The relation between gain in cognition during rehabilitation on functional outcome among hip fracture adult patients with and without pre- hip fracture dementia.

The purpose of the present study was focused on the relationship between change in cognition and the functional outcome during rehabilitation in demented and non-demented adult hip fracture patients. We studied seventy consecutive adult patients with hip fracture admitted to our rehabilitation wards. Functional outcome was assessed by the Functional Independence Measure (FIM). The gain in cognition during the rehabilitation process was measured by the difference in Mini Mental State Examination scores at admission and discharge. Data was analyzed by t-test, chi square-test and linear regression. Patients without dementia presented and discharged from the rehabilitation ward with statistically significant higher total, motor, and gain functional independence measure scores compared to patients with dementia. In a multiple regression analyses, gain in Mini Mental State scores examination were not independently associated with higher total and motor functional independence measure scores at discharge (beta = 0.086, p = 0.194; beta = 0.077, p = 0.309, respectively). Our findings suggest that there is no association between functional outcome and cognitive gain at the end of the rehabilitation process among adult hip fracture patients with and without dementia. However hip fracture adult patients with dementia should not be deprived of a post-acute rehabilitation.

Comparative characteristic of antimicrobial resistance in geriatric hospital: a retrospective cohort study.

BACKGROUND AND AIMS: To examine antimicrobial resistance of commonly isolated pathogens in elderly hospitalized patients. METHODS: Data regarding all clinically significant isolates from blood and urine cultures of patients admitted to a multilevel geriatric hospital during March 2015 to April 2016 were collected. Antimicrobial susceptibility testing was performed according to Clinical and Laboratory Standard Institute guidelines. RESULTS: Escherichia coli, Proteus mirabilis, and Klebsiella pneumoniae were the most common isolates, with proportions of extended spectrum beta-lactamase positivity of 60, 40, and 61% respectively. Adjusted logistic regression models indicated that resistance of Escherichia coli to ceftriaxone [odds ratio (OR) 2.8, 95% confidence interval (CI) 1.5-5.1], ceftazidime (OR 2.8, 95% CI 1.5-5.1), ciprofloxacin (OR 2.2, 95% CI 1.2-4.0), amoxicillin/clavulanic acid (OR 2.3, 95% CI 1.2-4.3), and trimethoprim/sulfamethoxazole (OR 2.4, 95% CI 1.4-4.3) was significantly higher in skilled nursing wards than in acute geriatric wards. Resistance of Proteus mirabilis to ceftriaxone (OR 3.1, 95% CI 1.5-6.4) and Klebsiella pneumoniae to ciprofloxacin (OR 3.2, 95% CI 1.3-7.9) was significantly higher in skilled nursing wards than in acute wards. CONCLUSIONS AND DISCUSSION: Antimicrobial resistance was found to be high in a multilevel geriatric hospital, especially in skilled nursing wards. These findings call for rethinking of the empirical antimicrobial therapy and of the efforts for prevention of nosocomial infection.

Blood transfusion reactions in elderly patients hospitalized in a multilevel geriatric hospital.

Background/Objectives. Blood transfusion is a critical issue for patients with chronic diseases such as heart failure, chronic kidney disease, and malignancy. However, side effects are not rare. The purpose of the study is to evaluate the frequency of adverse blood transfusion reactions in hospitalized elderly patients during a one-year period. Design/Setting/Participants. Blood transfusion reactions such as fever, chills, dyspnea, and others following blood transfusions in hospitalized geriatric patients during one-year period were examined. Results. 382 blood units (242 patients) were administered during the study period. In 40 (11%) cases, blood transfusion reactions occurred. Fever was the most common reaction in 29 cases (72%), four (10%) had shortness of breath, and 3 (8%) had vomiting and chills each. There were no lethal cases in the 24-hour period following blood transfusions. Conclusion. A relatively low rate of adverse blood transfusion reactions occurred in our geriatric patients. We may speculate that this is related to underreporting of minor symptoms due to the high percentage of demented patients in this population.

Staphylococcus aureus colonization in the nasopharynx of nasogastric tube-fed patients in a long-term care facility.

