老年髋部骨折术后谵妄的管理

老年髋部骨折患者进行手术具有较高风险,术后谵妄(POD)发生率高,严重影响术后康复及远期预后,需骨科、麻醉科、老年内科、内科、重症医学科、康复科、营养科、精神心理科等多学科团队分工协作,共同管理。术前应对POD相关危险因素进行综合评估,制定个体化综合预防措施;术中应关注老年患者的麻醉方式、微创术式选择等特殊问题;术后应有效控制疼痛、营养支持、预防术后并发症、尽早开展术后康复,保证医疗的连续性。西安交通大学第一附属医院相关专业在老年髋部骨折围术期管理经验基础上,结合国内外指南总结成文,旨在更好地开展老年髋部骨折患者围手术期管理,预防POD发生或及时干预POD进展,改善患者预后。     

老年脊柱手术患者术后早期谵妄的危险因素

<正>术后谵妄(POD)是老年患者术后比较常见的一种中枢神经系统并发症,表现为意识、注意力、认识力和感知力短暂性障碍,其可使患者康复延迟、住院时间延长〔1〕,影响患者术后生活质量。脊柱手术由于创伤大、手术时间长、术中出血量多,增加了老年患者POD发生的危险性。本研究筛选老年患者脊柱外科手术术后早期POD的危险因素。1资料与方法1.1研究对象选择拟行脊柱手术患者224例,年龄≥65岁,     

老年术后谵妄患者术前脑网络功能连接的特征研究

目的 通过静息态功能磁共振成像(rs-fMRI)研究术后谵妄(POD)患者术前脑功能的影像学特征性改变。方法 2021年4月—10月,选择34例择期于复旦大学附属华东医院行非心脏大手术的老年患者。术前1 d进行基线资料收集和rs-fMRI扫描,术后采用3 min谵妄诊断量表或ICU意识模糊评估法进行POD评估。根据患者有无POD分为POD组和非POD组。通过基于种子点的功能连接分析观察POD患者术前默认网络(DMN)、突显网络(SN)、中央执行网络(CEN)以及边缘系统网络(LN)中核心脑区的全脑功能连接变化。结果 12例患者发生POD, POD发生率为35.29%。校正年龄、性别和受教育时间后,POD患者术前DMN、 CEN和LN核心脑区的全脑功能连接强度较非POD患者明显降低。结论 POD患者术前DMN、 CEN和LN全脑功能连接模式可能存在异常改变,主要表现为连接强度广泛降低。     

老年人髋部骨折周围神经阻滞应用的研究进展

老年髋部骨折患者常经历中到重度的疼痛, 疼痛增加围术期并发症的风险、不利于患者术后早期活动和康复。周围神经阻滞被推荐用于老年髋部骨折患者的围术期镇痛。本文概述了髋关节神经支配、相关周围神经阻滞技术及其对老年髋部骨折患者术后并发症和术后康复的影响。基于现有的证据, 周围神经阻滞对老年髋部骨折患者的预后有潜在的积极作用, 未来仍需要高质量的临床研究进一步验证。     

老年人开胸术后急性谵妄的相关因素分析

老年人手术后谵妄(postoperative delirium,POD)是外科术后常见的一种急性精神错乱状态,通常在术后早期发生,病程呈波动性,临床基本特征表现为意识、注意力、认知和知觉障碍.全麻开胸手术创伤大、时间长,术后POD的发生率较高,在老年患者中尤为突出[1].     

GNRI联合NLR对老年髋部骨折患者术后谵妄的预测价值

目的 探讨老年营养风险指数（GNRI）联合中性粒细胞/淋巴细胞（NLR）对老年髋部骨折患者术后谵妄（POD）的预测价值。方法 选择老年髋部骨折患者223例，均接受手术治疗，发生POD 51例（POD组）、未发生POD172例（非POD组）。比较两组术前GNRI和NLR。收集老年髋部骨折患者术前基本资料、手术相关资料以及实验室检查资料，采用多因素Logistic回归模型分析老年髋部骨折患者发生POD的影响因素。采用受试者工作特征（ROC）曲线分析GNRI、NLR对老年髋部骨折患者POD的预测效能。结果 POD组GNRI低于非POD组，NLR高于非POD组（P均<0.05）。多因素Logistic回归分析显示，年龄（OR=1.081,95%CI:1.019～1.146）、脑卒中（OR=2.712,95%CI:1.011～7.271）、NLR(OR=1.484,95%CI:1.021～2.156)为老年髋部骨折患者发生POD的独立危险因素（P均<0.05），而GNRI(OR=0.880,95%CI:0.825～0.940)则为其独立保护因素（P<0.05）。ROC曲线分析显...     

