Aging and the esophagus: Common pathologic conditions and their effect upon swallowing in the geriatric population

Dysphagia in the elderly is most often oropharyngeal or hypopharyngeal in location and neuropathologic in etiology. Aging itself, although causing demonstrable structural and functional changes in the esophagus, does not cause any clinically relevant esophageal dysphagia. A variety of pathologic conditions seen in the geriatric population affect the esophagus and can alter esophageal function, resulting in symptomatic dysphagia. Accurate diagnosis requires a thorough evaluation performed in an unhurried fashion, often with the assistance of ancillary personnel. Treatment of these esophageal disorders is multidisciplinary and may involve dietary manipulations, the administration of medications, therapeutic endoscopic procedures, and occasionally surgery.     

Optimizing the use of antithrombotic therapy for atrial fibrillation in older people: a pharmacist-led multidisciplinary intervention

OBJECTIVES: To develop, implement, and evaluate a pharmacist-led multidisciplinary intervention in a hospital setting that would optimize antithrombotic use in elderly atrial fibrillation patients. The hypothesis that there would be an increase in the proportion of patients receiving antithrombotic therapy at discharge was tested. DESIGN: Evidence-based algorithms were developed to define the criteria (stroke risk vs contraindications) by which an elderly patient's requirement for antithrombotic therapy was assessed. SETTING: A major Sydney teaching hospital. PARTICIPANTS: Two hundred eighteen consecutively admitted elderly patients (mean age 85.2) were recruited over a 6-month period. INTERVENTION: A pharmacist-coordinated multidisciplinary review process was implemented to coordinate risk assessments and subsequently recommend appropriate antithrombotic therapy, as per the algorithms. MEASUREMENTS: The proportion of patients receiving antithrombotic therapy was assessed on admission (preintervention), at discharge (postintervention), and postdischarge (follow-up at 3 and 6 months). RESULTS: As a result of the intervention, 78 patients (35.8%) required changes to their existing antithrombotic therapy. Of these changes, 60 (76.9%) were "upgrades" to more-effective treatment options (e.g., from no therapy to any agent or from aspirin to warfarin). The remaining 18 (23.1%) changes were "downgrades" to less-effective, albeit safer, options. Despite a significant increase in anti thrombotic use overall (59.6% vs 81.2%, P<.001), fewer patients received warfarin postintervention, after having been assessed as inappropriate candidates (20.7% vs 17.4%, P=.39). CONCLUSION: A pharmacist-led multidisciplinary process was successfully developed and implemented within the hospital setting to increase overall antithrombotic use. Having addressed some of the known barriers and limitations to warfarin use, these algorithms may allow allied health workers, patients, and clinicians to work collaboratively to achieve optimal and, importantly, appropriate (i.e., safe and effective) antithrombotic use in at-risk elderly patients.     

Assessment of dementia in elderly outpatients: a comparative study of European centers and consensus statement

Large numbers of elderly patients, suspected of having dementia, need medical evaluation, often in early phases of their illness. A complete outpatient assessment clearly could be advantageous. Thirty-five centers from 15 European countries, known to their scientific gerontological and geriatric societies to have experience in outpatient care for elderly patients with dementia, participated in an effort to develop a consensus statement for the assessment needs of these patients. The comparison of the centers showed that a wide variety of approaches was currently in practice. Differences appeared to be mainly based on local facilities and organization. A consensus for diagnostic outpatient assessment was easily reached. Diagnosis should be based on DSM-IV criteria, which requires a standardized assessment (including neuropsychological, functional and technical evaluation) and should be multidisciplinary. An assessment of dementia of elderly outpatients appears to be very feasible - a consensus approach with minimum diagnostic requirements is presented.     

AIDS in the elderly: a case and its implications

Although acquired immunodeficiency syndrome (AIDS) remains relatively uncommon in the elderly, there are serious and unique implications associated with the diagnosis of AIDS in this age group. The most common mode of transmission is transfusion. With the growing number of elderly, an increase in AIDS in the elderly will occur despite improved screening methods. Dementia is a serious morbidity associated with AIDS in the elderly, which presents considerable diagnostic and ethical dilemmas. A case is presented which illustrates the geriatric multidisciplinary team approach to the care of a 90-year-old man with AIDS.     

