STOP-FALLING: A Simple Checklist Tool for Fall Prevention in a Nursing Facility.

Falls are highly prevalent and lead to major health morbidity and mortality in older adults. We developed a "STOP-FALLING" checklist as a multifactorial intervention tool kit for a single long-term care facility. The objective of this study was to determine feasibility and adherence of the checklist, and to determine whether STOP-FALLING reduces total number of falls, frequent fallers, and fall-related injuries. This is a quality improvement demonstration project comparing the effect on falls 3 months before and 3 months after introducing a STOP-FALLING checklist. All older adult patients who lived in the long-term care unit of a single facility were included. PTs, geriatricians, and registered nurses participated in the STOP-FALLING initiative. Staff were surveyed on satisfaction by 8-item questionnaires, which were obtained 3 months after checklist implementation. Data on the rate of falls, the number of recurrent fallers, the number of minor injuries, and the number of major injuries 3 months prior and 3 months after the intervention were collected by facility fall log. A total of 32 patients were screened using the STOP-FALLING checklist. Staff survey revealed a high satisfaction rate with ≤15 minutes to complete the checklist. Data at 3 months after initiation of the checklist revealed a reduction in the fall rates (2.80-1.65 falls per person-year), number of frequent fallers (5.00-2.30/mo after), number of falls without injuries (3.00-1.67/mo), number of minor injuries (4.00-2.67/mo), and number of major injuries (0.33-0/mo). We observed excellent staff satisfaction using the STOP-FALLING checklist. Our pilot project suggests that the intervention may decrease fall rates and other fall-related injuries.

Diabetes Management in the Elderly.

IN BRIEF Older adults with diabetes present unique challenges and require considerations that are not traditionally associated with diabetes management. In this review, we focus on issues that are unique to the older population and provide practical guidance for clincians who care for them.

The Study of Rhabdomyolysis in the Elderly: An Epidemiological Study and Single Center Experience.

Rhabdomyolysis is a syndrome caused by injury to skeletal muscle. There is limited data of rhabdomyolysis in the elderly. The objective of this study is to investigate demographic data, etiologies, laboratory values, prognostic factors, and mortality of rhabdomyolysis in the geriatric population. A 4-years retrospective chart review study was conducted. Our inclusion criteria were age above 65 years and creatinine kinase level excess five times of normal upper limit. Among 167 patients, 47.3% were male. The median age at diagnosis was 80.11 (66-101) years. The duration of follow up in the study ranged from 0 to 48 months. Fall (with or without immobilization) was the most frequent cause of rhabdomyolysis in 56.9%. The mean baseline glomerular filtration rate (GFR), GFR at diagnosis, and peak decline in GFR was 76.94, 48.96, and 54.41 cc/min respectively. The mean CK at diagnosis and peak CK was 5097.22 and 6320.07. There were 45 deaths (21%) over the span of 4 years. Multivariate analysis demonstrated that number of medications pre-admission (Meds No.), peak decline in GFR, and acute kidney injury (AKI) are independent predictors for overall survival for rhabdomyolysis in the elderly. To our knowledge, this is the first epidemiological study of rhabdomyolysis in the elderly. Falls (with and without immobilization) were the most common etiology. Meds No. (>8), peak decline in GFR (<30 cc/min), and evidence of AKI are associated with shorter overall survival and can serve as potential independent prognostic markers for rhabdomyolysis in elderly patients.

A Comprehensive Review of Non-Steroidal Anti-Inflammatory Drug Use in The Elderly.

NSAIDs, non-steroidal anti-inflammatory drugs, are one of the most commonly prescribed pain medications. It is a highly effective drug class for pain and inflammation; however, NSAIDs are known for multiple adverse effects, including gastrointestinal bleeding, cardiovascular side effects, and NSAID induced nephrotoxicity. As our society ages, it is crucial to have comprehensive knowledge of this class of medication in the elderly population. Therefore, we reviewed the pharmacodynamics and pharmacokinetics, current guidelines for NSAIDs use, adverse effect profile, and drug interaction of NSAIDs and commonly used medications in the elderly.

Clinical Characteristics, Management, and Outcomes of Suspected Poststroke Acute Coronary Syndrome.

BACKGROUND: Acute coronary syndrome (ACS) can complicate acute ischemic stroke, causing significant morbidity and mortality. To date, literatures that describe poststroke acute coronary syndrome and its morbidity and mortality burden are lacking. METHODS: This is a single center, retrospective study where clinical characteristics, cardiac evaluation, and management of patients with suspected poststroke ACS were compared and analyzed for their association with inpatient mortality and 1-year all-cause mortality. RESULTS: Of the 82 patients, 32% had chest pain and 88% had ischemic ECG changes; mean peak troponin level was 18, and mean ejection fraction was 40%. The medical management group had older individuals (73 versus 67 years, p < 0.05), lower mean peak troponin levels (12 versus 49, p < 0.05), and lower mean length of stay (12 versus 25 days, p < 0.05) compared to those who underwent stent or CABG. Troponin levels were significantly associated with 1-year all-cause mortality. CONCLUSION: Age and troponin level appear to play a role in the current clinical decision making for patient with suspected poststroke ACS. Troponin level appears to significantly correlate with 1-year all-cause mortality. In the management of poststroke acute coronary syndrome, optimal medical therapy had similar inpatient and all-cause mortality compared to PCI and/or CABG.

