Presented is an unusual case of a 66-year-old-resident of a long-term care facility, who manifested severe dysgeusia and impaired quality of life attributed to the angiotensin-converting enzyme (ACE) inhibitor enalapril; not realized at the time was the fact that he had an adverse reaction-cough-just weeks earlier from another ACE inhibitor in the same class, quinapril, thus illustrating different adverse effects to two antihypertensives in the same class. Cough and dysgeusia are symptoms that may be easily overlooked as side effects of medications. As polypharmacy is common in nursing home settings, health care providers need to be vigilant about adverse drug reactions which are common, but preventable and often reversible.

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Dialysis in the old: a centenarian nursing home resident with end-stage renal disease.

Aging trends in the U.S. have resulted in the over 65 years age group with End Stage Renal Disease (ESRD) becoming the fastest growing segment of the population presenting for dialysis. Their profile differs from younger adults in that they present with significant comorbidity and vascular access problems, and require earlier preparation for dialysis. ESRD in the geriatric population most commonly results from diabetes, hypertension, glomerular and tubulointerstitial nephritis. Described are experiences with initiating a centenarian nursing home resident with uremia on hemodialysis; resulting in improved quality of life and illustrating that age alone should never be a barrier to receiving dialysis. Renal replacement therapy can enhance quality of life and function even in the old. A review of select literature pertinent to ESRD in the geriatric population follows.

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Gastrostomy, esophagitis, and gastrointestinal bleeding in older adults.

INTRODUCTION: Percutaneous endoscopic gastrostomy tubes (PEG) are commonly used in older adults with dysphagia and poor nutrition. The association of PEG with upper gastrointestinal bleeding (UGIB) and role of gastroesophageal reflux disease (GERD) in relation to UGIB in patients with PEG are not well known. METHODS: We conducted a retrospective analysis of older patients with PEG, hospitalized for UGIB, during a 1-year period between 1997 and 1998. The study was performed in a university teaching hospital involving residents from long-term care facilities (LTCF) of the Bronx. RESULTS: A total of 38 patients with PEG were admitted for UGIB; 28 were evaluated with upper endoscopy. The mean age of the group who underwent endoscopy was 83.4 +/- 9.2 years, with 18 females and 10 males. In the same group, 13 patients were on H2 blockers and 4 patients used nonsteroidal antiinflammatory drugs before hospitalization. None of the residents were on proton pump inhibitors. The most common upper endoscopic findings were esophagitis, either alone (11 patients) or in association with other lesions (10 patients). Esophagitis predominantly involved the lower third of the esophagus. Other significant findings on endoscopy were gastric and duodenal ulcers, gastritis, and gastric erosions either alone or in combinations. CONCLUSIONS: Esophagitis is a common occurrence and a significant contributor for UGIB in patients with PEG. Use of H2 blockers does not appear to be an effective preventive measure for UGIB in these patients.

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Mild anemia and the risk of falls in older adults from nursing homes and the community.

OBJECTIVES: The objectives of this study were to determine if a relationship exists between a history of falls and anemia in older adults and to compare the findings by place of residence. DESIGN: The authors conducted a retrospective and observational study. PARTICIPANTS: One hundred forty-five adults (60-97 years of age) from nursing homes and the community hospitalized for hip fracture over a 2-year period were included in this study. MEASUREMENTS: Laboratory values (hemoglobin [Hb], hematocrit [Hct]), medical history, and demographics were measured. RESULTS: Falls occurred similarly in both nursing home patients and community patients (19% vs. 17%, P=0.785). Nursing home and community patients also had similar Hb (P=0.0899), Hct (P=0.1929), and rates of anemia (P=0.187). Nursing home residents were older (P=0.0188) and had lower serum albumin levels (P=0.0007) than community patients. When the two groups were combined, falls were more common in anemic individuals (30% vs. 13%; P=0.028). Furthermore, those with a history of falls were older (P=0.0447), had lower Hb (P=0.0257) and Hct levels (P=0.0310). After controlling for age, gender, place of residence, and arthritis in a logistic regression model, anemia predicted a threefold increased risk of falls (P=0.041), and a 45% decreased risk of falls was predicted for every 1.0-g/dL increase in Hb (P=0.005). Falls risk increased 7% per year of age (P=0.040), whereas musculoskeletal disease increased the falls risk 3.2-fold, both increases being independent of Hb levels or anemia. Finally, falls were not associated with gender or other comorbidity, nor did these variables alter the falls risk attributed to low Hb or anemia. CONCLUSIONS: These findings suggest a new and potentially important link between anemia and the risk of falls in patients sustaining hip fractures from both nursing homes and the community. Further studies will help determine if this risk is modified or eliminated with treatment of anemia and if the relationship applies to larger samples of older adults in different settings.

