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PubMed1997

[Geriatric psychiatry--a specialty gaining recognition].

Services for elderly, mentally ill people have developed in response to changing needs in society. In 1990 most of the 650 beds allocated to elderly patients in psychiatric hospitals were occupied by long-term care patients. Outpatient programmes hardly existed. In 1995 about 400 beds were allocated to geriatric psychiatry. They were served by 40 physicians and 20 psychologists. Out-patients' clinics were established. Most of the in-patients were short-term admissions. Nowadays, departments of geriatric psychiatry define themselves as diagnostic and short-term units. About a third of the in-patients suffer from dementia, a third from depression, and a third from various other psychiatric disorders. The authors recommend that a special unit for geriatric psychiatry should be established in every county in Norway. Funds should be allocated for professorships at all universities.

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PubMedDate not supplied

A strategic supportive model for health prevention in the elderly: profile of a Puerto Rican geriatric population in a public health sector.

OBJECTIVE: To introduce the ASSUME study with the presentation of a clinical, socio-demographic, preventive and psychological profile of a geriatric population of patients who receive their health care in the General Internal Medicine Ambulatory Sector of our institution. METHODS: The Assume study is a prospective, randomized trial which is directed at increasing the participation of patients in preventive health care strategies at a primary, secondary and tertiary level. In this paper we focus on the initial stage of the process which aims to define and synthesize predisposing risk factors in the geriatric patient which would be amenable to primary, secondary and tertiary preventive strategies. Through a process of patient interview profiles of a physical, social and psychological nature are have been constructed. With the availability of this profile a clearer definition of the potential benefit of preventive strategies could be established. In this paper we present the initial profile of patients of all patients randomized to the study as of Sept. 01, 1997. RESULTS: A total of 123 patients have been enrolled with 48(39%) males and 75(61%) females. The mean age of patients is 70 years with a median of 68 years. Cardiovascular disorders establish the leading disease events in our population of patients with Hypertension in 85%, Ischemic heart disease in 50%, Myocardial Infarction in 19% and 40% with a history of Congestive Heart failure. Diabetes and Heart Failure were seen in 40%. An average of 4.4 prescribed drugs per patient was documented. A minority of patients took more than 7 drugs and none took more than 9 medications. Most patients (67 or 55%) had not required hospitalizations in the preceding 12 months and none of the patients required more than 4 hospitalizations. The average LOS was 8.60 days. The Preventive Medicine profile reveals a large number of un-vaccinated adults. Regular cigarette smoking was seen in 12%. We have used the body mass index as a measure of adequacy of weight. We highlight the number of patients who have a BMI equivalent to an obese, severely obese or morbidly obese category (41%). The number of patients who follow a prescribed diet was found to be 54 patients for 44% of the study group. With regards to the interventions primarily designed for early cancer detecting, approximately half of the patients undergo the recommended annual screening interventions. The screening of visual accuracy was reported in 54%, dental screen (24%) and auditory screening (15%). Nearly a quarter of patients have severe depression. The CAPE testing reveal that in the information and orientation section most patients presented none or light dysfunction(87%). In the conductual phase marked or severe impairment was detected in 12% of patients. In the mental ability section 22% of patients presented marked or severe impairment. CONCLUSION: The geriatric population studied would benefit from modalities which would increment the modern modalities for primary and secondary prevention of disease. Follow-up studies will allow the evaluation of the effectiveness of the conceptual model proposed, which would increment the patient participation in these preventive modalities.

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PubMed1997

[Incidence and consequences of nosocomial infections in a geriatric short-stay department].

OBJECTIVES: Although large epidemiological studies have demonstrated that elderly people experience a greater incidence and mortality attributable to nosocomial infections, few studies have yet focused on this problem in geriatrics. PATIENTS AND METHODS: In order to assess the importance of nosocomial infections in geriatric short-stay department, we carried out a prospective study during a one-year period. RESULTS: Eighty-two nosocomial infections were recorded in 67 patients. The incidence was 10.3 nosocomial infections per 1000 patient-days. Pneumonia was the second most frequent type of nosocomial infection after urinary tract infections, but caused the highest rate of death. For infected patients, hospital stay was twice as long (31 versus 13 days) and mortality four times higher (26.9 versus 8.2%). CONCLUSION: These results confirm that elderly patients make up a high-risk population and that the prevention of nosocomial infections must be a priority in geriatrics.

