Intestinal transit time in constipated and non-constipated geriatric patients

Intestinal transit was measured by following a radioisotope capsule through the gut. The transit in 16 elderly patients with chronic constipation was compared with that in 16 patients of the same age and with 10 healthy younger people without constipation. Although the constipated patients generally had a slower total transit time through the gut, some old and young people without constipation also showed a slow total transit. Constipated patients had a significantly slower transit only through the rectosigmoidal part of the colon. It is also suggested that old age per se does not imply an increased transit time.     

Quality of life and psychosocial factors during treatment with antihypertensive drugs. A comparison of captopril and quinapril in geriatric patients

BACKGROUND: There is an increasing prevalence of older adults (> 65 years) with hypertension and the need for antihypertensive medication. It is well established that elderly hypertensive patients benefit from drug treatment with regards to cardiovascular morbidity and mortality. Due to the comorbidity and reduced quality of life (QOL) in the elderly, drug-induced changes of well-being and QOL are especially important to maintain compliance and social abilities. Whereas in most studies different antihypertensive agents exerted similar influences on QOL, Captopril was found to be superior to other antihypertensives in some trials. PATIENTS AND METHOD: In this controlled non-randomized study 100 elderly hypertensive patients (mean age 75.4 +/- 7.2 years; 56% female) were treated with Captopril (25-50 mg twice daily) or the newer ACE-inhibitor Quinapril (5-20 mg per day). Blood pressure and QOL were recorded initially and after 6 months, assessment of QOL was based on a validated questionnaire (PLC). RESULTS: Blood pressure fell from 153/82 mm Hg to 142/80 mm Hg with Captopril and 154/82 to 142/80 mm Hg [corrected] with Quinapril. An improvement of QOL was only seen with Quinapril, mainly due to better mood and lower depression scores. Analysis of underlying psychosocial factors on QOL found lack of social support, female sex and a current life event as additional significant negative influences on QOL. CONCLUSION: A favorable antidepressive effect of Quinapril in elderly hypertensive patients is concluded and should be studied in further investigations.     

Fiber intake and colonic transit time in functional constipated patients

BACKGROUND: Patients with functional constipation presenting no response to treatment using fibers supplement represents important clinical issue. AIMS: To evaluate the relations among the amount of ingested fiber, the constipation intensity and the colonic transit time in patients with functional constipation. METHODS: We evaluated 30 patients, presenting no response to treatment using fibers supplement, and 18 healthy volunteers conducting individual inquiry into fibers intake, constipation intensity and the total and segmental colonic transit evaluation using radiopaque markers. RESULTS: In the constipated, despite the good level of fiber intake (26.3 +/- 12.9 g, constipated x 9.3 +/- 5,2 g, control), the symptoms of constipation was serious (score = 21.3 +/- 4.07). Mean total colonic transit was 58.8h. The colonic transit was slower in the constipated group (41.0 +/- 22.8 hours, constipated x 21.8 +/- 18.5h, control). In constipated patients with slow colonic transit (>58.8h) there were colonic inertia (eight), outlet constipation (one) and slow transit in left colon (one), and among constipated patients with normal colonic transit (<58.8h), there were isolated slow transit, in the right colon (nine), left colon (three) and in the rectosigmoid segment (eight). There were no relation among the amount of ingested fiber, constipation intensity and the colon transit. CONCLUSIONS: In the functional constipation the gravity of symptoms does not depend only on the dietary fibers intake, which is not the only responsible for the differences in the colonic transit. The colonic transit can differentiate normal from constipated patients and, among them, those with altered transit that demand approaches distinct of fiber supplementation.     

