Symposium on geriatric care:.

Academic geriatricians are challenged to develop clinical programs which meet needs in the area of patient care as well as medical student and resident education and research. The creation of such programs within tertiary care institutions can be complex based on existing, traditional styles of care, the increasing demand for geriatric education and the fiscal reality of caring for frail, complex patients. In this article we discuss how five such institutions have met this challenge.

Angiodysplasia and lower gastrointestinal tract bleeding in elderly patients.

Angiodysplasia of the colon is one of the most common causes of major lower intestinal tract bleeding in the elderly; it occurs predominantly in the cecum and on the right side of the colon and is thought to result from degenerative changes associated with aging. The clinical presentation is varied, ranging from hematochezia or melena to iron-deficiency anemia resulting from long-term blood loss. Accurate diagnosis may require a combination of diagnostic techniques, such as angiography, nuclear scanning, and colonoscopy. The management plan should be individualized for each patient depending on severity, rate of rebleeding, and issues of comorbidity. Although conservative medical management is a reasonable option for many patients, endoscopic treatment has generally replaced surgery as the first line of definitive treatment for angiodysplasias in most of these patients. The risk of rebleeding is a considerable problem, and surgical therapy yields better results in this aspect. The role of hormonal therapy is not clearly established.

When your older patient can't sleep: how to put insomnia to rest.

Sleep disorders are common in midlife and older adults, coinciding with encephalographic changes in sleep patterns, stressful life events, and chronic diseases of aging. Differential diagnosis includes respiratory abnormalities (including obstructive sleep apnea), leg cramps, nocturia, ulcer-related pain, medication use, depression, and anxiety. Sedative-hypnotic agents may be appropriate for selected patients, with short-acting substances preferred in all cases. Dosage and dosing schedules should be discussed with the patient to ensure compliance and to avoid possible misuse of these agents.

Factors influencing physicians in recommending in-hospital cardiopulmonary resuscitation.

BACKGROUND: Cardiopulmonary resuscitation (CPR) is a dramatic, costly, and often futile intervention whose appropriate use is under scrutiny. Physicians often ask patients and families to make decisions about resuscitation for themselves or loved ones. Clinical variables and personal beliefs may influence physician recommendations about CPR. METHODS: Physicians (N = 451) at a tertiary care hospital were surveyed to determine the following: (1) the factors they consider when recommending in-hospital CPR, (2) the conditions under which they discuss CPR with patients, (3) their recent participation in CPR attempts, (4) their perceptions of its effectiveness, (5) their personal wishes regarding their own resuscitation, and (6) their personal and professional characteristics. RESULTS: The patient's self-reported wishes about resuscitation and physician judgment of medical utility were the most important influences on physician recommendations. Most physicians believe that patients with metastatic cancer or late Alzheimer's disease should not be resuscitated. Age alone was not viewed as an important clinical consideration. Guidance from hospital policies and ethics committees had the least influence on physicians. Physicians overestimated the likelihood of survival to hospital discharge after in-hospital CPR by as much as 300% for some clinical situations and predicted an overall success rate of 30%. CONCLUSION: These findings suggest that most physicians are thoughtful and discriminating in their recommendations to patients about CPR. Patient's wishes are of paramount importance, followed by physician judgment of medical utility. However, physicians do overestimate the efficacy of CPR and may thus misrepresent the potential utility of this therapy to patients and their families.

Cardiopulmonary resuscitation: how useful? Attitudes and knowledge of an elderly population.

Two hundred forty-eight elderly outpatients completed a survey designed to assess knowledge about the procedural aspects and efficacy of in-hospital cardiopulmonary resuscitation. We found that older people overestimate the percentage survival to actual hospital discharge following in-hospital cardiopulmonary resuscitation by nearly 300%. Most older people also have definite opinions about the appropriate application of cardiopulmonary resuscitation for different clinical circumstances. Most believe that patients with advanced Alzheimer's disease or widespread cancer should not be resuscitated, while patients with depression or early Alzheimer's disease should. Inaccurate beliefs about cardiopulmonary resuscitation efficacy can adversely impact on decision making about resuscitation by older patients. Educational efforts for the elderly may lead to more informed decision making and thereby more appropriate use of this technology.