Orthostatic hypotension in acute geriatric ward: is it a consistent finding?

BACKGROUND: Orthostatic hypotension (OH) is a common finding among older patients. We designed a study to examine the prevalence and consistency of OH during the day. METHODS: A total of 502 inpatients (241 men and 261 women) with a mean age of 81.6 years were included in the study. Orthostatic tests were performed 3 times during the day, 30 minutes after meals. In 13 patients only 2 sets of measurements were obtained, and they were omitted from some of the calculations. Orthostatic hypotension was defined as a fall of at least 20 mm Hg in systolic blood pressure and/or 10 mm Hg in diastolic blood pressure on assuming an upright posture. RESULTS: Three hundred thirty-two (67.9%) of 489 patients experienced OH at least once during the day. Of these, 170 patients (34.8% of the 489) had OH at least twice (persistent OH) and 162 patients (33.1%) experienced OH only once (variable OH). Diastolic OH was more prevalent than systolic OH (57.3% vs 43.4%; P<.001). The intraindividual consistency of OH was low (kappa = 0.2). Orthostatic hypotension was observed less frequently during the evening than during the morning and afternoon (P<.05 vs morning and P =.003 vs afternoon). The difference between meals' constituents (light vs heavy meals) did not affect the prevalence of OH. CONCLUSIONS: Orthostatic hypotension is very common in the elderly, and diastolic OH is more common than systolic OH. The prevalence of OH is the lowest during the evening, and meals do not increase the prevalence of OH. The intraindividual consistency of OH during the day is poor. Thus, in elderly patients, more attention should be paid to diastolic OH and the diagnosis should be based on repeated measurements.     

Is anaemia a risk factor for delirium in an acute geriatric population?

BACKGROUND/OBJECTIVE: Delirium is a common clinical problem in elderly patients. We aim to investigate whether anaemia is a risk factor for delirium in a hospitalized geriatric population. METHODS: During a 5-month prospective study, we investigated 190 elderly patients aged 70 years and older with a baseline Mini-Mental State Examination (short version), Confusion Assessment Method, demographic, clinical and laboratory data. RESULTS: Thirty-four patients were identified as delirious and 95 as anaemic according to the WHO criteria. Stepwise logistic regression revealed that anaemia (haemoglobin level <12 g/l in women and <13 g/l in men), male sex and a diagnosis of dementia were independent risk factors for delirium in the total study group. After adjustment for sex, age, diagnosis of dementia and dehydration, the odds ratio (OR) for anaemia (2.4; 95 CI = 1.02-5.54) remained significantly associated with delirium. When the study population was classified in groups according to sex, anaemia remained a significant risk factor for delirium in men (OR = 3.7; 95% CI = 1.03-15.6) after adjustment for the multiple variables but not in women (OR = 1.54; 95% CI = 0.48-4.9). When the haemoglobin levels were stratified into sex-specific quartiles, the adjusted OR for delirium for men with a haemoglobin level less than 11.1 g/dl was 13.1 (95% CI = 1.17-146). CONCLUSION: Anaemia is an independent risk factor for delirium and adds valuable information to previously validated predictive models in men but not in women and lower haemoglobin levels were associated with higher risk levels.     

Is a specific drinking pattern a consistent feature of the Mediterranean diet in Spain in the XXI century?

Background and aimOver the last 50 years, people in Spain have increasingly been eating their main meal away from home and are shifting from the typical Mediterranean diet (MD). In addition, wine consumption has decreased whereas beer intake has risen. Consequently, it is uncertain if the Mediterranean drinking pattern (MDP; moderate alcohol intake mainly from wine and during meals) is a habitual feature of the MD today.Methods and resultsCross-sectional study conducted from 2008 to 2010 among 8894 individuals representative of the Spanish population aged 18–64 years. Consumption of alcoholic beverages and food was collected with a validated diet history. Accordance with the MD was defined as a score ≥8 on the Mediterranean Diet Adherence Screener (MEDAS) or ≥5 in the Trichopoulou index (after excluding alcohol intake from both indices). Among individuals with MEDAS-based MD accordance, only 17.1% had a MDP. After adjustment for potential confounders, this drinking pattern showed a weak association with higher MD accordance (odds ratio (OR) 1.32; 95% confidence interval (CI) 1.12–1.57). Only 14.7% of those with Trichopoulou-based MD accordance had a MDP; this pattern showed an even weaker association with higher MD accordance (OR 1.17; 95% CI 1.01–1.36). Similar results were obtained when this drinking pattern was redefined to include persons who drank wine with or outside of meals, as well as those who were primarily beer drinkers.ConclusionsThe MDP is not a habitual feature of the MD in the early XXI century in Spain.     

