Joseph G. Ouslander

Drug therapy in the elderly.

Age-related biologic and physiologic changes in the elderly may lead to altered pharmacokinetics. Volume of distribution, half-life, systemic clearance, and receptor sensitivity have been shown to change with increasing age. Unique features of illness in the elderly may interfere with effective drug therapy more than changed pharmacokinetics in some patients. Physical, psychologic, and socioeconomic considerations often interfere with ability to obtain and comply with health care. Disease is often difficult to recognize in elderly patients. Multiple chronic conditions, many of which may be undetected, may be exacerbated by or alter drug therapy for other illnesses. Cognitive impairment and diminished vision and hearing may make patient education difficult, and compliance poor. The elderly are also more susceptible to adverse drug reactions. The recommendations for clinical practice and directions for future research that are presented should help make drug therapy in the elderly safer and more effective.

Potentially Avoidable Hospitalizations of Nursing Home Residents: Frequency, Causes, and Costs

OBJECTIVES: To examine the frequency and reasons for potentially avoidable hospitalizations of nursing home (NH) residents.

Interventions to Reduce Hospitalizations from Nursing Homes: Evaluation of the INTERACT II Collaborative Quality Improvement Project

A substantial proportion of hospitalizations of nursing home (NH) residents may be avoidable. Medicare payment reforms, such as bundled payments for episodes of care and value‐based purchasing, will change incentives that favor hospitalization but could result in care quality problems if NHs lack the resources and training to identify and manage acute conditions proactively. Interventions to Reduce Acute Care Transfers (INTERACT) II is a quality improvement intervention that includes a set of tools and strategies designed to assist NH staff in early identification, assessment, communication, and documentation about changes in resident status. INTERACT II was evaluated in 25 NHs in three states in a 6‐month quality improvement initiative that provided tools, on‐site education, and teleconferences every 2 weeks facilitated by an experienced nurse practitioner. There was a 17% reduction in self‐reported hospital admissions in these 25 NHs from the same 6‐month period in the previous year. The group of 17 NHs rated as engaged in the initiative had a 24% reduction, compared with 6% in the group of eight NHs rated as not engaged and 3% in a comparison group of 11 NHs. The average cost of the 6‐month implementation was

Does eradicating bacteriuria affect the severity of chronic urinary incontinence in nursing home residents

7,700 per NH. The projected savings to Medicare in a 100‐bed NH were approximately

Medical care in the nursing home

125,000 per year. Despite challenges in implementation and caveats about the accuracy of self‐reported hospitalization rates and the characteristics of the participating NHs, the trends in these results suggest that INTERACT II should be further evaluated in randomized controlled trials to determine its effect on avoidable hospitalizations and their related morbidity and cost.

