Brenda Breuer

Restraint Reduction Reduces Serious Injuries Among Nursing Home Residents

OBJECTIVES: To describe how removing physical restraints affected injuries in nursing home settings.

Buffered versus plain lidocaine as a local anesthetic for simple laceration repair

STUDY OBJECTIVE Buffered lidocaine was compared with plain lidocaine as a local anesthetic for simple lacerations. DESIGN Randomized, double-blind, prospective clinical trial. SETTING Urban emergency department. TYPE OF PARTICIPANTS Ninety-one adult patients with simple linear lacerations were enrolled. Patients with allergy to lidocaine and patients with an abnormal mental status were excluded. INTERVENTIONS Each wound edge was anesthetized with either plain or buffered lidocaine using a randomized, double-blind protocol. The pain of infiltration was measured with a previously validated visual analog pain scale. MEASUREMENTS AND MAIN RESULTS Analysis of pooled data and paired data (using patients as their own controls) revealed that infiltrating buffered lidocaine was significantly less painful than plain lidocaine (P = .03 and P = .02, respectively). There was no significant difference in the anesthetic effectiveness of the two agents during suturing. CONCLUSION Buffered lidocaine is preferable to plain lidocaine as a local anesthetic agent for the repair of simple lacerations.

Pain management by primary care physicians, pain physicians, chiropractors, and acupuncturists: a national survey.

Objectives: Chronic pain is a serious public health problem and is treated by diverse health care providers. In order to enhance policies and programs to improve pain care, we collected information about the distribution of pain patients among four major groups of pain management providers: primary care physicians (PCPs), pain physicians, chiropractors, and acupuncturists, and the variation in the attitudes and practices of these providers with respect to some common strategies used for pain. Methods: National mail survey of PCPs, pain physicians, chiropractors, and acupuncturists (ntotal = 3,000). Results: Eight hundred seventeen responses were usable (response rate, 29%). Analyses weighted to obtain nationally representative data showed that PCPs treat approximately 52% of chronic pain patients, pain physicians treat 2%, chiropractors treat 40%, and acupuncturists treat 7%. Of the chronic pain patients seen for evaluation, the percentages subsequently treated on an ongoing basis range from 51% (PCPs) to 63% (pain physicians). Pain physicians prescribe long-acting opioids such as methadone, antidepressants or anti-convulsants, and other nontraditional analgesics approximately 50–100% more often than PCPs. Twenty-nine percent of PCPs and 16% of pain physicians reported prescribing opioids less often than they deem appropriate because of regulatory oversight concerns. Of the four groups, PCPs are least likely to feel confident in their ability to manage musculoskeletal pain and neuropathic pain, and are least likely to favor mandatory pain education for all PCPs. Conclusions: There is substantial variation in attitudes and practices of the various disciplines that treat chronic pain. This information may be useful in interpreting differences in patient access to pain care, planning studies to clarify patient outcomes in relation to different providers and treatment strategies, and designing a system that matches chronic pain patients to appropriate practitioners and treatments.

Elevated Serum Total and LDL Cholesterol in Very Old Patients with Alzheimer’s Disease

The relationships of serum lipids with Alzheimer’s disease (AD) and other dementias in very old patients are not clear. All residents of an academic nursing home were studied clinically for dementia and for serum lipids. All those autopsied over a 7.7-year period had apolipoprotein E (apoE) genotyping and detailed neuropathological examination. Those with pathologically defined criteria for AD (n = 84) were compared to all others who also had clinical dementia but did not show AD changes (n = 22). In contrast to most other reports of serum lipids in very old patients with AD, total cholesterol (TC) and low density lipoprotein cholesterol levels were each significantly higher for those with AD. The lipid-AD associations were progressively stronger with increasing pathological certainty of AD diagnosis. These relationships remained significant after adjustment for apoE genotype and for other known risk factors. The lipid-AD associations in a very old cohort, and prior evidence that elevated TC in middle life is a risk factor for later dementia, prompt consideration of factors associated with lipid metabolism in the development of Alzheimer’s dementia.

The relationship between apolipoprotein E, dementia, and vascular illness

The purpose of this study was to concurrently assess the relationship of Apolipoprotein E (APOE) with both dementias and vascular illnesses in the very old. Nine hundred and fifty nine subjects (mean age 85 years) in a long-term care facility were genotyped and cognitively tested with the Mini Mental State Exam. All subjects were studied for the relationship of APOE with atherosclerotic heart disease, hypertension, or stroke without concomitant dementia. Four hundred fifty individuals met criteria for inclusion into one of the following groups: Alzheimers disease (n = 318), vascular dementia (n = 49), or not demented controls (n = 83) and were investigated for the relationship between APOE and these diagnostic categories. APOE epsilon4 was not associated with atherosclerotic heart disease, hypertension, or stroke without concomitant dementia. The APOE epsilon3 allele was more common in men with atherosclerotic heart disease. In contrast, the APOE epsilon4 allele was more common in patients with Alzheimers disease (22%) and vascular dementia (26%) than in not demented controls (7%). APOE epsilon4 is associated with dementias in the very old, whereas its relationship with either peripheral or central nervous system vascular disease without dementia is not as robust.

