Prognostic factors of long-term survival in geriatric inpatients. Should we change the recommendations for the oldest people?

OBJECTIVES: Identification of optimal predictors of the 5.5-year survival in former geriatric inpatients.Investigation of the direction and shape of the relationship between mortality risk and its predictors. DESIGN: Retrospective survival analysis with the application of the Cox proportional hazards model. SETTING: Teaching geriatric unit. PARTICIPANTS: 478 inpatients (mean age 77.9; +6.8) discharged from geriatric ward during year 2008, without any exclusion criteria. MEASUREMENTS: Comprehensive geriatric assessment of numerous health variables, body mass index (BMI), clinical and biochemical findings, and outcomes of the final diagnosis. Records on the dates of deaths were obtained from the Provincial Office of Population Register. RESULTS: During the 5.5-year follow-up 209 (43.7%) patients died. In the multivariate setup, six risk factors with an independent impact on mortality were identified: age (p=0.036), cognitive functioning on the Blessed test (p=0.005), score on instrumental ADL (p<0.0001), score on Charlson comorbidity index (p<0.0001), cholesterol level (p<0.0001), BMI (p<0.0001), and hemoglobin level (p=0.02). The latter two predictors exhibited a significant inverted J-shaped association with mortality, i.e., considerably higher risk of death corresponds to the lower values of these variables in comparison to their higher levels. CONCLUSION: Older age, worse IADL and cognitive functioning, and higher comorbidity were recognized as endangering one's long-term survival. On the other hand, moderate obesity (BMI 36), higher cholesterol and the absence of anemia (hemoglobin 13.6 g/dL) are associated with longer survival. Therefore, irrespective of the individualized treatment and physical exercise, nutrient-dense food seems to be a key recommendation to prevent frailty or malnutrition in the oldest and comorbid population.

Syncope and near-syncope as a multifactorial problem in geriatric inpatients: Systemic hypotension is an underrated predictor for syncope exclusively.

PURPOSE: Syncope (SC) and near-syncope (NS) are still misunderstood syndromes. Aim of study was to determine the risk factors for SC, NS, as well as for both entities (SC/NS) in geriatric inpatients reporting these events within the last year, irrespectively of the reason of admission to hospital. MATERIAL AND METHODS: The retrospective study covered 250 patients, consecutively admitted to the geriatric ward. Patients were assigned to the three models: SC and/or NS in total, n=106; isolated NS, n=72; SC with co-existing NS, if any, n=34, and compared with patients without any such events (n=144). The patients underwent a comprehensive geriatric assessment and complete clinical investigation. The binary logistic regression was applied to predict risk factors for each of the models. RESULTS: Falls were most predictive for NS model (OR 35.4; 95% CI 10.3-121.1), and systemic hypotension for SC model (OR 92.9; 95% CI 6.1-1421.0). The highest specificity (85%) and sensitivity (81%) were found for the SC/NS model, with the highest contribution by falls (OR 18.1; 95% CI, 7.6-45.2), orthostatic hypotension (OR 8.1; 95% CI, 3.5-18.5), a history of stroke or transient ischemic attack, treatment with an angiotensin receptor blocker, plasma creatinine >1.4mg/dL, negatively self-rated health, vertigo, pathology of carotid arteries, and lack of hypertension. CONCLUSIONS: Syncope and near-syncope in geriatric inpatients have multifactorial and cumulative aetiology, with blurred, frequently overlapping boundaries between them. The falls, postural hypotension, and/or brain hypoperfusion of different origin seem to be most predictive of the both events, however low systemic blood pressure was predictive for the syncope exclusively.

Kynurenine and its metabolites in Alzheimer's disease patients.

PURPOSE: The kynurenine pathway (KP) is a major route of tryptophan metabolism. Several metabolites of this pathway are proposed to be involved in the pathogenesis of Alzheimer's disease. The aim of this study was to evaluate peripheral KP in patients with Alzheimer type dementia and a detailed analysis of correlation between kynurenine (KYN), kynurenic acid (KYNA), 3-hydroxykynurenine (3-HK), anthranilic acid (AA), quinolinic acid (QUIN) and degree of neuropsychological changes in AD. MATERIAL/METHODS: The plasma concentration of tryptophan and its products degradation by kynurenine pathway were analyzed in 34 patients suffering from Alzheimer type dementia and 18 controls in similar age using high-performance liquid chromatography technique. RESULTS: In demented patients we found lower tryptophan and KYNA concentrations. There was a non-significant increase of KYN, 3-HK and AA levels, and a Marked increase of QUIN in Alzheimer's disease group. We observed positive correlations between cognitive function tests and plasma KYNA levels, and inversely correlations between these tests and QUIN levels in Alzheimer type dementia. CONCLUSIONS: Increased TRP degradation and simultaneous altered kynurenines levels were found in plasma of AD patients. It proves activation of peripheral kynurenine pathway in this type of dementia. The alterations of two main KYN metabolites: KYNA and QUIN seem to be associated with the impairment of the cognitive function in AD patients. This appears to offer Novel therapeutic opportunities, with the development of new compounds as a promising perspective for brain neuroprotection.

