Minimizing urinary incontinence in the nursing home.

In the nursing home, urinary incontinence is a common problem that all too often is treated as an irremediable "problem of aging" by physicians, nurses, and patients. Its etiologies are numerous, as are approaches to treatment in this setting. However, with a thoughtful approach to diagnosis and care, the primary care physician may be able to determine which patients, with which forms of urinary incontinence, will benefit from specific therapies.

Do-not-resuscitate orders in an extended-care study group.

We examined the charts of 911 nursing home patients in Hennepin County, Minnesota, to determine the prevalence of written do-not-resuscitate (DNR) orders. Information regarding demographic characteristics, and whether a surrogate decisionmaker was available and participated in the decision, was also collected. Twenty-seven percent of patients had DNR orders. Ninety percent of all patients had potentially available surrogate decisionmakers. However, for 31% of patients with DNR orders, there was no documentation of patient or surrogate participation in the DNR decision. Univariate analysis identified female sex; increased age, level of care (skilled versus intermediate), presence of a potential surrogate decisionmaker, and increasing length of time since nursing home admission as factors associated with presence of DNR orders. When a logistic regression model was used, increased age, increased length of time since nursing home admission, skilled versus intermediate level of care, and presence of a surrogate decisionmaker were independently associated with presence of DNR status. Several variables are independently associated with written DNR orders; their relationship to the factors physicians use in decision making requires further study.

UTI: managing the most common nursing home infection.

Urinary tract infections (UTIs) are the most common type of infection in nursing homes. Asymptomatic bacteriuria, the most common form, requires no treatment. Symptomatic UTI requires treatment, but symptoms (acute deterioration in functional ability or mental status) may be nonspecific. Complicated UTI is more common in nursing home residents than in other populations. Immobility and the use of bedpans instead of commodes contribute to decreased bladder emptying and an increased potential for UTI. Poor perineal hygiene in many females in nursing homes also increases the potential for UTI. For this reason, obtaining urine for culture by catheterization rather than voided specimen should be the norm for female nursing home patients.

Prospective study of lower respiratory tract infections in an extended-care nursing home program: potential role of oral ciprofloxacin.

PURPOSE: Infections of the lower respiratory tract pose an important problem in nursing homes. Despite the magnitude of this problem, few, if any, antibiotic studies have been targeted specifically at nursing home-acquired bronchopulmonary infections. Following the establishment of a teaching Extended-Care Nursing Home Program, which facilitated the early diagnosis and therapy of bronchopulmonary infections, a comparative trial of oral ciprofloxacin and intramuscular cefamandole was initiated in elderly patients with lower respiratory tract infections. In addition to assessing the relative efficacy and safety of ciprofloxacin and cefamandole, our goals were to identify problems and pitfalls associated with conducting clinical research in this nursing home setting, evaluate selected clinical and laboratory features of lower respiratory tract infection in this patient population, and measure outcomes in all study groups. PATIENTS AND METHODS: During a 20-month period, 40 patients with pneumonia and 20 patients with acute bronchitis were enrolled in this randomized study. Sixty-three patients with pneumonia who were ineligible for the randomized study were also followed prospectively. The mean age of the 111 participants (123 cases) was 80.8 years; all patients had at least one chronic medical condition. RESULTS: Although Streptococcus pneumoniae was the single most common isolate, gram-negative bacteria were cultured from 81 percent of the cases that yielded pathogens from a satisfactory sputum specimen. The in-hospital mortality rate was strikingly low (6.5 percent), and a large majority of patients in all study groups were discharged safely back to their nursing homes well within the Diagnosis-Related Group length of stay. CONCLUSION: Ciprofloxacin appeared to be as safe and effective as cefamandole in this nursing home program; however, additional studies are needed to determine its role in the treatment of elderly patients with bronchopulmonary infections.

Single and multiple dose pharmacokinetics of oral ciprofloxacin in elderly patients.

