RESUMO
OBJECTIVES: To identify signs and symptoms to differentiate cardiac from neurological syncope in patients over 70 using a standardized questionnaire. DESIGN: Prospective cohort study. SETTING: Five short-stay units in a French university hospital. PARTICIPANTS: One hundred thirty-one in-patients with syncope aged 70 and older. MEASUREMENTS: Patients were interviewed about the signs and symptoms that had been present before, during or after syncope. When possible, a witness who had been present during syncope was also interviewed to compare theirs and the patients' answers. The sensitivity and specificity of 35 questions were calculated among 3 groups defined according to the cause of syncope: cardiac (n = 58), neurological (n = 31) and syncope of unknown origin (n = 42). Statistical analyses were performed to determine discriminating signs and symptoms among the causes and crude agreement was calculated for answers from patients and witnesses. RESULTS: Only 8 and 3 of 35 questions had a sensitivity of at least 0.5 for cardiac and neurological causes respectively. A feeling of impending syncope, thoracic oppression, recall of events preceding syncope and a history of arrhythmia were independently and significantly discriminant among groups. Recall of events preceding syncope (Odds Ratio (OR) = 7.5; 95% confidence interval (CI) = 2.2-25.3) and a personal history of arrhythmia (OR = 4.8; 95% CI = 1.6-14.2) were discriminant between cardiac and neurological causes suggesting mostly a cardiac cause. Agreement between patients and witnesses was only found for questions on the patient's medical history or the circumstances surrounding the onset of syncope. CONCLUSIONS: Recall of events preceding syncope and a history of arrhythmia are strongly suggestive of a cardiac rather than a neurological cause of syncope. Interviews of witnesses are not helpful in suggesting a cause for syncope.
Assuntos
Inquéritos e Questionários/normas , Síncope Vasovagal/diagnóstico , Síncope/diagnóstico , Idoso , Estudos de Coortes , Diagnóstico Diferencial , Feminino , Humanos , Masculino , Análise Multivariada , Estudos Prospectivos , Recidiva , Sensibilidade e EspecificidadeRESUMO
UNLABELLED: In clinical practice the will to find out the cause of normocytic anemia (NA) in elderly patients is preferentially based on individual physician's background rather than on objective data such as their hemoglobin level. However, it could be postulate that this clinical performance depends on this "cut off" of hemoglobin (more this value is decreased more it could be easy to find the cause of anemia). The aim of this study was to investigate the relationship between the number of cases with defined cause of NA (after a standardized procedure) and the level of hemoglobin. METHODS: In this prospective study 211 inpatients aged 70 years or more with NA disclosed on admission or during hospitalization have been selected. In 162 of them finally included, a standardized procedure with complementary explorations was performed. RESULTS: In 134 patients, the cause of NA was established amongst inflammatory diseases and chronic renal failure was the most frequently identified. In 20%, anemia was multifactorial. Despite investigations anemia remained unexplained in 17.3% of studied patients. For a decrease of at least 10% below the normal range of hemoglobin level, sensitivity of diagnosis was 70% and specificity 60%. Positive predictive value to make the diagnosis when hemoglobin level was below 20% from normal value was 100%. CONCLUSION: The cause of NA in elderly patients after basic explorations may be assessed in up to 80% of cases. We found a significant relationship between the value of hemoglobin level and the number of anemia with confirmed diagnosis. More hemoglobin level is decreased better is clinical performance.
Assuntos
Anemia/sangue , Anemia/etiologia , Hemoglobinas/análise , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Estudos ProspectivosRESUMO
Pneumonia amongst elderly people living in institutions is common and is a frequent cause of mortality and hospital admission. It is important to distinguish between prevention of viral pneumonia, which primarily consists of influenza vaccination programmes, and prevention of bacterial pneumonia. Prevention of influenza infection in institutions requires the vaccination of as many as possible of both residents and caregivers. In the event of a declared epidemic then amantadine can be used to reduce the severity of, and complication rate of, influenza infection. The indications for giving this therapy need to be balanced against potential side-effects, especially neurological ones. For the prevention of bacterial pneumonia risk factors such as immobility or impaired swallowing should be first identified and dealt with as necessary. Anti-pneumoncoccal vaccination may be considered, but on current evidence, the value of systematic vaccination of residents has not yet been established.
