Family functioning in late late life.

This study of 150 individuals, 85 years and older, focused on their families and social networks. Using both structured and open-ended questions, we explored the extent to which the family functions as a source of support for the oldest old. The findings indicate that those with children are significantly more active with all relatives, most likely because children link them to grandchildren, great-grandchildren, and their relatives by marriage. For the 30 percent who are childless and unmarried, other relatives are not usually active providers of support, a finding which suggests that the principle of substitution does not operate effectively for this age group. Case studies illustrate the variations in family functioning in the support of their oldest members.     

Influence of personality and health behaviors on fatigue in late and very late life

There is limited understanding about variables associated with fatigue in late and very late life. The purpose of this study was to explore the longitudinal influences of personality and health behaviors on changes in fatigue. One hundred and seventy-eight participants of the Georgia Centenarian Study were part of this study. Multiple regression analyses were computed to assess the influence of personality, physical activity, stress management, and nutritional risk on fatigue after initial fatigue, self-reported health, and psychosocial variables were controlled for. Anxiety, physical activity, and nutritional risk had significant longitudinal effects on fatigue. Older adults who were anxious, less engaged in physical activity, and who had higher levels of nutritional risk were more likely to show increased fatigue levels. The results suggest that more clinical and research attention should be paid to changes of fatigue in older populations.     

The conundrum of late and very late stent thrombosis following drug-eluting stent implantation

PURPOSE OF REVIEW: Drug-eluting stents reduce restenosis compared with bare metal stents, but there is growing concern that drug-eluting stents may lead to higher rates of late stent thrombosis, a rare and potentially catastrophic complication following stenting. RECENT FINDINGS: While the data on the risk of late stent thrombosis are not definitive, several general conclusions may be drawn from the available data. Late thrombosis, while associated with high mortality and morbidity, is an uncommon complication of both drug-eluting stents and bare metal stents. Randomized trials of approved drug-eluting stents versus bare metal stents have shown additional cases of late stent thrombosis in drug-eluting stents, but no significant difference in the cumulative incidence of stent thrombosis, myocardial infarction, or cardiac death at 4 years of follow-up. Observational studies suggest higher very late stent thrombosis incidence, but the relative risks of drug-eluting stents versus bare metal stents in specific high-risk groups require further study. Although the etiology of late stent thrombosis is multifactorial, premature discontinuation of clopidogrel appears to be the most important risk factor. SUMMARY: Long-term follow-up of patients after coronary stenting has identified stent thrombosis as a rare but serious event. Ongoing clinical trials in broader patient populations will be helpful to understand the risk of late stent thrombosis with greater certainty.     

Airway hyperresponsiveness and late asthmatic responses

Late inflammatory sequelae following allergen (and occupational low molecular weight sensitizing chemical) exposure, including the late asthmatic response and increased nonallergic airway responsiveness, are now felt to be more important in the pathogenesis of atopic allergic and occupational asthma than are the early bronchospastic responses. These late sequelae can be inhibited by sodium cromoglycate and by corticosteroids but not by bronchodilators. Recognition that allergic and occupational (and likely all forms of) asthma are inflammatory conditions underscores the rationale for the early use of anti-inflammatory therapeutic strategies in the management of asthma. Such "anti-inflammatory" therapeutic strategies include environmental control, sodium cromoglycate, and both inhaled and oral corticosteroids.     

Sleep and depression in late life

Depression is one of the most serious and prevalent neuropsychiatric disorders of old age. Despite its prevalence, depression in the aged is frequently unrecognized or is misdiagnosed. This article reviews the existing knowledge of several sleep-related areas and discusses possible future studies into sleep as a prognostic indicator for recurrent and bereavement-related depressions in late life.     

