Boris Punchik

Orthostatic hypotension and drug therapy in patients at an outpatient comprehensive geriatric assessment unit.

Objective: To assess the rate of orthostatic hypotension and factors associated with it among elderly patients who underwent a comprehensive, ambulatory geriatric assessment. Methods: The study included patients 65 years and older who were assessed in the outpatient comprehensive geriatric assessment unit. Data were collected from the computerized medical record including sociodemographic data, lifestyle, falls, blood pressure, BMI, functional and cognitive status, medications, and comorbidity. Results: The study population consisted of 571 patients who underwent assessment over a nine-year period. The mean age was 83.7 ± 6.1, 35.9% were men, and 183 (32.1%) were diagnosed with orthostatic hypotension. Multiple drugs, in general, and multiple drugs with the potential to cause orthostatic hypotension in particular increased the risk for orthostatic hypotension after adjustment for age, sex, chronic comorbidity, and supine systolic blood pressure ≥150 mmHg [odds ratio (OR) = 1.09, 95% confidence interval (CI): 1.03–1.14 and OR = 1.22, 95% CI: 1.08–1.37, respectively]. In addition, &agr;-blockers and calcium channel blockers increased the risk for orthostatic hypotension after similar adjustments (OR = 1.82, 95% CI: 1.01–3.16 and OR = 1.66, 95% CI: 1.11–2.48, respectively). Similarly, two additional drug types increased the risk for orthostatic hypotension: selective serotonin reuptake inhibitors (OR = 2.09, 95% CI: 1.33–3.19) and tricyclic antidepressants (OR = 4.36, 95% CI: 1.85–10.06). There were no specific associations between age, cognitive and functional state, morbidity (as measured by the Charlson Comorbidity Index), and specific diseases, and orthostatic hypotension. Conclusion: The results of the present study reinforce evidence of an association between drug therapy and orthostatic hypotension.

Orthostatic Hypotension and Mortality in Elderly Frail Patients A Retrospective Cross-Sectional Study

AbstractOrthostatic hypotension (OH) is a common problem in the elderly age group, and some studies have reported an association between OH and increased mortality. We evaluated possible associations between OH and mortality in a retrospective study of frail elderly patients who came for a comprehensive geriatric assessment.The study included all patients ≥65 years who were assessed in the outpatient Comprehensive Geriatric Assessment Unit. Data were collected from the computerized medical record, including blood pressure, sociodemographic data, lifestyle, falls, pulse rate, body mass index, functional and cognitive status, and comorbidity. Data on mortlaity were also collected.The study population consisted of 571 patients who underwent assessment over a 9-year study period. The mean age was 83.7 ± 6.1, 35.9% were males, and 183 (32.1%) were diagnosed with OH. Systolic OH (OHS) was more common than diastolic OH (25.2% vs 15.6%). In univariate analyses, OHS was associated with increased overall mortality. Over the follow-up period, 30.2% of the OHS patients died compared with 22.3% (P = 0.037), but in the Cox models there was no statistically significant associations between OHS and overall mortality. In contrast, age, burden of comorbidity, a low high-density lipoprotein level, and low creatinine clearance were independent predictors of increased overall mortality.In a population of frail elderly patients with a high burden of comorbidity, OH was not an independent risk factor for overall mortality.

A Retrospective Analysis of the Sentence Writing Component of the Mini Mental State Examination: Cognitive and Affective Aspects

Background: One of the components of the Mini Mental State Examination (MMSE) is the request to write a sentence. We investigated the relationship between the characteristics of the written sentence of the MMSE and the cognitive and affective status of elderly patients. Methods: The characteristics of the sentence were compared to the total MMSE score, sociodemographic characteristics, tests evaluating cognition and affective status, and diagnoses. Results: The number of words was significantly associated with the degree of cognitive impairment, whereas the emotional polarity of sentences and concerns about health were associated with depression. Conclusions: Characteristics of the MMSE sentence may provide important additional information regarding both cognition and affect when assessing older people.

Out of sight, out of mind? Does terminating the physical presence of a geriatric consultant in the community clinic reduce the implementation rate for geriatric recommendations

AIM To assess the effect of moving the geriatric consultation from the primary care clinic to another setting, on the rate of implementation of geriatric recommendations by family physicians. METHODS A retrospective review of the computerized medical records of elderly patients in four primary care clinics. The rate of implementation of geriatric recommendations was compared between clinics in which a geriatric consultant was physically present (control clinics) and a clinic where the consultation took place elsewhere (study clinic). In addition, the results of the present study were compared to a previous study in which the geriatric consultation was carried out in the study clinic and the family doctor was an active participant. RESULTS 127 computerized files were reviewed in the study clinic and 133 in the control clinics. The mean age of the patients was 81.1±6.3 years and 63.1% were women. The overall implementation of geriatric recommendations by family doctors in the study clinic was 55.9%, a statistically significant decrease compared to the previous study where the rate was 73.9% (p<0.0001). In contrast, there was no change in the implementation rate in the control clinics at 65.0% in the present study and 59.9% in the previous one (p=0.205). CONCLUSIONS Direct, person-to-person contact between the geriatric consultant and the family doctor has a beneficial effect on the implementation of geriatric recommendations. This should be considered by healthcare policy makers when planning geriatric services in the community.

