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Diabetes mellitus is a common disease in older people, with almost 50% of Type 2 diabetic patients being over 60 years of age; despite this, half of older people with frank diabetes are not diagnosed. While insulin resistance is common in older people, large numbers also have impaired insulin secretion. Age, body habitus and physical activity all play a role in the pathogenesis of hyperglycaemia associated with diabetes mellitus. Leptin levels relate to insulin resistance in older people and amylin secretion is associated with delayed return of glucose levels to baseline. Depression, impaired cognitive function, and lack of recognition of thirst and subsequent dehydration are important factors to be taken into account in the management of older diabetic patients, who may also have impaired physical function, an increased rate of injurious falls, and increased prevalence of pressure ulcers, amputations and tuberculosis. Hyperglycaemia can result in a decreased pain threshold and incontinence. Dietary management plays less of a role in older diabetic patients but exercise, with a particular emphasis on balance and stability, is an important component of the management and treatment of older diabetic patients. The use of metformin as a treatment should be avoided in patients over 80 years of age because of declining kidney function. Insulin therapy is an option but as hypoglycaemia is related to advancing age, patients should be monitored carefully for the development of hypoglycaemia. Care providers also play an important role in the management of older people with diabetes mellitus. Glycaemic control can be obtained with minimal side-effects in most older diabetics including those patients in nursing homes.
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PMID:The elderly Type 2 diabetic patient: special considerations. 986 91

The aim of the present study was to document behavioral disturbances in dementia patients in a sample not specifically referred to a clinic. Ninety patients with dementia in a community were studied in relation to the behavioral and psychiatric manifestations as perceived by their caregivers. They were categorized into two subgroups based on severity of the illness, namely mild and moderate-severe, for the purpose of comparison. There were 68 patients with Alzheimer disease, 10 with vascular dementia, and the remaining 12 formed a miscellaneous group.The frequency of the following behaviors in relation to the severity of the dementia were assessed: aggression, physical violence, wandering, incontinence, disinhibition, binge-eating, hallucinations, delusions, and depression. The most common behavioral change was aggression (59%), followed by wandering (27%), delusions (22%), and incontinence (18%). Aggression caused the most distress to the caregiver. There was a higher incidence of wandering, incontinence (p= 0.009), and persecutory delusions (p=0.02) in the moderate severe group. A significantly higher proportion of the moderate-severe group required further care and intervention (p=0.04). This study is probably one of the rare nonclinical surveys on this subject.
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PMID:Behavioral and psychiatric manifestations in dementia patients in a community: caregiver burden and outcome. 987 61

Psychosomatic aspects of urogynecological disorders may play an important role in their clinical presentation. 72 patients presenting to the urogynecological clinics and a control group of 34 healthy women were included in this study. After informed consent had been obtained, all patients were subjected to (1) a detailed enquiry about personal- and medical history (2) psychological tests (Freiburg's personality inventory, a questionnaire focused on anxiety and anger, and Beck's depression inventory) and (3) routine urodynamic measurement. Patients with stress incontinence had a mean duration of symptoms of 59 months. In 67% there was a combination with clinical urge symptoms. 53% of the patients did not have regular sexual intercourse. Of those who had regular intercourse 23% had incontinence during intercourse and 25% were anorgasmic. 59% of the patients had dysmenorrhea and a negative attitude to their menarche. Urodynamic evaluation showed stress, urge or no incontinence in 39%, 12% and 39%, respectively. Analysis of the psychosomatic tests did not show a specific psychosomatic influence. Negative sexual life correlated with depressive mood, which was not based on the urogynecological problem. There was no causal relationship between personality traits and urogynecological problems. The individual perception of incontinence, however, may depend on or influence personality structure.
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PMID:Psychosomatic aspects of urinary incontinence. 1032 34

Diabetes mellitus is very common in older persons. Changes in exercise habits, body habitus, leptin, amylin, tumor necrosis factor alpha, and nitric oxide all play a role in the pathogenesis of age-related insulin resistance. In older persons elevated glucose levels not only produce retinopathy, neuropathy, and nephropathy but also decrease quality of life, pain tolerance, cognition, and functional status and increase injurious falls, nocturia, incontinence, pressure ulcers, and orthostatic hypotension. The availability of multiple new therapies has enhanced the ability of physicians to improve glycemic control in older persons without unacceptable levels of hypoglycemia. Caregivers play an important role in the management of older diabetics. Depression increases mortality rate and hospital admissions in older diabetics. In many nursing homes the quality of diabetic care is marginal. A new causative theory of the metabolic syndrome involving cytokines and nitric oxide-the NO cytokine theory-is proposed.
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PMID:An overview of diabetes mellitus in older persons. 1033 29

A generalized allergic reaction to or anaphylaxis from honeybee sting may involve the skin with erythema, puritus, urticaria, or angioedema; the respiratory tract with laryngeal edema, and brochospasm; the cardiovascular system with myocardial depression, hypotension, and shock; and the gastrointestinal system with nausea, vomiting, and incontinence. Acute pulmonary hemorrhage following a honeybee sting has never been reported. We describe a previously healthy 14-year-old girl who developed acute pulmonary hemorrhage, hypotension, and generalized skin rash after a single honeybee sting on her right fourth finger. Her serum immunoglobulin E (IgE) was high (360 IU/mL). Chest X-ray revealed perihilar alveolar infiltrative lesions. Metabolic acidosis and hypoxemia were also found. After treatment with antihistamines, dopamine, corticosteroids, bronchodilaters, fluid replacement, and mechanical ventilation, her condition improved dramatically. A hypersensitivity reaction to honeybee venom is the most likely explanation for this unusual case of acute pulmonary hemorrhage.
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PMID:Acute pulmonary hemorrhage following a honeybee sting: a case report. 1059 91

