Subtle ethical dilemmas in geriatric management and clinical research.

Routine management of geriatric problems often raises ethical problems, particularly regarding autonomy of the old person. The carers or children may be unaware of the sensitivity of role reversal in dealing with the financial affairs; the need for a residential carer may compromise the old person's privacy. Attending a day centre confers much benefit, but one must understand the old person's resistance to change in the proposal of a new daily regimen. Similarly his or her autonomy must be the priority in planning for admittance to an old age home, and not the assumption that the family knows best. A common dilemma is the assessment of an old person's competency in decision making, either about management of his affairs, or regarding consent to treatment, or participation in research. Because cognitive capacity is not always identical with competency, meaningful tools have recently been developed in which the emphasis is on the specific situation to be investigated.

Autonomy and paternalism in geriatric medicine. The Jewish ethical approach to issues of feeding terminally ill patients, and to cardiopulmonary resuscitation.

Respecting and encouraging autonomy in the elderly is basic to the practice of geriatrics. In this paper, we examine the practice of cardiopulmonary resuscitation (CPR) and "artificial" feeding in a geriatric unit in a general hospital subscribing to jewish orthodox religious principles, in which the sanctity of life is a fundamental ethical guideline. The literature on the administration of food and water in terminal stages of illness, including dementia, still shows division of opinion on the morality of withdrawing nutrition. We uphold the principle that as long as feeding by naso-gastric (N-G) or percutaneous endoscopic gastrostomy (PEG) does not constitute undue danger or arouse serious opposition it should be given, without causing suffering to the patient. This is part of basic care, and the doctor has no mandate to withdraw this. The question of CPR still shows much discrepancy regarding elderly patients' wishes, and doctors' opinions about its worthwhileness, although up to 10 percent survive. Our geriatric patients rarely discuss the subject, but it is openly ventilated with families who ask about it, who are then involved in the decision-making, and the decision about CPR or "do-not-resuscitate" (DNR) is based on clinical and prognostic considerations.

Sitting equilibrium 2 weeks after a stroke can predict the walking ability after 6 months.

The prediction of mobility soon after a stroke should allow proper selection for rehabilitation and suggest the long-term prognosis of gait ability. Stable gait is related to midline body orientation and equilibrium mechanisms. We proposed that the sitting balance during the 1st, 2nd, or 3rd weeks after a hemiplegia could be a prognostic indicator for gait at 6 and 12 months. Sitting equilibrium measured in hospital was correlated with gait at the time of discharge and after 6 and 12 months, assessed by standing up, walking, and climbing stairs. The power in the affected limbs in hospital was also correlated with gait at those times. In the 134 patients followed up at 6 months, the correlation of equilibrium with gait at 6 months was r = 0.675 (p < 0.0001), and that of arm power with gait was r = 0.551 (p < 0.0001). Correlations with gait at 12 months were smaller and less meaningful. Assessment of sitting balance, even before the patient can stand, forms an important part of early management of the stroke patient.

A comparison of clinical features of mycobacterial infections in young and elderly patients.

A comparison was made of the presentation of tuberculosis (TB) between a young immigrant population from Ethiopia (mean age 21.2 +/- 16 yr) and an elderly Israeli group (mean age 71.4 +/- 10 yr). Prominent differences were the complaint of weakness among the elderly who also had more anorexia and weight loss. The time between the onset of complaints and the diagnosis was 2 months in the elderly and 3.5 wk in the younger group (p < 0.05). Four of the elderly died, 2 from causes related to TB; none of the younger patients died. The insidious and non-specific symptoms in the elderly tend to cause a delay in the diagnosis unless there is a high index of suspicion.

Diuretic-induced severe hyponatremia. Review and analysis of 129 reported patients.

Thiazides were responsible for severe diuretic-induced hyponatremia (serum sodium level < 115 mEq/L) in 94 percent of 129 cases reported in the literature between 1962 and 1990. The hyponatremia developed within 14 days in most of the patients receiving thiazides but in none of the patients who were treated with furosemide. Diuretic-induced hyponatremia was four times more common in women than in men. Advanced age was not associated with a higher tendency for hyponatremia. In the majority of the patients who received thiazides, excess antidiuretic hormone activity, hypokalemia, and excess water intake were accompanying findings which, singly or together, appeared to contribute to the development of hyponatremia. In 12 patients, mortality was directly related to hyponatremia. Rapid average correction of hyponatremia and a relatively high total correction (over 20 mEq/L) in the first 24 h were significantly associated with higher mortality or demyelinating syndrome. The presence of neurologic signs is an indication for active sodium replacement. The onset of thiazide-induced hyponatremia may in some cases occur within 1 day and therefore needs to be corrected rapidly, but within a total elevation of 20 mEq/L in the first 24 h. Where the onset is judged to have been slow (over several days), the level should be corrected at a slow rate, up to a total of 12 to 15 mEq/L in 24 h.

Mortality in elderly patients with thermoregulatory failure.

