European postgraduate curriculum in geriatric medicine developed using an international modified Delphi technique.

BACKGROUND: the European Union of Medical Specialists (UEMS-GMS) recommendations for training in Geriatric Medicine were published in 1993. The practice of Geriatric Medicine has developed considerably since then and it has therefore become necessary to update these recommendations. METHODS: under the auspices of the UEMS-GMS, the European Geriatric Medicine Society (EuGMS) and the European Academy of Medicine of Ageing (EAMA), a group of experts, representing all member states of the respective bodies developed a new framework for education and training of specialists in Geriatric Medicine using a modified Delphi technique. Thirty-two expert panel members from 30 different countries participated in the process comprising three Delphi rounds for consensus. The process was led by five facilitators. RESULTS: the final recommendations include four different domains: 'General Considerations' on the structure and aim of the syllabus as well as quality indicators for training (6 sub-items), 'Knowledge in patient care' (36 sub-items), 'Additional Skills and Attitude required for a Geriatrician' (9 sub-items) and a domain on 'Assessment of postgraduate education: which items are important for the transnational comparison process' (1 item). CONCLUSION: the current publication describes the development of the new recommendations endorsed by UEMS-GMS, EuGMS and EAMA as minimum training requirements to become a geriatrician at specialist level in EU member states.

The effectiveness of supplementary arm and upper body exercises following total hip arthroplasty for osteoarthritis in the elderly: a randomized controlled trial.

OBJECTIVE: To determine whether arm and upper body exercises in addition to the standard rehabilitation programme improve outcomes after hip arthroplasty. DESIGN: Prospective, parallel, randomized, controlled trial. SETTING: Orthopaedic and rehabilitation departments. SUBJECTS: A total of 70 patients >60 years of age, who underwent hip replacement, out of 98 eligible candidates after exclusion criteria were implemented. INTERVENTIONS: The study group took part in the supplementary arm and upper body exercise programme to be compared with the standard rehabilitation programme group. MAIN OUTCOME: The primary outcome was a Harris Hip Score. Secondary outcomes were: Hand grip strength and Medical Outcomes Study 36-Item Short-Form Health Survey. Outcomes were assessed preoperatively, two weeks after surgery and at 12 weeks follow-up. RESULTS: In the intervention group, significant improvements were found: in functional ability - Harris Hip Score after two (mean difference = 4.7 points) and 12 (mean difference = 5.85 points) weeks; in muscle strength - handgrip for both hands (mean difference for dominant hand = 4.16 and for the other hand = 2.8) after 12 weeks; and in role-physical dimension SF-36 Health Survey (mean difference = 6.42 points) after 12 weeks. CONCLUSION: Results of this study indicate that arm and upper body exercises in addition to the standard rehabilitation programme improve outcomes 12 weeks after hip arthroplasty.

Prognostic value of health-related quality of life in elderly patients hospitalized with heart failure.

Purpose: Previous research has shown that poor health-related quality of life (HRQOL) is associated with adverse long-term prognosis in patients with heart failure (HF); however, there have been inconsistencies among studies and not all of them confirmed the prognostic value of HRQOL. In addition, few studies involved elderly patients and most focused on all-cause mortality and HF-related hospitalization as outcomes. The aim of our study was to determine whether HRQOL is a predictor and an independent predictor of long-term cardiac mortality, all-cause mortality, and HF-related rehospitalization in elderly patients hospitalized with HF. Patients and methods: This prospective observational study included 200 elderly patients hospitalized with HF in Serbia. HRQOL was measured using the Minnesota Living with Heart Failure questionnaire (MLHFQ). The median follow-up period was 28 months. The primary outcome was cardiac mortality, and all-cause mortality and HF-related rehospitalization were secondary outcomes. Survival analysis was conducted using the Kaplan-Meier method and Cox-proportional hazards regression. Results: Subjects with poor HRQOL (higher than the median MLHFQ score) had a higher probability of cardiac mortality (P=0.029) and HF-related rehospitalization (P=0.001) during long-term follow-up. Poor HRQOL was an independent predictor of cardiac mortality (HR: 2.051, 95% CI: 1.260-3.339, P=0.004), all-cause mortality (HR: 1.620, 95% CI: 1.076-2.438, P=0.021), and HF-related rehospitalization (HR: 2.040, 95% CI: 1.290-3.227, P=0.002). Conclusion: HRQOL is an independent predictor of long-term cardiac mortality in elderly patients hospitalized with HF. It also independently predicts all-cause mortality and HF-related rehospitalization. HRQOL could be used as a complementary clinical predictive tool in this patient population.

