重视老年人群的脑血管病

随着老年人群的迅速增加以及老年人群中脑血管病发病率的增高,老年脑血管疾病逐渐成为一个非常重要的医学和社会问题。老年人群中脑血管病的发生率高、症状重、预后差、容易复发,长期存活者认知功能障碍、痴呆和抑郁的发生率高,寻找老年脑血管病的危险因素,对其进行有效的二级预防是非常重要的。     

Cerebrovascular disease in the elderly: lipoprotein metabolism and cognitive decline

Data concerning the treatment of lipoprotein disturbances in patients with cerebrovascular disease (CVD) are less robust than those for coronary heart disease (CHD), raising clinical questions as to which is the appropriate therapeutic approach to stroke patients. Although observational cohort studies have failed to demonstrate an association between lipoprotein disorders and stroke incidence, recently completed trials of subjects at risk for CHD have shown that statins reduce not only the risk of myocardial infarction and death, but also that of brain infarction and transient ischemic attacks. At present, it seems reasonable to conclude that stroke patients with undesirable lipid profiles who have a history of CHD should receive specific treatment for the lipid disorder. Recommendations are more problematic for stroke patients with lipid disorder but no history of CHD. Furthermore, many of the risk factors for CVD and vascular dementia (VaD), including serum total cholesterol (TC), lipoprotein(a), diabetes, atrial fibrillation, hypertension, apolipoprotein E levels, and atherosclerosis, have also been shown to increase the risk of Alzheimer's disease (AD). In a recent study, we estimated the prevalence, incidence and rate of progression of Mild Cognitive Impairment (MCI) to dementia, and correlated vascular risk factors with incident MCI and its progression to dementia. We evaluated 2963 individuals from the population-based sample of 5632 subjects 65-84 years old of the Italian Longitudinal Study on Aging, with a 3.5-year follow-up. We found a progression rate to dementia (all causes) of 3.8/100 person-years. Furthermore, age was a risk factor for incident MCI, while education was protective, and serum TC evidenced a non-significant borderline trend for a protective effect. There was a non-significant trend for stroke as a risk factor of progression of MCI to dementia. In conclusion, in our population, among MCI patients who progressed to dementia, 60% progressed to AD and 33% to VaD. Vascular risk factors and CVD may influence the development of MCI and the rate of progression to dementia.     

Swallowing disorders, pneumonia and respiratory tract infectious disease in the elderly

Swallowing disorders (or dysphagia) are common in the elderly and their prevalence is often underestimated. They may result in serious complications including dehydration, malnutrition, airway obstruction, aspiration pneumonia (infectious process) or pneumonitis (chemical injury caused by the inhalation of sterile gastric contents). Moreover the repercussions of dysphagia are not only physical but also emotional and social, leading to depression, altered quality of life, and social isolation. While some changes in swallowing may be a natural result of aging, dysphagia in the elderly is mainly due to central nervous system diseases such as stroke, parkinsonism, dementia, medications, local oral and oesophageal factors. To be effective, management requires a multidisciplinary team approach and a careful assessment of the patient's oropharyngeal anatomy and physiology, medical and nutritional status, cognition, language and behaviour. Clinical evaluation can be completed by a videofluoroscopic study which enables observation of bolus movement and movements of the oral cavity, pharynx and larynx throughout the swallow. The treatment depends on the underlying cause, extent of dysphagia and prognosis. Various categories of treatment are available, including compensatory strategies (postural changes and dietary modification), direct or indirect therapy techniques (swallow manoeuvres, medication and surgical procedures).     

Bacterial pneumonia in the elderly

Bacterial pneumonia in the elderly is common, and causes more morbidity and mortality than in the younger adult. As patients live longer with more underlying disease and more iatrogenic disease, the incidence of nosocomial pneumonia will probably rise. Adequate sterilization of inhalation therapy equipment can reduce the risk of gram-negative nosocomial pneumonia. Methods to prevent colonization and microaspiration need to be investigated. The development of a gram-negative vaccine using Salmonella RE or E. coli J5 mutant would augur well for the future. Most important, the elderly patient with pneumonia should be managed promptly and aggressively in an attempt to determine the specific etiology of the pneumonia. The practice of antibiotic "shotgunning" of the elderly patient is to be avoided. Transtracheal aspiration or sheathed bronchoscopy can be performed if the patient is not able to produce sputum, or Gram stain is difficult to interpret. Morbidity and mortality can be reduced by early appropriate antibiotic therapy directed by Gram stain.     

Cerebrovascular disease in pregnancy

Opinion statement Cerebrovascular disease in pregnancy poses challenges to clinicians because of the difficulty in diagnosing the underlying etiology as well as the potential fetal toxicity of diagnostic testing and treatment. The underlying etiology for stroke in the pregnant patient must be aggressively sought and is critical to appropriate therapy: 1) If the arterial ischemic event in a pregnant patient remains cryptogenic, then either low-dose aspirin or another antithrombotic agent should be used. 2) Unfractionated heparin, or preferably, low molecular weight heparin, should be used to treat patients with a clearly identified etiology for which there is a specific clinical indication with at risk or symptomatic doses. Warfarin may be used in occasional cases when heparin is contraindicated (heparin-induced thrombocytopenia) and should be limited to the period after organogenesis in the second and third trimesters. 3) Using a heparin-warfarin-heparin alternating schedule to offset adverse events is impractical, because with each change in medications sustained anticoagulation cannot be easily obtained.     

