James P. Richardson

Bacteremia in the elderly

SummaryBacteremia has a high mortality rate in all elderly populations, but especially nursing home residents and the hospitalized elderly. Elderly patients with bacteremia may present in a nonspecific fashion with incontinence, with falls, or afebrile. Mortality is greater in patients whose bacteremia originates outside the genitourinary tract or who are bacteremic with gram-positive organisms. Early appropriate treatment has been found to reduce mortality in some studies, especially in patients over 85 years old or with gram-positive bacteremias.Gram-negative bacteremias are more common than those caused by gram-positive organisms in most studies.E. coli is the most common gram-negative isolate, followed in most studies by either Proteus or Klebsiella. Staphylococcus aureus is the most common gram-positive isolate; enterococcus and pneumococcus are also frequently isolated.Bacteremia in the elderly may present in a subtle fashion. Appropriate antibiotic therapy may reduce mortality and should include antibiotic coverage forS. aureus and gram-negative bacilli, as well as for anaerobes if pressure ulcers are suspected as the source. Clinicians who care for the elderly should be aware of the possible presentations of bacteremia and the appropriate treatment in all clinical settings.

STAFF AND ELDERLY KNOWLEDGE AND ATTITUDES TOWARD ELDERLY SEXUALITY

This study compared staff and elderly knowledge, attitudes, and practices related to sexual expression by elderly persons in a long‐term care setting. Volunteers (N = 194) responded agree or disagree to 159 items. Significant differences were observed between the staff and elderly responses on 36 items. Areas of greatest differences involved knowledge and attitudes about consensual sex and sexual abuse, issues related to family attitudes toward remarriage and sexual expression, and age‐related changes and health problems related to sexuality. Items related to masturbation received the greatest percentage of no response. The staff had significantly higher total scores as compared to the elderly reflecting more knowledge, positive attitudes, and support for more proactive responses toward elderly sexuality. Findings have major implications for staff training in long‐term care settings.

The management and prevention of tetanus

Tetanus is a rare disease in the United States, but it has a high mortality rate and is preventable through immunization. Using a computerized literature search, we reviewed English language articles on tetanus in the United States. We found that despite the availability of an effective vaccine, tetanus still causes considerable morbidity. The elderly are at great risk of tetanus, because they have never been immunized or their immunity has waned. Emergency physicians can reduce the likelihood of tetanus by ensuring appropriate wound care, including tetanus immunization and use of tetanus immune globulin, as appropriate. Treatment consists of neutralization of circulating toxin, surgical excision to eliminate the source of toxin, control of muscle spasms, and prevention of respiratory and metabolic complications. A case-finding approach for all persons who receive care in emergency departments will reduce the size of the susceptible population.

Management Of Tetanus In The Elderly

Background: Tetanus is primarily a disease of the elderly. Both the incidence and the case-fatality rates are higher in the elderly population. Physicians need to be aware of special needs concerning the treatment of tetanus in this population. Methods: A comprehensive review of the literature concerning the treatment of tetanus was undertaken. Using the key words “tetanus,” “geriatric,” “elderly,” and “aged,” the MEDLINE files were searched from 1985 to the present. Articles dating before 1985 were accessed by cross-referencing the more recent articles. Results and Conclusions: Once the diagnosis of tetanus is suspected, intensive, expectant management is necessary. The patient should receive intensive care with treatment aimed at prevention of muscle spasms, prevention of respiratory tract and metabolic complications, and neutralization of circulating toxin. Potential complications of tetanus include pulmonary embolus, aspiration pneumonia, malnutrition, and pressure sores.