Bleeding during enoxaparin treatment more common with age over 75 years and severe renal insufficiency.

BACKGROUND: Severe renal insufficiency, defined as a creatinine clearance <30 mL/min, increases the risk for bleeding in elderly patients receiving enoxaparin (enoxaparin sodium) treatment. METHODS: The risk/benefit ratios of enoxaparin and unfractionated heparin (UFH) in patients with acute myocardial infarction (AMI) aged >75 years were determined by investigating the parameters of efficacy (ischaemic event, lethal outcome), safety (bleeding events, renal insufficiency) or both (composite endpoint: ischaemic event or lethal outcome or bleeding event). RESULTS: The study included 113 patients (59 male, 52.2%) with AMI aged >75 years; 36 of these patients received enoxaparin. In the patients who had severe renal insufficiency, bleeding events were more frequent in those receiving enoxaparin than in those patients who received UFH (3 vs 1, respectively; p = 0.024). Irrespective of the presence of renal insufficiency, bleeding events occurred more often in patients who received enoxaparin than in those who received UFH (13 vs 8, respectively; p = 0.007). The composite endpoint showed a nonsignificantly better profile in patients who received enoxaparin than in those who received UFH. CONCLUSION: Although the use of enoxaparin (compared with UFH) and the presence of severe renal insufficiency significantly increased the occurrence of bleeding in patients with AMI aged >75 years, the risk/benefit difference in this population was not significant.

Ageism: does it exist among children?

Ageism is stereotyping and prejudice against individuals or groups because of their age. Robert Butler first used it in 1969, to express a systematic stereotyping and discrimination against elderly people. Available data appears to confirm that attitudes of children to the old age differ from that of adults. The study population consisted of 162 subjects (56 school children, 48 nurses and 58 elderly patients). Each subject in the survey was asked to respond to the following three questions: Question #1: "Is the old age unattractive?"; Question #2: "How old is an old man?"; Question #3: "What should you do to have a long life (what is good for longevity)? The majority of polled children (33) gave positive statements about ageing in their responses to the first item, while most of the nurses gave condition answers, like: "It is not unattractive if you are healthy". Elderly subjects made up a group with the majority of negative responses (in percentage), as only 33% of them answered that old age is not unattractive. All three groups of subjects demonstrated a good knowledge of what is considered good for longevity, and had a generally positive health attitude. Our results indicate that majority of children have positive perception and attitude about old age, which leads us to conclusion that ageism is adopted later in life.

Are all dilemmas in gerontology being swept under the carpet of intra-individual variability?

It is considered that there are great differences among elderly individuals, because the intra-individual variability is great. The differences among specific individuals grow with their age, so when adults reach a very old age, it seems that there are great differences among them--some are able to do some work, the others are not so able-bodied, whereas among high school students there is usually little difference in their physical ability. The research that supports the above mentioned points, however, does not exist and this opinion came about as a result of deduction. The goal of this study is to examine the fluctuations in the elderly and prove that the genetic difference plays a bigger role than the variability, as the intra-individual (or the between-person) variability is present everywhere, not only in very old people.

Specifics of Helicobacter pylori infection/NSAID effects in the elderly.

