RESUMO
Dr Marjory Warren was a remarkable, formidable physician who reversed the neglect of chronic sick patients and brought their treatment into the modern era. She advocated the creation of the specialty of geriatric medicine with units based in district general hospitals, and that medical students and nurses should be taught about the diseases of old age. She treated the whole patient, applied advances in medicine and therapeutics, devised new techniques and equipment to assist disabled elderly stroke and amputee patients, and made great improvements in the ward environment. She emphasized the importance of the patient's social background, and electrified both staff and patients with her drive and enthusiasm. Many patients were treated successfully and discharged. Bed requirements were reduced and vacated wards allocated for other uses. She wrote extensively and lectured across the world to national and international approbation.
Assuntos
Geriatria/história , Serviços de Saúde para Idosos/história , Idoso , Idoso de 80 Anos ou mais , História do Século XX , Humanos , Reino UnidoRESUMO
Professor Norman Exton-Smith was a highly respected, distinguished postwar consultant geriatrician with a worldwide reputation. He devoted his life to improving the medical care of elderly people and researching age-related decline in physical function, particularly thermoregulation and postural balance. He established thriving clinical and research departments at St Pancras Hospital, London. Many of his junior medical staff became well-known geriatricians. He published and lectured extensively, organized many meetings and conferences, and was advisor to the Department of Health and Social Security for many years. He was a valued authority on geriatric medicine within the Royal College of Physicians of London and a major influence in the British Geriatrics Society (BGS) of which he was Secretary and later the President.
Assuntos
Geriatria/história , Regulação da Temperatura Corporal , História do Século XX , Humanos , Equilíbrio PosturalRESUMO
Lord Amulree was unique amongst UK geriatricians in having a 'wide angled' view of the care of elderly people. This resulted from his work at the Ministry of Health, his clinical commitments and his position in the House of Lords, which enabled him to bring the problems of old age, elderly people and infirmity before a much wider audience. It can be argued that his joint Parliamentary Presentation in 1946 stimulated a surge in publications relating to the care of older people. He will be remembered for his maxim 'Adding Life to Years'
Assuntos
Inglaterra , Geriatria/história , História do Século XXRESUMO
Sales of over-the-counter (OTC) medicines are rising, and will continue to rise as more products are reclassified from prescription-only status to OTC medicines (either pharmacy-only or general sales list). Patients and doctors often omit discussion of OTC medicines when giving or taking a medication history. This has serious potential for identifying adverse drug reactions and drug-drug interactions, which are more common in older people. Therefore, medication histories should include documentation of any OTC medicines taken.
Assuntos
Geriatria , Medicamentos sem Prescrição/efeitos adversos , Idoso , Humanos , Pessoa de Meia-Idade , Medicamentos sem Prescrição/administração & dosagem , Relações Médico-Paciente , Reino UnidoRESUMO
Recent experimental observations have disclosed the existence of a septal-hippocampal feedback circuit, composed of medial septum diagonal band of Broca (ms-dbB) GABAergic projections to the inhibitory interneurons of the hippocampus, and hippocampal GABAergic projections to the ms-dbB, the major targets of which are the GABAergic septo-hippocampal projection cells. We propose that this feedback circuit provides the mechanism for the rhythmic suppression of interneuronal activity in the hippocampus, which is observed as low-level GABAergic-mediated theta activity. We also propose that this circuit may be the mechanism by which ascending brain stem pathways to the ms-dbB, in particular from the reticular formation, can influence hippocampal information processing in response to particular behavioral states, by exercising control over the level and frequency of theta activity in the hippocampus. In support of these proposals, we describe a minimal computational model of the feedback circuit which uses a set of four coupled differential equations describing the average dynamic activity of the populations of excitatory and inhibitory cells involved in the circuit. We demonstrate through simulations the inherently robust 4-6-Hz oscillatory dynamics of the circuit, and show that manipulation of internal connection strengths and external modulatory influences on this circuit changes the dynamics in a way which closely mimics corresponding manipulations in recent neurophysiological experiments investigating theta activity.
Assuntos
Tronco Encefálico/citologia , Hipocampo/citologia , Modelos Neurológicos , Septo do Cérebro/citologia , Ritmo Teta , Animais , Tronco Encefálico/fisiologia , Simulação por Computador , Retroalimentação/fisiologia , Hipocampo/fisiologia , Inibição Neural/fisiologia , Vias Neurais , Periodicidade , Septo do Cérebro/fisiologiaRESUMO
Older people in the UK receive a disproportionate amount of medication. They comprise 18% of the population but receive 45% of all prescription items. Not surprisingly they experience drug-related illnesses - in 1980, 1 in 10 admissions to acute geriatric units were wholly or partly due to adverse drug reactions. Drugs which should be used with particular care or even avoided in older people include benzodiazepines, warfarin, digoxin, aminoglycosides, tricylic antidepressants, antipsychotics and long-acting oral hypoglycaemic agents. Pharmacists can promote safer prescribing practices by advising both patients and doctors. The community pharmacist can assist in drug compliance by providing patients with additional information about individual drugs, identifying potential adverse drug reactions and interactions, supplying appropriate drug containers or compliance aids, and even arranging home visits for patients unable to visit the pharmacist. Some community pharmacists provide pharmaceutical advice and services to residential and nursing homes. Pharmacists' advice to doctors can include one to one discussions in either primary or secondary care, assisting in medication review, providing information to prescribing committees, compiling drug formularies, assisting in auditing of prescribing practices and organising disposal of unwanted medicines and poisons campaigns.
