Tube feedings in elderly patients. Indications, benefits, and complications.

During an 11-month period, 70 tube-fed patients aged 65 to 95 years were studied prospectively to determine the indications, benefits, and complications of enteral alimentation. Indications for alimentation were refusal to swallow (35 patients [50%], dysphagia without obstruction (33 [47%]), and esophageal obstruction (two [3%]). Nasogastric tubes (NGTs) were used initially in 69 patients; 15 of these subsequently required a gastrostomy tube (GT). One patient was treated initially with a gastrostomy. Indicators of nutritional status included weight, hemoglobin level, hematocrit, and serum albumin level. During the first two weeks the most common problems in the NGT group were agitation and self-extubation (36 patients [67%]) and aspiration pneumonia (23 [43%]). In GT patients the most common early problems were aspiration pneumonia (nine patients [56%]), tube dysfunction (eight [50%]), and agitation and extubation (seven [44%]). The common late problems were aspiration pneumonia (24 patients [44%] in the NGT group and nine [56%] in the GT group), and feeding tube dysfunction in six (38%) of the GT group. Self-extubation as a late problem was limited to the NGT group (21 patients [39%]). Twenty-eight (40%) of the 70 patients died during the study period.

Baseline characteristics of the diabetic participants in the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT).

OBJECTIVE: Hypertension (HTN) is a major risk factor for cardiovascular disease (CVD) in the setting of diabetes. There is no consensus on how best to treat hypertension among those with diabetes. Here we describe the characteristics of a cohort of hypertensive adults with diabetes who are part of a large prospective blood pressure study. This study will help clarify the treatment of HTN in the setting of diabetes. RESEARCH DESIGN AND METHODS: The Antihypertensive and Lipid-Lowering high-risk hypertensive participants, ages > or = 55 years, designed to determine whether the incidence of fatal and nonfatal coronary heart disease (CHD) and combined cardiovascular events (fatal and nonfatal CHD, revascularization surgery, angina pectoris, congestive heart failure, and stroke) differs between diuretic (chlorthalidone) treatment and three alternative antihypertensive therapies: a calcium channel blocker (amlodipine), an ACE inhibitor (lisinopril), and an alpha-adrenergic blocker (doxazosin). The planned follow-up is an average of 6 years, to be completed March 2002. RESULTS: There are 15,297 diabetic individuals in the ALLHAT study (36.0% of the entire cohort). Of these individuals, 50.2% are male, 39.4% are African-American, and 17.7% are Hispanic. Demographic and laboratory characteristics of the cohort are similar to those of other studies of the U.S. elderly population with HTN. The sample size has 42 and 93% confidence, treatments for the two study outcomes. CONCLUSIONS: The diabetic cohort in ALLHAT wil be able to provide valuable information about the treatment of hypertension in older diabetic patients at risk for incident CVD.

Caudal epidural blocks for elderly patients with lumbar canal stenosis.

OBJECTIVE: To determine the efficacy of caudal epidural blocks (CEB) in relieving pain and the duration of pain relief with CEB in elderly patients suffering from degenerative lumbar canal stenosis (LCS). DESIGN: This study was a descriptive, prospective study with a 10-month follow-up. PARTICIPANTS AND SETTING: Thirty patients, 76 +/- 6.7 years of age, with leg discomfort with or without back pain and with LCS documented by magnetic resonance imaging (MRI) within 1 year of the study, were recruited from the outpatient clinic of the Cleveland Clinic Florida. None of the subjects had received CEB or surgery for their leg discomfort and none had relief of pain by analgesics alone. MEASUREMENTS AND INTERVENTIONS: Subjects received a total of three doses of 0.5% Xylocaine with 80 mg Depo-Medrol into the caudal epidural space through the sacral hiatus at weekly intervals. The Roland 5-point pain rating scale was utilized before and at 2-month intervals up to 10 months after the CEB was administered. MRI was used to identify the degree of LCS. RESULTS: The degree of LCS on admission was moderate in 66.7% (n = 20) of the patients, mild in 23.3% (n = 7), and severe in the remaining 10% (n = 3). Patients had LCS involving 2.4 +/- 0.49 lumbar vertebrae. The degree of LCS is directly correlated with the pain level before CEB. After CEB, the pain level changed from 3.43 +/- 0.82 to 1.5 +/- 0.86 (P < 0.0000), with a significant relief of pain up to 10 months (the end of observation). The duration of pain relief ranged from 4 to 10 months (P < 0.0001). CONCLUSION: CEB offers significant pain relief and appears to be a reasonable therapeutic option among elderly patients with LCS. This alternative seems particularly important among patients with poor response to drug therapy and who are either poor surgical risks or who have refused surgery.

