Marc Willey, PhD, OTR/L, Department of Occupational Therapy, University of Central Arkansas

When assessing hand function, grip strength is frequently evaluated by hand surgeons and occupational therapists to determine the effects hand injuries and disorders have on the grasping strength. Historically, normative data has been provided for gender and age. A new study is underway that will look at occupation, hand and forearm size as correlating variables to grip strength.

Matthew Lacy, BS, OTS evaluates the grip strength of Lindsey Roe, BS, OTS
This research is being conducted under the supervision of UAMS Hand Surgery Director Theresa Wyrick, MD, Chad Songy, MD, PGY 3, Kim McCain RN, ONC, and Marc Willey, PhD, OTR/L who is an occupational therapy faculty member at UCA. Additional Investigators include Austin Cole MS II and Mathew Lacy, OTS (student). The overall purpose of this research is to determine the relationship of selected anthropometric variables (specifically forearm circumference and hand length) to grip strength in healthy adults using dynamometry. Dynamometry is defined as the measurement of force or power. The study will include participants ranging in age from 18 to 78.

The hand is the most important, complicated, and distinguishing tool on the human body (Angst et al., 2010). Occupational therapists and other healthcare providers frequently utilize grip strength evaluations as part of overall treatment planning. Currently, age and gender are the primary variables utilized for determining grip strength norms in adults 18 years of age or older. This study will determine the effect hand length and forearm circumference has on grip strength. Grip strength is primarily related to an individual’s hand function and has been used to determine injury severity, progress in therapy, ability to work, post-surgical success, overall mortality, likelihood of falls, and bone mineral density. Grip strength is impacted by position of shoulder, wrist, forearm, and body posture (Khan & Shruti, 2013; Angst et al., 2010; Bohannon, 2008). Norms are provided as a provider for the stages of hand injury and hand surgery recovery (Trampisch, 2012). This allows therapists to better determine the extent of injury and disease progression and the potential for rehabilitation progression (Richards, 1995). Previous studies have recorded norms based on factors such as sex, age, weight, height, and profession. Gender has been found to be the strongest predictor of grip strength, but outside of gender, few other variables have been found to be highly predictive. Recent studies have suggested that hand length and forearm circumference may be additional factors that can influence the results of one’s grip strength (Angst et al., 2010; Fallahi & Jadidian, 2011). In our study, each participant’s hands will be measured from the wrist crease to the distal tip of the middle finger and their forearm circumference will be measured at the widest point two inches distal to the lateral epicondyle. These measurements will be correlated with grip strength values for each participant. Former research studies have concluded that grip strength is a good indicator for future health problems (Louhevaara, 2000). Hand length and forearm circumference has the potential to be a more accurate variable to determine grip strength for functional activities of daily living and hand rehabilitation. When hand function has been significantly decreased, grip strength can be helpful in determining permanent disability.

References:

1. Angst, F., Drerup, S., Werle, S., Herren, D.B., Simmen, B.R., & Goldhahn, J. (2010). Prediction of grip and key pinch strength in 978 healthy subjects. BMC Musculoskeletal Disorders, 11 (94), 1-6.
2. Bohannon, Richard W. (2008). Hand-grip dynamometry predicts further outcomes in aging adults. Journal of Geriatric Physical Therapy, 31 (1), 3-10.
   Fallahi, A. A. & Jadidian, A. A. (2011). The effect of hand dimensions, hand shape and some anthropometric characteristics on handgrip strength in male grip athletes and non-athletes. Journal of Human Kinetics, 29, 151-159.
3. Louhevaara, V., Smolander, J., Aminoff, T., Korhonen, O., & Shen, N. (2000). Cardiorespiratory responses to fatiguing dynamic and isometric hand-grip exercise. European Journal of Applied Physiology, 82(4), 340.
4. Khan, T. & Shruti, M. (2013). Effect of different arm and forearm positions on grip strength. International Journal of Sports Sciences and Fitness, 3(2), 259–344.

by Gretchen Gibson, DDS, MPH

Most discussion regarding dental problems revolves around being able to eat, speak and even smile. These issues are key to a good quality of life. However, a recent article published by a group of dentists in Japan highlights the fact that dental problems can also be associated with accidents, especially in patients who suffer from dementia.