Anemia and transfusions in geriatric patients: a time for evaluation

Abstract

Anemia is common in the elderly, especially in very old patients who are often frail and may be institutionalized. Senescence, the ageing process, puts the elderly at risk of developing anemia for multiple reasons, but anemia may not be attributed to senescence unless a thorough diagnostic workup has excluded other etiologies. Nutritional deficiencies are common and need to be identified and treated appropriately. Inflammatory diseases and renal failure are also frequent etiological factors and tend to be chronic. Myelodysplastic syndromes increase in frequency with age and may be difficult to diagnose and only a minority of cases respond to appropriate treatment. Anemia is associated with poor outcome and symptomatic treatment with transfusions frequently has to be considered. Red blood cell transfusion has a high therapeutic index and is likely to be effective only if anemia is symptomatic or particularly severe, as a consequence, its use has been restricted to this group. Much of the evidence on usage is limited to younger adults and specific clinical situations. Geriatricians have to deal with a large number of patients with significant anemia but with an absence of well constructed guidelines for the frail and the very old. The object of the present article is to raise awareness that anemia in the geriatric group is multi-factorial and that the patients are more than merely older than those included in most studies, that the results of ongoing trials should be appropriately interpreted and will be important in guiding future practice.     

The effect of an anthraquinone laxative on colonic nerve tissue: a controlled trial in constipated women

Anthraquinone containing laxatives have been accused to cause degenerative changes in the colonic nerve tissue; prospective studies, however, are not available. This article reports the result of a semiprolective study in 11 matched pairs of chronically constipated women. Each pair consisted of one women having regularly taken an anthraquinone containing laxative for at least one year and a control person without such a medication. Six endoscopic biopsies were taken from the left colon and rectum which were evaluated by electron microscopy and subsequent ultramorphometry for the ratio of damaged to intact neurons, density of neurosecretory vesicles, axonal diameter and number of lysosomes. Medians of the three colonic locations were calculated in each individual and for each variable, and they were compared by non-parametric statistics. Medians of the ratio of damaged to intact neurons in anthraquinone treated women and controls were 0.162 and 0.146 (p = 0.0326, one-tail), medians of the number of type I vesicles were 293 and 348.5 per 100 microns 2 (p = 0.0365, one-tail), respectively. None of the other variables were different between groups. These data do not support the hypothesis that anthraquinone containing laxatives are able to provoke relevant degenerative changes in the colonic nerve tissue since the variables are either similar in both groups or only slight differences could be found which are unlikely to be of pathophysiological relevance.     

Acute appendicitis in the octogenarians and beyond: a comparison with younger geriatric patients

BACKGROUND: Difference of the clinical characteristics and outcome of acute appendicitis (AA) between young old (age 60 to 79 years) and octogenarian patients (age 80) is unknown. We hypothesized that octogenarian patients would have more atypical presentation and worse outcomes. METHODS: Our study was a 10-year retrospective analysis of a hospital based database. All patients with histopathologically confirmed AA from 1995 to 2005 registered in this database were selected for study. Demographic data, preexisting conditions, clinical manifestations, Alvarado score, delay in surgery, complications, and mortality were compared between the octogenarians and young old. Independent effect of age on outcomes was examined by logistic regression model controlling for sex, comorbidities, and time delayed for surgery. RESULTS: Octogenarian patients constituted 93 (14.8%) of 628 geriatric patients with AA. On clinical manifestations, migrating pain and localized iliac fossa tenderness were less common in the octogenarians. Low sensitivity of Alvarado score in diagnosing AA was noted in both young old (50.7%) and octogenarian (44.1%) patients. Compared with young old patients, octogenarians had a longer delay in surgery and worse outcomes. Octogenarians had a significantly higher perforation rate (65.6% vs 49.5%, P < 0.001), postoperative morbidity rate (18.3% vs 10.1%, P < 0.001), and mortality rate (6.5 % vs 1.5 %, P < 0.001). Octogenarian age was independently associated with appendiceal perforation (OR, 95% CI; 1.94, 1.23 approximately 3.08), postoperative morbidity (2.0, 1.10 approximately 3.62), and mortality (4.5, 1.54 approximately 13.41). CONCLUSIONS: The clinical presentation of AA in octogenarian patients is atypical and the outcomes are worse than young old patients.     