Continuous compared with intermittent tube feeding in the elderly.

The methods of continuous (C) and intermittent (I) nasogastric tube feedings in 60 patients, 54 men and 6 women, with a mean age of 72 +/- 9 years were compared in terms of number of complications, staff time used, and caloric intake. Patients were randomly assigned between these two methods and followed for 7 days. Diarrhea, aspiration pneumonia, clogged tubes, and self-extubation were observed in both groups. Diarrhea was significantly more frequent (96% of 30 patients) in the I group than the C group (66% of 30 patients) (p < .008). Furthermore, diarrhea was more prolonged (4 days or more) in 64% of 30 patients in the I group than the C group (4 days or more) in 58% of 30 patients (p < .02). However, clogged tubes occurred 3 times more often in the C group (p < .01). Self-extubation and aspiration pneumonia tend to be more frequent in the I group but the difference was not significant. The average time used by staff nurses in the maintenance of NGT feedings was not significantly longer in the I group (48.45 +/- 11 min/patient per day) than the C group (46.46 +/- 11 min/patient per day). In the C group the mean calories recommended were 2248 +/- 36 kcal/day but the actual caloric intake was only 1465 +/- 281 kcal/day, a deficiency of 783 +/- 291 kcal/day. The recommended calorie count for the I group was 2021 +/- 5 kcal/day but the amount delivered was only 1226 +/- 254 kcal/day, which resulted in a deficit of 795 +/- 259 kcal/day.(ABSTRACT TRUNCATED AT 250 WORDS)

Arm edema, subclavian thrombosis, and pacemakers--a case report.

This reports an arm edema that was initially treated as cellulitis and later diagnosed to be subclavian thrombosis due to pacemaker wire irritation. We present an 87-year-old Caucasian man with 5 weeks duration of left arm swelling and pain that was treated with two courses of antibiotics. An axillary venous Doppler study was interpreted as normal with no evidence of venous thrombosis. However, a venogram showed evidence of thrombosis involving the left innominate, subclavian, and axillary veins with multiple collateral veins diverting the blood to the contralateral side and into the superior vena cava. Intravenous anticoagulation was initiated and subsequently the patient was maintained on warfarin (Coumadin). The thrombosis subsequently improved and the original pacemaker was maintained. Arm edema are commonly mistaken for cellulitis, causing a delay in a more definite diagnosis of subclavian thrombosis. In a setting of a patient with pacemaker, subclavian thrombosis should be considered even with a normal screening venous ultrasound test. The incidence, manifestation, venous Doppler, and venogram findings are reviewed and discussed. Upper arm edema and superior vena cava syndrome are the most common presentation of this subclavian thrombosis associated with pacemakers. Venous ultrasound tests may be normal and a venogram is usually required to establish a diagnosis.

A comparison between aspirin and pentoxifylline in relieving claudication due to peripheral vascular disease in the elderly.

Peripheral vascular disease (PVD) commonly presents with leg claudication during walking and eventually limits the walking distance and daily activities. Aspirin or pentoxifylline are commonly prescribed to improve blood flow. Aspirin works through its antiplatelet aggregation mechanism, and pentoxifylline increases the red blood cell flexibility, which leads to increased tissue perfusion. Data on comparative studies of these drugs for improving claudication in the elderly are limited. The objective of this study was to compare pain relief offered by either aspirin or pentoxifylline for walking leg pain in the elderly with PVD. Patients sixty-five years or older with claudication were randomly assigned to receive aspirin or pentoxifylline. Their reported level of walking claudication pain with use of the visual analogue scale (0-5) and the distance walked during exercises were recorded. Six weeks later the same parameters were recorded and results were compared with Student's t test, and a P value less than 0.05 was considered a statistically significant difference. Of the 90 patients who participated, 45 received aspirin (325 mg daily) and 45 were prescribed pentoxifylline (400 mg tid) for six weeks. Both the aspirin and the pentoxifylline groups reported a moderate level of pain (2/5) and remained about the same (2/5 for aspirin and 1/5 for pentoxifylline, P = 0.9, NS) after six weeks. However, the pentoxifylline group reported a farther walking distance of 2 miles compared with the aspirin group of 1.2 miles (P < 0.05). The level of pain did not change significantly with either aspirin or pentoxifylline, but the walking distance was farther with the pentoxifylline group.

