Efficacy of routine annual studies in the care of elderly patients.

The authors reviewed the results of annual laboratory screening (SMA 20, T3, T4, UA, EKG, chest x-ray) performed on a population of 500 institutionalized and ambulatory patients retrospectively followed from 1 to 19 years. With 30 laboratory values recorded for each annual exam, there were an average of 1.56 new abnormal laboratory findings per year per patient. A sample of 100 patients was further reviewed to determine the incidence of new diagnoses and treatment initiated by the appearance of new abnormal laboratory findings; 756 new abnormalities were recorded out of a possible 15,000, and 66 medical work-ups were initiated, which lead to new diagnoses in 21 cases and a treatment plan in 12 cases. The authors suggest that, in view of the rapid increase in the number of elderly persons and the consequent need to conserve limited health care resources, "standard" laboratory screening may not be warranted on a yearly basis in the elderly population.

Screening for Alzheimer's disease by clock drawing.

The fear of Alzheimer's disease for both patients and families is growing along with the increasing evidence of the disease itself. This study (N = 312) of the validity of the clock drawing test in screening patients with probable Alzheimer's disease was conducted in an active outpatient geriatric clinic. Clock drawings by patients with normal mental status or depression were essentially normal. Alzheimer's patients were unable to complete a normal clock and demonstrated five characteristically abnormal patterns. As a test for Alzheimer's disease, clock drawing had a sensitivity of 86.7% and a specificity of 92.7%. There was correct identification in 97.2% of normals. These findings indicate that the clock drawing test, an easily administered, low cost screening tool, can be useful to health care professionals in characterizing cognitive loss in a general geriatric clinic population.

Hypouricemia, abnormal renal tubular urate transport, and plasma natriuretic factor(s) in patients with Alzheimer's disease.

OBJECTIVE: To study tubular urate transport in Alzheimer's disease (AD) and measure sodium and lithium transport rates in rats exposed to AD plasma. DESIGN: Cross-sectional study in three comparison groups. SETTING: Referral private institution involving outpatient and hospitalized patients. PATIENTS: AD, multi-infarct dementia (MID) and non-demented controls (C) were selected and evaluated by a geriatrician and a psychiatrist according to availability and willingness to participate in the study. Demented patients had brain imaging, categorized according to NINCDS-DSM III criteria, and had Mini-mental status examination (MMSE) scores determined. INTERVENTIONS: Injection of 0.5 mL of plasma I.P. followed 120 minutes later by an IV plasma injection of 0.2 mL priming dose and infusion of 1.8 mL of plasma at 0.01 mL/min in Sprague Dawley rats. MEASUREMENTS: Renal clearance studies were performed in subjects and in rats exposed to the plasma of study subjects. We measured serum urate concentration and fractional excretion (FE) of urate in subjects and FE sodium and FE lithium in rats. RESULTS: Serum urate was lower and FE urate higher in 18 AD patients compared with six patients with MID, P < 0.05 and P < 0.005, and 11 C, P < 0.02 and P < 0.005, respectively. Higher FE sodium and FE lithium were noted in rats given plasma from 19 AD patients compared with 12 with MID, P < 0.005 and P < 0.0025, and 14 C, P < 0.0025 and P < 0.0005, respectively. FE sodium and FE lithium decreased progressively after serial dilutions of three AD plasmas and FE lithium was negatively correlated with MMSE scores only in AD, r = -0.71 and P < 0.0005. CONCLUSIONS: In AD there is defective tubular urate transport and a plasma natriuretic factor(s). FE sodium and/or FE lithium in rats exposed to plasma of demented patients may differentiate AD from MID and estimate the severity of AD.

Are Alzheimer patients healthier?

At an active outpatient geriatric program the gerontological team observed that Alzheimer patients appear to have fewer physical ailments than other elderly patients. To test this hypothesis, we reviewed a sample of 348 clinic patients. One hundred forty-three had a normal mental status; 75 had Alzheimer's disease as defined by DSM-III criteria; 139 had an abnormal mental status attributed to other etiologies. The number of diagnoses was compiled in each of the three groups. The average number of diagnoses in the nondemented group was 5.0 in males, 5.4 in females. In the non-Alzheimer abnormal mental status group, the average number was 5.5 in males, 4.6 in females. In contrast, the number of diagnoses in the Alzheimer group was 2.9 in males and 2.8 in females (P less than 0.0001). Cardiovascular diseases, hypertension, and cerebrovascular accidents were less frequent in the Alzheimer population. This study suggests that Alzheimer patients are physically healthier than non-Alzheimer elderly patients.

Elevated circulating tumor necrosis factor levels in Alzheimer's disease.

Recent investigations have demonstrated a local inflammatory response in Alzheimer's disease (AD), including microglia and cytokines. Levels of the cytokine tumor necrosis factor alpha (TNF-alpha) in sera from patients with AD and age-matched controls were measured by an enzyme-linked immunoassay and a cytotoxicity bioassay. Significantly elevated levels of TNF were found in AD sera compared to controls. Elevated circulating TNF may be derived from the local CNS inflammatory reaction in AD, and may account for some systemic manifestations of AD such as weight loss. Future studies may determine if, in the absence of complicating disorders which may elevate TNF, circulating TNF could be a marker of AD inflammatory activity.

Energy requirements in Alzheimer's disease patients.

