Journal of the American Geriatrics Society
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Multicenter Study Comparative Study
Physical restraint use and falls in nursing home residents.
To examine the relationship between restraint use and falls while controlling for the effect of psychoactive drug use among nursing home residents, including subgroups of nursing home residents with high rates of restraint use and/or falls. ⋯ Restraints were not associated with a significantly lower risk of falls or injuries in subgroups of residents likely to be restrained. These findings support individualized assessment of fall risk rather than routine use of physical restraints for fall prevention. Researchers and clinicians should continue to focus efforts on developing a variety of approaches that reduce risk of falls and injuries and promote mobility rather than immobility.
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Clinical Trial Controlled Clinical Trial
Controlled trial of a geriatric case-finding and liaison service in an emergency department.
To evaluate the effects of a program of case-finding and liaison service for older patients visiting the emergency department. ⋯ Numerous previously unrecognized geriatric medical and social problems can be detected in older persons visiting the emergency department. Despite this, an emergency department-based geriatric assessment and management program failed to produce improved outcomes. This suggests that either disease acuity is an overwhelming factor in subsequent outcome or, alternatively, more control over medical and social service delivery during and after the emergency department visit than was demonstrated in this program will be required before successful outcomes can be assured.
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Many practitioners perform a thyroid stimulating hormone (TSH) assay as a screening test in older patients. The introduction of sensitive TSH assays with lower normal limits has created a laboratory abnormality that is often of uncertain significance. Mechanisms include autonomous overproduction of thyroid hormone, nonthyroidal illness including medication effects, and hypothalamic/pituitary dysfunction. ⋯ Low total T3 levels, TSH normalization, and excess mortality suggest that nonthyroidal illness plays a role in the pathogenesis of low TSH determinants in the nursing home. Autonomous production of thyroid hormone also plays a role. We believe that the term "subclinical hyperthyroidism" should be used only if the clinician believes that autonomous overproduction of thyroid hormone is the cause of a low TSH level. If subsequent research shows correctable adverse consequences associated with subclinical hyperthyroidism from autonomous overproduction of thyroid hormone, a more aggressive diagnostic approach will be needed to define the mechanism of a low TSH level at the time of its discovery.
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To assess patients' willingness to accept life-sustaining treatment when the expected outcome is a diminished mental health state. ⋯ In the case of "severe pneumonia", about half of our older male veterans reported a willingness to accept intubation and ventilatory support even if it resulted in persistent cognitive disability. These results suggest that experience in a medical intensive care unit with the ventilators and experience with strokes may make patients more tolerant of treatments that may result in impaired cognitive function.
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To determine the prevalence of pyuria and its relationship to bacteriuria in a representative sample of chronically incontinent nursing home residents. ⋯ Pyuria is common among chronically incontinent nursing home residents, both in the presence and absence of bacteriuria. Clinicians must therefore be cautious in interpreting the presence of pyuria to indicate symptomatic infection in this population. Using pyuria to determine the need for antimicrobial treatment could result in unnecessary expense and morbidity as well as contribute to the development of resistant organisms in nursing homes. Research is needed to define pyuria better, to determine its prevalence and relationship to bacteriuria among nursing home residents with symptoms of acute urinary tract infection, and to elucidate the etiology and significance of sterile pyuria in this population.