Emily Lubart

Dehydration among Long-Term Care Elderly Patients with Oropharyngeal Dysphagia

Introduction: Long-term care (LTC) residents, especially the orally fed with dysphagia, are prone to dehydration. The clinical consequences of dehydration are critical. The validity of the common laboratory parameters of hydration status is far from being absolute, especially so in the elderly. However, combinations of these indices are more reliable. Objective: Assessment of hydration status among elderly LTC residents with oropharyngeal dysphagia. Methods: A total of 28 orally fed patients with grade-2 feeding difficulties on the functional outcome swallowing scale (FOSS) and 67 naso-gastric tube (NGT)-fed LTC residents entered the study. The common laboratory, serum and urinary tests were used as indices of hydration status. The results were considered as indicative of dehydration and used as ‘markers of dehydration’, if they were above the accepted normal values. Results: The mean number of dehydration markers was significantly higher in the FOSS-2 group (3.8 ± 1.3 vs. 2 ± 1.4, p = 0.000). About 75% of these FOSS-2 patients had ≧4 dehydration markers versus 18% of the NGT-fed group (p = 0.000). A low urine output (<800 ml/day) was significantly more common in the FOSS-2 group (39 vs. 12%, p = 0.002). Above normal values of blood urea nitrogen (BUN), BUN/serum creatinine ratio (BUN/SCr), urine/serum osmolality ratio (U/SOsm), and urine osmolality UOsm, were significantly more frequent in the dehydration-prone FOSS-2 group. This combination of 4 indices was present in 65% of low urine output patients. In contrast, it was present in only 36% of the higher urine output patients (p = 0.01). Patients with a ‘normal’ daily urine output (>800 ml/day) also had a significant number (2 ± 1.5) of positive indices of dehydration. Conclusions: Dehydration was found to be common among orally fed FOSS-2 LTC patients. Surprisingly, probable dehydration, although of a mild degree, was not a rarity among NGT-fed patients either. The combination of 4 parameters, BUN, BUN/SCr , U/SOsm and UOsm, offers reasonable reliability to be used as an indication of dehydration status in daily clinical practice.

Bacteremia in a Multilevel Geriatric Hospital

BACKGROUND Bloodstream infection (BSI) is a major cause of morbidity and mortality in hospitals. Bacteremia in the elderly remains a diagnostic as well as a therapeutic challenge to the clinician. METHODS We investigate the clinical features, microbiological characteristics, and outcome of bacteremic episodes in a mixed LTC elderly population in a multilevel geriatric hospital. Data of patients with the diagnosis of BSI (during 2 years) was collected retrospectively from the records of the bacteriology laboratory of a 400-bed multilevel geriatric hospital. RESULTS During the 2 years of the study period, 3453 blood cultures have been performed; 368 positive blood cultures (10%) were detected in 309 patients. The total mortality rate at 2 weeks was 42%. One quarter of the deaths occurred in the first 3 days of the septic event (rapidly fatal period). Escherichia coli was the most common isolate (detected in 31% of cases). The second most common isolates were Staphylococcus aureus (19%; 63% of them MRSA) with a mortality of 39% and Proteus mirabilis (18%) with a 51% mortality rate. Urinary tract infection was the leading cause (70%), followed by decubitus ulcers (25%) and respiratory tract infections (12%). CONCLUSIONS the number of elderly skilled patients with severe and complex conditions in LTC facilities is increasing and more infections complicated by bacteremia are expected, requiring high clinical suspicion, close surveillance, and adequate reporting.

Postprandial hypotension in long-term care elderly patients on enteral feeding

OBJECTIVES: To examine the prevalence and nature of postprandial hypotension (PPH) in orally fed (OF), nasogastric tube (NGT)‐fed, and percutaneous endoscopic gastrostomy (PEG)‐fed older people.

