Common Problems in Medical Offices

Advances in office practices for the care of elderly patients have focused on preventing osteoporosis, fractures, and coronary artery disease and on the risks for developing Alzheimer disease.

Risks for Hip Fracture Were Identified

Cummings SR, Nevitt MC, Browner WS, Stone K, Fox KM, Ensrud KE, et al. Risk factors for hip fracture in white women. Study of Osteoporotic Fractures Research Group. N Engl J Med. 1996; 332:767-73.

One in every six white women will sustain a hip fracture in her lifetime [1]. Hip fractures are also strongly associated with subsequent death. A major clinical question is whether preventive measures can reduce the risk for hip fracture.

This cohort study included 9516 white women who were 65 years of age or older and had not previously had a hip fracture. Participants were followed four times a year for a mean of 4.1 years to determine the frequency of hip fractures. Baseline data included bone densities and the most recently recognized risk factors for hip fracture.

During the study, 192 women sustained a hip fracture for the first time. Important risk factors were current use of anticonvulsant drugs (relative risk, 2.8 [95% CI, 1.2 to 6.3]), inability to rise from a chair (relative risk, 2.1 [CI, 1.3 to 3.2]), history of maternal hip fracture (relative risk, 2.0 [CI, 1.4 to 2.9]), previous hyperthyroidism (relative risk, 1.8 [CI, 1.2 to 2.6]), resting pulse rate of 80 beats/min or greater (relative risk, 1.8 [CI, 1.3 to 2.5]), decrease in weight since 25 years of age (relative risk, 1.7 [CI, 1.4 to 2.0]), and decreased calcaneal bone density (relative risk, 1.6 [CI, 1.3 to 1.9]). Additional, lesser risks were age, tall height, self-rated poor health, use of benzodiazepines, caffeine intake, decreased ability to exercise, weakness of the lower body, and impaired vision. The incidence of fracture ranged from 1.1 per 1000 woman-years in women with two or fewer risk factors and normal bone density to 27 per 1000 woman-years in women with five or more risk factors (Figure 1).

View larger version (49K): [in this window] [in a new window]   Figure 1. Annual risk for hip fracture according to the number of risk factors and age-specific calcaneal bone density. The risk factors are age 80 years or older; maternal history of hip fracture; any fracture (except hip fracture) since age 50 years; fair, poor, or very poor health; previous hyperthyroidism; anticonvulsant therapy; current therapy with long-acting benzodiazepine; current weight less than weight at age 25 years; height at the age of 25 years of at least 168 cm; caffeine intake greater than the equivalent of two cups of coffee per day; on feet 4 or fewer hours per day; no walking for exercise; inability to rise from chair without using arms; lowest quartile of depth perception (SD >2.44); lowest quartile of contrast sensitivity ( 0.70 unit); and pulse rate greater than 80 beats/min. Reproduced with permission from Cummings SR, et al. N Engl J Med. 1995;332:767-73.

Women with multiple risk factors and low bone density have an especially high risk for hip fracture, but many of the important risk factors in women with and without osteoporosis can be treated and alleviated or improved. Older women should be encouraged to maintain a consistent body weight, exercise, avoid polypharmacy, decrease coffee intake, and obtain treatment for impaired vision.

Alendronate Increased Bone Mass

Chesnut CH 3d, McClung MR, Ensrud KE, Bell NH, Genant K, Harris ST, et al. Alendronate treatment of the postmenopausal osteoporotic woman: effect of multiple dosages on bone mass and bone remodeling. Am J Med. 1995; 99:144-52.

The bisphosphonate drugs have received much attention because of their ability to inhibit bone resorption. The oral aminobisphosphonate alendronate sodium has recently received attention because it is 100 to 500 times more potent than etidronate in inhibiting resorption. An early study [2] showed that alendronate increased spinal bone mass after 6 months of treatment. Chesnut and colleagues sought to determine the therapeutic efficacy of several different doses of alendronate during a 2-year period.