Patients in the later stages of dementia often cannot tell us if there are oral health issues that need to be addressed. These dental issues also have the potential to be responsible for painful and possibly life threatening accidents if not discovered and remedied. Kobayashi, et al (2016) looked a cohort of patients with dementia, which were referred to their hospital dental practice for evaluation as part of a swallowing disorder team. For these patients, they found that nearly 24% were positive for dental risk factors that could lead to painful incidents or accidents. These issues included:
• Teeth that were very loose and at a risk for falling out during daily eating or care, leading to choking and aspiration.
• Dental prostheses that were so loose that they would easily dislodge and could choke or impale the patient while they were trying to use them;
• Sharp broken teeth or sharp prostheses that could lacerate the patients mouth
• Recurrent temporomandibular joint dislocation, which is very painful
• Biting on edentulous gums with teeth on the other ridge, causing injury

In many long term facilities, it is staff that is responsible for the ongoing oral evaluation. The issues listed above can lead to painful and even life threatening incidents and it is important to keep them in mind when evaluating the patient. Look for:
• Teeth that are very loose and easily move when you touch them with your finger, or the patient can easily move with their tongue
• Dentures that have pieces missing along the borders with sharp edges
• Partial dentures that have wires that are sticking out too far or are broken, or metal/plastic sharp edges
• Partial dentures that are so loose that patients constantly flip them around in their mouth, often using their tongue
• Serious injuries to their edentulous gums from chewing on them
• Painful episodes when their jaw pops out of place or locks open while they are trying to eat

These are issues that need to be brought to the attention of a dental provider to address and reduce the likelihood of painful or serious injury. There are many ways that poor oral health and oral care can negatively affect a patient’s quality of life. For patients with dementia, it is often left to the caregiver to identify these risks through vigilance before an accident can happen.

References:

Kobayashi N, Soga Y, Maekawa K, Kanda Y, Kobayashi E, Inoue H, Kanao A, Himuro Y, and Fujiwara Y. Prevalence of oral health-related conditions that could trigger accidents for patients with moderate-to-severe dementia. Gerontology.2016 May 21
http://onlinelibrary.wiley.com/doi/10.1111/ger.12235/epdf

By Lori DeWese, BS, CDP, South Arkansas Center on Aging

As we age, we should be more aware of the potential health risks that are uniquely associated with both our age and the changing seasons. While people of all ages face specific health risks, seniors have particular health risks that need to be understood and monitored, especially in the heat of the summer. Below are some summer health tips for seniors as we finish the summer season:

1. Drink plenty of liquids — eight or more 8-ounce glasses per day of water to stay hydrated.
2. Avoid caffeinated (coffee, soda, even tea) and alcoholic beverages. These can make you dehydrated quickly. If at all possible, try to reduce the amount of these beverages, especially during hot weather. Plain or flavored water is a good substitute.
3. Dress appropriately. Wear loose-fitting clothes in natural fabrics like cotton. Dress in light colors that will reflect the sun and heat instead of darker colors that will attract them.
4. Sunblock. When outdoors, protect your skin from damage by wearing hats, sunglasses and a sunscreen of SPF 30 or higher.
5. Stay indoors during extreme heat. In extreme heat and high humidity, evaporation is slowed and the body must work extra hard to maintain a normal temperature.
6. Air conditioning. If you do not have air conditioning in your home, go somewhere that does. A movie theater, the mall, a friend or relative’s home or a community senior center are all good options.
7. Avoid extreme outdoor heat. If you need to get out of the house and don’t drive, call a taxi, a friend or a transportation service. Do NOT wait outside for the bus in extreme heat.
8. Take a cool shower or bath. If you are absolutely unable to leave the house and do not have air conditioning, take a cool bath or shower to lower your body temperature on extremely hot days.
9. Keep your home cool. Temperatures inside the home should not exceed 85 degrees Fahrenheit for prolonged periods of time.
10. Signs of heat stroke. Know the signs of heat stroke (e.g. flushed face, high body temperature, headache, nausea, rapid pulse, dizziness and confusion) and take immediate action if you feel them coming on.

Who’s At Risk?

