Venous thrombosis in the elderly: incidence,risk factors and risk groups

Summary. The incidence of venous thrombosis (VT) increases sharply with age: it is very rare in young individuals (< 1 per 10 000 per year) but increases to ～ 1% per year in the elderly, which indicates that aging is one of the strongest and most prevalent risk factor for venous thrombosis. The cause of this steep age gradient is as yet, unexplained. The aim of this review was to provide an overview of studies on the effect of conventional risk factors as well as age‐specific risk factors for thrombosis in the elderly. Limited data are available on risk factors for thrombosis in the elderly, i.e. all results are based on small study groups. Results indicate that, of the conventional risk factors, malignant disease, the presence of co‐morbidities and the genetic risk factors factor (F)V Leiden and the prothrombin mutation seem to be associated with an increased risk of venous thrombosis. In the elderly, the population attributable risk (PAR) of malignancy is approximately 35%, for co‐morbidities a PAR up to 25% is found, and the contribution of genetic risk factors to the thrombosis incidence is estimated to be 7–22%. Age‐specific risk factors of thrombosis, i.e. endothelial dysfunction and frailty may be important in the explanation of the increased incidence of VT in the elderly. In conclusion, as aging is a major risk factor for thrombosis, further identification of the risk factors for thrombosis in the elderly is needed to elucidate the age gradient of the incidence of VT and to target preventive measures.     

Thrombocytopenia in medical-surgical critically ill patients: prevalence, incidence, and risk factors

OBJECTIVE: The purpose of this study is to describe the prevalence, to analyze the incidence and independent risk factors for thrombocytopenia, and to examine the impact of thrombocytopenia developing in the intensive care unit (ICU) on patient outcome in a well-defined cohort of critically ill patients in a medical-surgical ICU. MATERIALS AND METHODS: As part of a prospective cohort study examining the frequency and clinical importance of venous thromboembolism in the ICU, we enrolled consecutive patients older than 18 years expected to be in the ICU for more than 72 hours. Exclusion criteria were an admitting diagnosis of trauma, orthopedic surgery or cardiac surgery, pregnancy, and life support withdrawal. Patients had platelet counts performed as directed by clinical need. We defined thrombocytopenia as a platelet count of less than 150 x 10(9)/L and severe thrombocytopenia as a platelet count of less than 50 x 10(9)/L. Protocol-directed care included routine thromboprophylaxis and twice weekly screening ultrasonography of the legs. Patients were followed to hospital discharge. RESULTS: Of the 261 enrolled patients, 121 (46%, 95% confidence interval [CI], 40%-53%) had thrombocytopenia (62 on ICU admission and 59 acquired during their ICU stay). Patients who developed a platelet count less than 150 x 10(9)/L during their ICU stay had higher ICU and hospital mortality (P = .03 and .005, respectively), required longer mechanical ventilation (P = .05), and were more likely to receive platelets (P < .001), fresh frozen plasma (P = .005), and red blood cell transfusions (P = .004) than patients who did not develop thrombocytopenia. The only independent risk factors for thrombocytopenia developing during the ICU stay were administration of nonsteroidal anti-inflammatory drugs before ICU admission (hazard ratio, 2.8; 95% CI, 1.3-6.0) and dialysis during the ICU stay (hazard ratio, 3.1; 95% CI, 1.2-7.8). Of the 33 patients who underwent 36 tests for heparin-induced thrombocytopenia, none tested positive. CONCLUSIONS: We found that about 50% of the patients admitted to the ICU had at least one platelet count of less than 150 x 10(9)/L during their ICU stay. Patients who developed thrombocytopenia were more likely to die, required longer duration of mechanical ventilation, and were more likely to require blood product transfusion. Heparin-induced thrombocytopenia was frequently suspected but did not develop in these critically ill patients.     