This multicenter, randomized, double-blind, placebo-controlled trial studied 188 postmenopausal women who were 42 to 75 years of age and had low bone density. Patients were assigned to receive regimens of alendronate that ranged from 5 mg/d to 40 mg/d. Outcome measures were markers of bone resorption, bone formation (measured by urinary deoxypyridinoline and serum osteocalcin levels), and bone mass (measured by dual-energy x-ray absorptiometry).

Alendronate administration significantly reduced markers of bone reabsorption and increased bone mass in the lumbar spine, hip, and total body. In the patients receiving 10 mg of alendronate, the mean urinary deoxypyridinoline-to-creatinine ratio had decreased by 47% at 3 months, and mean serum osteocalcin levels had decreased by 53% at 6 months (Figure 2). Bone density progressively increased during the 2-year study.

View larger version (23K): [in this window] [in a new window]   Figure 2. Mean (±SE) changes in bone mineral density of the spine in postmenopausal women, as measured by dual-energy x-ray absorptiometry. open circle = persons receiving placebo; = persons receiving 5 mg of alendronate; = persons receiving 10 mg of alendronate; \#9679; = persons receiving 20 mg of alendronate plus placebo; \#9632; = persons receiving 40 mg of alendronate plus placebo; = persons receiving 40 and 2.5 mg of alendronate. *P < 0.05 compared with baseline; **P < 0.01 compared with baseline; P < 0.001 for patients receiving alendronate compared with those receiving placebo. Reproduced with permission from Chesnut CH, et al. Am J Med. 1995;99:144-52.

Alendronate reduces markers of bone remodeling and significantly increases bone density in the spine and hip at doses of 5 mg/d and 10 mg/d. A drug that increases bone density by 10% will probably decrease the rate of fracture by 50%, and such positive outcomes will probably be seen in the next 5 to 10 years. Alendronate appears to be an effective therapy for postmenopausal osteoporosis, but it does have some drawbacks. First, it is expensive. Second, the patient must not ingest food within 30 minutes to 1 hour of taking alendronate. Third, a frequent side effect is upper-gastrointestinal upset, including nausea; treatment of this effect with histamine-2-blocker drugs may interfere with the absorption of alendronate. Finally, the exact indications for the use of alendronate have not yet been established.

Homebound Elderly Persons Had Vitamin D Deficiency

Gloth FM 3d, Gundberg CM, Hollis BW, Haddad JG Jr, Tobin JD. Vitamin D deficiency in homebound elderly persons. JAMA. 1995; 274:1683-6.

Many elderly persons, especially those who are homebound, are particularly susceptible to vitamin D deficiency. Most studies of vitamin D deficiency have been done in Europe, where little or no vitamin D dietary supplementation is available. The researchers of this cohort study assessed the vitamin D status of elderly persons ( 65 years of age) living in the United States relative to deprivation of sunlight, nutrition, and age-related changes in skin and renal function.

Three groups of patients were studied: 52 homebound persons, 64 nursing home residents, and 128 ambulatory controls. Both the homebound persons and nursing home residents were presumed to receive less sunlight; all persons in these two groups had been confined for at least 6 months. No participants had disorders or were receiving medications that would interfere with vitamin D metabolism. Serum levels of 25-hydroxyvitamin D and 1,25-dihydroxyvitamin D were measured in all participants. Levels of parathyroid hormone, ionized calcium, and osteocalcin and intake of vitamin D were measured in a subgroup of participants.

Fifty-four percent of homebound persons had serum levels of 25-hydroxyvitamin D that were below normal (normal range, 25 to 137 nmol/L). Thirty-eight percent of nursing home residents had levels below normal. A significant inverse relation was seen between 25-hydroxyvitamin D levels and parathyroid function, as measured by serum parathyroid hormone levels. Mean daily intakes of vitamin D and calcium were less than the recommended dietary allowance in 80% of homebound persons and 43% of nursing home residents.

Although homebound persons frequently use vitamin supplementation, they are especially likely to have vitamin D deficiency. Low vitamin D levels were associated with secondary hyperparathyroidism and thus might be further associated with lower bone density, muscle weakness, and pain. This study suggests that vitamin D deficiency is probably substantially underdiagnosed and undertreated in the United States. Even when vitamin D supplementation is used, older persons deprived of sunlight for long periods (especially those who are homebound) may still have vitamin D deficiency and require either more exposure to sunlight (an often impractical option) or more dietary supplementation.