Determination of total and segmental colonic transit time in constipated patients

Ninety-one patients with idiopathic constipation had segmental colonic transit studied with radiopaque markers using a new simplified technique to determine frequency and type of colonic transit time (CTT) abnormalities and to determine the utility of this test in planning therapy. Colonic transit studies defined four groups: normal CTT(N=49), right colonic stasis (N=16), outlet obstruction (N=12), and isolated left colonic stasis (N=14). Right colonic stasis and outlet obstruction were associated with frequent use of digital pressure to assist defecation. Right colonic stasis was characterized by a low stool frequency (<3 per week) in 93% of cases and failure to respond to bran therapy. Outlet obstruction also showed a poor response to bran therapy but weekly stool frequency was higher than 3 in 46% of cases. Normal colonic transit time and isolated left colonic stasis were characterized by a normal stool frequency (5.8±0.05 and 4.2±0.1, respectively) and clinical help with the use of bran treatment (72 and 64%, respectively). Our study suggested that patients who complain of idiopathic constipation represent a heterogenous group of disorders. Segmental CTT determination is a simple, useful, and noninvasive test of patients with constipation.     

A randomized, multicenter comparison of polyethylene glycol laxative and tegaserod in treatment of patients with chronic constipation

OBJECTIVE: Polyethylene glycol (PEG) 3350 (MiraLax) and tegaserod (Zelnorm), a serotonin subtype 4 receptor partial agonist, are currently approved for treatment of constipation. This study was designed to compare the efficacy of each product over a 4-wk treatment period. METHODS: Study patients who met defined criteria for chronic constipation were randomized in this open-labeled, parallel, multicenter study to receive the PEG laxative as a single daily dose of 17 g or tegaserod tablets 6 mg b.i.d., for 28 days. As a primary end point, treatment success was defined for each patient as relief of modified ROME criteria for constipation for 50% or more of their treatment weeks. Various secondary measures were also assessed. An interactive voice response system (IVRS) recorded patient reported daily bowel movement experience and study efficacy and safety information. RESULTS: A total of 237 patients were enrolled and received treatment at one of 25 centers. Successful treatment according to the primary end point was seen in 50.0% of the PEG and 30.8% of tegaserod patients (P= 0.003). By treatment weeks 3 and 4, significantly more PEG patients were successfully treated according to primary and secondary response definitions. PEG patients experienced more bowel movements per week (P= 0.019) and had significantly greater improvement in constipation symptoms (P= 0.016) based on results from a validated patient self-reported questionnaire. Tegaserod patients experienced a significantly higher incidence of headaches. Otherwise, there were no significant differences in adverse events. CONCLUSIONS: While PEG laxative and tegaserod are safe for their intended use in chronic constipation, PEG had superior efficacy, caused fewer headaches, and produced greater improvement of constipation symptoms.     

Comprehensive comparison between geriatric and nongeriatric patients with trauma

The incidence of geriatric trauma is increasing due to the growing elderly population. Healthcare providers require a global perspective to differentiate critical factors that might alter patients’ prognosis.We retrospectively reviewed all adult patients admitted to a trauma center during a 4-year period. We identified 655 adult trauma patients aged from 18 to 64 (nongeriatric group) and 273 trauma patients ≥65 years (geriatric group). Clinical data were collected and compared between the 2 groups.The geriatric group had a higher incidence of trauma and higher Injury Severity Scores than did the nongeriatric group. Fewer geriatric patients underwent surgical treatment (all patients: geriatric vs nongeriatric: 65.9% vs 70.7%; patients with severe trauma: geriatric vs nongeriatric: 27.6% vs 44.5%). Regarding prognosis, the geriatric group exhibited higher mortality rate and less need for long-term care (geriatric vs nongeriatric: mortality: 5.5% vs 1.8%; long-term care: 2.2% vs 5.0%).We observed that geriatric patients had higher trauma incidence and higher trauma mortality rate. Aging is a definite predictor of poor outcomes for trauma patients. Limited physiological reserves and preference for less aggressive treatment might be the main reasons for poor outcomes in elderly individuals.     

Relationships between defecographic findings,rectal emptying,and colonic transit time in constipated patients.