Fifty-four elderly patients with thermoregulatory failure were evaluated retrospectively. The most commonly associated cause was underlying sepsis, which occurred in 78% of cases. Underlying conditions that increased the incidence of hypothermia were hypoproteinemia (50%), cachexia (30%), and neuroleptic medications (21%), most commonly thioridazine. Digoxin toxicity was a common finding (20% of all cases). One third of the patients developed hypothermia in warm months and half of them developed it while in the hospital. Patients who presented with hypothermia from out of the hospital had lower temperatures, were more bradycardic and hemoconcentrated, and died more rapidly than the in-hospital group. This could be explained by lower outside temperature or delay in diagnosis and treatment of the underlying disease. The overall mortality rate was extremely high (74%) in both groups. The mortality rate was not affected by age, sex, or degree of hypothermia. We conclude that thermo-regulatory failure in the elderly can occur in warm as well as cold environments or climates. The development of hypothermia in elderly patients should be promptly treated as sepsis unless proven otherwise, in light of the poor prognosis of this condition.

Significance of the measurement of uric acid fractional clearance in diuretic induced hyponatraemia.

The biochemical features of severe hyponatraemia due to thiazide administration in 7 non-oedematous patients were compared with those in hyponatraemia due to frusemide. Hypouricaemia has been shown to occur in hyponatraemia due to the syndrome of inappropriate antidiuretic hormone activity and this was measured along with fractional uric acid clearances in all the patients. Five of the patients had been on thiazides (or hydrochlorothiazide with amiloride) for only a few days to a few weeks. Fractional uric acid clearance was elevated and serum uric acid levels were low in five of them and returned to the normal range on restoration of serum sodium to normal. By contrast, the patients on frusemide did not show any abnormality in fractional uric acid clearance at any stage. These results are consistent with excess ADH activity as having caused hyponatraemia induced by thiazides in 5 of the 7 cases, whereas frusemide caused a sodium depletion syndrome. Treatment in the former cases is by water restriction, and in frusemide-induced salt depletion by saline supplementation.

A new look at the natural history and clinical features of intracerebral haemorrhage: a clinical CT scan correlation.

Intracerebral haemorrhage (ICH), as documented in 77 patients by computerized tomographic (CT) scans, was studied with regard to presentation, neurological features and outcome. Death occurred in 34%, a lower figure than was thought in the pre-CT scan era, and comparable to reported series in the last 10 years. Survival was more common in patients with intralobar haemorrhage, in which there was a less close association with hypertension or with coma. Intraventricular haemorrhages carried a bad prognosis with 14 deaths out of the 24 patients thus diagnosed. Eighty-eight percent of the survivors returned home, and nearly half of them had almost normal function. The main negative prognostic factors as determined by discriminant analysis were: presentation with coma over several hours, abnormalities of pupils or eye movements, inability to be mobilized after an average of 4 days, large volume of haematoma as measured in CT scan and intraventricular bleeding. It is important to make the diagnosis in order not to give anticoagulant treatment inappropriately, and there should be awareness that ICH is more common than was previously thought.

Preleukemic syndrome in elderly patients--report of 11 cases.

The preleukemic syndrome occurs mainly after middle age. We report 11 patients, aged 62 to 92 years, who presented with weakness, fatigue, malaise and pallor. Eight patients died; survival from the time of diagnosis was between 2 and 21 months. Two of them developed acute myelomonocytic leukemia. A third patient developed Philadelphia chromosome-negative chronic myeloid leukemia within 9 months. Serum unsaturated B12 binding capacity and transcobalamin I were elevated in this patient, preceding the transformation to chronic myeloid leukemia. Five other patients died from sepsis or pneumonia. All patients were anemic, and 10 were leukopenic. Bone marrow was hypocellular in 1 and hypercellular in 10 cases. Chromosomal studies were performed in five patients, with three showing abnormal findings: 47xx, trisomy 8 and a tetraploid karyotype 92xxyy5q-. No cytotoxic treatment should be given during the preleukemic phase until transformation to acute leukemia occurs. Since preleukemic patients are very susceptible to infections, early diagnosis of the condition is important, as is supportive care in the case of surgery.

Environmental management of senile dementia.

A model is described of social activity in club settings geared to the needs of demented and cognitively impaired old people living in the community. As well as reality orientation, guided social interaction, physical activity, dance therapy and craftsmanship, important elements include transport, home assessment and follow-up visits. Parallel support groups for spouses are essential to the complete program, which coordinates planning with local authority agencies. The complex also includes educational programs for staff, professionals and the public. This design is seen as an on-going neighborhood project in which at focal points of the week, the patient enters a meaningful social environment with which he can cope.

Endogenous opiates mediate cardiac sympathetic inhibition in response to a pressor stimulus in rabbits.