Weight Loss Was More Effective than Exercise

Katzel LI, Bleecker ER, Colman EG, Rogus EM, Sorkin JD, Goldberg AP. Effects of weight loss vs aerobic exercise training on risk factors for coronary disease in healthy, obese, middle-aged and older men. A randomized controlled trial. JAMA. 1995; 274:1915-21.

Physicians frequently see so-called "couch potatoes," men who seek a physical examination around retirement age as they plan for a new phase of life. Such patients are usually sedentary and often have central adiposity, mild insulin resistance, mild hypertriglyceridemia, elevated low-density lipoprotein cholesterol levels, and mild systolic hypertension. We understand the dangers that such patients may face, but they are not yet "sick." The clinical question is, Can we help them avoid coronary heart disease or stroke? Katzel and coworkers compared the effect of weight loss with that of aerobic exercise on risk factors for coronary artery disease in sedentary obese men of retirement age.

The study participants were 170 obese (mean body mass index ± SE, 30 ± 1 kg/m²) men who were middle-aged or older (mean age, 61 ± 1 years). The participants were randomly assigned to participate for 9 months in a program for reducing weight through dietary restriction or in an aerobic exercise program. Outcome measures were body composition, blood pressure, lipoprotein levels, glucose tolerance, and maximal aerobic capacity.

In the participants who completed the weight loss program, weight was reduced by a mean of 10%; in the exercise cohort, weight did not change. However, the exercise group did increase its mean maximal oxygen consumption by 17% (P < 0.001). Weight loss, but not exercise, was associated with a 2% decrease in fasting glucose levels, an 18% decrease in insulin levels, a 13% increase in high-density lipoprotein cholesterol levels, and a decrease in blood pressure. Aerobic exercise without weight loss caused no major changes in these variables (Figure 3).

View larger version (25K): [in this window] [in a new window]   Figure 3. Relative changes (from values before intervention to values after intervention) in plasma lipoprotein lipid levels with intervention in the weight loss and aerobic exercise groups and at follow-up in the control group. Values with asterisks are significantly different at P < 0.05 (analysis of variance). Data are expressed as the mean ± SE. HDL-C = high-density lipoprotein cholesterol; LDL-C = low-density lipoprotein cholesterol; TG = triglycerides. Reproduced with permission from Katzel LI, et al. JAMA. 1995;274:1915-21.

A weight loss of 10% substantially reduced the severity of known risk factors for coronary artery disease in these men. The somewhat surprising finding that weight loss was more important than exercise should prompt a "back to basics" attitude. Although losing weight and sustaining the new body weight are difficult for sedentary patients, these practices form the basis of a successful preventive strategy. Aerobic exercise was less beneficial, but these two strategies will probably be highly synergistic in these populations. "Successful aging" can be greatly facilitated by careful physician-directed weight loss and by exercise programs that are aimed at persons nearing retirement.

Predictors of Dementia in Persons with Impaired Memory

Petersen RC, Smith GE, Ivnik RJ, Tangalos EG, Schaid DJ, Thibodeau SN, et al. Apolipoprotein E status as a predictor of the development of Alzheimer's disease in memory-impaired individuals. JAMA. 1995; 273:1274-8.

The "forgetful" patient is commonly seen in primary care practices. The possibility of progression to Alzheimer disease is usually a major concern of both patients and families. We now know that some persons are genetically predisposed to developing dementia. Much attention has been given to the apolipoprotein E (APOE) gene, of which there are three predominant alleles—2, 3, and 4. The 4 allele, which may be present in 15% of the population, appears to be over-represented in patients with Alzheimer disease. Petersen and associates examined the natural history of moderate cognitive impairment in older patients and sought to determine whether the presence of the 4 allele on the APOE gene predicted that outcome. The study participants were a consecutive sample of 66 patients who attended a general community clinic. All patients met simple, validated criteria for a diagnosis of mild cognitive impairment based on results of psychometric tests that are not commonly used in primary care practice. Results of commonly used tests of mental status, such as the Mini-Mental Status Examination, were in the natural age-adjusted range. For each participant, APOE genotyping was done at study entry. The main outcome measure was the development of frank dementia, as determined by the criteria of Diagnostic and Statistical Manual, Third Edition, Revised, during no more than 54 months of follow-up.

