Elderly Hypertensives: How Are They Different?

J Clin Hypertens (Greenwich). 2012;14:779–786. ©2012 Wiley Periodicals, Inc. Once considered an inconsequential part of the aging process, the development of isolated systolic hypertension represents a late manifestation of increased elastic artery stiffness and is the predominant hypertensive subtype in the middle‐aged and elderly populations. Its inherent increased risk for vascular events, such as coronary heart disease, stroke, heart failure, peripheral artery disease, chronic kidney disease, and dementia, highlights the importance of its control. The purpose of this short review is to summarize how hypertension is different in the elderly when compared with “essential hypertension” in younger adults. The emphasis will be on the multiple ways that increased artery stiffness affects the natural history and clinical manifestations of hypertension in the elderly.     

Do centenarians die healthy? An autopsy study

BACKGROUND: Our goal was to assess the prevalence of common causes of death and the demographic variables in a selected population of centenarians. METHODS: The autopsy reports and medical histories of all individuals > or =100 years, dying unexpectedly out of hospital, were gathered from 42,398 consecutive autopsies, performed over a period of 18 years at the Institute of Forensic Medicine, Vienna. These records were evaluated with regard to age and sex, circumstances of death, season, time and the cause of death, as well as the presence of any other comorbidity. RESULTS: Forty centenarians (11 men, 29 women) were identified with a median age of 102 +/- 2.0 (range: 100-108) years. Sixty percent were described as having been healthy before death. However, an acute organic failure causing death was found in 100%, including cardiovascular diseases in 68%, respiratory illnesses in 25%, gastrointestinal disorders in 5%, and cerebrovascular disease in 2%. Additionally, centenarians suffered from several comorbidities (cardiac antecedents, neurologic disorders, liver diseases, cholecystolithiasis), which were not judged to be the cause of death. CONCLUSIONS: Centenarians, though perceived to have been healthy just prior to death, succumbed to diseases in 100% of the cases examined. They did not die merely "of old age." The 100% post mortem diagnosis of death as a result of acute organic failure justifies autopsy as a legal requirement for this clinically difficult age group.     

Why Do Nonsurvivors from Community-Acquired Pneumonia Not Receive Ventilatory Support?

Objective

We investigated rates and predictors of ventilatory support during hospitalization in seemingly not severely compromised nonsurvivors of community-acquired pneumonia (CAP).

Methods

We used the database from the German nationwide mandatory quality assurance program including all hospitalized patients with CAP from 2007 to 2011. We selected a population not residing in nursing homes, not bedridden, and not referred from another hospital. Predictors of ventilatory support were identified using a multivariate analysis.

Results

Overall, 563,901 patients (62.3 % of the whole population) were included. Mean age was 69.4 ± 16.6 years; 329,107 (58.4 %) were male. Mortality was 39,895 (7.1 %). A total of 28,410 (5.0 %) received ventilatory support during the hospital course, and 76.3 % of nonsurvivors did not receive ventilatory support (62.6 % of those aged <65 years and 78 % of those aged ≥65 years). Higher age (relative risk (RR) 0.48, 95 % confidence interval (CI) 0.44–0.51), failure to assess gas exchange (RR 0.18, 95 % CI 0.14–0.25) and to administer antibiotics within 8 h of hospitalization (RR 0.48, 95 % CI 0.39–0.59) were predictors of not receiving ventilatory support during hospitalization. Death from CAP occurred significantly earlier in the nonventilated group (8.2 ± 8.9 vs. 13.1 ± 14.1 days; p < 0.0001).

Conclusions

The number of nonsurvivors without obvious reasons for withholding ventilatory support is disturbingly high, particularly in younger patients. Both performance predictors for not being ventilated remain ambiguous, because they may reflect either treatment restrictions or deficient clinical performance. Elucidating this ambiguity will be part of the forthcoming update of the quality assurance program.     

Why Don’t Patients Enroll in Hospice? Can We Do Anything About It?

BACKGROUND  

United States hospice organizations aim to provide quality, patient-centered end-of-life care to patients in the last 6 months of life, yet some of these organizations observe that some hospice-eligible patients who are referred to hospice do not initially enroll.     

Why should the gastroenterologist bother about obesity? An oncologic point of view

The incidence of obesity worldwide has increased dramatically during recent decades. As a consequence, obesity and associated co-morbidities constitute a serious threat in public health. Substantial epidemiologic evidence indicates that obesity is associated with increased risk of death, and increased incidence and progression of several cancers. Particular attention will be brought here to digestive and liver cancers. Plausible mechanisms by which obesity might participate to increased promotion and progression of cancer will be developed including hyperinsulinemia, insulin resistance and the pro-oxidative pro-inflammatory milieu characterizing the metabolic syndrome. We will focus on the specific case of hepatocellular carcinoma since the highest increase in mortality in obese individuals has been observed for this malignancy. Epidemiological evidence will be reviewed. We will next attempt to offer explanation for the higher risk of HCC in obese individuals although, at this point in time, we have insufficient knowledge to point towards the preeminence of factors directly related to obesity or more tightly linked to NASH itself, the underlying liver disease.     

Which Patent Foramen Ovales Need Closure to Prevent Cryptogenic Strokes?

Patients with cryptogenic strokes are more likely to have a patent foremen ovale than in the general population. It is speculated that these strokes are due to paradoxical embolism, that is, passage of a venous thrombus across the patent foremen ovale to enter the arterial circulation, resulting in an embolic stroke. Venous thromboembolism is rarely present in these cases of cryptogenic stroke. Thousands of patients with cryptogenic strokes have undergone transcatheter closure of their patent foremen ovale via a variety of devices. The first 3 randomized clinical trials comparing patent foremen ovale closure with medical therapy failed to show a significant advantage of patent foremen ovale closure. Three additional trials reported in 2017 had longer years of follow-up and demonstrated an advantage of patent foremen ovale closure versus medical therapy. Analysis of their data indicated that patent foremen ovale closure in patients with an atrial septal aneurysm in addition to a patent foremen ovale had a very significant decrease in cryptogenic strokes (P < .001). There was no decrease in strokes in patients without an aneurysm of the atrial septum who underwent patent foremen ovale closure (P = .37). Aneurysms of the atrial septum are easily recognized by echocardiography and are present in approximately one-third of patients with patent foremen ovales. These data suggest that closure of patent foremen ovales in patients with an atrial septal aneurysm is indicated. In patients with a patent foremen ovale without an aneurysm of the atrial septum, patent foremen ovale closure is not indicated.