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PubMed1997

[Geriatric rehabilitation from economic viewpoints].

The lecture describes geriatric rehabilitation in terms of economic aspects on the basis of several papers that are quoted in detail. Thanks to geriatric rehabilitation, a cost savings can be demonstrated because of increased independence and a reduction in the need for nursing care and the need for treatment. The ultimate goal of geriatric rehabilitation, however, is to improve the patient's quality of life. Measuring this is nearly impossible. At the end of the day the term "successful", therefore, remains a subjective assessment by the patient and the attending team. The measuring parameters can only give indications for the success.

Activities of Daily Living↗
PubMed1998

[Diogenes' syndrome. A geriatric entity].

OBJECTIVES: To familiarize physicians with this relatively rare syndrome; to review the signs and symptoms, with special emphasis on its nature and the terminology used; and to help physicians choose an appropriate course of action. DATA SOURCES: MEDLINE (1966 to 1997) and Psychlit (1990 to 1996), references from articles, reference texts on geriatrics and psychiatry. STUDY SELECTION: All of the articles reviewed involved case studies. SYNTHESIS: Descriptive articles enabled us to define this syndrome more clearly. The dissimilarity of the case studies indicates that the condition is not clearly defined, and the reference to the Greek philosopher Diogenes is misleading. CONCLUSION: The various features described to make up a geriatric syndrome characterized by extreme self-neglect, squalid living conditions, and social withdrawal. This complex geriatric problem poses clinical, social and ethical challenges.

Activities of Daily Living↗
PubMed1998

The geriatric resource nurse model of care: a vision for the future.

The geriatric resource nurse model of care is an innovative and effective method of integrating high quality, evidence-based geriatric nursing care into a clinical practice setting. The model creates expert bedside clinicians who recognize the vulnerability of older adults, who proactively educate and serve as consultants for peers, and who role model best practice geriatric nursing. This article describes the history and key features of this nursing model of care delivery with examples of how it was successfully implemented in a variety of hospitals around the country.

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PubMed1998

Using oral quality of life measures in geriatric dentistry.

OBJECTIVE: The purpose of this paper is to present potential uses of existing oral-specific quality of life (OQOL) instruments in geriatric dentistry. METHOD: Selected existing OQOL instruments were reviewed. Three examples of how such instruments have or could be used in geriatric dentistry are presented. CONTENT OF REVIEW: Nine OQOL instruments are briefly reviewed. The potential uses in geriatric dentistry include population applications and uses with individuals for political, theoretical and practical reasons. Practical uses include identification of persons needing treatment, assessing oral health needs in populations and estimating resources required to meet those needs, as endpoints in clinical trials and as measures of the impact of care provided. CONCLUSIONS: The ultimate value of OQOL measures will be measured by their usefulness in improving care of patients. The development of streamlined instruments and a core instrument which can be used in multiple populations and serve as a baseline to which other measures are added is recommended.

Activities of Daily Living↗
PubMed2005

The impact of medical issues in inpatient geriatric psychiatry.

At an advanced age, serious medical and psychiatric illnesses frequently coalesce. Often, the need for admission to inpatient geriatric psychiatric care arises from coexisting medical problems. While cognitive and behavioral interventions are important, the complexity of physical comorbidities usually becomes the focus of hospitalization and requires intensive medical treatments. This paper describes adaptations made in one metropolitan geriatric psychiatry unit in order to better treat complex patients who experience both medical and psychiatric illness. The need for all members of the interdisciplinary team to expand their practice and the importance of complementary approaches of psychiatry and medicine are emphasized.

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PubMed2003

Meckel diverticulum: a geriatric disease masquerading as common gastrointestinal tract disorders.

