Sleep‐related disorders are most prevalent in the older adult population. A high prevalence of medical and psychosocial comorbidities and the frequent use of multiple medications, rather than aging ...per se, are major reasons for this. A major concern, often underappreciated and underaddressed by clinicians, is the strong bidirectional relationship between sleep disorders and serious medical problems in older adults. Hypertension, depression, cardiovascular disease, and cerebrovascular disease are examples of diseases that are more likely to develop in individuals with sleep disorders. Conversely, individuals with any of these diseases are at a higher risk of developing sleep disorders. The goals of this article are to help guide clinicians in their general understanding of sleep problems in older persons, examine specific sleep disorders that occur in older persons, and suggest evidence‐ and expert‐based recommendations for the assessment and treatment of sleep disorders in older persons. No such recommendations are available to help clinicians in their daily patient care practices. The four sections in the beginning of the article are titled, Background and Significance, General Review of Sleep, Recommendations Development, and General Approach to Detecting Sleep Disorders in an Ambulatory Setting. These are followed by overviews of specific sleep disorders: Insomnia, Sleep Apnea, Restless Legs Syndrome, Circadian Rhythm Sleep Disorders, Parasomnias, Hypersomnias, and Sleep Disorders in Long‐Term Care Settings. Evidence‐ and expert‐based recommendations, developed by a group of sleep and clinical experts, are presented after each sleep disorder.
In 2003, The John A. Hartford Foundation Institute for Geriatric Nursing, New York University Division of Nursing, convened an expert panel to explore the potential for developing recommendations for ...the caseloads of advanced practice nurses (APNs) in nursing homes and to provide substantive and detailed strategies to strengthen the use of APNs in nursing homes. The panel, consisting of nationally recognized experts in geriatric practice, education, research, public policy, and long‐term care, developed six recommendations related to caseloads for APNs in nursing homes. The recommendations address educational preparation of APNs; average reimbursable APN visits per day; factors affecting APNs caseload parameters, including provider characteristics, practice models, resident acuity, and facility factors; changes in Medicare reimbursement to acknowledge nonbillable time spent in resident care; and technical assistance to promote a climate conducive to APN practice in nursing homes. Detailed research findings and clinical expertise underpin each recommendation. These recommendations provide practitioners, payers, regulators, and consumers with a rationale and details of current advanced practice nursing models and caseload parameters, preferred geriatric education, reimbursement strategies, and a range of technical assistance necessary to strengthen, enhance, and increase APNs' participation in the care of nursing home residents.
OBJECTIVE: Among the high risk groups for complications from influenza and pneumococcal disease, individuals aged 65 and older hospitalized within the previous year represent the group at highest ...risk. Studies have demonstrated that targeting hospitalized patients aged 65 and older for immunization before hospital discharge can be successful. This study addressed the efficacy of such a program within a managed care organization to immunize this highest risk group.
DESIGN: A cross‐sectional study
SETTING: Oxford Health Plans, a major managed care organization in New York serving a large Medicare population.
PARTICIPANTS: A total of 106 Primary Care Physicians caring for 153 patients aged 65 and older, who were hospitalized in one of 10 high volume hospitals during October and November of 1996. Nine of these facilities were located in New York and one was in New Jersey.
INTERVENTION: Patients aged 65 and older admitted to any of the 10 hospitals were identified daily. A fax was sent to each patient's primary care physician explaining the program and requesting that he/she administer influenza and/or pneumococcal vaccine to his/her patient before hospital discharge. Literature references citing past successful programs were included in the fax.
MEASUREMENTS: Measurements included medical record documentation of influenza and pneumococcal immunization, both ordered and given, for the individual member before discharge; patient age; sex; and primary and secondary diagnoses. Physicians were sent follow‐up questionnaires to determine reasons for not vaccinating.
RESULTS: A total of 206 patients were admitted during the eligible time period. One hundred fifty‐three hospitalized patients (average age = 74 years) participated. The median length of stay among this study population was 5 days (range, 1–63 days). The distribution of the median length of stay for the 25th and 75th percentiles was 3 and 9 days. The rate for influenza and pneumococcal immunization, both ordered and given, before hospital discharge was 1.96% for the influenza vaccine (n = 3) and .65% for the pneumococcal vaccine (n = 1), respectively.
Results of a follow‐up survey mailed to all physicians (n = 106) with eligible members in the study indicated that the most frequent reasons for not vaccinating included: patients were vaccinated before admission, patients were not stable enough to be vaccinated before discharge, and the acute care setting is not appropriate for vaccination. Response rate of 58% (n = 61) was achieved with an initial mailing and one follow‐up telephone call to all previous nonresponders. Some physician survey responses do not correlate with data obtained from retrospective patients' claims analysis.
