[Problems of pain measurement and pain therapy in the elderly]. / Problemfelder in der Schmerzmessung und Schmerztherapie im Alter.

Due to complex physical and psychological changes in aging, pain measurement and therapeutic treatment of older and geriatric patients present a special challenge. Nevertheless, even for this category of patients, good treatment results are achievable if age-related particulars and problems are consistently heeded and accounted for. That includes adverse sensory and cognitive effects as much as multimorbidity and the polypharmacy that is frequently related to it. An essential prerequisite for adequate pain therapeutic care in elderly patients is consistent pain measurement. While numerical and verbal scales have also proven their usefulness for patients in advanced age who are not cognitively impaired, instruments must be applied for older people with communicative and/or cognitive restrictions with which the observed behavior of those involved can be surveyed in a multidimensional way.

Prostate cancer in senior adults: over- or undertreated?

Despite the widespread use of prostate specific antigen for early prostate cancer (PCa) detection in younger men, PCa is still as disease of the elderly as 2/3 of incident cases are detected in men older than 65 years and 25% are older than 75 years at diagnosis. Opportunistic screening for PCa is not recommended for men with a life expectancy of less than 10 years. The therapeutic strategy for senior adults is driven by tumour stage/aggressiveness, co-morbidity and chronological age. Elderly patients with low/intermediate risk tumours - particularly those with a life expectancy of less than 10 years - are best managed by watchful waiting. Senior adults with intermediate/high risk tumours and a life expectancy of >10 years may benefit from curative local therapy such as radical prostatectomy or combined external beam irradiation/androgen ablation therapy. For elderly patients with metastatic disease, androgen deprivation remains the mainstay of therapy, intermittent androgen ablation is a promising approach.

Laboratory diagnosis and geriatrics: more than just reference intervals for the elderly...

As he/she approaches the end of life, the healthy elderly person comes to be seen rather as a "biological curiosity" than as a normal case. For laboratory testing it becomes increasingly difficult to determine appropriately stratified and statistically relevant reference groups. More appropriate would be individual monitoring, which, however, requires long-term stable quality in laboratory analyses. Despite "consolidation" in laboratory medicine, the pre-analytical phase, which is especially important in the elderly, remains underestimated. This problem is aggravated by insufficient harmonisation between laboratory tests, especially when point-of-care testing is included. Since in geriatrics, maintenance of life quality is more important than curative therapy, clinicians are forced to undergo therapeutic compromises applying symptomatic, supportive or palliative therapies. In this situation, information on "still remaining functional capacities" of organs is particularly helpful. Diagnostic problems resulting from underestimation of "multi-morbidity" and especially "multi-aetiology" can be complicated by "degradation of clinical information", especially in patients in cognitive and/or physical decline. The specific purpose of "geriatric" laboratory medicine seems to induce a change of paradigms: not only statistically established "evidence", but "individuality" in a single patient will need more profound insight. Not so much differentiation between "physiology" and "pathology", but the consideration of "clinical individuality" as relative risk in dimension of time is of importance.

The clinical diagnostic accuracy rate regarding the immediate cause of death in a hospitalized geriatric population; an autopsy study of 1594 patients.

BACKGROUND: In the geriatric population the autopsy rate is low, leading to mortality statistics often based on clinical diagnoses alone. OBJECTIVES: To determine the clinical diagnostic accuracy rate regarding the immediate cause of death (CDARCD), the number of major underlying diseases and sole diagnoses, and general data about the immediate cause of death in geriatric hospitalized patients. METHODS: The autopsy proven immediate cause of death was compared with the clinical diagnosis in 1594 patients over 69 years of age. Based on the autopsy protocols, the mean number of major underlying diseases and sole diagnoses were calculated. The immediate cause of death was classified into six groups: cardiovascular disease (CVD), malignant neoplasms (MN), bronchopulmonary disease (BPD), fatal pulmonary embolism (PE), miscellaneous (M), and marantic atrophy (MA). RESULTS: The overall CDARCD was 52.5%, being highest in MN (65.0%), followed by CVD (56.0%), MA (50%), BPD (48.3%), M (44.3%), and PE (26.7%). The most common cause of death was CVD (35.8%), followed by MN (24.3%), BPD (19.8%), PE (10.6%), M (7.7%) and MA (1.9%). The mean number of major underlying diseases and sole diagnoses was 2.0 and 14.4 respectively. CONCLUSIONS: The low CDARCD in our study strongly indicates the need for autopsy when reliable mortality statistics are desired.

Soluble transferrin receptor and iron status in elderly patients.

