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Within the health care of the elderly with prevention, diagnosis, therapy, rehabilitation, nursing care and social service, diagnostic procedures are of great importance to avoid under- and over-diagnosis. Many diagnostic difficulties exist in elderly patients such as changed reference values, changed normal values and changed signs and symptoms. Well-known examples of conditions which are likely to be under-diagnosed include depression and urinary incontinence. Examples are given from the cardiopulmonary field where e.g. dyspnoea showed to be very common, but in only 36% of males and 52% in females related to cardiac failure or pulmonary disease. The most common symptom of acute myocardial infarction in elderly patients was shown to be dyspnoea, whereas chest pain occurred in only one fifth of the cases. In another study of patients with ulcer disease loss of appetite and weight, nausea and anemia were more common than abdominal pain and heartburn. In peritonitis patients, abdominal pain was observed in only just more than half of the cases and guarding and/or abdominal rigidity in about one third. In patients with suspect age dementia a detailed investigation showed the prevalence of organic dementia to be 89% whereas 3% had treatable dementia and 8% non-dementia conditions. In geriatric long-term patients the mean hearing loss in the speech area was about 50 dB, in spite of the fact that only about 10% of the patients had hearing aids. The need for nursing diagnosis is also obvious. It is concluded that a detailed multidisciplinary diagnostic investigation procedure is very important in geriatric medicine.
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PMID:The importance of diagnostic procedures to ensure quality of health care in geriatric medicine. Examples from recent studies. 198 60

The clinical background relating to edema in elderly inpatients was investigated, in terms of various items in elderly (aged greater than or equal to 65) cases with edema (n = 96) and without edema (controls, n = 95). Both groups were matched for sex, age, and underlying diseases. As compared with the control patients, the patients with edema had longer hospital stays with more disabled status, and showed less activity of daily living (ADL). The rates of bed-restricted patients, dementia patients, and patients with decubitus, muscle atrophy, or incontinence were found to be significantly higher in the patients with edema. The measurement of biochemical parameters revealed that the patients with edema had significantly lower levels of serum albumin, Na, Cl, creatinine, and uric acid, in contrast to higher levels of C-reactive protein. According to the classification of the assumed causes of edema, we divided the patients with edema into five groups; group 1 (n = 33): edema associated with immobilization, group 2 (n = 18): edema due to heart failure, group 3 (n = 15): edema on paretic limbs, group 4 (n = 6): edema due to hypoproteinemia, group 5 (n = 5): edema associated with liver cirrhosis. Both group 1 and group 4 patients had lower levels of hemoglobin and albumin, whereas group 3 patients had higher scores of ADL, higher blood pressure, and higher levels of hemoglobin and albumin. These results suggest that immobilization and restriction in bed, as well as malnutrition, were important factors in causing edema in elderly inpatients.
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PMID:[A controlled study on edema in elderly inpatients]. 238 89

Computed tomography and magnetic resonance imaging in the elderly have demonstrated the common occurrence of deep white-matter lesions in the aging brain. These radiologic lesions (leukoaraiosis) may represent an early marker of dementia. At autopsy, an ischemic periventricular leukoencephalopathy (Binswanger's disease) has been found in most cases. The clinical spectrum of Binswanger's disease appears to range from asymptomatic radiologic lesions to dementia with focal deficits, frontal signs, pseudobulbar palsy, gait difficulties, and urinary incontinence. The name senile dementia of the Binswanger type (SDBT) is proposed for this poorly recognized, vascular form of subcortical dementia. The SDBT probably results from cortical disconnection most likely caused by hypoperfusion. In contrast, multi-infarct dementia is correlated with multiple large and small strokes that cause a loss of over 50 to 100 mL of brain volume. The periventricular white matter is a watershed area irrigated by long, penetrating medullary arteries. Risk factors for SDBT are small-artery diseases, such as hypertension and amyloid angiopathy, impaired autoregulation of cerebral blood flow in the elderly, and periventricular hypoperfusion due to cardiac failure, arrhythmias, and hypotension. The SDBT may be a potentially preventable and treatable form of dementia.
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PMID:Senile dementia of the Binswanger type. A vascular form of dementia in the elderly. 362 88

