Tube feedings in elderly patients. Indications, benefits, and complications.

During an 11-month period, 70 tube-fed patients aged 65 to 95 years were studied prospectively to determine the indications, benefits, and complications of enteral alimentation. Indications for alimentation were refusal to swallow (35 patients [50%], dysphagia without obstruction (33 [47%]), and esophageal obstruction (two [3%]). Nasogastric tubes (NGTs) were used initially in 69 patients; 15 of these subsequently required a gastrostomy tube (GT). One patient was treated initially with a gastrostomy. Indicators of nutritional status included weight, hemoglobin level, hematocrit, and serum albumin level. During the first two weeks the most common problems in the NGT group were agitation and self-extubation (36 patients [67%]) and aspiration pneumonia (23 [43%]). In GT patients the most common early problems were aspiration pneumonia (nine patients [56%]), tube dysfunction (eight [50%]), and agitation and extubation (seven [44%]). The common late problems were aspiration pneumonia (24 patients [44%] in the NGT group and nine [56%] in the GT group), and feeding tube dysfunction in six (38%) of the GT group. Self-extubation as a late problem was limited to the NGT group (21 patients [39%]). Twenty-eight (40%) of the 70 patients died during the study period.

Autopsy proven pulmonary embolism among the institutionalized elderly.

The presentation of pulmonary embolism is variable in the elderly as in any age group. Common symptoms such as chest pain, dyspnea, and hemoptysis may be absent. Furthermore, precursors such as phlebitis, malignancy, and recent surgery often may be absent as well. Our intent was to examine the occurrence in a long-term care institution of pulmonary embolism at autopsy and the extent of missed antemortem diagnosis of this condition, and to compare patients with and without pulmonary embolism by chart and autopsy review. The incidence of pulmonary embolism in our study of elderly patients during a six-year period in a teaching nursing home was 12.8%. Although our series is small, consisting of 47 autopsies, our results are in accord with reports from other patient sites. Few autopsies are performed on nursing home patients and even fewer have been studied with regard to the occurrence and characteristics of pulmonary embolism in this population. The diagnosis remains difficult and uncertain, especially so in the elderly, because of the variability of presentation and association, the lesser pursuit of aggressive or invasive diagnostic methods, and the paucity of postmortem documentation.

The nonuse of urethral catheterization in the management of urinary incontinence in the teaching nursing home.

A survey of all patients in a 527-bed skilled nursing facility was carried out to determine the prevalence of bladder catheterization. The institution surveyed is a teaching nursing home and rehabilitation center comprising three intermediate-stay and rehabilitation units of 126 beds and nine long-term care units. The institutional prevalence of recurrent urinary incontinence was 46 per cent, or 243 patients. The prevalence of chronic indwelling urethral catheters was 2.5 per cent, or 13 patients. The prevalence of urethral catheterization was further reduced to 1.5 per cent on the long-term care units, where the rate of recurrent urinary incontinence exceeded 60 per cent. The results of our survey were then compared with similar surveys at the institution during the years 1975 through 1980. Despite a fluctuating but increasing prevalence of incontinence over the years studied, a favorable trend was shown toward a reduction in the number of patients with indwelling urethral catheters. This study indicates that unless specific complicating factors are present, urinary incontinence in all but a very few of the elderly can be successfully managed without chronic indwelling catheterization. The authors believe that the introduction and growth of an education and research program in the nursing home environment has led to improvement in the standards of medical and nursing care.

Efficacy of routine annual studies in the care of elderly patients.

The authors reviewed the results of annual laboratory screening (SMA 20, T3, T4, UA, EKG, chest x-ray) performed on a population of 500 institutionalized and ambulatory patients retrospectively followed from 1 to 19 years. With 30 laboratory values recorded for each annual exam, there were an average of 1.56 new abnormal laboratory findings per year per patient. A sample of 100 patients was further reviewed to determine the incidence of new diagnoses and treatment initiated by the appearance of new abnormal laboratory findings; 756 new abnormalities were recorded out of a possible 15,000, and 66 medical work-ups were initiated, which lead to new diagnoses in 21 cases and a treatment plan in 12 cases. The authors suggest that, in view of the rapid increase in the number of elderly persons and the consequent need to conserve limited health care resources, "standard" laboratory screening may not be warranted on a yearly basis in the elderly population.

