[Delirium due to urinary retention: confusing for both the patient and the doctor]. / Een delier bij blaasretentie: verwarrend voor patiënt en dokter.

A delirium due to urinary retention confuses both patient and physician. Three patients presented with delirium and/or physical deterioration had a bladder retention. A man aged 82 had delirium and an acute renal failure due to a urinary retention with an enlarged prostate gland. A woman aged 81 had a delirium and a bladder retention due to an atonic bladder. A man aged 71 showed cognitive deterioration and a bladder retention due to a backbone-fracture and faecal impaction. In the elderly it is very important to include urinary retention in differential diagnosis because its presentation can be atypical.

Diuretic usage and withdrawal patterns in a Dutch geriatric patient population.

OBJECTIVES: To describe diuretic usage and withdrawal patterns in a population of very old geriatric patients and to evaluate the long-term probability of remaining free from diuretic therapy after withdrawal. DESIGN: Retrospective analysis of medical records and 1-year follow-up study. SETTING: University Hospital Nijmegen and Rijnstate Hospital Arnhem, a non-academic teaching hospital, The Netherlands. PARTICIPANTS: All 1547 patients, aged 75 years or older, visiting geriatric medicine departments in the two hospitals for the first time in the years 1990 through 1993. MEASUREMENTS: Data on medical history, physical examinations, and medication use were obtained from medical records. Diuretic withdrawal and motivation was recorded as reported. Record review indicating diuretic withdrawal prompted a 1-year follow-up investigation and collection of additional updated information from family care and/or nursing-home physicians. RESULTS: A total of 593 three patients (38.3%) were using diuretics. Use of diuretics increased with age from 33.6% in patients aged 75 to 79 years to 47.4% in patients aged 90 years or older (P < .05). Diuretics were withdrawn in 218 patients (36.8%), in 101 patients because of doubts about the initial or persistent indication for diuretic use and in 91 patients because of adverse effects. No reasons for withdrawal were reported in 26 patients. Withdrawal of diuretics was attempted more often in cases of diuretic prescriptions for unknown reasons (51.2%) or ankle edema without heart failure (45.0%) than when prescriptions were for heart failure (28.5%) or hypertension (35.4%). The overall probability of remaining free of diuretic therapy for 1 year was 0.41. Success of diuretic withdrawal was significantly less when congestive heart failure was the initial indication for prescription (probability 0.24). We did not find other clinical parameters related to the success of withdrawal. CONCLUSIONS: Our study demonstrates that diuretic therapy can be withdrawn for at least a 1-year period in a substantial number of very old geriatric patients receiving these medications, regardless of the initial indications for prescription. However, withdrawal is performed without application of uniform criteria. Future prospective studies should be directed at developing clear guidelines for diuretic withdrawal in order to facilitate identification of eligible patients and to further improve the success of withdrawal attempts.

[Diagnosis and discharge destination of patients admitted for mental dysfunctioning in a geriatric department]. / Diagnosen en ontslagbestemmingen van patiënten opgenomen wegens psychisch disfunctioneren op een afdeling Geriatrie.

OBJECTIVE: To determine the prevalence of psychiatric and somatic disorders and to evaluate functional status and discharge destinations of patients with impairment of mental functioning admitted to a geriatric unit of a general hospital. SETTING: Rijnstate Hospital Arnhem, the Netherlands. DESIGN: Descriptive prospective study. PATIENTS AND METHODS: In 1993, 43 patients with recent impairment in mental functioning were followed. Physical illness, course of physical and psychiatric problems and discharge destination were recorded. Psychiatric diagnoses were classified according to the DSM-III-R. The 'Barthel index' for activities of daily living (ADL), 'Mini-mental state examination', 'Hamilton depression scale' and 'delirium rating scale' were used in evaluation of functional status and mental functioning. RESULTS: All the patients had psychiatric problems (delirium 28, dementia 23, depression 6, several problems 21). Thirty-eight patients (88%) had recent physical illness, in 21 (49%) functional status was impaired (p < 0.001). In many patients improvement in mental functioning (70%), functional status (26%) and somatic condition (79%) was achieved. Improvement of the somatic condition (79%) was often (87%) accompanied by improvement of the psychiatric condition (other patients (21%): 50%, p < 0.05). Nursing home placement was needed in 53% (admitted geriatric patients in general: 13%, p < 0.001). CONCLUSION: Most patients suffered from delirium (65%). In 23 patients (53%) dementia was diagnosed, mostly for the first time. Improvement of the somatic condition was significantly related to improvement of the psychiatric condition. Patients admitted with recent impairment of mental functioning are at greater risk to be placed in a nursing home than admitted geriatric patients in general.

[Failure in self care and heart failure, thiamine deficiency in geriatric patients]. / Falen van de zelfzorg en falen van het hart, thiaminedeficiëntie bij geriatrische patiënten.