Assuntos
Instituição de Longa Permanência para Idosos , Casas de Saúde , Pneumonia/microbiologia , Pneumonia/prevenção & controle , Idoso , Humanos , VacinaçãoAssuntos
Espondilite Anquilosante/diagnóstico , Idade de Início , Idoso , Idoso de 80 Anos ou mais , Antirreumáticos/uso terapêutico , Sedimentação Sanguínea , Feminino , Genótipo , Antígeno HLA-B27/genética , Humanos , Imageamento por Ressonância Magnética , Espondilite Anquilosante/tratamento farmacológico , Espondilite Anquilosante/genética , Sulfassalazina/uso terapêuticoAssuntos
Infecções por Bactérias Gram-Positivas/etiologia , Hospedeiro Imunocomprometido , Leuconostoc , Infecções Oportunistas/etiologia , Doenças Raras/etiologia , Agamaglobulinemia/complicações , Idoso , Idoso de 80 Anos ou mais , Amoxicilina/uso terapêutico , Anemia Ferropriva/complicações , Feminino , Febre/microbiologia , Infecções por Bactérias Gram-Positivas/tratamento farmacológico , Humanos , Neoplasias Hepáticas/complicações , Neoplasias Hepáticas/secundário , Distúrbios Nutricionais/complicações , Infecções Oportunistas/tratamento farmacológico , Penicilinas/uso terapêutico , Doenças Raras/tratamento farmacológico , Resultado do TratamentoRESUMO
Pneumonia amongst elderly people living in institutions is common and is a frequent cause of mortality and hospital admission. It is important to distinguish between prevention of viral pneumonia, which primarily consists of influenza vaccination programmes, and prevention of bacterial pneumonia. Prevention of influenza infection in institutions requires the vaccination of as many as possible of both residents and caregivers. In the event of a declared epidemic then amantadine can be used to reduce the severity of, and complication rate of, influenza infection. The indications for giving this therapy need to be balanced against potential side-effects, especially neurological ones. For the prevention of bacterial pneumonia risk factors such as immobility or impaired swallowing should be first identified and dealt with as necessary. Anti-pneumoncoccal vaccination may be considered, but on current evidence, the value of systematic vaccination of residents has not yet been established.
Assuntos
Vacinas contra Influenza/uso terapêutico , Influenza Humana/complicações , Influenza Humana/prevenção & controle , Assistência de Longa Duração , Vacinas Pneumocócicas/uso terapêutico , Pneumonia Bacteriana/prevenção & controle , Idoso , Amantadina/uso terapêutico , Antivirais/uso terapêutico , Cuidadores , Surtos de Doenças , Geriatria , Humanos , Medicina Preventiva , Fatores de RiscoRESUMO
OBJECTIVES: To control whether prescriptions of curative doses of heparin (non fractioned heparins, enoxaparin, tinzaparin) in the hospital complied with the official recommendations; to provide the physicians with information adapted to the recorded misuse and to evaluate the influence of this information. METHODS: A prospective study was conducted between May and October 1999 on the prescriptions of 20 residents from 6 services in 3 phases: phase P1 with initial evaluation (particularly on the indications for heparin, the molecule administered, initial dose and monitoring), phase P2 with analysis and diffusion of an adapted information and phase P3 with final evaluation. RESULTS: 111 inpatients were included in the phase P1 (66.7% aged over 75 years, 18.9% with creatinin clearance below 30 ml/mn) and 101 inpatients were included in the phase P3 (56.4% aged over 75 years, 10.8% with renal failure). During phase P1: among the prescriptions of low molecular weight heparin (LMWH) 54.3% did not comply with the official recommendations; initial doses were too high in 15.3% of patients; mean initial doses of LMWH were not adapted to age, weight or creatinin clearance. Only 58.5% of patients had their platelets monitored. On the other hand, 15.3% of patients exhibited heparin side effects. During phase P3, the main modifications in prescriptions were a reduction in inappropriate indications for LMWH, reduction in LMWH prescriptions in patients aged over 75 or with excessive body weight or with renal failure, and increased platelet monitoring, but without significant difference. On the other hand, mean initial doses of each heparin were not modified. Heparin complications decreased but not significantly. CONCLUSION: This study highlights a real context of heparin prescription at curative doses, often differing from clinical studies, particularly with regards to age, renal failure and comorbidity; prescriptions often unadapted to official recommendations on indications, dose and monitoring; a real but limited influence of appropriate information for the physicians, which partially depends on the accuracy of official recommendations, particularly in patients with increased hemorrhagic risk.
