Paul J. Drinka

Surveillance definitions of infections in long-term care facilities: revisiting the McGeer criteria.

(See the commentary by Moro, on pages 978-980 .) Infection surveillance definitions for long-term care facilities (ie, the McGeer Criteria) have not been updated since 1991. An expert consensus panel modified these definitions on the basis of a structured review of the literature. Significant changes were made to the criteria defining urinary tract and respiratory tract infections. New definitions were added for norovirus gastroenteritis and Clostridum difficile infections.

Relations of endogenous anabolic hormones and physical activity to bone mineral density and lean body mass in elderly men.

OBJECTIVES It has been proposed that declining activities of the somatotrophic or gonadotrophic axes, or sedentary life style, are partial causes for geriatric losses of bone mineral density (BMD) and of lean body mass (LBM). The present study tested these hypotheses by determining, in both free‐living and institutionalized elderly men, the correlations of bone mineral density (BMD), total body bone mineral content (TBBMC) and lean body mass (LBM) with the following predictor variables: age, body mass index, body weight, serum insulin‐like growth factor I (IGF‐I), serum testosterone, habitual physical activity and mobility.

SHEA/APIC Guideline: Infection Prevention and Control in the Long-Term Care Facility

Long-term care facilities (LTCFs) may be defined as institutions that provide health care to people who are unable to manage independently in the community.1 This care may be chronic care management or short-term rehabilitative services. The term nursing home is defined as a facility licensed with an organized professional staff and inpatient beds that provides continuous nursing and other services to patients who are not in the acute phase of an illness. There is considerable overlap between the 2 terms. More than 1.5 million residents reside in United States (US) nursing homes. In recent years, the acuity of illness of nursing home residents has increased. LTCF residents have a risk of developing health care-associated infection (HAI) that approaches that seen in acute care hospital patients. A great deal of information has been published concerning infections in the LTCF, and infection control programs are nearly universal in that setting. This position paper reviews the literature on infections and infection control programs in the LTCF. Recommendations are developed for long-term care (LTC) infection control programs based on interpretation of currently available evidence. The recommendations cover the structure and function of the infection control program, including surveillance, isolation precautions, outbreak control, resident care, and employee health. Infection control resources are also presented. Hospital infection control programs are well established in the US. Virtually every hospital has an infection control professional (ICP), and many larger hospitals have a consulting hospital epidemiologist. The Study on the Efficacy of Nosocomial Infection Control (SENIC) documented the effectiveness of a hospital infection control program that applies standard surveillance and control measures.2 The major elements leading to a HAI are the infectious agent, a susceptible host, and a means of transmission. These elements are present in LTCFs as well as in hospitals. It is not surprising, therefore, that almost as many HAIs occur annually in LTCFs as in hospitals in the US.3 The last 2 decades have seen increased recognition of the problem of infections in LTCFs, with subsequent widespread development of LTCF infection control programs and definition of the role of the ICP in LTCFs. An increasingly robust literature is devoted to LTC infection control issues such as the descriptive epidemiology of LTCF infections, the microbiology of LTCF infections, outbreaks, control measures, and isolation. Nevertheless, there is as yet no SENIC-equivalent study documenting the efficacy of infection control in LTCFs, and few controlled studies have analyzed the efficacy or cost-effectiveness of the specific control measures in that setting. Although hospitals and LTCFs both have closed populations of patients requiring nursing care, they are quite different. They differ with regard to payment systems, patient acuity, availability of laboratory and x-ray, and nurse-to-patient ratios. More fundamentally, the focus is different. The acute care facility focus is on providing intensive care to a patient who is generally expected to recover or improve, and high technology is integral to the process. In LTCFs, the patient population may be very heterogeneous. Most LTCFs carry out plans of care that have already been established in acute care or evaluate chronic conditions. The LTCF is functionally the home for the resident, who is usually elderly and in declining health and will often stay for years, hence comfort, dignity, and rights are paramount. It is a low-technology setting. Residents are often transferred between the acute care and the LTC setting, adding an additional dynamic to transmission and acquisition of HAIs. Application of hospital infection control guidelines to the LTCF is often unrealistic in view of the differences noted above and the different infection control resources. Standards and guidelines specific to the LTCF setting are now commonly found. The problem of developing guidelines applicable to all LTCFs is compounded by the varying levels of nursing intensity (eg, skilled nursing facility vs assisted living), LTCF size, and access to physician input and diagnostic testing. This position paper provides basic infection control recommendations that could be widely applied to LTCFs with the expectation of minimizing HAIs in LTC. The efficacy of these measures in the LTCF, in most cases, is not proven by prospective controlled studies but is based on infection control logic, adaptation of hospital experience, LTCF surveys, Centers for Disease Control and Prevention (CDC) and other guidelines containing specific recommendations for LTCFs, and field experience. Every effort will be made to address the unique concerns of LTCFs. Because facilities differ, the infection risk factors specific to the resident population, the nature of the facility, and the resources available should dictate the scope and focus of the infection control program. In a number of instances, specific hospital-oriented guidelines have been published and are referenced (eg, guidelines for prevention of intravascular (IV) device-associated infection). These guidelines are relevant, at least in part, to the LTC setting but may be adapted depending on facility size, resources, resident acuity, local regulations, local infection control issues, etc. Reworking those sources to a form applicable to all LTCFs is beyond the scope of this guideline. Any discussion of infection control issues must be made in the context of the LTCF as a community. The LTCF is a home for residents, a home in which they usually reside for months or years; comfort and infection control principles must both be addressed.