Management of adverse clinical events by duty physicians in a nursing home

Background and aims: The nature of adverse clinical events (ACE) during duty hours (16:00-08:00 and holidays), as well as the way they are addressed by duty physicians (DP) in a nursing home (NH) are the subject of this study. Methods: Data, including medical details concerning ACEs and the resultant referrals to hospital, were collected prospectively during 183 consecutive days in a 90-bed NH. Results: Ninety-six residents experienced 370 ACEs, representing an average of one for every 44.5 patient days. The highest rate of events was during evening hours (18:00–21:00). The most prevalent ACE was fever (32%). Most cases (53%) were treated by the DPs on site. No intervention was needed in 19% of cases, whereas 28% of ACEs (104 cases) were referred to the Emergency Room (ER) of a general hospital. Sixty-six percent of these were actually admitted. The rate of ER referral of residents was one for every 158 patient days. About 40% of the referred patients had been discharged from hospital the previous week. High fever was the commonest cause for referral: 47%. During the working hours of the study period, the rate of referral by the staff physician was only 1 for every 915 patient days. Only 17% of these had high fever. Conclusions: Evening rounds by staff physicians, strengthening of working relations with hospital physicians, as well as fostering intravenous treatment in NHs, are suggested as means for reducing hospital transfers. A standardized method for the reporting of ACEs and referrals to hospitals should be adopted in order to facilitate comparisons between NHs and to evaluate its use as a quality indicator.

Pharmacokinetics of ciprofloxacin in hospitalized geriatric patients: comparison between nasogastric tube and oral administration.

Objectives: Drug administration to debilitated elderly patients on enteral feeding through a nasogastric tube (NGT) can modify the pharmacokinetic characteristics of the drug and influence its therapeutic blood concentration. The aim of this study was to evaluate the pharmacokinetics of ciprofloxacin administered through an NGT and to compare it with those of a group of patients receiving the drug orally. Methods: Twenty patients in stable clinical and hemodynamic condition from the long-term care ward of a geriatric multilevel hospital were studied. Patients in group 1 (n = 10) had oropharyngeal dysphagia and received food and medications, including ciprofloxacin, by NGT. Group 2 (n = 10) included age- and disease-matched orally fed patients from the same department receiving ciprofloxacin orally. Blood samples for ciprofloxacin concentration were taken at steady state, before drug administration, time 0, and at 1, 2, 3, 4, 6, 8, and 10 hours after drug administration. Ciprofloxacin was measured using liquid chromatography with tandem mass spectrometric detection. The mean daily dose was the same in both the groups: 1000 mg (500 mg twice daily). Results: Pharmacokinetic parameters of ciprofloxacin were not significantly different between the 2 groups: trough concentrations were 1.24 ± 0.95 &mgr;g/mL (0.25–3.67 &mgr;g/mL) versus 1.30 ± 0.61 &mgr;g/mL (0.21–2.36 &mgr;g/mL) (P = 0.76); Cmax 3.30 ± 2.16 &mgr;g/mL (1.54–8.62 &mgr;g/mL) versus 4.24 ± 1.99 &mgr;g/mL (2.24–9.02 &mgr;g/mL) (P = 0.356); tmax 2.8 ± 1.5 versus 3.1 ± 2.8 hours (P = 0.799); and AUC0–10 20.2 ± 12.1 &mgr;g·h−1·mL−1 (9–51.07 &mgr;g·h−1·mL−1) versus 24.4 ± 13.0 &mgr;g·h−1·mL−1 (5.57–52.48 &mgr;g·h−1·mL−1) (P = 0.493), in the oral fed versus NGT, respectively. Conclusions: Ciprofloxacin pharmacokinetic parameters are not significantly different between patients receiving the drug through NGT compared with those who received it orally, and therefore, in frail elderly patients, this route of administration can be considered.

Clostridium difficile-associated disease: A primary clinical evaluation of elderly patients in a geriatric hospital

The purpose of this study was to screen all cases of Clostridium difficile-associated disease during a 2-year period in a geriatric hospital to determine the incidence and clinical characteristics related to this risk. Twenty percent of suspected cases were diagnosed as positive and analyzed. The C difficile disease-associated clinical factors were ischemic heart disease and chronic obstructive pulmonary disease. Use of acetylsalicylic acid, other nonsteroidal anti-inflammatory drugs, and steroids were more frequently found in the non-C difficile group. There were fewer cases in men than in women and more in patients residing in skilled nursing wards.

Evaluation of an intra-institutional diabetes disease management program for the glycemic control of elderly long-term care diabetic patients

Increasing numbers of nursing home elderly patients suffer from diabetes requiring individually optimized glycemic control. This is a complicated challenge because of their high comorbidity level, and heterogeneous and changing eating status varying from independent to dysphagia and enteral feeding. In order to cope with these complex needs, we developed and implemented a diabetes disease management program. The purpose of the present study was to evaluate this program.

