Jacques Boddaert

Acute respiratory failure in the elderly: etiology, emergency diagnosis and prognosis

IntroductionOur objectives were to determine the causes of acute respiratory failure (ARF) in elderly patients and to assess the accuracy of the initial diagnosis by the emergency physician, and that of the prognosis.MethodIn this prospective observational study, patients were included if they were admitted to our emergency department, aged 65 years or more with dyspnea, and fulfilled at least one of the following criteria of ARF: respiratory rate at least 25 minute-1; arterial partial pressure of oxygen (PaO2) 70 mmHg or less, or peripheral oxygen saturation 92% or less in breathing room air; arterial partial pressure of CO2 (PaCO2) ≥ 45 mmHg, with pH ≤ 7.35. The final diagnoses were determined by an expert panel from the completed medical chart.ResultsA total of 514 patients (aged (mean ± standard deviation) 80 ± 9 years) were included. The main causes of ARF were cardiogenic pulmonary edema (43%), community-acquired pneumonia (35%), acute exacerbation of chronic respiratory disease (32%), pulmonary embolism (18%), and acute asthma (3%); 47% had more than two diagnoses. In-hospital mortality was 16%. A missed diagnosis in the emergency department was noted in 101 (20%) patients. The accuracy of the diagnosis of the emergency physician ranged from 0.76 for cardiogenic pulmonary edema to 0.96 for asthma. An inappropriate treatment occurred in 162 (32%) patients, and lead to a higher mortality (25% versus 11%; p < 0.001). In a multivariate analysis, inappropriate initial treatment (odds ratio 2.83, p < 0.002), hypercapnia > 45 mmHg (odds ratio 2.79, p < 0.004), clearance of creatinine < 50 ml minute-1 (odds ratio 2.37, p < 0.013), elevated NT-pro-B-type natriuretic peptide or B-type natriuretic peptide (odds ratio 2.06, p < 0.046), and clinical signs of acute ventilatory failure (odds ratio 1.98, p < 0.047) were predictive of death.ConclusionInappropriate initial treatment in the emergency room was associated with increased mortality in elderly patients with ARF.

Comparison of Brain Natriuretic Peptide and Probrain Natriuretic Peptide in the Diagnosis of Cardiogenic Pulmonary Edema in Patients Aged 65 and Older

Objectives: Differentiating cardiogenic pulmonary edema (CPE) from respiratory causes of dyspnea is difficult in elderly patients. The aim of this study was to compare the usefulness of B‐type natriuretic peptide (BNP) and amino‐terminal fragment BNP (proBNP), to diagnose CPE in patients aged 65 and older.

Postoperative Admission to a Dedicated Geriatric Unit Decreases Mortality in Elderly Patients with Hip Fracture

Background Elderly patients with hip fracture have a 5 to 8 fold increased risk of death during the months following surgery. We tested the hypothesis that early geriatric management of these patients focused on co-morbidities and rehabilitation improved long term mortality. Methods and Findings In a cohort study over a 6 year period, we compared patients aged >70 years with hip fracture admitted to orthopedic versus geriatric departments in a time series analysis corresponding to the creation of a dedicated geriatric unit. Co-morbidities were assessed using the Cumulative Illness Rating Scale (CIRS). Each cohort was compared to matched cohorts extracted from a national registry (n = 51,275) to validate the observed results. Main outcome measure was 6-month mortality. We included 131 patients in the orthopedic cohort and 203 in the geriatric cohort. Co-morbidities were more frequent in the geriatric cohort (median CIRS: 8 vs 5, P<0.001). In the geriatric cohort, the proportion of patients who never walked again decreased (6% versus 22%, P<0.001). At 6 months, re-admission (14% versus 29%, P = 0.007) and mortality (15% versus 24%, P = 0.04) were decreased. When co-morbidities were taken into account, the risk ratio of death at 6 months was reduced (0·43, 95%CI 0·25 to 0·73, P = 0.002). Using matched cohorts, the average treatment effects on the treated associated to early geriatric management indicated a reduction in hospital mortality (−63%; 95% CI: −92% to −6%, P = 0.006). Conclusions Early admission to a dedicated geriatric unit improved 6-month mortality and morbidity in elderly patients with hip fracture.

Stroke in elderly patients: management and prognosis in the ED

PURPOSE The aim of the study was to analyze the effect of age on management and prognosis of stroke. METHODS A retrospective study was performed in consecutive patients admitted to an emergency department (ED) with a diagnosis of stroke. Comparison according to age (< 75 vs > or = 75 years old) was done, with a 1-year follow-up including autonomy and outcome. RESULTS In older patients, brain magnetic resonance imaging (6% vs 27%, P < .001) and immediate referral to the stroke unit were less frequent (6% vs 28%, P < .001); median length of stay was longer (11 vs 8 days, P = .007); and in-hospital mortality tended to be higher (12% vs 6%, not significant). After discharge, 1-year mortality was higher (27% vs 14%, P = .004). In a multivariate analysis, severity of stroke, hemorrhagic stroke, and dementia were independent positive predictors of 1-year mortality, whereas age was not. CONCLUSION Despite the fact that age was not an independent predictor when stroke severity was considered, our data suggest differences in the management of elderly compared with younger stroke patients admitted to the ED.

