Biomedical subjects
E W Campion
Publications and source records attributed to E W Campion.
Desperate diseases and plasmapheresis.
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Falls in elderly patients with glaucoma.
We analyzed the determinants of serious falls among 489 ambulatory elders aged 65 years and older who received a comprehensive examination at a glaucoma consultation service. For the previous year, at least one fall requiring medical attention or restricted activity was reported by 9.6% (95% confidence interval [CI], 7.0% to 12.2%) of participants. Using logistic regression to adjust for potential confounding variables, the greatest single risk factor for falls was the use of nonmiotic topical eye medications (odds ratio [OR], 5.4; 95% Cl, 1.8 to 16.4). Additional risk factors for falls were female sex (OR, 2.3; 95% Cl, 1.1 to 4.7) and use of cardiac medications (OR, 2.5; 95% Cl, 1.1 to 5.6). Three other characteristics were also associated with the risk of falls: use of miotic eye medications (OR, 3.2; 95% Cl, 1.0 to 10.1); visual field impairment of 40% or greater (OR, 3.0; 95% Cl, 0.94 to 9.8); and use of sedatives (OR, 2.4; 95% Cl, 0.89 to 6.7). These findings suggest that ocular and systemic medications are the major predictors of falls even in this elderly population seeking ophthalmologic care for glaucoma. Medications appear to pose a greater risk for falls than even major visual impairment.
White blood cell count as a predictor of mortality: results over 18 years from the Normative Aging Study.
The ubiquitous white blood cell count (WBC) has rarely been analyzed as a predictor of future mortality. We examined WBC measured in prospective examinations of 2011 initially healthy men in the Normative Aging Study (mean age 47.5), followed for an average of 13.6 years with 27,402 man-years of observation. Between 1970 and 1987, 183 participants died. Mortality rates for men with baseline WBC over 9000 were 12.2/1000 man-years, 1.8-2.5 times those of men with lower WBC in each of three age groups. Proportional hazards models controlling for established risk factors including age, systolic blood pressure, cholesterol and smoking status, found WBC at the baseline exam to be an independent predictor of mortality over the following years. Even within the normal range, a difference of 1000 in the initial WBC increased the risk ratio by 1.2 (95% CI 1.1, 1.3). The relation of initial WBC to mortality was not affected by baseline age, body mass index (BMI), smoking or blood pressure. These findings are not explained by medication effects. We conclude that the WBC is an independent predictor of all-cause mortality.
Outcomes of cardiopulmonary resuscitation in the elderly.
STUDY OBJECTIVE: To determine the success rate of cardiopulmonary resuscitation in the elderly and to define characteristics of elderly patients for whom cardiopulmonary resuscitation is effective. DESIGN: Retrospective chart review. SETTING: Five Boston health-care institutions: two acute-care hospitals; two chronic-care hospitals; and one long-term-care institution. PATIENTS: Five hundred and three consecutive patients aged 70 and over who received cardiopulmonary resuscitation. MEASUREMENTS AND MAIN RESULTS: Of 503 patients, 112 (22%) survived initially but only 19 (3.8%) survived to hospital discharge. The poorest outcomes were for patients with unwitnessed arrests (1 of 116 survived), terminal arrhythmias such as asystole and electromechanical dissociation (1 of 237 survived), and patients with cardiopulmonary resuscitation lasting more than 15 minutes (1 of 360 survived). Only 2 (0.8%; CI, 0.0% to 2.0%) of 244 patients with out-of-hospital cardiopulmonary arrests left the hospital alive. Of 259 patients with in-hospital arrests, 17 (6.5%; CI, 3.4% to 9.6%) survived to discharge. Most survivors had ventricular arrhythmias and were resuscitated within minutes. Initial survivors with either impaired consciousness or functional impairment after the arrest had significantly worse chances of survival than patients without these impairments. CONCLUSION: Cardiopulmonary resuscitation is rarely effective for elderly patients with cardiopulmonary arrests that are either out-of-hospital, unwitnessed, or associated with asystole or electromechanical dissociation.
The effect of age on serum albumin in healthy males: report from the Normative Aging Study.
To clarify the relation between age and serum albumin, measures were obtained on a screened population of 1066 healthy males in the Normative Aging Study. Multiple regression analysis shows only a slight decline in albumin of 0.054 gm/dl per decade with R = -0.12 (p less than .001) on cross-sectional data. This small decline occurs entirely within the range of normal, contrary to many previous reports. Mean albumin values were 4.25 (+/- .26 SD) for subjects in the eighth decade and 4.13 (+/- .29 SD) in the ninth decade. Longitudinally, there was an upwards trend in albumin for five birth cohorts over an 8-yr period which may reflect laboratory drift. A multivariate model of cross-sectional data can explain only 5% of the variance. The age-related decline within healthy subjects is far less than previously described. Our data demonstrate that hypoalbuminemia is not a consequence of normal aging.
