Disseminated bacillus Calmette-Guérin (BCG): a cause of delirium in an older adult.

Intra-vesical Bacillus Calmette-Guérin (BCG) immunotherapy is an effective treatment for high-risk bladder cancer. Less well known is that fewer than 1% of patients receiving BCG treatment can develop disseminated BCG. The reaction can range from a mild flu-like illness to a systemic disorder with a fulminant course which in the most severe cases can lead to death. The diagnostic yield is low and diagnosis is often made after a comprehensive exclusion of more common causes of pyrexia of unknown origin. A high level of suspicion is therefore required in those who may be at risk. We report a case of disseminated BCG in an older patient for whom early involvement of his family was pertinent to determining the precipitant for delirium.

Prospective investigation of the incidence of falls, dizziness and syncope in haemodialysis patients.

BACKGROUND: Prevention of falls in the elderly is a major health care target. There are theoretical reasons why older dialysis patients may be at high risk of falls: co-morbidity, medication, and post-dialysis hypotension, which have not been well tested. Dialysis patients are also at higher risk of fracture if they do fall. METHODS: We prospectively interviewed all our centre haemodialysis patients over a 6 month period to see if they reported falls, syncope, pre-syncope or dizziness. Routine blood pressure (BP) and other clinical data were recorded. RESULTS: A total of 78 patients completed the study. There was a high incidence of all four symptoms but only falls was age-related. About 38% of patients aged >65 reported 1 or more fall compared to 4% of younger patients (p < 0.001). There were no significant differences in pre-dialysis, post-dialysis or standing BP between young and older patients or between fallers and non-fallers although the older patients did have a greater magnitude in change between pre-dialysis BP and post-dialysis standing BP. CONCLUSIONS: Older haemodialysis patients have a high incidence of falls. Falls can be prevented by addressing modifiable risk factors. Whether existing guidelines are applicable to this specialised population is uncertain. There is a high incidence of syncope in dialysis patients of all ages and the cause of this needs further exploration.

Are elderly haemodialysis patients at risk of falls and postural hypotension?

BACKGROUND: The numbers of older people on haemodialysis is rising. As aging and renal failure are risk factors for autonomic failure and haemodialysis involves significant fluid shifts we hypothesized that older patients would be susceptible to hypotensive events between dialysis sessions. Postural hypotension is a risk factor for falls. Falls are debilitating and a leading cause of morbidity and mortality in the elderly. AIM: To investigate whether postural hypotension and symptoms of hypotension and falls are common in older haemodialysis patients. METHODS: All 47 patients from a single unit aged 70 or over were asked about falls in the previous year and about symptoms that could be due to hypotension (syncope, presyncope, dizziness) between dialysis sessions. Twenty-three patients underwent pre- and post-dialysis orthostatic blood pressure measurement, 18 had 44 hour ambulatory blood pressure recording and 10 subjects had full autonomic function testing. RESULTS: Of 47 patients interviewed, 20 reported syncope/pre-syncope, 34 reported dizziness and 14 recalled at least one fall in the previous year. 8/23 had orthostatic hypotension pre-dialysis and 16/23 post-dialysis. Mean 44-hour blood pressure was 134/68 (+/- 21/9) with no nocturnal dip. Autonomic function was abnormal in all 10 subjects tested. CONCLUSIONS: Elderly haemodialysis patients have a high incidence of hypotensive symptoms between dialysis sessions, recalled falls in the previous year and significant postural hypotension post-dialysis. Physicians supervising elderly haemodialysis patients should ask about symptoms between dialysis sessions and explore the possibility of hypotensive events in symptomatic patients.