Journal of the American Geriatrics Society
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To determine factors associated with success or failure of oral antibiotic treatment for nursing home-acquired pneumonia (NHAP). ⋯ The majority of NHAP episodes were treated successfully with oral antibiotics, but 31% failed treatment in the NH. Patients with a mechanically altered diet or requiring feeding assistance by staff had significantly higher failure rates. Feeding dependence and need for a mechanically altered diet as well as abnormal vital signs are associated with oral antibiotic treatment failure. These factors should be considered in treatment decisions for NHAP.
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To examine the clinical utility of prehospital code status discussions in a nursing home (NH) setting and the health care outcomes of the decisions made. Also to identify patient factors and other variables associated with these decisions. ⋯ Prehospital code status decisions can be made effectively within the NH setting. Outside of medical intensive care, DNR orders have no impact on NH and hospital care intensity in the short term. In the final 6 months of life, however, hospital use is less for the DNR subgroup.
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To determine the incidence, and severity of postoperative delirium (POD) in older patients undergoing elective orthopedic procedures and to identify potential preoperative risk factors. ⋯ A simple model using clock-drawing scores and male gender for preoperative identification of elective patients at greatest risk for POD appears sensitive, predictive, and practical for the preadmission clinic setting, but it should be validated in a prospective trial.
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Because care of end-stage dementia is a significant clinical problem for which alternative modes of care are needed, this study examined the extent to which hospice programs served dementia patients. ⋯ A national survey of hospices revealed that few patients with primary dementia are currently treated by these programs, unless they have other terminal illnesses. An inability to predict survival was the major reason offered to explain this phenomenon. The higher percentage of patients with secondary dementia in hospice suggests that dementia per se does not make hospices care unfeasible. Similarly, the high proportion of for-profit hospices that enrolled patients whose dementia was primary implies the fiscal feasibility of providing hospice care for these patients. Further study is needed concerning the determinants of survival time in end-stage dementia.
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To identify predictors of 6-month mortality known before emergent admission to intensive care (IC) and to describe obstacles to the use of patient preferences in emergency triage decisions. ⋯ Patients with poor performance status or very advanced age have increased mortality within 6 months of emergent triage to IC. Mental status changes, absence of advance directives, and time constraints are common barriers to communication of patient preferences at the time of triage. Primary care physicians need to elicit and record patients' preferences before the time of emergent decisions about IC.