Those of us who work in acute care hospitals have only a limited view of the common problems encountered in long-term care facilities for the aged. At times elderly patients admitted to our hospitals from nursing homes are septic, volume-depleted, and azotemic. On inspection a urinary catheter may be found to be in place, and the patient may have many decubitus ulcers. The urine is loaded with pus cells and bacteria, the wounds are foul-smelling, and there may be polymicrobial bacteremia. The patient may die soon after admission; or if he or she survives, we wonder whether it would be prudent to return him or her to the nursing home. In truth, we have only a limited view of the care provided in the referring facility or the nature of the population at risk. We do not know the denominator, that is, how representative is this patient of all others cared for at the facility? The catheter is often blamed as the predisposing cause of sepsis, yet we really do not know how often and under what circumstances it becomes a lethal instrument. The report in this issue by Marron and her colleagues comes to me as a surprise. I had assumed that far more than 2.5 per cent of elderly patients in a skilled long-term care facility might need a urinary catheter. We must ask whether the infrequency of the use of catheters is the result of a conscious effort on the part of the staff or reflects some special characteristic of the mix of patients, or both. This prevalence study nevertheless forces us to reevaluate the indications for use of indwelling urinary catheters. Clearly, incontinence unaccompanied by obstruction of urinary flow can be managed by means other than the catheter. The critical issue is whether it is preferable for the patient to retain a large volume of urine in the bladder (because of obstruction or poor detrusor or sphincter function) and risk renal damage, or to have the bladder constantly drained and be at increased risk of infection. Stated differently, is it better to retain large volumes of sterile urine than to have small volumes of infected urine? Since bac-teriuria is common in the elderly, even in those without catheters, another dimension is added to the issue, that is, whether or not such infections should be treated. Committed geriatric physicians have an excellent opportunity to address these issues. To be helpful I have prepared a general study design which should help to provide some of the answers to these critical questions, yet still comply with the ethical issues of research in human subjects. I believe that the best information will be obtained by study over time of a population representative of the diverse problems of the institutionalized elderly. The elements of such a study should include those listed below. . The population dynamics must be clearly defined over time. This requires data on rates of admission, discharge, and death. The length of stay in the facility, that is, the period of risk, should be provided for each individual and summarized in statistical terms. . The distribution of risk factors among the individuals who make up the population must be characterized to permit comparison among institutions and in the same institution over time. These factors include age, sex, underlying disease (particularly diabetes, dementia, stroke, and cancer), and ambulatory ability. . The status of urinary tract and renal function should be determined and all leads followed. This requires periodic determinations of BUN or serum creatinine, urinalysis, and quantitative bacterial urine cultures. Residual urine volume (minimally) should be assessed in incontinent patients and others who report problems with urination. Structural studies of the urinary tract by IVP or ECHO should be performed in those patients with azotemia and/or large residual volumes. . Episodes of fever or suspected sepsis should be recorded and the most likely source be defined. This includes bronchitis, pneumonia, and decubitus ulcers, as well as urinary tract infections. Information about the use of antibiotics and other drugs and about hospitalization for further treatment is needed to show how physicians assess and manage these episodes. . The causes of death of subjects who die should be provided and autopsies obtained for confirmation as often as possible. . Studies should be conducted prospectively over at least two to three winter seasons to adjust for variations in the frequencies of influenza and respiratory disease. . The most difficult issue is when to use an indwelling catheter, since it is known to carry an added risk. This can be accomplished by establishing a set of criteria for catheter use. The number and the proportion of patients who might need a catheter as part of their care need to be defined. When use of a catheter meets established criteria, special studies can be attempted. The studies can be categorized as: . The catheter is essential for relief of obstruction—controls are not permissible except as designed to evaluate different methods of catheter care. . The catheter is likely to be of benefit, but we cannot be certain—controls are permissible and should be assigned at random. . The catheter is probably not needed and other measures can be equally effective—controls are not permissible except as designed to evaluate different methods of non-catheter care. 8. The value of antimicrobial therapy or prophylaxis in managing bacteriuric elderly people without catheters needs to be better defined using controlled clinical trials in a defined population over time. Emphasis should be placed on examining morbidity, episodes of sepsis, and alterations in renal function. The study reported by Marron and associates is a good first step in this process. They believe that decubiti may be avoided in the incontinent patient without the use of a catheter. To interpret these results adequately we need to know more about the population of incontinent patients, particularly about potential damage to renal function caused by obstruction to flow. It is essential to demonstrate that avoidance of catheters is not “benign neglect,” but optimum management for most patients in long-term care facilities.
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Calvin M. Kunin (1983) studied this question.