Elizabeth Langer

Efficacy of an Influenza Hemagglutinin‐Diphtheria Toxoid Conjugate Vaccine in Elderly Nursing Home Subjects During an Influenza Outbreak

To compare the efficacy of an influenza hemagglutinin‐diphtheria toxoid conjugate vaccine with the commercially available influenza hemagglutinin‐subunit vaccine in preventing influenza in older adults living in a nursing home.

Mortality following isolation of various respiratory viruses in nursing home residents

OBJECTIVE To compare mortality following isolation of influenza A to mortality following isolation of other respiratory viruses in a nursing home. SETTING The Wisconsin Veterans Home, a 688-bed skilled nursing facility for veterans and their spouses. PARTICIPANTS All residents with respiratory viral isolates obtained between 1988 and 1999. DESIGN Thirty-day mortality was determined following each culture-proven illness. RESULTS Thirty-day mortality following isolation of viral respiratory pathogens was 4.7% (15/322) for influenza A; 5.4% (7/129) for influenza B; 6.1% (3/49) for parainfluenza type 1; 0% (0/26) for parainfluenza types 2, 3, and 4; 0% (0/26) for respiratory syncytial virus (RSV); and 1.6% (1/61) for rhinovirus. CONCLUSIONS Mortality following isolation of certain other respiratory viruses may be comparable to that following influenza A (although influenza A mortality might be higher without vaccination and antiviral agents). The use of uniform secretion precautions for all viral respiratory illness deserves consideration in nursing homes.

Hearing loss in the nursing home. An institutional issue.

One hundred ninety‐eight nursing home admissions underwent audiometric assessment and answered questions regarding hearing difficulty in common listening situations. Twenty‐four percent demonstrated normal thresholds (0–25 dB) in the speech frequencies with only mild losses at 4000 Hz. Fifty‐four percent had normal thresholds through the speech frequencies with moderate to profound losses at higher frequencies, or mild losses (26–40 dB) in the speech frequencies. Such persons would be at risk in daily listening situations. Twenty‐two percent had moderate or greater losses (> 40 dB) through the entire frequency range. Sixteen percent of this significantly impaired group were not identified as having a hearing loss by either the admitting RN or physician. Sixty percent of residents reported trouble in a group if they could not see the speakers face, when watching television, and/or when using the telephone. The data indicate that a systematic hearing screening program is the most reliable means of identifying hearing loss and functional hearing handicap on an individual basis. The high prevalence of hearing problems suggests that this handicap also needs to be addressed from the perspective of institutional policy. Staff training and environmental modification should be undertaken to give hearing support to the entire nursing home population.

The Cockroft-Gault formula.

with scores on the Beck Depression Inventory, not with DSM-I11 psychiatric diagnoses. More significantly, Lesher excluded 50% of his potential subjects because of cognitive impairment, and Hickie and Snowden stated that they specifically excluded from their study patients with any evidence of dementia or delirium; thus, these studies were designed to validate the GDS in institutionalized elderly without significant cognitive impairment, not in the general population of institutionalized elderly persons, many of whom are in fact demented. Furthermore, the study of Hickie and Snowden was not even limited to institutionalized elderly; subjects were drawn from ”a day center, nursing homes, psychiatry outpatients, and a general psychiatry w a r d (p 5 1). It was for reasons such as these that we felt that the work of validating the GDS among institutionalized elderly should continue. We were unable to obtain a copy of Parmalee’s abstract in time to review for this letter.

READMISSIONS AND ACUITY IN THE NURSING HOME: How Will the Nursing Homes Manage?

Decreased hospital length of stay and the shift of location of death from the hospital to the nursing home have increased the burden of care that must be provided by nursing home staff. Complex interaction of multiple disease states was the dominant factor in the readmission of nursing home residents to hospitals within 30 days of their previous discharge. Advanced nursing practice provided by gerontological nurse practitioners can monitor acute and chronic illnessess and decrease rates of hospitalization, as well as provide educational expertise to improve the nursing assessment and planning skills of the nursing home staff.

