Märtha Sund-Levander

Inverse relationship between body mass index and mortality in older nursing home residents: A meta-analysis of 19,538 elderly subjects

Body mass index (BMI) and mortality in old adults from the general population have been related in a U‐shaped or J‐shaped curve. However, limited information is available for elderly nursing home populations, particularly about specific cause of death. A systematic PubMed/EMBASE/CINAHL/SCOPUS search until 31 May 2014 without language restrictions was conducted. As no published study reported mortality in standard BMI groups (<18.5, 18.5–24.9, 25–29.9, ≥30 kg/m2), the most adjusted hazard ratios (HRs) according to a pre‐defined list of covariates were obtained from authors and pooled by random‐effect model across each BMI category. Out of 342 hits, 20 studies including 19,538 older nursing home residents with 5,223 deaths during a median of 2 years of follow‐up were meta‐analysed. Compared with normal weight, all‐cause mortality HRs were 1.41 (95% CI = 1.26–1.58) for underweight, 0.85 (95% CI = 0.73–0.99) for overweight and 0.74 (95% CI = 0.57–0.96) for obesity. Underweight was a risk factor for higher mortality caused by infections (HR = 1.65 [95% CI = 1.13–2.40]). RR results corroborated primary HR results, with additionally lower infection‐related mortality in overweight and obese than in normal‐weight individuals. Like in the general population, underweight is a risk factor for mortality in old nursing home residents. However, uniquely, not only overweight but also obesity is protective, which has relevant nutritional goal implications in this population/setting.

Time for a change to assess and evaluate body temperature in clinical practice.

The definition of normal body temperature as 37 degrees C still is considered the norm worldwide, but in practice there is a widespread confusion of the evaluation of body temperature, especially in elderly individuals. In this paper, we discuss the relevance of normal body temperature as 37 degrees C and consequences in clinical practice. Our conclusion is that body temperature should be evaluated in relation to the individual variability and that the best approach is to use the same site, and an unadjusted mode without adjustments to other sites. If the baseline value is not known, it is important to notice that frail elderly individuals are at risk of a low body temperature. In addition, what should be regarded as fever is closely related to what is considered as normal body temperature. That is, as normal body temperature shows individual variations, it is reasonable that the same should hold true for the febrile range.

Morbidity, Mortality and Clinical Presentation of Nursing Home-acquired Pneumonia in a Swedish Population

Pneumonia has been estimated to be the second most common infection in nursing-home residents. However, to the authors’ knowledge, no such Swedish data are available. Therefore, this study investigated the incidence, risk factors, and 30 d case-fatality rate and clinical presentation of nursing home-acquired pneumonia (NHAP) in 234 nursing-home residents aged 66–99 y. Activities of daily living (ADL status), malnutrition and body mass index were measured at baseline. The residents were then followed prospectively during 1 y for symptoms and signs of pneumonia. Pneumonia was verified clinically and/or radiologically in 32 residents, corresponding to a yearly incidence of 13.7%. The 30 d case-fatality rate was 28%. Cough and sputum production were the most specific, and fever ≥38.0°C rectally and cognitive decline were the most common non-specific presenting symptoms. Chronic obstructive pulmonary disease, ADL status >5 and male gender were risk factors for acquiring pneumonia. In conclusion, NHAP is associated with high morbidity and mortality in Sweden. In order not to delay treatment, it is necessary to be aware that specific symptoms of pneumonia may be lacking in the clinical presentation in the nursing-home setting.

The impact of ADL status, dementia and body mass index on normal body temperature in elderly nursing home residents.

A subset of seniors might demonstrate a lower body temperature compared with younger subjects. However, data on normal body temperature in seniors are sparse. The aim of the study was to study normal body temperature with a view of predicting factors of low body temperature in non-febrile seniors. Elderly women (n=159) and 78 men, aged > or =65 years, living in community resident homes were included in the study. Data on chronic diseases and medication were collected from medical records. Tympanic and rectal temperature was measured twice daily; once at 7-9 AM and then at 6-8 PM. In addition, body mass index (BMI), activities of daily living (ADL) status, as well as details regarding dementia and malnutrition were recorded. The variation in tympanic and rectal temperatures ranged from 33.8 to 38.4 degrees C and 35.6 to 38.0 degrees C, respectively. ADL status, dementia and BMI were significantly related to lower and analgesic to higher tympanic temperature. Dementia was significantly related to lower rectal temperature. Therefore, dementia, BMI, ADL status and analgesic shall not be overlooked when assessing temperature in seniors. More research is needed to further clarify the influence of these predictive factors, as well as the impact of BMI and malnutrition.

