Annals of Long Term Care

Reviewed, prepared, and submitted by Thomas T. Yoshikawa, MD, Editor-in-Chief, Journal of the American Geriatrics Society

Title:
Pragmatic, Cluster Randomized Trial of a Policy to Introduce Low-Low Beds to Hospital Wards for the Prevention of Falls and Fall Injuries

Authors:
Haines, Terry P; Bell, Rebecca AR; Varghese, Paul N

Summary:
Falls in hospitals are common and debilitating adverse events. Medicare no longer reimburses hospitals for costs related to falls occurring as an inpatient. Despite numerous clinical trials using targeted or multifactorial interventions for falls, there is controversy whether these interventions are effective in reducing falls and/or fall-related injuries. In this study performed in Queensland, Australia 18 public hospitals, a policy for introducing low-low beds was tested and analyzed for reductions in falls or falls with injury. A cluster-randomized controlled trial separated 9 wards as controls (regular beds) and 9 wards as interventions (low-low beds) with outcomes measured 6 months later. There was a significant decrease in rate of falls between the preintervention and postintervention periods for both the control and intervention groups but insignificant change in rate of falls with injury in either groups. It was concluded that implementation low-low beds did not reduce falls or fall-related injuries.

Comment:
Low-low beds are thought to be beneficial because with a lower bed height, there would be less of an impact when patients fall from the bed. Moreover, with low bed height, it would more likely limit the ability of patients to stand from their bed. This study did not mention the age or gender of these patients so it is unclear if these findings would be sustained if older patients were only studied or if the predominant number of patients were women—both of whom would have a higher risk of falls and fall-related injuries.

The opinions expressed are solely those of the reviewer and do not necessarily reflect those of the American Geriatrics Society or Journal of the American Geriatrics Society.

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Title:
Diagnostic Value of Procalcitonin for Bacterial Infection in Elderly Patients in the Emergency Department

Authors:
Lai, Chih-Cheng; Chen, Shey-Ying; Wang, Chengi-Yi; et al

Summary:
Bacterial infection and its associated sepsis/septic shock increases in incidence with increasing age. However, the clinical features of bacterial infections may be caused by non-bacterial pathogens or noninfectious clinical disorders (e.g., collagen vascular disease, cancer, tissue injuries). Differentiation of systemic inflammatory response syndrome (SIRS) caused by non-bacterial infections is important so that inappropriate administration of antibiotics can be minimized. In this study of 262 elderly patients admitted to the emergency department (ED) with SIRS, 204 had bacterial infection (with 48 having bacteremia) and 58 patients had SIRS of non-bacterial origin. Blood samples for procalcitonin (PCT) along with complete blood count, biochemical studies, and microbiological tests were drawn within 2 hours of admission to the ED. The diagnostic sensitivity (96.0%), specificity (68.3%), positive predictive value (33.8%), and negative predictive value (98.8%) of PCT for bacteremia in patients aged 75 years and older were superior than in those aged 65 to 74 years. Moreover, the PCT was not an independent predictor of local (non-bacteremic) infections.

Comment:
The PCT test has been found to have variable sensitivities in predicting non-bacteremic localized infections (e.g., pneumonia, urinary tract infection) in other studies. In this study, PCT appeared to be reasonably sensitive in diagnosing bacteremia and helpful in excluding bacteremia in patients 75 years and older presenting with SIRS; it was not useful in the diagnosis of local infections not associated with bacteremia. The PCT test should not be used as an independent test to rule in or rule out infections in elderly patients—we still must assess clinical findings and other diagnostic and supportive data to make or exclude a diagnosis of infections.

The opinions expressed are solely those of the reviewer and do not necessarily reflect those of the American Geriatrics Society or Journal of the American Geriatrics Society.

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Title:
The Diagnosis and Treatment of Elderly Patients with Acute Exacerbation of Chronic Obstructive Pulmonary Disease and Chronic Bronchitis

Authors:
Albertson, Timothy E; Louie, Samuel; Chan, Andrew L

Summary:
This paper is a concise review of the clinical syndrome of chronic obstructive pulmonary disease (COPD) in older adults, which consists of (inflammatory) chronic bronchitis, bronchiectasis, emphysema, and reversible airway disease. The definitions of acute exacerbations of COPD (AECOPD) and acute exacerbations of chronic bronchitis (AECB) are described as well as the clinical implications and impact on healthcare costs of this clinical syndrome. The diagnostic criteria and severity of AECOPD and AECB according to the Global Initiative for Chronic Obstructive Lung Disease (GOLD) and Canadian Thoracic Society are reviewed and serve as a useful guide in managing COPD. There is a brief discussion on non-antibiotic treatment approach for elderly patients with AECOPD or AECB. The remainder of the paper focuses on selection of antibiotics for AECOPD and AECB since it is thought that 50% to 70% of AECOPD are caused by bacterial infections. A discussion based on meta-analysis of existing literature and opinions of the authors describe choices and selection of antibiotics for treating AECOPD/AECB.

Comment:
The use of risk stratification (although not specifically designed for older patients), potential presence of antibiotic-resistant bacteria, pharmacokinetic changes with aging, potential of drug interactions with other concurrently prescribed medications, and underlying multimorbidities/comorbidities should be considered whenever antibiotics are being considered for treatment of AECOPD/AECB.

The opinions expressed are solely those of the reviewer and do not necessarily reflect those of the American Geriatrics Society or Journal of the American Geriatrics Society.