限制性输血与开放性输血对髋关节置换术老年患者术后谵妄的影响

目的观察限制性输血与开放性输血策略对行髋关节置换术老年患者术后谵妄(POD)的影响。方法选择65岁以上美国麻醉医师协会(ASA)Ⅰ~Ⅲ级择期在蛛网膜下腔麻醉下行髋关节置换术老年患者165例,随机分为限制性输血组81例〔血红蛋白(Hb)维持在8~10 g/dl〕,开放性输血组84例(Hb维持在10~12 g/dl)。记录患者年龄、性别、体重、ASA分级、手术时间、围术期Hb浓度、术中输血量、预计失血量、住院时间、术后急性肺栓塞、心肌梗死、脑梗死、伤口感染率及POD发生率,并分析POD的相关危险因素。结果两组患者年龄、体重、性别比、手术时间、ASA分级、术前Hb浓度、预计失血量、住院时间、术后急性肺栓塞、心肌梗死、脑梗死、伤口感染率、POD发生率无明显差异(P0.05)。与开放性输血组相比,限制性输血组红细胞输注量明显降低(P0.05)。多因素分析显示:高龄、受教育年龄9年、ASA分级≥Ⅲ级、术前简易精神状态量表(MMSE)评分23分及术中输血量500 ml是POD的危险因素。结论限制性输血策略对髋关节置换术老年患者POD无明显影响,但可减少用血量,因而限制性输血策略对此类患者是安全可行的。     

术前营养不良的老年病人全麻下髋关节置换术后谵妄的危险因素

目的 探讨术前营养不良的老年病人全麻下髋关节置换术后谵妄(POD)的危险因素。方法 选取术前存在营养不良或营养不良风险且在气管插管全麻下行髋关节置换的老年病人149例为研究对象,根据术后是否发生POD分为POD组和非POD组,观察并比较2组相关临床资料。采用多因素Logistic回归分析营养不良老年病人髋关节置换术后发生POD的危险因素。结果 149例病人中60例发生了POD,POD发生率为40.27%。2组在年龄、BMI、低氧血症、电解质紊乱、营养状况、认知功能评分、血清白蛋白、血红蛋白、手术时间、术中出血量以及术后使用镇痛泵等方面差异有统计学意义(P<0.05)。多因素Logistic回归分析结果提示：年龄≥75岁、BMI<20、微型营养评定法简表评分<7分、MMSE评分<27分及血清白蛋白<30 g/L是术前存在营养不良或营养不良风险的老年病人全麻下行髋关节置换术后发生POD的危险因素(P<0.05),而术后镇痛是保护性因素(P<0.05)。结论 术前存在营养不良或营养不良风险老年病人在全麻下行髋关节置换术后POD发生率较高,其与病人的年...     

术后谵妄诊断方法的研究进展

正随着我国老年人口以及接受手术麻醉老年病人数量的增长,老年病人术后并发症也越发引起人们的重视。术后谵妄(postoperative delirium,POD)是老年病人术后常见的并发症之一,是一种以随时间波动的意识改变和注意力不集中为特征的急性状态,主要发生在术后24～72 h。国外研究结果显示,POD总体发病     