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Hip fracture. Risk factors, preoperative assessment, and postoperative management.

Hip fracture commonly results from falls in elderly patients, many of whom have osteoporosis. Hospitalization is typically required for surgical management, and the postoperative course is associated with significant morbidity and mortality. The authors discuss the primary care physician's role in diagnosing hip fracture, assessing the patient's clinical status, and managing patients after surgery. A key role is the coordination of a multidisciplinary team to ensure optimum outcome.

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Launching a geriatric unit. A Bronx medical center is prepared for the "graying of America".

Explore the source record for details and available documents.

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Drug-related hyperthermia.

The elderly are prone to disorders of thermoregulation. Hyperthermia, an elevation of core temperature, occurs as a result of several causes in older subjects. The elderly, particularly in nursing homes, are often prescribed multiple medications. Physiological changes with aging and the use of numerous predisposing drugs can contribute to disorders of temperature regulation. Presented is a dramatic case of drug- related hyperthermia in a nursing home resident with an adverse outcome in spite of recognition and treatment of the disorder.

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Outcome in ambulatory status immediately following hip fracture surgery in the acute setting: a comparison of nursing home residents and community older adults.

OBJECTIVE: To compare the ambulatory status following hip fracture surgery in the acute setting between older adults from long-term care facilities (LTCF) and the community. SETTING: A 650-bed, urban, inner city, university-affiliated teaching hospital. METHODS: One hundred forty hip fracture patients (60-97 years) from long-term care facilities and the community were examined. Ambulatory status before and after surgery was categorized four ways based on the degree of independence in ambulation: A1 = independent ambulation (with or without an assisting device), A2 = assistance of another person required, A3 = predominant use of a wheelchair, and A4 = bed-bound. Change in ambulatory status was designated as "moderate" if the deterioration was one status level only (A1 to A2, A2 to A3, and A3 to A4) or "major" if the deterioration was more than one status level (A1 to A3/A4 or A2 to A4). Additional variables such as age, sex, risk factors, length of stay, history of drug use, and laboratory results also were examined. RESULTS: Hip fracture patients from LTCF were older (P = 0.0160) and had more overall risk factors for hip fracture (P = 0.0039) than community patients. They also had higher rates of dementia (P < 0.000), arrhythmia (P = 0.025), delirium (P = 0.0016) and anxiolytics use (P = 0.019) than patients from the community. On admission, LTCF patients had lower serum calcium (P = 0.0003), phosphorus (P = 0.0210), and albumin (P = 0.0004) than community patients. Before hospitalization they also were less ambulatory (P = 0.002) than community patients. Post surgery, ambulatory status declined in both groups. However, a "major" change (decline) in ambulatory status occurred more often in LTCF patients (P = 0.001). CONCLUSIONS: A greater decline in ambulatory status is seen in patients from LTCF than in community patients, immediately following hip fracture surgery. Compared with community patients, LTCF patients are also older, sicker (higher total risk score) and have an increased risk for a decline in functional status.

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Hypothermia in the nursing home: adverse outcomes in two older men.

Older people are vulnerable to extreme changes of ambient temperatures caused by impaired thermoregulatory function. This results in a high mortality in older subjects during increases and decreases in the environmental temperature. From 1979 through 1994, a total of 11,817 deaths were reported in the United States for which hypothermia was the underlying cause (average annual number and rate: 739 and 0.3 per 100,000 population). Half of these occurred in adults older than age 65. For reasons that are unclear, mortality in men was more than double that in women (1.8 vs. 0.8). Presented are two cases of hypothermia with adverse outcomes in male residents living in long-term care facilities (LTCF).

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Appropriateness of laboratory testing in nursing home elderly with advanced dementia: an opinion poll among physicians.

OBJECTIVE: Dilemmas regarding selection of appropriate laboratory tests in older frail nursing home patients with advanced dementia are commonly encountered by physicians. Our objective was to study physician opinions about evaluating the appropriateness of laboratory testing in older hospitalized patients in nursing homes based on a real case. SETTING: A 750-bed university teaching hospital in the Bronx that regularly receives acutely ill older residents from long-term care facilities, with medical care provided by residents, fellows, and teaching faculty. DESIGN: An opinion poll was conducted among 53 physicians. Information was provided on the history, physical examination, and laboratory findings of a 92-year-old woman with advanced Alzheimer's dementia admitted for gastrointestinal bleeding to the acute care Geriatrics unit. A questionnaire sought opinions on selection of laboratory tests (emphasizing Troponin I) and management in this patient. Chi-square analysis was performed to analyze the data RESULTS: The majority of polled physicians (37/53, P = 0.01) felt that ordering Troponin I in the setting described hindered patient care and stated they would not have ordered the test. The opinion on overall management was divided (P = 0.861). CONCLUSION: Dilemmas regarding choosing appropriate laboratory tests, including their implications for care, are found frequently in the setting of frail, demented elderly from nursing homes hospitalized for acute care. We suggest that the choice of tests in these subjects with advanced dementia be individualized based on due consideration for life expectancy, quality of life, and surrogate opinion.

