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The areas of health promotion and disease prevention for older people have been neglected in medical practice. Many doctors, as well as the general community, believe that for people over 65 years of age it is too late for preventive care. This assumption is incorrect. However, there are a number of issues that are unique to prevention of health problems in later life. The goals of preventive care are broader than the issues of illness and life expectancy. Quality of life, autonomy and maintaining optimal function are equally important concerns for older people. Practising prevention involves not only reducing primary risk factors or screening for disease, but also encompasses psychological, environmental and social issues as these affect health and well-being. In addition, special medical problems require consideration; these include falls, incontinence, confusion, poor mobility and iatrogenic disease which are not the result of one disease process, but have many inter-related causes. Greater prominence should be given to patient education and counselling on these medical, social and psychological issues. General practitioners are ideally placed to initiate prevention as 87% of older Australians visit their GP once a year. While clear recommendations can be given on the effectiveness of some interventions, for others the doctor involved will have to make an informed decision based on individual clinical circumstances. Preventive care in later life is an integral part of good geriatric medicine.
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PMID:Prevention of health problems in later life. 823 12

1. The older patient has unique needs and vulnerabilities that pose a challenge to nursing. 2. Excess nosocomial infections, incontinence, confusion, activity limitations, skin breakdown, and increased posthospitalization mortality are potential negative outcomes of older adult hospitalization. 3. There is some evidence of age bias in clinical decisions made regarding the older patient. 4. Additional preparation in gerontological nursing, increased sensitization to the needs of older patients, more specialized units, and greater emphasis on basic needs in the acute care setting are necessary to enhance quality nursing care for the frail older patient.
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PMID:A vulnerable population: multiproblem older adults in acute care. 824 99

A 35-year-old negroid patient, known to have sickle cell-haemoglobin C disease, after heavy exercise developed an acute thrombotic crisis localised mainly in the brain. The clinical manifestations were those of an acute psychosis with severe confusion, aggressiveness, unco-operative behaviour and incontinence for faeces and urine. With adequate therapy he recovered after a few days. This so-called cerebral sickle cell crisis, confirmed by multiple small encephalomalacia lesions on the MRI which are typical of this disease, is a rare complication and difficult to diagnose.
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PMID:[Acute psychosis in a patient with a combination of sickle cell disease and hemoglobin-C disease]. 843 77

Age-related changes, for example reduced elasticity and earlier airways collapse, predispose the elderly to respiratory infection. Other factors such as a lifetime of smoking, the use of hypnotics, or the development of stroke also predispose. Pneumonia becomes increasingly common with advancing age, and both morbidity and mortality increase with associated disease burden. Diagnosis of pneumonia may be more difficult in the aged because of physiological changes. However, careful physical examination with accurate, regular recording of body temperature will usually reveal the characteristic features of pneumonia, which should be confirmed by chest radiograph. In the frail elderly, the onset of impaired function, such as confusion, immobility, falling or incontinence, should raise suspicion of infection. Pneumonia is classified as community-acquired, nursing home-acquired or nosocomial, which helps in the empirical choice of antibiotics. Streptococcus pneumoniae is the most common organism in the community, then Haemophilus influenzae and Branhamella catarrhalis. Gram-negative organisms like Klebsiella and Escherichia coli are more common in nosocomial infections. Nursing home patients with pneumonia tend to be more frail than those in the community. Treatment is directed at eradication of the organism with the appropriate antibiotic, maintaining hydration and oxygenation, as well as managing impaired mobility, faecal loading, urinary incontinence and confusion. Influenza vaccination is strongly recommended for the frail elderly. Tuberculosis remains an important diagnosis in the frail elderly and should always be considered, especially in patients with respiratory infection who fail to respond to conventional therapy.
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PMID:Treatment recommendations for respiratory tract infections associated with aging. 845 84

Demographic trends reveal the elderly to be the fastest growing segment of the population. Physicians can therefore anticipate encountering increasing numbers of older patients with alcohol-related problems. These problems include liver disease, dementia, confusion (masquerading as dementia), peripheral neuropathy, insomnia, late-onset seizure disorder, poor nutrition, incontinence, diarrhea, myopathy, inadequate self-care, macrocytosis, depression, fractures, and adverse reactions to medications. Despite the prevalence of alcohol use in older people, their risks and problems are often unrecognized. We reviewed published literature on the determinants and consequences of alcohol-related problems in persons aged 65 years and older and the usefulness of available screening measures. Thirteen of 25 eligible studies on determinants and consequences met quality criteria and were reviewed. Nine additional studies on screening tests were also evaluated. Determinants include history of alcohol use and abuse, social isolation, and reduced mobility; consequences consist of risks of hip fracture from falls, neoplasms, and psychiatric illness. Currently accessible screening tests focus on high levels of alcoholic beverage use and abuse and dependence. They are not useful in screening for hazardous consumption that may result from relatively low levels of alcohol use alone or in combination with medications, medical illness, or preexisting diminished physical, emotional, or social function. Research is needed on the consequences of lower levels of alcohol consumption on the physical and psychosocial health of older individuals and on methods for distinguishing alcohol-related from age-related problems. Existing screening tests should be expanded or new screening methods developed in anticipation of a growing public health problem.
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PMID:Alcohol-related problems in older persons. Determinants, consequences, and screening. 900 85

