Hypertension, orthostatic hypotension, and the risk of falls in a community-dwelling elderly population: the maintenance of balance, independent living, intellect, and zest in the elderly of Boston study.

OBJECTIVES: To investigate the relationships between uncontrolled and controlled hypertension, orthostatic hypotension (OH), and falls in participants of the Maintenance of Balance, Independent Living, Intellect, and Zest in the Elderly of Boston Study (N=722, mean age 78.1). DESIGN: Prospective population-based study. SETTING: Community. PARTICIPANTS: Seven hundred twenty-two adults aged 70 and older living within a 5-mile radius of the study headquarters at Hebrew Rehabilitation Center in Boston. MEASUREMENTS: Blood pressure (BP) was measured at baseline in the supine position and after 1 and 3 minutes of standing. Systolic OH (SOH) and diastolic OH at 1 and 3 minutes were defined as a 20-mmHg decline in systolic BP and a 10-mmHg decline in diastolic BP upon standing. Hypertension was defined as BP of 140/90 mmHg or greater or receiving antihypertensive medications (controlled if BP < 140/90 mmHg and uncontrolled if ≥ 140/90 mmHg). Falls data were prospectively collected using monthly calendars. Fallers were defined as those with at least two falls within 1 year of follow-up. RESULTS: OH was highest in participants with uncontrolled hypertension; SOH at 1 minute was 19% in participants with uncontrolled hypertension, 5% in those with controlled hypertension, and 2% in those without hypertension (P ≤ .001)). Participants with SOH at 1 minute and uncontrolled hypertension were at greater risk of falls (hazard ratio=2.5, 95% confidence interval = 1.3-5.0) than those with uncontrolled hypertension without OH. OH by itself was not associated with falls. CONCLUSION: Older adults with uncontrolled hypertension and SOH at 1 minute are at greater risk for falling within 1 year. Hypertension control, with or without OH, is not associated with greater risk of falls in older community-dwelling adults.

Establishing standards of quality for elderly patients undergoing pancreatic resection.

OBJECTIVE: To evaluate pancreatic surgery as a model for high-acuity surgery in elderly patients for immediate and long-term outcomes, predictors of adverse outcomes, and hospital costs. DESIGN: Retrospective case series. SETTING: University tertiary care referral center. PATIENTS: Four hundred twelve consecutive patients who underwent pancreatic resection from October 1, 2001, through March 31, 2008, for benign and malignant periampullary conditions. MAIN OUTCOME MEASURES: Clinical outcomes were compared for elderly (> or = 75 years) and nonelderly patient cohorts. Quality assessment analyses were performed to show the differential impact of complications and resource utilization between the groups. RESULTS: The elderly cohort constituted one-fifth of all patients. Benchmark standards of quality were achieved in this group, including low operative mortality (1%). Despite higher patient acuity, clinical outcomes were comparable to those of nonelderly patients at a marginal cost increase (median, $2202 per case). Cost modeling analysis showed further that minor and moderate complications were more frequent but no more debilitating for elderly patients. Major complications, however, were far more threatening to older patients. In these cases, duration of hospital stay doubled, and invasive interventions were more commonly deployed. CONCLUSIONS: Quality standards for pancreatic resection in the elderly can--and should--mirror those for younger patients. Age-related care, including geriatric consultation, supplemental enteral nutrition, and early rehabilitation placement planning, can be designed to mitigate the impact of complications in the elderly and guarantee quality.

Prevalence and characteristics of traumatic intracranial hemorrhage in elderly fallers presenting to the emergency department without focal findings.

OBJECTIVES: To determine the prevalence and associated characteristics of traumatic intracranial hemorrhage (ICH) in elderly fallers presenting to the emergency department (ED) without focal findings. DESIGN: Retrospective cohort study. SETTING: University-affiliated teaching hospital ED. PARTICIPANTS: Patients aged 65 and older presenting with a fall to the ED and undergoing a head computed tomography (CT) scan. MEASUREMENTS: Electronic medical records and CT scans of 404 consecutive patients were reviewed. Characteristics of patients with and without ICH were compared using unadjusted analyses. Patients taking warfarin, aspirin, or clopidogrel alone or in combination were compared with those not taking these medications. Multivariate logistic regression analyses were performed to determine variables independently associated with ICH. RESULTS: Forty-seven of 404 elderly fallers (11.6%) without focal findings had an ICH. Unadjusted analyses in these pilot data showed that warfarin was not significantly associated with ICH. Multivariate analyses indicated that elderly people living in at home were more likely to have ICH than those living in nursing homes or assisted living facilities (odds ratio (OR)=3.2, 95% confidence interval (CI)=1.30-8.13) and that those with head trauma were more likely to have ICH than those without (OR=3.9, 95% CI=1.25-7.80). Aspirin was found to be protective (OR=0.49, 95% CI=0.24-0.98). CONCLUSION: ICH is common in elderly fallers presenting to the ED without focal findings. Anticoagulation alone did not appear to increase the risk of ICH, and aspirin was found to be protective, but prospective studies are needed to better assess this relationship.