胰岛素样生长因子-1水平与老年腹部术后谵妄的相关性

目的探讨术前血清胰岛素样生长因子(IGF)-1的浓度水平与老年患者腹部手术后谵妄(PDD)发生的关系。方法选择择期开腹手术患者160例,年龄65～80岁,美国麻醉医师协会(ASA)分级Ⅰ～Ⅲ级。记录患者围术期基本情况及并发症的发生。术后当日及术后1、2、3 d随访患者,根据意识混乱评估法(CAM)和谵妄分级量表(DRS-R98)判断患者POD及其严重程度,每日2次评定。根据患者是否发生POD分为POD组和对照组,用酶联免疫吸附试验(ELISA)检测血清中C-反应蛋白(CRP)、白细胞介素(IL)-6和IGF-1浓度水平。结果 160例患者中有41例发生POD,POD组CRP、IL-6浓度水平明显高于对照组(P0.05)。IGF-1是POD发生的独立危险因素(P0.05)。用IGF-1构建的ROC曲线得出,Youden指数为0.614时ROC曲线上的最佳界值52.94 ng/ml,对应切点的敏感性80.8%,特异性80.6%。两组比较POD严重程度差异无统计学意义(P0.05)。结论 IGF-1是POD的独立危险因素,可作为老年患者腹部POD的预测因素之一。     

AIDS and the elderly.

Individuals 50 years of age or older continue to account for at least 10% of AIDS cases reported to the Centers for Disease Control and Prevention in recent years. Little research is devoted to addressing the specific issues affecting diagnosis, treatment, and prevention of AIDS in older Americans. Survival rates among elderly individuals infected with human immunodeficiency virus (HIV) are consistently decreased in comparison with those for younger patients. Elderly individuals also are less likely to use a condom during sexual intercourse or to participate in routine HIV testing. This article reviews the current literature concerning the changing epidemiology of AIDS among older Americans. The article also addresses AIDS-related morbidity and mortality, treatment issues, and HIV-prevention behaviors among the elderly. Enhanced clinician awareness of HIV in the elderly, along with further research concerning HIV treatment and prevention, is necessary to improve survival and outcome for those patients.     

Blood pressure lowering for the primary and secondary prevention of stroke: treatment of hypertension reduces the risk of stroke.

Hypertension is the most important risk factor in the development of stroke. It is also the risk factor most amenable to treatment. The results from 18 controlled trials show a reduction in relative risk of stroke of 25-47% among treated hypertensive patients. This reduction applies both to the elderly and to younger patients, but the absolute reductions are greater among the elderly and the number of patients with hypertension that need to be treated to prevent a stroke is lower in the elderly because they have a higher risk of stroke. The reductions in relative but not absolute risk appear to be similar for both isolated systolic hypertension and combined systolic and diastolic hypertension in the elderly. The case for antihypertensive treatment in the secondary prevention of stroke is less clear but the results of four clinical trials of antihypertensive treatment among patients with and without hypertension and a history of cerebrovascular disease point to a probable benefit. The results of the PROGRESS trial will elucidate this further.     

Dexmedetomidine effect on delirium in elderly patients undergoing general anesthesia: A protocol for systematic review and meta-analysis

Background:Delirium is a common postoperative complication. Many studies have found that dexmedetomidine is associated with a reduced incidence of postoperative delirium (POD). This meta-analysis aimed to analyze the effects of dexmedetomidine on POD incidence among elderly patients undergoing general anesthesia.Methods:We searched 4 electronic databases (i.e., Pubmed, Embase, Cochrane, and Web of Science) from inception to November 30, 2020, for randomized controlled trials that evaluated the effects of dexmedetomidine in preventing the occurrence of POD in elderly patients (aged ≥60 years). The study protocol was registered in PROSPERO (CRD42020192114).Results:14 studies with 4173 patients showed that dexmedetomidine was significantly associated with a decreased POD incidence among elderly patients (relative risk [RR] = 0.58; 95% confidence interval [CI] = 0.44–0.76). The incidence of POD was significantly reduced in the noncardiac surgery group (RR 0.51; 95% CI 0.37–0.72), when dexmedetomidine was applied during the postoperative period (RR = 0.53; 95% CI = 0.40–0.70), and in patients received low-doses (RR = 0.54; 95% CI = 0.34–0.87) and normal-doses (RR = 0.59; 95% CI = 0.42–0.83). There were no significant differences in POD incidence in the cardiac surgery group (RR = 0.71; 95% CI = 0.45–1.11), and when dexmedetomidine was applied during the intra- (RR = 0.55; 95% CI = 0.29–1.01) or perioperative period (RR = 0.95; 95% CI = 0.64–1.40).Conclusions:Our meta-analysis suggests that dexmedetomidine may significantly reduce POD incidence in elderly noncardiac surgery patients and when applied during the postoperative period, in addition, both low- and normal-doses of dexmedetomidine may reduce POD incidence. However, its use in cardiac surgery patients and during the intra- or perioperative period may have no significant effects on POD incidence.     

