Are atypical antipsychotics safer than typical antipsychotics for treating behavioral and psychological symptoms of dementia?

Atypical antipsychotics seem to be preferable than conventional agents in treating psychological symptoms of dementia (BPSD), because they have substantially lower risks of extrapyramidal neurological effects with lower reported rates of parkinsonism and tardive dyskinesia. However, in the course of time, with the increase in their use, more and more side effects have been reported. The benefits and risks of antipsychotic treatment should be carefully evaluated according to the co-morbidity and the severity of the psychological and behavioral symptoms and their impact on the individual elderly patient. It is recommended to keep those medications in the lower range of therapeutic doses. Due to the complexity of the individual patient, no guidelines have been yet established. Therefore, clinical judgment should be used in applying the dose and the type of those drugs.

ESPEN Guidelines on Parenteral Nutrition: geriatrics.

Older subjects are at increased risk of partial or complete loss of independence due to acute and/or chronic disease and often of concomitant protein caloric malnutrition. Nutritional care and support should be an indispensable part of their management. Enteral nutrition is always the first choice for nutrition support. However, when patients cannot meet their nutritional requirements adequately via the enteral route, parenteral nutrition (PN) is indicated. PN is a safe and effective therapeutic procedure and age per se is not a reason to exclude patients from this treatment. The use of PN should always be balanced against a realistic chance of improvement in the general condition of the patient. Lower glucose tolerance, electrolyte and micronutrient deficiencies and lower fluid tolerance should be assumed in older patients treated by PN. Parenteral nutrition can be administered either via peripheral or central veins. Subcutaneous administration is also a possible solution for basic hydration of moderately dehydrated subjects. In the terminal, demented or dying patient the use of PN or hydration should only be given in accordance with other palliative treatments.

Serum leptin level in geriatric patients with hip fractures: possible correlation to biochemical parameters of bone remodeling.

Osteoporosis and hip fractures are a major public health problem. Since leptin was suggested to be involved in bone remodeling, its possible involvement in fracture formation/prevention was evaluated, by determination of serum leptin level in geriatric population with hip fracture, and evaluation the relationships with biochemical parameters of bone remodeling. We studied 250 geriatric patients with hip fracture admitted to Sapir Medical Center and underwent operative treatment. Among them 172 females and 78 males, with a mean age of 81 years. Serum leptin level of this total population distributed between 1 and 134ng/ml. 40% of patients were in the normal range of our laboratory (10-40ng/ml), 40% had decreased leptin level (<10ng/ml) and 20% had higher leptin level (>40ng/ml). No correlation was detected between serum leptin level and vitamin D-25(OH)D3, which was under normal range in 60% of the patients. Leptin also did not correlate to ICTP level, which was high in 80% of the patients, suggesting an extensive bone resorption in this population. Evaluation of leptin level in female versus male suggests that leptin level is higher in females than males also in this age (28.4ng/ml vs. 14.4ng/ml, p<0.001). However, no difference were detected in either ICTP, or 25(OH)D3, which are involved in bone remodeling. The higher leptin levels in women was accompanied by higher serum levels of glucose, albumin, Ca, cholesterol, Na and FT4. Comparison of 50 patients with the lowest leptin levels (mean of 3.4ng/ml) to 50 patients with highest leptin levels (mean of 34ng/ml), did not indicate differences in both 25(OH)D3 and ICTP between these two populations in spite of the highly significant difference in leptin levels. The high range of serum leptin concentration in these geriatric patients with hip fracture of both sexes, and the absence of any correlation between leptin and the tested parameters of bone resorption and Ca metabolism, teleopeptide type I collagen (ICTP) and 25(OH)D3, does not support a direct massive involvement of serum leptin in hip fracture of the very old population.

ESPEN Guidelines on Enteral Nutrition: Geriatrics.

Nutritional intake is often compromised in elderly, multimorbid patients. Enteral nutrition (EN) by means of oral nutritional supplements (ONS) and tube feeding (TF) offers the possibility to increase or to insure nutrient intake in case of insufficient oral food intake. The present guideline is intended to give evidence-based recommendations for the use of ONS and TF in geriatric patients. It was developed by an interdisciplinary expert group in accordance with officially accepted standards and is based on all relevant publications since 1985. The guideline was discussed and accepted in a consensus conference. EN by means of ONS is recommended for geriatric patients at nutritional risk, in case of multimorbidity and frailty, and following orthopaedic-surgical procedures. In elderly people at risk of undernutrition ONS improve nutritional status and reduce mortality. After orthopaedic-surgery ONS reduce unfavourable outcome. TF is clearly indicated in patients with neurologic dysphagia. In contrast, TF is not indicated in final disease states, including final dementia, and in order to facilitate patient care. Altogether, it is strongly recommended not to wait until severe undernutrition has developed, but to start EN therapy early, as soon as a nutritional risk becomes apparent.

