Study finds multidrug-resistant gram-negative bacteria high in long-term care

The prevalence of a certain form of drug-resistant bacteria, called multidrug-resistant gram-negative (MDRGN) organisms, far surpassed that of two other common antimicrobial-resistant infections in long-term care facilities, according to a study conducted by researchers at Hebrew SeniorLife's Institute for Aging Research.

12 april 2009--Residents at long-term care facilities are one of the main reservoirs of antimicrobial-resistant bacteria. Epidemiological studies have focused primarily on two common antimicrobial-resistant organisms—methicillin-resistant Staphylococcus aureas (MRSA) and vancomycin-resistant enterococci (VRE).

"Recently, it has become apparent that multidrug resistance among gram-negative bacteria is becoming an even greater problem in these facilities, with nearly half of long-term care facility residents harboring multidrug-resistant gram-negative bacteria," write the researchers, led by IFAR's Erin'O'Fallon, M.D., M.P.H., in the January issue of the Journal of Gerontology: Medical Sciences.

MDRGN infection can lead to toxins in the bloodstream that cause inflammation and destroy healthy tissue. Left untreated, these infections can be fatal.

More than 80 percent of the MDRGN cases in the study were resistant to commonly prescribed antimicrobial medications, including ciprofloxacin, trimethoprim-sulfamethoxazole, and amipicillin/sulbactam. By definition all of the identified MDRGN bacteria were resistant to at least three different classes of antimicrobial drugs, with one-third of them resistant to four.

These findings, says Dr. O'Fallon, a staff geriatrician at Hebrew Rehabilitation Center and a research fellow in medicine at Harvard Medical School, raise concerns about the therapeutic options available to physicians in treating long-term care residents with MDRGN. Hospitals and long-term care facilities have only recently begun to include MDRGN in their surveillance of antimicrobial-resistant bacteria and have extended requirements for contact precautions to MDRGN.

Using more than 1,660 clinical cultures (urine, blood and wound specimens) obtained from residents at a large, urban long-term care facility, the researchers found 180 cases of MDRGN compared to 104 cases of MRSA and 11 cases of VRE. Of further concern, they say, was the steady rise in MDRGN over the two-year study period, which increased from 7 percent the first year to 13 percent in the last year.

Dr. O'Fallon says that infections caused by MDRGN are associated with higher mortality rates, longer hospital stays, and increased costs compared with infections caused by gram-negative bacterial infections that can be treated effectively with antibiotics. Risk factors for MDRGN infection in the long-term care population include pressure ulcers, poor functional status, advanced dementia, and antimicrobial exposure.

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Scientists at HSL's Institute for Aging Research conduct rigorous medical and social studies, leading the way in developing strategies for maximizing individuals' strength, vigor and physical well-being, as well as their cognitive and functional independence, in late life.

Common signs point to depression in nursing home residents

By Miriam E. Tucker
NATIONAL HARBOR, 18 dec 2008 – Weight loss, verbally abusive behavior, and moderate pain were all significant predictors of a new diagnosis of depression among established nursing home residents in a longitudinal analysis.

Although studies have shown that depression affects 20%-55% of nursing home residents, the condition frequently goes unrecognized because of factors such as limited availability of formal psychiatric services, attribution of symptoms to physical ailments, and the tendency to see depressive symptoms as normal in residents. Developing a set of observable indicators of depression may facilitate earlier diagnosis and treatment by nursing home staffs, said Dr. Lorraine J. Phillips and her associates in a poster at the annual meeting of the Gerontological Society of America.

The data were taken from a sample of 13,588 nursing home residents who were among the 127,587 included in the Missouri Minimum Data Set (MDS) from Jan. 1, 2003, to March 31, 2005. The MDS is the federal system of periodic assessments of all nursing home residents’ health and functional status, reported state by state and in a national database.

Among the study’s inclusion criteria were two sequential assessments 90 days apart (excluding admission and discharge assessments), age 65 years and older, no prior diagnosis of depression or use of antidepressant medications, and no severe cognitive impairment.

Mean age of the study population was 85 years, 74% were female, and 88% were white. More than 66% of residents were widowed, 19.5% were married, and 12% had never married. About 49% had less than a high school education, 37% had finished high school, and 14% had a college education.

Documentation of weight loss at the study’s first assessment was associated with a significantly increased chance of being diagnosed with depression between the first and second assessments (odds ratio 1.68, P value less than.0001). Verbally abusive behaviors, such as threatening, screaming, or cursing at others, also predicted a depression diagnosis between the two study assessments (OR 1.44, P = .0004).