Screening for Alzheimer's disease by clock drawing.

The fear of Alzheimer's disease for both patients and families is growing along with the increasing evidence of the disease itself. This study (N = 312) of the validity of the clock drawing test in screening patients with probable Alzheimer's disease was conducted in an active outpatient geriatric clinic. Clock drawings by patients with normal mental status or depression were essentially normal. Alzheimer's patients were unable to complete a normal clock and demonstrated five characteristically abnormal patterns. As a test for Alzheimer's disease, clock drawing had a sensitivity of 86.7% and a specificity of 92.7%. There was correct identification in 97.2% of normals. These findings indicate that the clock drawing test, an easily administered, low cost screening tool, can be useful to health care professionals in characterizing cognitive loss in a general geriatric clinic population.

Oral contraceptives and intravenous glucose tolerance. I. Data noted early in treatment.

PIP: The effect of oral contraceptives (OCs) on intravenous glucose tolerance tests (iv GGT) to see if the results in a "pseudopregnancy state" parallel those of actual pregnancy was evaluated. 65 women (41 nondiabetic; 24 diabetes suspects) took Enovid (5 mg norethynodrel with .075 mg mestranol) for 2-3 months. 12 women (7 nondiabetic; 5 diabetes suspects) took Ovulen (1 mg ethhynodiol diacetate and .1 mg mestranol) and 14 women (7 nondiabetic; 7 diabetes) with intrauterine devices (IUD) served as controls. All subjects had the iv GTT before and after treatment. The GTT was expressed as K, the % fall/min of the blood glucose level from 10-60 min after injection of 25 gm glucose. Enovid caused a significant k decline (p .005) but no change in fasting blood sugar levels. No women in the Ovulen or IUD group had abnormal k values. 6 women with previosly normal k values developed abnormally low values while taking Enovid. 2 of these were in the diabetes suspect group. Diabetes suspects using OCs appeared to show a greater loss in GT than nondiabetic subjects. No correlation was found between carbohydrate metabolism during pregnancy and that of the "pseudopregnancy state" of progestin-estrogen administration. The possible mechanisms responsible for these changes, in particular the role of estrogen, were discussed.^ieng

Use of a reduced-carbohydrate, modified-fat enteral formula for improving metabolic control and clinical outcomes in long-term care residents with type 2 diabetes: results of a pilot trial.

Physiologic responses of 30 enterally-fed long-term care residents with type 2 diabetes receiving total nutrition support via either a disease-specific (reduced-carbohydrate, modified-fat) formula or a standard high-carbohydrate formula for 3 mo were compared. Objectives of the study included evaluating metabolic response (glycemic control and lipids) and clinical outcomes. Thirty-four subjects requiring total enteral nutrition support by tube were enrolled in this prospectively randomized, double-blind, controlled, parallel group 3-mo pilot trial. Thirty were evaluable in that they completed 4 wk. Twenty-seven completed all 12 wk. The groups were well-matched for physiologic and demographic parameters at baseline. Fasting serum glucose and capillary (fingerstick) glucose values demonstrated better control in the disease-specific formula-fed group. Serum lipid profiles of this group were similar to or better than those of the standard formula-fed group. The amount of insulin administered to insulin-using subjects in the disease-specific formula-fed group was consistently less than before initiation of the formula, whereas the amount administered was consistently higher in the group fed the standard formula. Overall, subjects randomized to the disease-specific formula experienced better numerical biochemical control and better clinical outcomes when expressed on a numerical and percentage basis. These included surrogate markers of diabetes control such as serum glucose and glycohemoglobin, as well as clinical outcomes such as incidence of infections and pressure ulcers. These findings confirm that the disease-specific formula provides better glycemic control, poses no risk to lipoprotein metabolism, and provides for better clinical outcomes.

Energy requirements in Alzheimer's disease patients.