Dementia had developed in 24% of participants at 18 months, in 44% at 36 months, and in 55% at 54 months. Results of neuropsychological tests of memory loss were highly predictive, but the possession of the APOE 4 allele was the strongest predictor of clinical outcome (risk ratio, 4.36 [CI, 1.41 to 13.54]) (Figure 4).

View larger version (19K): [in this window] [in a new window]   Figure 4. Kaplan-Meier survival analysis of carriers and noncarriers of apolipoprotein E (APOE) 4 for conversion from mild cognitive impairment to dementia (P < 0.01). Reproduced with permission from Petersen RC, et al. JAMA. 1995;273:1274-8.

This study has begun to define the natural history of the progression to frank dementia in persons who present with reports of forgetfulness. Approximately half of these participants had progressed to dementia by 36 months of follow-up; this means, of course, that approximately half did not. This study also shows that, in these persons, neuropsychological testing seems to define more precisely the extent and probable prognosis of reports of forgetfulness. Finally, the APOE 4 allele is an important marker of enhanced risk for Alzheimer dementia. However, genetic testing is not yet sufficiently sensitive or specific for routine clinical use. Thus, genotyping should not be used as a diagnostic or prognostic test.

Practical Geriatric Assessment

Formal geriatric assessment is valuable, but it is expensive and time consuming and requires specialized expertise. Thus, because of the cost pressures of managed care, formal assessment is unlikely to be more widely used in its present form. In addition, the following studies have shown that the best outcomes occur when the patient's assessors are also the patient's caregivers.

A Motor Test Predicted Disability

Guralnik JM, Ferrucci L, Simonsick EM, Salive ME, Wallace RB. Lower-extremity function in persons over the age of 70 years as a predictor of subsequent disability. N Engl J Med. 1995; 332:556-61.

The U.S. population continues to age, and widespread concern surrounds the specter of a massive increase in the number of disabled persons, with attendant implications for care and quality of life. Using existing questionnaires and evaluating performance provide a reasonably accurate way to formally assess disability. These assessments are generally used in persons who are already disabled. Guralnik and colleagues ask the intriguing question, Can simple tests of physical performance that are suitable for office use predict the subsequent development of disability in older persons who are currently not disabled, thus allowing the use of preventive measures to avoid or alleviate these disabilities?

A cohort of 1122 persons older than 70 years of age was followed for 4 years. At baseline, the participants had no disabilities in performing activities of daily living, could walk a half mile, and could climb stairs without assistance. The following physical performance tests, suitable for use in primary care offices, were administered:

1. Standing balance: Participants were asked to maintain their feet in side-by-side, semi-tandem (heel of one foot beside the great toe of the other) and tandem positions for 10 seconds each. A score of 1 was given to participants who could hold a side-by-side position but no more; a score of 2 was given to those who could hold a semi-tandem position; a score of 3 was given to those who could maintain a tandem position for 3 to 9 seconds; and a score of 4 was given to those who could maintain a tandem position for 10 seconds.

2. Timed 8-foot walk: Participants were asked to walk 8 feet and were scored according to quartiles of the time required to walk that distance. A score of 1 was given for walking this distance in 5.7 seconds or more; a score of 2 was given for 4.1 to 5.6 seconds; a score of 3 was given for 3.2 to 4.0 seconds; and a score of 4 was given for 3.1 seconds or less.

3. Timed test of five repetitions: Participants were asked to fold their arms and stand up from a sitting position. If they were successful, they were asked to sit down and stand up again five times. This series was timed and scored according to quartiles: a score of 1 for 16.7 seconds or more, a score of 2 for 13.7 to 16.6 seconds, a score of 3 for 11.2 to 13.6 seconds, and a score of 4 for 11.1 seconds or less.

