Autopsy study of the elderly institutionalized patient. Review of 234 autopsies.

Autopsies are performed much less frequently in the elderly than in younger patients. Little information exists as to causes of death in the institutionalized elderly. The clinical diagnostic error rate documented by autopsy studies ranges from 6% to 68%. We analyzed the clinical and autopsy records of 234 patients who died during a 14 1/2-year period at our chronic care institution to determine the accuracy of clinical cause of death in addition to the pathologic cause of death. The most common causes of death included bronchopneumonia (33%), congestive heart failure (15%), metastatic carcinoma (14%), pulmonary embolism (8%), myocardial infarction (7%), cerebrovascular accident (6%), unknown cause of death (8%), and a miscellaneous group (9%). The highest diagnostic error rate was in the underdiagnosis of pulmonary embolism (39% antemortem accuracy rate). The most accurately diagnosed condition was cerebrovascular accident (92% antemortem accuracy rate). Pneumonia was correctly diagnosed antemortem in 73% of the patients studied. These data suggest that serious and potentially treatable illnesses are underdiagnosed in the elderly institutionalized patient and that there is valuable information to be learned by performing autopsies in the elderly population.

Epidemiology of acute respiratory illness during an influenza outbreak in a nursing home. A prospective study.

We observed an influenza epidemic caused by influenza A/Arizona/82 (H3N2) in a nursing home during 1982 to 1983. A survey indicated that 59% of the residents were immunized before the outbreak. The outbreak was observed to begin in November, peak in February, and disappear in April. A significant level of herd immunity may have accounted for the slow progression through the nursing home. In addition, serologic evidence of concurrent infection with respiratory syncytial virus, parainfluenza virus, and Mycoplasma pneumoniae was present in many residents. Epidemics of influenza in a closed, partially immunized population in a nursing home may proceed at a slower rate than in an open, largely unimmunized community. By monitoring for infection with other respiratory agents, the complex nature of the outbreak in this nursing home became evident.

Association of influenza immunization with reduction in mortality in an elderly population. A prospective study.

We prospectively studied the efficacy of influenza vaccine during an influenza A/Arizona/80 (H3N2) outbreak at the Jewish Home and Hospital for the Aged in New York in the winter season of 1982 to 1983. All patients had been offered influenza vaccine before the outbreak; 181 chose to be vaccinated and 124 refused vaccination but agreed to participate in the study. Among those with serologic evidence of influenza infection, respiratory illness was significantly more common in the unvaccinated group (six of 14 vs one of 22). The overall mortality was 13 (7.2%) of 181 in the vaccinated group and 22 (17.7%) of 124 in the control group. The vaccinated and the control groups were examined for comparability. A logistic regression analysis, which controlled for differences in sex and level of nursing care, indicated that the difference in mortality was still significant, with a summary odds ratio of 2.7. The relative risk of death in the unvaccinated group was comparable at 2.18. Influenza vaccine reduced the mortality by 59% in the vaccinated group compared with the control group.

Influenza vaccine and pneumonia mortality in a nursing home population.

The effectiveness of immunization against influenza in elderly persons is uncertain. A retrospective cohort study in a New York City nursing home examined the occurrence of pneumonia and its related mortality over three consecutive influenza seasons (Nov 1 through April 30, 1979 to 1980, 1980 to 1981, and 1981 to 1982). Nearly one half of approximately 450 residents (mean age, 84 years) accepted immunization each year. The vaccinated and unvaccinated groups were similar. The attack rate of pneumonia did not differ significantly between the vaccinated and unvaccinated groups in any of the three influenza seasons. When influenza was occurring in the community (1979 to 1980 and 1980 to 1981), however, the risk of death from pneumonia in the unvaccinated group was three-fold higher than in the vaccinated group (60% vs 18% and 73% vs 25%, respectively). In a year when influenza was specifically sought and not found in the facility (1981 to 1982), however, vaccination did not affect pneumonia-related mortality. This study also suggests that estimates of mortality due to pneumonia should include deaths that occur up to 60 days after onset of pneumonia; shorter follow-up may overestimate the protective effect of vaccination.

Ischemic and hypertensive heart disease in the aged: prognostic and therapeutic factors.

