Allan Moore

Diagnosis and Management of Asthma in Older Adults

Despite comprehensive guidelines established by the European Global Initiative for Asthma and the U.S. National Asthma Education and Prevention Program on the diagnosis and management of asthma, its mortality in older adults continues to rise. Diagnostic and therapeutic problems contribute to older patients being inadequately treated. The diagnosis of asthma rests on the history and characteristic pulmonary function testing (PFT) with the demonstration of reversible airway obstruction, but there are unique problems in performing this test in older patients and in its interpretation. This review aims to address the difficulties in performing and interpreting PFT in older patients because of the effects of age‐related changes in lung function on respiratory physiology. The concept of “airway remodeling” resulting in “fixed obstructive” PFT and the relevance of atopy in older people with asthma are assessed. There are certain therapeutic issues unique to older patients with asthma, including the increased probability of adverse effects in the setting of multiple comorbidities and issues surrounding effective drug delivery. The use of beta 2‐agonist, anticholinergic, corticosteroid, and anti‐immunoglobulin E treatments are discussed in the context of these therapeutic issues.

Orthostatic tolerance in older patients with vitamin B12 deficiency before and after vitamin B12 replacement

Orthostatic hypotension (OH) and vitamin B12 deficiency are common disorders in older people. Several case series have reported an association between vitamin B12 deficiency and OH. The effect of vitamin B12 replacement on this dysfunction has not been studied. We prospectively studied responses to head up tilt in patients over 70 years with vitamin B12 deficiency (intervention group) and compared their responses after replacement to those of matched patients with idiopathic OH and normal serum vitamin B12 concentrations (control group). Blood pressure (BP), heart rate (HR) and systemic vascular resistance (SVR) changes during orthostatic stress were evaluated using digital artery photoplethysmography. Eight patients and eight controls were studied. Initial head up tilt produced a mean BP decrease of 44/29 mmHg (s. e. m. 4/4 mmHg) in the intervention group and 33/12 mmHg (s. e. m. 3/2 mmHg) in the control group. Repeat head up tilt 6 months after vitamin B12 replacement produced a mean BP decrease of 15/9 mmHg (s. e. m. 5/2 mmHg) in the intervention group. The mean decrease in the control group was 30/12 mmHg (s. e. m. 2/2 mmHg). The difference in BP decreases between groups was statistically significant for both systolic and diastolic BP (p < 0.001 for both systolic BP and diastolic BP). Mean SVR in the intervention group decreased by 658 dynes/cm5/ sec (s. e. m. 74 dynes/cm5/sec) during initial head up tilt. Mean SVR during repeat head up tilt decreased by 79 dynes/cm5/sec (s. e. m. 12 dynes/cm5/sec). Mean SVR in the control group decreased by 158 dynes/cm5/sec (s. e. m. 10 dynes/cm5/sec) during initial head up tilt and by 258 dynes/cm5/sec (s. e. m. 31 dynes/cm5/sec). The difference in SVR changes between groups was statistically significant (p = 0.02). We conclude that replacing vitamin B12 in older patients with vitamin B12 deficiency is associated with improved orthostatic tolerance to head up tilt.

Treatment of Vasodepressor Carotid Sinus Syndrome with Midodrine: A Randomized, Controlled Pilot Study

Objectives: To evaluate the efficacy of treatment of the vasodepressor form of carotid sinus hypersensitivity (carotid sinus syndrome (CSS)) with midodrine.

Falls and fractures 2 years after acute stroke: the North Dublin Population Stroke Study

BACKGROUND Stroke patients are at increased risk of falls and fractures. The aim of this study was to determine the rate, predictors and consequences of falls within 2 years after stroke in a prospective population-based study in North Dublin, Ireland. DESIGN Prospective population-based cohort study. SUBJECTS 567 adults aged >18 years from the North Dublin Population Stroke Study. METHODS Participants were enrolled from an Irish urban population of 294,592 individuals, according to recommended criteria. Patients were followed for 2 years. Outcome measures included death, modified Rankin Scale (mRS), fall and fracture rate. RESULTS At 2 years, 23.5% (124/522) had fallen at least once since their stroke, 14.2% (74/522) had 2 or more falls and 5.4% (28/522) had a fracture. Of 332 survivors at 2 years, 107 (32.2%) had fallen, of whom 60.7% (65/107) had 2 or more falls and 23.4% (25/107) had fractured. In a multivariable model controlling for age and gender, independent risk factors for falling within the first 2 years of stroke included use of alpha-blocker medications for treatment of hypertension (P = 0.02). When mobility measured at Day 90 was included in the model, patients who were mobility impaired (mRS 2-3) were at the highest risk of falling within 2 years of stroke [odds ratio (OR) 2.30, P = 0.003] and those functionally dependent (mRS 4-5) displayed intermediate risk (OR 2.02, P = 0.03) when compared with independently mobile patients. CONCLUSION Greater attention to falls risk, fall prevention strategies and bone health in the stroke population are required.

