[Measuring the handgrip strength of geriatric patients]. / Het meten van handgreepsterkte bij geriatrische patiënten.

The handgrip strength of geriatric patients can be measured when the patient is hospitalized. This article elaborates on the intrinsic and extrinsic factors which have a direct or indirect influence on handgrip strength. For the best results the tests need to be taken in the best circumstances with attention to individual differences and the age of the patient. Handgrip strength as determination of biological vitality is a key concept. Besides the physical characteristics there are many psychological factors (cognition, psyching-up, test attitude…) influencing the results. These are barely mentioned or not mentioned at all in the usual procedures. Research of handgrip strength testing theories is mostly focused on young, healthy adults and less on elderly patients. The main goal of this article is stimulating experimental research on the measurement of handgrip strength with elderly people and involving them more actively with the procedure. It is not enough to acquire insight in function and predicting characteristics of handgrip strength. Next to the aiming for the best test performance is 'working interactively with elderly patients' a goal on itself in the modern vision of health care.

[Nutritional assessment in oncogeriatrics]. / Nutritionele screening bij de oncogeriatrische patient.

Geriatric patients are not defined by their age but by their general profile. Ageing is characterized by loss of organ function together with a reduced capability for adapting to changes in the environment (loss of homeostatic mechanisms) leading to frailty. In the older patient with cancer, there can be problems of dietary intake next to the effects of ageing per se. On top of this situation, the deleterious effects of the inflammatory processes induced by the tumour are superimposed. When these changes are translated into nutritional concepts, it is clear that, in the older cancer patient, there is a strong overlap of starvation, sarcopenia, and cachexia. Nutritional assessment should be part of the routine preliminary evaluation of the older oncology patient. Difference should be made between assessment of risk and actual nutritional status, which should be assessed with specific malnutrition indices. Body weight assessment with specific attention to unintended weight loss is essential in this evaluation. One should recognise the fact that body mass index (BMI) should be interpreted with caution, but that a low value for BMI still heralds an increased malnutrition risk. This increased alertness for nutritional problems has a lot to offer in the willingness for early intervention. The nutritional assessment, however, must be framed in a larger comprehensive geriatric assessment addressing several functional domains.

Donepezil-related toxic hepatitis.

Alzheimer's disease (AD) is the leading cause of dementia. It is characterized by the presence of senile plaques and neurofibrillary tangles in the brain, and impairment of the central cholinergic system, which contribute to memory loss and cognitive dysfunction. Cholinesterase inhibitors prevent the hydrolysis of acetylcholine and are currently approved for the symptomatic treatment of Alzheimer's disease. Donepezil, a piperidine-based, reversible and specific inhibitor of acetylcholinesterase, has been demonstrated to be clinically effective in the treatment of patients with mild to moderate AD. To date, clinical trials have not reported an association between treatment with donepezil and hepatotoxicity. We describe a case of toxic hepatitis, documented by liver biopsy, in a patient treated with donepezil.

[A screening tool to identify older people at risk of adverse health outcomes at the time of hospital admission]. / Een screeningsinstrument om de geriatrische liaison in het ziekenhuis op te starten: de Voorlopige indicator voor Plaatsing (VIP).

The proportional increase of the ageing population results in an ever growing percentage of elderly among hospitalised patients. Older patients have complex medical, social and psychological problems that could benefit from coordinated care or case management. Identification of high-risk older adults is mandatory to initiate a liaison geriatric management program. A simple screening tool is presented to identify older people at the time of admission who are at increased risk of adverse health outcomes. The instrument was validated during a period of 6 months when all (n = 618) older adults (> 70 year) hospitalised in non-geriatric departments of a general hospital were screened. This "Variable Indicative of Placement risk" (VIP) shows a good sensitivity (81%) and specificity (86%) and has a high Negative Predictive Value (97%). Furthermore, it shows a significant positive correlation with the length of stay (p < 0.001). The questionnaire turned out to be a very useful tool in the emergency department as well as in other wards because it probes premorbid frailty components with three simple questions. Due to its simplicity a nurse without geriatric training can complete it. Patients who are not at risk of an adverse outcome are easily recognised. A positive score indicates loss of functional independence and a risk of increased length of stay. Further geriatric assessment and intervention seem then appropriate.