Incontinence in the Nursing Home

Urinary incontinence is a multibillion-dollar health problem that afflicts almost 60% of some 2 million residents of the 20 000 nursing homes in the United States. Bacteriuria is also prevalent in this population, and the two conditions commonly coexist [1]. Incontinent nursing home residents are frequently prescribed antimicrobial agents for urinary tract infections, but the quality and appropriateness of such prescriptions have been questioned [2-5]. Unnecessary antimicrobial treatment may result in the undesired development of resistant organisms and substantial unnecessary morbidity and health care expenditure. Well-designed clinical trials have documented that treating asymptomatic bacteriuria in the nursing home population has no significant effects on morbidity and mortality and that it actually leads to the development of strains of bacteria that are resistant to commonly prescribed antimicrobial agents [6, 7]. However, no studies have carefully examined the effects of eradicating bacteriuria on the severity of incontinence in this population. In a longitudinal study of a cohort of older women, Boscia and colleagues [8] found no difference in self-reported symptoms of incontinence in patients with and without bacteriuria. This was, however, a study of bacteriuria and not of incontinence, and the participants had, on average, mild incontinence [9]. In one study of behavioral therapy for incontinence in nursing home residents, incontinence appeared to worsen in several of the study participants when bacteriuria developed [10]. Epidemiologic studies from Europe have reached different conclusions about the association between bacteriuria and incontinence in the geriatric population [11, 12]. Despite a lack of definitive data on the relation of bacteriuria to the pathogenesis and severity of incontinence in the nursing home population, recently implemented federal guidelines for the care of incontinence in nursing homes (Resident Assessment Protocol) [13] suggest that bacteriuria should be treated only when symptoms of urinary tract infection other than stable incontinence are present. If eradicating bacteriuria makes the bladder less irritable in this patient population, then the severity of incontinence and the use of expensive adult diapers might be reduced [14]. If, however, eradicating bacteriuria has no effect on the severity of incontinence, no rationale would exist for exposing incontinent nursing home residents with bacteriuria to the potential added morbidity and expense of antimicrobial therapy. We conducted a clinical trial to determine whether eradicating bacteriuria affects the severity of incontinence among nursing home residents. We defined bacteriuria as would a practicing clinician in a nursing home rather than by the strict definition used in most studies of the epidemiology of asymptomatic bacteriuria (that is, two consecutive cultures with growth of more than 105 colony-forming units [CFUs] of the same organism). We hypothesized that sterilizing the urine would have no short-term effect on the severity of chronic incontinence in this population. Methods Setting Our study was the first phase of a multifaceted clinical trial addressing the assessment and treatment of incontinence in nursing homes. It was done in one nonprofit and five proprietary nursing homes located close to the offices of the University of California at Los Angeles Borun Center for Gerontological Research at the Jewish Home for the Aging. The nursing homes had a total of 1011 beds (range, 99 to 256 beds) and a total of 832 residents. Patients We identified potential patients by asking nursing home staff to identify residents who were incontinent of urine on a regular basis [that is, several times per week to several times per day]. Patients were excluded if 1) their care was being reimbursed by Medicare [indicating either short-term rehabilitation or medical instability]; 2) their prognosis, as determined by the research staff nurse, was so poor that they would probably not live at least 3 to 4 months to complete the protocol; 3) daytime incontinence was not documented by random-hour checks for wetness [described below]; 4) the resident had a permanent indwelling bladder catheter; 5) the resident failed a cognitive status screening test [to pass, the resident had to either say their name or reliably point to one of two objects]; and 6) the resident manifested a severe behavioral disturbance, such as physical aggression or verbal abusiveness, during the wet-checking procedures. Informed consent was obtained from residents who could provide it (as determined by a facility nurse or social worker). If the resident was not capable of consenting, their assent was obtained (by describing a simple version of the protocol and then observing their cooperation as the protocol was initiated), and consent was then obtained from a responsible party. Procedures All patients for whom informed consent was obtained