The authors report a retrospective study of 320 primary resections for benign prostatic hypertrophy yielding a mean weight of 30 grams, only 5% exceeding 50 grams. Routine internal urethrotomy of the penible urethra carried out in 62 patients did not prevent urethral stenosis in 2 of them. There were no cases of fluid absorption syndrome, but the relatively frequent nature of the immediate (5 cases) or early (10 cases) abundant bleeding should be noted. Only one third of the patients required a transfusion. Seventeen developed a septicaemia and six epididymitis. Septicaemia (2 cases), pulmonary embolism (1 case) and cardiac insufficiency (1 case), were the causes of the 4 deaths (1.25%). There were 14 cases of urethral stenosis, 19 of incomplete resection, 1 fibrosis of the prostatic bed and 6 fibrosis of the bladder neck. There were 3 cases of complete incontinence (0.9%). In this retrospective series, spread over 7 years and involving 16 different surgeons, 80% of the patients undergoing resection had a perfect result, to which could be added 7%, following minor endoscopic re-operation for urethral stenosis or incomplete prostatic resection. The experience of the surgeon and the improvements in equipment appeared to be the two essential factors in the improvement of results of endoscopic resection for benign prostatic hypertrophy.
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PMID:[Transurethral resection of the prostate (author's transl)]. 617 82

From 1953 to 1982, 257 patients with complete rectal prolapse were operated upon. To the procedure described by Orr, we have added mobilization of the rectum prior to its suspension and eliminated the pouch of Douglas, and nylon strips have been used for suspension in most patients. There were 57 male and 200 female patients. Ages ranged from 11 to 90 years. Sixty-one patients had already undergone surgery for rectal prolapse with another procedure and prolapse had recurred. The postoperative course was uneventful in 96 per cent of patients. Two patients, aged 79 to 83 years, died of cardiac failure. Follow-up of 115 patients ranged from five to 23 years. Recurrent rectal prolapse was observed in 4.3 per cent of the patients in whom nylon strips were used to suspend the rectum. In 136 patients anal incontinence was associated with rectal prolapse. Normal continence was restored in 84.1 per cent of 107 patients with rectopexy alone and in 64.2 per cent of 14 patients who underwent rectopexy and anal sphincter repair. It is concluded that rectopexy to the promontory with nylon strips after mobilization of the rectum is a safe and efficient procedure for the treatment of rectal prolapse.
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PMID:Rectopexy to the promontory for the treatment of rectal prolapse. Report of 257 cases. 637 1

In addition to digitalis and diuretics, 10 patients with chronic cardiac failure were treated with prazosin (15 mg/d) over a period of 6 months. It was shown that the mean pulmonary artery pressure decreased significantly, on average by 30%, during both rest and exercise. Despite significant decrease of arterio-central venous oxygen difference no improvement of cardiac output was measured after 6 months on prazosin. Cardiac output increased clearly in only 4 patients, particularly during exercise. Heart rate and arterial blood pressure remained statistically unchanged. Eight patients reported subjective improvement of dyspnoea after 6 months. Prazosin plasma levels were between 9.4 and 58.6 ng/ml. Side effects such as orthostatic hypotension, urinary incontinence and disturbances of potency occurred in 4 patients. Antinuclear factors could not be demonstrated after 6 months. These data show that after 6 months of prazosin therapy haemodynamically significant improvement of pulmonary congestion can be demonstrated without concurrent increase of cardiac output. Prazosin is indicated in treatment of chronic cardiac insufficiency with predominant pulmonary congestion an an adjunct to digitalis and diuretic baseline treatment.
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PMID:[Prazosin long-term treatment in severe chronic cardiac failure (author's transl)]. 744 34

Reduction of hypertension, whether systolic and diastolic or isolated systolic, is associated with significant reductions in mortality and morbidity rates even in older asymptomatic patients, particularly those less than 80 years old. The increased availability of antihypertensive preparations makes it possible to individualize the choice of therapy to meet the particular needs of the older patient. Although most presently available antihypertensive agents are effective, each one possesses different properties and none is free of side effects. We review the indications for and the action and side effects of diuretics, angiotensin converting enzyme inhibitors, calcium channel blockers, and adrenergic blocking drugs, and we offer treatment suggestions for hypertension associated with other diseases such as diabetes mellitus, heart failure, peripheral vascular insufficiency, depression, dementia, and urinary incontinence. Orthostatic hypotension is particularly serious in older patients because it may precipitate falls. It is also possible that the relationship between blood pressure levels and mortality and morbidity risks is not linear but J-shaped, both low and high levels increasing risks. Caution in treating hypertensive elderly patients will minimize the incidence of side effects.
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PMID:Management of hypertension in older patients. 821 49

