Are Thyroid Hormone Values Obtained in Hospitalized Elderly Patients Reproducible? - A Cohort Study.

It is unclear whether TSH should be obtained in elderly hospitalized patients as several factors associated with hospitalization influence these levels, which may not truly represent the thyroid status of the individual. All patients≥65 years old hospitalized in a geriatric ward in the years 2012-2014 had TSH measured irrespective of the cause for hospitalization. All patients in whom TSH levels were performed in an ambulatory setting 2-12 months following hospitalization were identified and these TSH levels were correlated with levels recorded during hospitalization. Factors influencing TSH reproducibility were identified through review of patients' medical records. Of 562 patients hospitalized during the study period, 198 had repeat ambulatory TSH measurements during follow-up. The Katz Index of Independence was higher (9.43±2.98 vs. 8.43±3.67 p=0.002) and cerebrovascular disease was less prevalent (15.6 vs. 25.2% p=0.014) in those who had a repeat TSH measurement compared with those who did not, but other baseline characteristics and TSH levels on admission were similar. Ambulatory TSH values were significantly correlated with those obtained during hospitalization (correlation coefficient=0.677), irrespective of baseline systolic blood pressure, cause of hospitalization, or admission albumin levels. Mean TSH difference between in-hospital and ambulatory was 0.65±2.36 mIU/l and in more than 94% of cases TSH values differed by less than 2 mIU/l between the 2 measurements. In hospitalized patients≥65 years old, TSH levels are highly concordant with ambulatory values. TSH obtained during hospitalization may be used for making treatment decisions and has clinical utility in this population.

Tight calorie control in geriatric patients following hip fracture decreases complications: a randomized, controlled study.

BACKGROUND & AIMS: Optimizing nutritional intake has been recommended for geriatric patients undergoing hip-fracture surgery. Whether nutritional support guided by repeated measurements of resting energy requirements (REE) improves outcomes in these patients is not known. METHODS: A randomized, controlled, unblinded, prospective, cohort study comparing provision of energy with a goal determined by repeated REE measurements using indirect calorimetry, with no intervention. Oral nutritional supplements were started 24 h after surgery and the amount adjusted to make up the difference between energy received from hospital food and measured energy expenditure. RESULTS: 50 Geriatric patients were included in the study. Patients in the intervention group (n = 22) received significantly higher daily energy intake than the control group (n = 28) (1121.3 ± 299.0 vs. 777.1 ± 301.2 kcal, p = 0.001). This was associated with a significantly less negative cumulative energy balance (-1229.9 ± 1763 vs. -4975.5 ± 4368 kcal, p = 0.001). A significant negative correlation was found between the cumulative energy balance and total complication rate (r = -0.417, p = 0.003) as well as for length of hospital stay (r = -0.282, p = 0.049). CONCLUSION: We have demonstrated that nutritional support actively supervised by a dietician and guided by repeated measurements of REE was achievable and improved outcomes in geriatric patients following surgery for hip fractures. Clinicaltrials.gov Identifier: NCT017354435.

Attitudes and knowledge of medical and nursing staff toward elder abuse.

Although physicians and nurses are best positioned to recognize and diagnose cases of elder abuse, the level of reporting these cases is much lower than its true incidence. Our aim was to assess and compare knowledge and attitudes of physicians and nurses toward this phenomenon. Two hundred and thirty-five nurses and physicians were asked to participate in the study. One hundred nurses and 57 physicians ultimately completed the questionnaires. The main finding was that participants had a low level of knowledge of elder abuse issues and the relevant laws and regulations (mean correct answers 5.36+/-1.45 of 10 and 4.67+/-1.34 of 8, respectively). No significant differences were found in the physicians' knowledge according to medical specialty, hospital type, years in the profession and geriatric experience. Licensed practical nurses knew less than registered and academic nurses relating to the abuse issue and state reporting laws (p=0.003 and 0.02, respectively). No significant differences relating to the knowledge of elder abuse were found between nurses and physicians nor between general and geriatric hospital employees. Both physicians and nurses tended to have neutral attitudes regarding this issue. However, employees of geriatric hospitals had better attitudes than general hospital workers (p=0.008). Most responders believed that the unwillingness to get legally involved had been the main reason of not reporting suspected cases. This study emphasizes the need to take more efficient measures to improve the knowledge of the medical and nursing staff concerning elder abuse and to encourage medical personnel to be more concerned and involved in the safeguarding of the elderly.