Is there a role for routine colonoscopy in the follow-up after acute appendicitis?

Background: Mechanical obstruction of the appendiceal lumen is proposed as a possible factor in the pathogenesis of acute appendicitis. Hence, patients over the age of 40 are often referred to a follow-up colonoscopy after admission for acute appendicitis. The use of CT scans question whether routine colonoscopy still has a place in follow-up for these patients.

Methods: All patients aged over 40 years with confirmed acute appendicitis admitted to St. Olav’s Hospital in the period from 2010 to 2015 were included in this retrospective study. Findings and distribution of significant colorectal neoplasms (cancer and advanced adenomas) within three years after the admission were evaluated.

Results: Fifty-four (7.4%) of the 731 patients were found to have colonic neoplasms; 9 patients (1.2%) were found to have colorectal cancer of which 7 were located on the right side, 22 patients (3.0%) were found to have advanced adenomas and 23 patients (3.1%) were found to have non-advanced adenomas. The sensitivity and specificity for CT to discover cancer was 0.25 and 0.97, respectively. A total of 316 patients (43.2%) had colonoscopy within three years after admission.

Conclusion: There may be an increased risk of colorectal neoplasms in patients over the age of 40 admitted with acute appendicitis. There seems to be an increased proportion of right-sided cancer relatively to other colonic locations. The sensitivity for CT scans to discover colorectal cancer in this group is low. Further studies are needed to decide whether routine colonoscopy is indicated after acute appendicitis in patients over 40 years.     

Is there a role for serum endothelin in predicting the severity of acute pancreatitis?

BACKGROUND: Acute pancreatitis remains a common presentation to acute surgical units and carries significant morbidity and mortality. The progression of the disease to necrotizing pancreatitis and multi-organ dysfunction syndrome (MODS) is associated with a very poor clinical outcome, and persistendy high mortality. Increases in serum endothelin (ET) have been seen in animal models of acute pancreatitis and this study aims to investigate whether there is a change in serum ET-1 in patients with acute pancreatitis and whether any such change is linked to disease severity. METHODS: All patients admitted with acute pancreatitis were prospectively recruited from die emergency admissions at the Norfolk and Norwich University Hospital. Serum ET levels were determined on admission, at 24 hours and 5 days post admission. Healthy adult controls were recruited from dermatology outpatients. RESULTS: A total of 21 patients joined the trial after giving informed consent. There were 3 men and 18 women with a median age of 65 years (range 26-87 years). Serum ET levels were significantly higher in acute pancreatitis patients than in normal controls (P <0. 05). An association was seen between persistendy raised serum ET levels and progression to MODS. CONCLUSIONS: The study does demonstrate a correlation between the circulating levels of ET and acute pancreatitis in humans, although it does not elicit its involvement in the pathogenesis of the disease. The observation that a persistendy high level of circulating ET-1 is associated with progression to MODS may indicate a role for ET in the monitoring of acute pancreatitis patients for recovery or progression to MODS.     

Measuring orthostatic hypotension with the Finometer device: is a blood pressure drop of one heartbeat clinically relevant?

OBJECTIVE: The role of orthostatic hypotension in falls in older people is generally accepted. Because of the high degree of intra- and interobserver variability in conventional measurements of orthostatic hypotension, application of continuous measurement systems has been proposed. The clinical relevance of a blood pressure drop lasting one heartbeat, however, is unknown. We therefore investigated which time average of continuous-finger-blood-pressure measurement (Finometer) showed the best association between orthostatic hypotension and falls. This was also compared with conventional sphygmomanometer measurements. METHODS: In 217 geriatric outpatients supine and standing (finger) blood pressure to diagnose orthostatic hypotension was monitored with Finometry (beat-to-beat and 1, 5, 10, 15, 20 and 30 s averages) and sphygmomanometry. History of fall incidents (previous year) was registered. RESULTS: The best association (C=0.22, P=0.003) with falls history was found for the 5-s average of Finometry, whereas falls and orthostatic hypotension assessed by sphygmomanometry did not correlate. The odds ratio of a fall according to orthostatic hypotension using the 5-s average was 2.54 (95% CI: 1.37 to 4.71). CONCLUSIONS: Orthostatic hypotension and falls are correlated when using Finometry, with the best association found when using 5-s averages. As the etiology of falls is often multifactorial, orthostatic hypotension and falls are poorly correlated, irrespective of the method or time average that is applied.     