Follow-up of mild hypothyroidism in a nursing home

The course of untreated mild hypothyroidism was followed in 67 nursing home residents (mean age 78 years). The diagnosis was based on a normal free thyroxine index (FTI) and elevated thyrotropin concentration (TSH 4.6 to 15.0 μIU/mL, nl ≤ 4.5 μIU/mL). FTI and TSH were measured in follow‐up> 42–378 (mean 161) days after the diagnosis of mild hypothyroidism had been made. In 45 patients initial TSH was <6.8 μIU/mL; in 23 of these subjects TSH returned to normal during the observation period, whereas in 22 TSH remained elevated. In all 22 residents whose initial TSH was >6.8 μIU/mL, TSH remained elevated at follow‐up. In 4 subjects whose initial TSH concentrations ranged from 5.0 to 9.6 μIU/ml, FTI fell below normal 91–141 days after the diagnosis of mild hypothyroidism was made. Clinical progression of the signs or symptoms of hypothyroidism was not detected in the 4 patients who developed hypothyroxinemia. Three demonstrated positive thyroid antibody titers, and 1 had myasthenia gravis. These observations suggest a need for replacement therapy in debilitated patients with mild hypothyroidism and evidence of thyroid autoimmunity.

Laboratory measurements of nutritional status as correlates of atrophic glossitis

Objective:To perform a comprehensive laboratory assessment of nutritional status in two elderly patients selected for the presence of atrophic glossitis, a classic physical sign of malnutrition.Design:Case report.Setting:Inpatient internal medicine ward at the William S. Middleton Memorial Veterans Medical Center, Madison, Wisconsin.Measurements and main results:Blood specimens were analyzed by the Nutrition Evaluation Laboratory at the USDA Human Nutrition Research Center on Aging at Tufts University. Both subjects had biochemical evidence of protein-calorie malnutrition and were deficient or marginally deficient in several vitamins and trace minerals.Conclusions:Much work needs to be done to determine the sensitivity and positive predictive value of the classic physical signs of malnutrition as predictors of low biochemical levels and adverse clinical outcomes. The presence of atrophic glossitis should prompt the clinician to consider a basic nutritional assessment.

High rates of immunization in a nursing home

One-time pneumococcal’ and annual influenza vaccination2 are recommended for elderly nursing home residents. Elderly persons fall victim to 90% of influenza-related deaths duringepidemics?Unfortunately,influenzavaccination will not induce a substantial antibody response in many elderly persons.3-5 Despite this shortcoming, the vaccine is still efficacious in reducing the incidence of pneumonia and influenza-related hospitalizations and the mortality rate in both high-risk noninstitutionalized6 and institutionalized’ elderly populations. One nursing home study showed that residents were not protected from contracting pneumonia; however, findings indicated a threefold protection from pneumonia-related deaths.8 Work currently is under way in our nursing home to enhance the immune response to influenza vaccination with the use of standard influenza antigens coupled to diphtheria toxoid and injections of the thymic hormone thymosin . The mortality rate of bacteremic pneumococcal pneumonia in the elderly is 17% to 40%.g The efficacy of the pneumococcal vaccine in this group has been demonstrated in vaccinated

Overnight Pulse Oximetry in Nursing Home Residents with Behavior Problems: Case Reports

Sleep-related hypoxia is common in nursing home residents and may present as delirium, anxiety, agitation, or behavior problems as well as polycythemia, or it may exacerbate hypertension and/or congestive heart failure. Its mechanisms include chronic cardiopulmonary disease, sleep hypopnea or apnea syndromes (obstructive and central), pulmonary edema with nocturnal resorption of peripheral edema, and dependency-related small airway closure with continued perfusion of nonventilated alveoli. Sleep-related respiratory disorders are more common in individuals with dementia and may be exacerbated by sedatives such as benzodiazepines or metabolic abnormalities such as end-stage renal disease. When a resident presents with a neuropsychiatric problem, the practitioner should always evaluate and treat physical and metabolic illness that may be clouding the resident’s mind or mediating the release of catecholamines or cytokines, which can produce anxiety or dysphoria. The Wisconsin Veterans Home owns a pulse oximeter capable of performing overnight screening studies as well as a computer program to analyze the data. Nocturnal oximetry is often used to determine need for and dosage of nocturnal oxygen and to assist in obtaining external funding when predetermined standards of desaturation are met. The device is also used to screen patients for formal assessment in a sleep laboratory. The Wisconsin Veterans Home staff includes two nurse practitioners who are consulted by staff registered nurses with regard to resident behavior problems. Residents presenting with behavior problems or delirium have been encountered in whom overnight oximetry determined an apparent mechanism of the neuropsychiatric problem. This indication for nocturnal oximetry has seldom been reported in nursing home residents. RESULTS