The purpose of this paper is to investigate whether the presence of a nasogastric tube (NGT) for feeding has an impact on the nasal colonization by Staphylococcus aureus. Three groups of frail elderly were examined: 76 patients fed by NGTs and 52 orally fed patients in skilled nursing wards, and 33 orally fed patients in regular nursing wards. Samples from the nasal and oral cavities were cultured for S. aureus and susceptibility testing for oxacillin was performed. The prevalence of S. aureus (either oxacillin-susceptible or oxacillin-resistant) in the NGT-fed group was not significantly different to that in the two orally fed groups nor the nostril in which the NGT was placed. A significant correlation in colonization was found between the two nares and between the nares and oral cavity in the same patient (r > 0.45, P < 0.005) for both oxacillin-susceptible and oxacillin-resistant S. aureus. The presence of NGTs for feeding in elderly frail patients is not associated with higher rates of S. aureus colonization in the nares or oral cavity.

Dehydration among long-term care elderly patients with oropharyngeal dysphagia.

INTRODUCTION: Long-term care (LTC) residents, especially the orally fed with dysphagia, are prone to dehydration. The clinical consequences of dehydration are critical. The validity of the common laboratory parameters of hydration status is far from being absolute, especially so in the elderly. However, combinations of these indices are more reliable. OBJECTIVE: Assessment of hydration status among elderly LTC residents with oropharyngeal dysphagia. METHODS: A total of 28 orally fed patients with grade-2 feeding difficulties on the functional outcome swallowing scale (FOSS) and 67 naso-gastric tube (NGT)-fed LTC residents entered the study. The common laboratory, serum and urinary tests were used as indices of hydration status. The results were considered as indicative of dehydration and used as 'markers of dehydration', if they were above the accepted normal values. RESULTS: The mean number of dehydration markers was significantly higher in the FOSS-2 group (3.8 +/- 1.3 vs. 2 +/- 1.4, p = 0.000). About 75% of these FOSS-2 patients had > or =4 dehydration markers versus 18% of the NGT-fed group (p = 0.000). A low urine output (<800 ml/day) was significantly more common in the FOSS-2 group (39 vs. 12%, p = 0.002). Above normal values of blood urea nitrogen (BUN), BUN/serum creatinine ratio (BUN/S(Cr)), urine/serum osmolality ratio (U/S(Osm)), and urine osmolality U(Osm), were significantly more frequent in the dehydration-prone FOSS-2 group. This combination of 4 indices was present in 65% of low urine output patients. In contrast, it was present in only 36% of the higher urine output patients (p = 0.01). Patients with a 'normal' daily urine output (>800 ml/day) also had a significant number (2 +/- 1.5) of positive indices of dehydration. CONCLUSIONS: Dehydration was found to be common among orally fed FOSS-2 LTC patients. Surprisingly, probable dehydration, although of a mild degree, was not a rarity among NGT-fed patients either. The combination of 4 parameters, BUN, BUN/S(Cr ), U/S(Osm) and U(Osm), offers reasonable reliability to be used as an indication of dehydration status in daily clinical practice.

Candida colonization of the vagina in elderly residents of a long-term-care hospital.

The present study was conducted in order to determine the prevalence of vaginal colonization by Candida spp in elderly residents of a long-term-care hospital and to examine the determinants of vaginal candidiasis. Vaginal swabs for Gram stain and culture were obtained from 106 bedridden residents of a long-term-care hospital (study group; mean age, 83+/-7 years) and a control group of 50 similarly aged women admitted to an acute-care hospital for non-genital problems (mean age, 81+/-8 years). The characteristics of patients who tested positive for Candida spp were compared with those who tested negative. Candida spp were isolated from 34 (32%) patients in the study group and from four (8%) control patients (p=0.001). In the study group, Candida glabrata was by far the most common species isolated (51.2%). The warm and moist environment in the perineal area created by diaper use in incontinent individuals, together with decubitus ulcers and immobilization, which are common in elderly patients receiving long-term care, might be responsible for the high occurrence of vaginal colonization with Candida in these women.

Gastric microbiota in elderly patients fed via nasogastric tubes for prolonged periods.