Malnutrition in a home‐living older population: prevalence,incidence and risk factors. A prospective study

Aims and objectives. To prospectively investigate and describe the prevalence and incidence of malnutrition among home‐living older people, related to demographic and medical factors, self‐perceived health and health‐related quality of life. Another aim was to find predictors for developing risk of malnutrition. Background. Risk factors for malnutrition have previously been identified as diseases, several medications, low functional status, symptoms of depression and inadequate nutrient intake. Most studies are cross‐sectionally performed at hospitals or in nursing care settings. Design. A prospective study with a sample of 579 home‐living older people, randomly selected from a local national register. Examinations were performed at baseline and yearly follow‐ups two to four times. Method. Questionnaires validated and tested for reliability, to detect risk of malnutrition (Mini Nutritional Assessment), symptoms of depression (Geriatric Depression Scale‐20), cognitive function (Mini Mental State Examination), health‐related quality of life (Nottingham Health Profile), well‐being (Philadelphia Geriatric Center Multilevel Assessment Instrument) self‐perceived health, demographic factors, anthropometry and biochemical examinations. Predictors were searched for through multiple logistic regression analysis with the MNA as dependent factor. Results. The prevalence of risk for malnutrition was 14·5%, according to the MNA. Two risk factors for malnutrition were lower handgrip strength and lower self‐perceived health. The incidence of risk for malnutrition at follow‐ups was between 7·6% and 16·2%. Predictors for developing malnutrition were higher age, lower self‐perceived health and more symptoms of depression. Men with symptoms of depression had a higher risk of developing malnutrition. Conclusion. Lower self‐perceived health had the highest power to predict risk for malnutrition, with increased number of depression symptoms and higher age as second and third predictors. Relevance to clinical practice. A regular and combined assessment using the Mini Nutrition Assessment, Geriatric Depression Scale‐20 and self‐perceived health as a base for identifying people in need, is one way to prevent the development of malnutrition.     

Confusion in the hospitalized elderly: incidence, onset, and associated factors

Seventy-one non-surgical patients over age 60 years were studied to obtain information about the incidence, onset and variables associated with the onset of confusion. The incidence of confusion was 38%; 27 of the 71 subjects developed confusion during hospitalization. Nineteen of the 27 patients developed confusion by the second day of hospitalization; no new cases of confusion were detected after the sixth day of hospitalization. An examination of the psychophysiologic variables associated with the onset of confusion produced a profile of the confused elderly patient. Confused patients were: hypernatremic, hypokalemic, hyperglycemic, hypotensive, had elevated blood levels of creatinine and urea nitrogen, received more medications, were more frequently perceived by nurses as confused, had more orienting objects in their immediate environment, and fewer interactions with significant others. Recommendations for the continued investigation and care of confused patients are offered.     

Heart failure prevalence, incidence, and mortality in the elderly with diabetes

OBJECTIVE: The goal of this study was to determine heart failure prevalence and incidence rates, subsequent mortality, and risk factors for heart failure among older populations in Medicare with diabetes. RESEARCH DESIGN AND METHODS: We used a national 5% sample of Medicare claims from 1994 to 1999 to perform a population-based, nonconcurrent cohort study in 151,738 beneficiaries with diabetes who were age > or =65 years, not in managed care, and were alive on 1 January 1995. Prevalent heart failure was defined as a diagnosis of heart failure in 1994; incident heart failure was defined as a new diagnosis in 1995-1999 among those without prevalent heart failure. Mortality was assessed through 31 December 1999. RESULTS: Heart failure was prevalent in 22.3% in 1994. Among individuals without heart failure in 1994, the heart failure incidence rate was 12.6 per 100 person-years (95% CI 12.5-12.7 per 100 person-years). Incidence was similar by sex and race and increased significantly with age and diabetes-related comorbidities. The adjusted hazard of incident heart failure increased for individuals with the following: metabolic complications of diabetes (a proxy for poor control and/or severity) (hazards ratio 1.23, 95% CI 1.18-1.29), ischemic heart disease (1.74, 1.70-1.79), nephropathy (1.55, 1.45-1.67), and peripheral vascular disease (1.35, 1.31-1.39). Over 60 months, incident heart failure among older adults with diabetes was associated with high mortality-32.7 per 100 person-years compared with 3.7 per 100 person-years among those with diabetes who remained heart failure free. CONCLUSIONS: These data demonstrate alarmingly high prevalence, incidence, and mortality for heart failure in individuals with diabetes. Prevention of heart failure should be a research and clinical priority.     