The prognostic significance of risk factors for ischemic and hypertensive heart disease in the aged differs in many respects from that in younger persons. In old age, most risk factors for ischemic heart disease such as an elevated level of total serum cholesterol, cigarette smoking, obesity, Type A personality and abnormal glucose tolerance have a less adverse effect on morbidity and mortality from ischemic heart disease, while an elevated level of high density lipoprotein, and moderation in the use of alcohol each have a favorable effect. A high level of low-density lipoprotein cholesterol exerts an adverse effect. Both systolic and diastolic hypertension have an adverse influence on morbidity and mortality from ischemic and hypertensive heart disease, as does the electrocardiogrpahic pattern of left ventricular strain. Long-term controlled studies are needed to determine the effects on mortality and morbidity of the modification of risk factors by means of drugs, diet, and change of lifestyle. Such studies are necessary if we are to determine whether hoped-for favorable changes are offset by potential side effects on physical and mental health.

Challenging residents to assume maximal responsibilities in homes for the aged.

A program for activating residents of homes for the aged to assume maximal responsibilities is described. Promoting maximal physical and mental health through various modalities including activity programs, appropriate exercise and participation in democratic self-government mechanisms, will result in a happier, healthier population of residents in institutions for the aged. The increased demands on staff time and patience will be compensated for by relief of the too-frequent feelings of hopelessness and boredom endemic among the staff of long-term care facilities. Such programs demand constant effort by all staff members, patients, volunteers and relatives because if they succumb to the usual human dislike of persistency, short-term gains can easily be lost.

Cardiovascular side effects of long-term therapy with tricyclic antidepressants in the aged.

In a study to determine the nature and frequency of cardiac side effects during long-term administration of tricyclic antidepressant drugs in usual dosages in the aged, 32 geriatric patients were followed for an average of 36.6 weeks. Ten of them received amitriptyline in a daily dosage of 20-75 mg for 53 weeks (average); in 2, electrocardiographic side effects developed, viz, inversion of the T waves or evidence of acute coronary insufficiency. Imipramine was administered to 21 patients in a daily dosage of 20-100 mg (average, 66 mg) over a period of 40 weeks; in 3 instances major side effects developed--intermittent left bundle-branch block, acute coronary insufficiency with node dysfunction, or T-wave inversion with sinus tachycardia; in 1 instance there was a minor side effect, viz, tachycardia only. In 1 patient, acute myocardial infarction developed after two 10-mg doses of nortriptyline. Five of the 7 patients with cardiac side effects had prior organic heart disease. It was concluded that the incidence of cardiac side effects in aged persons given tricyclic antidepressant drugs in the usual therapeutic dosages for a prolonged period is great enough to warrant frequent careful monitoring of cardiac status during therapy.

Mortality of the aged with chronic brain syndrome: further observations in a five-year study.

In order to pursue the question of excess mortality due to chronic brain syndrome (CBS), 330 residents of a home for the aged were independently evaluated prior to admission by psychiatrists and by general physicians. Five years later, their medical records were searched to determine: 1) age on admission, 2) diagnosis of CBS on admission, 3) physical status on admission, and 4) if death had occurred, the age at death and the cause of death. Women outnumbered men by 3:1. Subjects with CBS outnumbered those without CBS by 2:1. A previous mortality study on 145 aged subjects at the same institution provided an excellent frame of reference for this investigation. Among the men there was no difference between the mortality rates for those with CBS and those without. Among the women a statistically significant difference in mortality was found between those with CBS and those without. Women with CBS and a "poor" physical status had the highest mortality rate. Those who initially had CBS died significantly sooner even if their admission physical status had been "good." Their mortality rate exceeded that for women with a "poor" physical status who did not have CBS. Bronchopneumonia caused death twice as often in subjects with CBS as in those without CBS, both among men and women. It is concluded that CBS per se is a significant factor in increasing mortality in the aged.

Initial adjustment to a long-term care institution: medical and behavioral aspects.

One hundred elderly persons consecutively admitted to the Jewish Home and Hospital for Aged were studied during the first month after admission. Medical changes (chiefly cardiovascular) and behavioral changes were analyzed independently and then correlated. Four subgroups were found: 1) smooth adjustment and no significant medical changes (33 subjects); 2) smooth adjustment with significant medical changes (17 subjects); 3) severe adjustment problems but no significant medical changes (31 subjects); and 4) severe adjustment problems with significant medical changes (19 subjects). The aged persons most likely to have initial adjustment difficulties usually had poor capacity for interpersonal relationships, were socially isolated, were either single or divorced, had a dependent personality, had severe chronic brain syndrome, had a negative or ambivalent attitude toward admission, and often had been referred for psychiatric evaluation before admission. Major patterns of reaction were anxiety, aggressiveness and depression. Significant medical changes were more likely to develop in those with previous poor health who manifested an advanced state of confusion and depressive trends. Depression was related to concomitant medical changes rather than to the previous health status; it exacerbated the reaction to medical illness, which resulted in a decline in the level of functioning. In 58 per cent of the 50 patients with initial adjustment difficulties, a satisfactory level of adaptation was reached during the first six months after admission.

