Cardiac cell therapy: A realistic concept for elderly patients?

Established therapeutic concepts for heart failure in elderly patients aim at long-term medical and/or surgical palliation. Heart transplantation is limited to younger individuals, and permanent mechanical assist devices are not yet widely used. In this situation, myocardial cell therapy offers fascinating new perspectives, the ultimate goal being the complete regeneration of heart muscle and blood vessel cells. In small animal models, myocardial cell therapy often leads to a striking improvement of heart function, but the success in man has so far been modest. A possible explanation for the problems with bench-to-bedside translation of cardiac cell therapy is that mainly autologous cell products from aged patients with chronic diseases have been used so far. The aim of this paper is to summarize the current state of development of clinical cardiac cell therapy, to outline how autologous regenerative cells are subject to ageing processes, and to discuss whether the cardiac cell therapy in its present form is a realistic concept for elderly patients.     

What is the optimal reperfusion strategy for elderly patients with acute MI?

The overview of the Fibrinolytic Therapy Trialists' (FTT) Collaborative Group showed that, in more than 3000 elderly patients, thrombolytic treatment is effective in reducing mortality of patients with acute myocardial infarction with ST elevation within 12 hours from the onset of symptoms. Small-scale clinical trials confirmed the superiority of primary percutaneous coronary intervention even in older patients. However, clinical practice largely differs from the setting of clinical trials and, specifically, with respect to primary percutaneous coronary intervention. As a consequence, the results observed with percutaneous coronary intervention in "real world" patients seem to be less favorable than those obtained in trials. For this reason, reperfusion therapy with fibrinolytic agents remains the first choice of therapy for ST elevation myocardial infarction in the majority of hospitals where direct percutaneous coronary intervention facilities are not available.     

What characterizes episodes of atrial fibrillation requiring cardioversion? Experience from patients with an implantable atrial cardioverter

Background Episodes of paroxysmal atrial fibrillation may cause disabling symptoms. Asymptomatic episodes of paroxysmal atrial fibrillation are, however, more common than symptomatic episodes. The aim of the study was to investigate whether episodes of atrial fibrillation for which the patient requires cardioversion differ from those in which the patient does not seek this therapy. Methods We studied 21 patients with atrial fibrillation treated with an implanted atrial cardioverter. The device displayed intracardiac electrograms from episodes of atrial fibrillation in which the patient received cardioversion and from episodes that did not lead to a hospital visit or cardioversion. The heart rate (mean, highest, and lowest) and the degree of ventricular interval irregularity were analyzed with these electrograms. Results There were 132 episodes of atrial fibrillation available for analysis, of which 73 led to cardioversion and 58 did not. Episodes leading to hospital/clinic visits and therapy had a higher maximum ventricular rate (130 vs 115/min, P = .0004) than episodes that did not cause the patients to seek therapy. This difference in heart rate was most prominent at the beginning of the episode, but tended to become more similar during the episode. There were no differences in ventricular cycle length irregularity between the 2 types of episodes. Moreover, treated episodes also had a significantly longer duration (mean duration 33 vs 9 hours, P = .002). Conclusions Episodes of atrial fibrillation that cause the patient to seek cardioversion are characterized by a high initial ventricular rate and a longer duration than those that go untreated. (Am Heart J 2003;145:670-5.)     

What characterizes patients who are unable to tolerate continuous positive airway pressure (CPAP) treatment?

Continuous positive airway pressure (CPAP) is the treatment of choice for obstructive sleep apnoea syndrome (OSAS), but many patients find this treatment intolerable. The aim of this study was to characterize patients who were unable to tolerate CPAP treatment (non-complaint) as opposed to those who continued using CPAP (complaint). A case-control study was performed in which the cases comprised of 40 patients who had been started on CPAP treatment but had found the treatment unacceptable and had ceased to use CPAP. The controls comprised of 63 patients with OSAS who had been prescribed CPAP and were still using it (follow-up period 18 months to 10 yr). The patients who stopped CPAP treatment had a higher mean age, had more frequently undergone uvulopalatopharyngoplasty (UPPP) and had a lower mean oxygen desaturation index (ODI) than patients who continued using CPAP. ODI was an independent negative predictor of non-compliance (OR5units=0.6(0.4-0.8), P<0.01). The two most common reasons for non-compliance were problems in the nose or pharynx and lack of subjective effect by the treatment. High age was an independent risk factor for non-compliance because of problems in the nose or pharynx (OR10years=2.8(1.3-6.1), P<0.01), while having undergone UPPP was a risk factor for non-compliance because of lack of effect (OR=4.5 (1.1-19.1), P<0.05). In conclusion, patients with less severe OSAS are more likely to discontinue CPAP treatment. The risk of experiencing nasal and pharyngeal side-effects of such severity that the patient stops using CPAP increases with age and patients who have undergone UPPP are less likely to experience a clinical improvement after being started on CPAP therapy.     

Is thrombolytic therapy effective in elderly patients?

