Book Review

Medical Care in the Nursing Home

N Engl J Med 1993; 329:66-67July 1, 1993

Article

Medical Care in the Nursing Home
By Joseph G. Ouslander, Dan Osterweil, and John Morley. 462 pp., illustrated. New York, McGraw-Hill, 1992. $49.95. ISBN: 0-07-047949-6

Since 2 million elderly people are receiving medical care in 19,000 nursing homes, it is appropriate and timely to devote careful thought to optimizing the care of nursing home residents. Medical Care in the Nursing Home is a distinguished contribution to this endeavor. The three geriatrician coauthors succeed admirably in their goal of producing a practical textbook of nursing home medicine. The book focuses on presenting specific features of caring for patients in the nursing home, rather than recapitulating topics in internal medicine, urology, psychiatry, and other fields as they apply to the elderly.

The book is divided into three parts: a section on general and administrative issues (including health maintenance and the role of the medical director), a section on specific clinical conditions (such as delirium, incontinence, and pressure sores), and a concluding section on general management issues (comprising miscellaneous topics such as ethics, education and research, and the use of computers). In each part, the authors carefully dissect out the issues most germane to the care of nursing home patients: when discussing infections, they home in on the epidemiology and bacteriology of infections acquired in nursing homes; when discussing economics and demographics, they present a series of interesting tables (many of them from the earlier book by Kane, Ouslander, and Abrass, Essentials of Clinical Geriatrics [New York: McGraw-Hill, 1989]) on the functional status of nursing home residents and on the sources of payment for care.

The greatest strength of this book is its compilation of policies, procedures, and flowcharts to provide guidance in care giving. In the spirit of practicality, there are algorithms for nurse practitioners or physician's assistants to use in managing fever, acute abdominal pain, and gastrointestinal bleeding. There are detailed protocols for the management of pressure sores and for bladder training. There is a sample record showing how incontinence may be monitored. Some of the data-summary forms developed at the Jewish Homes for the Aging of Greater Los Angeles (the home base of two of the authors) are included, such as a very useful medical face sheet, which lists data on functional status, neuropsychiatric status, and resuscitation status, as well as active medical problems. Every chapter includes numerous tables summarizing the differential diagnosis, workup, or management of the problems discussed.

The authors have had to struggle with the paucity of data in many areas of geriatrics. Since they wish to provide concrete recommendations, they are sometimes forced to give their personal opinions. On occasion these opinions are quite controversial, as in the case of their assertions that all patients should undergo a geriatric assessment before they enter a nursing home, that fluoxetine should generally not be given to nursing home residents, and that determination of fasting and postprandial blood sugar concentrations as well as monthly measurement of glycosylated hemoglobin should be performed in all patients with diabetes. To the authors' credit, it is usually clear when the recommendations represent their opinions rather than a consensus of geriatricians, and there are well-chosen references whenever available.

In general, the book is up to date and comprehensive. There are nonetheless a few omissions of topics that should be included in the next edition. Despite a good discussion of advance directives in the chapter on ethical and legal issues, there is no mention of the Patient Self-Determination Act, which went into effect in 1991 and which requires that nursing homes provide information to residents about advance directives. There is no mention of osteoporosis or recommendations about dietary calcium in either the chapter on nutrition or that on endocrinology. Finally, the authors might wish to include product names in the section on treatment of pressure sores, in addition to the terms “semipermeable membranes” and “calcium alginate dressings.”

Medical Care in the Nursing Home is pitched to a medical audience. However, because this textbook tends to be both practical and elementary (the authors define dysarthria and bradykinesia and include photographs of such commonly used assistive devices as a quadripod cane and a front-wheeled walker), it is more suitable for nurse practitioners and physician's assistants who provide care in nursing homes, and for residents and geriatric fellows practicing medicine in the long-term care setting for the first time, than for experienced physicians. Because of its strong focus on administrative issues, regulations, and protocols for care, it should be in the library of every nursing home medical director. It is a well-organized, clearly written, and much-needed reference work in a new and growing field.

Muriel R. Gillick, M.D.
Hebrew Rehabilitation Center, Roslindale, MA 02131