Impact of the Ottawa Influenza Decision Aid on healthcare personnel's influenza immunization decision: a randomized trial.

BACKGROUND: Influenza immunization for healthcare personnel reduces frequency and severity of nosocomial influenza outbreaks and influenza-associated morbidity and mortality among patients. The Ottawa Influenza Decision Aid (OIDA) was developed to assist undecided healthcare workers in deciding whether or not to be immunized. AIM: To assess the impact of the OIDA, and to ascertain whether its use would increase the level of confidence in healthcare workers' influenza immunization decision and positively affect their intent to be immunized. METHODS: Single-centre, single-blind, parallel-group, randomized controlled trial. FINDINGS: Eight per cent (151 of 1886) of the unimmunized healthcare personnel were randomized. Of 107 eligible respondents, 48 were in the Ottawa Influenza Decision Aid (OIDA) group and 59 in the control group. A statistically significant (P = 0.020) greater improvement in confidence in immunization decision was observed in the OIDA group compared with the control group. Whereas the odds of changing intent to be immunized from 'no/unsure' to 'yes' was 2.4 times greater in the OIDA group, this result did not reach statistical significance after adjusting for intent to be immunized at baseline. The post-OIDA intent to be immunized in the OIDA and control groups compared to the pre-OIDA intent to be immunized showed that the OIDA had a significant effect on reducing uncertainty (P = 0.035). CONCLUSIONS: Using an accessible, balanced, understandable format for all healthcare personnel about their influenza immunization decision appears to have an impact on both healthcare personnel's confidence in their immunization decision and in their intent to be immunized.

Safety and efficacy of physical restraints for the elderly. Review of the evidence.

OBJECTIVE: To critically review evidence on the safety and efficacy of physical restraints for the elderly and to provide family physicians with guidelines for rational use of restraints. DATA SOURCES: Articles cited on MEDLINE (from 1989 to November 1994) and Cinahl (from 1982 to 1994) under the MeSH heading "physical restraints." STUDY SELECTION: Articles that specifically dealt with the safety and efficacy of restraints and current patterns of use, including prevalence, risk factors, and indications, were selected. Eight original research articles were identified and critically appraised. DATA EXTRACTION: Data extracted concerned the negative sequelae of restraints and the association between restraint use and fall and injury rates. General data about current patterns of restraint use were related to safety and efficacy findings. DATA SYNTHESIS: No randomized, controlled trials of physical restraint use were found in the literature. A variety of study design, including retrospective chart review, prospective cohort studies, and case reports, found little evidence that restraints prevent injury. Some evidence suggested that restraints might increase risk of falls and injury. Restraint-reduction programs have not been shown to increase fall or injury rates. Numerous case reports document injuries or deaths resulting from restraint use or misuse. CONCLUSIONS: Although current evidence does not support the belief that restraints prevent falls and injuries and questions their safety, further prospective and controlled studies are needed to clarify these issues. Information from review and research articles was synthesized in this paper to produce guidelines for the safe and rational use of restraints.

A new behavioral assessment scale for geriatric out- and in-patients: the NOSGER (Nurses' Observation Scale for Geriatric Patients).

Although a great number of psychometric tests and rating scales for the assessment of psychogeriatric patients is available, there is still an urgent need, in research and practice, for a clinical rating instrument that meets the following main requirements: (1) applicable to institutionalized and community patients and covering a wide range of behavioral pathology; (2) acceptable and easy to use for professionals and lay persons alike; (3) covering a wide range of behavior relevant to daily functioning but independent of sex or social status of the individual assessed. The NOSGER contains 30 items of behavior, each rated on a 5-point scale according to frequency of occurrence. Item scores are summarized into 6 Dimension scores (memory, instrumental activities of daily life, self-care, mood, social behavior, and disturbing behavior) which are clinically relevant in dementia, depression, and other psychiatric disorders of old age. Validation studies with a preliminary version of the NOSGER indicated good acceptance of the scale, high inter-rater and test-retest reliability, and high correlations of all NOSGER Dimension scores with results of a variety of established assessment instruments. The NOSGER is currently being used in a number of European and North American centers and should turn out to be a useful instrument for longitudinal studies in psychogeriatrics.

Lymphocyte transformation in elderly non-insulin-dependent diabetics before and after improved glycaemic control.

Mitogen-induced lymphocyte transformation was examined in 23 elderly patients with poorly controlled Type II diabetes before and after achieving improved glycaemic control with sulphonylureas and compared with 11 healthy controls of similar age. No difference between groups was seen after incubation of lymphocytes with phytohaemagglutinin (PHA). Lymphocyte transformation after 10 micrograms/ml concanavalin A (con A) was significantly greater in diabetic patients after improved control and when compared to healthy controls (p less than 0.025). The response to 5 micrograms/ml and 10 micrograms/ml pokeweed mitogen (PWM) was greatest in diabetic patients after effective metabolic control.

Leukocyte microbicidal activity assessed by chemiluminescence in elderly non-insulin dependent diabetes mellitus.