Assuntos
Anticoagulantes/administração & dosagem , Serviços de Informação sobre Medicamentos , Prescrições de Medicamentos , Enoxaparina/administração & dosagem , Fibrinolíticos/administração & dosagem , Heparina de Baixo Peso Molecular/administração & dosagem , Heparina/administração & dosagem , Adulto , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Anticoagulantes/efeitos adversos , Peso Corporal , Ensaios Clínicos como Assunto , Comorbidade , Enoxaparina/efeitos adversos , Feminino , Fibrinolíticos/efeitos adversos , França , Heparina/efeitos adversos , Heparina de Baixo Peso Molecular/efeitos adversos , Humanos , Rim/fisiologia , Masculino , Pessoa de Meia-Idade , Monitorização Fisiológica , Estudos Prospectivos , Fatores de Risco , TinzaparinaRESUMO
We report the case of an 83-year-old woman with diffuse large B-cell lymphoma located in the right cardiac ventricle revealed by acute congestive heart failure. Complete and long-lasting disappearance of the cardiac tumor was observed with monochemotherapy (cyclophosphamide).
RESUMO
Because swallowing disorders are frequent in the elderly, we assessed the relationship between age and mylohyoideus muscle contraction, which is an important component of the initial step in swallowing. In a prospective study, 120 subjects without any personal history of diseases associated with swallowing disorders underwent electromyographic recording (EMG) of mylohyoideus muscle activity. Four groups of equal size (n = 30) were defined according to age (< or = 50, 51-70, 71-85, >85 years). The frequency and duration of mylohyoideus muscle asynchronisms were compared among the four groups. The comparison of mylohyoideus muscle EMG among groups did not show a significant difference in the mean number of asynchronisms, in duration per subject or in the frequency of long-lasting asynchronisms. Asynchronisms were a very frequent event, observed in 98% of subjects, and were mostly short, lasting less than 0.1 s in 90% of subjects. In healthy elderly patients, there was no linear relationship between the mean duration of asynchronisms and ageing. The occurrence of one or more long-lasting asynchronisms or of at least six asynchronisms during a sequence of 10 successive swallows should be considered to be abnormal.
Assuntos
Envelhecimento/fisiologia , Deglutição/fisiologia , Músculo Esquelético/fisiologia , Língua/fisiologia , Idoso , Eletromiografia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos ProspectivosRESUMO
PURPOSE: Although cognitive impairment related to hypothyroidism has been investigated, issues regarding treatment have been less extensively studied. The aim of this study was to assess cognitive function in patients with hypothyroidism just before treatment and after hypothyroidism had resolved. METHODS: Standardized psychometric assessment (including ten tests) was done in 30 outpatients with biochemical evidence of hypothyroidism (TSH = 92.1 mU/L, range: 11.4-400) and in 30 control subjects matched for age and gender with normal thyroid function. These tests were repeated twice before treatment and after hypothyroidism had been cured. Statistical analysis was done using the Mann-Whitney U test. RESULTS: The baseline characteristic of patients with hypothyroidism showed that attention, motor speed, memory and visual-spatial organization were significantly impaired. Cognitive decline was significantly greater with increasing age. Cognitive impairment significantly decreased after hypothyroidism had been cured, reaching values obtained in age-matched control subjects. CONCLUSION: Attention, motor speed, memory and visual-spatial organization are significantly impaired in hypothyroidism, particularly in the elderly, suggesting that ageing could have potential effects on cognitive functions. Hormone-replacement therapy leads to normalization of the cognitive functions.
Assuntos
Transtornos Cognitivos/tratamento farmacológico , Transtornos Cognitivos/etiologia , Terapia de Reposição Hormonal , Hipotireoidismo/tratamento farmacológico , Hipotireoidismo/psicologia , Tiroxina/uso terapêutico , Fatores Etários , Idoso , Atenção , Feminino , Humanos , Hipotireoidismo/diagnóstico , Testes de Inteligência , Masculino , Memória , Entrevista Psiquiátrica Padronizada , Pessoa de Meia-Idade , Psicometria , Desempenho Psicomotor , Valores de Referência , Tireotropina/sangueRESUMO
OBJECTIVE: to evaluate whether faecal incontinence can be improved by treatment of constipation in elderly patients with faecal incontinence associated with impairment of rectal emptying. DESIGN: a prospective randomized study with a 2-month follow-up. SETTING: five long-term care units. SUBJECTS: 206 patients with daily faecal incontinence associated with chronic rectal emptying impairments such as faecal impaction received either a single osmotic laxative (group I) or an osmotic agent along with a rectal stimulant and weekly enemas (group II). MEASUREMENTS: episodes of faecal incontinence and associated details of soiled laundry (used as indicators of the workload for caregivers). We performed periodic digital rectal examinations on group II patients to evaluate whether treatment resulted in complete and long-lasting rectal emptying. We compared data between groups and in group II between persistently constipated patients and patients with complete rectal emptying. RESULTS: the frequency of faecal incontinence did not significantly differ between the two groups. The 23 patients in group II who had complete rectal emptying had 35% fewer episodes of faecal incontinence and 42% fewer incidents of soiled laundry than the rest of the group. CONCLUSIONS: when long-lasting and complete rectal emptying is achieved by laxatives, the number of episodes of faecal incontinence as well as the workload for caregivers is reduced.