Sequential outbreak of influenza A and B in a nursing home : Efficacy of vaccine and amantadine

OBJECTIVE: To describe the sequential occurrence of influenza A and B in a nursing home, and to determine the efficacy of influenza vaccine and/or amantadine treatment with respect to incidence and sequelae.

Old Problem, Different Approach: ALTERNATIVES TO PHYSICAL RESTRAINTS

Individualized care, resident assessment by a multidisciplinary team, and rehabilitation enhance functional independence in nursing home residents. Creativity in choosing alternatives to restraints was important in successful restraint reduction. Residents free of restraints had higher ADL levels, were more continent, and sustained fewer serious injuries, all of which are important quality of life indicators.

The relationship of tamoxifen with dementia, depression, and dependence in activities of daily living in elderly nursing home residents.

ABSTRACT Objectives. To evaluate the association between tamoxifen treatment and the prevalence of Alzheimers disease, other dementias, depression, and the levels of dependence in activities of daily living (ADL) in elderly, nursing home residents. Participants. 93,031 women, at least 65 years old, whose data were part of the 1993 New York State MDS, and for whom there was documentation of treatment with at least one medication. Setting. New York State long-term care facilities. Design. Cross-sectional study via secondary analysis of 1,385 matched sets of residents. Each set included one resident who received tamoxifen treatment and up to four residents who did not. Measurements. Included age, ethnicity, tamoxifen treatment, hormone replacement therapy, depression, levels of dependence in ADL and in cognitive skills for daily decision-making, and documentation of Alzheimers disease and other dementias. Results. Women receiving tamoxifen were less likely to have a diagnosis of Alzheimers disease documented on the MDS (odds ratio: 0.674; 95% confidence interval: 0.551–0.823), were significantly more independent in bed mobility, eating, toileting (in each case P < 0.0001), personal hygiene (P = 0.0155), dressing (P = 0.0015), transferring (P = 0.0006), locomotion (P = 0.0016), and they had better cognitive skills for daily decision-making (P < 0.0001). They were, however, 42% more likely to have a MDS diagnosis of depression (P < 0.0001). All tests of statistical significance are two-sided. Conclusion. In this population, tamoxifen was associated with a higher level of independence in ADL and decision-making. While the MDS also suggested a relationship of tamoxifen with a lower prevalence of Alzheimers disease, there seemed to be an increased prevalence of depression among treated women. The findings of this cross-sectional study could be evaluated in the randomized clinical trial that has just begun, and that will compare tamoxifen and raloxifene treatments.

Relationships of sex hormone levels to dependence in activities of daily living in the frail elderly

OBJECTIVES We undertook this nursing home study in order to determine the relationships between dependency in activities of daily living (ADL) and blood levels of estrone, testosterone, androstenedione, and dehydroepiandrosterone (DHEA). Little is known about this issue. METHODS cross-sectional study of 370 nursing home residents. Hormone levels in blood specimens drawn in 1997 and 1998 were correlated with degree of ADL dependency recorded in medical charts. RESULTS Because of multiple comparisons associations were deemed significant for P-values < or =0.017 for males and < or =0.0125 for females. In males, the following were inversely related: testosterone levels with dependency in transferring and eating; estrone with eating and a summary ADL index; and androstenedione with toileting and a summary ADL index (in all cases, r=-0.4; P=0.007-0.015). Inverse trends existed between testosterone levels and dependency in mobility and a summary ADL index; and androstenedione and eating (in all cases r=-0.3; P=0.030-0.055). Among females the following were directly related: estrone levels with dependence in mobility, toileting, transferring, and a summary ADL index; and DHEA with transferring and a summary ADL index (r=0.2-0.3, P=0.0001-0.01). Trends existed between estrone and eating, and DHEA and toileting (r=0.1-0.2, P=0.04). CONCLUSION In male residents, higher sex hormone levels are associated with better ADL performance. Among females the opposite is true. While further studies are needed to elucidate these relationships, our results and recent findings of others suggest sex hormone actions in older women differ from those in younger populations. A possible stress-related mechanism is also presented.

Effect of Tamoxifen on Bone Fractures in Older Nursing Home Residents

OBJECTIVES: To evaluate the association between tamoxifen (TAM) treatment and rate of bone fractures in older, nursing home residents.