Is the patient going to die of cancer or with cancer? Is the patient going to suffer pain and disability due to cancer? Is the patient able to tolerate aggressive life-prolonging treatment? This paper tries to reply to the fundamentals of these questions by introducing the multidimensional assessment that evaluates areas where age-related changes are more likely. Chronologic age cannot be used to predict the degree of comorbidity and of functional deterioration of the single individual up to age 85 at least. Assessment of aging includes health, functional status, nutrition, cognition, socio-economic and emotion evaluations. This multidisciplinary assessment is referred to as comprehensive geriatric assessment (CGA). The risk of comorbid conditions increases with age and may result in underdiagnosis: in older patients, new symptoms may not be clearly recognized by the patient and may be dismissed by practitioners as manifestations of preexisting conditions. A meaningful assessment of comorbidity may be obtained with a comorbidity index. The Charlson scale and the Chronic Illness Rating Scale - Geriatric (CIRS-G), have enjoyed the widest acceptance. The Instrumental Activities of Daily Living (IADL) and the Activities of Daily Living (ADL) are the most sensitive assessment of function in older individuals. IADLs include shopping, managing finances, housekeeping, laundry, meal preparation, ability to use transportation and telephone and ability to take medications: in simple words, the IADLs are those skills a person needs to live independently. ADLs include feeding, grooming, transferring, toileting and are the skills necessary for basic living. Though a correlation exists among comorbidity, performance status, ADL and IADL, this correlation is not strong enough to be reflected in a single parameter. The Folstein Mini Mental Status (MMS), is the instrument of most frequent use to screen older individuals for dementia. The main problem with the MMS is lack of sensitivity to early stages of dementia. The Geriatric Depression Scale (GDS), a simple tool that can be completed by most patients at home, doubles the rate of detection of depression. The Mini Nutritional assessment is very sensitive to screen older persons for malnutrition. The risk of polypharmacy increases with age and partly results from the fact that older patients visit different practitioners. A CGA should also include evaluation of the so called Geriatric Syndromes like delirium, incontinence, osteoporosis, all of which represent a hallmark of frailty. The CGA may help the management of older individuals with cancer in at least three areas: detection of frailty, treatment of unsuspected conditions, removal of social barrier to treatment.
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PMID:The application of the principles of geriatrics to the management of the older person with cancer. 1096 Jul 97

Desirable dietary habits and other lifestyle practices reduce premature mortality and compress the period of morbidity experienced towards the end of life. Aging adults are at risk of nutritionally inadequate diets especially in relation to protein, vitamins D, B1, B6, B12, fluid and other food components. Interventions aimed at ensuring dietary adequacy also need to consider the social and cultural aspects of eating as food is fundamental to a person's well-being and quality of life. The nutrition-related health problems associated with aging such as frailty, depression, incontinence and chronic non-communicable diseases should be identified in both the individual and in the community before dietary and other health interventions are implemented. In older adults, these dietary and health promoting interventions should then focus on maximizing function and quality of life, be acceptable and finally, measurable in terms of effectiveness.
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PMID:Interventions aimed at dietary and lifestyle changes to promote healthy aging. 1104 Oct 87

The purpose of this study was to determine the effect on clinical outcomes for newly admitted nursing home residents when advanced practice gerontological nurses (APNs) worked with staff to implement scientifically based protocols for incontinence, pressure ulcers, depression, and aggressive behavior. Use of APNs in this manner differs from the usual way APNs have been used in nursing homes, in which their primary focus has been to augment the physician's role. The APN treatment was randomly assigned to two nursing homes and usual care was assigned to a third. Trajectories from admission to 6 months revealed that residents with APN input into their care (n = 86) experienced significantly greater improvement or less decline in incontinence, pressure ulcers, and aggressive behavior, and they had higher mean composite trajectory scores compared with residents receiving usual care (n = 111). Significantly less deterioration in affect was noted in cognitively impaired residents in the treatment group. Findings suggest that APNs can be effective links between current scientific knowledge about clinical problems and nursing home staff.
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PMID:Value-added outcomes: the use of advanced practice nurses in long-term care facilities. 1113 Oct 82

Overactive bladder (OAB), defined as symptoms of frequency, urgency, and urge incontinence, that occur singly or in any combination in the absence of local pathologic or metabolic factors, is a highly prevalent disorder with an unknown etiology. Few risk factors for OAB have been elucidated through epidemiologic studies, and even less is known about the contribution of OAB to other morbidities. An overview is provided of the impact of OAB on other problems now known to coexist with OAB including falls and fractures, urinary tract and skin infections, sleep disturbances, and depression.
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PMID:Comorbidities associated with overactive bladder. 1118

This article describes a set of strategies used by gerontologic advanced practice nurses (GAPNs) in three nursing homes to integrate the use of protocols into the daily care of residents. The protocols were developed as part of a larger study on the quality of care in nursing homes carried out by nurse researchers at the University of Minnesota and funded by the National Institute of Nursing Research (R01-NR03490). The GAPNs worked regularly with nursing home staff to incorporate aspects of protocols into daily care routines for residents with four specific problems common in elderly residents of nursing homes: pressure ulcers, incontinence, depression, and aggressive behavior. Outcomes of the larger study showed that residents with these four problems had better outcomes in the homes in which care was planned by the GAPNs using protocols that were integrated into the daily routines of staff.
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PMID:Better care in nursing homes: advanced practice nurses' strategies for improving staff use of protocols. 1118 64


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