Lower scores at baseline were associated with a significantly increased frequency of disability in activities of daily living and mobility-related disability (Table 1). Participants with the lowest scores were 4.2 to 4.9 times as likely to have disability at 4 years as were persons with the highest scores.

These simple tests of lower-extremity function strongly predicted subsequent disability. The National Institute of Aging is funding more studies that focus on easier ways to assess function and predict disability at a preclinical stage. For the busy practicing physician, the best way to select interventions that focus on preventing the most likely disability is to add a battery of tests that have known operating characteristics (such as the above-mentioned tests) to the routine assessment of patients.

In-Home Assessment Delayed Disability

Stuck AE, Aronow HU, Steiner A, Alessi CA, Bula CJ, Gold MN, et al. A trial of annual in-home comprehensive geriatric assessments for elderly people living in the community. N Engl J Med. 1995; 333:1184-9.

Interest in the potential value of home care for older, frail patients is increasing. European geriatricians have experimented with "preventive" home visits for many years, with varying results. However, comprehensive geriatric assessment at home had not been attempted until these researchers studied whether annual in-home comprehensive geriatric assessment and follow-up of elderly persons living in the community prevent progression of disability.

In a prospective experiment, 414 community-dwelling persons older than 75 years of age were randomly assigned to one of two groups and were followed for 3 years. Participants in the intervention group were evaluated in their homes by gerontologic nurse practitioners. Persons in the control group received regular medical care. Outcome measures were prevention of disability (defined as the need for assistance in performing basic activities of daily living [such as bathing, dressing, feeding, grooming, transferring from bed to chair, and moving around inside the house] or instrumental activities of daily living [such as cooking, handling finances and medication, housekeeping, and shopping]) and prevention of nursing home admissions.

At 3 years, 12% of persons in the intervention group and 22% of persons in the control group required assistance in performing the basic activities of daily living (odds ratio, 0.4 [CI, 0.2 to 0.8]). Nursing home admission was required in 4% of persons in the intervention group and 10% of persons in the control group. Admission to acute care hospitals did not differ between groups, and by year 3 persons in the intervention group had made more visits to physicians. The cost of intervention per disability-free year of life gained was $6000.

The results show that in-home comprehensive geriatric assessment delays the onset of disability and nursing home admission among community-dwelling elderly persons. A possibly negative finding is that persons in the intervention group made more visits to their physicians. However, most of those visits were for depression, which was not covered in the assessments. In most patients, the depression could be treated. Moreover, the overall cost of preventing 1 year of disability—$6000—is much less than, for example, the cost of preventing coronary artery disease by treating hypertension.

Therefore, even in a managed care era, parts of the traditional geriatric assessment can be simplified, streamlined, and put into routine practice to help patients and save money.

Hospital Care

In terms of health care dollars, growing old is expensive. Questions are increasingly being raised about the appropriateness of our current allocation of health care dollars to very old persons. Much of this discussion focuses on the costs and benefits of hospitalization, especially in persons who are near the end of life. The following two articles present important new perspectives on the true costs of this kind of care of the elderly and discuss new strategies to enhance the effectiveness of hospitalization.

Care at the End of Life Was Less Expensive in the Very Old

Lubitz J, Beebe J, Baker C. Longevity and Medicare expenditures. N Engl J Med. 1995; 332:999-1003.

One third of health care dollars is spent on the elderly, and much of this cost is incurred in the last years of life. The number of elderly persons will increase, as will the number of elderly persons who survive into very old age. It will be important to establish that these patterns of care are cost-effective, especially in persons who are near the end of life. These researchers sought to determine current patterns of Medicare expenses according to age at death and to estimate how future growth in the population of older persons will affect Medicare spending.

The investigators retrospectively analyzed the Medicare expenses of 129 166 Medicare beneficiaries 65 years of age or older who died in 1989 or 1990. Using simulation techniques, the researchers estimated the lifetime payments by Medicare for enrollees who turned 65 years of age in 1990 and for those who will do so in 2020.