Morphometric changes in microvasculature in rat myocardium during malnutrition.

BACKGROUND: Because the interrelationship between the parenchymal cell population and the microvasculature is critical in normal organ function, the effects of starvation on rat myocardium were studied morphometrically with respect to the microvasculature. METHODS: Morphometric analytical studies were performed on myocardium of adult, female Wistar rats (groups of 5-7 rats) on fasting days 0, 1, 2, 4, 6, 8 and 10. Since cardiac muscle is a tissue with a high level of anisotropy, methods based on the concept of vertical planes were used to describe quantitative alterations in the rat myocardium both at the cellular and ultrastructural level. RESULTS: Morphometric analysis of electromicrographs of myocardium showed an increase in capillary density together with a decrease in capillary lumen cross-sectional area during starvation (p < .05). There was no significant change in volume fraction of the capillaries but surface density of the myocytes increased significantly (p < .01) and the diffusion distance for oxygen from the capillary lumen to the mitochondrion decreased (p < .01). CONCLUSIONS: Malnutrition alters the interrelationship between parenchyma and vascularization in the heart. This leads to a significant decrease of the diffusion distance for metabolites. This decrease of diffusion distance may improve cellular energy supply and offers a relative protection of the metabolism in the malnourished myocyte.

Creatinine arm index as alternative for creatinine height index.

Nutritional assessment of elderly people is limited due to a lack of age-corrected standards. The objective of this study was to develop a new, more age-independent index for nutritional assessment by correcting the creatinine height index (CHI) for the age-induced changes in its variables. This might improve the differentiation between physiological reduction in muscle mass in elderly people and the changes induced by malnutrition. Seventy-four elderly and 100 young healthy volunteers were compared by anthropometric and biochemical-assessment variables. From the high correlation between total arm length and body length (r = 0.86; P less than 0.001) and the use of an alternative formula to calculate ideal body weight (IBW) from height and wrist circumference, a relatively age-independent estimate of IBW was determined. Creatinine arm index, as an adapted index of CHI, is proposed based on this age-independent IBW estimation and a specific creatinine coefficient for different age groups.

Effect of ageing and malnutrition on rat myocardium. I. The myocyte.

The effects of ageing and starvation on the rat myocardium were studied by morphometric methods. Since cardiac muscle is a tissue with a high level of anisotropy, methods based on the concept of vertical planes were used to describe quantitative alterations in the rat myocyte both at the cellular and ultrastructural level. During starvation rapid and important changes were noted, particularly in the transverse dimension of cells and organelles. The most striking change, however, was the immediate dilatation of the myocyte T-system, reflecting an adaptive interaction between the intra- and extracellular environment. At the same time exocytosis of intracellular components into the extracellular space of the T-system was observed. The ratio of mitochondria to myofibrils decreased progressively during starvation. Such a decrease, in general, may reach a point when cellular energy supply becomes compromised. A comparison between different regions of the heart showed no differences and it can be concluded that the morphological changes during starvation are the same, and equally distributed, in both ventricles. The changes described in the aged rat heart point in the direction of a hypertrophy of the aged myocyte. This leads to a lower ratio between surface and volume which finds its representation at the subcellular level in a more spherical shape of nuclei and mitochondria. Unlike what is seen in malnutrition, the mitochondrial/myofibril ratio is higher in the older rat. From the morphological point of view, the atrophy of malnutrition and the hypertrophy of ageing are opposed, but in both there is a change in the relationship of the myocyte to its environment which directly influences the substrate exchange capacity. This tends to protect the myocyte in starvation but jeopardizes the older cell.

Effect of ageing and malnutrition on rat myocardium. II. The microvasculature.