CONCLUSION: Well‐coordinated and timely attempts to encourage primary care physicians to immunize patients 65 years and older before hospital discharge were unsuccessful in our study. Rather than working with physicians, it may be that managed care organizations should work directly with hospitals to implement influenza and pneumococcal immunization programs.
The purpose of this study was to examine mechanisms involved in the response of native collaterals to coronary occlusion. In anesthetized dogs native collaterals were identified as vessels coursing ...between the left anterior descending and left circumflex arteries using fluorescence angiography. After a left anterior descending occlusion in 12 dogs, collaterals < 100 microns in diameter progressively dilated by 21 +/- 4% (n = 12) 1 min after occlusion and by 39 +/- 6% 15 min after occlusion. Collaterals > 100 microns in diameter did not dilate after coronary occlusion. NG-nitro-L-arginine (1 mg/min intracoronary) caused constriction under basal conditions in collaterals < 100 microns but did not prevent the dilation of collaterals after occlusion. In contrast, glibenclamide (10(-5) M), an inhibitor of ATP-sensitive potassium channels, had no effect on baseline diameter of collaterals < 100 microns diameter but completely prevented dilation of collaterals after occlusion. We conclude that collaterals are not maximally dilated immediately after a coronary occlusion but rather progressively dilate for at least 15 min after an occlusion. This dilation of native collaterals after an occlusion is not mediated by release of an endothelium-derived relaxing factor derived from L-arginine but is mediated by activation of ATP-sensitive K+ channels.
Examined differences among nursing homes in rates at which they transfer patients to hospitals. Data from nursing staff and charts on 286 most recent transfers from 10 nursing homes revealed that, ...from relatively equivalent patient populations, high-rate facilities transferred more chronically ill, physically frail patients and patients with infections and made transfers because of lack of resources. (Author/NB)
This study compared three interventions designed to increase acceptance of influenza and pneumococcal vaccines among elderly hospitalized patients. All individuals 65 and older able to give informed ...consent (73 patients) who were admitted to one medical floor of an acute care hospital were randomized to one of three groups. All groups received informational pamphlets explaining influenza and pneumococcal disease, their respective vaccines, and indications for their use. The first group received pamphlets only, the second received nursing follow-up, and the third received trained volunteer follow-up. Patients on another medical floor served as controls. The results showed a significant improvement in vaccine acceptance in all three study groups compared to controls for both influenza (78% vs 0%) and pneumococcal (75% vs 0%) vaccines. The differences among the three groups were not significant. No significant differences were found among patients accepting or refusing vaccination with regard to diagnosis, age, length of stay, sex, or having a private physician. We conclude that a simple educational program followed by offering vaccination before hospital discharge can be easily implemented, and dramatically increase immunization rates in this high risk group.
Infectious diarrheal diseases can be a serious problem in long-term care institutions. Aeromonas hydrophila, a facultative, anaerobic gram-negative rod, has not been implicated previously in an acute ...diarrheal outbreak in this setting. We report 17 patients with this disorder all characterized by the acute onset of painless, nonbloody diarrhea. Thirteen of 17 (76%) patients had two to four loose bowel movements and a duration of illness of less than 48 hours. Eleven of 17 (65%) patients were afebrile. Stool cultures were obtained in 11 patients; 4 (36%) were positive for A. hydrophila. The disease was fatal in one patient who experienced profuse diarrhea and developed fever, tachycardia, and hypotension. The original source of the A. hydrophila was not identified but transmission is known to be water- or food-borne. Although usually mild and self-limited, A. hydrophila infection as noted in one patient can be fulminant and severe. A. hydrophila diarrhea responds to antibiotic therapy; it is important to consider in the differential diagnosis of acute diarrheal illness among older persons in an institutional setting.
Kisspeptin plays a pivotal role in pubertal onset and reproductive function. In rodents, kisspeptin perikarya are located in 2 major populations: the anteroventral periventricular nucleus and the ...hypothalamic arcuate nucleus (ARC). These nuclei are believed to play functionally distinct roles in the control of reproduction. The anteroventral periventricular nucleus population is thought to be critical in the generation of the LH surge. However, the physiological role played by the ARC kisspeptin neurons remains to be fully elucidated. We used bilateral stereotactic injection of recombinant adeno-associated virus encoding kisspeptin antisense into the ARC of adult female rats to investigate the physiological role of kisspeptin neurons in this nucleus. Female rats with kisspeptin knockdown in the ARC displayed a significantly reduced number of both regular and complete oestrous cycles and significantly longer cycles over the 100-day period of the study. Further, kisspeptin knockdown in the ARC resulted in a decrease in LH pulse frequency. These data suggest that maintenance of ARC-kisspeptin levels is essential for normal pulsatile LH release and oestrous cyclicity.
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