The relations between defecographic findings, rectal emptying, and colonic transit time were analysed in 80 constipated patients (median age 49 years, range 22-87). Patients were classified into three clinically defined groups (slow transit, outlet obstruction, and a mixed group). Rectal evacuation was evaluation was evaluated by computer-based area calculation. There were no differences in defecographic findings except that evacuation was less efficient in the slow transit group compared with the mixed group (p < 0.01) and with the outlet obstruction group (P < 0.05). Transit time was prolonged in the slow transit and mixed groups compared with the outlet group (p < 0.001). Prominent impression of the puborectalis muscle during straining and the size of a rectocoele correlated with rectal emptying (p < 0.01). Perineal descent, anorectal angles, enterocoele, or intussusception were not significantly related to emptying. Prominent impression of the puborectalis muscle (p < 0.05) and impaired rectal emptying (p < 0.05) were more frequent in patients with prolonged transit time (six or more days). There was no significant correlation between transit time and rectal evacuation in the total study population. There was, however, an inverse relation between these variables (r = 0.40, p < 0.02) when all patients who claimed infrequent defecation (two or fewer/week) were analysed separately. These results did not confirm a direct relation between rectal evacuation and colonic transit time in constipated patients overall. The results are consistent with the suggestion that impaired colonic function may develop secondary to outlet obstruction in some patients.     

A randomised trial to compare the results of injection sclerotherapy with a bulk laxative alone in the treatment of bleeding haemorrhoids

In a prospective randomised trial, 43 patients with bleeding haemorrhoids were allocated to receive either a bulk laxative with injection of phenol (5%) in arachis oil (20 patients) (Group 1), or a bulk laxative alone (23 patients) (Group 2). Treatment was given by one author and patients were assessed blind by the other at 6 weeks, 3 months and finally at 6 months. At 6 weeks 12 (48%) in Group 1 and 12 (57%) in Group 2 were still bleeding (NS; ²= 0.54). At 3 months 10 (40%) in group 1 and 6 (35%) in group 2 (NS; ²=0.10), and at 6 months 10 (43%) in group 1 and 7 (47%) in group 2 were still bleeding (NS; ²=0.04). No significant difference in bleeding at 6 months after either injection sclerotherapy with bulk laxative or bulk laxatives alone was found.     

The place for cycler-assisted peritoneal dialysis in geriatric patients: comparison with hemodialysis

This study was designed to assess the place for cycler assisted peritoneal dialysis (CCPD) in the treatment of the elderly. The study population included 542 hemodialysis (HD) and 160 CCPD patients, including 206 HD and 60 CCPD patients older than 60 years of age. Physical activity (evaluated by the Karnofsky scale), risk of hospitalization, risk of death, subjective evaluation of health status (Nottingham Health Profile), peritonitis rate and peritoneal transport rates were evaluated. The incidence of peritonitis and solute transport rates among elderly and younger CCPD patients were similar. Physical activity scores were consistently lower among the elderly patients without differences between HD and CCPD. No apparent differences in the subjective assessment of physical health was seen between the elderly on HD and CCPD. Sixty percent of the elderly CCPD patients required partner assistance. The relative risk of hospitalization, risk of death and risk of discontinuation of therapy were higher for the elderly patients (p<0.05), without significant differences between HD and CCPD patients. No significant differences in the transfer rate to other therapy were seen between the elderly undergoing HD and CCPD. Our results show that CCPD is a viable alternative for the treatment of the elderly uremic patients. The increased need for partners among the elderly, and CCPD's advantage of facilitating partner assistance with minimal time demands, may increase the population of aging patients treated in their own home or in nursing homes. The economic impact of cycler therapy among the elderly deserves further evaluation.     

Lactulose syrup assessed in a double-blind study of elderly constipated patients.

