[Treatment of orthostatic hypotension with metoclopramide]. / Tratamento da hipotensão ortostática com metoclopramida.

A 38 year-old woman, with orthostatic hypotension secondary to autonomic dysfunction accompanied by sympathetic hyperactivity and excess of dopamine, was treated with an antagonistic dopaminergic drug, metoclopramide, 30 mg/day, with good tolerance. Support intervention as well as the use of various drugs (beta-blockers, caffeine, fludrocortisone, haloperidol) showed no effect. The answer to metoclopramide both subjective and objective were remarkable. The way in which metoclopramide acts has not yet been fully clarified. Being a widely used drug, well tolerated, its use must be considered in cases of severe orthostatic hypotension, especially those with an excess of dopamine.

[Programmed atrial pacemaker in the treatment of neurogenic orthostatic hypotension in the elderly]. / Marcapasso atrial programável no tratamento da hipotensão ortostática neurogênica no idoso.

A programmable atrial pacemaker was implanted in an elderly man, 75 years-old, with incapacitating orthostatic hypotension due to automatic dysfunction (Shy-Drager) unresponsive to traditional therapy. Initially, a temporary programmed atrial pacing was implanted paced at 96 beats/minute during the day, reducing the rate at night to 60 betas/minute. An increase in cardiac output was achieved. Favourable results encouraged us to implant a permanent programmed pacemaker. The manufacturer designed a simple, safe programmer operable by the patient which only alters the rate from night (60) to day (96). A marked improvement in symptoms has been observed during a follow-up of nine months without complications. It is recommended that this sort of treatment be considered in elderly patients with symptomatic orthostatic hypotension due to autonomic dysfunction with inadequate compensatory tachycardia who have not responded to traditional therapy.

[Orthostatic hypotension in elderly inpatients]. / Hipotensão ortostática em idosos hospitalizados.

PURPOSE: To determine the prevalence of orthostatic hypotension (OH) in elderly inpatients, to identify known risk factors as well as to investigate quality of care given to these patients. PATIENTS AND METHODS: One hundred elderly inpatients aged 60 and over (mean age: 69.2 years), 66 women and 34 men were investigated. We measured supine (after resting for 30 minutes) and one, two, three, four and five minutes standing blood pressures. Orthostatic hypotension was defined as a decrease in systolic pressure of 20 mmHg or more with or without symptoms. The case notes of these subjects were reviewed and the presence of risk factors (diseases and medications associated with OH) was recorded as well as the short of treatment given to these patients. RESULTS: The prevalence of OH was 30% (30 patients); 1/3 had symptoms, one or more known risk factors were found in every patient. Neurogenic orthostatic hypotension was found in 5 patients (5 out of 30 patients). Only one patient with OH was diagnosed (1-30 patients). CONCLUSION: There is a high prevalence of OH in elderly inpatients and its association with various known risk factors. Most patients are not diagnosed and therefore not managed properly.

[Use of digitalis in elderly patients admitted to a geriatric unit at a general hospital]. / Uso de digital em idosos admitidos em unidade de geriatria de um hospital geral.

PURPOSE: To determine the prevalence of digoxin use as well as its indications in elderly patients at the time of admission to a geriatric unit of a general hospital. METHODS: One hundred and thirty elderly patients aged 65 and over (mean age = 80 +/- 9 years), 100 women and 30 men were consecutively investigated. Each patient was submitted to a thorough clinical investigation, laboratory work-up, chest X-ray, electrocardiogram and doppler echocardiogram. The use of digoxin was considered appropriate, questionable or inappropriate. RESULTS: At the time of admission to the geriatric unit 27.6% of the patients were receiving digoxin. The indication was considered appropriate in 36.1%, questionable in 11.1% and inappropriate in 52.7%. CONCLUSION: We found a high prevalence of digoxin use in elderly patients admitted to a geriatric unit of a general hospital. In most cases its indications were considered inappropriate or questionable. Due to the increased risk of digitalis intoxication in this age group the drug should be prescribed under more strict indications.

An investigation of dementia among elderly outpatients.