Two different patterns of response to a pressor stimulus occurred in conscious rabbits. This difference was not apparent when a depressor stimulus was applied. At levels of mean arterial pressure exceeding 120 mmHg one group of animals exhibited a marked bradycardia which was due to sympathetic inhibition in addition to vagal activation while this sympathetic component appeared to be lacking in the second group of animals. Naloxone (0.1 mg/kg i.v.) markedly reduced the sympathetic inhibition elicited by phenylephrine but had no significant effect on the reflex vagal stimulation. Naloxone thereby abolished the difference in sensitivity of baroreflex control of heart rate in response to a pressor stimulus between the two groups of rabbits. Naloxone did not influence the sensitivity of the reflex response to nitroprusside. Morphine (2 mg/kg) increased the vagal component of the baroreceptor reflex in response to a pressor stimulus and the sensitivity of the reflex response to nitroprusside in all the rabbits, and this was antagonized by naloxone (0.1 mg/kg). Morphine also potentiated and naloxone antagonized the bradycardic response at levels of MAP exceeding 120 mmHg, in those rabbits which appeared to lack the cardiac sympathetic inhibitory component of the reflex. The results show that endogenous and exogenous opiates can increase the reflex bradycardia in response to a pressor stimulus in the conscious rabbit. The difference in baroreflex sensitivity in different animals may result from their varying ability to activate endogenous opioid systems which depress cardiac sympathetic activity.

Relative contributions of vagal and cardiac sympathetic nerves to the reflex bradycardia induced by a pressor stimulus in the conscious rabbit: comparison of 'steady state' and 'ramp' methods.

The bradycardic response to a pressor stimulus, phenylephrine, was studied simultaneously in conscious rabbits by two different methods. The 'steady state' method, in which bradycardia was measured at the peak of each pressor stimulus, demonstrated the existence of two groups of animals, in which the maximal heart periods were 867 (s.e.m. = 49) and 563 (s.e.m. = 34) ms and the slopes of the MAP-HP relationship were 24.6 (s.e.m. = 1.6) and 8.1 (s.e.m. = 0.7) ms/mmHg, respectively. The difference in baroreflex sensitivity in the two groups was abolished by sympathetic nerve blockade with guanethidine (10 mg/kg) but not by vagal blockade. The 'ramp method' which measures bradycardia during the rapid phase of MAP rise after phenylephrine did not detect any difference in response of the two groups of rabbits. Guanethidine did not alter the slope of the MAP-HP relationship in either group of rabbits when this was assessed by the 'ramp' method. These findings demonstrate that the 'steady state' method can detect changes in both vagal and sympathetic activity, while the 'ramp' method measures only vagally induced bradycardia. It is concluded that some rabbits may have a genetic ability to activate baroreflex pathways mediating cardiac sympathetic inhibition in addition to vagal stimulation in response to a pressor stimulus.

Fungal serology in the elderly.

90 geriatric patients without any clinical signs of systemic fungal infection had their sera tested for the presence of candida and aspergillus precipitins and cryptococcal antigens. None of the patients had positive aspergillus or cryptococcal serology. 13% of patients were found to have candida precipitins, but these cases were not significantly correlated with candida colonisation, length of hospitalisation, prior antibiotic therapy, steroid therapy or diabetes. Allowing for 13% false positives, serological testing might be helpful in identifying systemic candidiasis. It is probably highly specific for parenchymal involvement by aspergillus or cryptococcus.

Body positional effect on gas exchange in unilateral pleural effusion.

The positional effect on gas exchange was studied in eight patients who had unilateral pleural fluid without clinical or radiologic evidence of parenchymal lung disease. In all eight patients, PaO2 values were higher when the lung with the pleural fluid was uppermost. The mean PaO2 in this position was 71.9 +/- 9.3 mm Hg (mean +/- SE) compared with 66.7 +/- 8.7 mm Hg in the lateral decubitus position with the pleural fluid lowermost. The mean difference in PaO2 between the two positions was 5.1 +/- mm Hg (p less than 0.005). Larger positional differences were found in the patients with the smallest pleural effusions. These results are probably due to perfusion of areas of unventilated lung, accentuated by gravity with a consequent increase in shunting. A large effusion also causes a decrease in perfusion, so that ventilation-perfusion mismatching is decreased and the positional effect on gas exchange diminished.

Factors influencing admission or nonadmission of the aged to the hospital.

A prospective study was carried out to determine which social, functional, or medical factors influenced the decision to admit or not to admit aged people to a general hospital in Israel. The study also focused on characteristics of patients admitted to the geriatric ward of the medical division as distinct from those sent to the internal medicine ward. Two hundred patients over the age of 65 were examined during ten consecutive intake days for the internal medicine ward over a period of five weeks. One hundred and sixty-seven were interviewed in the emergency departments, and the others after transfer from other departments by prearranged consultation. Thirty-five per cent were not admitted, 28 per cent were admitted to internal medicine, and 26 per cent were admitted to the geriatric department. Social factors played little part in the selecting process, the dominant need being acuteness and severity of illness. However, patients in the geriatric ward were found to be functionally much more disabled in regard to mobility, mental state, and incontinence. This was also reflected in a longer average stay of 15 days compared with nine in internal medicine, a higher mortality (19 per cent as against 7 per cent) and a higher degree of disability on discharge from hospital.