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Query: UMLS:C0040822 (tremor)
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Some of the symptoms and signs of hypothyroidism and hyperthyroidism in elderly patients may be mistakenly attributed to "old age." Weight loss, muscle weakness, tremor, angina, congestive heart failure--all signs of hyperthyroidism--are also concomitants of aging. Fatigue, sluggishness, withdrawal behavior, senile atrophic skin changes--all signs of hypothroidism--are also a part of the normal aging process. Although screening elderly people for thyroid disease is economically unsound, the physician should maintain a high index of suspicion of its presence. Laboratory tests must be interpreted with extra care. Values of 131I uptake, serum T4 and T3, thyroid-stimulating hormone, and thyrotropin-releasing hormone are all helpful in diagnosis. Thyroid disease is easily treated in elderly patients, and results often are dramatic. Propranolol is effective in thyrotoxic patients when symptoms require prompt relief. The definitive treatment, however, is 131I; antithyroid drugs are difficult to manage. Hypothyroidism is easily treated with T4.
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PMID:How thyroid disease presents in the elderly. 2 76

Mitoxantrone is a new effective antineoplastic agent with activity against a wide range of tumors. Compared with the anthracycline drugs doxo- and daunorubicin, it exhibits a clearly lower toxicity and, most importantly, a reduced cardiotoxicity. The analysis of the side-effects recorded after accidental overdosage of the drug gives additional insight into its tolerability. Here we describe our observations in three patients who inadvertently received 100 mg m-2 (two pts) and 183 mg m-2 (one pt) as single slow bolus injections. The main side-effects were moderate nausea and vomiting, shaking chills, and profound but reversible neutro- and thrombocytopenia. There was no immediate cardiac toxicity. One patient with extensive previous daunomycin exposure developed congestive heart failure after 4 months. Two patients were not evaluable for late cardiac complications because of early death due to tumor progression.
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PMID:Accidental overdose of mitoxantrone in three patients. 255 63

In 1988 the fourth Joint National Committee (JNC IV) issued new guidelines for the detection, evaluation, and treatment of hypertension. Pharmacologic along with nonpharmacologic therapy is indicated for hypertensive patients whose diastolic blood pressures average greater than or equal to 95 mmHg over a period of time and for patients who have a diastolic blood pressure of 90 mmHg to 94 mmHg with evidence of target organ disease and/or other major risk factors. In the absence of target organ disease and/or other major risk factors, a trial of nonpharmacologic treatment is recommended for patients with a diastolic blood pressure of 90 mmHg to 94 mmHg. The JNC IV report recommends initiating pharmacologic treatment with any one of the following classes of drugs: diuretics, beta blockers, calcium channel blockers, or ACE inhibitors. In general, diuretics and calcium channel blockers are especially indicated for elderly and black patients and beta blockers and ACE inhibitors for young and white patients, but there are many exceptions. In selecting the appropriate step-one agent for a given patient, the therapeutic "two-for-one" concept is emphasized whereby one antihypertensive drug may also be beneficial for a coexisting condition. Examples are: diuretics or ACE inhibitors in congestive heart failure; calcium channel blocking drugs or beta blockers in angina pectoris or paroxysmal supraventricular tachycardia; and beta blockers for migraine headache or senile tremor.
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PMID:Mild hypertension: critical analysis of different therapeutic approaches. 266 23

The pharmacologic treatment of dilated cardiomyopathy encompasses measures such as temporary administration of amino acids and calories for those who may be undernourished and avoidance of drugs such as alcohol, nicotine, amphetamines and high doses of tricyclic antidepressants. Anticoagulants should be used in patients with persistent failure or marked dilatation of the cardiac chambers since about 20% suffer from major embolic complications. In patients with ventricular tachycardia, R-on-T, or multifocal ventricular ectopic beats, class I antiarrhythmic drugs, or if unsuccessful, amiodarone should be administered since the risk of sudden death is substantial. In addition to digitalis and diuretics, the use of vasodilators is generally accepted to be of clinical value for reduction of symptoms in heart failure. Reports concerned with long-term clinical and hemodynamic effects with drugs such as prazosin, captopril and the combination of hydralazine and isosorbide dinitrate are conflicting and, so far, there is no evidence that any vasodilator prolongs survival. The beta-agonists, such as prenalterol, are limited in their usefulness by tachycardia induction, a tendency to provoke serious arrhythmias, tremor and anxiety as well as hemodynamic tolerance development. While the noncatecholamine inotropics such as milrinone may provide symptomatic relief in severe congestive heart failure, they also increase heart rate, induce ventricular arrhythmias and are associated with high one-year mortality rates. The beneficial effect of long-term beta-blockade, which we first reported in 1975 to include a decrease in functional class, increase in exercise tolerance, improvement in physical findings, increase in ejection fraction and enhanced survival, has been met with scepticism.(ABSTRACT TRUNCATED AT 250 WORDS)
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PMID:Pharmacologic treatment of dilated cardiomyopathy with special reference to the role of beta-blockers. 286 98