Assuntos
Idoso , Tratamento Farmacológico , Farmacêuticos , HumanosRESUMO
The elderly have benefitted considerably from the vast increase in the range of drugs available for prescription. However it is now well recognized that the incidence in adverse drug reactions increases with age. This is mainly due to altered pharmacodynamics and pharmacokinetics as well as multiple prescribing and the effect of illness rather than the effect of age per se. Since adverse drug reactions are such a potent cause of illness, it is sensible for doctors to follow simple rules when prescribing for the elderly.
Assuntos
Idoso , Efeitos Colaterais e Reações Adversas Relacionados a Medicamentos , Humanos , Fatores de RiscoRESUMO
1. We have studied determinants of outcome of 7 day courses of treatment in 77 middle aged and elderly patients, in whom the general practitioner's diagnosis of urinary tract infections had been confirmed microbiologically. Bacteria were sensitive to cephalexin or trimethoprim. Where there was no preference, treatments were allocated randomly. Compliance was monitored using a pill box with a concealed electronic device which recorded openings of the box. 2. Prescribing trimethoprim, 200 mg twice daily, was more effective than cephalexin, 250 mg four times daily (cure rates 93 and 67%) (P less than 0.006). Those cured and not cured were not distinguished by age, gender, genitourinary history, or infecting organism. 3. Compliance as measured by box openings was worse for cephalexin than for trimethopim (P = 0.01). However, both totality and pattern of compliance were similar in patients cured and not cured by cephalexin. Thus rigid adherence to a conventional course did not promote cure: fewer doses could have been prescribed. 4. Estimating compliance is essential to clinical trials where medication is self-administered. Poor compliance may establish over exacting regimens. Counting box openings did overestimate compliance, but counting residual tablets overestimated it grossly: given the number of openings less than the ideal, there should have been 171 residual tablets, only 55 were found.
Assuntos
Infecções Urinárias/tratamento farmacológico , Idoso , Cefalexina/administração & dosagem , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Cooperação do Paciente , Fatores de Tempo , Trimetoprima/administração & dosagemRESUMO
It has previously been shown that the incidence of pressure sores is related inversely to the amount of movement made during the night. The present study of 30 in-patients of geriatric units suggests that the measurement of mean lateral displacement of the centre of gravity may better characterize those at risk than the total amount of movement. The mean displacement was reduced in Parkinson's disease and in dementia. The prevalence of pressure sores was markedly increased where Parkinson's disease and dementia coexisted.
Assuntos
Demência/complicações , Movimento , Doença de Parkinson/complicações , Úlcera por Pressão/etiologia , Idoso , Idoso de 80 Anos ou mais , Humanos , Hipnóticos e Sedativos/farmacologia , Movimento/efeitos dos fármacos , SonoRESUMO
We have introduced enalapril, in doses equal to or less than the 2.5 mg currently recommended, as an adjuvant to digoxin and diuretics in 17 patients of mean (SD) age 83 (5) years with severe heart failure. Only eleven patients tolerated its introduction. Unlike those reported in younger patients, all but one of the adverse drug reactions occurred 8 h or more after the first dose. Aged patients started on ACE inhibitors should be observed in hospital until stabilized on a maintenance dose. Three patients had an adverse reaction which differed in nature from those previously reported: acute confusional state, ataxia and mesenteric ischaemia. Ten patients were discharged on 5 mg or 10 mg maintenance doses of enalapril. In nine of them improvement on triple therapy was sustained for a minimum of three months. ACE inhibition was lost in the other patient when her compliance with enalapril therapy fell to around 75%: monitoring compliance is essential when ACE inhibitors are used in low dosages. Enalapril was withdrawn during follow up in three patients because of symptoms of mesenteric ischaemia and in four because of dramatic deterioration of renal function. One of the latter was found subsequently to have severe bilateral atheromatous renal artery stenosis. When isosorbide dinitrate was substituted for enalapril, symptoms of mesenteric ischaemia resolved and renal function returned to baseline. Continuing surveillance for adverse effects is essential in patients of this age group with severe heart failure, and the risk of occult renal artery stenosis requires regular biochemical screening during follow up.(ABSTRACT TRUNCATED AT 250 WORDS)
Assuntos
Baixo Débito Cardíaco/tratamento farmacológico , Enalapril/uso terapêutico , Idoso , Idoso de 80 Anos ou mais , Digoxina/uso terapêutico , Quimioterapia Combinada , Eletrocardiografia , Enalapril/efeitos adversos , Teste de Esforço , Feminino , Furosemida/uso terapêutico , Humanos , Masculino , Cooperação do Paciente , Peptidil Dipeptidase A/sangue , Fatores de TempoRESUMO
1. Insomnia is an even more frequent complaint in elderly patients with Parkinson's disease than might be expected from the effect of age alone on sleep. 2. A double-blind, placebo-controlled trial in eleven patients with Parkinson's disease of mean (s.d.) age 80(5) years, showed that nocturnal dosing with levodopa produced a clinically significant improvement in sleep both as assessed subjectively and by measurement of number of spontaneous moves in bed. 3. Despite the long interval between tablet administration and morning assessment, walking time was faster on mornings following active treatment.