Does obesity affect the results of lumbar decompressive spinal surgery in the elderly?

The prevalence of obesity among the population is increasing, including in many elderly people. The purpose of this study was to evaluate whether lumbar spinal surgery in elderly patients with different body mass indices influences pain, satisfaction rate, and activities of daily living. Two hundred ninety-eight elderly patients (older than 65 years), 153 women and 145 men, who had decompressive laminectomy, discectomy, or combinations of these procedures during 1990 to 2000 were followed up. Indications for surgery included limitation in doing activities of daily living, severe pain, or both. The patients were classified into one of four categories in terms of their body mass index. The operative parameters, pain reduction, satisfaction rate, and activities of daily living using the Barthel index were assessed. The more obese patients were younger, tended to be female, and were more symptomatic. All four groups of patients had reduction in pain, improvement in activities of daily living, and were satisfied with the operation. Our data suggest that it is reasonable to operate on patients who are elderly and obese and who have lumbar symptoms, with the appropriate indications.

[Scales for evaluation of the geriatric patient with hip fracture during the acute and rehabilitation phases].

The elderly population is increasing in the modern world. Societies in general and medical personnel are facing new ethical and medical dilemmas when treating extremely old patients. Many factors are known to cause fractures in elderly patients. Probably, the most important one is osteoporosis, which was shown to be the main pathology in elderly patients who fractured their hips. The increase in fall frequency, orientation to falls and the protective response to trauma were found to play a role in the pathogenesis as well. The rehabilitation of this group of patients is an important factor that helps to return the elderly patient to his or her own environment and to his or her skills prior to the falls. The decision of the potential for rehabilitation and the evaluation of the progress that the elderly does is very difficult and can vary substantially from one examiner to another. Reviewing the literature that exists on the evaluation of the geriatric patient with hip fracture during the acute and rehabilitation phases is our goal.

Recommended micronutrient supplementation for institutionalized elderly.

A committee nominated by the Israel Ministry of Health examined the relevant literature and the local recommendations as well as the recommendations from other countries and suggested a daily micronutrient supplementation for institutionalized elderly living in institutions supervised by the Ministry of Health. The micronutrient preparatory, tailored for this population, is designed to contain about half the RDA for most of the vitamins and some microelements. Biotin and vitamins C, D and B12 as well as zinc, copper, chromium and molybdenum are suggested at a level higher than half the RDA, whereas fluorine, at a lower level. Major elements (calcium, magnesium and phosphorus) are excluded and should be supplied separately. Vitamin K and iron are also excluded. Fat-soluble vitamins should be microencapsulated. Micronutrient supplementation for institutionalized elderly is part of the Ministry of Health s balanced nutrition policy. The committee s recommendations are also applicable to the free-living elderly population.

Dietary intake analysis in institutionalized elderly: a focus on nutrient density.

BACKGROUND: Inadequate food intake in old age can lead to marginal or suboptimal nutrient intakes causing the deterioration of physiological and health states. OBJECTIVE: To describe, by intake assessment, nutritional status of institutionalized elderly and to compare the data to other studies findings. DESIGN: Dietary intake was assessed in 50 (18 males, 32 females, average age 84 6 years) institutionalized elderly according to data collected by using structured food frequency questionnaires based on the institutional kitchen recipes, weekly menu and portion size. RESULTS: Daily energy intake was 1.91 0.48 Mcal and energy density was 4.97 kcal/g dry matter. Energy derived from protein and fat was 15.1% and 35.4%, respectively. Dietary fiber consumption was very low, 3.92 g/Mcal. Calcium intake of all of the subjects, and magnesium, zinc and copper intakes of most of them, were low. Iron intake of almost all of the subjects was sufficient or above RDA. Intake of vitamins D, E, B6, thiamin (vitamin B1) and folic acid in all or most of the subjects was low. In almost all of the 39 studies and reviews, including ours, densities of at least two nutrients did not meet the calculated RDA density. Particularly low were the nutrient densities of vitamins C and E, thiamin, vitamin B6, folic acid and vitamin D, as well as of calcium, magnesium, zinc and copper. CONCLUSION: Supplementation with half the RDA of micronutrients (except for vitamin A and iron) may result in micronutrient intakes that are higher than two-thirds of the RDA.

Surgical treatment of lumbar spinal stenosis in patients aged 65 years and older.