Aspiration of oropharyngeal contents is a constant threat for elderly patients fed via a nasogastric tube (NGT). Colonization of the oropharynx of these patients by pathological flora and the development of biofilms on the feeding tube has been documented recently. In addition, the presence of the NGT may interfere with the gastro-oesophageal sphincter, leading to gastro-oesophageal reflux. Thus, the passage of pathogenic bacteria in both directions is facilitated. The purpose of this study was to explore the microbiota of the gastric juice and the oropharynx in NGT-fed elderly patients. Samples of gastric juice were drawn after an overnight fast, and microbial cultures and direct pH measurement were performed. Concomitant cultures were obtained from the oropharynx. Overall, 107 gastric and oropharyngeal cultures were obtained from 52 subjects. Pathogenic flora (Gram-negative bacteria or Staphylococcus aureus) were isolated from 74% of stomach samples and from 69% of oropharynx samples. Proteus spp. (26%) and Escherichia coli (22%) were the most common isolates in the gastric juice, and Proteus spp. (24%) and Pseudomonas spp. (21%) were the most common isolates in the oropharynx. Similarity in the composition of the oropharynx and gastric flora was observed in most cases. The gastric pH was relatively high (4.57 +/- 0.65 at 3 h after feeding and 4.2 +/- 0.9 at 12 h after feeding) and was highly correlated with the isolation of pathogenic bacteria (r = 0.58, P < 0.01). These results support the view that in addition to the oropharynx, the stomach of NGT-fed elderly patients constitutes a reservoir of pathogens that could be associated with the risk of aspiration pneumonia. The cause of the high gastric pH and its relation to pathogenic bacteria warrants further study.

Plasma levels of amino acids in elderly long term care residents with oropharyngeal dysphagia: comparison of hand-oral with tube-enteral-fed patients.

BACKGROUND: Dysphagia and eating difficulties are highly prevalent in long term care patients. Evaluation of their nutritional status is complicated by comorbidity, frailty and individual patterns of feeding. In previous studies we found vitamin deficiencies (folic acid B6 and B12) in orally fed elderly in early stages of oropharyngeal dysphagia despite satisfactory nutritional parameters (BMI, albumin and hemoglobin). The aim of this study is to evaluate the plasma amino acids levels in these hand-oral fed elderly patients with dysphagia. METHODS: Plasma amino acids were measured in 15 orally fed elderly patients in early functional outcome swallowing scale (FOSS), stage 2, and compared with those of 15 matched nasogastric-tube-fed counterparts. RESULTS: The plasma levels of all measured amino acids, ratio of essential to nonessential, levels of conditionally essential and the immune-enhancing amino acids were similar in both groups and within the normal range of our laboratory. The traditional nutritional parameters were also similar in both groups and within the normal range. CONCLUSIONS: Plasma levels of amino acids in elderly patients in early stage of FOSS are satisfactory, supporting the view that their protein intake is adequate. Further studies should concentrate on patients in advanced stages of FOSS.

CD4 lymphocyte count and CD4/CD8 ratio in elderly long-term care patients with oropharyngeal dysphagia: comparison between oral and tube enteral feeding.

Many institutionalized elderly patients are at risk of undernutrition as a result of oropharyngeal dysphagia (OD) that possibly affects their immunological status. Tube enteral fed (TEF) patients on controlled intake of nutrients enables us to evaluate the effect of inadequate nutrition on the immune system in the orally fed elderly with OD. The aim of our study was to compare CD4 lymphocyte count and CD4/CD8 ratio between these two differently fed groups. Twenty-eight orally fed patients with OD in the Functional Outcome Swallowing Scale (FOSS) stage 2 (group A) and 17 TEF subjects (group B) were studied. CD4 and CD8 counts were determined by flow cytometry. Nutritional markers (albumin, hemoglobin, and basal metabolic index) were recorded for each group. The Charlson index was used for comparison of comorbidity between the two patient groups. The average count of CD4 lymphocytes was significantly lower in group A than in group B (754 +/- 365 vs. 1032 +/- 404 cells/ml, p < 0.01). Six patients in group A (21%) had a CD4 count of less than 400 cells/ml (lower threshold) while all the patients in group B had a CD4 count of over 500 cells/ml (p < 0.001). The CD4/CD8 average ratio was also significantly lower in group A (p < 0.008). Nutritional markers were within normal limits with no difference between the groups. These results confirm our presumption that a low CD4 lymphocyte count and a low CD4/CD8 ratio could prevail among elderly frail patients with dysphagia. This supports the view that under an apparently satisfactory nutritional profile these patients may be in a state of undernutrition that negatively influences their immunodefense.

