nursing facility. Measures included the MacCAT-T, two versions of theDecision Making Tool, the Mini Mental Status Exam, and other participantvariables including case mix index.Results: Results will be discussed with regard to the validity and reliability ofthe Decision Making Tool and its potential for use in a range of long termcare settings.Disclosures: Kerrie D. Smedley, PhD has no disclosures to be made that arepertinent to this abstract.
Diogenes syndrome: A self-neglect syndrome in elderly patients
Presenting Author(s): Jesus R. Duran, MD, Baylor Collage of MedicineAuthor(s): Jesus R. Duran, MD; Darshan Shah, MD; and Sarah Selleck, MD
Introduction/Objective: Diogenes Syndrome is a behavioral disorder of theelderly. The cardinal features of this condition include extreme self-neglect,domestic squalor, and tendency to hoard excessively. This is associated withself-imposed isolation, refusal of help, and marked indifference or lack ofawareness. Diogenes syndrome has been referred to as senile breakdown,social breakdown, senile squalor syndrome, and messy house syndrome.Design/Methodology: Case Report.Results: 83yo female with AAA, lung CA status post right throracotomy,urinary incontinence, HTN and prior falls, who was found by EMS on thefloor 3 days after a fall. She stated that she didn’t call for help after the fall,because “I am stubborn.” The day of the admission, neighbors noticed paperspilling up at the patient’s doorstep and subsequently found the patient lyingon the floor urinated on herself. She is single, lives alone and has no childrenand her nearest living relative is in California. She has poor hygiene and sheis uncompliant medications. Social worker has tried to place the patient in anursing home on prior admissions but, secondary to monetary issues, thepatient has not been able to be placed. The patient has no Medicare days leftand is Medicaid ineligible secondary to having insufficient assets. AdultProtective Services (APS) has been contacted in the past; the patient hasbeen repeatedly deemed unsafe to be at home. Patient has history of ETOHabuse, but does not use tobacco or illicit drugs. The apartment was grosslydirty with an offensive odor. Piles of old newspaper restricted the living space.Old food was found in the kitchen full of maggots. Several bottles of alcoholand beer were found on the floor. She sleeps on an old couch. She was in astate of gross physical neglect, dressed in layers of dirty clothing stained withurine. She minimized the seriousness of the damage in her apartment andexpressed her lack of undesire to move. While patient was in the hospital, shewas able to answer questions appropriately. Psychiatry assessment provided noevidence for dementia, or affective or psychological disorders. Neuropsycho-logical evaluation considered ”safety risk� to return home; however patienthas been found to have capacity to make decisions. Overall, the patient’sgeneral intellect was in the average range. Executive functions, attention,memory, language, and visual and spatial perception was grossly intact. Shestrongly opposed her hospitalization. She refused to take medications andwork with physical therapy. After two weeks of hospitalization, she wasdischarged from the hospital. The patient was found competent to make herown decisions, and she accepted daily home visits, M&W and supervision bythe APS, but refused to be transferred to a long term care facility.Conclusion/Discussion: Diogenes syndrome is a complex problem in geriat-rics. It includes clinical, social, and ethical decisions that healthcare profes-sionals must make when caring for older people with this syndrome.Disclosures: Jesus R. Duran, MD has no disclosures to be made that arepertinent to this abstract.
Do frequent fingersticks improve glycemic control in nursing homediabetic patients?