had a focused history, functional status assessment, cognitive assessment with the 30-point Mini-Mental State Examination, targeted physical examination, urinalysis, and urine culture. For the functional assessment, research staff used the Multidimensional Observational Scale for the Elderly Subject [15] to interview nursing home staff who knew the residents well. (When our study was implemented, the Minimum Data Set was not yet available.) Research staff used a standardized scale (Performance on Timed Toileting Instrument [16]) to objectively assess functional status specifically related to toileting skills. The physical examination was done by research staff and a physician coinvestigator and included abdominal, genital, pelvic, rectal, and neurologic examinations. Research staff collected urine from female patients by cleaning the perineal area with Betadine and having them void into a fracture bed pan or measuring hat that had been cleaned with an antiseptic solution. We compared the culture results of urine samples obtained by this procedure to urine samples obtained by catheterization in 101 of our female patients [17]. The prevalence of bacteriuria in the catheterized specimens was 29%. The sensitivity, specificity, and positive and negative predictive values of this procedure in detecting bacteriuria (with a catheter specimen used as the criterion standard) are 90%, 92%, 81%, and 95%, respectively. For men who could not void voluntarily, we used a previously validated technique that involved cleaning the glans penis with Betadine, applying a clean condom catheter, and processing the first voided specimen [18]. Urine specimens were subjected to screening tests done by research staff (including a dipstick method for leukocyte esterase and nitrite and a rapid enzyme-based test for bacteriuria [Uriscreen, Ventrex Laboratories, Portland, Maine]). A bioclinical laboratory used standard techniques to do a microscopic urinalysis and a urine culture and sensitivity test. We defined pyuria as the presence of more than 10 leukocytes per high-power field on microscopic examination of spun urine. Cultured specimens that grew more than 50 000 CFUs were considered to have significant growth. If significant growth of one or more urinary pathogens occurred on a second specimen, the patient was considered to be bacteriuric. Patients whose urine had significant growth of organisms that are not typically pathogens (for example, lactobacillus and -streptococcus) were not considered to be bacteriuric. Our quantitative definition of bacteriuria differs from the standard definition (presence of more than 100 000 CFUs) that has been used in most epidemiologic studies and intervention trials. However, there is controversy about the clinical significance of lower levels of growth [19], and in some studies in the elderly, bacteriuria has been defined as growth of less than 100 000 CFUs [20, 21]. We used the cutoff of 50 000 CFUs because our clinical laboratory reported results at this level, and we believe that most clinicians who practice in nursing homes would consider this to be significant growth when making decisions about treatment. Less than 10% of our cultures that were considered to have significant bacteriuria had growth of more than 50 000 CFUs. In addition, each patient identified as bacteriuric who had growth of more than 50 000 CFUs on one culture did have a second culture with growth of more than 100 000 CFUs; the only exceptions were two patients whose urine samples before treatment were collected by catheterization (see below). Most specimens obtained after antimicrobial treatment were collected by catheterization, which was done for a determination of postvoid residual volume in the second phase of the longer ongoing clinical trial. Six patients whose urine was initially not bacteriuric by the criteria outlined above were considered to be bacteriuric on the basis of the catheterized specimen and were enrolled in the antimicrobial trial. For these patients, follow-up urine samples were collected by the methods described above rather than by repeat catheterization. Eradication of bacteriuria was documented by culture in all but seven cases; in these cases, the screening tests were used to document that bacteriuria had been eradicated. We have shown that in our population, the presence of at least two negative results on these screening tests has a negative predictive value of more than 90% [22]. Bacteriuric patients were randomly assigned to receive either immediate treatment or delayed treatment (which was administered 2 to 3 weeks after the immediate treatment group had been treated) with a 7-day course of norfloxacin, 400 mg orally twice daily. In three cases, the organism or organisms were not susceptible to norfloxacin, and another antimicrobial agent (trimethoprim-sulfamethoxazole) was used on the basis of results of the sensitivity testing. Wet checks, the outcome measure used in our study and described in detail below, w