Health and lifestyle may raise the threat of a heat-related illness, according to the National Institute of Aging. The following health factors may increase the risk for seniors:
• Poor circulation, inefficient sweat glands, and changes in the skin caused by normal aging

• Heart, lung, and kidney diseases, as well as any illness that causes weakness or fever

• High blood pressure or other conditions that require changes in diet; for example, people on low-salt diets may face an added risk (but don’t use salt                         pills without asking your doctor)

• The inability to perspire caused by some drugs, including diuretics, sedatives, tranquilizers, and certain heart and blood pressure medicines

• Taking several drugs at once for various conditions; don’t just stop taking them: Talk with your doctor

• Being substantially overweight or underweight

• Drinking alcoholic beverages

Take time this summer to check on aging loved ones and seniors residing in your neighborhood. Invite him or her into air conditioning, offer to take them to the mall, a movie or another cool building. Spend time with a loved one by inviting them to be an overnight guest. Do anything you can to help seniors beat the heat this summer!

Reference:
n.d. “Ten Summer Health Tips for Seniors to Beat the Heat.” Associated Home Care. Beverly, Boston, Burlington, Leominster. Marblehead, Springfield, Worcester, Massachusetts. Accessed July 11, 2016. http://associatedhomecare.com/resources/10-summer-health-tips-for-seniors-to-beat-the-heat.

 

 

Centers for Disease Control and Prevention (CDCP)
Health Resources Services Administration (HRSA)
U.S. Department of Health and Human Services

Influenza can be a serious health threat, especially for populations at high risk for flu-related complications, like adults 65 years and older, and people living with long-term disabilities and chronic health conditions. It is important for all long-term healthcare personnel to take necessary steps to protect themselves and their patients from the flu virus this season by getting a flu vaccine. Vaccination is especially important for people 65 years and older because they are at high risk for complications from the flu. Flu vaccines are often updated to keep up with changing viruses and also immunity wanes over a year so annual vaccination is needed to ensure the best possible protection against influenza. People 65 years and older have two flu shots available to choose from – a regular dose flu vaccine and a newer flu vaccine designed specifically for people 65 and older with a higher dose. The high-dose vaccine is associated with a stronger immune response following vaccination.

The U.S. Department of Health and Human Services, National Vaccine Program Office (NVPO) and the Centers for Disease Control and Prevention (CDC) have partnered to create an online toolkit to help administrators in long-term care facilities launch successful influenza vaccination programs among their staff as an integral part of their influenza infection prevention plans. This web-based toolkit provides a repository of actionable and useful resources including educational materials, easy to download campaign resources, recommended strategies, and a variety of guidance documents to help your facility do all it can to protect its staff and its residents from influenza infection. Please check out the toolkit at http://www.cdc.gov/flu/toolkit/long-term-care/ for more information.

Share your successes! Share your success stories of how your long-term care facility increased influenza vaccination rates by emailing fluinbox@cdc.gov with the subject line “LTC Best Practice.” Please be sure to include information regarding your facility type and location, barriers or challenges, effective methods used, and the results.

 

Arkansas Geriatric Education Collaborative

By Jeremy Hanner (PharmD Student and Lisa C Hutchison, PharmD, MPH

The pneumococcal vaccines protect against serotypes of the bacteria, Streptococcus pneumoniae, whose infections can lead to pneumonia, sepsis, and meningitis. The Centers for Disease Control (CDC) estimate that 900,000 Americans contract pneumococcal pneumonia each year, resulting in as many as 400,000 hospitalizations annually. Additionally, there are around 3,700 deaths attributable to pneumococcal sepsis and meningitis each year. The CDC has recently set guidelines stating individuals over the age of 65 should be immunized with the series of 2 vaccines: conjugated vaccines (Prevnar 13, PCV 13), and polysaccharide vaccines (Pneumovax 23, PPSV 23) . Unfortunately, many of our senior citizens never had the pneumococcal series started, or had it only one component completed. This article reviews where to begin and how to continue when evaluating patients who have not received either pneumococcal vaccine, and those who have received either PPSV 23 or PCV 13 but not both.

When assessing adults 65 years and older for pneumococcal vaccination, first one must determine their vaccination history. If a patient has never been vaccinated, he/she should receive one dose of PCV 13 followed by one dose of PPSV 23, separated by at least one year. Those with certain risk factors (i.e., compromised immune system, CSF leaks, asplenia, or cochlear implant) can receive the doses 8 weeks apart .