Body mass index and risk of all-cause and cardiovascular mortality in hospitalized elderly patients with diabetes mellitus.

AIMS: Obesity is linked to increased morbidity and mortality risk in both the general population and in patients with diabetes mellitus; however, recent reports suggest that, in hospitalized elderly individuals, the association between body mass index (BMI) and mortality may be inverse. The present study sought to investigate the association between BMI and survival in hospitalized elderly individuals with diabetes mellitus. METHODS: The medical records of 470 patients (226 males, mean age of 81.5 +/- 7.0 years) admitted to an acute geriatric ward between 1999 and 2000 were reviewed. Of the 140 patients with diabetes mellitus, 122 had more than 6 months of follow-up and were included in this analysis. Patients were followed up until 31 August 2004. Mortality data were extracted from death certificates. RESULTS: During a mean follow-up of 3.7 +/- 1.6 years, 69 (56.6%) subjects died, 31 (25.4%) from cardiovascular causes. Those who died from any cause had lower baseline BMI than those who survived (24.0 +/- 4.0 vs. 27.1 +/- 4.3 kg/m(2); P < 0.0001). Similarly, those who died of cardiovascular causes had lower baseline BMI than those who did not (23.7 +/- 3.6 vs. 25.9 +/- 4.5, P = 0.01). BMI was inversely associated with all-cause [relative risk (RR) 0.89, 95% confidence interval (CI) 0.83-0.96, P = 0.002] and cardiovascular death (RR 0.83, 95% CI 0.74-0.93, P = 0.002) even after controlling for age, sex, smoking, dyslipidaemia and reason for hospital admission. CONCLUSIONS: In very elderly subjects with diabetes mellitus, increased BMI was associated with reduced mortality risk.

Orthostatic hypotension in the elderly: are the diagnostic criteria adequate?

Orthostatic hypotension (OH) is a common finding in the elderly. OH is defined as a fall of at least 20 mmHg in systolic blood pressure (BP) and/or 10 mmHg in diastolic BP upon assuming an upright posture. Some patients exhibit a fall in BP of less than the defined OH upon standing. The aim of this study was to estimate the prevalence of BP changes not defined as OH among elderly in-patients and to assess the relationship between these changes in the morning and the occurrence of OH during the day. Postural BP measurements were performed in 502 in-patients; in the morning, early afternoon, and in the evening. We defined intermediate postural drop (ID) in BP as a decrease of 10-19 mmHg in systolic BP and/or of 5-9 mmHg in diastolic BP. We observed that OH and ID occurred in 39.2 and 18.5% of the measurements in the morning, respectively. The prevalence of OH and ID was lower in the evening than in the morning (P<0.05) and afternoon (P<0.005). Postural BP changes in the morning correlated with those occurring later in the day. Patients who had ID in the morning had a 57% probability of having OH later during the day. In conclusions, ID is prevalent in elderly in-patients. ID in the morning predicts OH later in the day. Thus, postural BP drops below the OH range may be an important finding in the geriatric population.

Medial unicompartmental replacement for tricompartmental disease in the elderly.

Between 1993 and 1998, we performed 18 unicompartmental arthroplasties of the knee, all on the medial side, in a selected group consisting of 18 elderly patients aged 74-81 (mean 77.2), with severe arthrosis mainly in the medial compartment and mild arthrosis in the lateral compartment and the patellar articular surface mostly covered with articular cartilage. The patients were mainly housebound due to relatively advanced age and severe pain. Unicompartmental arthroplasty was chosen for this group because of a quicker and easier rehabilitation. Two patients had had a high tibial osteotomy 7 and 10 years ago. The average follow up was 5.5 years ranging in age from 5 to 8 years. The average initial American Knee Society Knee Score was 52, ranging from 28 to 70 which improved at follow up to 83 (range 60-92). All prostheses used were Allegretto (Sulzer). The operation was done through short medial arthrotomy. The purpose of this study is to report our results in these low demand patients and although the follow-up was only 5-8 years, the results are promising.

Dementia does not significantly affect complications and functional gain in elderly patients operated on for intracapsular hip fracture.