老年患者卵圆孔未闭多学科评估及封堵术后随访的单中心经验

目的 随机对照试验已经证实了经导管卵圆孔未闭 (PFO) 封堵在预防年轻PFO患者不明原因卒中的疗效。多项回顾性研究报道了老年人封堵术后复发性脑缺血事件的发生率较高。该研究基于多学科评估,探讨经导管 PFO 封堵术治疗老年高危PFO的安全性及疗效。 方法 选择于西安交通大学第一附属医院结构性心脏病科住院诊断为不明原因栓塞性卒中或短暂性脑缺血发作（TIA）并最终接受 PFO 封堵术的60 岁以上高危PFO患者。所有患者术前均接受多学科评估以排除具有明确病因或其他可能因素导致的卒中/TIA,随访观察手术并发症及缺血事件发生情况。 结果 共入选122例患者,平均年龄(64±5)岁,随访时间(2.5±1.7)年。共置入了两种封堵器,未发生严重不良事件,随访两种封堵器终点事件无差异。老年患者PFO封堵术后年复发性缺血性卒中/ TIA 的风险为0.67 %。 结论 经多学科评估严格筛选后的高危老年PFO患者行封堵术是安全有效的,此类患者可以考虑接受经导管卵圆孔未闭封堵术,以预防脑血管事件复发。     

Diagnosis of dementia

PURPOSE: The high prevalence of dementia, particularly of Alzheimer's disease, the increase of their incidence with age, and the population aging make this group of diseases a major problem for public health. Nevertheless, diagnosis is difficult because it depends on evolution of disturbances that patients often cannot precisely relate, on complex neuropsychological explorations, and on pathological examination difficult to obtain. Today in France, geriatricians are fully implicated in the diagnosis of dementia and all the physicians who give care to elderly, should lead easily a diagnosis of dementia. CURRENT KNOWLEDGE AND KEY POINTS: In February 2000 ANAES (French governmental agency for accreditation and evaluation of health system) published recommendations called "practical recommendations for the diagnosis of Alzheimer's disease". These recommendations allow physicians to standardize their practices and consist of a rigorous clinical history and examination, a neuropsychological analysis, standard investigations and application of diagnostic criteria already widely diffused and used. FUTURE PROSPECTS AND PROJECTS: Deepening of knowledge, in particular in the domains of neuropsychology and functional cerebral imagery, should allow physicians to diagnose early dementia. These early diagnosis should allow to initiate a multidisciplinary, preventive and effective care for patients. Specific drugs, that will be available, will be intended mostly for patients with early diagnosis, ideally at a pre-dementia state.     

原发性双癌老年患者手术前评估及处理

A 64-year old man was admitted on July 2011 with masses both in liver and right kidney.After PET-CT and blood test examination,dual primary advanced cancers were speculated to be co-existed in this patient,which having poor prognosis.By evaluation with comprehensive geriatric assessment,the patient also had hypertension,diabetes and atherosclerosis,liver and renal insufficiency.After multidisciplinary consultation and detailed discussion with the patient,the decision of "no surgery and just keep the follow-up" was made.The patient has been followed up for 18 months and the functional evaluation is the same as before.It is very important to evaluate the risk/benefit equation and improve the standard of care,and make the decision as patient centered rather than disease-centered in the elderly patients.     

老年低血糖脑病误诊分析

目的探讨老年低血糖脑病误诊原因。方法回顾性分析16例老年低血糖脑病患者的临床资料。结果16例老年低血糖脑病患者被误诊为急性脑血管病、癫痫或脑炎。结论老年低血糖脑病易被误诊,临床上对老年突发的意识障碍、癫痫发作及精神异常者应常规行血糖检查,及时确诊并尽早治疗,以免影响预后。     

Left atrial myxoma in the elderly. Report of four patients over the age of 70 and review of the literature

Myxoma of the atrium presents distinctive clinical profile, yet precise diagnosis of the tumor on the basis of clinical findings is often not made in the elderly patient as the symptoms are often attributed to "generalized arteriosclerosis of the elderly." The authors report the clinical findings in four elderly patients with left atrial myxoma in whom the diagnosis had not been clinically suspected before echocardiographic evaluation.     

Home safety and fall prevention.

In conclusion, the majority, or at least a large proportion, of accidental injuries in the elderly are preventable with careful medical and environmental evaluation and intervention. A vigorous diagnostic, therapeutic, and preventive approach is appropriate in all older patients who fall in addition to those at a high risk of falling. Any intervention that can make inroads on this major cause of death and disability in the elderly population will clearly have major impact.     

