Vitamin B12-responsive severe leukoencephalopathy and autonomic dysfunction in a patient with "normal" serum B12 levels.

Leukoencephalopathy and autonomic dysfunction have been described in individuals with very low serum B(12) levels (<200 pg/ml), in addition to psychiatric changes, neuropathy, dementia and subacute combined degeneration. Elevated homocysteine and methylmalonic acid levels are considered more sensitive and specific for evaluating truly functional B(12) deficiency. A previously healthy 62-year-old woman developed depression and cognitive deficits with autonomic dysfunction that progressed over the course of 5 years. The patient had progressive, severe leukoencephalopathy on multiple MRI scans over 5 years. Serum B(12) levels ranged from 267 to 447 pg/ml. Homocysteine and methylmalonic acid levels were normal. Testing for antibody to intrinsic factor was positive, consistent with pernicious anaemia. After treatment with intramuscular B(12) injections (1000 µg daily for 1 week, weekly for 6 weeks, then monthly), she made a remarkable clinical recovery but remained amnesic for major events of the last 5 years. Repeat MRI showed partial resolution of white matter changes. Serum B(12), homocysteine and methylmalonic acid levels are unreliable predictors of B(12)-responsive neurologic disorders, and should be thoroughly investigated and presumptively treated in patients with unexplained leukoencephalopathy because even long-standing deficits may be reversible.

Functional assessment. Easy-to-use screening tools speed initial office work-up.

The mnemonic DEEP-IN stands for a series of easy-to-administer, office-based screening tests designed to streamline initial assessment of the geriatric patient. These screens can quickly identify signs of delirium, dementia, depression, and adverse drug effects; vision and hearing deficits; risk for future impairments in activities of daily living; incontinence, and malnutrition. The author developed the mnemonic from personal experience and from an evidence-based application of validated geriatric and geropsychiatric studies.

Alternative medicine: what the data say about common herbal therapies.

An increasing number of Americans are turning to complementary and alternative medicine to help manage or prevent the onset of chronic disease, improve cognitive function, boost overall general well-being, and increase longevity. Some of the more widely-used herbal preparations designed to help accomplish these objectives include St. John's wort, ginkgo biloba, echinacea, garlic, and ginger. In general, the clinical trial data on these preparations is in the embryonic stages, whereas the popularity of these compounds is fueled in part by anecdotal evidence. Given the embrace by Americans--especially older persons--of these alternative remedies, knowledge of their uses and potential side effects can help the primary care physician better collaborate on a course of care that makes effective use of the best treatments, both traditional and alternative.

Managed Medicare: an overview for the primary care physician.

Medicare is looking to managed care to help solve its financial burden. Because managed care plans offer a number of advantages for Medicare enrollees, the number of plans and of enrollees are increasing dramatically. With some exceptions, the Medicare population appears to do as well or better in HMOs as in fee-for-service care, despite differences in utilization of services. For the primary care physician, the key to success in managed Medicare is finding and aggressively managing your frail or near frail patients. Basic tools for survival are the use of prevention strategies, screening of enrollees and targeting for needed services, geriatric assessment, use of alternate care settings to avoid or limit costly hospital care, and monitoring of medication use for compliance and adverse reactions.

Managed care: new challenges, new roles for the primary care physician. 2.

Managed care is revolutionizing health care, according to panelists in this roundtable discussion. Primary care physicians need to see patient care not as episodic but as a total, preventive package. In managed care, physicians hire nonphysician extenders for patient screening and function as a manager and consultant to an interdisciplinary team that extends beyond the four walls of the office practice. Patients need to know that primary care physicians can handle most of their problems; the specialist should be referred cases that are complicated and require procedures or second opinions. Outcome studies in managed care are lacking in important areas of geriatric medicine, such as treatment of psychiatric illnesses and Alzheimer's disease.

Managed care: what to expect as Medicare-HMO enrollment grows. 1.

Managed care is restructuring the American health care system and is beginning to make inroads into the Medicare-eligible population. Advantages of managed care for older patients include an emphasis on prevention, more flexibility in care delivery, and fewer restrictions and wider coverage (eg, prescriptions) than Medicare fee-for-service, and opportunities to develop measures for quality of care. Disadvantages include limitations on access and choice and a potential for professional conflict of interest. Early managed care enrollment favors the healthy "young-old;" questions remain about whether HMOs can provide quality care to the frail elderly with complicated and expensive health care needs.

Control of influenza outbreaks in the nursing home: guidelines for diagnosis and management.

A well coordinated plan that includes a mechanism for surveillance, rapid antigen detection testing and viral culture, infection control techniques and chemoprophylaxis is effective for aborting outbreaks of influenza A in the nursing home. Amantadine has been better studied in this situation, and experience with rimantadine is limited. The safety and efficacy of our dose guidelines for nursing home residents need to be studied and directly compared with rimantadine dose guidelines. Except for chemoprophylaxis, these guidelines can be applied to outbreaks of influenza B as well.

Aging and mental health: diagnosis of dementia and depression.

In this second segment of a panel discussion on aging and mental health, panelists focus on the primary care evaluation and management of the patient with dementia, including differential diagnosis of depression. Other topics of discussion include the roles of psychiatric referral and psychotherapy in patient management, suicide prevention, and alcoholism in elderly patients.