House officers' knowledge of geriatric health policy: are the gatekeepers learning the rules?
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The 'Do not resuscitate' order. A profile of its changing use.
The "do not resuscitate" (DNR) order has wide-ranging ethical, legal, and economic implications. We reviewed the course of 244 patients who died during two three-month periods, in 1982 and 1986. We found that 68% of patients who died had a DNR order written, including 94% with malignancy and half of patients with cardiovascular disease. Most orders (61%) were written within three days of death, with 64% written on medical-surgical floors and 34% in critical care units. Even among patients under the age of 60 years, 57% had a DNR order written by the time of death. Ninety-one percent of DNR orders were written by attending physicians, with accompanying explanatory note in 84%. Documentation showed only 14% of patients but 77% of families being consulted. In 1983 a new two-level DNR order system defined two levels of intensity: "all but cardiopulmonary resuscitation" and "comfort measures only." Equal numbers of patients received each order in the 1986 sample. No patient was transferred to the critical care units after a DNR order had been written. The prevalence of DNR orders written for patients dying of cardiovascular disease increased from 27% to 64% over the four years. We conclude, from study of deaths in this representative community hospital, that an explicit DNR order is now the rule rather than the exception, but decisions are made late and involve family far more than the patient.
The merits of geriatric consultation.
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Caring for the patient with Alzheimer's disease.
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Asymptomatic hyperuricemia. Risks and consequences in the Normative Aging Study.
To quantify the consequences of asymptomatic hyperuricemia, this study examined rates for a first episode of gouty arthritis based on 30,147 human-years of prospective observation. A cohort of 2,046 initially healthy men in the Normative Aging Study was followed for 14.9 years with serial examinations and measurement of urate levels. With prior serum urate levels of 9 mg/dl or more, the annual incidence rate of gouty arthritis was 4.9 percent, compared with 0.5 percent for urate levels of 7.0 to 8.9 mg/dl and 0.1 percent for urate levels below 7.0 mg/dl. With urate levels of 9 mg/dl or higher, cumulative incidence of gouty arthritis reached 22 percent after five years. Incidence rates were three times higher for hypertensive patients than for normotensive patients (p less than 0.01). The strongest predictors of gout in a proportional hazards model were age, body mass index, hypertension, and cholesterol level, and alcohol intake. When the serum urate level became a factor in the model, none of these variables retained independent predictive power. At the final examination, only 0.7 percent of participants had a serum creatinine level of 2.0 mg/dl or more, with no evidence of renal deterioration attributable to hyperuricemia. These data support conservative management of asymptomatic hyperuricemia.
Cimetidine use in nursing homes: prolonged therapy and excessive doses.
Patterns of cimetidine use were identified in a survey of 3032 patients in 31 nursing homes. Of these, 60 (2%) were receiving cimetidine. For these patients, ages ranged from 63 to 102 years (mean, 81 years). The patients received a range of 1 to 11 regularly scheduled medications (mean, 5.6 medications). Duration of cimetidine treatment averaged 19.6 months for 48 patients (81%) receiving the drug for longer than an eight-week course of therapy. Prescribing indications appeared unjustified in 54 of 60 patients (90%). Doses were rarely appropriately reduced for patient age, despite established reasons to do so and the well-known potential for adverse effects of cimetidine in the elderly. The risks associated with prolonged drug-induced suppression of gastric acid are not known. This study suggests that use of cimetidine without justifiable indication and for extended periods of time is common in nursing home patients. Studies are needed concerning the safety of long-term cimetidine use in elderly patients.
Overmedication of the low-weight elderly.
This study analyzes age, weight, and drug doses using cimetidine hydrochloride, flurazepam hydrochloride, and digoxin as tracers. Data were obtained for 1797 patients (mean age, 72 years) filling consecutive prescriptions from a national pharmacy service. With all three drugs, patients with lower weight received substantially higher doses with correlations of weight vs dose, based on milligrams per kilogram of body weight, ranging from -0.34 to -0.40. Because body weight declines with increasing age, lower-weight patients are also older and at greatest risk for drug toxicity. Patients weighing 50 kg or less (n = 155) received milligram-per-kilogram doses that were 31% to 46% higher than the group mean and 70% to 88% higher than patients weighing more than 90 kg. For all three study drugs, as patient weight declines, the mean milligram-per-kilogram dose rose sharply. There was no trend seen toward reducing doses for older patients. Low body weight, in addition to advanced age, is a major risk factor for overmedication. Physicians must recognize the need to reduce drug doses for their low-weight elderly patients.
