Evaluation of monoclonal gammopathies in the "well" elderly

The study of monoclonal gammopathies in the elderly provides an opportunity to define immunologic and neoplastic changes with aging. Previous reports using paper and cellulose acetate electrophoresis have documented an age-related increase in monoclonal gammopathies. In this study, the more sensitive techniques of high-resolution agarose gel electrophoresis and immunofixation were used, in conjunction with other protein studies, to further evaluate the prevalence of monoclonal gammopathies in 111 ambulatory residents (aged 62 to 95) of a retirement home. Eleven of the 111 residents (10 percent) were found to have a monoclonal gammopathy, ranging in concentration from 0.2 to 1.8 g/dl. All monoclonal gammopathies were confirmed by immunofixation, which also documented the presence of additional unsuspected monoclonal components in three of the 11 residents. The prevalence of monoclonal gammopathies by age ranged from 6 percent in the group younger than 80 years of age to 14 percent in the group older than 90 years of age. Only one of the 11 residents had any clinical or routine laboratory suggestion of a monoclonal gammopathy. The other 10 had normal ratios of total protein and albumin to globulin. Five of the 11 (45 percent) had an otherwise clinically unexplained erythrocyte sedimentation rate of more than 20 mm/hour, compared with only two of 100 in the group without monoclonal gammopathies. Follow-up studies one to three years after initial evaluation revealed that five of the 11 patients had died, two with evidence of disease progression. In the other six patients, monoclonal protein concentration and other protein values remained stable. An unexplained elevation of the erythrocyte sedimentation rate in the elderly warrants investigation for the presence of a monoclonal gammopathy. Agarose gel electrophoresis and immunofixation identify a higher percent of monoclonal gammopathies in the elderly than has previously been recognized. Identification of monoclonal components in this population is useful for the subsequent study of plasma cell dyscrasias, neoplastic disease, or other immune dysfunction in the aged.     

Ankylosing spondylitis and monoclonal gammopathies.

From 1960 to 1990, 557 patients with ankylosing spondylitis (428 men, 129 women) were diagnosed and indexed in the department of rheumatology. Monoclonal gammopathies were found in seven (five men, two women) patients (1.3%). With one exception, ankylosing spondylitis preceded monoclonal gammopathies by many years. The distribution of the isotypes of the mIg found in these seven patients was striking when compared either with previous reports of an association between ankylosing spondylitis and monoclonal gammopathies or with local data on the epidemiology of monoclonal gammopathies: five patients with IgG, four of them of the lambda (lambda) type, and two IgM, both of the kappa (kappa) type were found; no patients with mIgA were recorded. Two patients were HLA-B27 positive and had slight and transient monoclonal gammopathies, whereas three subjects were HLA-B27 negative and had important spikes, corresponding in two subjects to malignant diseases. This observation raises the question of whether the coexistence of HLA-B27 and ankylosing spondylitis might provide a protective action. Epidemiological studies are required to clarify such points.     

Angioplasty in the elderly]

Due to increasing age in the general population, patients > 75 years are more and more often submitted to cardiac catheterization. These patients have, in general, more severe and diffuse coronary disease, more severe comorbidities, and a higher risk for periprocedural complications. Elderly patients have traditionally been excluded from most clinical trials of coronary interventions, and most often receive medical undertreatment in clinical practice. The basis of evidence for an early invasive strategy, as compared to optimal medical management, is therefore limited in these patients and the risk/benefit ratio is poorly known, both in the setting of acute coronary syndromes and of more stable coronary heart disease. A broad review of the literature is summarized in this paper, to help make therapeutic decisions in these patients.     

Depression and suicide in the elderly]

The suicidal behavior in 155 patients older than 60 years is analyzed. Patients were treated for endogenous, neurotic, or reactive depression. Differences between diagnostic categories and sex are discussed in detail. Motivation and recent causes of suicidal behavior are analyzed. Psychopathological symptoms correlating with suicidal behavior in endogenous depression in the elderly are depicted. The social environment of and the therapeutic approach to suicidal elderly patients are discussed. The problem of rational suicide and the demand for voluntary death are mentioned.     