In two patients admitted to a geriatric ward cardiac failure was based on a thiamine deficiency (wet beri-beri). After supplementation with thiamine they recovered completely. The first patient had a insufficient diet of only canned food, whereas the second patient suffered from both alcoholism and insufficient nutrients. These geriatric patients suffered from a serious illness due to a combination of somatic, psychological, functional en social factors. Thiamine is a co-enzyme in many metabolic processes. A thiamine deficiency is defined as a serum concentration below 95 nmol/1. Other diseases associated with thiamine deficiency are the Wernicke-Korsakoff syndrome and peripheral polyneuropathy (dry beri-beri). Not only alcoholics but also elderly patients with malnutrition are at risk of thiamine deficiency and associated diseases. Do not hesitate to supplement thiamine in case of cardiac failure because of possible thiamine deficiency.

[Hypodermoclysis, an undervalued rehydration method in geriatrics]. / Hypodermoclyse, een ondergewaardeerde rehydratiemethode in de geriatrie.

The use of hypodermoclysis (hypo) as a method of rehydration in geriatrics has decreased in recent years. By interviewing the Dutch geriatricians (n = 41), the nursing home physicians in the district Arnhem-Nijmegen (N = 65) and the trainees for these disciplines (total number: 60), data were collected on the place of this method in clinical practice. A response of 72% was reached. A minority of the respondents (34%) uses hypo's. In a period of 1.5 years there was a mean prescription of 5.5 hypodermoclyses per physician. The acceptance by the patients was labeled as reasonably well or good. Lack of experience was one of the most important reasons for not using hypo's. Furthermore a retrospective investigation was carried out concerning the indications of hypodermoclysis and its usage in the psychogeriatric nursing home 'Joachim en Anna' (250 patients), where experience with this technique has accumulated. In 1993, 48 (19%) of their patients were given on average 5.1 liters of fluid in 3.6 days by means of hypodermoclysis. Only local edema was seen as complication in 9 cases. Case-histories illustrate possible indications of hypo's in the Dutch nursing home as well as in hospital. Finally, after a review of recent literature, we advocate a positive reappraisal of this rehydration method.

[Profile of a geriatric department in a general hospital]. / Contouren van een Geriatrische Afdeling in het Algemeen Ziekenhuis (GAAZ).

Clinical data of the Geriatric Department of the Municipal Hospital in Arnhem are presented. The article starts with a short historical review and the working procedure. The original domestic situation, qualities and destination of the patients are presented. Most patients have many medical an psychiatric problems, so their situation is very complicated. The majority of their diseases has a chronic character, half of which have improved during their stay in the hospital. The importance of good adjustment of provisions for the elderly is stressed.

No volatile N-nitrosamines detected in blood and urine from patients ingesting daily large amounts of ammonium nitrate.

Whole blood and urine from 23 patients ingesting ammonium nitrate daily in amounts varying from 2 . 5-9 g were analysed for volatile N-nitrosamines. By contrast with reports in the literature N-nitrosodimethylamine and N-nitrosodiethylamine were not found in blood (limit of detection 0 . 1 micrograms/kg) but a trace of N-nitrosopyrrolidine was found in the blood of one subject. Small amounts of N-nitrosomorpholine in some blood samples and in one blank were believed to be formed during the analysis since morpholine had been added to the samples to indicate artefactual nitrosamine formation. Traces of N-nitrosodimethylamine (0 . 1 microgram/kg) were found in six of the 23 urine samples.

Volatile N-nitrosamines, nitrate and nitrite in urine and saliva of healthy volunteers after administration of large amounts of nitrate.

Twelve healthy volunteers ingested orally 7-10.5 g of NH4NO3 in a single dose and 12 others received 9.5 g of NaNO3 intravenously in about 60 min. Samples of blood, saliva and urine were collected just before administration of nitrate and at various times afterwards during a 24 h period. Saliva and urine were analysed for volatile NA, nitrate and nitrite. Blood was analysed for nitrate. Neither in urine nor in saliva were NA other than NDMA detected. Of the 188 urine samples, only 13% contained more than 0.1 microgram NDMA/kg, the highest level being 0.5 microgram/kg. In 92% of the 179 saliva samples, less than 0.5 microgram NDMA/1 was found. The saliva of 1 person contained 0.7-8.9 microgram NDMA/1. Nitrate levels in blood rose sharply during the first hour after intravenous nitrate administration and 2 hours after oral intake, reaching peak values of ca. 6 mmol/1. Peak values for NO-3 + NO-2 in saliva, which were reached 2-6 hours after intake, varied strongly between individuals, ranging from 4 to 43 mmol/1. Nitrite was detected in 26% of the urine samples. There was no correlation between NDMA contents and nitrite in urine. An average of 75% of administered nitrate was excreted in urine in 24 h. However, nitrate contents in blood, urine and saliva after 24 h were still higher than before the nitrate intake.