Infection-related hypoglycemia in institutionalized demented patients: a comparative study of diabetic and nondiabetic patients.

Hypoglycemia is common in elderly community dwelling patients and may accompany episodes of acute infection. We analyzed the interrelations of clinical variables with infection-related hypoglycemia (IRH) and its outcome in institutionalized demented elderly patients, with and without diabetes mellitus (DM). This is a retrospective cohort study involving residents of a large long term-care facility. We measured demographic, clinical, functional, nutritional and cognitive data as well as blood counts and chemistry analysis. We identified 65 elderly patients with IRH and compared data of 33 diabetic patients with 32 nondiabetic patients. Mean age of patients was 77.7 years and mean Mini-Mental score of 1.8. Diabetic patients were younger, more cognitively impaired, had a lower functional score (nonsignificant differences), but presented with more comorbidities, compared with nondiabetics (p=0.004). Mean blood glucose levels in diabetics and nondiabetics were 53.2 and 54.3 mg/dl, respectively. Only 22% of the patients showed clinical signs indicating hypoglycemia. Multivariate analysis showed that, in groups, comorbidity and functional status, creatinine, albumin, C-reactive protein (CRP) and total cholesterol were all associated with IRH. During a 6 months period, 58% (38/65) of the patients died, out of whom 47% (18/38) died within one month following the documentation of IRH. There were no statistically significant differences in short and late mortality rates between patients with and without DM. we conclude that asymptomatic IRH in institutionalized demented elderly is frequently associated with common respiratory and urinary infections, in both diabetic and nondiabetic patients. IRH seems to indicate a poor general health status rather than being the cause of death. Blood glucose needs to be screened in this population during common infections, also in nondiabetics, to identify patients at high risk.

Functional recovery after hip fracture in old-old elderly patients.

Hip fracture is epidemic and prevalence increased with advanced age. Impact of comorbid and cognitive status, gender, type of fracture, operative delay and pre-fracture ambulatory levels on functional outcome was shown in previous studies. We studied functional outcome after rehabilitation for hip fracture in old-old elderly (85 years and older) and compared it to young elderly (65-74 years) community-dwelling patients. Before the fracture, old-old elderly patients were more functional dependent, has had more comorbid diseases, and more of them live alone than young elderly. The waiting time to surgery and mean length of stay in orthopedic ward were longer than in young elderly. On admission to rehabilitation treatment, old-old patients presented with more depressed mood, were more cognitive impaired, and more suffer from pain. Old-old patients presented with laboratory data of malnutrition (decreased serum levels of albumin, cholesterol, hemoglobin, hematocrit, lymphocyte count) and inflammation (increased of transferrin and C-reactive protein). Improvement in Functional Independence Measurement (FIM) scale was found in both groups but significantly better in young elderly than in old-old elderly. The change in FIM during the rehabilitation period (DeltaFIM) were in FIM total and in those parts of FIM concerning locomotion. The mean duration of rehabilitation stay was significantly longer in old-old elderly patients. On discharge old-old elderly patients more suffer from pain and difference between the groups according to the laboratory and to the cognitive data increased. Age per se is indicator of frailty and determinate functional recovery after hip fracture.

Plasma homocysteine levels and cognitive status in long-term stay geriatric patients: a cross-sectional study.

Many studies have established an association of total plasma homocysteine (Hcys) levels and the risk for dementia and Alzheimer disease. However, little is known on the relation between Hcys and cognitive status in long-term stay geriatric patients. This cross-sectional study was conducted in a long-stay geriatric center and included 186 eligible patients, staying for more than 6 months in the facility. We looked for patients' clinico-demographic data, as well as for laboratory data and cognitive status, evaluated by the mini-mental state examination (MMSE). Patients were divided into three groups according to Hcys levels and analyzed in order to explore potential association with cognitive levels, considering clinically important cofounders. Cognitive state of patients of the highest Hcys tertile was significantly impaired, compared with other groups (p < 0.0001) and characterized by a worse nutritional status. Pearson's correlation coefficient for Hcys and MMSE resulted -0.251 (p = 0.0005). The linear regression model for MMSE showed that homocysteine is significantly associated with MMSE: mean MMSE score of patients with homocysteine >13.7 was significantly lower than the mean MMSE of patients with homocysteine < or = 8.5, after controlling for all other parameters in the regression equation (beta = -2.7685, p = 0.007). We conclude that in our sample of patients, Hcys was associated with cognitive impairment. Hcys levels >13.7 micromol/l remained a significant independent parameter associated with the severity of cognitive impairment, after controlling for other confounders. A better understanding of the mechanisms underlying such interrelations may have research and interventional implications.