The measurement of soluble transferrin receptor (sTfR) has been proposed as a novel approach to the diagnosis of iron deficiency, especially in anaemia of chronic diseases (ACD). Our aim was to study the utility of sTfR under 'everyday conditions' as seen in a geriatric hospital in the following groups of patients: First, in a pilot group of 99 multimorbid geriatric patients (85 women, 14 men; 82.00 +/- 6.32 years) admitted for rehabilitation after recent surgical treatment of a bone fracture; second, in 677 geriatric patients (506 women, 171 men; 79.17 +/- 11.47 years) with different diagnoses admitted to a department of internal medicine; third, in some remarkable clinical cases in order to illustrate the diagnostic limits of sTfR. In general, both genders showed a remarkable age-dependent decrease in erythropoiesis. In patients with haemoglobin levels below 12.0 mg/dL, this parameter correlated significantly with sTfR. However, this was seen only in women, not in men. Moreover, an age-dependent increase in sTfR was seen in women, while in men it remained almost constant. Based on these findings, we conclude that there is a different, gender-specific aetiology of iron deficiency in the elderly. About 30% of patients of both genders simultaneously had low haemoglobin levels and low sTfR. This was interpreted as 'adaptation' or 'tolerance' to the iron deficiency. This was illustrated by a clinical case of megaloblastic anaemia: Initially low sTfR rose only during the vitamin B12 substitution and normalized after recovery. We conclude that sTfR provides an insight into the 'dynamics' of iron metabolism: A rise in sTfR indicates an 'acute readiness to refill iron stores', while a low (non-stimulated) sTfR level corresponds to the quite frequent adaptation to iron deficiency and/or inhibition of resorption. Finally, extremely high sTfR levels were observed in some cases of malignancy such as in acute leukaemia and in hypernephroma. Thus, increased sTfR levels can be caused by paraneoplastic effects.

Downregulation of carnitine acyltransferases and organic cation transporter OCTN2 in mononuclear cells in healthy elderly and patients with myelodysplastic syndromes.

Changes in key enzymes of oxidative metabolism at the mitochondrial level are known to be associated with the aging process, apoptosis, and many diseases. Considering the risk of acquiring a myelodysplastic syndrome (MDS) with age, the aim of this study was to quantify mRNA synthesis of the carnitine palmitoyltransferases (CPT1 and CPT2), carnitine acetyltransferase (CRAT), human specific microsomal CPT, and OCTN2 (organic cation transporter) in mononuclear cells of healthy humans of different age groups and MDS patients. Using quantitative reverse transcriptase real-time PCR we compared mRNA synthesis of the above mentioned enzymes in mononuclear cells from peripheral blood of 23 healthy persons (mean age 45 years), 9 blood and 22 bone marrow samples of 31 MDS patients with varying proportions of apoptotic cells (mean age 78 years), and blood samples of 30 age-matched controls. In addition, plasma carnitine levels were determined. Compared to younger adults, there was a 50% downregulation of CPT1 in elderly persons and in MDS patients. Reduction in CRAT, CPT 2, and OCTN2 was more than 85%. Reduction in microsomal CPT was more pronounced in MDS patients than in age-matched controls (96% vs. 43%). In MDS bone marrow cells there was a negative correlation of CPT1 and CRAT with the relative proportion of apoptotic cells. Plasma carnitine values were similar in all groups. The described reduction in transcription of different genes in blood cells which is well known in different tissues may reflect a systemic signaling process, associated with aging, apoptosis, and MDS.

[Vaccine protection in the elderly: are Austrian seniors adequately protected by vaccinations?]. / Impfschutz im Alter: Sind österreichische Senioren durch Impfungen ausreichend geschützt?

OBJECTIVE: The aim of the study was to evaluate, if elderly persons are sufficiently protected against infectious diseases by vaccination. PROBANDS AND METHODS: 300 elderly (> 60 years) and 300 young (< 35 years) persons from five Austrian cities were recruited according to the criteria of a field study. Antibody concentrations against tetanus, diphtheria, tickborne encephalitis and influenza were assessed by ELISA or by haemagglutination inhibition test. Disease and vaccination histories were recorded. RESULTS: The results of the study demonstrate that protection against infectious diseases was frequently insufficient in the elderly. This was partly due to the fact that old persons were not vaccinated according to recommended strategies. However, low antibody concentration and a short duration of protective humoral immunity were also observed in many elderly persons in spite of regular vaccination. This was not only the case in frail, but also in healthy elderlies. CONCLUSION: The data demonstrate that vaccination has a relatively weak and short-lasting effect in old age. The results of the study should stimulate discussions about strategies how vaccinations can be made more effective in old age. Improved campaigns, shortened vaccination intervals as well as the design of novel vaccines tailored to fulfill the specific demands of the aging immune system are imaginable.