A Review of Neurogenic Stunned Myocardium.

Neurologic stunned myocardium (NSM) is a phenomenon where neurologic events give rise to cardiac abnormalities. Neurologic events like stroke and seizures cause sympathetic storm and autonomic dysregulation that result in myocardial injury. The clinical presentation can involve troponin elevation, left ventricular dysfunction, and ECG changes. These findings are similar to Takotsubo cardiomyopathy and acute coronary syndrome. It is difficult to distinguish NSM from acute coronary syndrome based on clinical presentation alone. Because of this difficulty, a patient with NSM who is at high risk for coronary heart disease may undergo cardiac catheterization to rule out coronary artery disease. The objective of this review of literature is to enhance physician's awareness of NSM and its features to help tailor management according to the patient's clinical profile.

Dialysis Therapy and Conservative Management of Advanced Chronic Kidney Disease in the Elderly: A Systematic Review.

BACKGROUND: Dialysis in older adults with chronic kidney disease (CKD) and comorbidities may not be associated with improved life expectancy compared to conservative management. To inform clinical practice, we performed a systematic review of all available studies examining this hypothesis. METHODS: We performed a systematic review of retrospective and prospective cohort studies of older adults with stage-5 CKD who chose dialysis (hemodialysis or peritoneal dialysis) or opted for conservative management (including management of complications of CKD and palliative care). Outcomes of interest included hospitalizations and mortality. RESULTS: Twelve cohort studies (11,515 patients) were identified with most of them focusing on older adults. Patients choosing dialysis were younger compared to those opting for conservative management and were less functionally impaired. Patients opting for conservative management received care in a multidisciplinary setting focusing on palliative care and management of complications of CKD. Patients choosing dialysis and conservative management had a median survival time of 8-67 and 6-30 months, respectively. In a subset of studies of patients 65 years and older with an estimated glomerular filtration rate <15 mL/min/1.73 m2, and where the multivariable analyses included age and comorbidities, by meta-analysis, patients choosing dialysis had a pooled adjusted hazard ratio for mortality of 0.53 (95% CI 0.30-0.91, p = 0.02) relative to those opting for conservative management; however, significant heterogeneity precluded definitive conclusions. CONCLUSIONS: When caring for older adults with advanced CKD who are contemplating dialysis therapy vs. conservative management, efforts must focus on promoting patient values and preferences, shared decision-making, and symptom burden alleviation.

Prognostic Significance of Dementia in Older Adults with Solid Tumors.

BACKGROUND: The public health burden of cancer and dementia in the geriatric population is well documented. There is limited data on how dementia predicts mortality among geriatric patients with solid tumors. The objective of this study is to determine the prognostic significance of dementia on survival in patients with solid tumors. METHODS: We performed a 5-year retrospective study on elderly subjects aged ≥60 years with and without dementia that were diagnosed with solid tumors. RESULTS: Among 3,460 patients with solid tumors, 132 (3.8%) patients were found to have dementia. The median age at diagnosis was 71 years. Kaplan-Meier curves demonstrated that patients with dementia had an inferior median survival compared to the nondemented group (30 vs. 56 months; log-rank p < 0.001). Cox proportional hazard regression modeling identified age >80 years, female gender, diabetes mellitus, congestive heart failure, atrial fibrillation, chronic obstructive pulmonary disease, chronic kidney disease, dementia, and radiation therapy as risk factors for decreased overall survival. CONCLUSIONS: We demonstrated that dementia is associated with shorter overall survival in elderly patients with solid tumors.

The Prognostic Significance of Neutrophil-to-Lymphocyte and Platelet-to-Lymphocyte Ratios in Patients With Multiple Myeloma.

OBJECT: Neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) are simple, inexpensive prognostic markers for various conditions. The objective of this study was to determine the prognostic significance of NLR and PLR in patients with multiple myeloma (MM) in terms of survival. METHOD: A retrospective chart review study was conducted for 175 patients who met the criterion of diagnosis for MM between January 2004 and September 2014. RESULT: The median age of diagnosis was 69 years. Patients were divided into high and low NLR and PLR groups according to cutoff points from the receiver operating characteristic curve (2.78 and 155.58, respectively). The high NLR and PLR groups were associated with lower albumin level and higher staging. The high NLR group experienced inferior median survival compared with the low NLR group (37 vs. 66 months; log-rank P-value 0.005). However, there was no significant difference in median survival between the high and low PLR groups (45 vs. 62 months; P = 0.077). Multivariate analysis demonstrated that NLR is an independent predictor for OS of MM (HR 2.892; P = 0.009). CONCLUSION: We conclude that NLR is an independent prognostic factor for OS in MM.