Presenting Author(s): Stephen Hom, DO, Long Island Jewish Medical CenterAuthor(s): Stephen Hom, DO; Gisele P. Wolf-Klein MD; Barbara C. Tom-masulo, MD, CMD; Yosef Dlugacz, PhD; Charles Cal, MBA, MS, RN; andRoshan Hussain, MPH
Introduction/Objective: Diabetes affects over 20 million Americans and is asource of significant morbidity and mortality. It is prevalent in as many as26% of elderly nursing home residents. Yet, the majority of studies on
glycemic control focuses on the reduction of long-term microvascular andmacrovascular complications in younger patients. There is a dearth of clinicalevidence supporting glucose monitoring in the nursing home, particularly inthe presence of a stable HbA1c. Therefore, we decided to explore thefrequency of fingersticks and its correlation with glycemic control in longterm care diabetic patients.Design/Methodology: We performed a retrospective chart review of 100diabetic patients who have resided in a 672 bed skilled nursing facility for atleast 1 year. Patients were randomly assigned to one of the 21 primary carephysicians. We recorded demographic data, all HbA1c and fingerstick valuesover the preceding 6 months as well as changes in the diabetic therapeuticregimens and the presence of episodic hypo or hyperglycemia. Finally, thenutritional status was documented, using weight, BMI, food supplements,ability to self-feed and presence of depression.Results: In this preliminary data analysis, average age was 69.2. Forty percentof the subjects were male, 60% suffered from dementia, and 60% were treatedfor depression. Ninety percent of patients were on oral hypoglycemics, 60%received insulin and 50% were given both. In addition, 70% had orders forinsulin coverage. While 70% required assistance for feeding, only 40%received food supplements. The majority of diabetic patients (80%) werebeing monitored with frequent fingersticks during a six month period, aver-aging 54 fingersticks/month (range: 35–85/month). Only 6 episodes of severehyperglycemia (glucose: 400–513 mg/dl) were reported, but no patient be-came hypoglycemic (glucose �60 mg/dl). The average HbA1c for the fre-quently monitored diabetic patients was 7.35 with an average change of�0.35 from their initial HbA1c. Physicians ordered an average of 1.5 med-ication changes/6 months for each patient in this group; these patients wereadministered an average of 14 dosages of subcutaneous insulin each month.The 20% of patients that were monitored with daily or fewer fingersticksreceived an average of 8 fingersticks/month, revealing no episodes of hypo-glycemia or hyperglycemia. The average HbA1c for these patients was 7.1with an average change of �0.85 from their initial HbA1c. Physiciansordered an average of 0.5 medication changes/6 months in this group; noinsulin coverage was ordered.Conclusion/Discussion: In this study, frequent fingerstick monitoring didnot improve glycemic control. In addition, there were no episodes of hypo-glycemia noted and very few episodes of hyperglycemia which did not requirehospitalization. In view of the cost, burden and quality of life issues related toclose monitoring, we suggest that physicians reconsider the frequency of theirfingerstick orders for nursing home diabetic patients.Disclosures: Stephen Hom, DO, Barbara C. Tommasulo, MD, CMD, YosefDlugacz, PhD, Charles Cal, MBA, MS, RN, and Roshan Hussain, MPH haveno disclosures to be made that are pertinent to this abstract.
Extrapulmonary tuberculosis presenting as scrofula in long-term carefacility resident
Presenting Author(s): Inna Sheyner, MD, CMD, University of South FloridaAuthor(s): Inna Sheyner, MD, CMD; Vladimir Osipov, MD; and Pavel Sergeev, MD
Introduction/Objective: Tuberculous lymphadenitis known centuries ago asthe King’s evil and as scrofula when presenting in cervical region, continuesto be a clinical dilemma in the modern times. In the developed countries themajority of cases of tuberculous lymphadenitis occur in immigrants andtravelers to endemic areas. In the past it was commonly considered as adisease of the childhood, recently the peak age of onset has been shiftedtowards the ages of 65 years old and above.Design/Methodology: We describe the case of an elderly long term carefacility resident with ear ache and cervical “lump” presenting two monthsafter initiation of hemodyalisis. After evaluation he was diagnosed withtuberculous lymphadenitis (scrofula) and successfully treated with RIPAregimen.Results: We present a gross color picture of scrofula, color picture of necro-tizing granuloma and CT image of the cervical lyphadenopathy.Conclusion/Discussion: We would like to alert physicians practicing in longterm care facilities about importance of timely diagnosis and treatment ofextrapulmonary tuberculosis in elderly immunocompromised residents, de-scribe diagnostic approach as well as challenges of differential diagnosis ofcervical lymphadenopathy (including current recommendations for appropri-ate imaging studies) and necrotizing granulomas.
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