The modulating effects of ageing and malnutrition on rat myocardium were studied morphometrically with respect to the microvasculature. An increase in capillary density together with a decrease in capillary lumen cross-sectional area was noted during starvation. The important changes seen in the myocyte T-system were paralleled by a decreased diffusion distance for oxygen from the capillary lumen to the mitochondrion. The changes described in the aged rat heart point to an altered inter-relationship between parenchyma and vascularization with a lower capillary volume fraction and a greater diffusion distance from the capillary lumen to the mitochondrion; this is caused by hypertrophy of the aged myocyte. This reduction in capacity to exchange substrates is further reduced by the less developed T-system in the older myocyte.

Open evaluation of amlodipine in the monotherapeutic treatment of systolic hypertension in the elderly.

The antihypertensive efficacy and safety of amlodipine (5-10 mg once daily for 10 weeks) was assessed in elderly patients with primary systolic hypertension (average sitting and standing systolic blood pressure > or = 160 mm Hg and diastolic blood pressure < or = 95 mm Hg). Interim analysis of data from 25 patients shows that amlodipine treatment produced significant decreases in sitting blood pressure (-26.8/-11.4 mm Hg; p < 0.05). Efficacy assessments after 8 weeks of therapy showed 15 of 21 (71.4%) evaluable patients were considered therapeutic successes with amlodipine (defined as a fall from baseline in sitting systolic blood pressure of > or = 20 mm Hg or to < or = 150 mm Hg with a fall of > or = 10 mm Hg). Of the six evaluable patients who were not considered therapeutic successes using this definition, three had clinically beneficial falls in systolic blood pressure of 16-18 mm Hg. Fourteen patients were considered therapy successes on the basis of assessments taken 48 h postdose at the end of the study. Investigators' overall impression of efficacy was excellent or good in 21 patients (84%). Amlodipine treatment had no significant effect on heart rate. Amlodipine was generally well tolerated, with no patients being withdrawn due to side effects. Investigators' evaluation of toleration was excellent or good in 22 patients (88%).

Respiratory insufficiency in acid maltase deficiency: the effect of high protein diet.

A 27-yr-old woman with the myopathic form of acid maltase deficiency (AMD) developed severe respiratory insufficiency after a crash diet resulting in a 6-kg weight loss. While being maintained on home ventilation, an hypercaloric high-protein, low-carbohydrate diet (1800-2000 cal; 28% carbohydrates, 55% fat, 17% protein with 1.7 g protein/kg body weight) was instituted. This ameliorated her condition up to a level where useful life was possible and ventilation could be diminished.

Blood viscosity parameters in coronary heart disease: effect of fish oil supplementation.

We have evaluated blood viscosity parameters in 20 men suffering from coronary heart disease (CHD) and in 15 control subjects. Whole blood viscosity at a standardized haematocrit of 45% was significantly increased in the CHD-patients, both at low (p less than 0.001) and high (p less than 0.05) shear rate. The increased whole blood viscosity in these patients was explained by an increased plasma viscosity (p less than 0.01), while the erythrocyte suspension viscosity values at a standardized haematocrit of 70%, reflecting erythrocyte deformability, were within the normal range. We have studied the effects of a daily supplementation of 1.5 g omega-3 polyunsaturated fatty acids on blood viscosity in the CHD patients. After 6 weeks of treatment whole blood viscosity, at low and high shear rate, and plasma viscosity were significantly improved (all p less than 0.05), although not normalized. There was no effect of the fish oil on erythrocyte deformability.

Malnutrition and the heart: a microscopic analysis.

The effect of starvation on heart morphology was studied in the rat after total caloric deprivation. Morphometric analysis in subendocardial and subepicardial regions in the left and right ventricle was performed before and after starvation. A progressive fall in body weight was noted together with a biphasic change in ventricular weight. The ratio heart/body weight showed a continuous rise initially but stabilized at high levels in the later stage of starvation (p less than or equal to 0.005). The observed changes were analogous in the right and left ventricle. After starvation a significant increase in myocyte volume fraction was noted (p less than or equal to 0.01), but no regional differences were observed with respect to subendocardial-subepicardial and right-left ventricular zone comparison. The change in the non-myocyte fraction is situated in the vascular space and connective tissue. The volume fraction of non-capillary interstitial connective tissue, however, is significantly greater in the right ventricle than in the left (p less than or equal to 0.005). We conclude that in total starvation, after an initial rapid decline in heart weight, the heart is relatively spared. This leads to a rising heart/body weight ratio, until the later stage of malnutrition when the heart undergoes a hypotrophy to the same extent as other organs. This hypotrophy gives rise to a relative increase in myocyte volume fraction and a parallel decrease in capillary volume without major changes in the interstitial non-capillary connective tissue compartment.