Correlates of depression and burden for informal caregivers of patients in a geriatrics referral clinic.

Caregiver burden has been associated with patient dementia. In this study we tested the hypothesis that caregiver burden and depression are related to patient cognitive impairment. We analyzed records of 127 elderly male patients from a Veterans hospital geriatrics referral clinic. The patients and their informal caregivers had been referred to the clinic because the complexity and multiplicity of their problems were beyond the treatment capability of other clinics. There was a high prevalence of dementia (73%) and depression (69%) in these patients according to Diagnostic and Statistical Manual (DSM‐III) criteria.

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.

The effect of overlying calcification on lumbar bone densitometry.

SummaryWe studied bone mineral density (BMD) of the spine using dual photon absorptiometry, as well as standard anterior-posterior and lateral lumbar spine X-ray film in 113 ambulatory elderly male volunteers with a mean age of 72 years (range 66–91 years). Each subject had three measurements taken for lumbar vertebrae 1 through 4: BMD, length of aortic calcification (AC), and degenerative facet sclerosis graded 0–3. A separate statistical model was fit to BMD for each vertebra using analysis of covariance. AC did not contribute significantly to BMD. BMD was increased by 0.28–0.03 g/cm2 (L1–L4) with a sclerosis score of 2, and by 0.47–0.25 g/cm2 with a sclerosis score of 3,P<0.001. The association between increased BMD and overlying facet sclerosis may be related to the bone density within the sclerosis itself or to an association between degenerative joint disease and a generalized increase in subchondral bone.

Mechanisms of Unexplained Anemia in the Nursing Home

Objectives: To characterize anemia in elderly nursing home residents.

Low Circulating Levels of Insulin-Like Growth Factors and Testosterone in Chronically Institutionalized Elderly Men

Objective: To determine the prevalences of and the associations between hyposomatomedinemia and hypogonadism in healthy young men, healthy old men, and chronically institutionalized old men.

Lack of association between free testosterone and bone density separate from age in elderly males

SummaryIt is unclear what proportion of the variance in bone density in elderly males is accounted for by testosterone status. We studied 112 ambulatory, elderly volunteers (mean age 71.7 years) and determined free testosterone (FT), as well as bone density measurements by photon absorptiometry at multiple sites. Our studies of 35 of these subjects 4 years later includedmorning FT and dual energy X-ray absorptiometry. There were no significant correlations between FT and bone density at multiple scanning sites with the effects of age partialed out. We suspect that our inability to detect a significant effect of FT on bone density was related to the relative strength of other determinants of bone density, as well as to the fact that FT values are far more dynamic than bone density.

Augmentation of influenza antibody response in elderly men by thymosin alpha one. A double-blind placebo-controlled clinical study.

Influenza remains a major cause of illness and death in elderly people despite current vaccination programs. One factor is an immunization failure rate in the elderly that may be as high as 50%. To test whether administration of thymosin α 1 would result in greater antibody production, we administered it (900 μg/m2 subcutaneously twice weekly for eight doses) in conjunction with the 1986 trivalent influenza vaccine. Ninety men (65—99 years old, mean age 77.3 years) were randomized double‐blind to receive thymosin α1, or placebo by the same schedule; the sera from 85 of these men were acceptable for analysis. The two groups were similar with respect to underlying disease, medications, and age. No toxicity was observed in either group. Antibody response rate was defined as a four‐fold rise in antibody titer over 3—6 weeks following vaccination and was measured by an enzyme‐linked immunosorbent assay (ELISA). Analysis was performed on treatment groups and subgroups divided by the mean age: the older group consisted of subjects aged 77 years and older, and the younger group those aged from 65—76 years. Baseline and change in absolute antibody levels were compared by t test and using age as a continuous variable by multiple regression analysis. The response was greater in the thymosin α1 treatment group at 6 weeks compared to the placebo group (P = .023), and this difference in absolute amount of antibody produced could be attributed to the greater response to vaccine in the older thymosin α1 treated subjects (P = .039) as no difference was observed between the younger treatment groups, or between the older thymosin α1 treated subjects and the younger subjects. The ability of elderly men receiving thymosin α1 treatment to produce antibody to vaccine similar to their younger counterparts may be of clinical importance.