Assuntos
Catárticos/uso terapêutico , Constipação Intestinal/tratamento farmacológico , Incontinência Fecal/complicações , Institucionalização , Lactulose/uso terapêutico , Idoso , Idoso de 80 Anos ou mais , Catárticos/administração & dosagem , Catárticos/efeitos adversos , Constipação Intestinal/complicações , Constipação Intestinal/fisiopatologia , Seguimentos , Glicerol/administração & dosagem , Glicerol/efeitos adversos , Glicerol/uso terapêutico , Instituição de Longa Permanência para Idosos , Humanos , Lactulose/administração & dosagem , Lactulose/efeitos adversos , Casas de Saúde , Estudos Prospectivos , Resultado do TratamentoRESUMO
A COMMON PROBLEM: Adverse drug effects are common and severe in patients over 70. Most concern widely prescribed drugs or drugs with small safety margins. CLINIC: It is important to recognize the most frequently encountered modes of expression including cardiovascular, metabolic and neuropsychiatric manifestations. The effects of bleeding and low blood sugar are particularly severe. PREVENTION: Certain pharmacological favoring factors are closely related to the aging process. A large number of iatrogenic side effects could however be avoided if the patientís clinical situation is carefully considered in light of the risk of drug interactions, the patientís behavior (observance errors), or prescriber behavior (inappropriate prescriptions in light of the therapeutic goals).
Assuntos
Idoso , Tratamento Farmacológico/normas , Efeitos Colaterais e Reações Adversas Relacionados a Medicamentos , Doença Iatrogênica/epidemiologia , Tratamento Farmacológico/estatística & dados numéricos , Humanos , Doença Iatrogênica/prevenção & controleRESUMO
PURPOSE: This study was conducted to evaluate the incidence, identify the risk factors, and assess the prognosis of elderly institutionalized patients who develop fecal incontinence. PATIENTS AND METHODS: We enrolled 1,186 patients 60 years of age and older living in long-term care facilities who did not have fecal incontinence. We assessed their medical history, treatment, mobility, and cognitive function. Patients were followed up for 10 months to determine the incidence of fecal incontinence, defined as at least one involuntary loss of feces. Independent risk factors associated with fecal incontinence were identified using Cox proportional hazards models. The prognosis of incontinent patients was assessed by comparing their survival rate with that in the continent patients. RESULTS: Fecal incontinence occurred in 234 patients (20%), and was usually associated with acute diarrhea or fecal impaction. We identified five risk factors for the development of fecal incontinence: a history of urinary incontinence (rate ratio [RR]: 2.0, 95% confidence interval [CI] 1.5 to 2.6); neurological disease (RR: 1.9, 95% CI 1.0 to 3.4); poor mobility (RR: 1.7, 95% CI 1.2 to 2.4); severe cognitive decline (RR: 1.4, 95% CI 1.1 to 1.9); and age older than 70 years (RR: 1.7, 95% CI 1.0 to 2.8). Ten-month mortality in the 89 patients with long-term (> or = 8 days) incontinence was 26%, significantly greater than that observed in the continent group (6.7%) or in the 145 patients with transient incontinence (10%). CONCLUSIONS: Long-lasting or permanent fecal incontinence was associated with increased mortality, suggesting that this symptom is a marker of poor health in older patients. Actions that improve mobility might help prevent fecal incontinence in elderly patients.