Bedridden elderly and dementia]

The purpose of this study is to clarify possible correlations between dementia and long term bedridden elderly patients in our special nursing home and geriatric hospital. At the time of our study, 42.6% of all our patients were bedridden, and the ratio increased in those groups of advanced age. The percentage of bedridden female patients was higher than that of males. Most bedridden patients, suffered disorders of the nervous system particularly disorders caused by cerebrovascular disease. Among the bedridden patients, the incidence of dementia was 82.8%. In most these cases, the degree of dementia was severe. The types and respective percentages of dementia were as follows: Vascular type 45.1%, Alzheimer's type 23.2%, mixed type 19.5% and others 12.2%. We think that Alzheimer's type dementia may cause a patient to become bedridden. On the other hand, vascular type dementia may be promoted by a patient's being bedridden for a long time. Tube-fed patients comprised 20% of all bedridden patients and all of these patients showed dementia. We believe that a patient's getting out of bed and receiving rehabilitation as soon as possible is vital to the prevention of becoming permanently bedridden. In respect to the present study of bedridden dementia patients, we would like to further study tube feeding and terminal care.     

Cardiac rehabilitation in the elderly]

Cardiac rehabilitation is an integral component of secondary prevention, and is indicated for patients with a wide variety of cardiac conditions, ranging from coronary artery disease to chronic heart failure. Best results are obtained with integrated, multicomponent cardiac rehabilitation programs, which include exercise training together with counseling and psychosocial measures that may help patients maintain sustained changes toward a more healthy lifestyle. Evidence from randomized controlled trials and meta-analyses supports the efficacy of cardiac rehabilitation on clinically relevant outcomes such as reduced long-term morbidity and mortality, enhanced functional profile and improved control of cardiovascular risk factors. However, the vast majority of this evidence derives from trials with only small numbers of patients > 70 years of age. In elderly patients the goal of cardiac rehabilitation may differ from those of younger patients, and include the preservation of mobility, self-sufficiency and mental function. Cardiac rehabilitation my represent an opportunity to provide effective health care and achieve a high quality of life for older patients. Future research programs should therefore be aimed at specifically investigating the efficacy and effectiveness of cardiac rehabilitation in older, frail cardiac patients.     

Anesthesiologic problems in the elderly]

Nowadays approximately 20% of all patients operated are older than 60 years of age. So it seems to be interesting to investigate the effect on the increase of systemic disease of these patients, to estimate a proper anaesthesiological management. Anaesthesiological problems occur pre- and postoperatively because of restrictions of the cardiovascular and respiratory system, compromised renal function and defeds of the CNS. Therefore preoperatively registration and therapy of these risks are necessary, however diagnostic evaluation cannot be standardized. There is no typical anaesthesia for the elderly.     

Gastrointestinal motility in the elderly]

The existence of specific, age-related changes in gastrointestinal motility with clinical significance is controversial. Beside the more infrequent primary motility disorders, secondary motility disturbances associated with collagen vascular diseases, endocrinopathies, and neuromuscular diseases are prominent in the older and often multimorbid patients. Especially in geriatric patients, motility associated symptoms are undesired side-effects of drug therapy. The pathophysiology, clinical syndromes, and therapeutic principles of motility disorders in the elderly are discussed. The major symptoms of esophageal dysfunction are dysphagia, chest pain, heartburn, and regurgitation. Oropharyngeal dysphagia, mostly caused by cerebrovascular accidents and other neurologic disorders, leads to disturbances in food intake, and is often complicated by broncho-pulmonary infections arising from recurrent aspiration of food or saliva. Gastrointestinal reflux disease and spastic motility disorders of the esophagus are regarded as possible causes of angina-like chest pain after exclusion of cardiac diseases. Motility disturbances of the stomach and small bowel are often related to systemic disease (i.e., diabetes mellitus, chronic intestinal pseudo-obstruction) of drug side-effects. Mental and physical decline, reduced fluid intake, and constipating drugs are the most relevant factors for idiopathic constipation in the elderly. Fecal incontinence means a great psychological strain for older patients and leads to social isolation.     

