RESUMO
The widespread availability of coronary artery bypass grafting and percutaneous transluminal coronary angioplasty presents important treatment options for the older patient. The findings from a number of surgical series of coronary artery bypass grafting and percutaneous transluminal coronary angioplasty are summarized. Certain trends are evident. Perioperative mortality, cardiovascular morbidity, and other complications, while declining, remain somewhat higher in elderly patients. However, the impact of age alone is slight. In both coronary artery bypass grafting and percutaneous transluminal coronary angioplasty, complications are more closely correlated with the presence of serious concomitant disease. Long-term survival and pain relief after coronary artery bypass grafting are excellent in older patients, and percutaneous transluminal coronary angioplasty may be the treatment of choice in some elderly patients with coronary artery disease. As in younger patients, prolongation of survival should not be the exclusive goal. Rather, a focus on quality of life and freedom from dependency should be seriously considered.
Assuntos
Doença das Coronárias/terapia , Idoso , Idoso de 80 Anos ou mais , Angioplastia Coronária com Balão , Ponte de Artéria Coronária , Doença das Coronárias/mortalidade , Humanos , Qualidade de Vida , Taxa de SobrevidaRESUMO
BACKGROUND: Recognition and medical record documentation of dementia in the primary care setting are thought to be poor. To our knowledge, previous studies have not examined these issues in private practice office settings within the United States. OBJECTIVE: To determine the rate of unrecognized and undocumented dementia in a primary care internal medicine private practice. METHODS: This was a cross-sectional study of 297 ambulatory persons aged 65 years and older attending an internal medicine private group practice within an Asian American community of Honolulu, Hawaii. Of the subjects, 95% had been with their current primary care physician for at least 1 year. Each subject's primary care physician noted the presence or absence of dementia by questionnaire at the time of an office visit. An investigating physician (V.G.V.) subsequently assessed cognitive function using the Cognitive Abilities Screening Instrument, and confirmed the presence of dementia and its severity, if present, using Benson and Cummings' criteria and the Clinical Dementia Rating Scale, respectively. A trained research assistant completed telephone interviews to proxy informants for collateral information concerning cognition, behavior, and occupational or social function. Subjects' outpatient medical records were reviewed for documentation of problems with cognition. RESULTS: Twenty-six cases of dementia were identified. Of these 26, 17 (65%) (95% confidence interval, 44.3-82.8) were not documented in outpatient medical records; of 18 patients, 12 (67%) (95% confidence interval, 40.9-86.7) were not thought to have dementia by their physicians at the time of the office visit. Recognition and documentation rates increased with advancing stage of disease. CONCLUSION: Dementia is often unrecognized and undocumented in private practice settings. Arch Intern Med. 2000;160:2964-2968
Assuntos
Demência/diagnóstico , Avaliação Geriátrica , Atenção Primária à Saúde , Idoso , Transtornos Cognitivos/diagnóstico , Estudos Transversais , Feminino , Havaí , Humanos , Modelos Logísticos , Masculino , Testes PsicológicosRESUMO
BACKGROUND: Constipation is frequent in PD, although its onset in relation to clinical PD has not been well described. Demonstration that constipation can precede clinical PD could provide important clues to understanding disease progression and etiology. The purpose of this report is to examine the association between the frequency of bowel movements and the future risk of PD. METHODS: Information on the frequency of bowel movements was collected from 1971 to 1974 in 6790 men aged 51 to 75 years without PD in the Honolulu Heart Program. Follow-up for incident PD occurred over a 24-year period. RESULTS: Ninety-six men developed PD an average of 12 years into follow-up. Age-adjusted incidence declined consistently from 18.9/10,000 person-years in men with <1 bowel movement/day to 3.8/10,000 person-years in those with >2/day (p = 0.005). After adjustment for age, pack-years of cigarette smoking, coffee consumption, laxative use, jogging, and the intake of fruits, vegetables, and grains, men with <1 bowel movement/day had a 2.7-fold excess risk of PD versus men with 1/day (95% CI: 1.3, 5.5; p = 0.007). The risk of PD in men with <1 bowel movement/day increased to a 4.1-fold excess when compared with men with 2/day (95% CI: 1.7, 9.6; p = 0.001) and to a 4.5-fold excess versus men with >2/day (95% CI: 1.2, 16.9; p = 0.025). CONCLUSIONS: Findings indicate that infrequent bowel movements are associated with an elevated risk of future PD. Further study is needed to determine whether constipation is part of early PD processes or is a marker of susceptibility or environmental factors that may cause PD.