Relation of long-term electronic cardiac pacing to mental status and adaptation in the institutional aged.

The long-term effects of cardiac pacemakers on the mental status and adjustment of an aged population were investigated. In an institution for the aged, 25 residents (average age, 85) in whom pacemakers had been implanted for an average of 53 months were compared to 18 residents of the same age and sex who had a slow heart rate. A semistructured interview was given to determine mental status, affective condition, perceived health, and other concerns. Cardiac status was rated for all subjects according to the criteria of the New York Heart Association. By the measures of adjustment and mental status, no differences were found between pacemaker patients and those with a slow heart rate. Cardiac status was somewhat poorer in the pacemaker group. When comparison was made between the pacemaker patients with uncompromised or only slightly compromised cardiac status and subjects with a slow heart rate and similar cardiac status, no significant differences were found in the foregoing measures. These findings suggest that although there may be changes in functioning in the acute phase following implantation of a pacemaker, there are no long-term effects on adjustment in subjects of advanced age. Adaptation in an institution for the aged may be more related to personality factors than to specific health problems.

Acute myocardial infarction in a long-term care institution for the aged.

We reviewed the clinical characteristics and outcome of cases of acute myocardial infarction occurring from January 1, 1985, through December 31, 1987, in the population of a long-term care institution for the elderly. The total number of patients in the series was 43. Comparisons were made between those patients transferred to a general acute-care hospital and those who remained at the facility. The most common initial symptoms of acute myocardial infarction in 32 of 48 patients were, in order, dyspnea, dizziness or syncope, precordial pain, and abdominal pain. Nine (of 43) patients were asymptomatic. In the 14 (of 43) patients transferred to an acute-care hospital, cardiac failure, arrhythmias, and cardiogenic shock were much more frequent than among those retained in the long-term care facility. We concluded that a high index of suspicion for the diagnosis of acute myocardial infarction in the institutionalized elderly is indicated. Patients with mild infarction can be retained in long-term care institutions; resulting mortality from cardiac disorders should be low in adequately staffed and equipped long-term care institutions.

Orthostatic change in blood pressure in non-demented, ambulatory nursing home patients.

While postural hypotension was present in almost 20% of ambulatory patients of this long-term institution, associated symptoms were infrequent. A comparison of the groups with and without a history of falls in the prior year revealed no relationship to the presence of postural hypotension and no relationship to a number of medications which have been reported to be associated with orthostatic hypotension. Blood pressure readings should be obtained at 1,3 and 5 min after assuming the erect position as significant falls in blood pressure were found at each interval.

The ECG in old age: implications for diagnosis, therapy, and prognosis.

The electrocardiogram is a valuable aid in diagnosing and treating heart disease in the elderly and in determining the prognois. In general, mortality is lower in old persons with ECG abnormalities than in younger ones, and some changes are not considered abnormal. P wave notching, slurring, and loss of amplitude are too common to be of diagnostic significance, and T wave inversions and S-T segment depressions have too many causes to be specific. A persistently prolonged P-R interval often is associated with recurrent atrial arrhythmias, junctional rhythms, and conduction distrubances. A short interval, on the other hand, may be noted for a long time without paroxysmal atrial tachycardias. Degenerative and ischemic changes in the conduction system result in a variety of arrhythmias and conduction disturbances. The classic sick sinus syndrome is not seen as often as the incomplete forms, such as sinus bradycardia with atrial premature contractions. With the exception of left inferior hemiblock, bundle-branch blocks are common. Similarly, ventricular and atrial premature contractions increase with age. ECGs taken routinely over a period of years help differntiate ventricular from supraventricular tachycardias with aberrant conduction.

Bullous pemphigoid in a one hundred year old woman.

A one hundred year old woman presented with eosinophilia, pruritus, and an erythematous rash which developed into a generalized bullous eruption. Histologic and immunologic examination as well as clinical course confirmed the diagnosis of bullous pemphigoid. the possibility of an allergic or drug-induced disease was considered because of her initial clinical and laboratory findings. Furosemide was suspected. Prior cases of bullous pemphigoid appearing after furosemide therapy were reviewed and compared. After other possible etiologies were excluded, prednisone therapy was instituted with resolution of the bullous skin lesions.