Quality of teamwork of family doctors and community nurses in primary care for the elderly in two organizational settings--opinions of the family doctors.

PURPOSE: The elderly are a growing part of the society and a further growth is expected in the demand for both medical and nursing services performed by primary health care institutions. The aim of this work is to answer the question: "Does the form of employment of community nurses in primary health care institutions influence the quality of interdisciplinary cooperation in caring for elderly patients?" MATERIAL AND METHODS: The research was conducted among family doctors, who provided health care in the city of Bialystok under the contract with the National Health Fund. The questionnaire was answered by 104 family doctors. Of this number 69 employed a family nurse and 35 co-operated with a non-public community nursing unit. The database of institutions and doctors employed was acquired from the National Health Fund. The research tool was an anonymous questionnaire. CONCLUSIONS: The opinions of family doctors on the quality of geriatric care provided by the nurses depend strongly on their form of employment. Family doctors' units which employ nurses have a greater scope and better quality of care services for the elderly in comparison to those, which only co-operate with nurses.

Community nursing care of the elderly during transformation of the primary health care system.

PURPOSE: Worsening of health as well as raising disability in course of aging lead to the increase in the needs for medical and nursing services. The on-going reforms of the primary health care system has brought the organizational transformation in community nursing care into the forms of non-public community nursing units. The aim of the study was to describe the characteristics of community nursing care provided to older people with regard to the differences between a traditional model of the public (SPZOZ) and new model of non-public units (NZOZ). MATERIAL AND METHODS: The study was carried out in all 113-community nurses employed in Bialystok, regardless of the form of employment. The questionnaire was answered by 101 nurses, from which one was excluded due to double employment in public (SPZOZ) and non-public (NZOZ) settings. From among of the remaining 100, 76 were employed in SPZOZ and 24 in NZOZ. As the research tool was used the questionnaire. RESULTS: The data obtained show the predominance of the therapeutic (95%) and diagnostic (78%) services which were more frequently provided by nurses employed in public sector (SPZOZ). Assessment of social situation as well as a caring process, education was rarely provided in both groups of nurses. CONCLUSIONS: Mostly instrumental and therapeutic activities predominated in the community nursing. Generally, any significant differences between two settings of nursing care there were not found. The traditional model of community nursing care enables the realization the full professional competence of nurse in the primary health care system.

Falls amongst older people living in the community.

PURPOSE: Falls (instability)--as well as immobility, incontinence, intellectual impairment, depression and visual and auditory impairment are considered to be serious problems in the field of geriatrics. They have multiple causes, tend to reoccur, have no simple cure and make the older person dependent on others for care. This paper presents the results of the study on the prevalence of falls and their determinants in communities of older people (aged 75 and over). MATERIAL AND METHODS: The study design: cross-sectional questionnaire study and survey. The studied population lived in two chosen areas (urban and rural). The questionnaire, as well as instruments to verify the respondent's skills and functional ability, were used. Doctors and nurses employed in the studied areas were interviewers. RESULTS: 457 randomly selected older people (228 from the rural area and 229 from the urban one) took part in the study. Falls in the course of the last year were reported by 45.1% of the group; more frequently by people living in the rural area (58.3% versus 31.9% in the urban one), by women (66.7% versus 44.8% in the men's group) and by people with different disabilities (cognitive impairment, locomotive disabilities, ADL-dependence, visual and auditory impairment), with poor self-reported health status and living arrangements. The score according to Tinetti's test--conducted in the rural areadetermined the frequency of the falls reported. CONCLUSIONS: The study has confirmed that falling is an increasing hazard for older people, especially for women, for people living in rural areas and for those with different mental and physical disabilities.

The COPE index--a first stage assessment of negative impact, positive value and quality of support of caregiving in informal carers of older people.

Data was collected in five countries from informal carers of older people (n = 577) via a common protocol. Carers completed: (1) a 17-item version of the Carers of Older People in Europe (COPE) Index, an assessment of carers' perceptions of their role : (2) a questionnaire on demographic and caregiving circumstances : and (3) three instruments included for the criterion validation of the COPE Index (the General Health Questionnaire, the Hospital Anxiety and Depression Scale, and the World Health Organization Quality of Life-BREF). Principal Component Analysis of the COPE Index was followed by internal consistency analysis of emergent components. Scales derived by summing items loading on the components were analyzed for their association with the criterion measures. Two components, negative impact and positive value, emerged consistently across countries. A third component, quality of support was less consistent across countries. Scales derived from the negative impact and positive value components were internally consistent and significantly associated with the criterion validity measures. These two scales and four items drawn from the quality of support component were retained in the final COPE Index. While further testing is required, the COPE Index has current utility in increasing understanding of the role perceptions of carers of older people.

