Journal of the American Medical Directors Association
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Pneumonia is the leading cause of mortality, morbidity, and transfers to acute care facilities among residents of nursing homes. With the expected growth of the nursing home population over the next 30 years, the annual incidence of nursing home-acquired pneumonia (NHAP) is expected to reach 1.9 million cases. Yet there is growing evidence to suggest that the transfer of nursing home residents to hospitals with NHAP results in little to no improvement in overall mortality or morbidity when compared with residents treated in the nursing home. Furthermore, recent evidence suggests that nursing home residents admitted to hospitals may be at greater risk for functional decline, delirium, and pressure ulcer formation following hospitalization. The author therefore performed a comprehensive review of the literature to consider the salient issues confronting a clinician faced with the question of whether to transfer a nursing home resident diagnosed with pneumonia to an acute care facility. ⋯ There is growing evidence to suggest that hospitalization for residents with NHAP is not required and may result in increased cost, morbidity, and mortality. To date, studies show that residents may benefit from hospitalization if their respiratory rate is over 40. Otherwise, if appropriate treatment can be initiated expeditiously in the nursing home, resident mortality and morbidity may decrease. Numerous barriers to treating acutely ill residents in the nursing home exist, including a difficulty in obtaining antibiotics quickly, inadequate staffing, and poor documentation of a resident's wishes for hospitalization. More studies need to be conducted to further identify these barriers to nursing home care.
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Falls are prevalent in elderly patients residing in nursing homes, with approximately 1.5 falls occurring per nursing home bed-years. Although most are benign and injury-free, 10% to 25% result in hospital admission and/or fractures. Primary care providers for nursing home residents must therefore aim to reduce both the fall rate as well as the rate of fall-related morbidity in the long-term care setting. Interventions have been demonstrated to be successful in reducing falls in community-dwelling elderly patients. However, less evidence supports the efficacy of fall prevention in nursing home residents. ⋯ More studies must be done to clarify the effects of high-risk medication reduction, the optimal nature and intensity of exercise programs, and patient targeting criteria to maximize the effectiveness of nursing home fall prevention programs. Based on the current literature, an effective multifaceted fall prevention program for nursing home residents should include risk factor assessment and modification, staff education, gait assessment and intervention, assistive device assessment and optimization, as well as environmental assessment and modification. Although there is no association between the use of hip protectors and fall rates, their use should be encouraged because the ultimate goal of any fall prevention program is to prevent fall-related morbidity.
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As a matter of practical reality, what role patients will play in decisions about their health care is determined by whether their clinicians judge them to have decision-making capacity. Because so much hinges on assessments of capacity, clinicians who work with patients have an ethical obligation to understand this concept. ⋯ A study of clinicians and ethics committee chairs carried out under the auspices of the NEC identified the following 10 common myths clinicians hold about decision-making capacity: (1) decision-making capacity and competency are the same; (2) lack of decision-making capacity can be presumed when patients go against medical advice; (3) there is no need to assess decision-making capacity unless patients go against medical advice; (4) decision-making capacity is an "all or nothing" phenomenon; (5) cognitive impairment equals lack of decision-making capacity; (6) lack of decision-making capacity is a permanent condition; (7) patients who have not been given relevant and consistent information about their treatment lack decision-making capacity; (8) all patients with certain psychiatric disorders lack decision-making capacity; (9) patients who are involuntarily committed lack decision-making capacity; and (10) only mental health experts can assess decision-making capacity. By describing and debunking these common misconceptions, this article attempts to prevent potential errors in the clinical assessment of decision-making capacity, thereby supporting patients' right to make choices about their own health care.
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Aspiration pneumonia is a significant cause of morbidity, hospitalization, and mortality in the nursing home population. Patients who aspirate have three times higher mortality than patients who do not aspirate. We discuss the factors known to increase the risk of aspiration and its consequences, and recognize some of the preventive measures for aspiration pneumonia. We suggest approaches to decrease the risk of this very prevalent syndrome.