The next situation to consider is an elderly patient who has received one pneumococcal vaccine, but not the other. If a single dose of PPSV 23 was given after age 65, it is recommended that these patients receive one dose of PCV 13, at least one year after the PPSV 23 vaccination was given. Exactly opposite, if a single dose of PCV 13 was given after age 65, it is recommended that the patient receive one dose of PPSV 23, at least one year after the PCV 13 was given . Both vaccines are needed for better coverage, and it is preferred that PCV 13 is administered first in sequence when possible .

The final population to consider is those who have completed the pneumococcal series earlier in life and need to be vaccinated again. Younger patients at high risk for pneumococcal disease usually receive PCV 13, followed by PPSV 23, with another PPSV 23 booster five years later. So if a patient has received both vaccines before the age of 65; it is recommended that they receive one final dose of PPSV 23 at or after age 65. This final dose must also be at least 5 years apart from the previous PPSV 23 dose .

The three types of patient populations above represent the most common pneumococcal immunization scenarios. More complicated patients may present requiring referral back to the vaccine recommendation guidelines. Either way, proper administration of pneumococcal vaccines is useful to reduce morbidity and mortality in the elderly population.

References:
1. “Fast Facts.” Centers for Disease Control and Prevention. Centers for Disease Control and Prevention, 2015.

2. Miwako Kobayashi, MD1,2; Nancy M Bennett, MD3,4; Ryan Gierke, MPH1; Olivia Almendares, MSPH1; Matthew R Moore, MD1; Cynthia G. Whitney, MD1; Tamara Pilishvili, MPH1 , “Intervals Between PCV13 and PPSV23 Vaccines: Recommendations of the Advisory Committee on Immunization Practices (ACIP).” Centers for Disease Control and Prevention. Centers for Disease Control and Prevention. September 4. 2015 / 64(34); 944-947.

3. Immunization Action Coalition. “Ask the Experts: Diseases & Vaccines.” Ask the Experts: Pneumococcal Vaccines (PCV13 and PPSV23). Saint Paul Minnesota.
http://www.immunize.org/askexperts/experts_pneumococcal_vaccines.asp

by Roy Lee Aldridge, Jr., PT, EdD
Hippotherapy is the use of natural movements of a horse for a treatment tool in individuals with disabilities utilized by occupational therapists, physical therapists, and speech therapists. The word hippos is derived from the Greek word meaning “horse”; giving therapy on a horse the name, Hippotherapy. The history of Hippotherapy dates back to before the 1900’s. In ancient Greece there was a chapter written on ‘Natural Exercise’ and it mentions riding a horse. In the late 1960’s therapeutic riding centers had developed throughout Europe, Canada, and the USA.1

Hippotherapy has many indications for use in children, adults, and older adults. These indications include: abnormal muscle tone, impaired balance, abnormal reflexes, impaired coordination, impaired communication, poor oral motor functioning, impaired sensorimotor function, postural asymmetry, poor postural control, impaired mobility, and delayed speech and language.1 It has been hypothesized that Hippotherapy can enhance the balance and functions of older adults and, therefore, prevent falls. All of the impairments listed manifest in some or all of the following medical conditions: autism, chromosomal abnormalities or deletions, cerebral palsy, cerebral vascular accident or stroke, developmental delay, functional spine curvature (scoliosis, kyphosis, and lordosis), multiple sclerosis/neuromuscular dysfunction, sensory integrative dysfunction, and brain injury.1

Horses and humans have very similar pelvic movements during gait. Aging adults having poorer balance ability than younger adults and have a higher risk of falls. During gait of older adults, temporary instability can occur when the body is supported by one foot and balance recovery occurs on the stepping foot to restore the center of gravity to within the base of support. During a walking gait of a horse there is a 4 beat rhythm that is symmetrical. Horses have a vertical and lateral pelvic shift, and pelvic rotation just like humans do. Lateral pelvic shifts in the horse are about 6 to 7 degrees whereas in the human it is about 1 to 2 degrees. There are no data found on vertical pelvic shifts in the horse but the human has 2 inches of vertical pelvic shift. Pelvic rotation in the horse is 7 to 9 degrees and in the human it is normally 4 degrees forward and 4 degrees backwards for a total of 8 degrees.1, 2 When mounted on a horse during gait, a human being is close to a normal gait pattern due to the movements the horse manifests during its gait.