[Care of the frail elderly in population studies]. / Opiekunowie niedoleznych osób starszych w badaniu populacyjnym.

UNLABELLED: The paper is one of the publications presenting the Polish part of the study on the EASY-Care questionnaire. The study was carried out as the multi-centre project "Supporting Clinical Outcomes in Primary Care of the Elderly". The EASY-Care Questionnaire is an instrument to assess the health care needs and social situation of older people for use in primary care. OBJECTIVES: To identify the main providers of help to the frail community-dwelling elderly people aged 75 years and over. DESIGN: Cross-sectional questionnaire study, survey. SETTING: Community-dwelling elderly people living in the administrative borders one of the community health care centres in Bialystok-city. PARTICIPANTS: 117 randomly selected people aged 75 years and over; the interviewers were doctors and nurses, serving the studied area. MEASUREMENTS: Elderly Assessment System EASY-Care, version 1997,98. RESULTS: 81 persons of the studied group (69.2%) were ADL-dependent. Most of the elderly people in need of care were women, more often with the suspicion of depression and with cognitive impairment. Most of the caregivers (80%) of the frail community-dwelling elderly people 75 and over were family members living together (42%), living apart (21%) or it was wife/husband (17%). Almost 10% of the ADL-dependent elderly had no carer at all. The category of carers fulfilling all of the needs of the care recipient were more often the spouse. The role of the public care providers was marginal. CONCLUSIONS: The family is still the basic source of support and the central element in the care system for the elderly in Poland. The family is insufficiently supported by formal and informal carers.

[The assessment of the functional state of elderly people by family physician with the help of EASY-Care questionnaire]. / Ocena stanu funkcjonowania ludzi w podeszlym wieku przez lekarza rodzinnego za pomoca kwestionariusza. EASY-Care.

The multiplicity and complexity of diagnostic and therapeutical problems affecting elderly patients requires a special approach which has come to be known as the comprehensive geriatric assessment. This approach demands the interdisciplinary cooperation of several practitioners in the field of geriatric care, led by the family doctor. An essential prerequisite for their cooperation to be successful is that there should be some commonly acknowledged starting point in the form of a standardised assessment of the functional state of elderly patients, irrespective of the the number and type of chronic conditions from which they may be suffering. The aim of this paper is to put forward a short and straightforward instrument for assessment of the functional state of elderly people in the form of the EASY-Care questionnaire for the use of family doctors. EASY-Care is a system "picture" of the needs of elderly people. It focuses more on the quality of life of the elderly person rather than on his/her illnesses and takes into consideration the role played by family carers. EASY's main aim is to provide family doctors and other primary care practitioners with information to help them to improve the services that they provide for the elderly. Moreover, the data gained from the use of EASY may help to serve epidemiological purposes, by providing measures of the social and medical needs of the elderly together with information about the degree to which these are being met. Consequently, it also provides a rationale for the provision of funding, directing research and developing a policy for the care of the elderly. The EASY-Care questionnaire has been developed in order to promote a common approach in Europe for the assessment of the elderly.

[Hypokalemic metabolic alkalosis with hypomagnesemia and hypocalciuria; Bartter's syndrome in Gitelman's variant--case report]. / Hipokaliemiczna zasadowica metaboliczna z hipomagnezemia i hipokalciuria; zespól Barttera w wariancie gitelmana--opis przypadku.

A case is presented of a 30-year old man with long-term history of painful muscle cramps, episodes of tetany, general malaise and persistent hypokaliemia. On the ground of clinical appearance and biochemical data the Bartter's syndrome in Gitelman's variant was diagnosed. In differential diagnosis we considered renal tubular acidosis, other tubular defects (Liddle's syndrome), primary and secondary hyperaldosteronism. Other possible causes of hypokaliemia were excluded such as surreptitious diuretic and lexative abuse, persistent vomiting and diarrhea. Good therapeutic effect were achieve using spironolacton, indomethacin, propranolol and potassium supplementation.

A socio-medical survey of the old citizens of Bialystok, Poland: 5 years longitudinal observation.

The aim of the longitudinal study was the evaluation of the changing socio-medical conditions of the old citizens of Bialystok during a 5 year period of observation. The study was based on the analysis of 6 age/sex cohorts of 100 men and 100 women born in 1899, 1909, 1919. A stratified systematic sampling of the entire population of the city in the required generation was used. The survey was conducted twice, in 1979 and 1984, and employed a questionnaire prepared by the Editorial Board of the Comparative Study of Eleven Countries developed by WHO. The questionnaire included items concerning personal data, occupation, housing conditions, health status, functional ability, the use of health services, social activity and life satisfaction. The data allow us to consider aging in all its aspects - health status, life style, opinions and feelings of the elderly - according to age group (cross-sectional analysis) and according to the progression of chronological age in the same cohorts (longitudinal analysis).