The ageing of HIV: implications for geriatric medicine.

The prevalence of human immunodeficiency virus (HIV) in the over 50 age group is increasing as a consequence of younger adults ageing with HIV, in addition to new diagnoses in later life. We conducted searches in MEDLINE for English language studies published between January 1984 and January 2010 using search terms 'HIV', 'AIDS', 'HIV testing' and 'HIV complications' and selected articles relevant to adults aged 50 years and over. The prevalence, natural history and complications of HIV infection and treatment in older adults are reviewed. In 2007 the Centers for Disease Control and Prevention in the United States reported that 16.8% of new diagnoses of HIV that year were in individuals aged over 50 years. Older adults are vulnerable to late or missed diagnosis, and poorer treatment outcomes, due to the misconception that they are not at risk. A heightened awareness of HIV as a possible diagnosis in older adults is becoming increasingly important. As the HIV population ages, the emergence of disease and treatment complications such as cardiovascular disease, osteoporosis and dementia are evident. Management of older adults with HIV and multiple co-morbidities presents challenges to infectious diseases physicians and geriatricians alike. Inclusion of older adults in future HIV clinical trials will help design healthcare models to provide for this growing population.

The effects of usual footwear on balance amongst elderly women attending a day hospital.

OBJECTIVE: to examine the effects of footwear on balance in a sample of older women attending a day hospital. DESIGN: this was a crossover trial with a quasi-randomised allocation. SETTING: assessments took place in the geriatric day hospital. SUBJECTS: a cohort of 100 older women aged 60 years and over attending a day hospital. METHODS: demographic data and a brief falls history were recorded. Participant's footwear was assessed using a footwear assessment form. A Berg Balance Scale (BBS) was completed under two conditions--shoes on and shoes off with order counter-balanced. RESULTS: the mean BBS was 39.07 (SD 9.14) with shoes on and 36.54 (SD 10.39) with shoes off (P < 0.0001). Balance scores were significantly higher with shoes on for 10 of the 14 Berg subcategories. Lower barefoot BBS scores were associated with a greater beneficial effect of footwear on balance (P < 0.001). Shoe characteristics were not associated with change in the BBS score. CONCLUSIONS: Wearing their own footwear significantly improved participants' balance compared to being barefoot. The greatest benefit of footwear was seen in those with the poorest balance. Further studies should investigate whether particular types of footwear are associated with greater benefit.

Interventional treatment for acute ischaemic stroke in an 86-year-old.

An 86-year-old lady presented to the accident and emergency department with a 90 min history of receptive and expressive dysphasia. There were no motor symptoms or visual symptoms reported. A partial anterior circulation stroke was diagnosed. On examination, she had a National Institutes of Health Stroke Scale of 6. CT angiography showed an occlusive thrombus within the left internal carotid artery extending into the left M1 segment of the middle cerebral artery and the proximal A1 segment of the anterior cerebral artery. Intra-arterial thrombectomy was preformed. Full recovery was achieved.

Extubation versus tracheostomy in withdrawal of treatment-ethical, clinical, and legal perspectives.

The provision of life-sustaining ventilation, such as tracheostomy to critically ill patients, is commonly performed. However, the utilization of tracheostomy or extubation after a withdrawal of treatment decision is debated. There is a dearth of practical information available to aid clinical decision making because withdrawal of treatment is a challenging scenario for all concerned. This is further complicated by medicolegal and ethical considerations. Care of the "hopelessly ill" patient should be based on daily evaluation and comfort making it impossible to fit into general algorithms. Although respect for autonomy is important in healthcare, it is limited for patients in an unconscious state. Beneficence remains the basis for withdrawing treatment in futile cases and underpins the "doctrine of double effect." This article presents a relevant clinical case of hypoxic brain injury where a question of withdrawal of treatment arose and examines the ethical, clinical, and medicolegal considerations inherent in such cases, including beneficence, nonmaleficence, and the "sanctity of life doctrine." In addition, the considerations of prognosis for recovery, patient autonomy, patient quality of life, and patient family involvement, which are central to decision making, are addressed. The varying legal frameworks that exist internationally regarding treatment withdrawal are also described. Good ethics needs sound facts, and despite the lack of legal foundation in several countries, withdrawal of treatment remains practiced, and the principles described within this article aim to aid clinician decision making during such complex and multifaceted end-of-life decisions.

Diagnosis and management of asthma in older adults.

Despite comprehensive guidelines established by the European Global Initiative for Asthma and the U.S. National Asthma Education and Prevention Program on the diagnosis and management of asthma, its mortality in older adults continues to rise. Diagnostic and therapeutic problems contribute to older patients being inadequately treated. The diagnosis of asthma rests on the history and characteristic pulmonary function testing (PFT) with the demonstration of reversible airway obstruction, but there are unique problems in performing this test in older patients and in its interpretation. This review aims to address the difficulties in performing and interpreting PFT in older patients because of the effects of age-related changes in lung function on respiratory physiology. The concept of "airway remodeling" resulting in "fixed obstructive" PFT and the relevance of atopy in older people with asthma are assessed. There are certain therapeutic issues unique to older patients with asthma, including the increased probability of adverse effects in the setting of multiple comorbidities and issues surrounding effective drug delivery. The use of beta 2-agonist, anticholinergic, corticosteroid, and anti-immunoglobulin E treatments are discussed in the context of these therapeutic issues.