Influenza in care homes

Influenza causes substantial mortality and morbidity in elderly people, particularly those with chronic diseases. Excess deaths during influenza epidemics are not limited to obvious causes such as influenza and pneumonia but also include circulatory and other respiratory causes. People in elderly care homes and hospital wards are at particular risk, because high risk individuals are concentrated in an environment susceptible to the spread of respiratory pathogens. A recent BMJ article reports the impact of vaccinating healthcare workers in elderly peoples homes on mortality in residents.

Most developed countries offer elderly people vaccination against predicted influenza strains for the next season. However, the age related decline of immune function reduces the ability of elderly patients to respond to the influenza vaccine, and the vaccine is less effective in patients with chronic diseases. So even if all elderly people in residential care were vaccinated, the effect on reducing the risk of complications of influenza may be modest. It therefore makes sense to examine alternative strategies, such as vaccination of healthcare workers in elderly care establishments.

Until now, the best evidence in support of vaccinating healthcare workers came from two related trials conducted in long term geriatric care wards in Scotland in the 1990s. Both found that vaccination significantly reduced mortality in residents in years when influenza activity was two to three times higher than recent years and when the vaccine match to the circulating strain was reasonable. Assuming the estimates are robust, such a policy is likely to be cost saving or at the worst highly cost effective.

A new paper provides robust evidence that vaccinating healthcare workers against influenza benefits elderly patients. The trial was conducted over two seasons in 44 private care homes around the United Kingdom. Staff of 22 homes were offered influenza vaccination and those of 22 matched control homes were not. During the 2003-4 periods of influenza activity, five fewer deaths occurred per 100 residents in intervention homes compared with control homes. Episodes of influenza-like illness, consultations with general practitioners for influenza-like illness, and hospital admissions for such illness also decreased significantly. In the following season, influenza activity was much lower and no significant differences in patient morbidity or mortality were seen.

So should all healthcare workers in elderly care establishments be vaccinated? Evidence shows that healthcare workers themselves would benefit by reducing their risk of influenza with minimal adverse effects, employers may benefit by reduced absenteeism, and elderly people in care homes would benefit from reduced morbidity and mortality.

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Tube feeding in dementia

Questions about tube feeding in advanced dementia continue to bedevil doctors.  A recent BMJ article shows that the dilemma of whether or not to tube feed an incompetent, demented patient can always be clarified, and often resolved, by applying the principles of nutritional physiology.

Reduced food intake and weight loss are normal features of advancing old age. Food intake by elderly people may be pathologically curtailed by factors such as ill fitting dentures, functional disability, depression, isolation, and poverty. There is increasing evidence that non-demented, elderly malnourished people benefit from nutritional supplements.  No randomised clinical trials have been carried out in tube fed, severely demented patients, but observational data and the results of trials of tube feeding in other conditions have led to a consensus of expert opinion that tube feeding patients with advanced dementia neither prolongs their life nor improves its quality.

Tube feeding shortens the life of some patients, and it is often inefficient at delivering food. But problems with the procedure do not fully explain its ineffectiveness. Severely demented patients usually fail to benefit from tube feeding for two main reasons: they lack the potential for physical or neurological rehabilitation, and they are not starving.

People who reach the advanced stage of dementia when food intake is curtailed have a low metabolic rate. Their resting metabolic rate is low because muscle wasting has shrunk their lean body mass and their brains are atrophic; their metabolic rate above basal is low because they are physically inactive. Finally, they have a history of weight loss, which the body adapts to by reducing its metabolic rate and retaining dietary protein more efficiently.

Doctors can readily determine which of their patients are progressively starving by weighing them. In advanced dementia, a constant body weight, even if subnormal, rules out progressive starvation and eliminates any medical indication for tube feeding.

There is no physiological reason nor any medical evidence to presume that a medically stable, severely demented person whose body mass index exceeds 18.5 is at high enough risk of the complications of malnutrition to justify the indignity, discomfort, and danger of tube feeding. Indeed, a body mass index as low as 17 can be tolerated without discomfort by young adults.

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Child safety in cars

In 2005 in the United Kingdom, 24 children aged under 10 years were killed while travelling in cars and a further 226 were admitted to hospital. When used properly, child passenger restraints reduce injury by 90-95% for rear facing systems and 60% for forward facing systems compared with not using a restraint.

On 18 September 2006 the law on carrying babies and children in cars, vans, and goods vehicles in the UK changed . The law states that children under 3 years cannot legally travel in cars unless they are in an appropriate baby or child seat. The one exception is when a baby or young child is carried in a taxi and no child restraint is available; in these circumstances the child may travel unrestrained on the back seat.

The law is more complicated for children over 3 years. When a child is 12 years old or reaches 1.35m an adult seat belt can be used without increasing the risk of injury. Children under 12 years who are less than 1.35m tall are now required to use appropriate child restraints. Such restraints are child seats with integral harnesses or so called booster seats, in which the adult seat belt passes around the front of the child; the function of the booster seat is to position the belt correctly on the child's body.

Failure to comply with the law can result in a £30 fixed penalty notice or a fine of up to £500 if the case goes to court. Despite changes in the past 10 years, child restraints are still not that easy to use. Although not an argument against using it the expensive Isofix, methoid  is an example of poorer families being disadvantaged compared with better off families by the cost of technological development.

BMJ Dec 9 2006

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