Fifty-three elderly patients with intracapsular hip fracture were hospitalized in the Department of Orthopaedics. Forty-two underwent operations: 38 hemiarthroplasty; 2 total hip replacements and 2 closed reduction interior fixation. They were followed up and assessed prospectively five times for 6 months post-fracture. Cognition was evaluated by the Mini-Mental State Examination. Pre-fracture functioning was determined by the Functional Independence Measure (FIM) and the Katz index of activities of daily living (ADL). The functional outcome was assessed by the FIM gain defined as the difference between FIM scores at 6 months and just prior to discharge. FIM gain, length of stay, complications and mortality rates were not significantly different between three cognitive groups: normal, moderately and severely demented patients. The majority of patients were independent and partially dependent in their ADL. We conclude that dementia does not significantly affect complications and functional gain in elderly patients operated on for intracapsular hip fracture if they were mobile before the fracture.

Outcome of medically unstable elderly patients admitted to a geriatric ward after hip fracture.

Outcome of surgical treatment is superior to that of conservative treatment for hip fractures. Nevertheless, for a number of patients, the operation is either delayed or unfit due to their unstable medical conditions. We retrospectively reviewed patients admitted to a geriatric ward after hip fracture, and investigated complications, functional outcome and survival in different cognitive, pre-fracture functional and treatment groups. Patients hospitalized (N=78) from January 1993 to June 1999 were included (1/2 demented, 1/3 fully dependent in Basic Activities of Daily Living, and 2/5 high operative risk patients). Following stabilization, 14 subjects (17. 9%) were operated. The mean and range of surgical delay was 9+/-7.2, and 3 to 30 days, respectively. Comparison between surgical and conservative treatment groups, and cognitive and pre-fracture functional groups showed no differences in age, gender, chronic medical conditions, fracture type, reasons for surgical delay or conservative approach, complications, survival curves and laboratory results. Thirteen operated patients were in ASA I + II grades, only 1 in ASA grades III + IV (low and high operative risk, American Society of Anesthesiologists grading system) (p=0.004). Functional outcome was similar in the surgical vs the conservative group, and intracapsular vs extracapsular fractures. ASA I + II patients had a higher survival rate compared to ASA III + IV patients (p=0. 02). We conclude that after stabilization of acute medical conditions, the most important preoperative consideration is the anesthetic risk, and surgical and conservative approaches may be equally considered in selected groups of elderly, frail patients with hip fracture who are medically unstable for more than a few days.

Prevalence and survival of myelodysplastic syndrome of the refractory anemia type in hospitalized cognitively different geriatric patients.

BACKGROUND: Myelodysplastic syndrome (MDS) is predominantly a disease of old age. The number of MDS cases diagnosed over the last 20 years has risen substantially due to increased awareness and improved geriatric care. Although MDS is increasingly diagnosed, the prevalence and prognosis of early-stage affected elderly are not completely known. OBJECTIVE: To evaluate the prevalence, characteristics and prognosis of newly diagnosed MDS patients hospitalized in an acute and subacute geriatric department. METHODS: Between 1993 and 1996, 3,275 patients hospitalized in the geriatric department of a teaching hospital for acute care or short-term rehabilitation were investigated for unexplained hematological abnormalities. Demographic, chronic comorbidities, cause of hospitalization, functional and cognitive status, hematological and other laboratory parameters were collected. RESULTS: Two hundred and forty-five (7.5%) patients had unexplained cytopenia, macrocytosis or monocytosis, of whom 37 (15%) were diagnosed as having MDS. Only 9 patients were hospitalized for evaluation of anemia, 28 for infections, cardiac, cerebrovascular events and other causes. Thirty-four patients had refractory anemia (RA), two had RA with ringed sideroblasts and 1 had RA with an excess of blasts (RAEB). The follow-up period was up to 70 months. No differences were found between demented and cognitively normal patients in age, sex, comorbidities or laboratory parameters. Comparison of survival curves (excluding the RAEB case) according to demographic, clinical and hematological parameters has shown that only dementia adversely affects survival, compared to cognitively normal patients (p = 0.024). CONCLUSIONS: MDS of the RA type is a common and incidental finding in older hospitalized patients. It is a frequent cause of anemia and other hematological abnormalities but has less significance on survival rates than dementia, although its full impact remains to be determined.

Convulsions induced by metronidazole treatment for Clostridium difficile-associated disease in chronic renal failure.

Clostridium difficile-related diarrhea and colitis are common health problems, especially in elderly, frail hospitalized patients. The drug of choice is metronidazole, which can be associated, in long or high doses, with neurotoxic side effects. We report convulsions induced by short-term metronidazole therapy used in conventional doses for Clostridium difficile colitis in an elderly patient with chronic renal failure.