BACKGROUND: Meckel diverticulum (MD) is traditionally considered a pediatric disease that is associated with intestinal hemorrhage or perforation. Symptomatic MD is rarely a consideration in the geriatric population. OBJECTIVE: To notify clinicians of the clinical variety and diagnostic uncertainty of MD in the elderly, we report 7 cases of complicated MD that presented as common disorders of the gastrointestinal (GI) tract in patients older than 65 years. METHODS: A retrospective record review at 2 university-affiliated hospitals revealed 7 patients older than 65 years with MD and abdominal complaints necessitating laparotomy. The patients represented a subset of 27 adults (age range, 21-89 years; mean age, 39 years) with symptomatic MD who required surgery during a 7-year period. RESULTS: The presenting complaints represented a variety of common GI presentations, including nausea, vomiting, and acute abdominal pain (n = 3); acute abdominal pain with peritonitis (n = 2); crampy abdominal pain lasting several weeks (n = 1); and rectal bleeding (n = 1). Meckel diverticulum was a preoperative consideration in only 2 of 7 cases. The preoperative diagnoses were consistent with common disorders of the GI tract in the elderly, including small-bowel obstruction (n = 2), ischemic colitis (n = 1), unrelenting bleeding in the GI tract (n = 1), perforated viscus (n = 1), diverticulitis (n = 1), and appendicitis (n = 1). In contradistinction to the pediatric age group, only 1 of 7 patients had an MD with ectopic mucosa. CONCLUSIONS: Many different mechanisms can be responsible for complications due to MD in the geriatric population. Misdiagnosis occurs frequently in the elderly because of the poor sensitivity of diagnostic tests, nonspecificity of complaints, and lack of recognition that this anomaly can present in this age group. Clinicians must be cognizant of this common pediatric disease and its varied guises when they are evaluating unexplained acute or intermittent abdominal pain, nausea and vomiting, rectal bleeding, peritonitis, or obstruction in geriatric patients.

Abdominal Pain↗
PubMed2004

Effects of the serotonin transporter gene promoter polymorphism on mirtazapine and paroxetine efficacy and adverse events in geriatric major depression.

BACKGROUND: The "long/short"polymorphism (5HTTLPR) in the promoter of the serotonin transporter gene (SLC6A4) has been proposed as a pharmacogenetic marker for antidepressant efficacy. Some but not all studies have found that the short form of 5HTTLPR (S allele) results in decreased efficacy of selective serotonin reuptake inhibitors. OBJECTIVE: To determine if the 5HTTLPR polymorphism influences the efficacy and tolerability of mirtazapine and paroxetine hydrochloride, 2 frequently prescribed antidepressants with differing pharmacologic profiles, in geriatric depression. DESIGN: Double-blind, randomized 8-week study. SETTING: Eighteen academic and private outpatient clinics. PATIENTS: We evaluated 246 cognitively intact patients 65 years or older with major depression. INTERVENTIONS: Antidepressant therapy with 15 to 45 mg/d of mirtazapine (n = 124) or 20 to 40 mg/d of paroxetine (n = 122). MAIN OUTCOME MEASURES: The Hamilton Depression Rating Scale-17 and Geriatric Depression Scale, severity of adverse events and dosing compliance indexes, and discontinuations due to adverse events. Outcome measures were stratified according to 5HTTLPR genotypes. RESULTS: Geriatric Depression Scale scores indicated that S allele carriers treated with paroxetine showed a small impairment in antidepressant response. Among mirtazapine-treated patients, there was little indication that the 5HTTLPR genotype affected antidepressant efficacy. However, the 5HTTLPR polymorphism had a dramatic effect on adverse events. Among paroxetine-treated subjects, S allele carriers experienced more severe adverse events during the course of the study, achieved significantly lower final daily doses, and had more discontinuations at days 14, 21, 28, 42, and 49. Surprisingly, among mirtazapine-treated subjects, S allele carriers had fewer discontinuations due to adverse events, experienced less severe adverse events, and achieved higher final daily doses. CONCLUSIONS: These results support the hypothesis that the S allele of 5HTTLPR at the SLC6A4 locus is associated with a poor outcome after treatment with selective serotonin reuptake inhibitors. However, the major effect was on the tolerability of these drugs rather than efficacy. Results from mirtazapine-treated patients indicate that the effect of this polymorphism on outcome may depend on the mechanism of antidepressant action.