Characterization of the colony-forming cell in monoclonal gammopathies

The nature of the colony-forming cell in the bone marrow of patients with monoclonal gammopathy, as defined in the stem cell assay described by Hamburger and Salmon, has been studied. It could be shown that the colony-forming cells produce immunoglobulins of the same idiotype, heavy chain and light chain, as the monoclonal bone marrow cells in the patient. Data regarding the presence or absence of J chain in the colonies, the failure to observe isotype-switch in the growing colonies, as well as the lack of inhibition of colony formation using antiidiotypic antibodies, strongly suggest that colony formation in vitro reflects proliferation of the clonogenic stem cell in the bone marrow without apparent differentiation. The stem cell may be of plasma cell nature.     

Guanidino compounds in the elderly]

To examine the metabolism of guanidino compounds in the elderly, we measured the serum concentrations of urea nitrogen, creatinine (Cr), guanidinoacetic acid (GAA) and creatine (CR) in middle-aged and elderly subjects. We also measured muscle mass in the elderly. The elderly subjects tended to have lower serum GAA concentrations than middle-aged subjects. On the contrary, CR concentrations of elderly subjects were higher than those of middle-aged subjects. Bedridden elderly subjects tended to have lower serum GAA concentrations and lighter muscle mass than ambulatory elderly subjects. On the contrary, serum CR concentrations of bedridden subjects were higher than those of ambulatory subjects. CR is an essential substance for muscle energy metabolism. These results indicate that high serum CR concentrations due to low CR metabolism in skeletal muscle might suppress glycine amidinotransferase (GAT) activity, resulting in decreased GAA production in the elderly.     

Infective endocarditis in the elderly]

To elucidate clinical features of infective endocarditis in the elderly, 20 elderly patients aged > or = 60 years were compared in detail with 30 others aged < 60 years retrospectively. Twelve of the 20 elderly patients had a calcific aortic valve or an artificial device as a predisposing heart disease, whereas 16 middle-aged patients had mitral valve prolapse or congenital heart disease (p = 0.001). The prevalence of major extracardiac disorders such as neurological disease were higher in the elderly than in the middle (9/20 vs 3/30; p < 0.01). The frequency of infected valve was similar; mitral in 8, aortic in 11 and other valves or congenital defect in 2 in the elderly versus 14, 11 and 6, respectively in the middle. Among 39 patients in whom causative microorganisms were identified, staphylococcus epidermidis was most frequently identified in the elderly (5/20), whereas streptococcus species was found in the middle (12/30). Time from the onset of symptoms to correct diagnosis was usually delayed in the entire group; the delay was longer particularly in the elderly than in the middle-aged patients (72 +/- 87 vs 36 +/- 32 days; p < 0.1). Maximal body temperature was less in the elderly than in the middle-aged patients (38.5 +/- 0.7 vs 39.3 +/- 1.1 degrees C; p < 0.01), whereas peak level of C-reactive protein (10.4 +/- 6.1 vs 13.0 +/- 7.9 mg/dL), the incidences of heart failure (9/20 vs 10/30), and embolic complications (7/20 vs 10/20) were similar in the 2 groups. Cardiac operation was performed less in the elderly than in the middle-aged patients (9/20 vs 21/30; p < 0.08). Five elderly patients had disease-related mortality, whereas only one middle-aged patient died (p = 0.02). These results suggest that although predisposing heart disease and causative microorganism in infective endocarditis are different between the elderly and middle-aged patients, the incidence of major complications are similar. However, due to the delay of correct diagnosis in the elderly who usually have major extracardiac disorders, the prognosis of infective endocarditis in the elderly is poor.