The laxative effects of 50% lactulose syrup and 50% glucose syrup were compared in a 12-week, double-blind study of 47 elderly constipated patients living in a nursing home. The dosage was 30 ml daily taken at bedtime; it was reduced to 15 ml if the initial dosage produced two or more bowel movements daily. The number of bowel movements during treatment in comparison to pretreatment was significantly increased in the 42 patients (19 lactulose, 23 glucose) who completed at least 8 weeks of the study. Laculose was superior to glucose in the mean number of bowel movements per day (p less than 0.02) and in the percentage of days in which at least one bowel movement occurred (p less than 0.05). Reduction in the severity of each 5 symptoms (cramping, griping, flatulence, tenesmus, bloating) was greater with lactulose. For relief of all 5 symptoms, lactulose was significantly more effective than glucose (p less than 0.04). The striking reduction in the number of fecal impactions (only 6 in the lactulose patients vs 66 in the controls) was highly significant (p less than 0.015). The lactulose patients needed fewer enemas than did the controls. No abnormal values were observed in laboratory tests.     

Detection of subclinical autonomic neuropathy in constipated patients using a sweat test.

Chronic idiopathic constipation may be the result of an autonomic neuropathy. This hypothesis was tested in 23 constipated patients and 17 age matched controls, using the acetylcholine sweat spot test devised to test autonomic integrity in diabetes. Acetylcholine (0.01%) was injected in the dorsum of the foot painted with a mixture of starch and iodine. Active sweat glands appeared on the surface of the skin as small black dots which were photographed and counted, using a grid with 60 subareas. Two measurements were made: the number of dots per unit subarea (sweat spot test score) and the % number of abnormal subareas (with less than six spots). These two parameters were correlated. The median sweat spot test score was 9.53 in patients and 13.92 in controls (p = 0.0001), the receiver operating characteristic curve showing that a score of 12 delimited normal and abnormal subjects. Increasing age was correlated with a low score in patients, probably because of prolonged symptoms. Seventy per cent of patients and one control had a borderline or abnormal number of subareas. These results suggest that idiopathic constipation is associated with a degree of autonomic denervation. The sweat spot test is an easy, inexpensive method to test this hypothesis and deserves a place in the clinical assessment of slow transit constipated patients.     

Response to a behavioural treatment, biofeedback, in constipated patients is associated with improved gut transit and autonomic innervation

BACKGROUND: Although behavioural treatment (biofeedback) successfully treats the pelvic floor abnormalities in patients with idiopathic constipation, many patients also normalise their impaired bowel frequency. We postulated that a response may be associated with altered cerebral outflow via extrinsic autonomic nerves to the gut. We investigated whether treatment changes extrinsic innervation, using mucosal laser Doppler flowmetry, whether autonomic changes are gut specific, and whether it changes gut transit. MATERIALS AND METHODS: Forty nine patients (44 female, mean age 39 years) with idiopathic constipation were studied before and after biofeedback treatment (mean five sessions). Rectal mucosal blood flow was measured by laser Doppler flowmetry to assess direct extrinsic gut nerve autonomic activity. To assess general autonomic activity, RR (interval between successive R waves on the electrocardiogram) variability, Valsalva ratio, orthostatic adjustment ratio, and phase II:IV blood pressure ratio (II:IV) of the Valsalva manoeuvre were measured. All autonomic tests were compared with those of 26 healthy volunteers (19 female, mean age 37 years). RESULTS: Twenty nine of 49 patients were symptomatically improved. Treatment reduced those with < or =3 bowel actions per week (27 v 9, pre v post), need to strain (26 v 9), and laxative or suppository use (34 v 9). Biofeedback reduced retained markers by 32% in those with slow transit and by 20% in those with normal transit. Twenty two had slow transit before treatment-14 felt symptomatic improvement of whom 13 developed normal transit. There was a significantly greater increase in rectal mucosal blood flow in patients who subjectively improved compared with those who did not (29% v 7%; p<0.03) and in those with improved bowel frequency (33% v 9%, increased v unchanged bowel frequency; p<0.05). Thirty five patients had abnormal RR variability and 33 an abnormal Valsalva ratio; one had an abnormal orthostatic adjustment ratio and one an abnormal II:IV ratio. None of the general cardiorespiratory autonomic reflexes was changed by treatment. CONCLUSIONS: Biofeedback treatment affects more than the pelvic floor. Successful outcome after biofeedback treatment is associated with improved activity of the direct cerebral innervation to the gut and improved gut transit. This effect is gut specific; cardiovascular autonomic reflexes were not altered.     