On the basis of the retrospective analysis, estimated lifetime payments ranged from $13 044 for persons who died at age 65 years to $56 094 for those who died at age 80 years to $65 633 for those who died at age 101 years or older. However, the payments associated with an additional year of life and the average annual payments throughout a lifetime decreased as the age at death increased (Figure 5). Furthermore, the costs of medical care in the last 2 years of life decreased with advancing age (Figure 6). Life expectancy is expected to increase by 7.9% between 1990 and 2020, but this increase will be associated with an estimated 2.0% increase in lifetime Medicare payments (in constant dollars).

View larger version (25K): [in this window] [in a new window]   Figure 5. Estimated lifetime Medicare payments for persons in the study sample, according to age at death. These enrollees died in 1989 or 1990 at 65 years of age or older. Reproduced with permission from Lubitz J, et al. N Engl J Med. 1995; 332:999-1003.

View larger version (18K): [in this window] [in a new window]   Figure 6. Medicare payments in the last 2 years of life for persons in the study sample, according to age at death. These enrollees died in 1989 or 1990 at 65 years of age or older. Reproduced with permission from Lubitz J, et al. N Engl J Meal. 1995; 332:999-1003.

Contrary to popular political belief, increased longevity may not have a great effect on Medicare spending. The growth in Medicare spending will probably come primarily from the overall increase in the number of persons older than 65 years of age. Spending seems to level off with age; thus, physicians are probably more conservative with the use of hospitalization and high technology in the very old. The message from this study is that we must distinguish between the costs of caring for individual patients (which may not directly increase with age) and the costs of caring for a group (which in this case is increasing).

An Interdisciplinary Unit Resulted in Better Outcomes than Did Usual Hospital Care

Landefeld CS, Palmer RM, Kresevic DM, Fortinsky RH, Kowal J. A randomized trial of care in a hospital medical unit especially designed to improve the functional outcomes of acutely ill older patients. N Engl J Med. 1995; 332:1338-44.

Financial pressures that result from hospitalizations prompt the question of whether ill elderly persons could receive better care in a setting other than an acute care hospital. Most studies have focused on diseases, treatments, or the behavior of physicians. These researchers addressed an entire system.

An acute care unit was established to care for ill persons older than 70 years of age who required short-term hospitalization. A team approach stressed multi-disciplinary comprehensive assessment and attention to function and rehabilitation. Protocols for preventing disability and for rehabilitation were implemented and reviewed daily. For example, patients who could walk were not allowed to stay in bed, and activity orders were specific (Table 2). Of 651 patients identified, 327 were randomly assigned to the program and 324 were assigned to receive usual care elsewhere in the hospital. The main outcome measures were the changes that occurred between admission and discharge in the number of basic activities of daily living (bathing, dressing, toileting, moving from a bed to chair, and eating).

At hospital discharge, patients in the intervention group had significantly more restoration and preservation of function. Thirty-four percent of persons in the intervention group and 24% of controls had an absolute increase of one or more specific activities of daily living. Fewer patients in the intervention group were discharged to a long-term care facility (14% compared with 22%). More older patients can be discharged to their homes and admission to long-term care facilities can be avoided if methods easily applicable at most community hospitals are used. Attention to preservation and restoration of the functional abilities of older persons should be a part of every care plan. If a program such as the one described above is to be successful, communication among the various caregivers involved must be consistent.

Nonsteroidal Anti-Inflammatory Drugs Were a Major Cause of Hospitalization

Smalley WE, Ray WA, Daugherty JR, Griffin MR. Nonsteroidal anti-inflammatory drugs and the incidence of hospitalizations for peptic ulcer disease in elderly persons. Am J Epidemiol. 1995; 141:539-45.

The dangers of nonsteroidal anti-inflammatory drugs (NSAIDs) are well known. Renal insufficiency, dyspepsia, and confusion are common side effects, but NSAIDs are still used widely. This retrospective cohort study was designed to determine the rate of clinically significant ulcer disease in older users of NSAID.

A total of 103 954 persons older than 65 years of age were studied. Outcomes included rates of hospitalization with peptic ulcer disease or upper gastrointestinal hemorrhage. Patients were classified according to duration of NSAID use and daily NSAID dose.

