health maintenance in nursing home patients

Management: 1) screening a) history & physical examination yearly - required by regulations - yield is debated; focused exam may be more appropriate b) weight monthly - generally required by regulations - persistent weight loss should prompt a search for treatable causes c) functional status assessment yearly - includes balance & gait assessment - mental status examination - screen for depression - generally done more frequently by nursing staff d) visual screening yearly - acuity - intraocular pressure e) auditory screening yearly f) dental screening yearly g) podiatry screening yearly - more frequently in diabetics & patients with peripheral vascular disease h) tuberculosis - at time of admission & yearly - all residents & staff should be tested - control skin tests & booster testing (2-step) generally recommended for nursing home patients i) laboratory testing yearly - fecal occult blood - complete blood count (CBC) - chem 7: glucose, creatinine, electrolytes - Ca⁺², albumin, phosphorous - thyroid function (TSH, T4) 2) monitoring a) all residents: - vital signs & weight monthly - more often if unstable or subacutely ill b) diabetics - fasting & post-prandial glucose monthly - hemoglobin A1c every 3 months c) patients on diuretics or with renal insufficiency - chem 7 every 2-3 months - nursing home residents are prone to dehydration, hyponatremia & hypokalemia d) patients receiving non-steroidal anti-inflammatory agents - hemoglobin, creatinine & BUN every 2-3 months e) anemic patients with hemoglobin < 10 g/dL - hemoglobin monthly until stable, then every 2-3 months f) therapeutic monitoring of specific drugs - every 3-6 months, or more frequently when adjusting dose - agents - digoxin - phenytoin (Dilantin) - quinidine - procainamide - theophylline - nortriptyline 4) prevention a) influenza - influenza vaccine yearly - all residents - staff with close resident contact - oseltamivir within 24-48 hours of suspected outbreak of influenza A b) pneumococcal vaccine - once & again after age 75 c) aggressive dental care may reduce nursing home pneumonias 35-40% [3] d) tetanus booster - every 10 years - every 5 years with tetanus-prone wounds e) tuberculosis - isoniazid 300 mg QD for 1 year + pyridoxine 25 mg QD - skin test conversion in selected residents - abnormal chest X-ray - diabetes - end-stage renal disease - hematologic malignancies - steroid or other immunosuppressive therapy - malnutrition f) antimicrobial prophylaxis - dental procedures - genitourinary procedures - most operative procedures - chronically catheterized patients should not be treated with continuous antibiotic prophylaxis g) body positioning & range of motion for immobile patients - frequent turning is necessary to prevent pressure sores - semi-upright position to prevent aspiration - swallowing disorders - enteral feeding - range of motion to immobile limbs & joints to prevent contractures h) infection control & surveillance (ongoing) - policies & protocols should be in effect in all nursing homes - surveillance of all infections should be continuous to identify outbreaks & resistance patterns i) environmental safety - appropriate lighting & colors - removal of hazards for falling - routine monitoring of potential safety hazzards & accidents

General

health maintenance (preventive medicine)

References

Ouslander, JAMA 262:2582, 1989
Ouslander JG, Osterweil D. Physician evaluation and management of nursing home residents. Ann Intern Med 120:584, 1994 PMID: 8116998
Journal Watch 25(4):31, 2005 Quagliarello V, Ginter S, Han L, Van Ness P, Allore H, Tinetti M. Modifiable risk factors for nursing home-acquired pneumonia. Clin Infect Dis. 2005 Jan 1;40(1):1-6. Epub 2004 Dec 01. PMID: 15614684 Terpenning M. Prevention of aspiration pneumonia in nursing home patients. Clin Infect Dis. 2005 Jan 1;40(1):7-8. Epub 2004 Dec 01. No abstract available. PMID: 15614685

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