Shirley M. Neitch

Standing orders in an ambulatory setting increases influenza vaccine usage in older people

Objectives: To determine whether standing orders for influenza vaccine increase its usage in an ambulatory setting in elderly patients.

Barriers to Vaccinating the Elderly With H1N1 Vaccine

Introduction:The development of a monovalent 2009 H1N1 influenza (swine flu) vaccine for the 2009–2010 season prompted a nationwide campaign of vaccination. The authors assessed the frequency of influenza vaccine usage among 3858 elderly patients with their practice and the most common barriers to receiving vaccine. Methods:The authors calculated the usage of seasonal and 2009 H1N1 vaccines among seniors with their university practice and surveyed a cohort of 64 patients to determine whether they had received the 2009 H1N1 vaccine and their reasons for not receiving it. Results:Of the 555 elderly vaccinated with seasonal influenza vaccine, only 18% were vaccinated with 2009 H1N1 vaccine. Among the survey cohort, 72% had not received the 2009 H1N1 vaccine; 39% of them offered no reason for refusing and 22% stated they were unaware of the need for it. Conclusions:Acceptance rates of seasonal influenza vaccine among elderly were low, and a significant proportion did not receive the 2009 H1N1 vaccine because it was unclear that they should receive it. Unambiguous education of patients and physicians is needed to achieve high rates of influenza vaccination among the elderly.

A misidentification delusion in two Alzheimer's patients.

he clinical changes accompanying the evolution of Alzheimer’s disease have been classified into two primary domains, cognitive, T which relates to declining intellectual and cortical functioning, and behavioral symptomatology, which includes paranoid and delusional ideation, hallucinations, and affective disturbances including depression, anxiety, and phobias. We report two patients with a delusion, not previously described in the literature, of pictures perceived as real. We discuss two known neuropsychiatric disorders, which are possibly pathogenetically related, as well as an immediate therapeutic implication for demented patients in long-term care settings. For patients suffering this delusion, there may be significant negative emotional effects if the common psychosocial modalities of reality orientation, reminiscence and life review, are used indiscriminately.

A Pilot Program to Improve Recognition of Cogntive Impairment in Acute Care

Cognitive impairment is a critically important clinical occurrence, but because symptoms may be subtle, it can be overlooked. Conversation about identifying cognitive impairment in the acute care setting often becomes sidetracked by efforts to choose the best screening tool or protocol, with little attention paid to the very first step – recognition that impairment is present. We review how this important problem may not always be detected, documented, and dealt with, and suggest a simple approach to ensuring that affected patients are not missed. This project entails utilizing an old concept in an innovative way. Working with the well-known principle of Universal Precautions, i.e., assuming that any and all body fluids may be contaminated, we refashion the idea into “Universal Observations”, a way of recognizing that any and all acutely ill persons may have cognitive impairment. Additionally, we demonstrate application of the phrase “If you see something, say something” to the hospital environment.

The above letter was referred to the authors of the original paper, and their reply follows

readmission by a physician and research nurse. Medication non-compliance was considered to be a direct contributory cause to readmission only if iflagrant errors in compliance occurred (eg, patient ran out of medication and did not refill prescription). Similarly, dietary sodium intake was not quantified, but only major excesses in sodium ingestion (eg, regular use of canned soups or eating ai bag of potato chips just prior to readmission) were classified as contributing to readmission. These assessments are admittedly subjective, but it should be noted that the intent of our study was not to measure compliance, which is fraught with difficulties, but to determine to what extent major and easily identifiable lapses in compliance contributed directly to readmission. To this end, quantification of compliance may not have been helpful, since there is no objective method for determining what degree of non-compliance may lead to readmission. Moreover, a patient may take all prescribed medication for 2 months, then discontinue therapy and be rehospitalized shortly thereafter. Calculated as a percentage, compliance would be high, yet non-compliance clearly contributed to rehospitalization. Thus, we believe our methods were appropriate given the goals of our study, and we are confident that the percentages provided in Table 3 are an accurate reflection of the degree to which these factors clearly contributed to readmission in our population.’ Nonetheless, we agree with Dr. Kruse that the effect of non-compliance on hospitalization in the elderly requires further study, and in our ongoing research in this area we are assessing medication and dietary compliance objectively (by pill counts and food logs, respectively) as well as subjectively. Several other points in Dr. Kruse’s letter are worthy of comment. First, we agree that readmissions for dehydration were most likely due to overprescribing of diuretics by physicians rather than excessive diuretic use by the patient as originally implied. Second, we concur that in order to optimize compliance, physicians must simplify medication regimens as much as possible, not only with regard to the number of medications prescribed but also the number of dosing intervals throughout the day. Finally, changes in medications following initial discharge were evaluated in our study but did not contribute directly to readmission in our patients.