These movements are what make up the use of Hippotherapy for therapists. During certain gait cycles, cadences, and directions that the horse is in determines the outcome of motions in the human while riding. A forward swing of the horse’s hind leg promotes rotation of the horse’s pelvis and therefore causing a lateral pelvic tilt in the rider. A lateral pelvic tilt in the rider further causes elongation of that side and shortening of the opposite side. A lateral flexion of the horse’s barrel (midsection) during forward swing and reach of the hind leg promotes pelvic rotation in the rider. To accomplish a posterior pelvic tilt in the rider the horse accelerates movement of the hind leg during swing phase. To promote an anterior pelvic tilt; the horse does the opposite. The center of gravity with each step the horse takes is shifted side to side to promote a lateral shift of the rider’s pelvis.1

The benefits of all of these components together include improved balance by making the rider constantly maintain balance on the horse due to movement. Coordination, reflexes, and motor planning are improved through repetition of patterned movements required in controlling a horse; this quickens the reflexes and aids in motor planning. In the aging adult, increases in step length and step speed increase the ability to cope with the risk of falls when balance has been lost. In some studies, step length has increased significantly and step time decreased indicating a decrease in fall risk with Hippotherapy. Grooming can help with decreased range of motion in the upper extremities. Decreased spasticity accomplished by lowering the amount of abnormal movement patterns can also improve range of motion. Sensory integration plays a major role with Hippotherapy. Through changes in the horse’s speed/direction, barn smells, controls of the horse, sounds, and receptors in human muscles, tendons, ligaments, and joints the following are stimulated: tactile, vestibular, olfactory, vision, auditory, and proprioceptive.3 Other benefits found in the older adult include lessening of depression, fears, and anxiety while gaining self-confidence, as well as improving non-verbal communication.

References:
1. American Hippotherapy Association. Treatment principles level 1: workshop manual 1st ed. 2006:2-18.
2. Magee DJ. Assessment of gait. Orthopedic physical assessment 5th ed. Saunders Elsevier. 2008:940-971.
3. Riding for the Disabled Association (Malaysia). 2001-2008. Available at: http://www.rda-malaysia.org/physical.html. Accessed March 12, 2009.

By Letha Mosley PhD, OTR/L, FAOTA

 

In 2012 there were over 36 million individuals age 65 years or older who were licensed drivers in the United States (Centers for Disease Control, n.d.). While some older adults tend to avoid driving due to a decline in physical, cognitive, or perceptual skills others may continue to drive with impairments rather than give up their keys and feel dependent on others. For individual and societal safety, it is extremely important for older adults to have accurate knowledge of their driving skills, confidence in driving ability, safe driving performance, and/or use of community resources to be able to engage in daily occupations and activities necessary for independence or a high quality of life (Stav & Lieberman, 2008). However, there are a limited number of programs that provide the scope of services that can assess their skills and provide avenues for sustaining some level of control and independence in their ability to navigate within their communities. To address this problem, the UCA Department of Occupational Therapy is working to strengthen education, research, direct services, and networking related to driving and community mobility within Arkansas.

Driving and community mobility is defined as “planning and moving around in the community and using public or private transportation, such as driving, walking, bicycling, or accessing and riding in buses, taxi cabs, or other transportation systems” (AOTA, 2014, p. S19). Occupational therapists (OTs) have a primary role in evaluation and treatment in driving and community mobility for individuals across the lifespan with varying abilities and conditions (AOTA, n.d.). A systematic review indicated that five interventions used by OTs have a positive effect on improving older adults’ driving performance; these included patient and family education, cognitive and perceptual training, therapy to enhance physical fitness, simulation training, and behind-the-wheel training (Golisz, 2014). The UCA OT Master’s program provides students with educational experiences with each of the aforementioned interventions and, with current efforts to move to doctoral education, will provide more in depth training to increase the competence and confidence of OT practitioners in addressing the growing needs of Arkansans. Although several barriers such as limited fiscal, physical, and infrastructure resources has prevented the development of driving programs in some health facilities in Arkansas, the UCA OT department has acquired resources that can be used in collaboration with local practitioners and health facilities to offer free or low cost services for the community. The most recent purchase was the Virage VS-500 3-Screen Driving Simulator (pictured). In collaboration with local practitioners, the VS-500 has been used as one component of a driving evaluation for clients. Occupational therapy students within the program get the opportunity to experience simulated driving on the VS-500 from a client’s perspective as well as learn to operate the evaluation and/or treatment components of the driving simulator to identify potential problems that may need to be addressed prior to a client engaging in a behind-the-wheel or on-the-road assessment. Under the guidance of Drs. Mosley, Moore, and Stearns, four graduate students will be engaging in research from 2016 to 2017 using the VS-500 and determining how different non-invasive interventions influence clients’ physiological responses to the driving simulation. The ultimate goals for the UCA OT program related to driving and community mobility are to: 1) prepare graduates with the skills, confidence, and commitment to address driving and community mobility, especially as related to adults and older adults; 2) serve as a collaborator or resource to practitioners in the state who may not be afforded the opportunity to have a driving simulator in their clinic but who want/need to use this as a form of assessment and/or treatment; and 3) close the gaps and provide a pathway or network for physicians and other practitioners to refer clients to the scope of driving and community mobility services available within the state or surrounding areas. For further information about driving and community mobility, feel free to peruse the American Occupational Therapy Association’s Older Adult Driving and Community web page at: http://www.aota.org/olderdriver or contact Dr. Mosley at letham@uca.edu .