Cardiac late potential signals and sources

Most studies of cardiac late potentials (LPs) recorded from the body surface use signal processing definitions to characterize these abnormal ventricular potentials. For many years, the focus of the clinical studies have been on those signals that outlast the QRS complex; however, cardiac mapping studies have clearly identified that the such abnormal activation occurs during the QRS complex as well and can be distinguished from normal QRS potentials using advanced signal processing tools. Thus, both the abnormal intra-QRS potentials and the LP represent a continuum of the same signal sources. The electrogram recordings of these signals are often characterized as multiphasic with ambiguous/multiple depolarization times spanning tens of milliseconds within very short distances (<1.0 mm). The biophysical basis for these ambiguities does not fit conventional theories of cardiac propagation. This work examines the role that myofibroblasts (MFs) may play in facilitating conduction and producing very long conduction delays (10-30 milliseconds) between populations of close but isolated regions of normal cells. The prerequisite element of this hypothesis is that the MF can express gap junction proteins that align with the corresponding proteins in the myocardial cells. Membrane responsiveness studies of the MF did not detect, as expected, any ion channels capable of producing significant transmembrane currents or depolarizing potentials. However, in tissue-cultured preparations of neonatal mouse myocytes, a nonconducting gap (200-400 μm) was seeded with MF, and this gap was electrotonically bridged by the MF resulting in conduction velocities of 0.1 m/s. Such passive cell mediation of cardiac conduction would provide a biophysical explanation of LP as well as forming the basis of several hypothesized mechanisms of cardiac arrhythmias, such as microreentry. A fiber model using a series of coupled Luo-Rudy cardiac cell models was interspersed with a simple resistor-capacitor model of the MF, which then demonstrated a range of conduction disorders including excessive delays (>30 milliseconds) and decremental conduction. Hence, the role of this passive cell coupling in the generation of abnormal patterns of conduction as well as arrhythmogenesis has yet to be fully determined but may in fact define another mechanism of cardiac conduction.     

Myocardial infarction and late pericarditis]

The post-infarction syndrome was observed in 8 out of 138 consecutive patients with acute myocardial infarction; 24 other cases of the post-infarction syndrome diagnosed over the preceeding 3 years were also reviewed. In order to determine the clinical significance and the prognosis, this group of 32 was compared to another of 105 patients with myocardial infarction without pericarditis, with respect to age, sex, medical history and characteristics of the underlying necrosis (location and size). Several clinical signs are discussed. This study showed the post-infarction syndrome was associated with large infarcts, the course of which was marked by arrhythmias, conduction defects and haemodynamic problems. A considerable inflammatory syndrome was often observed. The relation between the post-infarction syndrome and early pericarditis is not proved; on the other hand, a close correlation between late pericarditis, atrial fibrillation and left pleural effusion was demonstrated. The long term prognosis of infarcts complicated by the post-infarction syndrome is without doubt determined by the size of the necrosis and by the presence of ventricular aneurysms which are frequently associated.     

Drug-induced early and late proarrhythmia.

Proarrhythmia is the provocation of a new arrhythmia or the exacerbation of a spontaneously occurring arrhythmia due to drug therapy. A drug's toxic effect may occur early after its initiation, and specific definitions have been offered to detect its presence. Primary and secondary forms of proarrhythmia as well as the type of early proarrhythmic events (fatal, serious, and nonserious) have been recognized. More recently, the concept of a late proarrhythmic event (enhanced arrhythmic death) has been defined using placebo-controlled trials. This late proarrhythmic response is extremely important in defining the benefit versus risk ratio that is the key to proper use of drug therapy.     

Suicide and euthanasia in late life

Epidemiological studies of suicide in the elderly indicate that, in the last few decades, there has been a relevant increase in suicide rates in old age in a number of Asian and Latin nations, with an almost parallel decrease in Anglo-Saxon counties. Mental disorders, particularly depression, physical illness, personality traits such as hostility, hopelessness, the inability to verbally express psychological pain and dependency on others, recent life events and losses are all factors that may contribute to suicide in later life. Compared with suicide in other age groups, mors voluntaris in late life is associated with the use of highly lethal methods, less ambivalence and impulsivity, and more determination and intent to die. Accordingly, elderly suicidal individuals are more likely than younger subjects to complete rather than attempt suicide. Some evidence suggests also that the characteristics of elderly individuals who attempt suicide may not overlap with those who complete suicide. Death thoughts and suicidal ideations are relatively rare among mentally healthy elderly adults, and are less predominant in this age bracket. However, whether elderly suicidal behaviour exists along a continuum, progressing in severity from death thoughts and suicidal ideation to suicide attempts and completed suicide, remains unclear. Assisted suicide and euthanasia in the elderly have been associated with the desire to escape chronic physical pain and suffering caused by terminal illness, and to relieve mental anguish and feelings of hopelessness, depression and extreme "tiredness of life." The role of the family and those treating chronically ill members is crucial in the final stages of life, particularly when autonomy and the ability of the elderly individual to make end-of-life decisions are compromised. The main aspects associated with these controversial phenomena, particularly from a transcultural perspective, are reviewed in this article.