Natasha Bagdasarian, MD, Department of Internal Medicine, Divisions of Infectious Diseases, University of Michigan Health System, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, MI, USA.
Preeti N. Malani, MD, Department of Internal Medicine, Divisions of Infectious Diseases and Geriatric Medicine, University of Michigan Health System, Veterans Affairs Ann Arbor Healthcare System; Geriatric Research Education and Clinical Center, Ann Arbor, MI, USA.

The treatment and prevention of Clostridium difficile infection (CDI) in the long-term care (LTC) setting presents unique challenges. In this review, we offer an overview of CDI treatment along with a brief discussion of infection control strategies in the LTC setting. The approach to recurrent CDI is also addressed.
Key words: Clostridium difficile, aging, metronidazole, vancomycin, long-term care.

D.F. Gilpin, PhD, Research Fellow, School of Pharmacy, Queen’s University, Belfast, Northern Ireland.
M.M. Tunney, PhD, Senior Lecturer, School of Pharmacy, Queen’s University, Belfast, Northern Ireland.
N. Baldwin, PhD, Research Fellow, School of Pharmacy, Queen’s University, Belfast, Northern Ireland.
C.M. Hughes, PhD, Professor, School of Pharmacy, Queen’s University, Belfast, Northern Ireland.

Methicillin-resistant Staphlyococcus aureus (MRSA) and vancomycin-resistant Enterococci (VRE) are responsible for substantial morbidity and mortality in acute care settings. Older residents in long-term care (LTC) facilities possess many of the risk factors for colonization with these antibiotic resistant bacteria, and the potential exists for both transmission, via transiently colonized staff, within LTC, and subsequent reintroduction into hospitals. Infection control policies in LTC are primarily based on those used in acute care and may not be appropriate for this unique environment. Studies to determine which infection control procedures are effective at reducing the prevalence and transmission of MRSA and VRE in LTC are required.
Key words: long-term care, MRSA, VRE, colonization, infection control.

Cathy R. Kessenich, DSN, ARNP, Professor of Nursing, University of Tampa, Tampa, FL, USA.
Darlene A. Higgs, RN, BSN, Nurse Practitioner Student, University of Tampa, Tampa, FL, USA.

Osteoporosis is a major cause of health problems in residents of long-term care facilities. It often results in bone fracture, causing poor quality of life and a national financial burden. As the population ages, the incidence of osteoporosis and its consequences increase. It is essential to employ fracture-prevention strategies that have proven most beneficial in long-term care settings and those tailored to promote adherence among older adults. This article reviews osteoporotic treatment appropriate for individuals in long-term care, including treatment through pharmacology, nutritional support, fall prevention, and hip fracture prevention.
Key words: osteoporosis, long-term care, hip protectors, fall prevention, vitamin D.

Victoria J. Scott, PhD, RN, Clinical Assistant Professor, School of Population and Public Health; Senior Advisor, Falls & Injury Prevention, BC Injury Research & Prevention Unit and Ministry of Healthy Living and Sport, Victoria, BC.
S. Johnson, PhD, Professor, Faculty of Kinesiology and Health Studies, University of Regina, SK.
J.F. Kozak, PhD, Assistant Professor, School of Population and Public Health, University of British Columbia; Director of Research Centre for Healthy Aging, Providence Health, Vancouver, BC.
Elaine M. Gallagher, PhD, RN, Professor, School of Nursing; Director, Centre on Aging,
University of Victoria, Victoria, BC.

Approximately one in two older adults living in long-term care (LTC) settings sustains a fall every year, resulting in significant human suffering and treatment costs. The complex set of factors that contribute to fall risk among this population demands a multidisciplinary approach to this problem, with physicians playing a pivotal role in risk assessment, prevention, and management. We describe a study where facility personnel from five LTC sites were trained in the use of a standardized surveillance tool to track falls, fall injuries, and contributing factors over 16-months. Using a pre-/post-test design, interventions included a multidisciplinary, evidence-based approach to fall risk assessment and monitoring, environmental modifications, exercise, and education strategies. Interventions by a multidisciplinary team, including physicians, were successful in reducing fall-related injuries and relatively successful in reducing the rate of falls among LTC residents. Further study is needed over a longer period of time, using a randomized control trial, to determine the effectiveness of specific interventions and to generalize findings to the larger population of LTC residents.
Key words: fall prevention, long-term care, multidisciplinary approach, older adults.