Colorectal cancer in geriatric patients： Endoscopic diagnosis and surgical treatment

AIM: To investigate the prevalence of colorectal cancer in geriatrie patients undergoing endoscopy and to analyze their outcome. METHODS: All consecutive patients older than 80 years who underwent lower gastrointestinal endoscopy between January 1995 and December 2002 at our institution were included. patients with endoscopic diagnosis of colorectal cancer were evaluated with respect to indication, localization and stage of cancer, therapeutic consequences, and survival. RESULTS: Colorectal cancer was diagnosed in 88 patients (6% of all endoscopies, 55 women and 33 men, mean age 85.2 years). Frequent indications were lower gastrointestinal bleeding (25%), anemia (24%) or sonographic suspicion of tumor (10%). Localization of cancer was predominantly the sigmoid colon (27%), the rectum (26%), and the ascending colon (20%). Stage Dukes A was rare (1%), but Dukes D was diagnosed in 22% of cases. Curative surgery was performed in 54 patients (61.4%), in the remaining 34 patients (38.6%) surgical treatment was not feasible due to malnutrition and asthenia or cardiopulmonary comorbidity (15 patients), distant metastases (11 patients) or refusal of operation (8 patients). patients undergoing surgery had a very low in-hospital mortality rate (2%). Operated patients had a one-year and three-year survival rate of 88% and 49%, and the survival rates for non-operated patients amounted to 46% and 13% respectively. CONCLUSION: Nearly two-thirds of 88 geriatrie patiente with endoscopic diagnosis of colorectal cancer underwent successful surgery at a very low perioperative mortality rate, resulting in significantly higher survival rates. Hence, the clinical relevance of lower gastrointestinal endoscopy and oncologic surgery in geriatrie patients is demonstrated.     

Calcemic status of geriatric patients: a longitudinal study.

Serum ionized (CaI), total (CaT) and albumin-'corrected' total (CaA) calcium concentrations were measured in 108 geriatric long-term inpatients on admission and again 37 months (mean) later. Mean CaI, especially when pH adjusted, remained extremely stable, indicating well-preserved homeostatic calcemic control even in the terminal years in the elderly. Further, the results indicate that in addition to their previously shown invalidity in interindividual comparisons, CaT and CaA are inferior to CaI and can also be misleading in the detection of slight longitudinal changes in the 'true' calcemic status of an individual geriatric patient.     

A comparison of a two-wheeled walker and a three-wheeled walker in a geriatric population.

OBJECTIVE: There are few data on the effect of walkers on gait and mobility or on comparisons of different walker types. We compared a commonly used 4-legged, 2-wheeled walker and a newer 3-legged, 3-wheeled walker in measures of gait, mobility, and patient satisfaction. DESIGN: Cross-over controlled trial. SETTING: In the Physical Therapy Department of a Veterans Affairs hospital. PARTICIPANTS: Subjects were 15 male and female frail elderly veterans (mean age, 82 years), both inpatients and outpatients, consecutively enrolled from a sample of 35 patients referred to the Physical Therapy Department for mobility problems. Subjects met the following criteria: age 65 or over, ambulatory, no prior use of a wheeled walker, stable medical condition, and informed consent. INTERVENTION: Subjects were evaluated without either walker and with each of the two walkers on a 15-foot walkway and a 60-foot obstacle course. Subjects were asked which walker they preferred. OUTCOME MEASURE: Outcome measures were stride length on the walkway, time on an obstacle course, and walker preference. RESULTS: Stride length was 1.4 inches (3.6 cm) greater with the 3-wheeled walker than with the 2-wheeled walker (P = 0.016 by Wilcoxon signed-rank test). Time on the obstacle course was 16.0 seconds less with the 3-wheeled walker than the 2-wheeled walker (P = 0.002). The 3-wheeled walker was subjectively preferred. CONCLUSIONS: The 3-wheeled walker appears to have a greater positive impact on gait and mobility than the 2-wheeled walker.