Combined hypertension and orthostatic hypotension in older patients: a treatment dilemma for clinicians

The combination of hypertension and orthostatic hypotension in older individuals is becoming increasingly recognized. Managing this combination of disorders presents a treatment dilemma – how to lower blood pressure to provide cardiovascular risk protection without predisposing to syncope. At present, there is no specific evidence base available with regard to managing such patients. Some antihypertensive drug classes (e.g., α-blockers) appear more problematic in this regard than others. In the absence of controlled-trial evidence, use of antihypertensives with a more gradual onset of effect commenced at lower doses and use of lower-limb compression hosiery appears to be a reasonable approach. Abdominal compression devices and elevating the head of the bed may also help to combat orthostatic hypotenstion in older patients with hypertension and warrant future research.

A refractory case of vasovagal syncope treated with theophylline

Abstract.We report the case of a 23 year-old female with neurocardiogenic syncope refractory to treatment with other agents who responded to theophylline. Despite inconsistent clinical trial evidence to support its use, theophylline may prove useful in individual cases.

POSTTRAUMATIC SUBGALEAL HEMATOMA WITH ORBITAL EXTENSION ASSOCIATED WITH CLOPIDOGREL USAGE IN AN ELDERLY PATIENT: CASE REPORT

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Dispelling myths regarding the safety of ‘bronchoscopy in octogenerians’

was defined using a reported version of the Edmonton Frail Scale, a validated scale for use by non-clinicians that assesses cognition, health attitudes and mood, medication use, nutrition, continence, burden of medical illness, social support and functional independence [2]. Furthermore, our study found a significant difference in the rates of embolic stroke and death between patients deemed frail and those deemed non-frail. The study also found that frail patients were more likely to have a haemorrhagic event 3 and 6 months post-discharge. Frailty was associated with age but not directly related to age. In fact frailty was better correlated with disability and co-morbidity than with age. Our findings support the view of Drs Khan and Myers that age alone should not (and does not) determine prescribing of antithrombotic medication for older patients with AF. A previous interventional study in the same hospital acknowledged this issue by specifically excluding age per se from the decision-making process, and instead focussing on medical, functional, cognitive, iatrogenic and social factors affecting the use of antithrombotics [3]. The present study follows from this in evaluating additional factors that may help determine the optimum treatment for older patients with AF. We found that frailty may be a useful risk stratification tool for such patients. Most of the factors that Drs Khan and Myers advocate considering in anticoagulation of older patients would be assessed using the frailty tool that was applied in our study. Differences in the event rates observed between our studies may relate to the populations studied: our participants all had AF, were recruited from acute care wards, were followed over 6 months and were not all anticoagulated; while their participants had a range of conditions, were followed for an average of 3.78 years in the community and were all anticoagulated. It is possible that there was a higher prevalence of frailty in our study (64% of participants) than in the population reported by Drs Khan and Myers, which may contribute to the higher rates of adverse events we observed. Risk stratification tools such as frailty are valuable when prescribing for older patients, who have wide inter-individual variability, and potentially have much to gain from medication as well as a high risk of adverse drug reactions.

Management of transient ischemic attack: 2005

Transient ischemic attack is a common presenting problem to clinicians. Historically, these events were defined by the resolution of new neurologic symptoms within a 24-h time-frame; however, recent data suggests that a 1-h time frame is more appropriate. New imaging techniques and clinical evidence suggests that transient ischemic attacks present a higher risk of impending stroke than previously thought. This has led to a redefinition of what constitutes an attack, and also to a focus on both earlier investigation and treatment of correctable causes. New antiplatelet agents are now available and pose a challenge as to how they should be prescribed. Carotid endarterectomy is the standard of care for a subset of transient ischemic attack patients with significant carotid stenosis. Carotid angioplasty and stenting are more recent developments that may further expand treatment options.