Assuntos
Constipação Intestinal/fisiopatologia , Doença de Parkinson/etiologia , Fatores Etários , Idoso , Constipação Intestinal/epidemiologia , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Fatores de RiscoRESUMO
BACKGROUND: Evidence suggests that nigrostriatal system disorders are associated with PD and adiposity. Whether patterns of adiposity coexist or predate clinical PD is unknown. This report examines the relation between midlife adiposity and the risk of PD. METHODS: Measurement of adiposity occurred from 1965 to 1968 in 7,990 men in the Honolulu Heart Program (aged 45 to 68 years and without PD). Adiposity measures included body mass index (BMI), subscapular skinfold thickness (SSF), and triceps skinfold thickness (TSF). Follow-up for incident PD occurred over a 30-year period. RESULTS: During the course of follow-up, PD was observed in 137 men. Among the measures of adiposity, age-adjusted incidence of PD increased threefold from 3.7/10,000 person-years in the bottom quartile of TSF (1 to 5 mm) to 11.1/10,000 person-years in the top quartile (11 to 32 mm, p < 0.001). Effects of TSF on PD were independent of cigarette smoking, coffee consumption, physical activity, daily caloric and fat intake, and the other measures of adiposity (p < 0.001). Whereas rates of PD were lowest in the bottom quartile of BMI and SSF vs higher quartiles, associations with PD were weaker than they were for TSF. The effect of TSF on clinical onset before age 65 years was similar to the effect that was observed in later life. CONCLUSIONS: Increased triceps skinfold thickness measured in midlife is associated with an elevated risk of future PD. Whether patterns of adiposity reflect a unique metabolic pathology in individuals at a high risk of PD warrants further study.
Assuntos
Tecido Adiposo/patologia , Índice de Massa Corporal , Obesidade/epidemiologia , Doença de Parkinson/epidemiologia , Idoso , Idoso de 80 Anos ou mais , Intervalos de Confiança , Seguimentos , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Obesidade/complicações , Obesidade/patologia , Doença de Parkinson/etiologia , Doença de Parkinson/patologia , Modelos de Riscos Proporcionais , Fatores de RiscoRESUMO
OBJECTIVE: To assess the relationship between impaired glucose tolerance and both vascular dementia and AD. BACKGROUND: Diabetes and abnormalities of glucose metabolism have been associated with stroke and poor cognitive function. In addition, glycoproteins and glycosylation have been postulated to be associated with the development of neuritic plaques characteristic of AD. METHODS: A historical prospective cohort study of Japanese-American men (n = 3,774), who were examined at ages 45 to 68 (1965 through 1968) and again at ages 71 to 93 (1991 through 1993). Measurements were obtained by clinical and home examinations: assessment of glucose intolerance (nonfasting 1 hour after glucose load) from 1965 through 1968 and history of diabetes diagnosed by a physician at examinations given from 1965 through 1968 and from 1976 through 1978. At the 1991 through 1993 examinations, the Cognitive Assessment Screening Instrument (CASI)-an instrument designed for use in cross-cultural settings combining features of the Folstein Mini-Mental State Examination, the Modified Mini-Mental State Examination, and the Hasegawa Dementia Screening Scale-was used. Diagnosis and classification of AD and vascular dementia were made by a consensus panel using neuropsychologic assessment data, a neurologist's evaluation, and information from a family informant. Diagnostic and Statistical Manual of Mental Disorders, 3rd ed., revised criteria were used to establish dementia, and subclassification by cause was based on other published criteria. RESULTS: No association between AD and diabetes, present either 25 or 15 years previously, was found after adjustment for age and education in a multiple regression model. A significant association was found between impaired glucose tolerance at baseline and vascular dementia (p < 0.01). CONCLUSIONS: These findings confirm expected relationships between impaired glucose tolerance and stroke-related dementia but do not support an association of disordered glucose metabolism with AD.