Congestive heart failure in type 2 diabetes: prevalence, incidence, and risk factors

OBJECTIVE: To estimate the prevalence and incidence of congestive heart failure (CHF) in populations with and without type 2 diabetes and to identify risk factors for diabetes-associated CHF. RESEARCH DESIGN AND METHODS: We searched the inpatient and outpatient electronic medical records of 9,591 individuals diagnosed with type 2 diabetes before 1 January 1997 and those of an age- and sex-matched control group without diabetes for a diagnosis of CHF. Among those without a baseline diagnosis of CHF, we searched forward for 30 months for incident cases of CHF. We constructed multiple logistic regression models to identify risk factors for both prevalent and incident CHF. RESULTS: CHF was prevalent in 11.8% (n = 1,131) of diabetic subjects and 4.5% (n = 435) of control subjects at baseline. We observed incident cases of CHF in 7.7% of diabetic subjects free of CHF at baseline (650 of 8,460) and in 3.4% of control subjects (314 of 9,156). In diabetic subjects, age, diabetes duration, insulin use, ischemic heart disease, and elevated serum creatinine were independent risk factors for both prevalent and incident CHF. Better glycemic control at baseline, and improved glycemic and blood pressure control at follow-up predicted the development of CHF. CONCLUSIONS: Despite controlling for age, duration of diabetes, presence of ischemic heart disease, and presence of hypertension, insulin use was associated with both prevalent and incident CHF. Why insulin use and better glycemic control both at baseline and follow-up independently predicted CHF deserves further study.     

Syncope prevalence in the ED compared to general practice and population: a strong selection process

Objective

We assessed the prevalence and distribution of the different causes of transient loss of consciousness (TLOC) in the emergency department (ED) and chest pain unit (CPU) and estimated the proportion of persons with syncope in the general population who seek medical attention from either their general practitioner or the ED/CPU.

Methods

A review of the charts of consecutive patients presenting with TLOC at the ED/CPU of our university hospital between 2000 and 2002 was conducted. Patients younger than 12 years or with a known epileptic disorder were excluded. Age and sex of syncopal patients were compared with those in a general practice and general population data sets.

Main Findings and Conclusions

During the study period, 0.94% of the patients visiting the ED/CPU presented with TLOC (n = 672), of which half had syncope. Only a small but probably selected group of all people with syncope visit the ED/CPU.     

Donor testing and risk: current prevalence, incidence, and residual risk of transfusion-transmissible agents in US allogeneic donations

Over the past 20 years, there has been a major increase in the safety of the blood supply, as demonstrated by declining rates of posttransfusion infection and reductions in estimated residual risk for such infections. Reliable estimates of residual risk have been possible within the American Red Cross system because of the availability of a large amount of reliable and consistent data on donations and infectious disease testing results. Among allogeneic blood donations, the prevalence rates of infection markers for hepatitis C virus (HCV) and hepatitis B virus have decreased over time, although rates for markers of human immunodeficiency virus (HIV) and human T-cell lymphotropic virus did not. The incidence (/100?000 person-years) of HIV and HCV among repeat donors showed apparent increases from 1.55 and 1.89 in 2000 through 2001 to 2.16 and 2.98 in 2007 through 2008. These observed fluctuations confirm the need for continuous monitoring and evaluation. The residual risk of HIV, HCV, and human T-cell lymphotropic virus among all allogeneic donations is currently below 1 per 1 million donations, and that of hepatitis B surface antigen is close to 1 per 300?000 donations.     

Syncope in elderly patients. Why their risk is higher.

The elderly are at increased risk for syncope not only because of physiologic changes due to aging but also because they have a higher incidence of chronic illness and use a greater number of medications that may cause orthostatic hypotension. Although evaluation should emphasize cardiovascular and neurologic components, the cause may remain elusive in as many as 50% of patients.     

