Arthur Leibovitz

Dehydration among Long-Term Care Elderly Patients with Oropharyngeal Dysphagia

Introduction: Long-term care (LTC) residents, especially the orally fed with dysphagia, are prone to dehydration. The clinical consequences of dehydration are critical. The validity of the common laboratory parameters of hydration status is far from being absolute, especially so in the elderly. However, combinations of these indices are more reliable. Objective: Assessment of hydration status among elderly LTC residents with oropharyngeal dysphagia. Methods: A total of 28 orally fed patients with grade-2 feeding difficulties on the functional outcome swallowing scale (FOSS) and 67 naso-gastric tube (NGT)-fed LTC residents entered the study. The common laboratory, serum and urinary tests were used as indices of hydration status. The results were considered as indicative of dehydration and used as ‘markers of dehydration’, if they were above the accepted normal values. Results: The mean number of dehydration markers was significantly higher in the FOSS-2 group (3.8 ± 1.3 vs. 2 ± 1.4, p = 0.000). About 75% of these FOSS-2 patients had ≧4 dehydration markers versus 18% of the NGT-fed group (p = 0.000). A low urine output (<800 ml/day) was significantly more common in the FOSS-2 group (39 vs. 12%, p = 0.002). Above normal values of blood urea nitrogen (BUN), BUN/serum creatinine ratio (BUN/SCr), urine/serum osmolality ratio (U/SOsm), and urine osmolality UOsm, were significantly more frequent in the dehydration-prone FOSS-2 group. This combination of 4 indices was present in 65% of low urine output patients. In contrast, it was present in only 36% of the higher urine output patients (p = 0.01). Patients with a ‘normal’ daily urine output (>800 ml/day) also had a significant number (2 ± 1.5) of positive indices of dehydration. Conclusions: Dehydration was found to be common among orally fed FOSS-2 LTC patients. Surprisingly, probable dehydration, although of a mild degree, was not a rarity among NGT-fed patients either. The combination of 4 parameters, BUN, BUN/SCr , U/SOsm and UOsm, offers reasonable reliability to be used as an indication of dehydration status in daily clinical practice.

Effect of chromium supplementation on blood glucose and lipid levels in type 2 diabetes mellitus elderly patients.

Intervention trials have shown the beneficial effects of chromium supplementation in type 2 diabetes (non-insulin-dependent diabetes mellitus). This study investigated the effects of chromium picolinate on elderly diabetic patients within a rehabilitation program. Thirty-nine diabetic subjects, average age 73 years (18 males and 21 females), undergoing rehabilitation following stroke or hip fracture, were recruited to participate in this study. An additional 39 diabetic patients constituted the control group. Along with standard treatment for diabetes, the study group received 200 microg of chromium twice a day for a three-week period. Blood samples, dietary intake, and anthropometric data were collected prior to and post-intervention. Throughout the study period, participants received a diet of approximately 1500 kcal/day. Significant differences in the fasting blood level of glucose compared to the baseline (190 mg/dL vs 150 mg/dL, p < 0.001) were found at the end of the study. HbA1c also improved from 8.2% to 7.6% (p < 0.01). Total cholesterol was also reduced from 235 mg/dL to 213 mg/dL (p < 0.02). A trend towards lowered triglyceride levels was also observed (152 mg/dL vs 136 mg/dL). We conclude that, in this population of elderly, diabetic patients undergoing rehabilitation, dietary supplementation with chromium is beneficial in moderating glucose intolerance. In addition, chromium intake appears to lower plasma lipid levels.

Pseudomonas aeruginosa and the Oropharyngeal Ecosystem of Tube-Fed Patients

We evaluated whether elderly patients fed with nasogastric tubes (NGT) are predisposed to Pseudomonas aeruginosa colonization in the oropharynx. Fifty-three patients on NGT feeding and 50 orally fed controls with similar clinical characteristics were studied. The tongue dorsum was swabbed and cultured. P. aeruginosa was isolated in 18 (34%) of the NGT-fed group but in no controls (p<0.001). Other gram-negative bacteria were cultured from 34 (64%) of NGT-fed patients as compared with 4 (8%) of controls (p<0.001). Antibiotic susceptibility of the oropharyngeal P. aeruginosa isolates was compared with that of isolates from sputum cultures obtained from our hospital’s bacteriologic laboratory. The oropharyngeal isolates showed a higher rate of resistance; differences were significant for amikacin (p<0.03). Scanning electron microscope studies showed a biofilm containing P. aeruginosa organisms. The pulsed-field gel electrophoresis profile of these organisms was similar to that of P. aeruginosa isolates from the oropharynx. NGT-fed patients may serve as vectors of resistant P. aeruginosa strains.

