Geriatric syndromes: medical misnomer or progress in geriatrics?

Both in geriatric and internal medicine journals, and in medical textbooks certain (aggregates of) symptoms are labelled as 'geriatric syndromes'. In frail elderly patients a large number of diseases present with well-known and highly prevalent atypical symptoms (e.g. immobility, instability, impaired cognition and incontinence), which are referred to as geriatric syndromes. While classically the term syndrome is used for grouping together multiple symptoms with a single pathogenetic pathway, geriatric syndrome primarily refers to one symptom or a complex of symptoms with high prevalence in geriatrics, resulting from multiple diseases and multiple risk factors. The geriatric workup should therefore consist of both a search for and treatment of the aetiologically related diseases and a risk factor assessment and reduction. Effectiveness and efficiency of this specific geriatric syndrome workup has been demonstrated predominantly for combinations of geriatric syndromes that often serve as targeting criteria for geriatric interventions, and for some specific geriatric syndromes. Therefore, we argue that the concept of geriatric syndromes is valuable as a theoretical frame, a directive for diagnostic analysis and as an educational tool in teaching geriatrics to medical students and trainees. Added to this, explaining the heterogeneous way 'syndrome' is used in current clinical practice, as opposed to 'disease', will also substantially improve clinical reasoning both in geriatrics and general internal medicine.

Secondary prevention of breast cancer in older women.

Periodic mammography is well studied and widely applied as a screening programme to reduce breast cancer-related mortality and morbidity in women aged 50 to 69 years. Despite the fact that age is a major risk factor for breast cancer, no evidence-based data are available on survival benefit of screening in women older than 69 years. The most commonly cited guidelines for screening in breast cancer disagree on the upper age limit of the target population. This age limit is a matter of cost-effectiveness and is influenced by active life expectancy, risk for breast cancer, comorbidity and functional status. Benefit of screening also depends on adherence rate of elderly women in screening programmes and optimal treatment of identified tumours. In a selected population of elderly women, screening for breast cancer might be cost-effective.

Importance of volume factors in dialysis related hypertension.

OBJECTIVE: To evaluate the relation between total body water and dialysis related hypertension. PATIENTS AND METHODS: Thirty stable chronic hemodialysis patients were studied. Twenty-four-hour ambulatory blood pressure on the day before dialysis, blood pressure before and after dialysis, weight gain, ultrafiltration and total body water were determined. Total body water was measured by body impedance analysis and expressed as percentage of dry weight (TBW %). Ambulatory blood pressure recordings were defined as hypertensive when the blood pressure load (% of readings above 140/90 mmHg) was more than 40%. RESULTS AND CONCLUSION: Patients, classified as normotensive (n = 11) or hypertensive (n = 19), based on 24-hour blood pressure measurements, had significantly different TBW % (54.7 +/- 5.3 vs. 58.9 +/- 4.6%, p = 0.046). Ambulatory blood pressure and postdialysis blood pressure, but not predialysis blood pressure, were significantly correlated with TBW %. Acute volume changes, as reflected by interdialytic weight gain and ultrafiltration did not correlate with TBW %. These changes correlated weakly with predialysis blood pressure. Multivariate analysis showed that only TBW % and antihypertensive medication had an independent influence on 24-hour blood pressure measurements. We conclude that 24-hour blood pressure and blood pressure after dialysis are better related to total body water than blood pressure before dialysis, which was however weakly related to the acute volume overload, induced by interdialytic weight gain. We hypothesize that this could be the result of a more important chronic volume overload leading to an increase in systemic vascular resistance. On the contrary the acute but less important changes in extracellular volume between dialyses cause no hypertension after dialysis and no sustained hypertension over 24 hours, but only in some cases a temporary increase in the blood pressure just before dialysis. This volume overload can be easily determined by measurement of total body water by bioelectrical impedance analysis.

Interstitial lung disease and adult-onset Still's disease.

Adult-onset Still's disease is an uncommon rheumatological syndrome with a diversity of signs and symptoms. Pulmonary manifestations described are pleuritis and usually transient radiologic infiltrations. The patient presented in this case report had biopsy-proven lung fibrosis when adult-onset Still's disease was diagnosed. Three years after diagnosis, the patient developed clinical signs of the interstitial lung disorder. Radiological and histological progression was observed. Other causes of interstitial lung disorders were excluded. Clinicians should be aware that interstitial lung disease can be a complication of adult-onset Still's disease and can compromise the clinical status of the patient.

Quality and efficiency of bystander CPR. Belgian Cerebral Resuscitation Study Group.