Pressure ulcer risk in long-term units: prevalence and associated factors

AIM: This paper is a report of a study to assess pressure ulcer prevalence in a group of long-term units and to describe the main factors associated both with risk for and presence of a pressure ulcer. BACKGROUND: Despite being potentially preventable, pressure ulcers are highly frequent among institutionalized patients and are associated with increased morbidity and mortality. METHOD: A cross-sectional study was carried out, involving 571 patients from 10 long-term units in Rome, Italy. Healthcare staff in each unit evaluated pressure ulcer risk and collected clinical data while a single Registered Nurse assessed all patients to identify pressure ulcers. Univariate and multivariate analyses were performed for the two outcomes: condition at risk for pressure ulcers (Braden score < or = 16) and pressure ulcer presence. The data were collected in February-March 2005. FINDINGS: The overall prevalence of pressure ulcers was 27%. Multivariate analysis showed a statistically significant positive association between high-risk condition of pressure ulcer and previous stroke (OR = 1.96; 95% CI 1.30-2.96), previous trauma (OR = 1.83; 95% CI 1.12-2.99) and cognitive decline (OR associated with a 1 point Short Portable Mental State Questionnaire increase = 1.26; 95% CI 1.05-1.50). The model for pressure ulcer presence confirmed a statistically significant excess in patients with cardiovascular diseases (OR = 1.79; 95% CI 1.13-2.85), with high Activity of Daily Living scores (OR associated with a 1 point increase 1.38; 95% CI 1.03-1.84) and low Braden Scale scores (OR associated with a 1 point increase = 0.80; 95% CI 0.70-0.87). The risk of pressure ulcers according to number of full-time nurses and auxiliary staff per 10 beds lower than five was marginally statistically significant (OR = 1.60; 95% CI 0.98-2.61). CONCLUSION: Further research is needed to validate our findings and further prospective research is needed to identify ways of preventing pressure ulcers. Our data on staffing suggest that organizational factors should be taken into account when exploring determinants of pressure ulcers.     

Chronic frequent headache in the general population: prevalence and associated factors

We studied the prevalence and short-term natural course of chronic frequent headache (CFH) in the general population and identified risk factors. In the Netherlands everyone is registered at a single general practice. We sent questionnaires to all persons (n = 21 440) aged 25-55 years, registered at 16 general practices. We compared the characteristics of 177 participants with CFH (>14 headache days/month for >3 months) with 141 participants with infrequent headache (1-4 days/month) and 526 without headache (<1 day/month). The prevalence of CFH was 3.7% [95% confidence interval (CI) 3.4, 4.0]. In 5 months, 12% showed a clinically relevant decrease to <7 days/month. In both headache groups 70% were women vs. 41% in the group without headache. Compared with the group with infrequent headache, the CFH group had more subjects with low educational level [35% vs. 11%; odds ratio (OR) 4.3, 95% CI 2.3, 7.8], medication overuse (62% vs. 3%; OR 38.4, 95% CI 13.8, 106.9), sleeping problems (44% vs. 8%; OR 8.1, 95% CI 3.6, 18.1), a history of head/neck trauma (36% vs. 14%; OR 4.0, 95% CI 2.2, 7.1), high scores on the General Health Questionnaire (62% vs. 34%; OR 2.7, 95% CI 1.3, 3.6) and more smokers (45% vs. 19%; OR 3.1, 95% CI 1.9, 5.3). We conclude that headache frequency fluctuates. CFH is common and associated with overuse of analgesics, psychopathology, smoking, sleeping problems, a history of head/neck trauma and low educational level. Female sex is a risk factor for headache, not for chronification of headache.     

Sleep apnea: prevalence of risk factors in a general population

People with snoring, excessive daytime somnolence, and nocturnal breath cessation are very likely to have sleep apnea, particularly if they are obese or hypertensive. We collected epidemiologic data to determine the frequency of these findings in an unselected adult population. Respondents in a random digit dialing telephone survey included 685 people (356 women and 329 men, with a mean age of 50 years). Snoring was reported by 37%, gasping by 8%, excessive daytime somnolence by 36%, and hypertension by 28%; all symptoms were more prevalent in respondents older than 50 years. Snoring and gasping were more common in men than in women. Six persons (1%) had all four risk factors, plus a body mass index of one standard deviation above the mean. Eleven respondents (2%) had all four risk factors, but lower weight. We conclude that all risk factors for sleep apnea are more prevalent in persons over the age of 50 years, and that the incidence of sleep apnea in the general population may be 1%.     