打鼾与脑血管病关系的调查

对1987年江苏城乡两个社区524例脑血管病与打鼾关系的病例对照研究,结果提示,打鼾是CVD的危险因素,OR为1.51(95％CI1.05～2.16)。研究还显示,打鼾与高血压、体质指数高度相关,OR分别为11.66、4.78,其结果与以往的报道相似。本资料为脑血管病研究的拓展提供了又一线索和依据。     

Aspiration pneumonia and dysphagia in the elderly

Community-acquired pneumonia (CAP) is a major cause of morbidity and mortality in the elderly, and the leading cause of death among residents of nursing homes. Oropharyngeal aspiration is an important etiologic factor leading to pneumonia in the elderly. The incidence of cerebrovascular and degenerative neurologic diseases increase with aging, and these disorders are associated with dysphagia and an impaired cough reflex with the increased likelihood of oropharyngeal aspiration. Elderly patients with clinical signs suggestive of dysphagia and/or who have CAP should be referred for a swallow evaluation. Patients with dysphagia require a multidisciplinary approach to swallowing management. This may include swallow therapy, dietary modification, aggressive oral care, and consideration for treatment with an angiotensin-converting enzyme inhibitor.     

Community-acquired pneumonia in the elderly.

The incidence of community-acquired pneumonia (CAP) in the elderly is higher compared to younger populations. In addition, pneumonia in the elderly is a life-threatening problem. As our demographics have changed, clinicians have developed a heightened interest in managing pneumonia in the elderly. The development of pneumonia in elderly patients differs from that in younger individuals due to a complex array of factors. (1) The organisms involved depend on the setting in which the pneumonia developed: either the nonhospitalized elderly patient with CAP or the institutionalized patient who develops nursing-home-acquired pneumonia. (2) Underlying comorbid conditions commonly exist in the elderly that affect the etiology and outcome of pneumonia. Overall, Streptococcus pneumoniae and Haemophilus influenzae are still the most common etiologies of pneumonia in the elderly. The true role of gram-negative bacilli remains unclear although these micro-organisms may be more common etiologic agents in nursing-home pneumonia. Some recent studies from Mediterranean areas have reported high rates of infection by Chlamydia pneumoniae, but the real role of this micro-organism has to be confirmed. Another important issue is that the presenting symptoms of pneumonia in the elderly can be subtle and sometimes difficult to recognize. Fever is frequently absent, and delirium or alteration of functional physical capacity may be the only manifestations. Mortality in the elderly with CAP is higher when compared to younger populations. However, this may be explained by the concomitant presence of comorbid conditions more than by age per se. This statement has to be kept in mind when considering hospital and, particularly, intensive care unit admissions. Finally, antibiotic pharmacokinetics in the elderly populations with CAP ought to be considered to avoid frequent side-effects and complications. Overall, antibiotic regimens in hospitalized elderly patients with CAP do not differ from other hospitalized CAP populations. An organized approach to assessing elderly patients with suspicion of pneumonia and an awareness of common pitfalls in the management of this pulmonary infection in this population are essential to improving outcomes.     

Community-acquired pneumonia in the elderly.

Pneumonia in the elderly is a common and serious problem with a clinical presentation that can differ from that in younger patients. Older patients with pneumonia complain of significantly fewer symptoms than do younger patients, and delirium commonly occurs. Indeed, delirium may be the only manifestation of pneumonia in this group of patients. Alcoholism, asthma, immunosuppression, and age >70 years are risk factors for community-acquired pneumonia in the elderly. Among nursing home residents, the following are risk factors for pneumonia: advanced age, male sex, difficulty in swallowing, inability to take oral medications, profound disability, bedridden state, and urinary incontinence. Streptococcus pneumoniae is the most common cause of pneumonia among the elderly. Aspiration pneumonia is underdiagnosed in this group of patients, and tuberculosis always should be considered. In this population an etiologic diagnosis is rarely available when antimicrobial therapy must be instituted. Use of the guidelines for treatment of pneumonia issued by the Infectious Diseases Society of America, with modification for treatment in the nursing home setting, is recommended.     

Bacteremic pneumococcal pneumonia in the elderly

Pneumococcal pneumonia is an increasingly important disorder of the elderly. We reviewed, retrospectively, the clinical and laboratory manifestations of 29 elderly patients with bacteremic pneumococcal pneumonia during a five year period and surveyed the capsular serotypes of all blood isolates. Pneumococcal pneumonia frequently presented with subtle manifestations in these elderly patients: 50% lacked historical features suggestive of pneumonia at the time of diagnosis. A common presentation was fever, altered mental status and dehydration. Recognizing this will allow earlier diagnosis and initiation of therapy. Sixty percent of patients had potential pulmonary pathogens other than pneumococcus in cultures of sputum at the time of pneumococcal bacteremia. Reversible abnormalities of liver function were frequent. Sixty-nine percent of pneumonias were caused by serotypes included in the commercially available vaccine. Continued surveillance of pneumococcal serotypes is important to determine if the widespread use of the vaccine will result in an increased incidence of infection by serotypes which are not in the vaccine. The high mortality associated with pneumococcal pneumonia (31% in this series), particularly in the elderly, emphasizes the need for an effective vaccine.