Moderate pain was a third significant predictor (OR 1.43, P less than.0001), reported Dr. Phillips of the Sinclair School of Nursing at the University of Missouri-Columbia, and her associates.

Conversely, frequent urinary incontinence was significantly associated a lower incidence of depression (OR 0.70, P less than .0001). Post hoc analysis showed a correlation between incontinence and cognitive impairment, suggesting that the lower incidence of depression being diagnosed in nursing home residents can be explained by cognitive impairment impeding the recognition of depression, the investigators said.

Never being married also predicted a lower incidence of depression (OR 0.66, P = .0004), as did age 95 and above (OR 0.70, P = .0006).

Among the residents with depression, only 12 had “excruciating” pain, a number too small for statistically significant analysis, the researchers noted.

This research was funded by the University of Missouri MDS and Quality Research Team (www.nursinghomehelp.org), an interdisciplinary research group that aims to improve the quality of nursing home care in Missouri and elsewhere. The team began work in 1993, and members have received funding for their work since 1994 through the Missouri Division of Aging, the Health Care Financing Administration, the National Institute for Nursing Research, the Agency for Health Care Policy and Research, and other agencies and foundations.

Long-term care workers struggle with elderly population boom

13 aug 2008--As America's aging population increases, so does its need for long-term care. And the workers who provide these services often lack the support they need — particularly in the area of pay and work relationships, according to "Better Jobs Better Care: New Research on the Long-Term Care Workforce," the latest special issue of The Gerontologist (Volume 48, Special Issue 1).
Those aged 65 and older are projected to represent at least 20 percent of the total U.S. population by 2030, with the number of those 85-and-older increasing the most. The growth of this demographic will have a major effect on the demand for and supply of long-term care services.
Better Jobs Better Care (BJBC) was the nation's largest single initiative created to reduce the high vacancy and turnover rates of direct care workers and improve workforce quality through both policy and practice changes.
With funding from the Robert Wood Johnson Foundation and the Atlantic Philanthropies, this four-year program was directed and managed by the Institute for the Future of Aging Services at the American Association of Homes and Services for the Aging, with technical assistance from PHI (formerly the Paraprofessional Healthcare Institute).
"The effort was to see what ideas are out there for improving direct care work — to make sure people have what they need to stay in their homes and communities," said special issue editor Susan C. Reinhard, RN, PhD, FAAN.
Through two-types of grants — state-based demonstration projects and applied research projects — BJBC tested new approaches to providing a more stable and qualified long-term care staff and systematically evaluating what works best to achieve this objective. The special issue, which contains 12 articles, represents the findings of the BJBC program.
In addition to a need for better pay and improved work relationships, the studies found that recruitment and retention is an industry-wide problem, not just limited to nursing homes; greater job satisfaction translates to a better quality of life for patients; and older people themselves have roles to play in the long-term care workforce.
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Funding for the special issue came from the Robert Wood Johnson Foundation. Purchase information is available at http://www.geron.org/.
The table of contents is as follows:
INTRODUCTION The Origins of Better Jobs Better Care Better Jobs Better Care: A Foundation Initiative Focusing on Direct Care Workers
FINDINGS FROM THE BETTER JOBS BETTER CARE DEMONSTRATION PROGRAM What Do Direct Care Workers Say Would Improve Their Jobs? Differences Across Settings Implementation of the Better Jobs Better Care Demonstration: Lessons for Long-Term Care Workforce Initiatives
FACTORS THAT PREDICT BETTER RETENTION Nursing Assistants' Job Commitment: Effect of Nursing Home Organizational Factors and Impact on Resident Well-Being Love, Money, or Flexibility: What Motivates People to Work in Consumer-Directed Home Care The Impact of Stress and Support on Direct Care Workers' Job Satisfaction
ORGANIZATIONAL AND MANAGEMENT INTERVENTION A Mixed-Method Evaluation of a Workforce Development Intervention for Nursing Assistants in Nursing Homes: The Case of WIN A STEP UP A Facility Specialist Model for Improving Retention of Nursing Home Staff: Results From a Randomized, Controlled Study
EXPANDING THE LABOR POOL Older Workers: An Opportunity to Expand the Long-Term Care/Direct Care Labor Force Retention of Paid Related Caregivers: Who Stays and Who Leaves Home Care Careers?
MEASURING PERSON-DIRECTED CARE Development and Initial Testing of a Measure of Person-Directed Care
The Gerontologist is a refereed publication of The Gerontological Society of America, the nation's oldest and largest multidisciplinary organization devoted to research, education, and practice in the field of aging. The principal mission of the Society — and its 5,000+ members — is to advance the study of aging and disseminate information among scientists, decision makers, and the general public