Incorrectly performed bystander CPR might compromise survival of the cardiac arrest patient. We therefore evaluated the outcome in 3306 out-of-hospital primary cardiac arrests of which 885 received bystander CPR. bystanders performed CPR correctly in 52%, incorrectly in 11%, 31% performed only external chest compressions (ECC) and 6% only mouth-to-mouth ventilation (MMV). The initial ECG in cases without bystander CPR was ventricular fibrillation in 28% (95% confidence interval: 27-30%); 45% (41-50%) and 39% (29-48%), respectively when bystander CPR was performed correctly or incorrectly; 43% (37-49%) when only ECC was applied and 22% (11-33%) when only MMV was practiced. Long term survival, defined as being awake 14 days after CPR, was 16% (13-19%) in patients with correct bystander CPR; 10% (7-14%) and 2% (0-9%), respectively when only ECC or only MMV was performed; 7% (6-8%) when no bystander was involved; 4% (0-8%) when bystander CPR was performed incorrectly. Bystander CPR might have a beneficial effect on survival by maintaining the heart in ventricular fibrillation by ECC. A negative effect of badly performed bystander CPR was not observed compared to cases which had not received bystander CPR.

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.

Survival after out-of-hospital cardiac arrest in elderly patients. Belgian Cerebral Resuscitation Study Group.

STUDY OBJECTIVES: To study whether age of the cardiac arrest patient is related to prognostic factors and survival. STUDY DESIGN: Retrospective analysis of a prospective registration of cardiac arrest events in the mobile ICUs of seven participating hospitals. STUDY POPULATION: Two thousand seven hundred seventy-six out-of-hospital cardiac arrests in which advanced life support was initiated. Cardiac arrests with a precipitating event requiring specific therapeutic consequences and with specific prognosis were not included in the analysis (eg, trauma, exsanguination, drowning, sudden infant death syndrome). RESULTS: Neither resuscitation rate (23%) nor mortality caused by a neurologic reason (9%) was significantly different between age groups. Mortality after CPR of non-neurologic etiology was significantly higher in the elderly patient (younger than 40 years, 16%; 40 to 69 years, 19%; 70 to 79 years, 30%; 80 years or older, 34%; P less than .005) and had a negative effect on survival in resuscitated elderly patients (P less than .05). Elderly patients more frequently had a dependent lifestyle before the arrest (P less than .025), an arrest of cardiac origin (P less than .001), electromechanical dissociation as the type of cardiac arrest (P less than .025), and a shorter duration of advanced life support in unsuccessful resuscitation attempts (r = -.178, P less than .0001). CONCLUSION: Because survival two weeks after CPR was not significantly different between age groups, we suggest that decision making in CPR should not be based on age but on factors with better predictive power for outcome and quality of survival.

Knowledge, skills and counselling behaviour of Belgian general practitioners on CPR-related issues.

General practitioners (GP) can identify potential cardiac arrest victims. They have the opportunity to inform cardiac patients and their families about the risk of sudden cardiac death and can motivate family members to attend a CPR-course. To study actual counselling practices concerning basic CPR-training a questionnaire was mailed to a representative sample of Belgian GPs (n = 1119). The level of CPR-training of the GPs was fairly good: 67% had received BLS training on a manikin and 63% had already attended a cardiac arrest event. A discrepancy was observed between the positive attitude towards CPR and the counselling of family members to attend a CPR-course (9%). GPs feared to inflict additional stress to the patient (32%) or the family (43%) or did not know where CPR courses were organised (37%). GPs are a primary target group for CPR-training and should learn how to counsel potential bystanders of a cardiac arrest to attend a CPR-course without inflicting additional anxiety on the patient or his family.

The physiologic response of CPR training.

STUDY OBJECTIVE: To determine the physiologic response of CPR training. DESIGN: Cardiovascular and ventilatory parameters were investigated during 40 minutes of CPR performance and during a maximum exercise test in seven female and nine male subjects (mean age, 30 years; range, 16 to 49 years). RESULTS: During CPR performance, mean oxygen consumption (0.36 +/- 0.10 L/min), and mean minute volume (21.9 +/- 6.0 L/min) were 16% and 26%, respectively, of the levels reached during a maximum exercise test. Systolic blood pressure (153 +/- 23 mm Hg) and heart rate (132 +/- 25 beats/min) were 75% and 73%, respectively, of the levels reached during a maximum exercise test. Serum lactate levels at rest and after CPR performance were not significantly different (1.08 +/- 0.99 vs 1.54 +/- 1.03 mEq/L). Valsalva reflex remained present throughout total CPR time at varying degrees depending on individual differences in CPR technique (eg, incomplete extension of the manikin's head, holding the breath during chest compression). CONCLUSION: CPR performance seems to be a primarily aerobic effort that induces changes in cardiorespiratory parameters that were reasonably well tolerated by our study population.