Adrenergic alpha-Antagonists↗
PubMed2000

Management of the geriatric trauma patient at risk of death: therapy withdrawal decision making.

HYPOTHESIS: The management of geriatric injured patients admitted to a trauma center includes the selective decision to provide comfort care only, including withdrawal of therapy, and a choice to not use full application of standard therapies. The decision makers in this process include multiple individuals in addition to the patient. DESIGN: Retrospective review of documentation by 2 blinded reviewers of the cohort of patients over a recent 5-year period (1993-1997). SETTING: Trauma service of a level I trauma center. PATIENTS: A convenience sample of patients aged 65 years and older who died, and whose medical record was available for review. MAIN OUTCOME MEASURES: Patients were categorized as having withdrawal of therapy, and documentation in the medical record of who made the assessment decisions and recommendations, and to what extent the processes of care were documented. RESULTS: Among 87 geriatric trauma patients who died, 47 had documentation interpreted as indicating a decision was made to withdraw therapy. In only a few circumstances was the patient capable of actively participating in these decisions. The other individuals involved in recommendations for withdrawal of therapy were, in order of prevalence, the treating trauma surgeon, family members (as proxy reporting the patient's preferences), or a second physician. Documentation regarding the end-of-life decisions was often fragmentary, and in some cases ambiguous. Copies of legal advance directives were rarely available in the medical record, and ethics committee participation was used only once. CONCLUSIONS: Withdrawal of therapy is a common event in the terminal care of geriatric injured patients. The process for reaching a decision regarding withdrawal of therapy is complex because in most circumstances patients' injuries preclude their full participation. Standards for documentation of essential information, including patients' preferences and decision-making ability, should be developed to improve the process and assist with recording these complicated decisions that often occur over several days of discussion.

Advance Directives↗
PubMed1994

Mortality factors in geriatric blunt trauma patients.

OBJECTIVE: To examine various clinical factors for their ability to predict mortality in geriatric patients following blunt trauma. DESIGN: In this retrospective study, trauma registries and medical records from three trauma centers were reviewed for patients 65 years and older who had sustained blunt trauma. The following variables were extracted and examined independently and in combination for their ability to predict death: age, gender, mechanism of injury, admission blood pressure, and Glasgow Coma Scale score, respiratory status, Trauma Score, Revised Trauma Score, and Injury Severity Score. SETTING: Three urban trauma centers. PATIENTS: Geriatric trauma patients entering three trauma centers (Stanford [Calif] University Hospital, Vanderbilt University Medical Center, Nashville, Tenn, and Maryland Institute for Emergency Medical Services Systems, Baltimore) following blunt trauma during a 7-year period (1982 to 1989). RESULTS: The Injury Severity Score was the single variable that correlated most significantly with mortality. Mortality rates were higher for men than for women and were significantly higher in patients 75 years and older. Admission variables associated with the highest relative risks of death included a Trauma Score less than 7; hypotension (systolic blood pressure, < 90 mm Hg); hypoventilation (respiratory rate, < 10 breaths per minute); or a Glasgow Coma Scale score equal to 3. CONCLUSIONS: Admission variables in geriatric trauma patients can be used to predict outcome and may also be useful in making decisions about triage, quality assurance, and use of intensive care unit beds.

Abbreviated Injury Scale↗
PubMedDate not supplied

Immune alterations in geriatric mice dosed subacutely with diethylstilbestrol (DES).