Raised leg exercises for leg edema in the elderly.

UNLABELLED: Leg edema is a common problem in the elderly and requires further evaluation and management. METHOD: From October 1990 to July 1992, 245 patients presented to the Cleveland Clinic Florida with leg edema. All patients were counseled about the benefits of twenty-minute, three-times-a-day raised-leg exercises. Fifty seven (57) of the 245 patients were not compliant with this regimen (nonexercise group). Although not true controls, they formed a comparison group for those who performed the exercise regimen. The exercise group was composed of 188 patients with a mean age of 73 +/- 6.8 years, 25 (13%) men and 163 (87%) women; the nonexercise group was composed of 57 patients with a mean age of 71.9 +/- 4.3, 19 (33%) men and 38 (67%) women. Workup for leg edema included: comprehensive history, clinical examination including prostate or pelvic examination, complete blood count, chemistry profile, thyroid profile, electrocardiogram, chest radiograph, and, when indicated, pelvic or leg ultrasound and pelvic computed tomographic scan. The circumference of the leg with the maximum amount of edema was measured initially and on the fourth week. RESULTS: In this study, the common causes of leg edema in the elderly population were venous stasis (63.2%), drug induced (13.8%), and heart failure (15.1%). Postphlebitic syndrome, cirrhosis, lymphedema, lipedema, prostate carcinoma (CA), and ovarian mass were the less frequent findings. Upon comparison of the circumference of leg edema on initial visit and four weeks after, both the exercise and nonexercise groups showed significant decreases in the measurement of the leg edema (P < .001) except those caused by lymphedema.(ABSTRACT TRUNCATED AT 250 WORDS)

Age-related changes in human memory: normal and abnormal.

The evaluation of memory complaints in the elderly is one of the major challenges in geriatric medicine. Determining this deficit as either age-related change or dementia is a frequent problem in primary care practice. A careful history, an interview of a collateral source, and neuropsychological tests will shed light on the seriousness of the memory complaint. Several factors affect memory function of the elderly: anxiety, depression, and failure to use specific learning strategies commonly used by younger age groups. Memory training programs using mnemonics, lists, categorization, visual aids, rehearsal, and imagery may improve memory function.

Leg edema: clinical clues to the differential diagnosis.

Leg edema is a common problem in older patients, with a wide range of possible causes. The diagnosis can be narrowed by categorizing the edema according to its duration (acute or chronic), distribution (unilateral or bilateral), and accompanying symptoms (such as dyspnea, pain, thickening of skin, and pigmentation). The differential diagnosis includes systemic illnesses such as heart failure, liver disease, malnutrition, and thyroid disorder; local conditions such as pelvic tumors, infection,, trauma, and venous thrombosis; and various medications known to increase the risk of edema of the lower extremities. Appropriate therapy is based on the presentation of edema and its identified cause.

Tinnitus: a stepwise workup to quiet the noise within.

Patients with tinnitus--ringing in the ears or head--frequently present initially to their primary care physician. Tinnitus may be subjective (audible only by the patient) or objective (audible to the examiner). Subjective tinnitus is more common and may be due to peripheral or central auditory pathology, a metabolic abnormality, or anxiety/depression. Objective tinnitus is rare and is frequently due to a vascular or neuromuscular condition, intracranial or head/neck tumor, or some specific structural defect of the ear, cochlea, or retrocochlear area. The stepwise workup of tinnitus includes a comprehensive history and physical exam, audiologic evaluation, blood profile analysis, and referral when necessary. Treatments include hearing aids, masking devices, drugs, and biofeedback.

Clinical approach to urinary incontinence: a comparison between internists and geriatricians.