Assuntos
Doença de Alzheimer/sangue , Diabetes Mellitus/sangue , Teste de Tolerância a Glucose , Idoso , Idoso de 80 Anos ou mais , Asiático , Circulação Cerebrovascular , Humanos , Estudos Longitudinais , Masculino , Pessoa de Meia-Idade , Fatores de RiscoRESUMO
BACKGROUND: The Honolulu Heart Program (HHP) is a prospective study of heart disease and stroke that has accumulated risk factor data on a cohort of 8,006 Japanese American men since the study began in 1965. A recent examination of the cohort identified all patients with vascular dementia (VaD) using the criteria of the California Alzheimer's Disease Diagnostic and Treatment Center. OBJECTIVE: To characterize patients with VaD by stroke subtype and to investigate risk factors for VaD in a cohort of Japanese American men, aged 71 to 93, living in Hawaii and participating in the HHP. METHODS: Sixty-eight men with VaD were compared with 3,335 men without dementia or stroke (NSND). Men with VaD were also compared with 106 men with stroke who were not demented (SND). Candidate risk factors were measured prospectively. RESULTS: Of the 68 men with VaD there were 34 (50%) whose VaD was attributed to small vessel infarcts, 16 (23%) whose VaD was related to large vessel infarcts, and 11 (16%) with both large and small vessel infarcts. The remainder could not be classified. In a multivariate logistic regression model for VaD compared with NSND containing variables found to be associated with VaD in a univariate analysis, age (odds ratio [OR] 1.19, 95% confidence interval [CI] 1.13 to 1.27), coronary heart disease (OR 2.50, 95% CI 1.35 to 4.62), and 1-hour postprandial glucose (OR 1.41, 95% CI 1.06 to 1.88) remained significantly predictive of VaD, whereas preference for a Western diet (OR 0.54, 95% CI 0.30 to 0.98) as opposed to an Oriental or mixed diet and use of supplementary vitamin E (OR 0.32, 95% CI 0.12 to 0.82) were protective. A similar model for the comparison of men with VaD and SND revealed age (OR 1.24, 95% CI 1.14 to 1.35) was predictive of VaD, whereas preference for a Western diet (OR 0.43, 95% CI 0.22 to 0.86) was protective. CONCLUSIONS: The most common stroke subtype associated with VaD was lacunar stroke. Age and traditional vascular risk factors are important contributors to the development of VaD in late life. The antioxidant vitamin E and presently unknown factors related to a Western diet as opposed to an Oriental diet may be protective against developing VaD.