Dysphagia following fundoplication: "slipped" fundoplication versus achalasia complicated by fundoplication

Failure to obtain preoperative esophageal manometry in patients being considered for antireflux surgery can result in immediate persistent postoperative dysphagia due to a missed diagnosis of achalasia. We describe the clinical assessment and management of a case of delayed postoperative dysphagia due to a "slipped" fundoplication, which is contrasted with three patients with immediate postoperative dysphagia due to a missed diagnosis of achalasia. Surgical revision was required to correct the "slipped" fundoplication, and pneumatic dilatation was successfully used in two of three cases of achalasia complicated by fundoplication. Careful preoperative esophageal evaluation with manometry is essential to rule out the presence of a primary esophageal motor disorder.     

Intracerebral aneurysms: a review with special attention to geriatric aspects

Rupture of an intracranial aneurysm (ICA) remains a devastating complication associated with a high degree of morbidity and mortality. In the past 2 decades, older people were often excluded from active treatment on the unique basis of their chronological age. Recent developments of less-invasive techniques for the diagnosis and treatment of ruptured and unruptured ICAs suggest that this fatalistic attitude toward older patients should be reconsidered. Furthermore, taking into account the heterogeneity of the elderly population, the use of a comprehensive geriatric assessment approach, based on a multidisciplinary evaluation, appears particularly helpful in proposing the optimal treatment strategy for each older patient. This article reviews the geriatric features of epidemiological, physiopathological, as well as clinical and therapeutic aspects of ruptured and unruptured ICAs.     

"Diastolic" heart failure and pulsed pressure

Cardiac failure is the leading cause of hospital admission after 65 years of age. Several studies have confirmed the frequency of cardiac failure with normal systolic function ("diastolic" cardiac failure) in the elderly (nearly half the cases). The cause is commonly isolated systolic hypertension. The pulsed pressure depends on ventricular ejection, arterial rigidity and the precocity of reflected pulse waves. In the elderly, the pulse pressure is a powerful predictive factor for mortality and adverse cardiovascular events (acute coronary syndromes, cardiac failure and cerebrovascular accidents). Patients with isolated systolic hypertension or an increased pulsed pressure usually have left ventricular hypertrophy or concentric remodelling, abnormal relaxation, alteration of hypertrophied myocytes with increased myocardial oxygen consumption and subendocardial ischaemia, especially when the coronary reserve is reduced. The decrease of the diastolic blood pressure reduces the presence of coronary perfusion. Moreover, an increase in the pulsed pressure predisposes to coronary atherosclerosis. These patients are very symptomatic on exercise because they do not have a reserve of preload and easily develop acute pulmonary oedema after a volume overload (increased salt intake, postoperative rehydratation). A recent study showed that the left ventricular ejection fraction was preserved during acute pulmonary oedema of hypertensive patients. The diagnosis of "diastolic" cardiac failure is often suspected by elimination (clinical signs of cardiac failure with a normal left ventricular ejection fraction), and echographers have proposed many criteria to detect abnormal relaxation, filling or distensibility of the left ventricle. Mortality would seem to be half that of systolic cardiac failure. Treatment should normalise the hypertension, ischaemia, tachycardia, and maintain or reestablish sinus rhythm, but it remains empirical.     

"Dormant" secondary metal-alkyl complexes are not omnipresent

This theoretical study was inspired by the perpetual debate over the so-called "dormancy" of the active sites in propylene polymerization, i.e., a drop in their activity after a regioerror (2,1-insertion), which was reported to occur in many (although not all) catalytic systems. To explore the range of possible situations, we have selected two homogeneous systems of fundamentally different structure: an octahedral system of C2 symmetry with a tetradentate -O-N-N-O- ligand and a bridged indenyl catalyst. This choice was not accidental; it is in these two systems where the experimentalists cannot reach a consensus about dormancy. Our density-functional theory calculations explain why in certain catalytic systems both primary and secondary alkyl complexes can be equally reactive toward propylene polymerization, despite the intuitive concept of dormancy. To understand such a behavior, it was imperative to build an extensive model, including the counteranion and solvent effects. The discussion is also supplemented by our latest calculations on the classical second-generation Ziegler-Natta system.     