Evelyn Hutt, MD, Associate Professor of Medicine, University of Colorado at Denver and Health Sciences Center; Director, Colorado Research in Care Coordination, VA Eastern Colorado HCS, Denver, CO, USA.
Martha D. Buffum, DNSc, APRN, BC, CS, Associate Chief Nurse for Research, VA Medical Center, San Francisco; Associate Clinical Professor, School of Nursing, University of California, San Francisco, CA, USA.
Regina Fink, RN, PhD, FAAN, Research Nurse Scientist, University of Colorado Hospital, Aurora, CO, USA.
Katherine R. Jones, RN, PhD, FAAN, Sarah Cole Hirsh Professor and Associate Dean for Evidence-Based Practice, Frances Payne Bolton School of Nursing, Case Western Reserve University, Cleveland, OH, USA.
Ginette A. Pepper, PhD, RN, FAAN, Professor and Helen Lowe Bamberger Colby Endowed Chair in Gerontological Nursing Associate Dean for Research and PhD Program, University of Utah College of Nursing, Salt Lake City, UT, USA.

Pain is common among long-term care residents and is often undertreated. A high prevalence of dementia, sensory impairment, and disability, as well as structural issues such as staffing patterns and turnover in long-term care facilities make assessment and management of pain challenging. An overview of the evidence regarding the assessment and treatment of pain in individual residents, and recommendations for improving the overall quality of pain management in the long-term care setting, is presented.
Key words: pain, dementia, long-term care, pain assessment, pain management.

Mohammed Al Houqani, MBBS, Department of Medicine, University of Toronto, Toronto, ON.
Theodore K. Marras, MD, FRCPC, Attending Staff, Division of Respirology, Department of Medicine, University Health Network and Mount Sinai Hospital; Assistant Professor of Medicine, University of Toronto, Toronto, ON.

Long-term care-acquired pneumonia is a clinical syndrome of pneumonia that develops in a resident of a long-term care facility who has not been recently hospitalized. It is one of the leading causes of mortality and morbidity among the residents of long-term care facilities. Streptococcus pneumonia, Haemophils influenza, and Moraxella catarrhalis are the most frequently identified bacterial causative. Poor oral hygiene increases the risk of long-term care-acquired pneumonia. In this review, we discuss the risk factors, pathogenesis, etiology, management, and the preventive measures for long-term care-acquired pneumonia.
Key words: Long-term care, nursing home, health care facilities, pneumonia, fluoroquinolones.

Jayna M. Holroyd-Leduc, MD, FRCPC, Assistant Professor, Department of Medicine, University of Toronto; Clinician-Investigator, University Health Network, Toronto, ON.
Cara Tannenbaum, MD, FRCPC, MSc, Assistant Professor, Department of Medicine, University of Montreal; Director, Geriatric Incontinence Clinic, McGill University Health Centre; Director, Institut Universitaire de Geriatrie de Montreal, Montreal, QC.

Urinary incontinence is a prevalent condition among long-term care residents, particularly those with dementia. The costs and morbidity associated with urinary incontinence are significant. Urinary incontinence can be easily assessed within the long-term care setting. Several modifiable risk factors should be identified and addressed. Effective behavioural treatment options for incontinence exist and several treatment strategies can be used successfully for patients with dementia.

Key words: urinary incontinence, dementia, long-term care, diagnosis, management.

Leigh Turner, PhD, 2003-2004 Member, Institute for Advanced Study, School of Social Science, Princeton, NJ, USA; Assistant Professor, Biomedical Ethics Unit, Department of Social Studies of Medicine, McGill University, Montreal, QC.

Bioethicists typically pay little attention to how social and physical environments in health care facilities shape moral experience. Social scientists studying hospitals and long-term care facilities often characterize such facilities as bleak, alienating institutions. Too often, the ethics of place is overlooked as ethicists focus upon dramatic moral issues. Drawing upon my experience working as a clinical ethicist at Baycrest Centre for Geriatric Care, I suggest how long-term geriatric care facilities can be designed to promote respect for privacy, foster a warm social environment, and help preserve the dignity of residents, family members and staff members.
Key words: bioethics, hospital design, long-term care, geriatric care.

Dr. Lindsay E. Nicolle, MD, FRCPC, Department of Internal Medicine and Medical Microbiology, University of Manitoba, Winnipeg, MB.

The prevalence of asymptomatic bacteriuria increases with advancing age in community populations, and approaches 50% in the functionally impaired, institutionalized elderly. Asymptomatic bacteriuria is usually associated with pyuria, but has not been shown to contribute to any short- or long-term negative clinical outcomes in the older population. Treatment of asymptomatic bacteriuria is not recommended. Clinical trials evaluating antimicrobial therapy have found no improved outcomes, and therapy is usually followed by recurrence of bacteriuria. Antimicrobial treatment also is associated with increasing antimicrobial resistance and adverse drug effects. Due to the high prevalence of positive urine cultures, bacteriuria is not a useful diagnostic test for symptomatic urinary tract infection. However, a negative urine culture may exclude the urinary tract as a potential source of infection.
Key words: urinary tract infection, bacteriuria, older adults, long-term care.