JAGS Abstracts: From the Journal of the American Geriatrics Society

CLINICAL INVESTIGATIONS

Effect of Influenza Vaccination of Nursing Home Staff on Mortality of Residents: A Cluster-Randomized Trial
Magali Lemaitre, MPH, Thierry Meret, MD, Monique Rothan-Tondeur, PhD, Joel Belmin, MD, Jean-Louis Lejonc, MD, Laurence Luquel, MD, François Piette, MD, Michel Salom, MD, Marc Verny, MD, PhD, Jean-Marie Vetel, MD, Pierre Veyssier, MD, and Fabrice Carrat, MD, PhD

OBJECTIVES: To evaluate the effect of staff influenza vaccination on all-cause mortality in nursing home residents.

DESIGN: Pair-matched cluster-randomized trial.

SETTING: Forty nursing homes matched for size, staff vaccination coverage during the previous season, and resident disability index.

PARTICIPANTS: All persons aged 60 and older residing in the nursing homes.

INTERVENTION: Influenza vaccine was administered to volunteer staff after a face-to-face interview. No intervention took place in control nursing homes.

MEASUREMENTS: The primary endpoint was total mortality rate in residents from 2 weeks before to 2 weeks after the influenza epidemic in the community. Secondary endpoints were rates of hospitalization and influenza-like illness (ILI) in residents and sick leave from work in staff.

RESULTS: Staff influenza vaccination rates were 69.9% in the vaccination arm versus 31.8% in the control arm. Primary unadjusted analysis did not show significantly lower mortality in residents in the vaccination arm (odds ratio=0.86, P=.08), although multivariate-adjusted analysis showed 20% lower mortality (P=.02), and a strong correlation was observed between staff vaccination coverage and all-cause mortality in residents (correlation coefficient=−0.42, P=.007). In the vaccination arm, significantly lower resident hospitalization rates were not observed, but ILI in residents was 31% lower (P=.007), and sick leave from work in staff was 42% lower (P=.03).

CONCLUSION: These results support influenza vaccination of staff caring for institutionalized elderly people. J Am Geriatr Soc Soc 2009;57(9):1580-1586. ____________________________________________________________________________________

BRIEF REPORTS

Pilot Testing of Intervention Protocols to Prevent Pneumonia in Nursing Home Residents
Vincent Quagliarello, MD, Manisha Juthani-Mehta, MD, Sandra Ginter, RN, Virginia Towle, M Phil, Heather Allore, PhD, and Mary Tinetti, MD

OBJECTIVES: To test intervention protocols for feasibility, staff adherence, and effectiveness in reducing pneumonia risk factors (impaired oral hygiene, swallowing difficulty) in nursing home residents.

DESIGN: Prospective study.

SETTING: Two nursing homes.

PARTICIPANTS: Fifty-two nursing home residents.

INTERVENTION: Thirty residents with impaired oral hygiene were randomly assigned to manual oral brushing plus 0.12% chlorhexidine oral rinse at different frequencies daily. Twenty-two residents with swallowing difficulty were randomly assigned to upright feeding positioning, teaching swallowing techniques, or manual oral brushing. All protocols were administered over 3 months.

MEASUREMENTS: Feasibility was assessed monthly and defined as high if the protocol took less than 10 minutes to administer. Adherence was assessed weekly and defined as high if full staff adherence was demonstrated in more than 75% of assessments. Effectiveness for improved oral hygiene (reduction in oral plaque score) and swallowing (reduction in cough during swallowing) was compared at baseline and 3 months.

RESULTS: Daily manual oral brushing plus 0.12% chlorhexidine rinse demonstrated high feasibility, high staff adherence, and effectiveness in improving oral hygiene (P<.001 vs baseline); this combination administered twice per day showed the highest plaque score reduction. Daily manual oral brushing and upright feeding positioning demonstrated high feasibility, high staff adherence, and effectiveness in improving swallowing.