Functional recovery after hip fracture.
This investigation was designed to describe the 12-month functional recovery following hip fracture, testing the hypothesis that intensive rehabilitation would enhance the level of functional recovery. The study included 50 patients with intertrochanteric, and 25 patients with subcapital hip fractures who were admitted to the Massachusetts General Hospital teaching service (67% women, mean age = 78 yr). Twenty-nine percent of the patients died in the year after fracture. Among survivors, only 33% and 21% regained their prefracture function in five basic and six instrumental activities of daily living, respectively. Twenty-six percent regained their prefracture level of social/role functioning. There were no statistically significant differences in mortality, hospital discharge status, or pattern and level of functional recovery, between patients receiving experimental and standard approaches to hospital rehabilitation.
Functional outcomes following medical intensive care.
This study describes the long-term functional outcomes of a medical and coronary care ICU population. Baseline and 1-yr follow-up data were collected prospectively from all 2213 patients admitted during a 2-yr period. Patients were stratified into three groups based on their preadmission functional status: active (n = 917), sedentary (n = 1017), or severely limited (n = 279). Those with severe functional limitation before admission were twice as likely to undergo major interventions (p less than .005). This group also had a significantly (p less than .001) higher mortality and incurred significantly (p less than .01) higher hospital charges than the other two groups, even though hospital lengths of stay were similar. Finally, cumulative mortality was significantly (p less than .001) greater for the severely limited patients: 33% expired in the ICU, 42% died while still in the hospital, and 63% died after discharge. Most survivors regained their preadmission functional status, with 60% of the previously employed returning to work. However, even for hospital survivors, mortality was high and was related to prior functional status: active 7%, sedentary 20%, severely impaired 37%.
Rehabilitation home visits.
This chart review study describes 40 geriatric hip fracture patients focusing on the in-home functional and environmental assessment done before discharge from a rehabilitation hospital. Patients were aged 65 to 96 years. Before hospitalization all ambulated independently and three-quarters required limited or no social support. On discharge, none ambulated independently and all required support. Discharge plans for three patients were changed by the home visit, resulting in two nursing home placements. The role and structure of the rehabilitation home visit are outlined together with the common safety recommendations and equipment needs. The home visit assessment form is presented. The rehabilitation home visit is a practical tool to help achieve successful home discharge for elderly hip fracture patients. It is particularly useful in discharge planning for elderly patients with hip fracture, amputation, or stroke.
Age and the declining rate of autopsy.
To better understand declining autopsy rates, data have been gathered prospectively on 1080 consecutive deaths over six years among patients admitted to a medical intensive care/coronary care unit. Overall autopsy rate was 36%. Autopsy rates declined sharply with age from 60% for those aged 16 to 34 years to 23% for those 85 and over (P less than .001). The highest rates by diagnosis were aortic aneurysm (70%), hepatic failure (52%), heart rhythm disturbance (48%), pulmonary embolism (45%), and sepsis (41%). Patients receiving major procedures had a significantly higher autopsy rate (38 versus 29%, P less than .05) but rates bore little relation to prognoses given at admission by house officers, suddenness of death, sex, marital status or year of admission. Even among intensively treated patients, autopsy rates decline strikingly with age, demanding honest re-appraisal to restore the place of autopsy in medical education, clinical research, and quality of care assessment for an increasingly elderly population.
The development of benign prostatic hyperplasia among volunteers in the Normative Aging Study.
This study describes the development of benign prostatic hyperplasia among 2,036 volunteers in the Veterans Administration Normative Aging Study, a longitudinal study of human aging situated in Boston. Men were followed from enrollment in the study (between 1961 and 1970) until their last examination prior to May 15, 1982. Two indications of benign prostatic hyperplasia were considered: 1) a clinical diagnosis made at a uniform physical examination, and 2) surgical treatment. Incidence rates for both a clinical diagnosis and surgery for benign prostatic hyperplasia increased through the eighth decade. Life table analysis estimated the lifetime probability of surgical treatment to be 0.29. Known risk factors for cardiovascular disease and diabetes as well as marital and socioeconomic status, religion, cigarette smoking and alcohol and coffee consumption were evaluated as risk factors. Controlling for age in proportional hazards models, statistically significant predictors of surgery were prior clinical diagnosis, lower socioeconomic status, Jewish religion, and not currently smoking cigarettes; whereas only body mass index was a significant predictor of a clinical diagnosis. Although a prior clinical diagnosis was an important predictor of surgery (adjusted odds ratio 3.52, 95% confidence interval = 1.93-6.42), this diagnosis is neither sensitive nor specific in its association with surgery.