pain and comparing scores in homes in which the intervention was more effective with those in which it was less effective, using the Fisher exact and Student t tests. Interrater and test-retest reliability were measured.
Results: The mean total PMAS was 64% of optimal. Fewer than half of residents with predictably recurrent pain were prescribed scheduled pain medication; 23% received at least one high-risk medication. PMAS scores were better for residents not in pain (68% vs 60%, P=.004) and in homes where nurses’ knowledge of pain assessment and management improved or stayed the same during the intervention (69% vs 61%, P=.03).
Conclusion: The PMAS is useful for assessing pain medication prescribing in NHs and elucidates why so many residents have poorly controlled pain. J Am Geriatr Soc 2006;54 (2): 231-239.
___________________________________________________________________________________________________________________
Oral Care Provided by Certified Nursing Assistants in Nursing Homes
Patricia Coleman, PhD, RN, APRN, BC, ANP, and Nancy M. Watson, PhD, RN
The purpose of this study was to describe the actual daily oral care provided by certified nursing assistants (CNAs) for dentate elderly nursing home (NH) residents who required assistance with oral care. The study was conducted in five nonrandomly selected NHs in upstate New York using real-time observations of CNAs providing morning care to residents, retrospective chart review, and CNA screening interviews. Oral care standards developed and validated by a panel of 10 experts (dentists, dental hygienists, registered nurses) to be appropriate for dentate NH residents were used to evaluate the oral care provided by 47 primary dayshift CNAs to a convenience sample of 67 residents. CNAs were blinded to the study’s specific focus on oral care. Adherence to individual standards was low, ranging from a high of 16% to a low of 0%. Teeth were brushed and mouths rinsed with water in 16% of resident observations. One resident had her tongue brushed.
Standards never met were brushing teeth at least 2 minutes, flossing, oral assessment, rinsing with mouthwash, and wearing clean gloves during oral care. Most residents (63%) who received oral care assistance were resistive to CNA approaches. For most observations, oral care supplies were not evident. Actual oral care provided to residents contrasts sharply with CNAs’ self-reported practices in the literature and suggests that NH residents who need assistance receive inadequate oral health care. J Am Geriatr Soc 2006;54(1):138-143.