A data base of 1,245 patients treated for ventricular arrhythmias, most of whom had serious cardiac disease, was reviewed. Only 2.9% of these patients had benign ventricular arrhythmias without structural heart disease. The overall incidence of proarrhythmia in this population was 9.2% (115/1,245), but was as frequent as 16% in patients with a history of cardiomyopathy. The proarrhythmic form was new sustained ventricular tachycardia in 22 patients (1.8%). Only 2 of 71 patients (2.8%) with primary arrhythmia had a proarrhythmic event. The incidence has decreased markedly over the past years as reduced doses and gradual titration have been used. There were 137 deaths in the data base of which 82 were sudden, all in patients with advanced (79) or moderately severe (3) cardiac disease. High initial doses, prior myocardial infarction and congestive heart failure (CHF) were positively associated with sudden cardiac death. There were no deaths among the 71 patients with benign arrhythmias. Death rates were related to the severity of the arrhythmia being treated. Comparisons with published survival curves indicated modest improvement; in no case was survival decreased. Invasive and noninvasive measures of left ventricular function indicated no adverse hemodynamic effects. There was only 1 case of new and 3 cases of worsened CHF probably related to encainide. Only 5 patients discontinued for CHF or related signs and symptoms. The most frequent drug-related noncardiac adverse reactions were dizziness (26%), abnormal or blurred vision (19%), QRS interval prolongation (5%), taste perversion (4%) and tremor (3%). In conclusion, the use of reduced doses and gradual titration of encainide has markedly decreased the incidence of proarrhythmia.(ABSTRACT TRUNCATED AT 250 WORDS)
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PMID:Safety of encainide for the treatment of ventricular arrhythmias. 309 26

The role of pindolol in treating ventricular arrhythmia was studied in 43 patients with this disorder. Of these patients, 23 had coronary heart disease, 5 had valvular disease, and 15 had no demonstrable heart disease. patients underwent acute drug testing with 20 mg pindolol (phase 1) followed by maintenance therapy (phase 2) for 3 days (20 to 80 mg daily). Efficacy during both phases was evaluated by ambulatory monitoring and treadmill exercise testing. During acute drug testing, 50% of te patients responded. A concordant response between acute drug testing and phase 2 monitoring was seen in 81% (p less than 0.005) of patients and between acute drug testing and phase 2 exercise testing in 88% (p less than 0.005). Arrhythmia was suppressed during the phase 2 exercise test in 53% of patients; these included 80% of the patients without heart disease and 50% of those with coronary heart disease (not significant). During phase 2 monitoring, 60% of patients without heart disease responded vs. 25% with coronary heart disease (not significant). Side effects occurred in 12 patients (28%). These included congestive heart failure (3 patients); fatigue, lightheadedness, and insomnia (2 patients each); nausea, tremor, urinary retention, and bronchospasm (1 patient each); and aggravation of arrhythmia (7 patients). It is concluded that although pindolol alone is marginally effective for treating ventricular arrhythmia in patients with coronary heart disease, it appears to be more valuable in those without heart disease, especially when arrhythmia is provided by exercise. Acute drug testing proved highly predictive of the results with maintenance therapy and is a valuable rapid-screening procedure for identifying potential responders to pindolol.
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PMID:Pindolol for ventricular arrhythmia. 710 35

We examine the association of the menopause transition, congestive heart failure, and Parkinson's disease on body composition and energy expenditure. We present evidence suggesting that the normal menopausal transition is associated with accelerated loss of fat-free mass, a decline in resting metabolic rate, and increased central body fatness. Second, we show that the cardiac cachexia associated with heart failure is partially due to an elevated level of energy expenditure. Despite having a lower quantity of fat-free mass, congestive heart failure patients have a higher resting metabolic rate (approximately 283 kcal/d) for their metabolic size than healthy elderly. The elevated level of resting energy expenditure probably contributes to their unexplained weight loss. Parkinson's patients experience muscular rigidity and tremor which could contribute to inappropriately high levels of energy expenditure and difficulty in maintaining body weight and composition. We examined resting metabolic rate and body composition in eight Parkinson's patients and 34 healthy age-matched controls. Parkinson's patients showed lower levels of fat-free mass (approximately 6 kg), but similar resting metabolic rates (1601 +/- 250 kcal/d) versus healthy controls (1671 +/- 212 kcal/d), suggesting a hypermetabolic state. A re-examination of daily energy needs and the metabolic factors contributing to periods of energy imbalance during the menopausal transition and in several disease states may be a prerequisite to offsetting accelerated sarcopenia.
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PMID:Sarcopenia in aging humans: the impact of menopause and disease. 749 23