Assuntos
Levodopa/uso terapêutico , Doença de Parkinson/tratamento farmacológico , Carbidopa/uso terapêutico , Ensaios Clínicos como Assunto , Método Duplo-Cego , Combinação de Medicamentos , Humanos , Levodopa/administração & dosagem , Doença de Parkinson/fisiopatologia , Distribuição Aleatória , Sono/efeitos dos fármacosRESUMO
A double-blind, placebo-controlled, cross-over trial of quinine in leg cramps occurring at rest was conducted in 22 elderly cramp sufferers. Despite demonstration of impaired quinine elimination in the elderly, prescription of the traditional dose of 300 mg quinine bisulphate at night failed to produce a significant (P = 0.1) reduction in the number or severity of cramps. There was a significant relationship between serum quinine concentration and attenuation of cramps. However, the simple expedient of increasing the nightly dose of quinine may carry the concomitant risk of cinchonism.
Assuntos
Perna (Membro) , Cãibra Muscular/prevenção & controle , Quinina/uso terapêutico , Idoso , Ensaios Clínicos como Assunto , Método Duplo-Cego , Feminino , Humanos , Masculino , Quinina/sangue , Distribuição AleatóriaRESUMO
Some physicians regard patients of Geriatric Units as a homogeneous population with respect to digoxin dosage requirements. Others advocate the use of pharmacokinetic models in prescribing digoxin for the elderly. Sixty in-patients of Geriatric Units were studied and the results compared with those previously obtained from 129 patients of other adult Units; all were receiving maintenance digoxin. For each patient the dose required to achieve a mean steady-state serum digoxin concentration of 1.6 nmol X l-1, the standardized dose, was calculated, assuming proportionality between the dose given and the concentration achieved. A mean of four estimates of standardized dose for each individual was used in the analysis. Threefold ranges of standardized dose covered the requirements of approximately 85% of patients both of Geriatric Units (62.5 to 187.5 micrograms per day) and of other adult Units (125 to 375 micrograms per day). The variables, serum creatinine concentration, sex, age, and body weight were of relatively little value in predicting the standardized dose for the patients in Geriatric Units. There was a sub-group of these in-patients for whom the standardized dose was extremely large.
Assuntos
Digoxina/administração & dosagem , Adulto , Fatores Etários , Idoso , Creatinina/farmacocinética , Digoxina/farmacocinética , Feminino , Humanos , Masculino , Taxa de Depuração Metabólica , Pessoa de Meia-IdadeRESUMO
We report our efforts to make a rehabilitation hospital work. The simple intervention of introducing a patient record system, in which problems, management, achievements and discharge plans were clearly documented, doubled the number of patients who returned home over an eight-month period. This resulted in greater availability of acute geriatric beds at the District General Hospital (DGH), where two thirds of the elderly medical inpatients occupy beds on other units, and in an improvement in morale of patients and staff. Greater co-operation between geriatric and medical teams in selecting those patients who would benefit from continuing rehabilitation is required. The advantages of accommodating such patients separately from patients with a poor prognosis and those requiring long-term care are discussed.
Assuntos
Serviços de Saúde para Idosos/organização & administração , Registros Médicos Orientados a Problemas , Prontuários Médicos , Centros de Reabilitação/organização & administração , Idoso , Inglaterra , HumanosRESUMO
A major role of therapeutic drug monitoring services is to advise on the dose of a drug which would be required to bring the concentration in the blood to within specific 'therapeutic' limits. Monitoring digoxin usage constitutes a substantial part of the work load. We have examined the potential variability in recommendations for digoxin dosages based on a series of serum digoxin measurements in each of 80 out-patients. In over a third of cases a dose, which seemed to be optimal on the basis of the first assay result, would have produced concentrations outside the conventional therapeutic range when the measurement was repeated. This was despite careful supervision of medication and the timing of the blood sample in relation to its administration. In routine practice the apparent variability in dose requirements would be far greater. Objectives of therapeutic drug monitoring services remain the same, the way forward would seem to lie in their taking on a heavy commitment to counsel and supervise patients before repeated blood sampling. However, effort and resources might be better channelled into producing simple prescribing aids relating the risk of cardiotoxicity directly to the size of the maintenance dose and the individual's renal function.