Vulvovaginal examinations in elderly nursing home women residents

The purpose of this study was to survey nursing home women residents for pathologies in the vulvovaginal area. A total of 96 nursing and skilled nursing elderly woman, from four long-term care (LTC) wards entered the study. The average age was 82 (range 66-98). A total of 88% were wheel chair bound, 86% were urinary incontinent and 80% were communication handicapped. A total of 29% of the examined women had vulvovaginal pathologies. Atrophic vaginitis was detected in 14 cases. Candida vaginitis was found in four cases. Six women had uterine prolapse, three had lichen sclerosus and two had cervical polyps. Such a high rate of findings is probably influenced by age related changes, immobilization and incontinence. This study, a first of its kind emphasizes the importance of routine vulvovaginal examination in elderly LTC women.

Early and late effects of low-dose aspirin on renal function in elderly patients

BACKGROUND Although low-dose aspirin is used by many elderly patients, monitoring of renal function is currently not recommended. We recently reported transient retention of uric acid and creatinine caused by aspirin in doses of 75 to 325 mg/d. We therefore evaluated the renal effects of aspirin (100 mg/d), including post-treatment effects. METHODS We studied 83 stable geriatric patients in long-term care (aged 56 to 98 years) who were treated with low-dose aspirin (100 mg/d) for 2 weeks and 40 control patients. Other medications and diet were kept constant. Biochemical monitoring including blood samples and 24-hour urinary collections for creatinine and uric acid at baseline and weekly for a total of 5 weeks. RESULTS After 2 weeks on aspirin, urinary excretion of creatinine decreased in 60 (72%) and excretion of uric acid decreased in 54 (65%) of the 83 patients, and their mean clearances decreased; during the same period, serum blood urea nitrogen, creatinine, and uric acid levels increased (P <0.05 for all). Deterioration from baseline levels was significantly greater (and more prevalent) in the aspirin-treated group than in the 40 control patients (P = 0.001 to 0.09). After withdrawal of aspirin these parameters improved. However, 3 weeks after stopping aspirin, 48% (35 of the 73 in whom this measurement was available) had a persistent decline in creatinine clearance from baseline, as compared with only 8% (3/36) controls (P <0.001). CONCLUSION Short-term low-dose aspirin treatment may affect renal function in elderly patients. These effects persist 3 weeks after cessation of the drug in some of these patients.

Anemia, serum vitamin B12, and folic acid in patients with rheumatoid arthritis, psoriatic arthritis, and systemic lupus erythematosus

ObjectiveAlthough anemia is frequent in inflammatory rheumatic diseases, data regarding vitamin B12 status is scarce. The purpose of this study was to analyze the incidence and nature of B12 and folic acid (FA) deficiencies in a cohort of rheumatic patients with rheumatoid arthritis (RA), psoriatic arthritis (PsA), and systemic lupus erythematosus (SLE).MethodsLevels of B12, FA, and parameters of anemia were recovered or examined in 276 outpatients. In those with recent findings of low serum B12 levels, further studies of serum homocysteine (Hcy) and urine methylmalonic acid (MMA) levels were performed.ResultsThe incidence of anemia was high: 49%, 46%, and 35%, in RA, SLE, and PsA, respectively. Low levels of serum B12 were also frequent (24%), with almost similar occurrence in the three disease groups. Deficiency in FA was rare (<5%). Mean levels of both vitamins did not differ significantly among the three groups. No correlation between serum B12 levels and anemia was found. In the 15 patients with recently detected low B12 levels, Hcy and MMA were evaluated before and following B12 therapy. In ten of them, baseline Hcy levels were high, while MMA was increased in one patient only. Response to B12 administration, i.e., a decrease in Hcy and/or MMA levels, was noticed in four patients only, suggesting that only 26% of the low-serum-B12 patients had true B12 deficiency.ConclusionsThe incidences of anemia and decreased serum B12 levels were high in these three groups of rheumatic patients. However, true tissue deficiency seems to be much rarer.