CONCLUSION: Manual oral brushing, 0.12% chlorhexidine oral rinse, and upright feeding positioning demonstrated high feasibility, high staff adherence, and effectiveness in pneumonia risk factor reduction. A protocol combining these components warrants testing for its ability to reduce pneumonia in nursing home residents. J Am Geriatr Soc Soc 2009;57(7):1226-1231.
___________________________________________________________________________________________________________

BRIEF REPORTS Diagnosis and Management of Urinary Tract Infection in Hospitalized Older People
Henry J. Woodford, MBBS, and James George, MBBS

OBJECTIVES: To compare the diagnosis and management of urinary tract infection (UTI) in hospitalized older people with clinical criteria and therapeutic guidelines.

DESIGN: A retrospective case series of emergency hospital admissions collected over an 18-month period.

SETTING: An acute general hospital in northwest England.

PARTICIPANTS: Two hundred sixty-five patients aged 75 and older with a diagnosis of UTI at hospital discharge.

MEASUREMENTS: Data relating to age, sex, presenting complaint, admission and discharge destinations, background comorbidities and medications, investigations performed, treatment given, length of stay, and complications were obtained using chart review.

RESULTS: Of the 265 patients (mean age 85.4) the overdiagnosis of UTI was common, with 43.4% of patients not meeting criteria. Only 32.1% of patients overall had any urinary tract symptoms (48.7% in the UTI group). Of the non-UTI group, 12 (10.4%) had urinary tract symptoms with a negative urine culture, 43 (37.4%) had asymptomatic bacteriuria (ASB), and 60 (52.2%) had neither urinary tract symptoms nor bacteriuria. Treatment given varied greatly. The mortality rate was 6.0%, and the average length of stay was 29.9 days (median 17.0, range 1–192). Complications were frequent, including Clostridium difficile diarrhea (8%), falls (4%), methicillin-resistant Staphylococcus aureus infection (3%), and fracture (2%).

CONCLUSION: More-reliable criteria are needed to aid the diagnosis of UTI in hospitalized older people. Better adherence to clinical management guidelines may improve outcomes. J Am Geriatr Soc 2009;57(1):107-114.
____________________________________________________________________________________________________

BRIEF REPORTS

Environmental Risk Factors for Community-Acquired Pneumonia Hospitalization in Older Adults
Mark Loeb, MD, MSc, Binod Neupane, MSc, Stephen D. Walter, PhD, Rhona Hanning, PhD, Soo Chan Carusone, PhD, David Lewis, PhD, Paul Krueger, PhD, Andrew E. Simor, MD, Lindsay Nicolle, MD, and Thomas J. Marrie, MD

OBJECTIVES: To investigate the risk of hospitalization for pneumonia in older adults in relation to biophysical environmental factors.

DESIGN: Population-based case control study with collection of personal interview data.

SETTING: Hamilton, Ontario, and Edmonton, Alberta, Canada.

PARTICIPANTS: Seven hundred seventeen people aged 65 and older hospitalized for community-acquired pneumonia (CAP) from September 2002 to April 2005 and 867 controls aged 65 and older randomly selected from the same communities as the cases.

MEASUREMENTS: Odds ratios (ORs) for risk of pneumonia in relation to environmental and other variables.

RESULTS: Exposure to secondhand smoke in the previous month (OR=1.73, 95% confidence interval (CI)=1.04–2.90); poor nutritional score (OR=1.83, 95% CI=1.19–2.80); alcohol use per month (per gram; OR=1.69, 95% CI=1.08–2.61); history of regular exposure to gases, fumes, or chemicals at work (OR=3.69, 95% CI=2.37–5.75); history of regular exposure to fumes from solvents, paints, or gasoline at home (OR=3.31, 95% CI=1.59–6.87); and non-English language spoken at home (OR=5.31, 95% CI=2.60–10.87) were associated with a greater risk of pneumonia hospitalization in multivariable analysis. Age, congestive heart failure, chronic obstructive lung disease, dysphagia, renal disease, functional status, use of immunosuppressive disease medications, and lifetime history of smoking of more than 100 cigarettes were other variables associated with hospitalization for pneumonia.

CONCLUSION: In elderly people, present and past exposures in the physical environmental are associated with hospitalization for CAP. J Am Geriatr Soc 2009;57(6):1036-1040.