Rhinoscleroma in an octogenarian woman.

Rhinoscleroma, a granulomatous infection caused by Klebsiella rhinoscleromatis and usually afflicting young adults, was diagnosed in an 81-year-old woman. Treatment was started with orally administered antibiotics but was soon halted because of side effects. She was treated instead by local spread of a 3% rifampin ointment. After 6 weeks, the lesion cleared up and she improved remarkably. There was no recurrence during 18 months of follow-up. The current report is the second published case of rhinoscleroma in an elderly person and the first report on its cure by local treatment with a 3% rifampin ointment. This favorable experience contributes to the limited knowledge on rhinoscleroma in the elderly.

Age-associated neovasculopathy with recurrent bleeding.

We hypothesize the existence of an age-associated neovasculopathy with recurrent bleeding. It could be the result of age-related defects in the regulation of the angiogenetic process creating pathologic small vessels with a bleeding tendency. Conditions like subdural hematoma, ocular angiopathies, intestinal angiodysplasia, coronary atherosclerotic plaques and others, may be the clinical expression of such a neovasculopathy.

Clinical, radiologic, demographic, and occupational aspects of hand osteoarthritis in the elderly.

OBJECTIVE: Osteoarthritis (OA) of the hand is common in elderly patients. The aim of this study was to characterize OA frequency, severity, and distribution and to trace interrelationships between these findings and the demographic, occupational, and medical data from elderly Jewish nonrheumatologic patients. METHODS: Study participants were 253 consecutive patients admitted to a geriatric center for a variety of nonrheumatic medical conditions. Excluded patients were those with rheumatoid arthritis; neurologic, orthopedic, or other conditions that would interfere with symmetric hand function; and mental or medical states that would interfere with history taking and radiographic studies. Patient occupations were graded as workload degree (on a scale of 1 to 3) and as the total occupational score (workload degree multiplied by the duration of each job). Clinical findings of Heberden nodes, Bouchard nodes, and malignment, graded on a scale of 0 to 3, were summed as the clinical OA score. Hand radiographs were independently read (modified Altman method), grading 5 parameters in each joint on a scale of 0 to 3, summed as a radiologic OA score. Statistical analyses included the Student t test, chi(2) test, ANOVA, Pearson correlation, and partial correlation coefficients. RESULTS: Among 253 elderly patients (171 women, 82 men; mean age, 79 years) OA was frequent (occurring in about 80% of patients), involving most severely the second and third distal interphalangeal, right first interphalangeal, and both first carpometacarpal joints. The prevalence of OA was similar in women and men, with higher scores in women, and reached significance only in the distal interphalangeal joints. Metacarpophalangeal joints were more involved in men. Age had a clear influence on OA scores. Ethnicity affected OA severity, with Ashkenazi Jews having significantly higher scores than Sepharadi Jews. Dominant hands had significantly higher global OA scores as well as isolated joint scores (except for the first carpometacarpal joint). Occupational load, housekeeping tasks, and the number of children did not influence the total or specific joint OA scores. Associated conditions such as obesity, diabetes, hypothyroidism, and chondro calcinosis were not associated with more pronounced OA. CONCLUSIONS: Hand OA was prevalent in our elderly cohort, and its severity was influenced by inherent traits such as age, female gender, ethnicity, and handedness. In contrast, acquired factors such as workload, number of children, and associated diseases did not appear to influence OA expression.

Seasonal variation in the incidence of delirium among the patients of a geriatric hospital.