Folate status and folate related anemia: a comparative cross-sectional study of long-term care and post-acute care psychogeriatric patients.

Aging is associated with increased risk of anemia, poor nutrition, chronic illness, and impaired folate status. We aimed to investigate and compare folate status in long-term care psychogeriatric patients (LTCPP) and in post-acute care psychogeriatric patients (PACPP). This is a cross-sectional study conducted in a psychogeriatric medical center with long-term care and post-acute care wards. A total number of 553 LTCPP and 373 PACPP were studied. Low serum folic acid levels were found in 10% of LTCPP and in 13% of PACPP. Folic acid anemia (FAA) was found in 67% of LTCPP and 87% of PACPP (P = 0.046) with low serum folate levels. Mean levels of serum folate were similar but red blood cells folate (RBC-folate) was higher in PACPP (P = 0.025) and in males compared with women (P = 0.009). 56% of PACPP and 68% of LTCPP who had folic acid anemia presented with another type of anemia. Anemia of chronic disease was the most frequent coexisting anemia and was found in 65% of LTCPP and 52% of PACPP, followed by B12 deficiency anemia and iron deficiency anemia. We conclude that PACPP represent only a slightly different group, compared with LTCPP, with regard to the folate status. These high rates of folate and RBC-folate deficiencies, as well as of FAA and coexisting anemia, call for a routine evaluation of folate status in all psychogeriatric patients, whether LTCPP or PACPP.

Hypodermoclysis (subcutaneous infusion) effective mode of treatment of dehydration in long-term care patients.

Dehydration is associated with morbidity and mortality in frail elderly patients. Intravenous fluid administration in these patients is sometimes hard, especially in agitated patients. The purpose of this study was to review of 57 long-termed care patients received hypodermoclysis infusion on 118 different occasions during the 9 months. Data collection included: demographic data, functional and mental status, indication hypodermoclysis, duration of the infusion, type of solution, laboratory data, adverse effects, and outcome. The main reasons for initiation of the hypodermoclysis were either dehydration (64%) or febrile illness (21%). The average duration of infusions was 15.9 days and average daily volume was 1161 ml per day. After hydration by hypodermoclysis, in 77% of the patients, clinical improvement occurred manifested as general improvement (88%), cognitive status improvement (84%), and improved oral intake (81%). During the course of the study, failure of the treatment was observed in 12% of the patients, mortality of 11% was observed. Nobody developed signs of fluid overload. Local complications were reported in 12% of patients: local swelling (6/57), complain of local pain at site (3/57) and local inflammation (2/57). Hypodermoclysis is a safe, effective and suitable alternative to intravenous re-hydration in long-term care patients.

Outcomes of decompression surgery for lumbar spinal stenosis in elderly diabetic patients.

The purpose of this study was to assess and compare the outcome of surgical decompression for spinal stenosis in diabetic and non-diabetic elderly patients. This is a retrospective chart analysis conducted in a university affiliated referral hospital. The participants were consecutive patients, age 65 and older, undergoing laminectomy for spinal stenosis during 1990-2000. We assessed patients' clinical and demographic data, procedures, perioperative complications, preoperative and postoperative pain intensity, basic activities of daily living (BADL), patients' satisfaction, the need for repeated surgery, and overall mortality. A total number of 62 elderly diabetic group (DG) patients undergoing decompression surgery for spinal stenosis were compared with a sex and age-matched non-diabetic control group (CG) at baseline, and a mean of 40.3 months thereafter. We found that the DG patients had more pain ( p=0.042), and suffered more frequently from neurogenic claudication ( p=0.0018), motor weakness ( p=0.021) and numbness of the affected limb ( p=0.0069) than the CG patients. Nocturnal pain was reported in 24% of the DG patients. Pain relief was successfully achieved in both groups ( p<0.001), but the patients' satisfaction was greater in the non-diabetic patients ( p=0.0067). Revision surgery was more frequently performed in the DG than the CG (non-significant difference), and the time interval for such a second intervention was shorter ( p=0.04) in the DG. A higher rate of post-operative complications was observed in the DG ( p<0.0001). It is concluded that surgical treatment of elderly diabetic patients suffering from spinal stenosis improves BADL and ameliorates pain, but the results remain worse than those observed in non-diabetics. The outcome of diabetic patients depends upon the presence of other comorbidities, concurrent diabetic neuropathy, duration of diabetes and insulin treatment. Successful postoperative pain reduction remained the strongest factor associated with patients' satisfaction.