A total of 110 unselected demented outpatients aged 60 and over (mean age: 76.2 years), 69 women and 41 men, were prospectively investigated. A potentially reversible cause of dementia was found in 26 patients (normal pressure hydrocephalus 2, cerebral tumor 1, hyperthyroidism 2, hypothyroidism 4, vitamin B12 deficiency 13, pseudodementia 4). Follow-up investigation showed that the only true reversible dementia in which improvement from abnormal to normal mental status occurred and was sustained for up to 2 years was 1 case of normal pressure hydrocephalus and 1 case of pseudodementia. In all cases of vitamin B12 deficiency, hypothyroidism and hyperthyroidism, despite proper treatment, mental status did not improve significantly and follow-up in most cases showed persistant cognitive deterioration. It can be concluded that although true reversible dementias do exist, they do not seem as prevalent as previously reported. Most elderly outpatients with reversible causes of dementia do not revert to normal and continue showing progressive decline.

Vitamin B12 deficiency and dementia.

We set out to investigate the possible beneficial effects on cognitive function of demented patients with cobalamin deficiency after cobalamin replacement. A total of 181 consecutive, demented (DSM-III or DSM-III-R criteria and score below 24 on the Mini-Mental State Examination [MMSE]) outpatients (mean age 77.5 years) were prospectively evaluated and had their vitamin B12 level measured by radioimmunoassay. The frequency of vitamin B12 deficiency (less than 200 pg/mliter) was 25% (46 patients). Treatment outcome was obtained in 19 patients (19 of 46). Despite cobalamin replacement, 16 of 19 patients persisted in showing progressive decline during follow-up visits (3 to 24 months). The nonresponse to vitamin B12 replacement in most cases seems to reflect the presence of associated irreversible dementia or a follow-up of shorter duration in a few patients. All of the patients who showed some improvement (MMSE returned to normal values) had mild dementia with a history of less than 2 years. Thus, screening for B12 deficiency should be considered in patients with recent onset of mild mental status changes.

Incontinencia urinaria no idoso (Revisao). / Urinary incontinence in the elderly (Review)

A incontinencia urinaria no idoso e problema muito comum, gerador de consequencias sociais embaracosas, o que leva o paciente a oculta-la, sendo tambem frequentemente considerada como um acompanhante desagradavel do envelhecimento, pelo proprio paciente e, muitas vezes, pelo proprio medico, que entao omite investigacao e tratamento adequados. Este trabalho reve as principais causas, realca a importancia de se obter um diagnostico acurado atraves de investigacao urodinamica, antes de se instituir o tratamento adequado. Com a utilizacao dos meios diagnosticos e do arsenal terapeutico ja existente em outros centros, em muito se pode melhorar o estilo de vida de nosso idoso incontinente. E bom frisar que a incontinencia urinaria no idoso, como outros sintomas, pode ser algumas vezes curada; frequentemente melhorada e sempre melhor controlada

Sinais e sintomas cardiorrespiratórios no paciente idoso: diferenças e dificuldades de interpretação / Cardiorespiratory signs and symptoms in the elderly

O objetico deste artigo é rever sinais e sintomas cardiorrespiratórios que guardam peculiaridades no paciente idoso, particularmente no muito idoso. Os autores ressaltam a importância em se conhecer a especificidade da Semiologia Geriátrica, particularmente no paciente muito idoso, que pode diferir substancialmente daquela do adulto, havendo usualmente apresentação atípica das doenças e/ou através dos chamados sinais cardinais geriátricos (delirium, incontinências, quedas, imobilidade).

Eletroconvulsoterapia no tratamento da depressao e das manifestaçöes da doença de parkinson / Treatment of parkinson's disease with elctroconvulsive therapy

Mulher, 73 anos, apresenta-se con Doença de Parkinson(DP) em fase avançada sem resposta a medicaçäo classica, associada a quadro depressivo maior. Foi submetida a sete sessöes de ECT com boa toleräncia. A resposta tanto da sintomatologia depressiva quanto das manifestaçöesparkinsonianas (mensurada pela escala de Webster) foi considerada satisfatória. No entanto, a recidiva dos sintomas parkinsonianos e depressivos ocorreu em tempo relativamente curto. Recomendamos que esta modalidade terapêutica seja considerada em pacientes portadores de DP avançada sem resposta à terapêutica clássica principalmente se associada à depress