Elderly/Long-term Care

Studies focus on care for respiratory tract infections in the elderly

Overuse of antibiotics for acute respiratory infections, particularly lower respiratory infections (LRIs), promote the spread of antibiotic-resistant strains of bacteria such as Streptococcus pneumoniae. Many of these infections are caused by viruses, which are not treatable by antibiotics. This is a problem, especially for elderly adults, who have much higher rates of infection with S. pneumoniae.

Indeed, LRI, including pneumonia, is the leading cause of hospitalization and death in nursing home residents. Yet, even after educating doctors and elderly Medicare patients about the proper use of antibiotics for respiratory infections, patients were often prescribed antibiotics for respiratory conditions unlikely to benefit from them, according to a study supported in part by the Agency for Healthcare Research and Quality (HS13001). A second AHRQ-supported study (HS08551) found that do-not-resuscitate (DNR) orders reduce the risk of hospitalization for LRI among nursing home residents. Both studies are discussed here.

Gonzales, R., Sauaia, A., Corbett, K.K., and others (2004, January). "Antibiotic treatment of acute respiratory tract infections in the elderly: Effect of a multidimensional educational intervention." Journal of the American Geriatrics Society 52, pp. 39-45.

This study found that elderly Medicare patients were often prescribed antibiotics for conditions that are not responsive to antibiotic treatment, such as bronchitis and upper respiratory infections, even after they and their doctors received educational materials about antibiotic resistance and the proper use of antibiotics for acute respiratory infections (ARIs). The researchers mailed these materials to households of Medicare managed care patients in the Denver, CO, metropolitan area who were diagnosed with ARIs during baseline (winter 2000/2001) and intervention (winter 2001/2002) periods. During the intervention period, the researchers also provided educational posters for waiting and examination rooms to four intervention practices but not to the 51 control practices. The goal was to reduce unnecessary antibiotic use for ARIs in the elderly.

The researchers analyzed antibiotic prescribing for ARIs for a total of 4,270 patient visits, including 341 patient visits in intervention practices. The educational intervention was not associated with greater reduction in antibiotic prescription rates for either total or condition-specific ARIs beyond a modest secular trend in reduced antibiotic use for ARIs. Furthermore, antibiotic prescribing for ARIs varied widely across practices, ranging from 21 to 88 percent.

Antibiotic prescription rates varied little by patient age, sex, or underlying chronic disease. However, prescription rates did vary by diagnosis: sinusitis (69 percent), bronchitis (59 percent), pharyngitis (50 percent), and nonspecific upper respiratory tract infection (26 percent). In the setting of an ongoing physician intervention, the patient education intervention had little effect. This is in contrast to multiple studies in children and nonelderly adults which have found that patient education is a critical component of effective intervention strategies. This suggests that factors other than patient expectations and demands play a strong role in antibiotic treatment decisions for the elderly.

Zweig, S.C., Kruse, R.L., Binder, E.F., and others (2004, January). "Effect of do-not-resuscitate orders on hospitalization of nursing home residents evaluated for lower respiratory infections." Journal of the American Geriatrics Society 52, pp. 51-58.

DNR orders are associated with a reduced probability of hospitalization for LRI among nursing home residents. Therefore, this study suggests DRN orders may also function as a marker for undocumented care limitations or a mandate to limit care unrelated to resuscitation, including hospitalization. The investigators examined the associations between resident, physician, and nursing home characteristics, as well as the presence of a DNR order, and hospitalization within 1 month after evaluation for an LRI among nearly 4,000 residents in 36 nursing homes in Missouri. Overall, 1,031 residents had an LRI.

Sixty percent of residents had a DNR order, and 2 percent had a do-not-hospitalize order. After controlling for other factors, residents with a DNR order before the acute LRI episode were 31 percent less likely to be hospitalized. Residents with DNR orders were more likely to live in facilities with more licensed beds, a lower proportion of Medicaid recipients, and a higher prevalence of influenza vaccination. Also, older, white, and cognitively impaired residents were more likely than other nursing home residents to have DNR orders.

Although the decision not to hospitalize individual residents may have reflected the preferences of residents or their surrogates, the available records did not support this conclusion. These data are consistent with clinical experience that DNR orders often serve as an unspoken proxy for limiting other care, even though much more explicit discussions and documentation about the use or withholding of medical interventions, including hospitalization, is warranted, conclude the researchers.

Editor's Note: A related study shows that older adults' preferences for life-sustaining medical treatment remain stable over time and across changes in life condition. For more details, see Ditto, P.H., Smucker, W.D., Danks, J.H., and others (2003). "Stability of older adults' preferences for life-sustaining medical treatment." (AHRQ grant HS08180) Health Psychology 22(6), pp. 605-615.

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