Spinal stenosis syndrome affects mainly patients at their 5th-6th decades of life. The main goals of surgical treatment in the elderly are to allow the individual to walk longer distances, maintain the activities of daily living (ADL) and social life. Our aim was to evaluate the results of surgical treatment for lumbar spinal stenosis in elderly patients. All patients over 65 years of age who underwent surgery due to spinal stenosis syndrome between 1990 and 1998 were evaluated. There were 29 males and 17 females aged between 65 and 90 years. The clinical presentation included low back pain (89%), intermittent claudication (100%) and neurological involvement (87%). The radiological examination showed a frequent narrowing at the level L4-L5 in 93.5% of the patients. The results of the surgery in a mean follow-up of 22 months were good to excellent in 80% of the patients, fair in 11%, and poor in 9%. An improvement in the intensity of pain and in walking distances was noted in 89 and 85% of the patients, respectively. Improvement was achieved in the level of daily activity and in social lives in 57 and 61%, respectively. Major and minor complication rates were 6.5 and 19.5%, respectively. No mortality was noted in this series. Eighty-seven percent of the patients were satisfied with the results of the surgery. We conclude that Surgery for spinal stenosis is a successful and relatively safe procedure, also for patients aged over 65, and should be considered as a treatment option for these patients.

Cholesterol lowering in the older population: time for reassessment?

Hypercholesterolaemia is an established major risk factor for coronary heart disease (CHD) in the general population. In the vast majority of studies that focused on this particular age group and carefully eliminated other confounding factors such as co-morbid conditions, hypercholesterolaemia was a risk factor for CHD in the older population. Because the prevalence of CHD increases with advancing age, studies that consider not only the relative risk attributed to cholesterol but also the absolute numbers of people affected, show hypercholesterolaemia to be an even stronger risk factor in the elderly. Large primary and secondary prevention studies of HMG-CoA reductase inhibitors (statins) in the elderly have shown a reduction in major coronary events similar to that observed in the younger age group. The role of hypercholesterolaemia as a risk factor for stroke is less clear, and a major limitation is the heterogeneous nature of the disease. Nevertheless, most studies that evaluated non-haemorrhagic strokes separately showed a positive association with cholesterol levels, and statin therapy is effective in preventing stroke. These data provide a rationale for treating older hypercholesterolaemic people with statins, not only to prevent CHD, but also to prevent stroke.

[Micronutrient (vitamins and minerals) supplementation for the elderly, suggested by a special committee nominated by Ministry of Health].

The elderly tend to be at a higher risk for nutritional deficiencies and in particular for micronutrient deficiencies. A committee nominated by Ministry of Health examined the relevant literature and the local recommendations as well as the recommendations from other countries and suggested a daily special micronutrient supplementation for institutionalized elderly. The preparatory will contain about half the RDA for most of the micronutrients, except for fluorine that is recommended at a lower level and biotin, vitamins D, C, B12 as well as zinc, copper and molybdenum at a level higher than half the RDA. Major elements such as calcium, are not included in the preparatory and would be supplied separately when needed. Vitamin K and iron are excluded as well. The suggested preparatory composition, mg: vitamin A, 0.450; vitamin D, 0.015; vitamin E, 10; thiamin, 0.6 Pound riboflavin, 0.7; biotin, 0.030; pantothenic acid, 3; niacin, 8; vitamin C, 60; vitamin B6, 0.8; folic acid, 0.120; vitamin B12, 0.0024; choline up to 275; zinc, 8; copper, 0.9; fluorine, 0.5; manganese, 1.2; chromium 0.020; molybdenum, 0.045; selenium, 0.030; and iodine, 0.075. Fat-soluble vitamins should be microencapsulated. Micronutrient supplementation is part of Ministry of Health balanced nutrition policy. The committees recommendations are also applicable for the free-living elderly.

[Nutritional status and vitamin B6 supplementation in the institutionalized elderly].

Nutritional status and vitamin B6 status were assessed in 18 men and 32 women, average age 84, living in a home for the aged. Average proportion of energy derived from protein was higher than the recommended; fiber intake was very low. Also low were intakes of calcium, magnesium, zinc, copper, vitamins D and E, thiamin, folic acid and vitamin B6. Supplementation with vitamin B6 (10 mg/d) for 28 days in those with the lowest B6 status assessed by B6 intake, activation coefficient of aspartate transaminase and plasma pyridoxamine concentrations led to improved B6 status (marked decrease in activation coefficient) and increased synthesis and decreased degradation of many short-lived neutrophil proteins. Though our elderly enjoy a variety of foods, some have marginal deficiencies that can be improved. Therefore, in the institutionalized elderly, micronutrient supplementation should be administered at a level low enough to be safe (below recommended upper level of intake) but high enough to be effective.