Metabolic alkalosis in skilled nursing patients

Renal failure is common among the long-term care (LTC) elderly. Little is known about the acid/base status of these patients. The aim of this study is to evaluate the relationship between the acid base status and renal function in a representative group of skilled nursing patients and relate it to their feeding status. LTC elderly patients, in stable clinical condition, 50 on naso-gastric tube (NGT) feeding, 40 orally fed (OF), were recruited to this study. As controls, we studied a group of 30 elderly independent, ambulatory patients admitted to the acute geriatric departments of the hospital for different causes which were not related to their acid-base status. Venous blood was taken for the routine tests and blood gases. In the LTC study groups a 24-h urine collection was examined for biochemical parameters and calculations of all clearances. Glomerular filtration rate (GFR) was estimated by the Cockroft and Goult and MDRD formulas. Renal function was similar in the two main study groups. Daily secretion of sodium and chloride were 50% lower in the NGT fed patients (p<0.001). The LTC elderly patients had significantly higher venous pH values, with no differences in pCO(2) or HCO(3). An alkalotic state (pH>7.45) was found in 13.6% of them (18% in the NGT and 6.5% in the OF) while none of the independent elderly had such values (p<0.05). Similarly, HCO(3)>34 was found in 12% of the LTC elderly versus none in the independents (p=0.06). Values of pO(2) and O(2) saturation were significantly higher in the nursing elderly and mainly those fed by NGT. Hemoglobin levels had a significantly negative correlation with the pH (r=-0.3, p<0.002). In conclusion, unexpected metabolic alkalosis was found in a group of skilled nursing patients, more prominent in those fed by NGT. This finding warrants the inclusion of routine pH determination in patients whenever pharmacokinetic considerations are essential.

Roxithromycin Pharmacokinetics in Hospitalized Geriatric Patients: Oral Administration of Whole Versus Crushed Tablets.

Background: Drug administration as tablets to debilitated elderly patients in crushed form can modify the pharmacokinetic characteristics of the active components. Only scarce information is available on the pharmacokinetics when administered in such form. The aim of this study was to evaluate the pharmacokinetics of roxithromycin administered in crushed form and to compare it with the pharmacokinetics of a group of geriatric patients receiving it in the conventional tablet form. Methods: Twenty patients from the acute ward of the Shmuel Harofeh Geriatric Medical Center in stable, clinical, and hemodynamic condition were studied. Patients in group 1 (n = 10) received medications orally in tablet form. Group 2 (n = 10) included age- and disease-matched patients from the same department, who received oral roxithromycin in crushed tablet form. The mean daily dose was the same in both groups: 300 mg (150 mg twice daily). The patients received the drug for 3 days before the initiation of the study. Blood samples for determination of the roxithromycin concentration were taken at the baseline, 1 hour before the drug administration, and at 1, 3, 4, 6, 8, and 10 hours after drug administration. Roxithromycin concentration was measured by a liquid chromatography–tandem mass spectrometry method. Results: Pharmacokinetic parameters of roxithromycin were significantly different between the 2 groups: the Cmin and Cmax were significantly higher, the tmax significantly longer, AUC0–10 larger, and CL/F smaller in group 2. Conclusions: Roxithromycin pharmacokinetic parameters were significantly different between the 2 patient groups resulting in higher drug serum concentrations in the crushed tablets group. The impact of the increased drug exposure is unclear.

Blood Transfusion Reactions in Elderly Patients Hospitalized in a Multilevel Geriatric Hospital

Background/Objectives. Blood transfusion is a critical issue for patients with chronic diseases such as heart failure, chronic kidney disease, and malignancy. However, side effects are not rare. The purpose of the study is to evaluate the frequency of adverse blood transfusion reactions in hospitalized elderly patients during a one-year period. Design/Setting/Participants. Blood transfusion reactions such as fever, chills, dyspnea, and others following blood transfusions in hospitalized geriatric patients during one-year period were examined. Results. 382 blood units (242 patients) were administered during the study period. In 40 (11%) cases, blood transfusion reactions occurred. Fever was the most common reaction in 29 cases (72%), four (10%) had shortness of breath, and 3 (8%) had vomiting and chills each. There were no lethal cases in the 24-hour period following blood transfusions. Conclusion. A relatively low rate of adverse blood transfusion reactions occurred in our geriatric patients. We may speculate that this is related to underreporting of minor symptoms due to the high percentage of demented patients in this population.