Computed tomography, electroencephalography, and clinical features in the differential diagnosis of senile dementia. A prospective clinicopathologic study.

The accuracy of computed tomography, electroencephalography, and clinical features in the differential diagnosis of senile dementia was studied prospectively. Out of 50 demented patients, autopsy revealed 32 cases with either senile dementia of the Alzheimer's type (SDAT), multi-infarct dementia (MID), or a combination of both. Eighteen patients had dementia caused by other diseases. Based on a combination of computed tomography, electroencephalography, and clinical features, senile dementia of the Alzheimer's type was differentiated from all 50 patients, with a specificity of 83% and a sensitivity of 80%. Focusing on senile dementia of the Alzheimer's type, multi-infarct dementia, or a combination of both, specificity decreased to 65% and sensitivity to 47%. Comparing the different methods, multi-infarct processes were diagnosed with a higher sensitivity by the clinical features (73%) than by computed tomography (18%) or electroencephalography (18%). None of the methods validly differentiated multi-infarct dementia from a combination of multi-infarct dementia and senile dementia of the Alzheimer's type.

Seventy-two hour polygraphic and behavioral recordings of wakefulness and sleep in a hospital geriatric unit: comparison between demented and nondemented patients.

Continuous 72-h polygraphic recordings were carried out in 30 hospitalized, mostly severely demented patients and 14 nondemented control patients. Mean age was greater than 80 years in both groups. In the dementia group, the diagnoses were senile dementia Alzheimer type (n = 16), multi-infarct dementia (n = 8), and mixed or undefined dementia (MIX) (n = 6). The nondemented controls suffered from various medical or psychiatric disorders or were recovering from previous accidents. Dementia patients had less stage 2 and REM sleep and thus less total sleep time than did control subjects. No statistically significant differences were noted between dementia subgroups. There were no differences between controls and demented patients in terms of NREM-REM cycle, and there was no association between the severity of the clinical condition and any of the sleep parameters in the demented patients. In contrast to healthy elderly and old persons, women and men patients with dementia showed no differences in their sleep patterns. In both patient groups, most sleep occurred at night, and wakefulness was predominant during the day. Only three of the dementia patients displayed somewhat more daytime than nighttime sleep. The main conclusions were that polygraphic sleep recordings did not contribute to a better differential diagnosis in patients with advanced dementia and that inversion of the sleep/wakefulness rhythm was uncommon in these separately roomed demented patients.

Skin oxygen tension as a function of imposed skin pressure: implication for decubitus ulcer formation.

Pressure is a crucial factor in the formation of decubitus ulcers. To elucidate the effect of imposed skin pressure, a new cutaneous oxygen sensor was used to measure the skin oxygen tension under increasing pressure upon skin tissue at "hard sites" (bony prominences) and at "soft sites" (muscle-padded areas). At hard sites the skin oxygen tension fell rapidly under increasing pressure (y = 90.9--0.39. X; r = 0.98) from an initial value of 86.4 +/- 10.6 to 20.2 +/- 12.1 mm Hg under an imposed skin pressure load of 175 gm/cm 2. At soft sites a pressure load of 175 gm/cm 2 decreased the skin oxygen tension only from 82.9 +/- 5.8 to 71.4 +/- 10.0 mm Hg. These results may explain why hard sites (bony prominences) are preferential areas for decubitus ulcer formation.

Decubitus ulcer prevention: a new investigative method using transcutaneous oxygen tension measurement.

Sacral skin oxygen tension, measured by a noninvasive technique in ten healthy subjects, remained in the normal range when they were lying on a "super-soft" mattress or in the 30 degrees lateral position. Therefore, these methods are effective in decubitus ulcer prevention. Skin oxygen tension measurement allows immediate assessment of the efficacy of measures to prevent decubitus ulcers.

Impaired migration of epidermal cells from decubitus ulcers in cell cultures. A cause of protracted wound healing?

Cultured epidermal cells of explants from decubitus ulcer edges showed significant (P less than 0.05) decreased maximal growth rate (range, 1.3-15.6%) and decreased area of outgrowth per explant (mean and SD, 1.6 +/- 1.7 mm2) when compared with explants obtained 4-5 cm distant from the ulcer edge (range, 46.7-68.8% and 4.6 +/- 2.7 mm2, respectively) and from healthy skin (range, 78.8-93.3% and 6.6 +/- 1.2 mm2, respectively). In contrast, epidermal cells in biopsies from the ulcer edge were significantly (P less than 0.05) more prevalent (range, 1.9-48.2%) as compared with biopsies of healthy skin (range, 3.1-5.1%). Therefore, the decreased growth rate and decreased area of outgrowth may be caused by a defective migration potential rather than an impaired mitotic activity. The latter seems to be normal, as demonstrated by the histomorphometry, which indicates the in vivo situation. Decreased migration potential of epidermal cells could explain the clinically observed protracted epithelialization of decubitus ulcers.

Clinical pictures of malnutrition in ill elderly subjects.

Malnutrition in ill elderly subjects is common in hospitals, nursing homes, and home care. Depending on the type and composition of the groups of patients under consideration, the prevalence of malnutrition is cited at up to 60%. With advancing age, the amounts of food consumed daily diminish and become significantly smaller than the amounts consumed by the younger population. The elderly mostly eat food of low nutrient density. Especially at times of high energy requirements such as acute or chronic illness, this results in an energy deficit and general malnutrition. Precise diagnosis of malnutrition can be facilitated by determination of a number of biochemical parameters. Knowledge of these permits individualized nutrition therapy. The most important deficits affecting ill elderly subjects are those relating to proteins, iron, zinc, selenium, and vitamins B12, B1, B6 and D. Malnutrition prolongs hospital stays, imposes enormous costs on health services, and causes considerable mortality. The present, very rapid increase in the size of the elderly population will exacerbate the problem of malnutrition. Therefore more attention should be paid to malnutrition by treating it as a disease in its own right and including it in the training of doctors and nurses.