A comparative study of the syndrome of inappropriate antidiuretic hormone secretion in community-dwelling patients and nursing home residents.

BACKGROUND AND AIMS: Limited data exist about the clinical characteristics of the syndrome of inappropriate antidiuretic hormone secretion (SIADHS) in hospitalized elderly. Moreover, there may be differences regarding this syndrome between populations, depending on the referral source to hospitals. The objectives of the study were to determine the etiology, clinical characteristics and hospital outcome in a sample of elderly hospitalized patients with SIADHS, and to compare community-dwelling patients (CDP) with nursing home residents (NHR). METHODS: This retrospective chart analysis was conducted in a university affiliated referral hospital. The participants were consecutive elderly patients, admitted with hyponatremia (< 135 mmol/L), and ultimately diagnosed as having SIADHS. We examined patient demographics, medical history, clinical presentation, laboratory and imaging studies, and hospital outcome. RESULTS: Of the 179 patients presenting with hyponatremia, 79 patients (44%) fulfilled the criteria for SIADHS; 73% of these patients were CDP and 27% were NHR (mean ages, 74.4 +/- 6.9 and 75.7 +/- 7.2 years, respectively). Most CDP complained of weakness and dizziness, while NHP presented with confusion, seizures and vomiting. Mean sodium levels and mean plasma osmolality values were similar in both groups, however, the number of patients with sodium levels < or = 121 mmol/L was significantly higher among NHR. The leading causes of SIADHS in both groups were medications, idiopathic form, and concurrent malignancies. In patients older than 81 years, idiopathic (50%) and drug-induced (20%) SIADHS were more frequent, compared with younger age groups. The overall in-hospital mortality rate was significantly higher in NHR as compared with CDP (p = 0.014), yet, it was similar in both groups once only patients with sodium levels of 121 mmo/L or lower were considered. CONCLUSIONS: While leading causes of SIADHS in community and nursing home residents are similar, there are marked differences in clinical presentation and outcome. This knowledge should help in identifying high-risk patients and taking appropriate measures.

Delayed recurrent SIADH associated with SSRIs.

BACKGROUND: Depression is a common problem in elderly patients and is frequently treated with selective serotonin-reuptake inhibitors (SSRIs). OBJECTIVE: To report a case of delayed recurrent hyponatremia after switching from one SSRI to another. CASE SUMMARY: An 87-year-old depressed woman began treatment with fluvoxamine. One week later, she was diagnosed with hyponatremia, most likely syndrome of inadequate antidiuretic hormone. Following discontinuation of fluvoxamine, the serum sodium concentration normalized. Later, she began treatment with paroxetine. Sixteen months after initiating paroxetine, she developed symptomatic recurrent hyponatremia. After paroxetine was discontinued, the sodium concentration normalized. DISCUSSION: In this case, unlike those previously reported, hyponatremia recurred 16 months after a different SSRI was initiated. The Naranjo probability scale indicates a probable relationship between recurrent hyponatremia and paroxetine. The mechanism of SSRI-induced hyponatremia is multifactorial. CONCLUSIONS: This case illustrates that replacement of one SSRI with another can cause delayed, recurrent hyponatremia in elderly patients. Plasma sodium concentrations must be monitored, not only in the first weeks of treatment, but throughout the full course.

Observations on the safety and efficacy of surgical decompression for lumbar spinal stenosis in geriatric patients.

This retrospective study examines the results of surgical decompression of the lumbar spinal canal in 122 geriatric patients (age range 75-89 years) treated under general anesthesia by the same surgeon between the years 1990 and 1999. Patient demographics, perioperative complications, pain profiles before surgery and at the time of data collection (December 2000), as well as overall mortality were recorded. One hundred and twenty-two patients were studied. The average age at the time of surgery was 78.8 years (range 75-89 years). No perioperative deaths were recorded. The mean time elapsed from surgery until patient follow-up was 45.7 months (range 12-119 months). Fourteen patients had died at the time of patient follow-up (December 2000). When compared to pain experienced before surgery, at the time of the interview a significant (P<0.0001) improvement in low-back and radicular pain as well as in the ability to perform daily activities (dressing, washing, getting out of bed and walking) was described. We conclude that, for geriatric patients rated as physical status I-II (>75 years) under the American Society of Anesthesiologists (ASA) classification, surgical release of lumbar spinal stenosis is a safe and effective treatment option. However, the suitability of ASA III patients requires further investigation.