Role of early symptoms in assessment of syncope in elderly people: results from the Italian group for the study of syncope in the elderly.

OBJECTIVES: To assess the ability of specific early symptoms to predict cardiac and noncardiac syncope in elderly people. DESIGN: Multicenter cross-sectional observational study. SETTING: Inpatient geriatric acute care departments and outpatient clinics. PARTICIPANTS: Two hundred forty-two patients with syncope (mean age 79+/-8) consecutively referred for evaluation of transient loss of consciousness to any of six clinical centers participating in the Italian Group for the Study of Syncope in the Elderly (GIS Study). MEASUREMENTS: All patients were assessed according to European Society of Cardiology Syncope guidelines and interviewed about symptoms and signs present before syncope. RESULTS: One hundred seventy-four of 242 patients (75.4%) had noncardiac syncope, and 34 (14.7%) had cardiac syncope; 165 patients (71.1%) related symptoms before the loss of consciousness. When elderly patients with syncope were stratified for the presence and absence of symptoms, noncardiac syncope showed the highest prevalence of symptoms (75.3%, P<.01). Awareness of being about to faint, sweating, blurred vision, and nausea are more prevalent in noncardiac syncope. Dyspnea is more prevalent in cardiac syncope. All symptoms except awareness of being about to faint and weakness had good specificity, but sensitivity was low for all symptoms considered. Multivariate regression analysis adjusted for sex and age indicated that nausea (relative risk (RR)=3.7, 95% confidence interval (CI)=1.26-11.2), blurred vision (RR=3.5, 95% CI=1.34-9.59), and sweating (RR=2.8, 95% CI=.21-6.89) were predictive of noncardiac syncope. Dyspnea (RR=5.5, 95% CI=1.0-30.2) was the only symptom predictive of cardiac syncope. CONCLUSION: The data show that symptoms such as nausea, blurred vision, and sweating are predictive of noncardiac syncope, whereas only dyspnea is predictive of cardiac syncope in elderly people.

From Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines to current clinical practice : an overview of the pharmacological therapy of stable chronic obstructive pulmonary disorder.

BACKGROUND: The Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines have been promulgated to improve the management of chronic obstructive pulmonary disorder (COPD). OBJECTIVE: To evaluate the extent to which the current therapeutic approach to COPD conforms to GOLD guidelines. METHODS: This was a multicentre observational study of elderly COPD patients enrolled for acute care in general medicine or geriatric wards in tertiary hospitals in Italy in April 2002. Our series consisted of 471 patients >64 years of age consecutively admitted for acute exacerbations of COPD to wards participating in the study. Data describing drugs used prior to exacerbation and prescribed at discharge were collected using a standardised protocol. Changes in prescription at discharge were then compared with home therapy. Demographic variables and indices of COPD severity and co-morbidity were tested as potential correlates for the main outcome measure 'variant prescription', i.e. prescription of a drug considered as a third-line treatment (e.g. methylxanthines) or not recommended (e.g. mucolytics) by GOLD guidelines. The correlation was assessed first by univariate analysis and then by logistic regression analysis. RESULTS: At discharge, prescription of short-acting beta(2)-adrenoceptor agonists had decreased from 26.3% to 14.0%. Conversely, increases in prescription of long-actingbeta(2)-adrenoceptor agonists (from 43.1% to 68.4%), inhaled corticosteroids (50.7% to 69.6%) and anticholinergics (17.2% to 22.3%) were seen. The rate of use of methylxanthines was 49.7% before admission and 44.8% at discharge, with previous use being the main correlate of discharge prescription for this class of drugs (odds ratio [OR] = 4.35; 95% CI 2.88, 6.54). The rate of use of mucolytics was 26.3% before admission and 26.8% at discharge, with use of mucolytics prior to admission being the only correlate of discharge prescription (OR = 4.10; 95% CI 2.47, 6.82). CONCLUSIONS: Hospitalisation resulted in increased adherence to GOLD guidelines in patients with COPD, but the rate of use of anticholinergics was distinctly low and that of methylxanthines and mucolytics surprisingly high. A carry-over effect (i.e. of therapy prescribed by general practitioners on that prescribed by hospital-based physicians) likely accounts for most of the 'variant prescriptions' seen at discharge from the acute care hospital.

Improved exercise tolerance and quality of life with cardiac rehabilitation of older patients after myocardial infarction: results of a randomized, controlled trial.

BACKGROUND: Whether cardiac rehabilitation (CR) is effective in patients older than 75 years, who have been excluded from most trials, remains unclear. We enrolled patients 46 to 86 years old in a randomized trial and assessed the effects of 2 months of post-myocardial infarction (MI) CR on total work capacity (TWC, in kilograms per meter) and health-related quality of life (HRQL). METHODS AND RESULTS: Of 773 screened patients, 270 without cardiac failure, dementia, disability, or contraindications to exercise were randomized to outpatient, hospital-based CR (Hosp-CR), home-based CR (Home-CR), or no CR within 3 predefined age groups (middle-aged, 45 to 65 years; old, 66 to 75 years; and very old, >75 years) of 90 patients each. TWC and HRQL were determined with cycle ergometry and Sickness Impact Profile at baseline, after CR, and 6 and 12 months later. Within each age group, TWC improved with Hosp-CR and Home-CR and was unchanged with no CR. The improvement was similar in middle-aged and old persons but smaller, although still significant, in very old patients. TWC reverted toward baseline by 12 months with Hosp-CR but not with Home-CR. HRQL improved in middle-aged and old CR and control patients but only with CR in very old patients. Complications were similar across treatment and age groups. Costs were lower for Home-CR than for Hosp-CR. CONCLUSIONS: Post-MI Hosp-CR and Home-CR are similarly effective in the short term and improve TWC and HRQL in each age group. However, with lower costs and more prolonged positive effects, Home-CR may be the treatment of choice in low-risk older patients.