Gozde Sengul Aycicek

A letter on the canadian emergency department study

only diffuse slow waves could be detected. Valproate was stopped because she experienced valproate-induced hyperammonemia. Because of the acute illness and dementia, oral intake remained poor, and tube feeding was required. Weaning of tube feeding was to be considered on follow-up. NCSE is described as a change in mental processes and behavioral disturbances with continuous epileptiform discharges on EEG without major motor signs. It is likely that it is due to previous silent infarcts and underlying Alzheimer’s disease. Time from symptom onset to treatment of 12 days and from admission to treatment of 5 days are close to the recently reported durations in a retrospective review of NCSE in a major hospital. Diagnosis of NCSE is challenging especially in elderly adults because it can mimic delirium and such patients can easily have a CAM score of 3 or greater, which is suggestive of delirium. It can also mimic behavioral and psychiatric disturbances in elderly adults with underlying dementia. The current case illustrates how NCSE could present as “refusal to eat,” a common problem in older adults with dementia. The clues to NCSE in this case were the history of generalized tonic– clonic convulsions, impaired mental status, and subtle ocular movement abnormalities. In individuals in whom there is high clinical suspicion of NCSE but unremarkable initial EEG, continuous EEG should be considered because 50% of NCSE can be detected only using continuous EEG. Common etiologies of NCSE include intracranial infection (60%), metabolic disturbances (20%), and severe systemic infections (8%). There is limited evidence that NCSE can lead to permanent neurological damage. In a recent retrospective review involving 34 individuals with NCSE, 26.5% recovered, 50% had partial improvement, and 23.5% did not recover or died. NCSE can also result in other complications in elderly adults, including pneumonia and falls. In conclusion, an elderly adult with underlying dementia with NCSE can present as “refusal to eat.” Clinicians should pay attention to the history of seizures and subtle clinical signs to arrive at an early diagnosis of NCSE, which is treatable.

Can We Equate All Proton Pump Inhibitors with One Another

To the Editor: In response to our study on the diagnostic challenges of distinguishing protracted from new-onset delirium, Alici raises two important questions for research on the persistence of delirium: use of the Confusion Assessment Method (CAM) for assessing the presence of persistent delirium and frequency of reassessments. As for the CAM, use of the question “Is there evidence of an acute change in mental status from baseline” is potentially problematic for two reasons. First, the question does not specify which baseline the interviewer is referring to, the original baseline before admission (weeks or months earlier) or a more-recent baseline since admission. Second, it does not distinguish new-onset delirium from a fluctuation in mental state in the context of persistent delirium. The original baseline was used as the reference; most informants told the interviewer that the patient’s mental state had not been the same since admission to the hospital. Admittedly, this is an additional potential limitation of the study. There is a need to develop and validate a CAM modified to assess the persistence of delirium. As to the frequency of reassessments for persistent delirium, daily face-to-face reassessments may be feasible in hospital and postacute care settings, but they are not feasible after discharge in most healthcare systems (including our system), where patients may be dispersed over a large metropolitan area and may move to different settings during the follow-up period. It was challenging to complete even the two face-to-face reassessments described in the present study. The limited number of reassessments was, nonetheless, an acknowledged limitation of the study. Future studies of the persistence of delirium conducted in special healthcare contexts (e.g., managed care programs) may be able to conduct more-frequent reassessments over longer follow-up periods.

Effect of Multimodal Exercise Program on Physical Function, Falls, and Injuries in Older Women.

1. Sumer F, Arik G, Aycicek S et al. Study of factors associated with incomplete bladder emptying in older women. J Am Geriatr Soc 2016;64:456– 457. 2. Park J, Palmer MH. Factors associated with incomplete bladder emptying in older women with overactive bladder symptoms. J Am Geriatr Soc 2015;63:1426–1431. 3. Groutz A, Blaivas JG, Chaikin DC. Bladder outlet obstruction in women: Definition and characteristics. Neurourol Urodyn 2000;19: 213–230. 4. McCrery RJ, Appell RA. Bladder outlet obstruction in women: Iatrogenic, anatomic, and neurogenic. Curr Urol Rep 2006;7:363–369. 5. Yoshimura N, Chancellor MB. Differential diagnosis and treatment of impaired bladder emptying. Rev Urol 2004;6(Suppl 1):S24–S31. 6. Shakeri S, Rasekhi AR, Yazdani M et al. The incidence of diverticula of urinary bladder in patients with benign prostatic hypertrophy and the comparison between cystoscopy and cystography in detecting bladder diverticula. Iran Red Crescent Med 2007;9:36–41. 7. Prakash, Rajini T, Bhardwaj AK et al. Urinary bladder diverticulum and its association with malignancy: An anatomical study on cadavers. Rom J Morphol Embryol2010;51:543–545. 8. Echaiz JF, Cass C, Henderson JP et al. Low correlation between self-report and medical record documentation of urinary tract infection symptoms. Am J Infect Control 2015;43:983–986. 9. Giesen LG, Cousins G, Dimitrov BD et al. Predicting acute uncomplicated urinary tract infection in women: A systematic review of the diagnostic accuracy of symptoms and signs. BMC Fam Pract 2010;11:78.

Higher Serum Endocan Level Is Associated with Alzheimer Disease

Background: The novel molecule endocan, which is released by endothelium and is regulated by proangiogenic and proinflammatory cytokines, may have a role in the pathophysiology of Alzheimer disease (AD). The aim of this study was to evaluate the relationship between serum endocan levels and AD. Methods: A total of 134 patients (47 AD, 42 amnestic mild cognitive impairment [aMCI], and 45 control patients) 65 years of age and older were recruited in this study. Cognitive status of the patients was evaluated by performing the Montreal Cognitive Assessment (MOCA) and the Mini-Mental State Examination (MMSE). Serum endocan levels were measured with an enzyme-linked immunosorbent assay kit. Results: Median serum endocan level was significantly higher in AD patients (380.1 ng/mL) than in both aMCI patients (247.7 ng/mL) and controls (277.6 ng/mL; p < 0.01). Serum endocan level had a weak but significant correlation with MMSE and MOCA scores (r = –0.219 and r = –0.232; p = 0.012 and p = 0.01, respectively). Serum endocan level was detected as a factor independently associated with AD. The cutoff serum level of endocan predicting AD was >288.94 ng/mL in receiver operating characteristic curve analysis (area under the curve 0.71, 95% CI 66.7–90.9, sensitivity 80.9%, specificity 59.8%; p < 0.01). Conclusion: Higher serum endocan levels may be associated with the pathogenesis of AD.

Study of Factors Associated with Incomplete Bladder Emptying in Older Women

bump in the HSA literature in 2014. Friedman and colleagues suggest that, with the burgeoning older population, an increased focus on fostering better aging trajectories is warranted but has yet to reach its full potential. We completely agree. That said, the HSA paradigm faces challenges that the frailty paradigm does not in terms of scope (including biomedical and psychosocial components) and conceptualization (absence of a consensus definition). There are many constituent components of HSA, capturing components similar to frailty (e.g., physiological functioning and reserve), as well as psychosocial components (e.g., social engagement and psychological well-being), but it is encouraging that HSA research is keeping pace with frailty and that both are on the rise. Further articulation of the HSA literature and greater focus on fostering better aging trajectories can ensure that the discipline ages well.