Strength in an elderly population

Strengths of several upper- and lower-limb muscle groups were measured in an elderly population by using a simple, adaptable dynamometer. The bladder of a sphygmomanometer was modified by folding and surrounding it in a sewn cloth bag. It was then attached to a board for improved stability during the tests. Thirty-seven men and 81 women aged 62 to 102 years were tested. Four muscle groups were statistically determined to best represent strength-two for upper limb and two for lower limb. These strength measures were correlated with anthropometric indices, and a step-wise multiple regression was used to determine the degree of association between the variables. Men were significantly stronger than women in absolute strength, but were not different when strength was expressed relative to body weight. Within each sex, however, age was the most important variable related to loss of strength; body weight was secondary or not significant. These results suggest that age is the most important factor for relating differences in strength in an older elderly population (those aged 75 to 90 or more years). This factor must be accounted for just as body weight or cross-sectional muscle area often are, when comparing strengths in a younger population.     

The lifetime occurrence of Herpes zoster and prevalence of post-herpetic neuralgia: A retrospective survey in an elderly population

One-thousand-and-seventy-one randomly chosen elderly persons (537 women, 534 men; median age 80) were recruited from the Institute of Human Aging (Dept of Psychiatry, University of Liverpool). Almost a quarter (23.8%; equal numbers of both sexes) had had shingles (HZ), at a median age of 60 (for both sexes); 39 subjects (3.6% of all respondents, 15% of those who had had shingles), two thirds of whom were female, developed post-herpetic neuralgia (PHN), defined as pain persisting for more than 3 months; they acquired HZ at a median age of 70. In 22 of them, pain had resolved by the time they were questioned, but in 17 it was ongoing (from less than 12 to 504 months). Two new independent risk factors for PHN were identified: (1) female gender; and (2) living alone at the time of HZ acquisition (p = 0.009). In addition to confirming the well-known factor of: (3) age at shingles acquisition (up to the early 90s); and (4) scarring, presumed to be a consequence of rash severity, was significantly commoner in subjects whose HZ was followed by PHN.Extrapolating the prevalence figures to the whole UK population, of whom 9.28 million were over 64 in 1992, it can be conservatively estimated that at any one time, some 200 000 people in the UK have PHN.     

Current prevalence and incidence of infectious disease markers and estimated window-period risk in the American Red Cross blood donor population

BACKGROUND: There has been continuing progress in measures to reduce the risk of transfusion-transmitted infection, including introduction of serologic tests of increased sensitivity and the recent implementation of investigational NAT in small pools of samples. STUDY DESIGN AND METHODS: Data relating to all blood donations to the American Red Cross have been consolidated into a single database. The prevalence of confirmed-positive test results for HBsAg, HCV, HIV, and HTLV were evaluated for each year for first-time donors from 1995 through 2001. Incidence rates for these infections were evaluated among repeat donors having at least two donations in a 2-year period. The frequencies of HIV-1 RNA- and HCV RNA-positive, seronegative donations were assessed for first-time and repeat donations. The relationship risk = (window period) x (incidence) was used to assess residual risk among repeat donations and to evaluate the incidence of HCV and HIV infection among first-time donors. RESULTS: During the study period, prevalence rates for all markers declined significantly over time: in 2001, the rates per 100,000 were 75.6 for HBsAg, 299 for HCV, 9.7 for HIV, and 9.6 for HTLV; the corresponding incidence rates (/100,000 person-years) were 1.267, 1.889, 1.554, and 0.239, respectively. Estimates of residual risk in donations from repeat donors (after NAT) for HCV and HIV were 1 per 1,935,000 and 1 per 2,135,000, respectively. However, incidence rates for these agents are approximately two times greater among first-time donors. For both HCV and HIV, NAT yield was concordant with that predicted by current window-period models. CONCLUSION: These data cover about half of all the whole blood collected in the United States. They suggest increasing improvement in transfusion safety and clearly define the benefit of pooled NAT.