A prospective analysis of elective upper gastrointestinal endoscopy in the elderly.

The effectiveness of esophagogastroduodenoscopy in the elderly was evaluated in a prospective study of 656 consecutive patients undergoing endoscopic examination of the upper gastrointestinal tract. Forty-six percent of the patients were younger than 65 years, and 13% were in the age group above 79 years. Initial complaints and final endoscopic diagnosis were related to sex and age. Statistically significant age-related differences in outcome diagnosis were found for gastritis in younger men (p less than 0.01) and negative examinations in younger women (p less than 0.01). Duodenitis (p less than 0.05) and duodenal ulcer disease (p less than 0.05) occurred more frequently in men, whereas hiatal hernia was more frequent in women (p less than 0.05). Older people presented with a more nonspecific pattern of complaints and symptoms, but, nevertheless, a good correlation was observed between complaints and endoscopic abnormalities in the elderly compared with a younger group. Since esophagogastroduodenoscopy was well tolerated and did not provoke a higher incidence of complications in the elderly, it was concluded that endoscopic evaluation of the upper gastrointestinal tract is a safe and effective examination for the investigation of upper abdominal complaints in a geriatric patient population.

Vitamin E status in a normal population: the influence of age.

Plasma vitamin E levels and age have been positively correlated up to the sixth decade of life. Since antioxidants protect biomembranes in vivo against oxidative damage, it has been hypothesized that free radical scavengers such as vitamin E may have protective effects against aging. In the present study, plasma vitamin E and lipids were determined in 95 healthy volunteers [mean age (+/- S.D.) 55.9 +/- 24.5 yr]. Special attention was focused on vitamin E status in the elderly: 23 individuals were older than 80 years. A significant age effect (p less than 0.005) was observed for both vitamin E and cholesterol, both being increased in the middle-aged group (40-59 yr) and decreased in the elderly (greater than or equal to 80 yr). Since a high plasma cholesterol represents a major risk factor for ischemic heart disease, decreasing levels of plasma cholesterol with advancing age in a healthy population-sample appears to be the result of negative selection. Plasma vitamin E concentration was correlated (p less than 0.001) with total cholesterol, triglyceride, and total lipid. Since vitamin E is mainly transported by plasma lipoproteins, these strong correlations suggest that changes in vitamin E should be considered as an epiphenomenon of altered plasma transport capacity. The determination of plasma vitamin E is therefore a poor indicator of the real tissue vitamin E activity.

Vitamin E status in normocholesterolemic and hypercholesterolemic diabetic patients.

The close relationship between vitamin E, lipid and prostaglandin metabolism stresses the need for an accurate definition of the status of vitamin E in a diabetic population. Plasma vitamin E and plasma lipids were determined in 34 type I and 21 type II normocholesterolemic and in 7 hypercholesterolemic diabetics. They were also measured in 62 age- and sex-matched controls, 34 normocholesterolemic controls for type I, 21 normocholesterolemic controls for type II and 7 hypercholesterolemic individuals. Plasma vitamin E levels were not significantly different in type I and type II diabetics as compared to their respective control groups. Vitamin E levels were significantly increased (p less than 0.001) in hypercholesterolemic individuals, both in diabetics and in non-diabetics. The vitamin E/cholesterol ratio in these subjects was, however, not different from that of normocholesterolemic. Plasma vitamin E was correlated with plasma lipids, especially with total and LDL-cholesterol (p less than 0.001). Since vitamin E is mainly transported by plasma lipoproteins, these strong correlations suggest that changes in plasma vitamin E should be considered as an epiphenomenon of altered plasma transport capacity.