"Tight control" in geriatrics: the emperor wears a thong

The deep-seated faith in tight glycemic control for patients with type 2 diabetes mellitus shows signs of moderating, especially for elderly adults, but faith in the importance of a glycosylated hemoglobin goal of 7% retains a strong influence over many clinicians. This faith persists despite weak evidence from randomized controlled trials of any meaningful benefit from "tight control" in any patient group, consistent evidence of lack of benefit for many outcomes, and an almost complete lack of evidence about elderly adults or those with extensive vascular disease. Clinicians who care for these vulnerable individuals face a strong public belief in "tight control" and an orchestrated campaign to increase medication use. Although no benefit has been shown in elderly adults, some harms are clear, and others are likely.     

Reviewing the definition of "elderly"

Conventionally, "elderly" has been defined as a chronological age of 65 years old or older, while those from 65 through 74 years old are referred to as "early elderly" and those over 75 years old as "late elderly." However, the evidence on which this definition is based is unknown. We have attempted to review the definition of elderly by analyzing data from long-term longitudinal epidemiological studies, and clinical and pathological studies that have been accumulated at the Tokyo Metropolitan Geriatric Hospital and the Tokyo Metropolitan Institute of Gerontology. Our recommendation might be a starting point in developing a strategy for a successful society by reviewing the definition of elderly based on comprehensive evidence in all aspects of social, cultural and medical sciences.     

Aspiration pneumonia and dysphagia in the elderly

Community-acquired pneumonia (CAP) is a major cause of morbidity and mortality in the elderly, and the leading cause of death among residents of nursing homes. Oropharyngeal aspiration is an important etiologic factor leading to pneumonia in the elderly. The incidence of cerebrovascular and degenerative neurologic diseases increase with aging, and these disorders are associated with dysphagia and an impaired cough reflex with the increased likelihood of oropharyngeal aspiration. Elderly patients with clinical signs suggestive of dysphagia and/or who have CAP should be referred for a swallow evaluation. Patients with dysphagia require a multidisciplinary approach to swallowing management. This may include swallow therapy, dietary modification, aggressive oral care, and consideration for treatment with an angiotensin-converting enzyme inhibitor.     

Unexplained weight loss in the ambulatory elderly

Significant unexplained and unintentional weight loss was found in 45 elderly patients who were identified by computer search of the diagnostic files of seven family practice centers. We performed a case series chart review study which revealed that 24% of the 45 cases had no definitive etiology for the weight loss after two years of extensive clinical investigation. Depression was found to be the most common diagnosis made (18%) followed by cancer (16%). Only four patients died during the study period and all had cancer. The most prevalent diagnosis in this group of ambulatory elderly patients did not prove to be cancer, as often though, but rather "unexplained weight loss." CT scans were not found to be helpful as screening tests in the evaluation of weight loss. Using the data from this study, the diagnostic evaluations of elderly patients with unexplained weight loss may be more efficiently directed.     

The prevalence of valvular abnormalities in patients who were referred for echocardiographic examination with a primary diagnosis of "heart murmur"

INTRODUCTION: The prevalence of valvular abnormality and innocent murmur in patients who are referred for echocardiographic evaluation with the diagnosis of "murmur" is not known. The goal of this study was to evaluate the prevalence of valvular abnormalities in such patients. METHODS: We retrospectively reviewed the echocardiograms that were referred with the primary ordering diagnosis of "murmur," for the presence of valvular abnormalities. For comparison, we used other documented primary reasons for echocardiographic referral, such as chest pain, shortness of breath, etc. RESULTS: In this cohort, 7,684 echocardiogram reports documented primary diagnostic reasons for echocardiographic referral. A total of 3,460 echocardiogram reports (45%) were coded "murmur" as the primary reason for the study referral. There was a higher prevalence of female patient referrals for heart murmur evaluation (61.8% vs. 38.2%). Although, patients with murmur had a higher prevalence of valvular abnormalities, compared to other reasons for echocardiographic examination, the prevalence of valvular abnormality was less than 50% (48.6% vs. 35.5%) in both groups. Despite the higher number of female patients referred with the diagnosis of murmur, the percentage of abnormal valves was lower in women (45.6% vs. 53.4% in men). CONCLUSION: The prevalence of valvular abnormalities in patients who were referred with the diagnosis of murmur for echocardiographic examination was less than 50%, with a lesser degree found in women. Routine utilization of echocardiography for evaluation of all murmurs may be unwarranted.