Delirium syndrome is common in the hospitalized elderly population. However, data on its numerous etiological factors are scarce. Clinical observations suggest that delirium incidence could be related to seasonality. In order to evaluate the seasonal influence on the incidence of delirium syndrome among the patients of a geriatric hospital, we performed a retrospective study reviewing the medical records of 5218 patients aged 65 years and older, who were hospitalized in three medical wards between the years 1991 and 1997. The diagnoses of delirium were made according to ICD-9-CM. Of the 4929 subjects enrolled, 3548 (72%) were referred for assessment to the psychiatric or neurologic specialist, because of acute changes in their mental or behavioral status. Of those patients, 312 (6.3%) were diagnosed with delirium at admission, and 234 (4.7%) developed delirium during their hospitalization. Statistical analysis of incidence revealed a seasonal variation, with higher rates in the winter than in the summer months (P<0.001). This study suggests a seasonal influence on delirium syndrome incidence and a possible etiological relation with seasonal factors like the light -dark cycle.

Preliminary evaluation of a convalescence cardiac unit for older patients as a model of "transitional facility" from hospital to home.

OBJECTIVES: The increasing number of older cardiac patients combined with the tendency to reduce hospital stays created the need for a Convalescence Cardiac Unit (Con.CU). It functions as a transitional facility for elderly patients discharged from hospitals after cardiac events, and was established within a geriatric medical center using existing infrastructure and staff. METHODS: Patients from 5 neighboring general hospitals (including 23 internal medicine wards and 3 departments of cardiac surgery) were offered the option of one week stay in the Con.CU after discharge. During the stay in the unit they received medical supervision as well as counsel on matters of nutrition and physical activity. RESULTS: 78 patients were admitted during the first 14 months. Forty patients were after coronary artery bypass grafts (CABG) (51%)30 after acute myocardial infarction (MI) (38%). The average age was 75 +/- 2.5 (SD). Medical complications developed in 57%. Most of these patients were treated by the local staff. Five cases had to be readmitted to the hospital they came from. Elderly cardiac patients that chose the option of Con.CU and their families expressed high appreciation regarding this experience and its contribution in facilitating return home. CONCLUSION: This innovative model is aimed to improve continuity of care for elderly cardiac patients and provide them with a new service in this era of "early discharge" from hospitalization. Geriatric settings striving to diversify their services, and medical directors required to contribute to policy development may learn from this experience.

Postmortem examinations in patients of a geriatric hospital.

The rate of postmortem examinations (PME) especially in elderly patients is continuously declining, mostly due to the low interest of the medical staff and the reluctance of relatives. We surveyed PME performed over a 20-year period in patients of a geriatric hospital in Israel. The 93 autopsies represent a rate of 2.8% in the first five years which went down to 0.25% in the later years. In 58% of the cases, clinical cause of death was confirmed by the PME. Pulmonary embolism had the lowest confirmation rate, and was more frequently found in females (28%) than in males (10%) (p<0.03). Undiagnosed conditions in the elderly present a clinical challenge that increases with the patient's age. However, despite progress in diagnostic technology, confirmation rates of death causes have not changed much. Therefore, as the age of death rises, it is important to preserve and foster PMEs, the most reliable source of medical evidence.

A 10-year perspective on the patients referred to a geriatric rehabilitation complex: the influence of managed care.

OBJECTIVE: In the past 10 years, HMOs have used managed care to reduce patients referrals for rehabilitation in our Geriatric Rehabilitation Complex (GRC). DESIGN: This study compares data regarding patients referred for rehabilitation for 4 months in 1998 with data from a similar study we performed in 1989. SETTING: The GRC, which is part of a 396-bed geriatric hospital, includes a 36-bed ward complemented by departments of physical and occupational therapy, a speech therapy unit, and a rehabilitation psychologist. It is supported by modern rehabilitation equipment and facilities and is staffed by experienced, highly qualified academic personnel. RESULTS: The overall number of patients referred for rehabilitation decreased by 36% during this period. However, the average age of patients is higher, the number of patients with Recc. Stroke dominates, and length of stay was reduced by 20%. CONCLUSION: Although the rehabilitation needs of older people are increasing, fewer patients are referred to our GRC. Those who are referred are older, and their condition is more complicated; nevertheless, their length of stay has also been reduced. These are the results of HMO policies to refer older patients to new "rehabilitation settings" that charge lower prices while offering services of still unproved quality. As geriatricians, it is our duty to prevent cost considerations from overtaking the need to maximizing functional recovery.