The Effects of Patterned Urge‐Response Toileting (PURT) on Urinary Incontinence among Nursing Home Residents

EVERY day more than 1.5 million Americans awaken in 1 of close to 20 000 nursing homes.1Some of these facilities provide excellent care, but the poor quality of care provided by many nursing homes has been repeatedly documented in the lay press, medical literature, and congressional testimony (Los Angeles Times. February 17, 1989; pt 1:3).2-4While the problems of many nursing home residents are more functional and psychosocial than medical,1,5the increasing acuity of medical conditions in this population since the implementation of the prospective payment system6,7demands that physicians be intimately involved in care provided in nursing homes. Yet, the majority of primary care physicians do not participate in the care of nursing home residents,8and very few of those who do provide care for substantial numbers of nursing home residents have received formal training in geriatric medicine or long-term care. Physician visits

Reducing Unnecessary Hospitalizations of Nursing Home Residents

Incontinence is one of the most common conditions encountered in the nursing home population. Recently implemented rules and regulations for nursing home care (Omnibus Budget Reconciliation Act [OBRA] 1987) [1] require that incontinent nursing home residents have a basic diagnostic assessment and that residents managed by an indwelling bladder catheter have an appropriate indication for this device documented in their medical record. The federally mandated Minimum Data Set (MDS) [2] includes a separate section for the documentation of continence status that is completed by nursing home staff within 14 days of admission and updated on a quarterly basis. Incontinence documented on the MDS should trigger the use of the Resident Assessment Protocol for incontinence [3]. Some of this assessment can be done by a trained nurse practitioner, physicians assistant, or clinical nurse specialist with input from members of the nursing home interdisciplinary team. The assessment does, however, require the involvement of the primary physician. We provide an overview of the assessment and treatment of incontinence in the nursing home setting. Prevalence and Morbidity Urinary incontinence affects approximately half of nursing home residents [4, 5]. The prevalence varies among individual facilities depending on the case mix; rates may range from 40% to 70% or even higher in facilities with a functionally impaired resident population. In contrast to urinary incontinence among ambulatory community-dwelling geriatric patients, urinary incontinence among nursing home residents is more severe and more commonly associated with fecal incontinence. Incontinent nursing home residents generally have multiple episodes of urinary incontinence throughout the day and night, and approximately half are also incontinent of stool more than once per week [5, 6]. Urinary incontinence in the nursing home is associated with substantial morbidity and cost. It can predispose patients to skin irritation, make pressure ulcers difficult to heal [7], and result in symptomatic urinary tract infection when urinary retention with overflow urinary incontinence remains undiagnosed or when urinary incontinence is inappropriately managed by long-term use of an indwelling catheter [8, 9]. It may also lead to falls among residents with nocturia and urge urinary incontinence and impaired balance or gait [10]. The adverse psychological effects of urinary incontinence among nursing home residents have been difficult to document systematically [11], but incontinent residents who do not have severe dementia are often embarrassed and frustrated by their urinary incontinence. Nursing home staff generally consider urinary incontinence to be one of the most onerous and difficult conditions for which they care, and they perceive that they spend a disproportionate amount of time on the care of incontinent residents. The economic costs of urinary incontinence in the nursing home have been estimated to be close to

The Interventions to Reduce Acute Care Transfers (INTERACT) Quality Improvement Program: An Overview for Medical Directors and Primary Care Clinicians in Long Term Care