Beliefs and Policies of Maryland Nursing Home Medical Directors Regarding Tetanus Immunization

Tetanus is more common in the elderly, who have a higher case‐fatality rate than younger age groups. Immunization against tetanus is recommended for all elderly, including nursing home residents, but the tetanus immunization policies of nursing homes are unknown. Nursing home medical directors in Maryland were surveyed about their beliefs concerning tetanus and the tetanus immunization policies of their nursing homes. One hundred twenty‐five directors of 212 responded (59%). In most of the nursing homes, no policies existed for routine tetanus immunization. Medical directors graduating from medical school after 1960 and medical directors with more than 50 nursing home patients were more likely to believe that tetanus immunization is cost‐effective in nursing home patients. Only 3% of the respondents always immunize their nursing home patients with chronic skin ulcers. We believe tetanus immunization is an uncommon practice in Maryland nursing homes. Nursing home medical directors should establish policies to promote tetanus immunization.

Health Promotion For The Nursing Home Patient

Background: The current nursing home population numbers at least 1.5 million and is growing. Although care of the nursing home patient has been emphasized recently, health promotion activities for these patients appear underused. Current recommendations for health promotion are based on expert opinion, because well-controlled studies to support such activities in the elderly are lacking for most practices. Methods: Using the key words “health promotion” and “preventive health services,” cross-referenced with “aged,” articles were selected from MEDLINE files from 1979 to the present. Bibliographies of these references were reviewed to select additional references. Results: A review of the literature shows that although health promotion activities are not appropriate for every nursing home patient, many patients live for years in the long-term care facility and can benefit from health promotion. Health promotion activities can be organized around patients’ length of stay. Procedures that should be considered include breast cancer screening, Papanicolaou smears for cervical cancer, hearing and vision loss screening, fall prevention assessment, immunizations, screening for dementia and depression, drug evaluation, screening for thyroid disease, and advance directives. Conclusions: Physicians who practice in nursing homes should consider health promotion for select nursing home patients.

TESTING FOR FECAL OCCULT BLOOD

We report this outbreak because it suggests that fomites, especially clothing and linens, may be a more efficient means of transmission of head lice than previously thought. Increasing numbers of ambulatory elderly choose to live in settings where the instrumentalities of daily living are assisted, such as meals, housekeeping, and l a ~ n d r y . ~ Thus, non-institutionalized elderly constitute a growing population at risk for pediculosis. Public health ordinances do not compel hotel managers or tenants to accept delousing programs. Fortunately, in this case, the management and many residents accepted intervention. Follow-up by the on-site physician identified no new cases after our intervention. There have been reports of lindane-tolerant scabies and Pediculosis ~api t i s .~ The very young and the very old may be more susceptible to toxicity.6, In this outbreak, several affected residents had previously been treated. No toxic reactions were recorded in subsequent visits from one of the physicians. However, in an on-going infestation the likelihood of repeated treatment and resulting toxicity is increased. We, therefore, recommend that pediculosis in an ambulatory, non-institutionalized elder prompt an inquiry into housing circumstances and provision of population-based interventions as needed.

Tetanus immunization: concerns about the elderly and about diphtheria reemergence.

pervis ing faculty m e m b e r . Our resul ts may no t be general izable to a cont inui ty clinic. Fur the rmore , cons t ra in t s of the research design (faculty we re ins t ruc ted to p u r s u e in d e p t h all significant f indings) may have increased supervisory time. Thus, Dr. Kountz s c o m m e n t s abou t t ime r e q u i r e m e n t s are wel l taken. It remains clear, however , tha t w h e n a t t end ing physic ians are based in a c o n f e r e n c e r o o m it may b e difficult for t h e m to have substantial con tac t wi th pa t ien ts w h o s e care they are supervising. Our s tudy h ighl igh ted the po ten t ia l def ic iencies of this model of ou tpa t i en t teaching, and cal led a t t en t ion to the need for a l ternat ive approaches . The firm system desc r ibed by Dr. Kountz is exact ly the sor t of innova t ive a l ternat ive that addresses the p rob l ems identif ied in our study.--VIRGINIA i . GENNIS, MD, and MARK A. GENNIS, MD, Division o f General Internal Medicine, University o f Wisconsin Medical School, Milwaukee Clinical Campus, Milwaukee, WI 53201-0342