Prospective study of progression of kidney dysfunction in community-dwelling older adults.

AIM: Few prospective studies have assessed renal dysfunction in older persons. We sought to define kidney dysfunction among a community-based cohort of elderly subjects and to determine the factors for its progression. METHODS: The Epidemiologia do Idoso (EPIDOSO) Study is a prospective study of individuals > or =65 years old (mean 72.6 +/- 0.3), living in the community in the city of São Paulo. The creatinine clearance (CrCl) of 269 individuals of this cohort was estimated during 8 years of follow-up. The rate of decline in CrCl was calculated using linear regression analysis and dividing the group into tertiles of CrCl change. RESULTS: Overall mean change in CrCl was -2.37 +/- 0.23 mL/min per year. Mean age increased with the greatest degree of decline in renal function (71.1 +/- 0.59, 72.5 +/- 0.54 and 74.3 +/- 0.58, for the first, second and third CrCl change tertiles, respectively, P < 0.01). A higher value of baseline CrCl was associated with progressive decline in CrCl (P < 0.01). Diastolic BP was greater in the second versus the first estimated glomerular filtration rate tertile (83 +/- 1 vs 80 +/- 1 mmHg, P < 0.05). High-density lipoprotein (HDL) cholesterol was inversely associated with CrCl decline (P < 0.05). CONCLUSION: Progression of kidney dysfunction occurs in most community-dwelling elderly. Strategies aimed at slowing the progression should be considered for possible risk factors of older age, baseline CrCl, BP and HDL.

Development of geriatrics-oriented faculty in general internal medicine.

The need for adequate geriatrics training for the physician workforce has been recognized for decades. However, there are not enough academic geriatricians to provide for the educational needs of trainees, and this situation is not expected to change in the future. General internists are often responsible for teaching medical students and internal medicine residents to care for elderly patients in inpatient and ambulatory settings. These academic general internists could play a pivotal role in providing geriatrics instruction. To characterize what is being done to develop geriatrics-oriented general internal medicine faculty, we identified current practices, "best practices," goals and targets, and barriers to achieving those goals and targets. We reviewed the literature on faculty-development programs for general internal medicine faculty, and we held focus groups and structured interviews with general internal medicine unit chiefs and directors of Geriatric Centers of Excellence at 46 medical schools throughout the United States. We found a need for programs to develop geriatrics-oriented academic general internists. Although general internal medicine faculties seem receptive to further geriatrics training, important obstacles exist. These include inadequate time and resources as well as motivational and attitudinal challenges. We discuss potential solutions for overcoming these barriers and the implications of these solutions for stakeholders.

Prognosis of ARF in hospitalized elderly patients.

BACKGROUND: Differentiation between hospital-acquired acute renal failure (ARF) and community-acquired ARF may have epidemiological implications that lead to different prognoses in hospitalized patients. Such a comparison has not yet been made among elderly individuals. METHODS: We performed a 3-year prospective study in a tertiary referral hospital of 325 patients aged 60 years or older who presented with ARF. Patients were divided into 2 groups; those with hospital-acquired ARF (n = 154) and community-acquired ARF (n = 171), and were followed up in relation to mortality. Multiple logistic regression was used in the analysis. RESULTS: The overall mortality rate in this elderly population was 54%; 59% for the group with hospital-acquired ARF and 41% for the group with community-acquired ARF (P < 0.001). Groups differed (P < 0.01) in relation to cause of ARF, preexisting diseases, organ failure, sepsis, and performance of dialysis, among other factors. The adjusted mortality risk for the group with hospital-acquired ARF was 2.23 times greater than for the group with community-acquired ARF (95% confidence interval [CI], 1.21 to 4.08). In the group with hospital-acquired ARF, factors associated with mortality were neurological failure (odds ratio [OR], 2.97; 95% CI, 1.17 to 7.60), hematologic failure (OR, 4.30; 95% CI, 1.63 to 11.34), and oliguria (OR, 12.14; 95% CI, 4.62 to 31.87). In the group with community-acquired ARF, significant factors were neoplasia, cardiac disease, hepatic disease, cardiovascular failure, oliguria, and sepsis. CONCLUSION: Differentiation between hospital-acquired ARF and community-acquired ARF is important in determining the prognosis of ARF in the elderly. Mortality risk factors are different in these 2 groups, and knowledge of their characteristics may allow better management of such patients.

Dementia: when is it not Alzheimer disease?

The advent of symptomatic therapies for Alzheimer disease has placed increasing emphasis on early diagnosis of the dementia syndrome and its various types. This article reviews the definition and epidemiology of the condition that affects up to 50% of all Americans over the age of 80. Also discussed are the main causes of dementia, focusing on those that are not Alzheimer disease and a diagnostic approach that is based on guidelines recently published by the American Academy of Neurology.