Is postural hypotension a real problem with antihypertensive medication?

Historically, postural hypotension has been cited as a consideration which might influence the selection of antihypertensive therapy. The common symptoms (dizziness, blackouts, syncope) give cause for concern but they are not attributed to every class of antihypertensive drug. For example, administration of a beta-blocker is not generally associated with symptomatic postural hypotension, whereas the alpha-blocker prazosin was particularly problematical, with a significant and well-recognized risk of first-dose postural effects. Titration from a low starting dose and careful selection/monitoring of patients have been successfully used to circumvent this problem. However, since there is a relatively high incidence of postural hypotensive symptoms in elderly patients in general, it may be a misconception to attribute such symptoms to any particular type of antihypertensive drug. Furthermore, with the newer alpha(1)-blockers, such as doxazosin, which have a more gradual onset of action, there is a markedly reduced tendency for postural hypotension to occur. Thus, it is perhaps time to reassess the real significance of iatrogenic postural hypotension in the selection of antihypertensive therapy.     

Does nutritional supplementation influence the voluntary dietary intake in an acute geriatric hospitalized population?

Undernutrition is a significant problem in hospitalized elderly patients, and is associated with a higher morbidity and mortality. The aim of this study is to assess the effect of an oral nutritional supplementation on the total daily caloric intake in an acute geriatric hospitalized population. A dietary assessment and a total food intake were collected on admission and every other day (day 0, 2, 4, 6 ...) during hospitalization (mean duration, 12.8 days+/-6) in 50 randomly chosen elderly patients (mean age 82.5+/-5.5 years, 18 men and 32 women). The mean daily caloric intake was calculated from 108 dietary assessments after receiving oral supplementation (Nutridrink-Nutricia, 300 kcal/200 mL), and 154 when a voluntary diet without supplementation was consumed. The mean voluntary energy intake (including parenteral fluid) was similar on days a nutritional supplementation was given or not (1546 kcal/d vs 1475 kcal/d, respectively, p=0.27), but the total caloric intake was significantly higher on days a nutritional supplementation was consumed (1825 kcal/d vs 1475 kcal/d, p=0.0006). This beneficial effect of a nutritional supplementation on the total caloric intake existed when patients were divided into well nourished (N=15) and those at risk or malnourished (N=35), according to the Mini-Nutritional Assessment. In conclusion, short-term nutritional supplementation has a beneficial effect on the total daily caloric intake in elderly hospitalized patients with and without malnutrition, but the wastage remains high.     

Is there a place for inhaled nitric oxide in the therapy of acute pulmonary embolism?

Acute pulmonary embolism (PE) is a serious complication resulting from the migration of emboli to the lungs. Although deep venous thrombi are the most common source of emboli to the lungs, other important sources include air, amniotic fluid, fat and bone marrow. Regardless of the specific source of the emboli, very little progress has been made in the pharmacological management of this high mortality condition. Because the prognosis is linked to the degree of elevation of pulmonary vascular resistance, any therapeutic intervention to improve the hemodynamics would probably increase the low survival rate of this critical condition. Inhaled nitric oxide (iNO) has been widely tested and used in cases of pulmonary hypertension of different causes. In the last few years some authors have described beneficial effects of iNO in animal models of acute PE and in anecdotal cases of massive PE. The primary cause of death in massive PE that is caused by deep venous thrombi, gas or amniotic fluid, is acute right heart failure and circulatory shock. Increased pulmonary vascular resistance following acute PE is the cumulative result of mechanical obstruction of pulmonary vessels and pulmonary arteriolar constriction (attributable to a neurogenic reflex and to the release of vasoconstrictors). As such, the vasodilator effects of iNO could actively oppose the pulmonary hypertension following PE. This hypothesis is consistently supported by experimental studies in different animal models of PE, which demonstrated that iNO decreased (by 10 to 20%) the pulmonary artery pressure without improving pulmonary gas exchange. Although maximal vasodilatory effects are probably achieved by less than 5 parts per million iNO, which is a relatively low concentration, no dose-response study has been published so far. In addition to the animal studies, a few anecdotal reports in the literature suggest that iNO may improve the hemodynamics during acute PE. However, no prospective, controlled, randomized clinical trial addressing this issue has been conducted to date. Future investigations addressing the effects of iNO combined with other drugs such as vasoconstrictors and inhibitors of phosphodiesterase III or V, may increase the responsiveness to iNO in acute PE.