结核病患者老年密切接触者结核病防治知识知晓情况调查分析

目的 调查结核病患者老年密切接触者对结核病防治知识知晓情况,为制定其结核病防治对策提供依据。 方法 选取2019年6—12月于湖南省胸科医院住院的结核病患者老年密切接触者(年龄≥60岁)作为调查对象,进行问卷调查。调查问卷为自行设计,内容包括:调查对象一般情况、结核病防治核心知识及获得知识的途径。共发出问卷199份,剔除无效问卷后回收193份,有效率97.0%。对调查对象的结核病防治核心知识知晓情况及影响因素进行分析。结果 193名调查对象以小学文化程度为主[47.2%(91/193)],职业以农民为主[62.2%(120/193)];对7条结核病防治核心知识总知晓率为56.3%(760/1351)。7条结核病防治核心知识中,以“结核病是一种严重危害人类健康的传染病”及“咳嗽咳痰2周以上,应怀疑得了肺结核”的单一知晓率较高,分别为74.1%(143/193)和60.1%(116/193);以“结核病的诊断方法”及“结核病防治定点医疗机构检查治疗结核病是否有减免政策”的单一知晓率最低,均为47.7%(92/193)。单因素分析显示,大专及以上文化程度者结核病防治核心知识知晓水平得分[中位数(四分位数)]为85.7(74.9,85.7),明显高于小学文化程度者[57.1(28.5,85.7)];经宣传活动获得知识者结核病防治核心知识知晓水平得分为85.7(67.8,100.0),明显高于未经宣传活动获得知识者[57.1(28.5,85.7)],差异均有统计学意义(H=9.87,P=0.020;Z=-3.70,P=0.000)。多因素logistic回归分析显示,相对于小学文化程度者,大专及以上文化程度者结核病防治核心知识知晓水平高[OR(95%CI)=7.44(1.81~30.58)];经宣传活动获得知识者结核病防治核心知识知晓水平高[OR(95%CI)=3.71(1.68~8.19)]。结论 结核病患者老年密切接触者结核病防治知识知晓率低,文化程度及知识获取途径是其结核病防治知识知晓水平的影响因素。     

65例老年糖尿病合并低血糖症临床疗效观察

目的 探讨和分析老年糖尿病患者合并低血糖症的发病原因和临床治疗效果.方法 选取该院自2012年10月-2013年9月所收治的老年糖尿病合并低血糖症患者共65例,在分析病因的基础上给予对症的治疗.结果 全部患者经过紧急治疗以后,在8h内的血糖水平恢复到正常标准,患者的病情得到明显的好转,低血糖症状和体征随即消失.全部患者也没有1例误诊或者死亡发生,治疗的有效率为100％.结论 对于老年糖尿病合并低血糖患者,只要加强预防,在发现病情后给予科学及时的治疗,就一定能够明显缓解患者的低血糖状态,在临床应引起足够的重视.     

Pain intensity and postoperative pulmonary complications among the elderly after abdominal surgery

OBJECTIVE: The purpose of this study was to determine whether postoperative pain intensity differs between elderly abdominal surgery patients in whom postoperative pulmonary complications (PPC) develop and those in whom they do not. METHODS: The exploratory secondary analysis of data from a prospective study of risk factors for PPC had a convenience sample of 86 patients (> or =60 years old) after abdominal surgery at 3 Midwestern hospitals. Daily measurements from postoperative day (POD) 1 to 6 included: pain (rated 0 to 10) at rest, with coughing, deep breathing, movement and walking, and frequency of ambulation. RESULTS: Sixteen subjects (18.6%) had a PPC develop. Subjects with PPCs had higher mean pain intensities on all measures on each POD than those without. Those with PPCs had significantly higher pain intensities at rest on POD4 (P = .010), with deep breathing on POD2 (P = .015), POD4 (P = .009), POD5 (P = .006), and POD6 (P = .009), were up to a chair significantly fewer times on POD2 (P = .043), and walked significantly fewer times on POD5 (P = .002) and POD6 (P = .000) than those without PPCs. Length of stay for those with PPCs (mean, 17.9 days; standard deviation, 15.9 days; median, 10.0 days) was significantly longer than for those without PPCs (mean, 8.5 days; standard deviation, 4.8 days; median, 7.0 days; P = .000). CONCLUSION: Results provide support for viewing pain as a factor that contributes to the development of PPCs among the elderly population after abdominal surgery. Therefore, nursing interventions of pain assessment and management, deep breathing, and ambulation may influence the incidence of this outcome.     