Clinical decision-making process for early nonspecific signs of infection in institutionalised elderly persons : experience of nursing assistants

AIM To illuminate nursing assistants experiences of the clinical decision-making process when they suspect that a resident has an infection and how their process relates to other professions. BACKGROUND The assessment of possible infection in elderly individuals is difficult and contributes to a delayed diagnosis and treatment, worsening the goal of good care. Recently we explored that nursing assistants have a keen observational ability to detect early signs and symptoms that might help to confirm suspected infections early on. To our knowledge there are no published papers exploring how nursing assistants take part in the clinical decision-making process. DESIGN Explorative, qualitative study. SETTING Community care for elderly people. PARTICIPANTS Twenty-one nursing assistants, 22-61 years. METHODS Focus groups with verbatim transcription. The interviews were subjected to qualitative content analysis for manifest and latent content with no preconceived categories. FINDINGS The findings are described as a decision-making model consisting of assessing why a resident feels unwell, divided into recognition and formulation and strategies for gathering and evaluating information, influenced by personal experiences and preconceptions and external support system and, secondly, as taking action, consisting of reason for choice of action and action, influenced by feedback from the nurse and physician. CONCLUSION Nursing assistants assessment is based on knowing the resident, personal experiences and ideas about ageing. Nurses and physicians response to the nursing assistants observations had a great impact on the latters further action. A true inter-professional partnership in the clinical decision-making process would enhance the possibility to detect suspected infection early on, and thereby minimize the risk of delayed diagnosis and treatment and hence unnecessary suffering for the individual. RELEVANCE TO CLINICAL PRACTICE   In order to improve the clinical evaluation of the individual, and thereby optimise patient safety, it is important to involve nursing assistants in the decision-making process.

Guidelines for preventing urinary retention and bladder damage during hospital care

AIMS AND OBJECTIVES To develop evidence-based guidelines for adult patients in order to prevent urinary retention and to minimise bladder damage and urinary tract infection. BACKGROUND Urinary retention causing bladder damage is a well known complication in patients during hospital care. The most common treatment for urinary retention is an indwelling urinary catheter, which causes 80% of hospital-acquired urinary tract infections. Appropriate use of bladder ultrasonography can reduce the rate of bladder damage as well as the need to use an indwelling urinary catheter. It can also lead to a decrease in the rate of urinary tract infections, a lower risk of spread of multiresistant Gram-negative bacteria, and lower hospital costs. DESIGN An expert group was established, and a literature review was performed. METHODS On the basis of literature findings and consensus in the expert group, guidelines for clinical situations were constructed. RESULTS The main points of the guidelines are the following: identification of risk factors for urinary retention, managing patients at risk of urinary retention, strategies for patients with urinary retention and patient documentation and information. CONCLUSION Using literature review and consensus technique based on a multiprofessional group of experts, evidence-based guidelines have been developed. Although consensus was reached, there are parts of the guidelines where the knowledge is weak. RELEVANCE TO CLINICAL PRACTICE These guidelines are designed to be easy to use in clinical work and could be an important step towards minimising bladder damage and hospital-acquired urinary tract infections and their serious consequences, such as bacteraemia and the spread of multidrug-resistant bacteria in hospitals.

Differences in levels of albumin, ALT, AST, γ-GT and creatinine in frail, moderately healthy and healthy elderly individuals.

Abstract Background: Reference intervals are widely used as decision tools, providing the physician with information about whether the analyte values indicate ongoing disease process. Reference intervals are generally based on individuals without diagnosed diseases or use of medication, which often excludes elderly. The aim of the study was to assess levels of albumin, alanine aminotransferase (ALT), aspartate aminotransferase (AST), creatinine and γ-glutamyl transferase (γ-GT) in frail, moderately healthy and healthy elderly indivuduals. Methods: Blood samples were collected from individuals >80 years old, nursing home residents, in the Elderly in Linköping Screening Assessment and Nordic Reference Interval Project, a total of 569 individuals. They were divided into three cohorts: frail, moderately healthy and healthy, depending on cognitive and physical function. Albumin, ALT, AST, creatinine and γ-GT were analyzed using routine methods. Results: Linear regression predicted factors for 34% of the variance in albumin were activities of daily living (ADL), gender, stroke and cancer. ADLs, gender and weight explained 15% of changes in ALT. For AST levels, ADLs, cancer and analgesics explained 5% of changes. Kidney disease, gender, Mini Mental State Examination (MMSE) and chronic obstructive pulmonary disease explained 25% of the variation in creatinine levels and MMSE explained three per cent of γ-GT variation. Conclusions: Because a group of people are at the same age, they should not be assessed the same way. To interpret results of laboratory tests in elderly is a complex task, where reference intervals are one part, but far from the only one, to take into consideration.