The prevalence of Helicobacter pylori (HP) infection increases with age worldwide. Unlike in younger patients, the presentation of peptic disease in the elderly population is subtle and atypical, and thus leads to a delay of diagnosis. Due to comorbidities and advanced age, it results in increased complications, morbidity and mortality. Bleeding and perforation are frequent complications and therefore peptic ulcer in adult patients represents a serious disease. The relationship between the infection caused by HP and the use of non-steroidal anti-inflammatory drugs (NSAID) in the pathogenesis of peptic ulcer disease is still controversial. However these two factors, independently or in synergy, represent the principal cause of peptic ulcer development in the adult population. In patients diagnosed with peptic ulcer caused by HP, more than half take medications containing aminosalicylic acid. Helicobacter pylori infection in elderly NSAID users is associated with an increased ulcer incidence, but not with an increased prevalence of upper digestive tract bleeding. Helicobacter pylori and NSAID consumption are independent and unrelated risk factors for upper gastrointestinal tract bleeding. Eradication of HP is recommended before the initiation of a long-term aspirin administration in elderly patients. Low aspirin dosages are associated with a high risk of ulcer bleeding. The risk of upper gastrointestinal bleeding in elderly patients is significantly higher in the cases of acute abuse of NSAIDs relative to its chronic use. The simultaneous use of NSAID or aspirin and selective serotonin reuptake inhibitors--antidepressants, increases the risk of upper gastrointestinal bleeding. Peptic ulcer disease in the adult population, if combined with old age, presence of serious and/or life- threatening diseases, as well as repeated ulcer bleedings, shows a high mortality rate.

Quality-of life of the elderly in urban and rural areas in Serbia.

BACKGROUND/AIM: The number of elderly people in the world is growing, in Serbia as well. Serbia is already among the top ten countries with the oldest population, it is the fact. Aging influences the quality of life in different ways. The aim of this study was to assess the health-related quality of life of the elderly in urban and rural areas in Serbia. METHODS: The study included 100 elderly people aged 65 years and above in urban and rural areas in Serbia. The next questionnaires were used: a socio-demographic questionnaire and a Serbian version of standardized European Euro-QoL questionnaire (EQ-5D-3L), as a basic index for the assessment and description of the quality of life. RESULTS: In the structure of the respondents, according to the achieved social contacts (p = 0.012), the life of those with family members (p = 0.009), and health status (p = 0.000), in relation to the place of residence there was a statistically significant difference. There was a significant difference (p = 0.040), predominantly poor score for anxiety/depression within the rural population. The average value of quality of life in urban and rural areas was not statistically significant (p = 0.720). For those living in rural areas there was a statistically significant positive correlation between anxiety/depression and age, wealth status, marital status, living with family members and achieving social contacts, while a negative correlation was observed between anxiety/depression and education. CONCLUSION: On the basis of the data of our study, we can say that the presence of anxiety/depression among older people is greater in rural than in urban areas. The results of this study show that the perception of anxiety/depression among older in rural areas is bigger with the age and poverty increasing, the loss of a spouse, life without family members, lack of achievement of social contacts and lower education.

Are we faced with two human species?

Problems could be found in the fact that we very often look for one deciding, definitive reason for the process of aging. It is a sort of search for a big discovery, like a fountain of youth or such. More and more authors are trying to explain the unknowns in the understanding of these observations about aging by adding the statement that there are two subgroups in the general population. This acknowledgment of two subpopulations explains why there are numerous cases that cannot be explained, defined, or fitted in basic observations about caloric restrictions and the delay of reproduction. The identification of those two groups would allow us to find more realistic results in studies and therefore a more efficient therapy of certain diseases. This hypothesis does not contradict theories of aging that we have accepted (at least not the majority of accepted theories), and this hypothesis also does not contradict the fact that there is a large interindividual variability. This hypothesis doubts, and claims there are exceptions to, the starting assumption of geriatrics and gerontology that: "parallel to the aging process the functions of all organs and organ systems lessen."

Magnesium, aging, and the elderly patient.