To compare the initial approach and pattern of practice between internists and geriatricians in treating urinary incontinence. A retrospective chart review of 300 consecutive charts of elderly patients over the age of 65, seen by either internists (IM) or Geriatricians (GERI) for urinary incontinence at the Cleveland Clinic Florida was performed. The clinical approaches to the management of urinary incontinence were compared between IM and GERI groups by using a Student's t test. The mean age for these patients was 77 y for the IM group and 79 y for the GERI group. Majority of patients suffered from two chronic illnesses. We found that geriatricians performed more initial work up such as urodynamic testing before referring, while internists obtained more referrals to gynecologist with special interest in urologic disorders (currently called urogynecologist) without initial workup. IM and GERI groups equally prescribed medications for incontinence. However, the GERI group recommended Kegel exercises more frequently. This study showed that geriatricians manage urinary incontinence more extensively by performing more initial work up including urodynamics and providing initial behavioral therapy (Kegel exercise and toilet schedule) before referring to specialists. Perhaps geriatricians feel more comfortable treating urinary incontinence as shown by their lower frequency of referrals and are therefore more comfortable than internists at addressing this medical issue. On the contrary, the internist did the initial evaluation but preferred to get a referral perhaps due to less familiarity with urinary incontinence.

Gait training and falls in the elderly.

1. Patients with gait and balance disorder, as measured by the Tinetti Mobility Scale, can benefit from physical therapist-assisted gait training. 2. Score in the Tinetti Mobility Scale negatively correlates with the number of recurrences of falls. 3. The nurse's role includes identification of those who are at risk for falls, assessment of their response to training in preventing recurrence of falls, and the effect of training in their mobility and independence.

Xerostomia: a prevalent condition in the elderly.

Although xerostomia is associated with aging, studies have determined that salivary gland function is well preserved in the healthy geriatric population. Therefore, dry mouth is probably not a condition of aging, but most likely one of systemic or extrinsic origin. Saliva seems to undergo chemical changes with aging. As the amount of ptyalin decreases and mucin increases, saliva can become thick and viscous and present problems for the elderly. One of the most prevalent causes of xerostomia is medication. Anticholinergics, such as psychotropic agents and antihistamines, and diuretics can dry the oral mucosa. Chronic mouth breathing, radiation therapy, dehydration, and autoimmune diseases, such as Sjögren's, can also diminish salivation, as can systemic illness such as diabetes mellitus, nephritis, and thyroid dysfunction. Xerostomia can lead to dysgeusia, glossodynia, sialadenitis, cracking and fissuring of the oral mucosa, and halitosis. Oral dryness can affect denture retention, mastication, and swallowing. Dry mouth symptom can be treated with hydration and sialagogues or with artificial saliva substitutes. Because patients are at risk for dental caries, they should be referred to a dentist for preventive care. In patients with Sjögren's syndrome and in those who have undergone radiation therapy, pilocarpine has been used recently with good results.

Functional impairment among elderly women with osteoporotic vertebral fractures.

Back pain is a significant cause of functional impairment in elderly women with vertebral fractures. To determine the degree of functional impairment due to painful osteoporotic vertebral fractures, investigators compared 75 white women with a mean age of 77 (+/- 7.2) years who had a mean number of 2.8 (+/- 0.87) vertebral fractures with 83 white women with a mean age of 74 (+/- 6.5) years who had no vertebral fractures. These patients were seen within a 2-year period. The Katz Activities of Daily Living scale was used to assess the patients' functional status. All patients underwent a comprehensive evaluation that included a detailed history and a physical examination. Bone density was evaluated in most of the patients and the evaluation revealed osteoporosis in all of the patients with vertebral fractures. The women with vertebral fractures were found to be more significantly dependent in the following activities of daily living: bathing, toileting, dressing, transfer, and continence. These findings have important nursing implications for rehabilitation of the elderly with this condition.

Indications for tube feedings in elderly patients.

Tube feedings are utilized in elderly patients with acute and chronic problems. Inadequate oral intake with malnutrition, comatose state, neurologic disorders with severe dysphagia, extensive burns, massive gastrointestinal resection, and oropharyngeal and upper gastrointestinal malignancies are the commonly encountered conditions requiring tube alimentation. Dysphagia with frequent aspiration is the most common indication for use of tube feedings in the elderly. Nasogastric tube is preferred for short-term feeding, while gastrostomy or jejunostomy is indicated for long-term or permanent nutritional support. Nutritional assessment should be done initially and on a regular basis. Specific formulas are available to calculate height, weight, and caloric needs of bedbound elderly patients. Various enteral feeding formulas are available for a specific clinical condition and are preferably administered by continuous drip using a pump. Parenteral nutrition is also indicated for certain situations in which enteral feeding cannot meet the patient's nutritional requirement, and in particular situations where enteral feeding is contraindicated and not feasible. Optimal patient care is dependent on adequate nutritional support.