The impact of hemiparalysis on the expression of osteoarthritis

OBJECTIVE Primary generalized osteoarthritis (OA), the most prevalent joint disease, is usually symmetric. Sporadic case reports mention decreased OA manifestations in limbs in which there are neurologic deficits, but no systematic research has been published. The aim of the present study was to examine these observations in a planned and controlled survey in a group of patients with OA. METHODS Seventy-five geriatric patients with a history of stroke and hemiparalysis were studied clinically and radiographically (hand radiographs; graded according to a modified Altman method) for the presence and the degree of OA in the hands. Detailed clinical and radiologic scores were calculated for each hand. Demographic, occupational, and neurologic data were collected. Patients with other joint or neurologic conditions were excluded. A group of 55 elderly patients without stroke were similarly studied (controls). Scores in the paralyzed hand were compared with those in the nonparalyzed hand in the stroke patients and subgroups (by Students paired t-test and Wilcoxon test). Scores in the dominant hands were compared with those in the nondominant hands in stroke patients and control subjects (by Students paired t-test and Mann-Whitney test). Correlation between the degree of neurologic damage and OA asymmetry (Pearsons correlation coefficient) was also sought. RESULTS Paralyzed hands showed significantly fewer OA changes than nonparalyzed hands, both clinically and radiologically. This trend, accentuated in patients with more severe paralysis, disappeared in those with mild residual paresis. Asymmetry of OA was more pronounced in patients with flaccid, compared with spastic, paralysis. The degree of paralysis and loss of muscle strength correlated with the degree of OA asymmetry. Women had significantly higher OA scores than men. In the control group, dominant hands had higher OA scores, but this finding was concealed among hemiparalyzed patients. Lifetime gross occupational load and present grip strength did not correlate with the degree of OA. CONCLUSION In elderly patients, hemiparalysis reduces ipsilateral hand expression of OA, while OA is accentuated (or increased) in the dominant hand of patients without paralysis. This first systematic study confirms the findings of previous case reports and lends support to the role of biomechanical factors in the development of OA.

Mortality after Nasogastric Tube Feeding Initiation in Long-Term Care Elderly with Oropharyngeal Dysphagia – The Contribution of Refeeding Syndrome

Background: The refeeding syndrome (RS) is an underappreciated but clinically important entity characterized by acute electrolyte abnormalities, mainly hypophosphatemia, fluid retention and dysfunction of various organs and systems, which can result in significant morbidity and occasionally death. Objective: To examine the incidence of death cases and death causes following nasogastric tube (NGT) feeding initiation in frail elderly with particular reference to RS. Methods: Forty patients with feeding problems for at least 72 h before restarting of alimentation by NGT were included. Excluded were those in any critical clinical situation. Clinical parameters and nutritional assessment were recorded before and after refeeding. Blood samples were taken before, daily for the first 3 days and 1 week after refeeding initiation. Results: During the 1st week of refeeding, 9 patients (22.5%) died and within 1 month 10 more, summing to 47.5%. Most deaths were due to infectious causes [15 out of 19, (79%)]; some were due to no obvious reason [4 out of 19, (21%)]. Significant electrolyte changes were observed in the 2–3 days following refeeding. Significant were the decreases in phosphorus and elevations in potassium and lymphocytes (day 7). We found no correlations between the severity of decreases in levels of phosphorus and mortality. Conclusions: Mortality after NGT feeding initiation was high, mainly due to infectious complications. However, in a considerable number of patients hypophosphatemia was noted, suggesting that RS could be a contributory factor of mortality. Since this is a treatable condition, more attention should be paid to detecting and coping with this problem.

Postmortem examinations in patients of a geriatric hospital

The rate of postmortem examinations (PME) especially in elderly patients is continuously declining, mostly due to the low interest of the medical staff and the reluctance of relatives. We surveyed PME performed over a 20-year period in patients of a geriatric hospital in Israel. The 93 autopsies represent a rate of 2.8% in the first five years which went down to 0.25% in the later years. In 58% of the cases, clinical cause of death was confirmed by the PME. Pulmonary embolism had the lowest confirmation rate, and was more frequently found in females (28%) than in males (10%) (p<0.03). Undiagnosed conditions in the elderly present a clinical challenge that increases with the patient’s age. However, despite progress in diagnostic technology, confirmation rates of death causes have not changed much. Therefore, as the age of death rises, it is important to preserve and foster PMEs, the most reliable source of medical evidence.

Pathogenic Colonization of the Stomach in Enterally Fed Elderly Patients: Comparing Percutaneous Endoscopic Gastrostomy with Nasogastric Tube

OBJECTIVES: To compare the gastric juice microbiota of older people fed through a percutaneous endoscopic gastrostomy tube (PEG) with that of those fed through a nasogastric tube (NGT).