Gretchen Gibson, DDS, MPH, Veterans Healthcare System of the Ozarks (VHSO)

Dentistry still does not have a silver bullet that will cure all cavities for our patients…but we have not given up. In the meantime, silver diamine fluoride (SDF) was approved for use to prevent cavities and began being marketed in the United States in 2015. For those of us treating frail older patients where more extensive dental care is difficult for many reasons, this material may prove to be a needed help.

SDF was FDA-approved to treat dentin or tooth sensitivity. However, much like fluoride varnish, which was also approved to treat tooth sensitivity, this material has a large body of evidence behind it regarding the arrest of existing cavities and the prevention of new cavities. SDF has been in use to treat cavities in other countries throughout the world for over 75 years.

The product currently available in the US is 38% Ag(NH3)2F. It is a colorless liquid with a pH of 10. When the material is placed on a cavity, a matrix of silver/protein forms and then fluoride and other minerals will form a matrix on top. All of this forms a hardened surface to the lesion and decreases the depth of the lesion, leading to remineralization of the lesion. Though this remineralization may not be to the depth of the lesion, it seals it and “arrests” the carious lesion, negating its continued growth. In addition, the silver has antibacterial properties. This product is currently marketed in the United States by one company, Elevate Oral Care, under the name Advantage Arrest^TM.

This treatment has been championed for pediatric and frail patients, when dental care is not easily tolerated. To use this product to arrest cavities, it is placed directly on the dried and isolated dental cavity and allowed to soak for 1-3 minutes if possible. Excess material is wiped off. Research suggests that that to maintain the lesion arrest, the product needs to be reapplied every 6-12 months for at least three years.

This material is not without its detractions. The biggest is the fact that all carious tooth structure that it touches will turn very dark. If this is experienced in the anterior region of the mouth, then it can cause a very negative aesthetic outcome. Side effects are minimal, but include some gingival irritation at times, non-permanent darkening or tattooing of the soft tissue and staining of clothing and countertops. Protocols for use include minimizing gingival contact and draping of surfaces and clothing to avoid these issues. A true silver allergy would be a contraindication of this product. Safety literature reviews show that using one drop per treatment, even a lifetime exposure of 400 times would be within safety standards. It is suggested that one drop will treat up to six teeth and that is usually more than is needed in a visit to arrest specific lesions.

As a geriatric dentist, this is an exciting addition to my armamentarium. Dementia patients who cannot sit for long periods of time would benefit if I could maintain their natural teeth longer. High cavity risk patients, such as those with Sjogren’s syndrome or post head and neck radiation may be able to hold on to teeth much longer if we can arrest the caries, rather than trying to restore each new lesion and risk more cavities around the new fillings. This is certainly not the treatment for all patients, but it is exciting to know that we now have other options to help us maintain natural teeth much longer for our frail and high risk patients.

 

Reference:
*Horst JA, Ellenikiotis H, Milgrom PM. UCSF protocol for caries arrest using silver diamine fluoride: Rationale, indications and consent. J Calif Dent Assoc.2016;44(1):16
*This article is available for free download through PubMed.