Assuntos
Transtornos Cerebrovasculares/epidemiologia , Demência Vascular/epidemiologia , Idoso , Idoso de 80 Anos ou mais , Ásia , Havaí , Humanos , Masculino , Razão de Chances , Estudos Prospectivos , Fatores de RiscoRESUMO
OBJECTIVE: To determine diagnostic accuracy for AD in a population-based study of Japanese-American men. AD is neuropathologically confirmed for more than 80% of cases at major referral centers (primarily Caucasians); however, information on diagnostic accuracy in population-based studies and studies of different ethnic groups is limited. METHODS: There were 3,734 men who participated in the Honolulu-Asia Aging Study 1991 through 1993 dementia examination and 2,603 in the 1994 through 1996 examination. Diagnoses were based on published criteria. Neuropathologists blinded to clinical data quantified neurofibrillary tangles (NFT) and neuritic plaques (NP). RESULTS: Of 220 autopsied subjects, clinical evaluation revealed 68 with normal cognition, 73 intermediate, and 79 with dementia: 20 AD, 27 vascular dementia, 19 AD + other, and 13 other dementia. Among 20 cases with pure AD, the median value for maximum neocortical NFT density was 6.9/mm(2) and for neocortical NP density was 8.0/mm2. Corresponding densities for other groups were <3.0/mm2. Using established neuropathologic criteria, 25% (5/20) of clinical AD cases had enough NP to meet definite AD criteria, whereas 65% (13/20) had sufficient NP to meet neuropathologic definite or probable AD criteria. Among nine AD cases with moderately severe dementia, only two (22%) had NP densities great enough to meet definite neuropathologic criteria, whereas seven (78%) met neuropathologic criteria for probable AD. CONCLUSIONS: Neuropathologic confirmation and NP density among decedents with clinical AD in this population-based study were lower than reported by referral centers and similar to reports from two other community studies. Ethnic differences in propensity for amyloid deposition as well as differences in clinical severity and representativeness of cases might contribute to these findings.
Assuntos
Doença de Alzheimer/patologia , Idoso , Idoso de 80 Anos ou mais , Ensaios Clínicos como Assunto , Havaí , Humanos , Masculino , Vigilância da PopulaçãoRESUMO
Severe acute and chronic hepatic damage occurred in a white man who had taken phenelzine sulfate (Nardil) 45 mg daily for 70 days. Liver biopsy showed a mixed hepatitic and cholestatic pattern with extracellular deposition of a unique homogeneous collagenous substance. Portal cirrhosis developed and has persisted. The patient was found to have a "rapid acetylator phenotype" and high rate of metabolism of antipyrine. These innate factors may have predisposed to hepatic injury due to phenelzine.
Assuntos
Doença Hepática Induzida por Substâncias e Drogas/patologia , Fenelzina/efeitos adversos , Espaço Extracelular , Humanos , Fígado/patologia , Masculino , Pessoa de Meia-IdadeRESUMO
Relations between cognitive test scores in later life and prior myocardial infarction (MI), coronary artery bypass graft surgery (CABG), and stroke were examined for this study. Subjects were 3,734 Japanese-American men (80% of surviving Honolulu Heart Program cohort) aged 71 to 93 years at the time of cognitive testing. Impairment was defined as scoring below the 16th percentile on a validated cognitive assessment scale. Prior MI, stroke, and CABG were established using hospital surveillance, history, and record review. After adjustment for age, years of education, and years of childhood spent in Japan, men with prior stroke were significantly more likely than others to have poor cognitive performance (odds ratio 4.4, 95% confidence limits 3.0 to 6.7). History of > 1 stroke was associated with an odds ratio of 50 (95% confidence limits 10.5 to 238.3). There was no significant association between cognitive performance and > or = 1 prior MI or history of CABG. Time between events and cognitive function testing did not affect results. Analyses support a significant association between clinical stroke and persistent cognitive impairment, but fail to implicate CABG or MI.
Assuntos
Envelhecimento/fisiologia , Transtornos Cerebrovasculares/complicações , Transtornos Cognitivos/etiologia , Cognição/fisiologia , Ponte de Artéria Coronária/efeitos adversos , Infarto do Miocárdio/complicações , Idoso , Idoso de 80 Anos ou mais , Envelhecimento/psicologia , Transtornos Cognitivos/diagnóstico , Transtornos Cognitivos/etnologia , Humanos , Masculino , Infarto do Miocárdio/cirurgia , Razão de Chances , Vigilância da População , Testes Psicológicos , Estudos RetrospectivosRESUMO
Environmental factors such as excessive sodium ingestion and increasing adiposity are suspected to play a major role in the development of hypertension in elderly persons. Both aging and hypertension are associated with similar vascular structural changes including atherosclerosis. Despite the observed age-related changes in vascular structure, other factors must be important in contributing to the elevated pressure in isolated systolic hypertension. Alterations in sympathetic nervous system function may play a major role in the age-related increases in blood pressure and hypertension, especially isolated systolic hypertension.
