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Release:  Oct. 14, 1999

Infections in nursing home patients are due to physical changes, environment

IOWA CITY, Iowa -- Elderly patients in nursing homes get often-deadly infections at a growing rate each year, due to their own bodies' changes with age and characteristics of the nursing home environment.

Since the number of elderly patients requiring nursing home care is increasing as America grows older, health care practitioners need to know the risk factors for these infections and the best methods of managing them, according to a University of Iowa Health Care researcher.

In his recently published paper, Michael Ernst, Pharm.D., assistant professor (clinical) in the College of Pharmacy, reviewed the most common infections that afflict elderly patients in nursing homes and summarized their characteristics and varieties of treatment. The goal was to encourage health care providers to be vigilant and thorough.

"We put together this article to review the guidelines for treatment of infections as more and more antibiotics emerge and more and more elderly need care," Ernst said. "Health care providers need to be reminded why their patients develop these infections and select the appropriate antibiotic to use. This should provide a quick reference."

Research into elderly patients and nursing homes is lacking, Ernst said. However, some information regarding the elderly in nursing homes is known. Ernst notes that more than 1.5 million infections occur annually in American nursing homes, with around 10-20 infections per 100 residents per month. This means about 1-2 infections for each resident each year, and these figures are most likely underreported.

The most common infections that afflict the patients are bacterial pneumonia, urinary tract infections and skin and soft tissue infections. The increased rates of infection are caused in part by bodily changes as patients grow older, including less elastic skin, less respiratory and gastrointestinal ability, and the presence of comorbid illnesses. This means having a chronic illness, like diabetes or asthma, which makes the patient more susceptible to infection and immune system illnesses.

In addition to bodily conditions that may cause infections, the nursing home environment has an effect, as well.

In a closed environment with other patients that may be ill or have infections, the likelihood of becoming ill increases. Also, many instruments used that stay in the body for a long time, such as catheters and feeding tubes, make it easy for infecting agents to enter the body. The large number of prescribed drugs patients receive each day, at an average of 5-10 drugs per resident per day, may increase side effects and other illnesses. Finally, the tendency for many elderly patients to have other chronic conditions including diabetes, asthma, dementia or other cognitive problems, may make it difficult for patients to know when they are sick or to tell the health care providers if they are.

The role nursing homes play in infections is hard to separate from the part aging plays, Ernst said.

"It's hard to separate the issues. The significance of infections depends on the patients, but location does play a role, especially the fact that transmission is facilitated in the closed environments. Influenza outbreaks can occur that are deadly," he said.

After describing the common infections and their causes, the researchers reviewed the options for treatment through drugs. In many cases, however, infections and other illnesses have developed resistance to these drugs. When treatment is ineffective or illnesses are not immediately detected, the patients may be hospitalized, which is extremely costly and often carries the same risks associated with nursing homes.

Because of this, health care providers need to be vigilant in observing their elderly patients. Ernst recommends this article as review for nursing homes professionals, in particular, in order to provide the best care possible.

"A bit of review always helps, to remember the important characteristics and the subtleties of these infections. Individual nursing homes may want to look at their own facilities and see which infections are common. Also, they may want to think about their antibiotic use and how infections are identified, managed and treated.

"The key is to watch carefully for infection and institute the appropriate therapy. This may delay or prevent hospitalization, saving cost and maybe the patient's well-being," he said.

Ernst's review attempts to fill a void that exists in studies on the elderly. One difficulty in conducting studies with institutionalized patients is the need for each participant's consent, which can be a barrier for the many patients who have developed cognitive problems. The increasing number of elderly patients and patients in nursing homes calls for increased efforts to learn more about them and determine the best treatments available, Ernst said.

Ernst's practice and research interests are in family medicine and geriatrics. Erika Ernst, Pharm.D., who is co-author of the paper with her husband, conducts research in infectious diseases.

The paper was published in the September issue of the journal Pharmacotherapy.

University of Iowa Health Care describes the partnership between the UI College of Medicine and the UI Hospitals and Clinics and the patient care, medical education and research programs and services they provide.