Leukocyte dysfunction may contribute to infection in the elderly diabetic. Leukocyte oxidative metabolism assessed by chemiluminescence, correlates with microbicidal activity, and may be impaired with hyperglycaemia and ageing. The leukocyte chemiluminescence response to zymosan +/- luminol was assessed in 12 healthy controls (3M, 9F), aged 69 +/- 5 (mean +/- SD) years and in 23 non-insulin dependent diabetics, aged 68 +/- 5 years, before and after improving glycaemic control with sulphonylureas, when the glycosylated haemoglobin fell from 11.2 +/- 2.3 to 7.9 +/- 1.4% (p less than 0.001). The onset of maximal chemiluminescence with zymosan was similar in controls and diabetics, although the actual counts after improved glycaemic control were less in diabetic patients at all time points than initially (p range less than 0.025-less than 0.001) or when compared to the controls (p range less than 0.05-less than 0.005). Following luminal enhancement the onset and magnitude of maximum chemiluminescence was similar in all groups although an increase early response was observed in diabetics initially. We suggest that sulphonylureas may modify chemiluminescence by suppressing superoxide radical generation. Hyperglycaemic elderly non-insulin dependent diabetics may have subtle disturbances of the leukocyte oxidative burst but in general behave in a similar fashion to healthy elderly controls.

'Silent' pyrexia in the elderly.

Simultaneous oral, rectal and axillary temperatures were measured in 73 elderly patients on a geriatric unit. Axillary and oral temperatures were significantly lower than rectal readings. If oral or axillary temperatures alone had been measured, pyrexia would have been missed in two thirds of patients with a rectal temperature of 37.5 degrees C or more, and about three quarters of those with a rectal temperature of 38 degrees C or more. These findings suggest that oral or axillary temperature measurements are inadequate screening tests for pyrexia in the elderly.

The role of chest radiography in the evaluation of the 'geriatric giants'.

Three hundred and eighty admissions to a geriatric assessment unit had a routine chest radiograph. Forty-four per cent presented atypically with one or more of Isaacs' 'geriatric giants'--falls, immobility, incontinence or deteriorating mental function. The chest radiograph was abnormal in 164 (44%), of whom 57 had no classical clinical cardiopulmonary features. The chest radiograph was especially useful in the investigation of the geriatric giants, where 22% had evidence of cardiopulmonary disease, in the absence of classical clinical features.

Golytely: a new approach to faecal impaction in old age.

Forty-five elderly subjects with faecal impaction were entered into a study of the efficacy of golytely. Twenty-three were treated with golytely 2 l/day for 2 days and then lactulose 30 ml b.d. and daily enemas. Twenty-two were treated with lactulose 30 ml b.d. and daily enemas alone. A good response was achieved in 13 (56%) within 1 week and in 20 (87%) within 2 weeks when golytely was used, as compared to only 5 (23%) within 1 week and 9 (41%) within 2 weeks when it was not used.

Changes in erythrocyte transketolase activity and the thiamine pyrophosphate effect during storage of blood.

Whole blood and washed erythrocytes from nutritionally normal and abnormal elderly patients were stored at room temperature, 4 degrees C and -20 degrees C for up to 14 days. In both groups, and under all storage conditions, the erythrocyte transketolase (ETK) activity and the thiamine pyrophosphate (TPP) effect decreased with time of storage. The ETK activity for specimens stored at -20 degrees C decreased significantly by day 14 (P less than 0.05). The TPP effect in specimens stored at -20 degrees C decreased significantly in the nutritionally abnormal group at 4 days (P less than 0.05) and in the nutritionally normal group by day 14 (P less than 0.05). These significant changes in ETK activity and TPP effect with storage can lead to misleading interpretation of thiamine nutritional status.

The frequency of physical signs usually attributed to meningeal irritation in elderly patients.

Nuchal rigidity, which may be a sign of meningitis, was found in 35 per cent of geriatric patients on acute-care and rehabilitation wards and in 13 per cent of younger patients on an acute-care ward. It was significantly associated with cerebrovascular disease, confusion, abnormal plantar responses, and primitive reflexes. Elderly patients who have nuchal rigidity with no history of neurologic or cognitive disorders should be investigated for meningitis.

Necropsies in the elderly.

A retrospective analysis of 332 necropsies in the over-65-year-olds and 129 necropsies in the over 85-year-olds (overall necropsy rate 35%) showed that the commonest cause of death in elderly patients admitted acutely to hospital was pneumonic illnesses. 27-31% of the necropsies revealed the presence of a potentially treatable contributory factor to death that was undiagnosed during life. In only 4.5% of the necropsies in the over-85-year-olds was the cause of death uncertain.

Gynecologic sepsis as a cause of covert infection in old age.

Three cases of endometritis, which presented covertly in elderly women, are described. All three patients were in a poor state of nutrition, and two had serious intercurrent disease. It is believed that cyclical shedding of the endometrium and "normal" vaginal flora (under the influence of estrogen) are the major defenses against infection. These are lost after the menopause, and were therefore absent in the three patients described here. The waning of the immune response associated with aging, particularly the progesterone-stimulated uptake of polymeric IgA in the endometrium, may be important, as may the immunosuppressive effect of malnutrition. It is suggested that a nonspecific deterioration in an elderly woman or infection of uncertain site should prompt a careful re-examination, including a thorough pelvic examination.

The white nails of old age (neapolitan nails).

Nail changes similar to those reported by Terry and Lindsay were defined in an elderly inpatient population. Two hundred fifty-eight patients were studied, and an overall incidence of 19 per cent was found. There was no significant difference between men and women. The only significant correlations in this study were with osteoporosis and thin skin. Eight men with nail changes were compared with seven men without such changes by calculating the metacarpal index of cortical bone mass. The index was much lower in patients with nail changes (t = 2.64; P less than 0.01). All patients with nail changes had thin skin. No correlations were found with serum albumin, liver function, or kidney function. These nail changes are less frequent in the "less frail" elderly living in the community. Changes of the Terry type are common in children but disappear by early adult life. It is suggested that the nail changes are age-related phenomena and that they may reflect an underlying disturbance of collagen being manifested as changes in the nail bed, skin, and bone.