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Clostridium difficile colitis in older adults in long-term facilities and the community: do their outcomes differ?

OBJECTIVE: To determine if older adults from long-term care facilities (LTCF) have a greater risk of death than older people in the community after the development of Clostridium difficile (CD) colitis during hospitalization. DESIGN: A retrospective review of medical records from all older hospitalized patients with a confirmed diagnosis of CD colitis from February 1995 to February 1997 at Our Lady of Mercy Medical Center, Bronx, NY, a University hospital of the New York Medical College. METHODS: A total of 108 patients (aged 60-97 yrs.) with a positive diagnosis of CD colitis (EIA of CD cytotoxin A and B) were identified. Residence (nursing home vs. community), sex and age, length of hospital stay, laboratory values, the number, dose, and duration of all antibiotics used, and co-morbid medical conditions were examined as potential risk factors for adverse outcome (mortality). RESULTS: Fifty-two nursing home and 56 older patients living in the community were compared. Outcome (survival vs. death) was equivalent between nursing home (13 of 52 died, 25% death rate) and community elderly (13 of 56 died, 23% death rate). The patients in the nursing home were, on average, 3 years older than community those in the community, but age was not related to outcome in either group. Death occurred significantly more often in LTCF and community patients who received prolonged antibiotic therapy (P = 0.0056) or were prescribed four or more antibiotics (P = 0.036) during hospitalization. Low serum albumin level was found to be a strong predictor of death (P = 0.002). However, nursing home and community elderly had similar mean serum albumin levels (P = 0.2797). Death was also predicted by the use of clindamycin alone (P = 0.046) or penicillin-like antibiotics (excluding cephalosporins) and clindamycin (P = 0.021), or a history of cardiac disease (coronary artery disease or congestive heart failure) (P = 0.022). CONCLUSIONS: Patients from LTCF do not have an increased risk of mortality compared with older people in the community after developing CD colitis during hospitalization. Factors such as low serum albumin, prolonged antibiotic therapy, the number of antibiotics used, use of specific antibiotics, and cardiac disease were significantly related to an increased risk of death in both LTCF and community older adults. Age did not influence outcome in either group of older adults.

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Vitamin B12 status in hospitalized elderly from nursing homes and the community.

OBJECTIVE: To assess vitamin B(12) status in a large sample of hospitalized, inner-city older adults from nursing homes and communities with low socioeconomic status. To determine additionally if hypoalbuminemia can help identify older subjects who are at risk for vitamin B(12) deficiency. DESIGN: A cross-sectional study of hospitalized, inner-city older residents. SETTING: Acute Care Geriatrics Division, a 75-bed inpatient care service at Our Lady of Mercy Medical Center (OLMMC), a University Affiliate of New York Medical College. PARTICIPANTS: A total of 466 older patients (aged 65 to 102 years) from the community (n = 374) and nursing homes (n = 92) who were admitted to the acute care geriatrics division from 1993 to 1996. MEASUREMENTS: Patients admitted to the hospital had serum vitamin B(12) and albumin levels determined along with other nutritional parameters, routine blood tests, and physical examinations. RESULTS: On admission, 19% of hospitalized subjects had marginal serum B(12) levels (200-350 pg/mL) and 6% had low serum B(12) levels (<200 pg/mL). Mean serum B(12) levels did not differ significantly between patients from nursing homes and those from the community. Sixty-four percent 64% of all patients had low serum albumin levels (alb < 3.5 g/dL), with patients from nursing homes showing significantly lower mean serum albumin than patients admitted from the community (P <.000). We observed no positive correlation between serum albumin and serum vitamin B(12) in our older hospitalized patients from either nursing homes or community. CONCLUSIONS: In this sample of hospitalized older adults, 24% were found to have marginal or low serum B(12) status. Thus, we believe that periodic determinations of serum B(12) would be a useful addition to the general health and nutritional assessment in this age group. Our findings also suggest that hypoalbuminemia is not helpful as a predictor of low B(12) status in older hospitalized persons.

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