Assuntos
Hipertensão/fisiopatologia , Idoso , Envelhecimento/fisiologia , Feminino , Humanos , Masculino , Pessoa de Meia-IdadeRESUMO
Blood pressure dysregulation syndrome is characterized by abnormal swings in blood pressure following postural changes, meals, exercise, and during sleep. Although the syndrome may occur in normotensive individuals, a growing body of evidence suggests an association between blood pressure dysregulation and hypertension. Diagnosis can be aided using 24-hour ambulatory blood pressure monitoring. Improved understanding of the syndrome and heightened awareness of its existence in older persons can help clinicians provide more effective management of hypertension. Adequate control of blood pressure throughout the circadian cycle should be a treatment objective.
Assuntos
Ritmo Circadiano , Hipertensão/fisiopatologia , Hipotensão/fisiopatologia , Exercício Físico , Frequência Cardíaca , Humanos , Hipotensão Ortostática/fisiopatologiaRESUMO
The U.S. has focused attention on the rising costs of health care coincident with the increasing age of the population. Arguments have been made to overtly ration care to older persons; however, general acceptance of the need to ration scarce resources, whether or not such a policy is actually formalized, can lead to covert rationing. Some overt rationing has already occurred, some of the data put forth to justify that rationing needs to be challenged, and ethical principles need to be applied to provide appropriate and perhaps less costly care.
Assuntos
Cuidados Críticos/economia , Custos de Cuidados de Saúde , Alocação de Recursos para a Atenção à Saúde , Futilidade Médica , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Envelhecimento , Tomada de Decisões , Liberdade , Política de Saúde , Humanos , Estados UnidosRESUMO
Donepezil (Aricept) is a reversible acetylcholinesterase inhibitor which is indicated for the treatment of mild to moderate dementia of the Alzheimer's type. We did a retrospective analysis of 41 elderly Alzheimer's subjects of different ethnic groups including a large number of Asian and Hawaiian patients. Donepezil appears to be clinically effective in patients of different ethnicities with mild to moderate Alzheimer's disease, even at advanced age.
Assuntos
Doença de Alzheimer/tratamento farmacológico , Inibidores da Colinesterase/uso terapêutico , Indanos/uso terapêutico , Piperidinas/uso terapêutico , Idoso , Idoso de 80 Anos ou mais , Povo Asiático , Donepezila , Feminino , Havaí , Humanos , Masculino , Estudos RetrospectivosAssuntos
Relações Médico-Paciente , Médicas/psicologia , Direitos da Mulher , Feminino , Humanos , Estados UnidosRESUMO
OBJECTIVE: To examine the relation between milk and calcium intake in midlife and the risk of Parkinson disease (PD). METHODS: Findings are based on dietary intake observed from 1965 to 1968 in 7,504 men ages 45 to 68 in the Honolulu Heart Program. Men were followed for 30 years for incident PD. RESULTS: In the course of follow-up, 128 developed PD (7.1/10,000 person-years). Age-adjusted incidence of PD increased with milk intake from 6.9/10,000 person-years in men who consumed no milk to 14.9/10,000 person-years in men who consumed >16 oz/day (p = 0.017). After further adjustment for dietary and other factors, there was a 2.3-fold excess of PD (95% CI 1.3 to 4.1) in the highest intake group (>16 oz/day) vs those who consumed no milk. The effect of milk consumption on PD was also independent of the intake of calcium. Calcium from dairy and nondairy sources had no apparent relation with the risk of PD. CONCLUSIONS: Findings suggest that milk intake is associated with an increased risk of Parkinson disease. Whether observed effects are mediated through nutrients other than calcium or through neurotoxic contaminants warrants further study.