Rates of hospitalization in persons who did not use NSAIDs and in persons who currently used NSAIDs were 4.2 per 1000 person-years and 16.7 per 1000 person-years, respectively. In new users, hospitalization rates were 26.3 per 1000 person-years during the first 30 days of therapy and 20.9 per 1000 person-years during the subsequent 31 to 180 days. In long-term users (>6 months), the hospitalization rate remained at 15.3 per 1000 person-years. Excess hospitalization depended on the NSAID dose (range, 6.0 per 1000 person-years for the lowest dose category to 17.8 per 1000 person-years for the highest).

Because the excess rate of hospitalization in older persons taking NSAIDs is extremely high and because these agents have other known adverse effects, alternatives should be tried in most cases.

Common Problems in the Nursing Home

Nursing home caregivers frequently call physicians in the middle of the night with questions about fever and cough or fever and symptoms of urinary tract infection.

Feeding Patterns Predicted Treatment Failure in Pneumonia

Degelau J, Guay D, Straub K, Luxenberg MG. Effectiveness of oral antibiotic treatment in nursing home-acquired pneumonia. J Am Geriatr Soc. 1995; 43:245-51.

The prevalence of pneumonia in nursing homes is as high as 2.5%; the condition is often treated with oral antibiotic therapy. However, predictors of the effectiveness of this approach had not been tested until these researchers sought to identify clinical factors that predict the success or failure of oral antibiotic therapy for nursing home-acquired pneumonia.

Outcomes for all identifiable cases of nursing home-acquired pneumonia were retrospectively studied in 31 community nursing homes. Participants were 124 patients (mean age, 85.2 years) who had a new respiratory symptom and new infiltrate on chest radiograph and were prescribed oral antibiotics. The outcomes assessed were rates of subsequent hospitalization and mortality at 30 days.

Sixty-three percent of 198 episodes of nursing home-acquired pneumonia were initially treated in the facility with oral antibiotics. Treatment failure and subsequent hospitalization occurred in 30% of these episodes. The overall mortality rate at 30 days was 13%. Persons in whom treatment failed had higher pulse rate, temperature, respiration rate, and feeding dependence than did persons in whom treatment did not fail and who had mechanically altered diets. Mortality increased as the number of risk factors increased.

Most episodes of nursing home-acquired pneumonia were treated successfully with oral antibiotics. Patients who had mechanically altered diets or who required feeding assistance had higher failure rates, possibly because of aspiration or failure of the oral drug to reach the gut. These factors, in combination with more dramatically altered vital signs (temperature >37.7 °C, pulse >100 beats/min, or respiration rate >30 breaths/min) can be used to identify patients who are likely to have failure of oral antibiotic therapy in the nursing home.

Chronic Incontinence Was Not Associated with Bacteriuria

Ouslander JG, Schnelle JF. Incontinence in the nursing home. Ann Intern Med. 1995; 122:438-49.

It has been reported that asymptomatic bacteriuria in nursing home residents has no effect on mortality, but morbidity has not been addressed. As many as 70% of nursing home residents have urinary incontinence, at an annual cost as great as $5 billion. In addition, asymptomatic bacteriuria occurs in about 50% of residents. These researchers sought to determine whether eradicating otherwise asymptomatic bacteriuria would alter the severity of urinary incontinence in nursing home residents.

Urine culture was used to classify nursing home residents as having bacteriuria or not having bacteriuria. Persons in the treatment group received a 7-day course of norfloxacin, 400 mg twice daily. The main outcome measure was the severity of incontinence, measured by physical checks for wetness at baseline and for 3 days after treatment.

One hundred seventy-six persons completed the study. Bacteriuria was eliminated in 40% of treated residents. The severity of incontinence remained unchanged after bacteriuria was eliminated, and the presence of pyuria did not affect the results.

Eradicating bacteriuria has no short-term effect on the severity of chronic urinary incontinence among nursing home patients. This study did not address nursing home residents who suddenly became incontinent. These data support the Health Care Financing Administration Resident Assessment Protocol's recommendation that asymptomatic bacteriuria not be treated.

Dr. Roberts (Series Editor): York Health System, York, PA 17403.