The pharmacokinetics of oral ciprofloxacin were evaluated in 20 elderly patients with serious respiratory tract or musculoskeletal infections after single and multiple dose regimens of 750 mg of drug every 12 h. The single dose phase evaluations were performed on day 1 of therapy (n = 20) while the multiple dose phase evaluations were performed at the end of therapy (n = 11). Serum and urine ciprofloxacin concentrations were determined using high-performance liquid chromatography. Peak serum concentration (Cmax), terminal elimination half-life (t1/2 beta), apparent total body clearance (CL/f) and apparent volume of distribution (Vd/f) were 6.58 +/- 2.88 mg/l, 4.99 +/- 1.79 h, 6.69 +/- 3.73 ml/kg/min, and 2.87 +/- 1.86 l/kg, respectively, during the single dose phase. Only the Vd/f increased significantly during the multiple dose phase (4.40 +/- 3.32 vs. 2.71 +/- 1.53 l/kg, p = 0.047). Although Cmax increased and CL/f decreased markedly after multiple doses (8.83 +/- 2.79 vs. 6.65 +/- 2.28 mg/l, p = 0.057 and 5.61 +/- 2.53 vs. 6.53 +/- 3.03 ml/kg/min, p = 0.074, respectively), these changes were not statistically significant. The results of this study are consistent those previously derived from single dose studies in healthy and mildly-ill elderly subjects, but are markedly different from previous observations in young adult volunteers. Thus, acute illness does not significantly alter the pharmacokinetics of ciprofloxacin in the elderly suggesting that dosage adjustments based on the presence of acute illness do not appear warranted.(ABSTRACT TRUNCATED AT 250 WORDS)

Pharmacokinetics of ciprofloxacin in acutely ill and convalescent elderly patients.

The pharmacokinetics of ciprofloxacin were evaluated in 13 elderly patients with serious infections who were receiving 750 mg orally every 12 hours. The acute evaluations were performed within 24 hours of admission (n = 13), whereas the convalescent evaluations were performed at the end of therapy (n = 7). Serum and urine concentrations of ciprofloxacin were measured using high-performance liquid chromatography. Peak serum concentration (Cmax), terminal elimination half-life (t1/2 beta), apparent total body clearance (CL/f), and apparent volume of distribution (Vd/f) of ciprofloxacin were 5.97 +/- 2.95 mg/liter, 5.31 +/- 2.00 hours, 8.12 +/- 3.83 ml/kg/minute, and 3.63 +/- 1.91 liters/kg during the period of acute illness. Cmax and Vd/f values were moderately increased during the convalescent phase (8.56 +/- 3.43 mg/liter versus 5.87 +/- 2.25 mg/liter, p = 0.138, and 5.95 +/- 3.23 liters/kg versus 3.46 +/- 1.40 liters/kg, 0.05 less than p less than 0.1). The CL/f and t1/2 beta (four to 12 hours) values, however, were not significantly altered. The observed pharmacokinetic characteristics, which are consistent with those derived from single-dose studies in healthy elderly subjects, are markedly different from previous observations in young adult volunteers. However, acute illness does not alter the pharmacokinetics of ciprofloxacin in the elderly. Dosage alterations because of the presence of acute illness in the elderly do not appear to be warranted.

Bacterial changes in the urine samples of patients with long-term indwelling catheters.

The bacterial flora in the urine samples of 15 nursing home patients with long-term, indwelling catheters were examined monthly for one year. There was a rapidly changing polymicrobial flora averaging 2.0 changes per month in species with colony counts greater than 100,000/mL, and 3.2 changes per month when changes in species, biogram, and quantity of bacteria were considered. The flora changed significantly more frequently, and cultures of Pseudomonas aeruginosa, Providencia stuartii, and Citrobacter diversus were significantly more frequent in those receiving sulfamethoxazole and trimethoprim prophylaxis than in those who did not. There was no difference in incidence of urinary tract infection (UTI) between those patients who received sulfamethoxazole and trimethoprim prophylaxis and those who did not. Ampicillin or gentamicin was effective against 99% of species cultured that are of established UTI pathogenicity. Owing to the rapidity of bacterial flora changes, routine monthly cultures are of little predictive value in patients with indwelling catheters. This study does not support the efficacy of sulfamethoxazole and trimethoprim prophylaxis in such patients.

Extended care in nursing homes: a program for a county teaching medical center.

A continuity care program for patients in nursing homes using internal medicine residents in training has been developed in a county teaching hospital. Resident physicians on a paid basis assume primary care responsibility for 1000 patients in 29 private community nursing homes. A faculty internist coordinates the activities of the residents and monitors patient care through an extended care office in the county hospital. The program has produced a significant upgrading of the continuity and quality of care of patients in these nursing homes as well as providing medical residents with geriatric and nursing home experience. The increased sensitivity and concern for the needs of nursing home patients developed by the medical residents seems to continue after they complete their training.