Assuntos
Incontinência Fecal , Institucionalização , Idoso , Incontinência Fecal/diagnóstico , Incontinência Fecal/epidemiologia , Incontinência Fecal/etiologia , Feminino , França/epidemiologia , Instituição de Longa Permanência para Idosos , Humanos , Incidência , Masculino , Análise Multivariada , Casas de Saúde , Prognóstico , Fatores de RiscoRESUMO
BACKGROUND: Depression in older people is often unrecognised and untreated or under-treated. Antidepressant treatment may itself exacerbate a pre-existing illness, interact with concomitant medications or produce undesirable cognitive and sedative side effects. Newer antidepressants may offer advantages in terms of a lesser burden of adverse effects. METHODS: The comparative tolerability of the unique selective noradrenaline reuptake inhibitor (selective NRI) reboxetine (4-6 mg/day; n = 176) and that of imipramine (50-100 mg/day; n = 171) was assessed in an elderly ( > 65 years) cohort of depressed or dysthymic patients in an 8-week, double-blind, multicentre trial. Comparative efficacy was also assessed. RESULTS: Overall, 68% of patients in the reboxetine group experienced adverse events compared with 71% in the imipramine group. Reboxetine-treated patients were less likely to develop hypotension and related symptoms (7% vs. imipramine 16%) or cardiovascular disorders (12.5% vs. imipramine 21.1%), while those treated with imipramine were less likely to experience insomnia (6.3% vs. 2.9%). Adverse events were more often assessed as related to treatment (43%) and moderate to severe in intensity (73%) with imipramine than with reboxetine (33% and 65%, respectively). Furthermore, there were fewer serious adverse events in the reboxetine-treated group (P = 0.019). The reduction in the Hamilton Rating Scale for Depression (HAM-D) was comparable between the treatment groups in the total population. At the last assessment, the majority of patients in both treatment groups were assessed as normal to borderline or mildly ill using the Clinical Global Impression (CGI) scale. In a subanalysis of the dysthymic patients a modest but significant difference in favour of imipramine was observed for both HAM-D and CGI assessments. This may have been a reflection of a trend towards more severe depressive symptoms at baseline in the reboxetine group. CONCLUSIONS: Reboxetine is as effective as imipramine in the treatment of depression in elderly patients but is at least as well tolerated with a lower risk of hypotension and related symptoms, fewer serious adverse events, adverse event-related withdrawals and treatment-related adverse events.
Assuntos
Antidepressivos Tricíclicos/uso terapêutico , Antidepressivos/uso terapêutico , Transtorno Depressivo/tratamento farmacológico , Imipramina/uso terapêutico , Morfolinas/uso terapêutico , Idoso , Envelhecimento/psicologia , Antidepressivos/efeitos adversos , Antidepressivos/farmacologia , Antidepressivos Tricíclicos/efeitos adversos , Antidepressivos Tricíclicos/farmacologia , Método Duplo-Cego , Feminino , Psiquiatria Geriátrica , Humanos , Hipotensão/induzido quimicamente , Imipramina/efeitos adversos , Imipramina/farmacologia , Masculino , Morfolinas/efeitos adversos , Morfolinas/farmacologia , Reboxetina , Resultado do TratamentoRESUMO
BACKGROUND: Although nosocomial febrile illness (NFI) is common in hospitalized patients, it has been less extensively studied in the elderly. OBJECTIVE: To determine the frequency, causes, and risk factors of NFI in elderly inpatients. METHODS: This prospective study involved 608 patients (> or = 65 years of age) admitted in an acute geriatric unit. Investigators followed this cohort until 1 of the following events occurred: development of NFI, discharge from the geriatric unit, or death. The cause of NFI was classified into 3 groups: infectious, noninfectious, and no apparent diagnosis. We systematically studied 17 comorbid conditions, 6 drugs, and 7 invasive procedures. For comparison, the patients were stratified into 2 groups: patients with NFI and patients without NFI. RESULTS: Sixty-six patients (10.9%) with NFI were identified. They were compared with the remaining 542 patients without NFI. In 49 patients (74%) with NFI, the cause was infectious; in 9 (13.5%), it was noninfectious; and in 8 (12.5%), there was no apparent cause. After multivariate analysis, only fecal incontinence (odds ratio [OR], 5.54; 95% confidence interval [CI], 2.13-14.5), congestive heart failure (OR, 2.97; 95% CI, 1.53-5.76), and pressure ulcers (OR, 2.93; 95% CI, 1.19-7.17) were independent risk factors for NFI. The number of invasive procedures preceding the febrile episode was a significant predictor of infection (OR, 3.68; 95% CI, 1.14-9.21). CONCLUSIONS: Nosocomial febrile illness is a common event in elderly hospitalized patients. In 74% of the patients with NFI, an infection is found. Measures to decrease infectious NFI in the elderly require a reduction in the number of invasive procedures.
Assuntos
Infecção Hospitalar/complicações , Febre/etiologia , Hospitalização , Idoso , Feminino , Febre/epidemiologia , Febre/microbiologia , França/epidemiologia , Humanos , Incidência , Masculino , Estudos Prospectivos , Fatores de RiscoRESUMO
Pulmonary artery thrombosis caused by giant cell arteritis is an extremely rare condition. We report the case of an 86-year-old woman, who was hospitalized for dyspnea. Pulmonary artery thrombosis was confirmed by pulmonary angiogram and was linked to giant cell arteritis. This observation is accompanied by a discussion of the literature.