Brooklyn Pruett, PharmD and Lisa C. Hutchison, PharmD, MPH

Nitrofurantoin (Macrobid®) is a broad-spectrum antibiotic with gram-positive and gram-negative activity commonly used for treatment and prevention of urinary tract infections (UTIs).1 Nitrofurantoin is excreted into the urine by the kidneys where it achieves therapeutic concentrations. Once in the urine, nitrofurantoin inhibits bacterial protein synthesis, aerobic energy metabolism, DNA synthesis, RNA synthesis, and cell wall synthesis. Adverse effects of nitrofurantoin include pulmonary toxicity, hepatic dysfunction, peripheral neuropathy, hemolytic anemia, and Clostridium difficile-associated diarrhea.

Previously, nitrofurantoin was on the American Geriatrics Society (AGS) Beers Criteria of medications potentially inappropriate for use in older adults. The guideline recommended to avoid nitrofurantoin in geriatric patients with a creatinine clearance less than 60mL/min due to lack of efficacy.2 The recommendation also stated to avoid use for long-term suppression of UTI because of the potential for pulmonary toxicity, hepatotoxicity, and peripheral neuropathy. However, in the 2015 AGS Beers Criteria the threshold for creatinine clearance concern was decreased to 30mL/min for nitrofurantoin because of questions about the old evidence regarding nitrofurantoin excretion and new, albeit low quality, evidence for effectiveness.3

Two studies support use of nitrofurantoin in older women for treatment of UTI. The most recent study was a retrospective cohort study that compared use of nitrofurantoin and trimethoprim in women with renal impairment and a UTI.4 Inclusion criteria were women greater than 18 years of age who received a prescription for nitrofurantoin or trimethoprim for a treatment of a UTI which was defined as (1) no antibacterial treatment six-months prior to receiving either treatment, (2) at least a one- year medication history prior to the antimicrobial starting date, and (3) a six-month follow up medication history after starting the antimicrobial therapy. Exclusion criteria included patients with antibacterial use less than three days or greater than ten days. The primary outcome was treatment failure defined as starting a second antibiotic for treatment of a UTI within one month. The secondary outcome was hospitalization due to adverse effects.

For nitrofurantoin, the overall incidence for ineffective treatment was 14.4% as compared to 16.6% for trimethoprim. The occurrence of treatment failure increased with decreased renal function, but this was not statistically significant. Adverse events that occurred included pulmonary reactions (painful respiration, pleural effusion), and blood dyscrasias. For nitrofurantoin users the risk of an adverse event was significantly higher in patients with renal impairment, defined as a GFR less than 50 mL/min/1.73m2. These results indicate that nitrofurantoin reaches therapeutic effects in the urine for bactericidal activity at least as effective as trimethoprim. However, results also suggest that adverse events were significant in renal impaired patients.

Based on these findings and reconsideration of the old data, the 2015 AGS Beers Criteria panel of experts changed the recommendation so nitrofurantoin is considered inappropriate for treatment of UTI when the patient has a creatinine clearance less than 30mL/min (instead of 60mL/min). The use of nitrofurantoin for long-term suppression of UTI is still considered potentially inappropriate given the risk for toxicity.

 

References:

1. Macrobid® . North Norwich, NY: Norwich Pharmaceuticals, Inc; 2009.
2. Resnick, Barbara, and James T. Pacala. “2012 Beers Criteria.” Journal of the American Geriatrics Society 60.4 (2012): 612-13. The American Geriatrics Society. Web. 15 Jan. 2016. http://www.americangeriatrics.org/files/documents/beers/2012AGSBeersCriteriaCitations.pdf
3. “American Geriatrics Society 2015 Updated Beers Criteria for Potentially
Inappropriate Medication Use in Older Adults.” Journal of the American Geriatrics Society 63.11 (2015): 2227-246. Accessed 15 Jan. 2015. http://onlinelibrary.wiley.com/store/10.1111/jgs.13702/asset/jgs13702.pdf?v=1&t=ijkhj451&s=034b8ee90406aeba02f3ceb2d969e01d3b9c7e7c
4. Geerts, Arjen F. J., et al. “Ineffectiveness and Adverse Events of Nitrofurantoin in  Women with Urinary Tract Infection and Renal Impairment in Primary Care.” European Journal of Clinical Pharmacology Eur J Clin Pharmacol 69.9 (2013):  1701-707. Web.  http://link.springer.com.libproxy.uams.edu/article/10.1007%2Fs00228-013-1520-x