Hospitalization transfers from a skilled-nursing facility were studied. A hierarchically arranged questionnaire on acute medical deterioration and treatment aggressiveness was used to study the degree of discordance between the transfers actually made and the preferences of nursing home head nurses. According to the nurses, 37 per cent of the patients involved should not have been hospitalized even under the most compelling circumstances; however, 76 per cent of this subgroup had in fact been hospitalized under physician's orders. The nurses would have refrained from instituting any new treatment in 14 per cent of the cases, all of which involved chronic neurological impairments; 36 per cent of this subgroup had nevertheless been hospitalized in the 12 months prior to the study.

OBJECTIVES To derive weighted‐incidence syndromic combination antibiograms (WISCAs) in the skilled nursing facility (SNF). To compare burden of resistance between SNFs in a region and those with and without protocols designed to reduce inappropriate antibiotic use. DESIGN Retrospective analysis of microbial data from a regional laboratory. SETTING We analyzed 2484 isolates collected at a regional laboratory from a large mixed urban and suburban area from January 1, 2015, to December 31, 2015. PARTICIPANTS A total of 28 regional SNFs (rSNFs) and 7 in‐network SNFs (iSNFs). MEASUREMENTS WISCAs were derived combining Escherichia coli, Proteus mirabilis, Klebsiella pneumoniae, and reports restricted to fluoroquinolones, cefazolin, amoxicillin clavulanate, and trimethoprim/sulfamethoxazole. RESULTS Pooling the target isolates into WISCAs resulted in an average of 28 of 37 achieving a number greater than 30 with an average of 50 isolates (range = 11‐113; >97% urinary). Significant differences were found in antibiotic susceptibility between grouped rSNF data and iSNF data of 75% vs 65% (2.76‐11.77; P = .002). The susceptibilities were higher in iSNFs with active antibiotic reduction protocols compared with iSNFs without protocols and rSNFs (effect size = .79 vs .67 and .65, respectively) (I2 = 93.33; P < .01). Susceptibilities to cefazolin (95% vs 76%; P < .001) and fluoroquinolones (72% vs 64%; P = .048) were significantly higher in iSNFs with active urinary tract infection protocols as compared with iSNFs without antibiotic reduction protocols. CONCLUSION These results suggest that WISCAs can be developed in most SNFs, and their results can serve as indicators of successful antibiotic stewardship programs. J Am Geriatr Soc 68:55–61, 2019

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A review of the relevant literature was stimulated by recent publications urging extensive laboratory assessment of elderly patients presenting with intellectual impairment. Published data regarding reversible causes of impairment are limited and exist only for hospitalized patients, with rare exceptions. The frequencies of azotemia, hyponatremia, volume depletion, hypoglycemia, cardiac arrhythmia, cerebrovascular disease, sensory impairment, hypercarbia, congestive heart failure, infections, subdural hematoma, and chemical intoxications as causes of the intellectual impairment are entirely unknown. It is reported that 8 per cent of patients hospitalized for dementia are depressed; alcoholism is causative in 8 to 13 per cent of patients with mental impairment; normal pressure hydrocephalus is reported in 7 to 12 per cent. The frequency of the latter conditions in outpatients is not known. While estimates exist for the frequencies of hypothyroidism, hyperparathyroidism, neurosyphilis, and vitamin B12 and folate deficiencies among the elderly, no prevalence data exist for these disorders among the intellectually impaired.