Thrombolytic therapy (TT) is applied in patients (<75 years of age) with acute myocardial infarction (AMI) with ST-segment elevation. It is recommended for elderly patients who have percutaneous transluminal coronary angioplasty (PTCA) or bypass surgery. For PTCA and bypass surgery a cardiosurgery medical team, which can be found in large medical hospitals, has to be prepared. Patients with AMI with ST-segment elevation who are older than 75 and who do not have TT have a dubious prognosis for longevity and quality of life. The aim of this study was to propose recommendations and behavior for reperfusion with TT of the coronary arteries of elderly patients. The investigation was conducted for a period of 5 years (2000 to 2004). Investigators registered 2462 patients, 502 of whom had AMI, and 103 (54 men, 49 women) of whom were older than 75 years. Reteplase (Rapilysin, Hoffman La Roche, Switzerland) was applied to 10 patients. The general and mental state of patients as well as comorbidity were assessed. The H2- blocker Famotidine (Quamatel-Gedeon-Richter, Hungary) was used to prevent bleeding from the gastrointestinal tract. The applied TT had a positive effect on these >75-year-old patients. The oldest woman was 89 years old and the oldest man was 93. There were no complications during the treatment of these elderly patients. Aging related to serious health problems can be improved with the application of TT to elderly patients with AMI, and ST-segment elevation is an excellent reperfusion therapy. It is possible to achieve a dose reduction of the thrombolytic agent, arterial pressure no higher than 160/100 mmHg, individual risk assessment for intracranial hemorrhage, and prevention of bleeding from the gastrointestinal tract.     

What outcomes matter to patients?

OBJECTIVE: This study estimates the relative value to patients of physical, mental, and social health when making treatment decisions. Despite recommendations to use patient preferences to guide treatment decisions, little is known about how patients value different dimensions of their health status. DESIGN: Cross-sectional data from quasi-experimental, prospective study. SETTING: Forty-six primary care clinics in managed care organizations in California, Texas, Minnesota, Maryland, and Colorado. PATIENTS: Consecutive adult outpatients (n = 16,689) visiting primary care providers. MEASUREMENTS AND MAIN RESULTS: Medical Outcomes Study 12-Item Short Form (SF-12) health-related quality of life and patient preferences for their current health status, as assessed by standard gamble and time trade-off utility methods, were measured. Only 5% of the variance in standard gamble and time trade-off was explained by the SF-12. Within the SF-12, physical health contributes substantially to patient preferences (35%-55% of the relative variance explained); however, patients also place a high value on their mental health (29%-42%) and on social health (16%-23%). The contribution of mental health to preferences is stronger in patients with chronic conditions. CONCLUSIONS: Patient preferences, which should be driving treatment decisions, are related to mental and social health nearly as much as they are to physical health. Thus, medical practice should strive to balance concerns for all three health domains in making treatment decisions, and health care resources should target medical treatments that improve mental and social health outcomes.     

Sleep in the elderly. What is normal?

Sleep is a basic biologic function that changes with normal aging and in many pathologic states. Some of the changes with aging are so profound that it is difficult to separate normal aging from disease. The problem is made worse by the difficulty of recognizing many common sleep disorders. Complaints of poor sleep or daytime somnolence are common in all adults but are more prevalent in elderly individuals. This article addresses normal sleep and the changes expected with aging, and reviews the more common sleep diseases in the elderly population, such as insomnia, sleep-disordered breathing, periodic limb movements of sleep, and the rapid eye movement sleep-behavior disorder.     

What defines quality of care for older people in aged care? A comprehensive literature review

The quality of the care provided to frail older people in aged care is a concern for all Australians and for the citizens of many other countries internationally. This paper summarizes the methods and findings from an Australian study commissioned by the Royal Commission into Aged Care Quality and Safety to identify and synthesize international literature relating to the quality of care in aged care. A comprehensive literature review was undertaken to search and identify the literature (grey and peer reviewed) relating to quality of care and/or person-centered care in aged care. The review identified nine key themes as salient to the quality of care experience, which include treating the older person with respect and dignity; acknowledging and supporting their spiritual, cultural, religious and sexual identity; the skills and training of the aged care staff providing care; relationships between the older person and the aged care staff; social relationships and the community; supporting the older person to make informed choices; supporting the older person's health and well-being; ensuring the delivery of safe care in a comfortable service environment; and the ability to make complaints and provide feedback to the aged care organization. In practice, particularly in the context of residential care, quality of care has traditionally been measured using clinical indicators of care quality. These findings highlight the central importance of person-centered care and care experience as fundamental tenets of the quality of aged care service delivery in Australia and internationally. Geriatr Gerontol Int 2021; 21: 765–778 .     

Clinicopathologic characteristics of gastric carcinoma in elderly patients： A comparison with young patients

AIM: To examine the clinicopathologic features of elderly patients with gastric carcinoma and to investigate the relationship between prognosis and age. METHODS: We reviewed the hospital records of 2 014 patients with gastric carcinoma retrospectively to compare the clinicopathologic findings in elderly (age＞70 years) and young (age＜36 years) patients during the period from 1986 to 2000 in a tertiary referral center in Gwangju, Korea. Overall survival was the main outcome measure. RESULTS: Of the 2 014 patients, 194 (9.6%) were in the elderly group and 137 (6.8%) were in the young group. The elderly and young patients had similar distributions with respect to depth of invasion, nodal involvement, hepatic metastasis, peritoneal dissemination, tumor stage at the initial diagnosis, and type of surgery. Synchronous multiple carcinomas were found in 14/194 (7.2%) of the elderly group and 4/137 (2.9%) of the young group (P＜0.05). Using the Borrmann classification, type Ⅳ was more frequent in the young patients than in the elderly patients (P＜0.05). Significantly more elderly patients had a well or moderately differentiated histology, and more young patients had a poorly differentiated histology and signet ring cell carcinoma (P＜0.001). The 5-year survival rates of elderly and young patients did not differ statistically (52.8% vs 46.5%, P=0.5290). Multivariate analysis showed that the histologic type, nodal involvement and operative curability were significant prognostic factors, and age itself was not an independent prognostic factor of survival for elderly gastric carcinoma patients. CONCLUSION: Elderly patients with gastric carcinoma do not have a worse prognosis than young patients. The important prognostic factor is whether the patients undergo a curative resection.