老年急诊患者心脑血管常见疾病分析

目的对老年急诊患者心脑血管常见疾病进行分析,为老年心脑血管病的预防和救治提供参考资料。方法回顾分析2008年1月～2010年12月在我院老年急诊科就诊的老年心脑血管病患者1292例,根据年龄分为60～79岁组335例,≥80岁组957例,分析比较2组心脑血管病的差异。结果所有患者中心血管病发生率(65.48%)明显高于脑血管病(34.52%,P<0.05),但2组患者心血管病和脑血管病比较,差异无统计学意义(P>0.05)。60～79岁组患者疾病排名依次为短暂性脑缺血发作(TIA)、心绞痛、高血压、心房颤动、其他心律失常;≥80岁组患者疾病排名依次为TIA、心绞痛、心房颤动、高血压、脑梗死。≥80岁组惠心肌梗死、心力衰竭、脑梗死明显高于60～79岁组,而高血压患病明显低于60～79岁组(P<0.05)。结论 TIA、心绞痛、心房颤动、高血压是老年急诊患者常见的心脑血管病,对年龄≥80岁的老年患者,更应加强对心肌梗死、心力衰竭、脑梗死等疾病的预防和救治。     

社区老年人口服抗栓药物预防心脑血管疾病的现况与对策分析

目的分析北京某社区老年人口服抗栓药物进行心脑血管疾病一级预防和二级预防的应用现状。方法2019年10月至2020年3月期间在北京市翠微西里由社区医师通过标准问卷调查老年人的高血压、冠心病、糖尿病、脑梗塞、心房颤动等系统性疾病的患病情况和长期口服抗血小板聚集(APA)与抗凝(AC)药物治疗情况。结果328例老年人参与调查,其中158例(48.2%)长期口服抗栓药物治疗,144例(43.9%)口服APA药物,20例(6.1%)口服AC药物。罹患高血压、糖尿病、脑梗塞、冠心病的老年人仍未抗栓治疗比例分别为44.9%、45.0%、36.7%、8.1%。心房颤动患者AC治疗比例仅为50%,而与APA治疗患者的卒中风险和出血风险无差异。合并1或2种疾病的老年人占大多数(约占26.2%或28.7%),但其抗栓治疗比例仅为29.3%~61.7%。结论社区医师仍需加强对老年人抗栓治疗的教育,特别是罹患疾病较少的患者;房颤患者抗凝治疗亟待提高。     

Update on Primary Hypobetalipoproteinemia

Owing to the progressive aging of the population, and the fact that cardiovascular disease (CVD) is the leading cause of death among the elderly, the prevention of CVD in the elderly is becoming increasingly important. Although there is no doubt that statin treatment should be used for reducing CVD risk in the elderly in secondary prevention in the same way as in younger individuals, the evidence that such treatment really prolongs life in elderly subjects in primary prevention is still not so clear. However, it seems that it does reduce CVD morbidity in elderly individuals. Because of limited evidence regarding the benefit of such therapy, particularly in very old subjects (older than 80–85 years), the decision whether to treat or not treat an elderly individual with statins in primary prevention should be based on good clinical judgment and considering the individual subject’s situation regarding comorbidities, polypharmacy, and possible adverse effects.     

重视老年慢性肾脏病的诊治与预防

老年人是慢性肾脏病(CKD)的高危人群,并且老年人已成为新透析的主要人群,因此老年人是中国今后CKD防治的重点。目前老年CKD的诊治还存在不少问题：老年CKD诊断标准尚未统一;老年CKD并发症的治疗靶目标值也未确定;老年非透析CKD的临床防治策略制定相对复杂;老年终末期肾脏疾病(ESRD)的治疗手段需要综合权衡。因此,治疗方案需要多方人员参与、综合权衡制定。老年CKD的防治,要特别强调以病人为中心、而非以疾病为导向的个体化综合管理。