Prolongation of the QTc interval (a QT interval that has been corrected for heart rate) increases the risk of cardiac arrhythmias, and is an important topic with regard to psychotropic medication. Several typical (e.g., pimozide, thioridazine, haloperidol) and atypical (e.g., sertindole, ziprasidone) antipsychotics may cause QTc prolongation as well as some antidepressants in overdose (e.g., citalopram). We wish to present a case of QTc prolongation that was due to an overdose of propranolol (used in psychiatry for the treatment of akathisia, lithium-induced tremor, and performance anxiety; used in medicine for hypertension and congestive heart failure).
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PMID:QTc prolongation due to propranolol overdose. 1296 35

Amiodarone-associated thyrotoxicosis (AAT) is often poorly tolerated owing to underlying cardiac disease, and it is frequently refractory to conventional medical treatment. The goal of this study was to describe the patient characteristics, management, and outcomes of all the patients treated surgically for AAT at a single institution. We conducted a retrospective chart review of all patients managed surgically for AAT (April 1985 through November 2002) at the Mayo Clinic in Rochester, Minnesota. Altogether, 29 men and 5 women, ages 39 to 85 years (median 60 years), treated with amiodarone for 3 to 108 months underwent near-total or total thyroidectomy. Frequent symptoms were worsening heart failure, fatigue, weight loss, and tremor. Altogether, 12 patients failed medical management of their AAT, and 21 received no preoperative medical therapy. One patient had been successfully managed medically but required definitive treatment. Common indications for operation were the need to remain on amiodarone, cardiac decompensation, medically refractory disease, and severe symptoms, both hyperthyroid and cardiac, necessitating prompt resolution. The median+/-SD American Society of Anesthesiologists (ASA) classification (1 = healthy through 5 = moribund) was 3.00+/-0.58. A total of 27 specimens had histology consistent with AAT. Complications included death (n = 3), rehospitalization (n = 3), symptomatic hypocalcemia (n = 2), pneumonia (n = 2), cervical hematoma (n = 1), prolonged ventilatorywean (n = 1), and stroke (n = 1); one patient developed hypotension, adult respiratory distress syndrome, and sepsis. Of the 31 surviving patients, 25 (80%) remained on amiodarone postoperatively. The median follow-up was 29 months, at which time all surviving patients were free of hyperthyroid symptoms. Thyroidectomy is an effective treatment for AAT but has a high incidence of perioperative morbidity and mortality. The cardiovascular co-morbidities and high operative risk in this group of patients may account for the increased complication rate.
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PMID:Surgical management of amiodarone-associated thyrotoxicosis: Mayo Clinic experience. 1549 61

We examined the relation of type 2 diabetes mellitus to parkinsonian signs in older persons. Participants were 1030 women and men (mean age 80.3 y, education 14.5 y, Mini-Mental State Examination 27.9) without dementia or Parkinson disease, enrolled in the Rush Memory and Aging Project, an epidemiologic study of aging. We used separate linear and logistic regression models, adjusted for age, sex, and education, to examine the relation of diabetes, identified by history and medication inspection, to each of the scores of global parkinsonian signs and 4 separate parkinsonian signs. Diabetes was present in 140 (14%) participants. Most participants had mild parkinsonian signs. Diabetes was associated with a more severe global parkinsonian signs score (beta=0.20, SE=0.10, P=0.05) and postural reflex impairment-gait disturbance (beta=0.40, SE=0.17, P=0.02), but not with bradykinesia, rigidity, or tremor. Associations were no longer significant after controlling for vascular risk factors or conditions, particularly body mass index and congestive heart failure. Overall, there was no evidence that vascular variables modified the relation of diabetes to parkinsonian signs. In summary, we found that diabetes was associated with parkinsonian signs, especially postural reflex impairment-gait disturbance, and that vascular factors may play a role in this association.
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PMID:Diabetes and parkinsonian signs in older persons. 1754 40


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