Magnesium, beyond any doubt, plays an important role in metabolism. Alterations of magnesium levels have an impact on many organs and systems, especially during aging. We had 156 participants aged 60-93 years (average 74.7 years) in our survey. Of them, 49 were men and 107 were women. Treatment with loop diuretics (Furosemid and Bumetanide) and magnesium levels was correlated, as well as the influence of magnesium levels on life span. Serum magnesium levels were measured in patients receiving diuretics and in the control group. Also, magnesium levels were measured in patients who passed away in the course of their disease and were compared with the control group. Magnesium levels in the diuretic group (100 patients) were 0.93 +/- 0.094 mmol/l, while the average levels in the control group of 56 patients were 0.89 +/- 0.075 mmol/l. In 29 patients who passed away, average magnesium levels were 0.92 +/- 0.078 mmol/l, while in the control group (127 patients), magnesium levels were 0.93 +/- 0.083 mmol/l. The differences were not statistically significant. There were no differences in serum magnesium of the elderly persons investigated regarding age group, gender, or type of diuretics. If methods of determining ionizing magnesium in serum or intracellular magnesium are not available, normal magnesium values in the serum are to be taken with a qualified acceptance.

Health-related quality of life in elderly patients hospitalized with chronic heart failure.

BACKGROUND: Chronic heart failure is a very common condition in the elderly, characterized not only by high mortality rates, but also by a strong impact on health-related quality of life (HRQOL). Previous studies of HRQOL in elderly heart failure subjects have included mostly outpatients, and little is known about determinants of HRQOL in hospitalized elderly population, especially in Serbia. In this study, we tried to identify factors that influence HRQOL in elderly patients hospitalized with chronic heart failure in Serbia. METHODS: The study population consisted of 136 patients aged 65 years or older hospitalized for chronic heart failure. HRQOL was assessed using the Minnesota Living with Heart Failure questionnaire. Predictors of HRQOL were identified by multiple linear regression analysis. RESULTS: Univariate analysis showed that patients with lower income, a longer history of chronic heart failure, and longer length of hospital stay, as well as those receiving aldosterone antagonists and digoxin, taking multiple medications, in a higher NYHA class, and showing signs of depression and cognitive impairment had significantly worse HRQOL. Presence of depressive symptoms (P<0.001), higher NYHA class (P=0.021), lower income (P=0.029), and longer duration of heart failure (P=0.049) were independent predictors of poor HRQOL. CONCLUSION: Depressive symptoms, higher NYHA class, lower income, and longer duration of chronic heart failure are independent predictors of poor HRQOL in elderly patients hospitalized with chronic heart failure in Serbia. Further, there is an association between multiple medication usage and poor HRQOL, as well as a negative impact of cognitive impairment on HRQOL. Hence, measures should be implemented to identify such patients, especially those with depressive symptoms, and appropriate interventions undertaken in order to improve their HRQOL.

Old age as a privilege of the "selfish ones".

In the past couple of centuries, scientists proposed great number of aging theories but neither of them appears to be fully satisfactory. In the statistical sense, we are dealing with an even greater challenge because large array of factors affects the aging process. Although at this point the most of these factors are well known, it is the very fact of their innumerability that complicates approaches to the issue at hand. Both in life and in medicine, the cause behind an effect can rarely be unequivocally determined. Thus, it appears that through out human history longevity has been primarily affected by eradication of diseases, especially by eradication of infectious diseases and introduction of the vaccines. For that reason, maybe we should not be referring to this issue as the «fountain of youth¼ but rather as the «vaccine of youth¼. The postulate that genetic instability is the precipitating factor both of aging and cancer has withstood many tests and keeps on being reaffirmed. For this reason, it is legitimate to pose a question of whether long-lived individuals may be those with «selfish¼ genes and more stable genetic material. They certainly cannot avoid aging, but aging in such individuals could be delayed due to steady character of their genome, which is less susceptible to mutations. On the population level, they constitute minority because stable genome would represent an obstacle to successful evolution of the species. If this was not the case, we might not be writing all these texts today.

Morphometric study of healthy jejunal and ileal mucosa in adult and aged subjects.