Sensorineural Organs Dysfunction and Cognitive Decline: A Review Article.

Vision, hearing, olfaction, and cognitive function are essential components of healthy and successful aging. Multiple studies demonstrate relationship between these conditions with cognitive function. The present article focuses on hearing loss, visual impairment, olfactory loss, and dual sensory impairments in relation to cognitive declination and neurodegenerative disorders. Sensorineural organ impairment is a predictive factor for mild cognitive impairment and neurodegenerative disorders in the elderly. We recommend early detection of sensorineural dysfunction by history, physical examination, and screening tests. Assisted device and early cognitive rehabilitation may be beneficial. Future research is warranted in order to explore advanced treatment options and method to slow progression for cognitive declination and sensorineural organ impairment.

Effect of N- and T-type calcium channel blocker on proteinuria, blood pressure and kidney function in hypertensive patients: a meta-analysis.

The combination of a calcium channel blocker (CCB) and a blocker of the renin-angiotensin-aldosterone system (RAAS) is recommended in clinical practice guidelines. L/N- and L/T-type CCBs might provide an additional effect on lowering proteinuria. Therefore, we conducted a meta-analysis to assess the efficacy of L/N- and L/T-type CCBs in hypertensive patients with proteinuria. We searched MEDLINE, Scopus, Cochrane Central Register of Controlled Trials and ClinicalTrials.gov for single-arm studies and randomized controlled trials (RCTs) that examined the effect of L/N- and L/T-type CCBs as add-on therapy compared with standard antihypertensive regimen for proteinuria on hemodynamic and kidney-related parameters in hypertensive patients with proteinuria. Random-effect model meta-analyses were used to compute changes in the outcomes of interest. We identified 17 RCTs, representing 1905 patients. By meta-analysis, L/N- and L/T-type CCB add-on therapy did not yield significant changes in systolic and diastolic blood pressure compared with standard treatment, but there was a significant lowering of the pulse rate. However, L/N- and L/T-type CCBs resulted in a significant standardized net decrease in albuminuria and proteinuria (-1.01; 95% confidence interval (CI), -1.78 to -0.23; P=0.01), and a standardized net improvement in the estimated glomerular filtration rate and serum creatinine (0.23; 95% CI, 0.11 to 0.35, P<0.001; and -0.25; 95% CI, -0.46 to -0.03; P=0.02, respectively). Despite no additional lowering effect on blood pressure, L/N- and L/T-type CCBs combined with a blocker of the RAAS provided a decrease in proteinuria and improvement in kidney function. Further studies are required to establish the long-term kidney benefits of this combination therapy.

Jackfruit anaphylaxis in a latex allergic patient.

Several fruits have been reported to crossreact with latex antigen in latex allergy patients but little is known regarding tropical fruits in particular. Here we report the case of a 34-year old nurse who developed anaphylaxis following the ingestion of dried jackfruit (Artocarpus heterophyllus). The patient had a history of chronic eczema on both hands resulting from a regular wear of latex gloves. She and her family also had a history of atopy (allergic rhinitis and/or atopic dermatitis). The results of skin prick tests were positive for jackfruit, latex glove, kiwi and papaya, but the test was negative for banana. While we are reporting the first case of jackfruit anaphylaxis, further research needs to be conducted to identify the mechanisms underlying it. In particular, in-vitro studies need to be designed to understand if the anaphylaxis we describe is due to a cross reactivity between latex and jackfruit or a coincidence of allergy to these 2 antigens.

Healing the orphaned heart: heart failure in a patient with glucose-6-phosphate dehydrogenase deficiency.

Patients with glucose-6-phosphate dehydrogenase (G6PD) deficiency are not represented in clinical trials for heart failure. Moreover, many of the recommended medications can cause haemolysis in this group of patients. We present the case of a 71-year-old woman with G6PD deficiency admitted for acute non-ischemic heart failure with reduced ejection fraction. Our experience showed that a combination of ethacrynic acid and spironolactone is safe and effective for relief of volume overload in this group of patients. Studies are needed to determine whether the morbidity and mortality benefits of established heart failure regimens extend to patients with G6PD deficiency.

Dual prosthetic heart valve presented with chest pain: a case report of coronary thromboembolism.

Coronary embolism from a prosthetic heart valve is a rare but remarkable cause of acute coronary syndrome. There is no definite management of an entity like this. Here we report a case of 54-year-old male with a history of rheumatic heart disease with dual prosthetic heart valve and atrial fibrillation who developed chest pain from acute myocardial infarction. The laboratory values showed inadequate anticoagulation. Cardiac catheterization and thrombectomy with the aspiration catheter were chosen to be the treatment for this patient, and it showed satisfactory outcome.