Weight loss in Alzheimer's patients has been observed by many clinicians and reported in the international geriatric literature. It represents a puzzling challenge for clinicians and researchers, and it is an important issue for caregivers and nursing home staff concerned with state and federal requirements for nutrition and weight monitoring. Using indirect calorimetry, we studied the resting energy expenditure of 21 elderly patients; 12 were residing in a community setting, and 9 were institutionalized. Of the 12 community-living patients studied, 5 had early to moderate Alzheimer's disease, and 7 were nondemented control subjects. Of the 9 institutionalized patients, all were severely demented, bedridden, and fed exclusively by gastric tube in a closely monitored clinical environment with daily bedside weighing. Four had Alzheimer's disease, and 5 had multi-infarct dementia (MID). Among the outpatients, the Alzheimer's group showed increased energy requirements (p = 0.028) and a significantly different pattern of fat-free mass compared with control subjects (p = 0.031). These observations on community-residing elderly were consistent with, and extended by our findings on energy requirements of, the demented institutionalized patients. The calorie intake necessary for weight maintenance of the bedridden institutionalized patients was determined during their prolonged institutionalization. The presumed maintenance level of calorie intake was then verified during a 10 wk study. During the 10 wk, we documented no significant change in weight with constant energy intake. Compared with MID patients, Alzheimer's patients tended to weigh less (52.84 vs 56.4 kg; p = 0.20) but actually required more calories (1626 vs 1341 kcal, p < 0.011).(ABSTRACT TRUNCATED AT 250 WORDS)

Demographic changes and their financial implications.

The impressive rise in the number of elderly persons (65 years and over) will continue in the next two to three decades. Urinary incontinence is a common problem in the elderly, adversely affecting medical, social, and "quality of life" aspects. The cost of urinary incontinence is substantial and is expected to escalate enormously (e.g., by 160% from 1980 to 2040). An aggressive approach toward the diagnosis and management of urinary incontinence can result in an impressive reduction in health care costs and improvement in the quality of life.

The effect of nutritional status on length of stay in elderly hip fracture patients.

BACKGROUND: In this period of cost constraints, any indicator, such as nutritional status, which may predict the outcome of rehabilitation for a common problem, such as hip fractures, merits evaluation. METHODS: Nutritional indices--serum albumin, cholesterol, and body mass index--were assessed in 114 subacute rehabilitation hip fracture patients. RESULTS: Hypoalbuminemia was very common, occurring in 101 of 114 patients (88.6%). Using a forward stepwise regression model which considered age, total protein count, albumin, cholesterol, weight, height, and body mass index, serum albumin was the only variable that was significantly correlated with the length of stay (b=-0.23; p<.015). A scatterplot showed that almost all the albumin values in this elderly group fell between 2.4 mg/dl and 3.2 mg/dl, relatively low values, with a significant negative linear relationship between serum albumin and length of stay in this range. The average length of stay at 3.2 mg/dl was 44 days and at 2.4 mg/dl was 56 days. CONCLUSION: Hypoalbuminemia remains an important indicator of poor health outcome. Early biomedical monitoring of elderly subacute patients may lead to a reduction in length of stay and consequently reduce the costs of rehabilitation.

Screening examinations in the elderly: which are worthwhile?

The elderly are requiring more medical services than ever before, expecting high-quality medical care and routine checkups. Few guidelines exist on appropriate screening of healthy adults. The health care screening of elderly patients must be geared to common geriatric diseases that may present with atypical symptoms.

New Alzheimer's drug expands your options in symptom management.

Gradually progressive memory loss is the keystone of Alzheimer's disease (AD). Other diagnostic signs include deterioration of language and perception, judgment losses, and behavioral problems such as agitation and paranoia. The clock drawing test is a simple in-office measure of spatial orientation. CT or MRI is recommended to rule out vascular injury; blood tests can exclude other types of dementia. Serial mental status exams can document disease progression. Drug therapy is appropriate for managing mental symptoms, including early depression and anxiety. Some patients may derive benefit from tacrine. Management must also include education and support of the AD patient's caregivers.

A new onset of fatigue in an active elderly man.

Fatigue is often perceived as part of normal aging. Yet for many active elderly, a complaint of generalized, non-specific weakness should alert the physician to the existence of possible underlying pathology, as this case demonstrates.

Predictors of hospital length of stay and nursing home placement in an elderly medical population.

OBJECTIVE: To identify predictors of adverse outcomes (nursing home placement and hospital length of stay) in a cohort of older hospitalized patients. DESIGN: Prospective cohort study. SETTING: A suburban medical center in the New York City metropolitan area. PARTICIPANTS: Patients aged 65 years and older admitted from the emergency department to medical services who could be seen within 24 hours. Patients with terminal illness, planned stays < 2 days, and admission to other than medicine were excluded. MEASUREMENTS: Sociodemographic data, mobility, Activities of Daily Living (ADL), Instrumental Activities of Daily Living (IADL), mental status, length of stay (LOS), discharge diagnosis, and disposition (nursing home vs. other). RESULTS: Of 681 patients screened, 322 were eligible and assessed at admission,206 were reassessed at discharge. Using multiple regression, greater dependency in IADL, more household help, and impaired mental status at admission predicted hospital LOS significantly (P = 0.0001). Compared with those discharged home, the nursing home (NH) group had lower scores on mean mobility and mean ADLs and IADLs and was more likely to exhibit a decline in at least one ADL. Stepwise discriminant analysis was performed using admission, discharge, and combined variables. In our final model of the predictors of discharge disposition, the use of admission functional variables, age, and sex correctly classified 100% of the NH group and 91% of the other group, with IADL, ADL, and mobility defining the function that discriminated the groups. CONCLUSIONS: Our data indicate the value of cognitive and physical function at admission as predictors of adverse outcomes and support early assessment of the elderly for discharge planning for long-term care.