Small intestine mucosa is often affected with malabsorptive, autoimmune and inflammatory pathological processes. However, morphometric data on the healthy human small intestine mucosa, especially ileum, are scarce. We aimed to obtain histoquantitative data on the healthy jejunal and ileal mucosa and assess the effects of gender and ageing on these parameters. Computer-aided morphometric analysis was performed on 24 jejunal and 25 ileal biopsy samples collected upon routine endoscopy screening of healthy persons with a family history of intestinal malignancy. Subjects were distributed in four groups according to age and sex: adult (<60 years) and elderly (>60 years) males, and adult (<60 years) and elderly (>60 years) females. Results were statistically analyzed with Mann-Whitney U test. Jejunal mucosal thickness was significantly reduced in elderly subjects (p<0.05), especially in elderly females compared to adult ones (p<0.05). Jejunal villi were significantly wider in adult than in the elderly subjects (p<0.05), whereas ileal villi were significantly wider in elderly compared to adult subjects (p<0.01) and in male compared to female subjects (p<0.05). No statistically significant differences were found in other histoquantitative parameters (mucosa epithelium height, crypt numerical density, villous height, crypts and villous perimeter, diameter and epithelium height) of jejunal and ileal mucosa. This study provides complete morphometric data on the healthy human jejunum and the first relevant data on the healthy ileal mucosa, thus representing a valuable morphometric reference for future histoquantitative studies of human small bowel mucosa in both healthy and disease affected individuals.

[Evaluation of effect of therapy of somatic diseases and cognitive impairment in geriatric patients].

INTRODUCTION: Human aging is characterized by progressive decrease of the homeostatic reserves of every organ system with a possible impairment of cognitive functions. The study was aimed at examining and proving the correlations between cognitive failure and somatic diseases in patients belonging to geriatric population as well as at following the efficiency of treatment of somatic diseases by Mini mental examination test score. MATERIAL AND METHODS: A group of 100 geriatric patients did Mini mental examination test at the beginning of hospitalisation and after three weeks of treatment of different.somatic diseases. The patients underwent many examination tests-biochemical analyses of blood and urin, ultrasound examination, X-ray examination of lungs and heart, hormones of thyroid gland, concentrations of B12 vitamin, folan acid. RESULTS: The statistical study showed that there was a significant correlation between the recovery of somatic diseases and the score of cognitive functions of patients. MMSE score was significantly increased after three weeks of successful treatment of somatic diseases in hospital. CONCLUSION: The highest statistical significance in the difference of M'ISE score at the beginning and after three weeks of hospital treatment was found in the group of patients with successful results of the treatment of their somatic diseases such as cardiomyopathies and disorders of respiratory system, such as pneumonia. MMSE score did not increase in patients chronic disease with malignant diseases of lungs or liver and chronic disease with frequent exacerbations. It was a group of patients without significant change in their somatic state.

[Articles on elderly in Serbian medical journals].

INTRODUCTION: Population aging is a feature of all countries in the world. According to statistics, the Republic of Serbia is one of the countries with the majority of the elderly. Taking this into account, are articles on the elderly well represented in domestic medical journals? OBJECTIVE: The aim of the paper was to determine whether there was a sufficient number of articles on the elderly in domestic medical journals. METHODS: The articles on the elderly were searched using search engines in domestic and foreign medical journals for the last 5 years compared with the number of articles on children in the same publications for the same period. RESULTS: In the Serbian Citation Index, 11 articles on the topic of the elderly, and 487 on children were registered. In Srpski arhivza celokupno lekarstvo, there was registered only one article on the topic of the elderly, and 30 on children. In Vojnosanitetskipregled, 2 articles on the elderly and 13 on children were registered (p < 0001). For the last five years, in the New England Journal of Medicine, there were 593 articles on the elderly and 759 articles on children; in the JAMA, there were 63 articles on the elderly and 303 articles on children; and in The Lancet, in the last five years, 46 articles on the elderly and 148 articles on children were published. CONCLUSION: The themes of the elderly were rarely represented in Serbian medical journals.This has reduced the interest of physicians in medical problems of this growing population of patients and further sent them away from making standards in the diagnosis and treatment of the elderly.