We present a 81-year old male who developed dementia, gait disturbance and right hemiparesis. He was well until the age of 74 when he developed a hemorrhagic infarction in the right occipital region, which left him left homonymous hemianopsia. One year later he had one TIA attack consisting of dizziness, headache, and some clouding of consciousness. At that time, atrial fibrillation was found. At age 79, he was attacked by right hemiparesis. Cranial CT scans revealed a lesion consistent with a hemorrhagic infarct in the left middle cerebral artery territory. Two months prior to his final admission, he had a gradual onset of forgetfulness, labile affect, nocturnal agitation and hallucination which were followed by gait disturbance and urinary incontinence. On admission, he was alert but moderately demented. In addition he showed difficulty in repetition, limb kinetic and ideomotor apraxia of the left hand indicative of sympathetic apraxia, and constructional apraxia bilaterally. Granial nerves appeared intact except for left homonymous hemianopsia. His gait was wide-based and small stepped. No weakness or ataxia was noted. Deep reflexes were diminished on the left side. Plantar reflex was equivocally extensor of the left. Light touch and pain was slightly diminished on the right side. Cranial CT scans revealed a large low density area in the left fronto-temporo-parietal region. Also ventricular dilatation, diffuse low density change in the subcortical white matter, and diffuse cortical atrophy were seen. His clinical course was complicated by melena, anemia, pneumonia, cardiac failure and renal failure. He expired 2 months after his admission.(ABSTRACT TRUNCATED AT 250 WORDS)
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PMID:[A 81-year-old man with dementia, gait disturbance, hemiparesis, and sympathetic apraxia]. 833 25

A 78 year-old male presented with a bilateral pyramidal syndrome, urinary incontinence and mild intellectual slowing. He died seven months after onset of the neurological signs from cerebral infarct and heart failure. Neuropathological examination showed predominant involvement of the cerebral white matter including diffuse myelin pallor, astrocytic gliosis and small necrotic foci. Polyglucosan bodies were diffuse in the cerebral cortex, white matter, brainstem, cerebellum and proximal part of the cranial nerves. In these latter, some polyglucosan bodies were found within myelinated axons but the inclusions mostly involved astrocytic processes. This case is characteristic of the polyglucosan body disease. It is compared with the autopsy and biopsy cases previously reported in the literature.
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PMID:[Polyglucosan body disease]. 839 Aug 20

Many patients find polyethylene glycol-based preparations (PEG) difficult to take because of the large volume of fluid they are required to consume. One hundred and sixteen predominantly elderly patients were randomized to receive either sodium phosphate (n = 61) or PEG (n = 55) bowel preparations before colonoscopy. Patients with a history of symptomatic ischaemic heart disease or cerebrovascular disease in the preceding 6 months, severe liver disease or heart failure, or serum creatinine above 200 micrograms/L were excluded from the study. Each patient filled in a questionnaire about the bowel preparation prior to the procedure. The colonoscopists, who were not aware which preparation had been used, were asked to complete a questionnaire about the quality of the bowel preparation after the procedure. The patients found the sodium phosphate preparation slightly more tolerable than PEG. Side effects were slightly more common with sodium phosphate. Neither difference was statistically significant. However, 91% of patients who had previously had PEG found sodium phosphate easier to take. Approximately 25% of patients in each group experienced at least one episode of incontinence. The colonoscopists found no difference in the overall quality of the bowel preparation. The amount of fluid in the colon was greater in patients prepared with PEG. As expected, patients taking sodium phosphate developed hyperphosphataemia (mean phosphate level before colonoscopy 1.56 mmol/L, normal 0.8 -1.3). They also had a lower mean serum potassium level (3.8 mmol/L) than the PEG group (4.2 mmol/L). However, there were no clinically significant consequences. Sodium phosphate was a safe and effective bowel preparation for colonoscopy in this carefully selected group of patients. It was preferred by patients who had previously had PEG. Many elderly patients were found to develop faecal incontinence, irrespective of the type of bowel preparation used.
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PMID:Bowel preparation for colonoscopy: a randomized prospective trail comparing sodium phosphate and polyethylene glycol in a predominantly elderly population. 867 52


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