Variability of blood pressure response to orthostatism and reproducibility of the diagnosis of orthostatic hypotension in elderly subjects.

BACKGROUND: Orthostatic hypotension (OH) is a major problem in the elderly population. Its diagnosis is based on measurement of the blood pressure (BP) response to orthostatism (BPRO). This study investigates the within-day and day-to-day variability of the BPRO and the reproducibility of the diagnosis of OH in this population. METHODS: BP was measured in the supine position and after 1 and 2 minutes of orthostatism in 53 consecutive elderly patients (43 women and 10 men aged 83.7 +/- 9.5 years) of an intermediate care geriatric ward. BPRO was assessed 4 times on the same day (8-9 AM, 10-11 AM, 1-2 PM, and 5-6 PM) and twice more on another day of the same week (8-9 AM and 1-2 PM). RESULTS: There were significant within-day differences between the four orthostatic changes in systolic BP (OCs, supine minus standing systolic BP) after 1 minute or 2 minutes (p < .05). Day-to-day differences between the OCs measured at the same times were not significant. OH defined as an OCs of 20 mm Hg or more at 1 or 2 minutes of orthostatism, was found in ten cases (19%) in the initial set of measurements on the first day. A cumulative diagnosis of OH after the six BPRO tests was found in 23 cases (43%). The reproducibility of the diagnosis of OH was mild or poor (all kappa values were below 0.47). CONCLUSIONS: BPRO exhibits significant within-day variability in elderly patients. Within-day and day-to-day reproducibility of the diagnosis of OH, based on conventional criteria, were found to be poor.

[Nutritional support in elderly malnourished patients]. / L'assistance nutritionnelle chez les malades âgés dénutris.

ASSESSMENT OF NUTRITIONAL STATUS: Protein-calorie malnutrition is frequent and often severe in fragile hospitalized or institutionalized elderly subjects. Underdiagnosis and undertreatment is commonplace. Since under- or malnutrition is more difficult to correct in the elderly than in the young subject, a careful assessment of the nutritional status must be made in order to recognize any nutritional disorder early and initiate proper treatment early. NUTRITIONAL ASSISTANCE: High-protein oral supplementation and complementary enteral nutrition can improve the clinical status of certain under- or malnourished elderly subjects. It is particularly important to initiate nutritional assistance early and provide effective treatment for any recognized surgical or medical cause of malnutrition. Patient cooperation is crucial. EXPECTED RESULTS: Associated early with rehabilitation therapy, nutritional assistance can be expected to improve the functional independence of the elderly patient. Treatment efficacy and patient tolerance must be evaluated regularly to adapt nutritional assistance to the patient's particular clinical situation. Intensive enteral nutrition is not appropriate for elderly patients with severe malnutrition whose quality of life is compromised by motor, psycho-cognitive, or sensorial handicaps.

[Quality of the information collected during admission to a hospital geriatric service: importance of a structured medical record]. / Qualité du recueil d'information à l'admission en service hospitalier de gériatrie: intérêt d'un dossier médical structuré.

OBJECTIVES: The medical record (MR) is a key document for hospitalized patients. Several audits have however demonstrated that much important information is often missing in hospital MR. We conducted this survey with the aim of improving the quality of MR in a geriatric unit. PATIENTS AND METHODS: A structured MR was elaborated and implemented in order to guide and record the assessment of patients admitted in our geriatric ward. MR of 54 consecutive patients admitted after implementation of the structured MR were studied and compared to those of 108 consecutive patients admitted on the preceeding year (classical MR). Quality of data collected at admission was assessed using a 33-item guide, proposed by 3 experts in geriatric medicine unaware of the structured MR studies. For each item, a binary score (present/absent) and a precision score were used. A validation study was conducted using the same methods in another geriatric ward which has not participated to development of the structured charts MR studied. RESULTS: For most items studied, information was present in a significantly higher proportion in structured MR than in classical MR. Likewise, the precision score was significantly higher in structured MR. The validation survey found analogous results. CONCLUSION: Use of a structured MR significantly improves the quality of data collection at admission in geriatric units. This improvement appears to be related more to the use of the structured MR than the effect of developing a new tool.

[Alteration of cardiovascular vagosympathetic control evaluated by spectral analysis of variations of heart rate and blood pressure in obesity]. / Altération du contrôle vagosympathique cardiovasculaire évalué par l'analyse spectrale des variations de fréquence cardiaque et de pression artérielle chez les obèses.

Several studies suggest alterations of parasympathetic and sympathetic control in obesity. We have already shown that more than 40% of non diabetic obese subjects have alterations of parasympathetic control of heart rate (HR) variations. The present study aimed to investigate parasympathetic and sympathetic cardiovascular control by using spectral analysis. Sixty-two non diabetic obese subjects were compared to 38 sex-matched healthy controls. Spectral analysis was performed by Anapres system and identified two particular peaks: the one of high frequency (0.20-0.25 Hz) for heart rate variations during controlled breathing which depends on parasympathetic activity, the other of low frequency (around 0.10 Hz) for systolic BP variations in the standing position which mainly depend on sympathetic activity. In control subjects the amplitude of the high frequency peak (r = -0.556, p < 0.0001) but not the amplitude of the low frequency peak correlated negatively with age. In the obese subjects both the high and low frequency peaks correlated negatively with age (r = -0.249; p = 0.05 and r = -0.289, p = 0.036 respectively) and did not correlate with body mass index. The high frequency peak was significantly lower than in controls (4.80 +/- 3.37 (SD) vs 8.38 +/- 4.14; p < 0.0001). In the 25 obese subjects over 40 years the low frequency peak was also significantly lower than in controls (10.00 +/- 3.10 vs 11.95 +/- 4.25; p < 0.05). This study suggests that 1) age must be taken into account when interpreting the cardiovascular parameters under vagosympathetic control; 2) in non diabetic obese subjects vagal activity is decreased and in those over 40 years sympathetic activity is also decreased.

Impairment of antidiuretic hormone and atrial natriuretic peptide regulation in the obese woman with a swelling syndrome and an increase in capillary permeability to albumin.

OBJECTIVE: To study the regulation of antidiuretic hormone (ADH) and atrial natriuretic peptide (ANP) in obese and lean women with a swelling syndrome. PATIENTS: Thirty-four obese women and 12 lean women with a swelling syndrome and an abnormal isotopic test of capillary permeability to albumin were investigated. MEASUREMENTS: After 10 nocturnal hours of fluid restriction, subjects were asked at 8am to ingest a tap water load of 20 ml/kg within 10 min and to remain strictly recumbent until twelve noon on the first day, and to remain standing and to walk around until twelve noon on the second day. Free water clearance and the cGMP/creatinine and albumin/creatinine ratios were determined hourly in the morning. RESULTS: The total 4 h-urinary volume/ingested water volume ratio was significantly lower on the second day both in the lean and the obese patients, the differences being slightly larger in the obese patients. The increase in free water clearance was significantly less on the second day in the obese patients. The increase in cGMP/creatinine ratio was also significantly lower on the second day in the obese patients. The maximum level of the urinary albumin/creatinine ratio was significantly higher on the second day in the obese patients. CONCLUSION: In obese women with a swelling syndrome: (1) The higher increase in the urinary albumin excretion rate after water loading followed by a sustained upright position suggests a widespread alteration in capillary function, which is also indicated by the isotopic test of capillary permeability to albumin. (2) The water load-induced inhibition of ADH secretion and stimulation of ANP secretion or ANP activity, more defective in the upright position than in the recumbent one, is probably another major contributing factor to orthostatic oedema.