Exposure to both physiological and pharmacological doses of estrogenic compounds has been reported to alter immunologic responses in humans as well as in developmental and adult murine models. Despite the current therapeutic use of potent estrogens, including diethylstilbestrol (DES), in geriatric human disorders, elucidation of the effects of these agents on the aged immune system is limited. The present report describes highly significant alterations in the thymus and bone marrow of aged mice (21 +/- 1 months) exposed subacutely to DES. Severe thymic hypocellularity developed in treated mice following five consecutive days of intraperitoneal injection with 1.5 or 6.0 mg kg(-1) DES. Cell maturation within the thymus was also affected, as indicated by a significant decrease in CD4+8+ cells and a concomitant increase in CD4-8- cells. Cellularity of the bone marow was unchanged by DES. However, significant changes were observed in percentages of bone marrow cells expressing surface antigens CD45 (common leukocyte lineage), Mac-1 (macrophage lineage) and CD45R (B-lineage lymphocytes). Both percentages and total numbers of cells in the spleen expressing Thy 1.2 (T-lineage lymphocytes) were also reduced. These immune changes in geriatric mice exposed to DES were similar in direction but more severe than those reported in either young adult or perinatal models. These data may suggest a need for considering the geriatric immune system separately from other age groups when determining effects of immunosuppressive or immunotoxic compound exposure.

Aging↗
PubMed2000

Efficacy of venlafaxine in geriatric depression.

Geriatric patients with major depression present clinical challenges not encountered in younger individuals, including a greater incidence of medical comorbidity, higher rates of multiple medication use, changes in drug metabolism due to age or physical illness, and increased sensitivity to antidepressant side effects. Nevertheless, successful treatment of depressive disorders in the elderly improves mental and physical functioning, decreases morbidity and perhaps mortality, and enhances quality of life. Recent research indicates that newer antidepressants are effective for late life depression and safer for older individuals. Among newer antidepressants, venlafaxine has a pharmacological profile that makes it an attractive choice for geriatric patients. It has limited potential to interact with other medications because it only weakly inhibits the cytochrome P450 system and binds to plasma proteins at a low level. Dosing may have to be adjusted for patients with renal failure, but typically not for those with liver disease or other medical conditions. Data from three double-blind and four open clinical trials support the safety and efficacy of venlafaxine for geriatric depression. Patients may experience transient, generally tolerable side effects such as insomnia, nausea, agitation, or dry mouth early in treatment, but more serious problems such as falls or cardiac rhythm disturbances seem to be rare. Treatment emergent hypertension occurs in a small percentage of older patients, generally at doses above 150 mg/day. Finally, emerging data suggest that venlafaxine may be effective for conditions such as stroke, anxiety, and neuropathic pain that frequently accompany depressive disorders in the elderly.

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PubMed2004

Competence to consent to treatment of geriatric patients: judgements of physicians, family members and the vignette method.

OBJECTIVE: In absence of a gold standard of methods to assess competence, three judgements of competency of geriatric patients are evaluated: the judgements of a physician, the judgement of a family member, and the judgement of an instrument. METHODS: Competence of 80 geriatric patients was judged both by a physician and a family member. Decision making capacity was assessed with a vignette. A vignette describes a treatment choice, after which the following abilities are evaluated: evidencing a choice, understanding, reasoning and appreciating a situation. Cognitive functioning was measured with the Mini-Mental State Examination. RESULTS: Most of the geriatric patients were judged competent by all three methods. Disagreement between the three judgements was found for 25 patients. Agreement about incompetence was only reached for one patient. Physicians appeared to be most lenient in their incompetency judgement: only three patients were judged incompetent. These patients scored significantly lower than competent patients on cognitive functioning, the decisional ability of understanding, and the total vignette score. Family members appeared to be most stringent in their judgement: they considered 22 patients incompetent. Incompetent patients scored significantly lower than competent patients on cognitive functioning, reasoning and the total vignette score. CONCLUSIONS: The disagreement between the judgements suggests a difference in factors given emphasis by the three methods. The finding that both the judgement of physicians and family members are associated with the assessment of the vignette, suggests that the vignette method has more than a legal theoretical base and is associated with daily life experience and knowledge as well. Physicians can be helped to assess competence by the vignette method to evaluate decisional abilities and by family members who can provide more information about patients' values.

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PubMed2001

MRI white matter hyperintensities, (1)H-MR spectroscopy and cognitive function in geriatric depression: a comparison of early- and late-onset cases.