Decubitus ulcers: preventive techniques for the elderly patient.

The at-risk older patient must immediately be placed on a supersoft support, with heels protected with sheepskin boots. If reddened skin is found the next morning, the patient must be turned to a 30 degrees-oblique position on alternate sides every 2 hours. Any condition that greatly decreases frequency of involuntary movement or lowers critical arteriolar closing pressure is a risk factor. Without intervention, the probability that immobile patients will develop decubitus ulcers is 100%.

Decubitus ulcers: treatment through five therapeutic principles.

Without relief of localized pressure, no healing is possible, and all other therapeutic measures are futile. If other factors are mistakenly blamed (incontinence, perspiration, malnutrition) attention may be diverted from the essential--relief of localized pressure and maintenance of patient mobility. Dressings should protect healing ulcers from mechanical damage and external bacterial recontamination after removal of pathogens by local disinfection. Dressings should be kept moist with Ringer's solution to create conditions that promote new granulation.

Practical management of catheter-associated UTIs.

In the long-term catheterized elderly, damage to the epithelial wall is primarily responsible for bladder infections, due to the presence of the catheter as a foreign body and its frequent manipulations. The presence of bacteriuria, a classic sign of infection in the non-catheterized patient, is of little diagnostic importance in the long-term catheterized patient, since it is both permanent and inevitable. Routine preventive measures--eg, frequent catheter changes, prophylactic antibiotics--are of no value. Other measures are worth considering and, if instituted, will reduce the frequency of severe complications from long-term catheterization and improve quality of life.

Recent findings on decubitus ulcer pathology: implications for care.

Vasodilators are ineffective therapy for decubitus ulcers because blood vessels are absent in the necrotic areas. Systemic application of vasodilating drugs actually decreases the nutritional blood flow through the damaged zone. Protracted healing of decubitus ulcers may be explained by an altered nutrient transport rate to the cells caused by fibrin thrombi in the capillaries and fibrin deposits in the intercellular space, resulting from decreased fibrinolytic activity.

Beta-carotene in tube feeding.

The supplementation of an enteral feeding formula on soya-basis specially designed for geriatric patients with 1,5 mg to 2 mg beta-carotene per day increases its corresponding plasmatic concentration from 20 mcg/L to normal to optimal levels near 500 mcg/L. This intake is much lower than the proposed safe intake of 6-20 mg beta-carotene per day. A close incorporation of beta-carotene in the lipid moiety of the ready-to-use formula might increase its bioavailability. The other anti-oxidative vitamins A and E remain to their respective normal levels at a supplemental daily intake of 2500 IU vitamin A and 12,5 mg vitamin E. The new enteral feeding formula for geriatric patients seems to cover their global nutritional needs.

[Bladder infection due to long-term indwelling catheters]. / Harnblasenentzündung bei Langzeitkatheterträgern.

In the long-term catheterized elderly, damage do the epithelial wall is primarily responsible for bladder infections, due to the presence of the catheter as a foreign body and its frequent manipulations. The presence of bacteriuria, a classic sign of infection in the non-catheterized patient, is of little diagnostic importance in the long-term catheterized patient, since it is both permanent and inevitable. Routine preventive measures, as frequent catheter changes or prophylactic antibiotics, are of no value. Other measures are worth considering, since they will, if instituted, reduce the frequency of severe complications from long-term catheterization and improve quality of life.

[Decubitus ulcers in geriatrics--pathogenesis, prevention and therapy]. / Dekubitalulzera in der Geriatrie--Pathogenese, Prophylaxe und Therapie.

Magnitude and duration of interface pressure are the crucial etiological factors in the decubitus ulcer formation. Small amounts of interface pressure that exceed the average capillary pressure (range: 2.7 to 6.3 kPa) may lead to compression of the skin microcirculation and resultant tissue necrosis when a critical duration of interface pressure of more than 2 h is reached. The principles of decubitus ulcer prevention are derived from the pathophysiology of ulcer formation as noted: reduction of interface pressure below 3 kPa by bedding each at-risk patient on a 'super-soft' mattress and shortening the duration of interface pressure below 2 h. by turning of patients from the supine position to the right and left 30 degrees oblique back position every two hours. Decubitus ulcers typically show impaired wound healing. Conditions most conspicuously protracting normal wound healing are: tissue hypoxia, fibrin deposits, necrotic tissue, local infection, defective migration of keratinocytes, impaired general condition, etc. Based on these pathophysiological mechanisms, five therapeutical principles are proposed: complete relief of interface pressure, débridement of necrotic tissue, treatment of infection using systemical antibiotics, wet and air-permeable wound dressing, improvement of patient's general condition.

[Wound healing: from polypragmasy to rational therapy concepts--can growth factors contribute anything?]. / Wundheilung: Von der Polypragmasie zu rationalen Therapiekonzepten--Können Wachstumsfaktoren mehr?

Impaired wound healing as seen in diabetic, arterial, venous and decubital ulcers is still an unsolved problem. The lack of precise knowledges of wound pathophysiology renders efficient therapeutic approaches difficult. Many local and systemic factors are delaying wound repair, e.g., tissue ischemia, intra- and extravascular fibrin depositions, vasodilatation of the non-nutritive microcirculation, necrosis, infection, impaired migration of the epithelial cells of the ulcer edge and an inadequate cytokines pattern. With regard to these factors general therapeutic measures are proposed. We believe that in the near future cytokines may substantially improve our actual treatment methods of chronic ulcers.