Relationship between routine hematological parameters, serum IL-3, IL-6 and erythropoietin and mild anemia and degree of function in the elderly.

To investigate the influence of functioning on unexplained senile anemia, we measured commonly used hematological parameters (serum iron, transferrin, iron saturation and ferritin) in addition to specific erythropoietic factors, such as interleukin-3 (IL-3), interleukin-6 (IL-6), and erythropoietin (EPO) in 48 elderly subjects aged 65-90 years. The subjects were divided into 3 groups: 1) 17 patients with unexplained mild anemia; 2) 17 non-anemic patients with newly acquired stroke and who previously were functionally active; 3) 14 functionally active patients with no major disease who served as controls. Anemia was defined as hemoglobin (Hb) values under 12.0 g/dL. The degree of functional ability was defined and scored by the "functional independence measure" (FIM) test. Data are presented as mean values +/- SD. The results revealed a correlation between the functional state and levels of Hb, iron and transferrin with unchanged iron saturation. Patients in the mild anemia group were found to be functionally declined (FIM = 57 +/- 19.4) with the relatively lowest mean iron (75.1 +/- 17 micrograms/dL) and transferrin levels (243 +/- 42.6 micrograms/dL). The stroke group (FIM = 62 +/- 17.7) had intermediate levels of iron (85.4 +/- 20.3 micrograms/dL) and transferrin (245 +/- 45.2), and with the continuation of the declined functional state the Hb level decreased significantly (13.7 +/- 0.9 to 12.0 +/- 1.0 g/dL, p < 0.001). The highest mean values of iron (102 +/- 27.9 micrograms/dL) and transferrin (322 +/- 42.7 micrograms/dL) were found in the control group (FIM = 122.7 +/- 5.8). The ferritin levels showed an opposite trend. IL-3 values were undetectable in the anemic and control groups, and were elevated in some patients in the stroke group. The lowest IL-6 level was observed in the anemic group, and the highest in the control group. Serial IL-6 assays in the stroke group showed an upward trend. Erythropoietin levels in all groups showed no difference.

The prehospitalization functional and cognitive status and the course of acute infectious disease in the elderly.

A total of 105 elderly patients hospitalized for acute infectious disease were classified into prehospital demented and non demented groups and into dependent and independent groups. Demographic data, clinical and biological parameters and previous health problems were recorded. There was a significant difference between the two cognitive and functional groups in complications, length of stay, dehydration, confusion, albumin and hemoglobin. A logistic regression analysis taking into account the epidemiologic parameters, functional and cognitive status and the medical health problems has shown that only age, dementia and previous neurologic disease (mainly stroke) are independent risk factors for confusion and complications. Thus, the prehospitalization function, cognitive status and previous neurologic disease in elderly patients with acute infections may have a predictive and prognostic value.

The importance of brain infarct size and location in predicting outcome after stroke.

Fifty-six consecutive elderly ( > or = 65 years) patients, admitted for acute stroke to a geriatric department were included in the study and underwent CT scanning. Functional status was graded according to the modified Rankin scale. Three patients had primary intra-cerebral haemorrhage, 22 deep hemispheric infarct, 17 had anterior circulation cortical infarcts, five had posterior circulation infarcts and in nine the CT scan was normal. Stroke risk factors were equally distributed among the different CT scan groups, and all three larger groups had similar rates of non-neurological major complications including death (41%). However, independence in ADL (Rankin 0-2) was observed in 72% of deep infarct survivors, but only 15% of the cortical infarct group (p = 0.00018). For the normal scan group, functional recovery was intermediate. In the cortical infarct group patients with an infarct of > or = 50 mm mean diameter (five cases) should worse functional recovery than did eight patients with small infarcts. The mean difference between pre- and post-stroke Rankin score (DR) was 3.4 for the larger infarct patients and 1.9 for the smaller infarct group (p = 0.027). Pearson correlation revealed a direct relationship between the infarction size and DR (p = 0.039). Such a relationship was not observed for the deep hemispheric group.

Calcium pyrophosphate dihydrate crystal deposition disease in the elderly.

Calcium pyrophosphate dihydrate deposition disease can mimic a large number of joint diseases. We report on three patients with predominantly systemic symptoms. Diagnostic pitfalls and treatment delays in these patients are discussed. Once the diagnosis is considered, confirmation is readily obtained by examination of the joint fluid and treatment promptly relieves symptoms.