UNLABELLED: BACKGROUND AND OBJECTIVES Geriatric depression is often thought to differ from that at other times of adulthood. Recently, several studies have shown that the incidence of white matter hyperintense lesions identified by brain MRI is higher in patients with geriatric depression than in healthy elderly subjects, but a consensus has not yet been reached on the relationship between the severity of white matter lesions and either cognitive impairment or depressive symptoms. METHOD: Forty-seven patients aged 50 to 75 years with major depression were divided into two groups based on age at onset of depression: early-onset (< 50 years) group (20 patients; mean age, 62.7 +/- 6.7) and late-onset (> or =50 years) group (27 patients; mean age, 65.6 +/- 5.4). The severity of hyperintense white matter lesions on MRI was classified by region, then a proton magnetic resonance spectroscopy ((1)H-MRS) focusing on the white matter of the frontal lobes, multidimensional neuropsychological tests and evaluation of depressive symptoms were conducted. RESULTS: The severity of the deep white matter lesions, the deterioration of cognitive function related to subcortical/frontal brain system and clinician-rated depressive symptoms were all more pronounced in the late-onset group compared with those in the early-onset group. It was further observed that the more severe the deep white matter lesions, the lower the levels of N-acetylaspartate/creatine. With the age of onset as the covariate, the patients with moderate deep white matter lesions had more pronounced cognitive impairment and clinician-rated depressive symptoms than those with none and/or mild lesions. CONCLUSION: These results suggest that subcortical/frontal type cognitive impairment and the persistence of depressive symptoms in geriatric depression is related to moderate deep white matter lesions more often complicated in the late-onset group. The (1)H-MRS findings were suggested to be a useful indicator of neuronal/axonal loss in the white matter of the frontal lobes which precedes cognitive impairment.

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PubMed2002

Hippocampal volume and antidepressant response in geriatric depression.

BACKGROUND: Biological markers of treatment response may include structural brain changes seen on neuroimaging. While most imaging studies have focused on cerebrovascular disease, evidence is growing that the hippocampus may play a role in depression, particularly geriatric depression. METHOD: We studied 60 depressed elderly patients enrolled in a longitudinal study who were treated with antidepressant medications using a treatment guideline-based approach. Baseline and 12-week Montgomery-Asberg Depression Rating Scale (MADRS) scores were obtained via interview with a geriatric psychiatrist. All subjects had a baseline magnetic resonance imaging (MRI) brain scan. MRI scans were processed using standard protocols to determine total cerebral volume and right and left hippocampal volumes. Hippocampal volumes were standardized for total cerebral volume. MADRS scores less than 10 were used to define remission. RESULTS: When the group with the lowest quartile of standardized hippocampal volumes was compared to those above the first quartile, those with small right and total hippocampal volumes were less likely to achieve remission. In a subsequent logistic regression model controlling for age small standardized right hippocampal volumes remained significantly associated with remission. CONCLUSION: Further studies with larger sample are needed to determine if left-right hippocampal volume differences do exist in depression, and basic neuroscience studies will need to elucidate the role of the hippocampus in geriatric depression.

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PubMedDate not supplied

Geriatric rehabilitation: nursing interventions and outcomes focusing on urinary function and knowledge of medications.

This article describes the nursing interventions that focus on urinary function and medication knowledge of older adults in a geriatric rehabilitation program. The authors review the interventions needed to achieve bladder retraining and self-administration of medication and consider what predicts urinary function and knowledge of medication administration in older adults. The descriptive study included 251 consecutive patients who were admitted into a geriatric rehabilitation unit. An evaluation of urinary function was done on admission and based on patient need to (a) maintain urinary function, (b) decrease urinary incontinence, and (c) resolve urinary retention. All patients received routine medication teaching from admission to discharge during each daytime administration of medication. From admission to discharge, there was a decrease in incidences of urinary incontinence and urinary retention and an increase in knowledge of medication regimens. Although the study was descriptive, the findings suggested that nursing interventions in geriatric rehabilitation may decrease urinary incontinence and retention and improve knowledge of medication regimens in this population.

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