Can home care for homebound patients with chronic heart failure reduce hospitalizations and costs

Background Congestive heart failure (CHF), a common problem in adults, is associated with multiple hospitalizations, high mortality rates and high costs. Purpose To evaluate whether home care for homebound patients with CHF reduces healthcare service utilization and overall costs. Methods A retrospective study of healthcare utilization among homebound patients who received home care for CHF from 2012–1015. The outcome measures were number of hospital admissions per month, total number of hospitalization days and days for CHF only, emergency room visits, and overall costs. A comparison was conducted between the 6-month period prior to entry into home care and the time in home care. Results Over the study period 196 patients were treated by home care for CHF with a mean age of 79.4±9.5 years. 113 (57.7%) were women. Compared to the six months prior to home care, there were statistically significant decreases in hospitalizations (46.3%), in the number of total in-hospital days (28.7%), in the number of in-hospital days for CHF (66.7%), in emergency room visits (47%), and in overall costs (23.9%). Conclusion Home care for homebound adults with CHF can reduce healthcare utilization and healthcare costs.

The results of a cross-over placebo-controlled study of the effect of lavender oil on behavioral and psychological symptoms of dementia

Studies of the effect of aromatherapy on patients with behavioral and psychological symptoms of dementia (BPSD) have yielded contradictory results. One possible explanation for this lack of consistent results is the site of application of the oil. The aim of the study was to evaluate the effect of lavender oil on the rate of BPSD when applied close to and away from the olfactory system. A crossover placebo-controlled study was conducted in the two psychogeriatric long term care departments. Patients in Department A received lavender oil on their face during the first month and on their foot in the second month, sunflower seed oil on their foot in the third month and on their face in the fourth month. Patients in Department B received sunflower seed oil on their face during the first month and on their foot in the second month, and lavender oil on their foot in the third month and on their face in the fourth month. Forty-two patients completed the study. Their mean age was 76.1 ± 11.2 years. After 4 months of treatment, the mean Neuropsychiatric Inventory score in Department A dropped from 13.1 ± 8.3 (median 12.0) to 3.5 ± 3.8 (median 2.0; p < 0.0001) and in Department B it dropped from 9.7 ± 9.6 (median 6.0) to 1.4 ± 2.5 (median 0; p < 0.0001). This reduction was not associated with the type of oil or the site of application. Based on these results, lavender oil has no advantage over sunflower seed oil in the reduction of BPSD, regardless of the place of application.

Orthostatic hypotension and overall mortality in 1050 older patients of the outpatient comprehensive geriatric assessment unit: Orthostatic hypotension and mortality

Orthostatic hypotension is a common problem in individuals aged ≥65 years. Its association with mortality is not clear. The aim of the present study was to evaluate associations between orthostatic hypotension and overall mortality in a sample of individuals aged ≥65 years who were seen at the Outpatient Comprehensive Geriatric Assessment Unit, Clalit Health Services, Beer‐Sheva, Israel.

Doctors’ Knowledge and Attitudes Regarding Enteral Feeding and Eating Problems in Advanced Dementia

Background: The use of feeding tubes (FTs) in patients with advanced dementia does not yield positive health outcomes and can have a negative effect. Methods: A cross-sectional study assessed the knowledge and attitudes of physicians on the use of FTs for patients with advanced dementia. Results: 201 of 240 doctors (83.8%) participated in the study; 61.7% of the doctors claimed that FTs prevent aspiration, 51.7% that they prevent pneumonia, and 38.8% that they prevent weight gain. Almost one-third (32.3%) said that the decision to use FTs could be taken by a hospitalist or a primary physician (28.9%). Conclusion: We found large gaps in knowledge among doctors about the use of FTs and consequences in patients with advanced dementia.

Visual-spatial perception: a comparison between instruments frequently used in the primary care setting and a computerized cognitive assessment battery

Background The development of screening instruments will help the primary care team to determine when further comprehensive cognitive assessment is necessary. Design A retrospective analysis based on medical records. Patients and setting Patients referred to a comprehensive geriatric assessment unit. Analysis Cognitive screening and assessment included visual-spatial components: the Mini Mental State Examination, the Clock Drawing Test, the Montreal Cognitive Assessment Test, and the Neurotrax (Mindstreams) computerized cognitive assessment battery. Results The average age of the 190 eligible patients was 81.09±5.42 years. Comparing the individual tests with that of the visual-spatial index of Neurotrax, we found the Trail Making B test to be most sensitive (72.4%) and the Cube Test to have the highest specificity (72.8%). A combination of tests resulted in higher sensitivity and lower specificity. Conclusion The use of a combination of visual-spatial tests for screening in neurocognitive disorders should be evaluated in further prospective studies.