Weight loss in Alzheimer's patients has been observed by many clinicians and reported in the international geriatric literature. It represents a puzzling challenge for clinicians and researchers, and it is an important issue for caregivers and nursing home staff concerned with state and federal requirements for nutrition and weight monitoring. Using indirect calorimetry, we studied the resting energy expenditure of 21 elderly patients; 12 were residing in a community setting, and 9 were institutionalized. Of the 12 community-living patients studied, 5 had early to moderate Alzheimer's disease, and 7 were nondemented control subjects. Of the 9 institutionalized patients, all were severely demented, bedridden, and fed exclusively by gastric tube in a closely monitored clinical environment with daily bedside weighing. Four had Alzheimer's disease, and 5 had multi-infarct dementia (MID). Among the outpatients, the Alzheimer's group showed increased energy requirements (p = 0.028) and a significantly different pattern of fat-free mass compared with control subjects (p = 0.031). These observations on community-residing elderly were consistent with, and extended by our findings on energy requirements of, the demented institutionalized patients. The calorie intake necessary for weight maintenance of the bedridden institutionalized patients was determined during their prolonged institutionalization. The presumed maintenance level of calorie intake was then verified during a 10 wk study. During the 10 wk, we documented no significant change in weight with constant energy intake. Compared with MID patients, Alzheimer's patients tended to weigh less (52.84 vs 56.4 kg; p = 0.20) but actually required more calories (1626 vs 1341 kcal, p < 0.011).(ABSTRACT TRUNCATED AT 250 WORDS)

Demographic changes and their financial implications.

The impressive rise in the number of elderly persons (65 years and over) will continue in the next two to three decades. Urinary incontinence is a common problem in the elderly, adversely affecting medical, social, and "quality of life" aspects. The cost of urinary incontinence is substantial and is expected to escalate enormously (e.g., by 160% from 1980 to 2040). An aggressive approach toward the diagnosis and management of urinary incontinence can result in an impressive reduction in health care costs and improvement in the quality of life.

The effect of nutritional status on length of stay in elderly hip fracture patients.

BACKGROUND: In this period of cost constraints, any indicator, such as nutritional status, which may predict the outcome of rehabilitation for a common problem, such as hip fractures, merits evaluation. METHODS: Nutritional indices--serum albumin, cholesterol, and body mass index--were assessed in 114 subacute rehabilitation hip fracture patients. RESULTS: Hypoalbuminemia was very common, occurring in 101 of 114 patients (88.6%). Using a forward stepwise regression model which considered age, total protein count, albumin, cholesterol, weight, height, and body mass index, serum albumin was the only variable that was significantly correlated with the length of stay (b=-0.23; p<.015). A scatterplot showed that almost all the albumin values in this elderly group fell between 2.4 mg/dl and 3.2 mg/dl, relatively low values, with a significant negative linear relationship between serum albumin and length of stay in this range. The average length of stay at 3.2 mg/dl was 44 days and at 2.4 mg/dl was 56 days. CONCLUSION: Hypoalbuminemia remains an important indicator of poor health outcome. Early biomedical monitoring of elderly subacute patients may lead to a reduction in length of stay and consequently reduce the costs of rehabilitation.

Simplifying the intravenous glucose tolerance test.

When used for classifying pregnant patients as normal or abnormal in terms of carbohydrate intolerance, the k value computed from a two-sample intravenous glucose tolerance test (IVGTT) (10 and 60 minutes) is reliable except in a zone of +/- 0.10 k points from the appropriate lower limit of normal. Retesting with six samples obtained in one hour may be required for patients with values within the doubtful range, +/- 0.10 of the lower limit of normal. Considerable savings can be realized nevertheless with the use of this test as compared with doing a full, seven-sample test on each subject. Our results suggest that the abbreviated IVGTT be used more widely as a routine screening procedure for diabetes rather than being restricted to use on suspect populations. One can make a direct conversion of blood sugar readings into k with the use of a table presented in the paper.

Weight loss in Alzheimer's disease: an international review of the literature.

Alzheimer's disease affects an estimated 2 million elderly in the U.S. and challenges primary care physicians to assist caregivers in dealing with the daily management of these patients. To support the clinical observation of weight loss in Alzheimer patients despite adequate food intake, we reviewed the existing literature. To date, eight international studies have focused on nutrition in Alzheimer's disease and all have found weight loss. It is not clear whether this weight loss is a component of or a consequence of the disease. These findings suggest systemic, metabolic alterations in Alzheimer's disease. They require further investigation as to their nature and as to their appropriate recognition and management to retard the deteriorating effects of chronic weight loss and malnutrition. Finally, some reports lead to speculation that nutritional strategies may improve cognitive function.