5 billion annually, including the costs of staff time, laundry, and supplies [12]. Types and Causes of Urinary Incontinence The pathogenesis of urinary incontinence among nursing home residents is often multifactorial, involving urologic and gynecologic conditions, neurologic disorders, behavioral and psychological factors, and functional impairments. Thus, the approach to assessment and treatment must be comprehensive and consider all of these potential factors. The most important factors to consider are those that are reversible. Potentially reversible conditions that can contribute to urinary incontinence in nursing home residents are listed in Table 1. These factors can be recalled by the acronym DRIP (delirium; restricted mobility, retention; infection, inflammation, impaction; polyuria, pharmaceuticals). Although identification and management of these reversible factors may not cure the urinary incontinence, its severity may be reduced and thereby be made more manageable by other interventions. In addition, identification and management of these conditions may have important benefits for the residents overall functioning and quality of life. Table 1. Potentially Reversible Conditions That Can Cause or Contribute to Urinary Incontinence in Nursing Home Residents A classification of the basic types of persistent urinary incontinence is shown in Table 2. Three important features of this classification should be noted. First, from a neurologic perspective, this classification is greatly simplified and does not include all of the pathophysiologic types of urinary incontinence. For example, patients with suprasacral spinal cord lesions, such as those that can occur in multiple sclerosis, may have detrusor hyperreflexia with external sphincter dyssynergy that can result in incontinence and incomplete bladder emptying (detrusor-sphincter dyssynergy). Second, many incontinent nursing home residents have mixtures of these types of incontinence. The predominant abnormality of lower urinary tract functioning found among nursing home residents is detrusor hyperactivity (involuntary bladder contractions found on cystometry; also called detrusor instability, unstable bladder, and detrusor hyperreflexia [the latter occurs in the presence of a neurologic disorder]). Although most often associated with urge urinary incontinence, detrusor hyperactivity is commonly seen with sphincter weakness and stress urinary incontinence among women and with obstruction in men with benign or malignant enlargement of the prostate. Interestingly, detrusor hyperactivity is also seen in continent elderly people (men more frequently than women) [13, 14]; thus, its precise role in the pathogenesis of incontinence in the nursing home population is incompletely understood. In nursing home residents, detrusor hyperactivity is commonly associated with impaired bladder contractility that results in incomplete bladder emptying (called detrusor hyperactivity with impaired contractility) [15, 16]. Nursing home residents with this disorder may have symptoms that mimic stress, overflow, or urge incontinence. Third, and most importantly, functional urinary incontinence should be a diagnosis of exclusion because most nursing home residents have impairments of cognitive or physical functioning that may interfere with their ability to use a toilet. These residents may also have other potentially treatable conditions that contribute to their urinary incontinence. Thus, a search for reversible factors and other types of urinary incontinence should be done before a nursing home residents urinary incontinence is labeled as functional. Table 2. Types and Causes of Urinary Incontinence Assessment Nursing home residents are heterogeneous, and a realistic and appropriate goal for one type of resident may be unrealistic and inappropriate for another [17, 18]. The approach to urinary incontinence brings this concept into sharp focus. A resident having active rehabilitation after a hip fracture or a stroke may, after a thorough incontinence assessment, benefit from a specific bladder-retraining protocol or pharmacologic therapy for detrusor hyperactivity; incontinence undergarments and indwelling catheters are probably inappropriate for this type of resident. On the other hand, a resident with end-stage dementia and severe agitation may be most appropriately managed by an incontinence undergarment after reversible causes of their urinary incontinence have been excluded. Thus, an important aspect of incontinence care is to determine, through the interdisciplinary care-planning process, if a particular resident has the potential to respond to specific interventions for the urinary incontinence. Because even severely impaired residents may respond well to a prompted voiding program (see below), a bias in favor of thorough assessment and a therapeutic trial is appropriate. Basic assessment of bladder and bowel function as indicated on the MDS is required for all newly admitted nursing home residents. A bladder and bowel record is helpful in documenting the continence status of new residents and can also be used as part of periodic reassessments. A legible record, such as the one shown in Figure 1, should be used [19]. The specific symbols used are not important, but the record should provide a simple way of documenting wetness, dryness, appropriate toileting, and bowel status and a space for comments. Records such as the one shown in Figure 1 can be reduced so that several records fit on one page. This type of record is also helpful in monitoring responses to therapeutic interventions. Because many newly admitted residents come from acute-care hospitals, they frequently arrive at the nursing home with an indwelling bladder catheter. In this situation, it is essential to determine why the catheter was placed (for example, to monitor urinary output or for urinary retention or management of urinary incontinence) and to consider the resident for a bladder-retraining program. The catheter should be removed unless there is an appropriate indication for retaining it. Figure 1. Example of a record that is helpful in assessing incontinent nursing home residents and in following their response to intervention. Basic Evaluation After these initial assessments and documentation, incontinent nursing home residents should have a basic evaluation that includes a history, physical examination, urinalysis, and determination of postvoid residual urine volume. Much of this evaluation can be done by nursing home staff and a physician extender [nurse practitioner, physicians assistant, or clinical nurse specialist]. This basic evaluation has three objectives: 1) to identify potentially reversible factors (Table 1); 2) to identify potentially serious underlying conditions or conditions that may require further urologic, gynecologic, or urodynamic evaluation (Table 3); and 3) to determine the type of incontinence (urge, stress, overflow, or mix

Effect of fesoterodine in vulnerable elderly subjects with urgency incontinence: A double-blind, placebo controlled trial

To test an individualized form of habit training for urinary incontinence (UI) among long‐stay cognitively and/or physically impaired elderly nursing home residents over time.