Three patients, two men of 21 and 38 years and a woman of 20 years old, showed atypical seizures with motor agitation without tongue bite, incontinence or postictal confusion. After extensive video-EEG registration frontal lobe epilepsia was diagnosed. This is a relatively recently recognized disease entity.
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PMID:[Paroxysmal and bizarre motor agitation as manifestation of partial frontal lobe epileptic seizures]. 866 79

Loss of consciousness and falling are the key features of syncope. Common accompaniments include tonic and myoclonic muscle activity, eye deviations, automatisms, vocalizations and hallucinations which may render the distinction from epileptic seizures difficult. Differential diagnosis is based on the specific features and not the mere presence of these phenomena. Recognition of syncope depends also on accurate information about precipitants, premonitory symptoms and postictal events: the absence of postictal confusion has been identified as the single most powerful factor discriminating syncope from epileptic seizures whereas incontinence and head injury are common in both conditions. Investigations such as electroencephalogram, tilt testing and postictal prolactin or creatine kinase levels may be helpful but are never diagnostic in isolation. Exceptionally, hypoxic and epileptic mechanisms interact within a single attack.
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PMID:Recognizing syncope: pitfalls and surprises. 877 33

Although memory disorders and the aphaso-apraxo-agnosic syndrome are the most relevant clinical symptoms in dementia, behavioral changes, mood-related disturbances and sleep disorders are the major cause of institutionalization and caregiver concern. In the present study we have investigated the frequency and progression of cognitive and noncognitive symptoms in Alzheimer's disease (AD) as well as the APOE-related frequency of clinical symptoms in dementia. Memory decline (100%), aphasia (94%), apraxia (99%), agnosia (94%) and motor dysfunction (90%) appeared in practically all cases with mild (GDS-3), moderate (GDS 3-4) and severe (GDS 6-7) dementia. The most frequent noncognitive symptoms include anxiety (76%), depression (68%), behavioral changes (67%), psychotic symptoms (43%), sleep disorders (43%), incontinence (23%) and cerebrovascular symptoms (75%). Anxiety, depression, behavioral changes, psychotic symptoms, motor dysfunction and cognitive deterioration paralleled the severity of dementia, increasing their frequency from mild to severe dementia. The most important sleep disorders were irregular sleep-wake pattern (67%) and insomnia (47%). Disorientation (90%) and drug administration (88%) appeared to be the most important factors in causing sleep disorders in dementia. Disorientation, agitation and motor disorders were slightly more frequent in patients with APOE-4/4, while anxiety and sleep disorders appeared more frequently in APOE-3/4. Behavioral changes and psychotic symptoms did not show any clear association with specific APOE subtypes. In conclusion, our results suggest that noncognitive symptoms are very important clinical events in the disease progression and in decision making for therapeutic intervention and institutionalization. Furthermore, it is likely that some brain dysfunctions leading to particular clinical symptoms might be associated with specific AD genotypes.
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PMID:APOE-related frequency of cognitive and noncognitive symptoms in dementia. 912 Dec 26

Falls occurring in elderly in-patients during periods of hospitalization are common, and attempts have been made to predict and prevent them based on risk factor analysis. These have not looked extensively at specific elderly care wards. We have investigated in-patient falls in mixed acute and rehabilitation elderly care wards in a case-controlled study. Fifty fallers were paired with fifty non-fallers, and their risk factors for falling evaluated. Only three risk factors were significantly more common in the fallers. These were: a previous history of falls; the presence of confusion/disorientation, and needing help to toilet/incontinence/diarrhoea. Prediction of falls based on the presence of the first two of these risk factors gives a sensitivity of 68% and a specificity of 88%. A risk factor approach to the prediction of falls in an in-patient elderly care setting seems to be less practical than was previously hoped.
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PMID:An evaluation of risk factors for in-patient falls in acute and rehabilitation elderly care wards. 913 72

Confusion between syncope and epileptic seizures is a common problem in clinical practice. Recently, new insights into the phenomenology of transient cerebral hypoxia have been gained from video analysis of experimentally induced syncope. Common elements of syncope include multifocal and generalized myoclonus, tonic body extension, automatisms, vocalizations, eye deviations and hallucinations. Thus, it is not the presence or absence of these features but their specific character that distinguishes syncope from epileptic seizures. Other clues for differential diagnosis include precipitating factors, premonitory symptoms and postictal events, such as tongue bites and postictal confusion, which has been identified as the single most powerful factor discriminating syncope from epileptic seizures. In contrast, incontinence and head injury are common in both conditions. Investigations such as electroencephalogram, tilt testing and postictal prolactin or creatine kinase levels may aid diagnosis but are never diagnostic in isolation. In rare cases, hypoxic and epileptic mechanisms may interact within one attack.
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PMID:[Syncope. Phenomenology and differentiation from epileptic seizures]. 938 Feb 6


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