Prognostic Value of Serum Procalcitonin After Orthopedic Surgery in the Elderly Population

Background Orthopedic surgery is more and more frequent in the older patients and is associated with a high mortality rate. Although serum procalcitonin levels are associated with prognosis in young adults, data are still lacking in the elderly population, and especially after surgery. The main objective of this study was to determine the prognostic value of procalcitonin levels in a large geriatric orthopedic population, and we compared it with clinical variables and biomarkers. Methods This is a prospective study including patients admitted in our dedicated geriatric postoperative unit, after orthopedic surgery with immediate postoperative measured procalcitonin levels. Collected data included age, sex, medical history, functional status (activities of daily living [ADL]), fracture type, Cumulative Illness Rating scale (CIRS), postoperative complications, and biological data. The primary endpoint was the 30-day mortality. Results 436 patients (age 85±6 years) were included. Hip fracture surgery was the most frequent (n = 310; 71%), and the 30-day mortality rate was 6.9%. Compared with C-reactive protein (CRP), albumin, CIRS, and ADL, procalcitonin had the highest area under the receiver operating characteristic curve for predicting 30-day mortality (0.74; 95% CI: 0.70-0.78). Using a cutoff at 1 µg/L, procalcitonin was more specific than CIRS to predict 30-day mortality (92 vs 77%; p < .001). In a multivariable analysis, procalcitonin level higher than 0.39 µg/L is a significant predictor of mortality within 30 days (odds ratio 3.84; 95% CI: 1.61-9.14, p = .002). Conclusion Elevated procalcitonin values were strongly and significantly associated with mortality within 30 days in older patients after orthopedic surgery.

Late-Onset Bing-Neel Syndrome Associated with Delirium and Lewy Body Dementia

four of 12 who did not had ventricular rupture, a 33% incidence of death for each group. In other series, 19% of patients did not have surgery, and none of them suffered ventricular rupture during follow-up. In a recent series of nine chronic pseudoaneurysms that were not repaired, none of the individuals died from cardiac rupture, and the 4-year cumulative survival rate was 74.1%. The current series was a small retrospective one, which limits the value of Kaplan–Meyer analysis, but most knowledge about the management of pseudoaneurysms is based on collections of cases or small single-center experiences. The individuals included in this sample were not representative of the whole population of individuals with MI; they were elderly, and most of them came to the hospital very late or did not come during the acute episode. None was treated with mechanical reperfusion therapy, which reduces the risk of cardiac rupture. They were survivors. Maintained normal physical activity after a MI could increase the risk of cardiac rupture because of an increase in stress on the damaged ventricular wall. This would happen more easily after silent MI, which is more frequent in elderly adults. This, and not only a moreconservative surgical attitude, could help explain why chronic pseudoaneurysms are more frequent in elderly adults and explains the frequent presentation as an incidental finding: 50% in our series and 48% in others. The long-term course of chronic ventricular pseudoaneurysm can be considered to be benign. Incidental finding of this entity is frequent in elderly adults, and surgical repair is not indicated in older, asymptomatic, or high-risk individuals.

Secondary Assessment of Life-Threatening Conditions of Older Patients

People aged 65 years and older have higher rate of emergency department (ED) use than other age groups. Critically ill older ED people have specific characteristics. Older patients with life-threatening conditions often present with atypical signs and symptoms unspecific of the altered organ or tissue, and often usual severity criteria are missing. Some symptoms such as delirium, faintness, general malaise, digestive problems, fatigue, balance impairments, or falls can be incorrectly regarded as mild, whereas they are the only sign of a life-threatening condition. Even small initial insults in patients with multisystem deterioration and loss of physiological reserve (frailty) can induce a disabling cascade of adverse effects, called the “domino” effect, which can threaten the life of older patients. Determining whether the older patient is frail, i.e., his (her) medical, psychological, and functional ability to cope with the acute condition, is therefore crucial in older ED patients for optimizing therapeutic options and anticipating treatment adverse effects. Ethical consideration and whether the patient has an advanced directive, health-care power of attorney, or living will on admission are also crucial parts of the assessment of older ED patients. The present chapter displays a model of geriatric secondary assessment adapted to critically ill older ED patients that takes into account the above specificities and particular needs of these patients.

Ventricular tachycardia: An electrocardiographic artifact induced by tremors: Letters to the Editor

A 90-year-old man, institutionalized in a long-term care unit for a severe neurodegenerative disorder, presented with an acute onset of chest pain. He had a history of ischemic heart disease with recurrent chest pain, and permanent atrial fibrillation, chronic renal failure and type 2 diabetes. His blood pressure was 135/65 mmHg, and his pulse was 90 b.p.m. with no other symptoms. Electrocardiogram (ECG) showed an aspect of regular tachycardia with enlarged QRS complexes in the peripheral leads (except lead III), with a fusion complex on the third QRS complex, which could evoke ventricular tachycardia (VT; Fig. 1). The final diagnosis was that of an ECG artifact mimicking ventricular tachycardia. The diagnosis was based on the difference in clinical presentation between good tolerance and the suspected diagnosis, the discrepancy between the measured pulse and the heart rate shown on the ECG, and the normalcy of lead III (apart from known atrial fibrillation), which ruled out VT. This electrocardiographic artifact has been described in parkinsonian patients, and should not be mistaken for VT. On this ECG, lead III was not affected by tremor, probably due to depolarization of the direction, suggesting a right arm tremor, but this point was not specified at the time of the examination; in a preceding report of this type of ECG artifact in a parkinsonian patient, the absence of artifact in lead II suggested left arm rest tremor. Retrospectively, we can suspect in the present patient undiagnosed Lewy body dementia with parkinsonian tremor by taking into account the frequency of the tremor (calculated at 4.5 Hz), advanced cognitive impairment, and the history of hallucinations and repeated falls (found in medical records after secondary reading). As an inaccurate diagnosis of VT might lead to unjustified explorations and treatments, this diagnosis should be known to geriatricians. The key signs to differentiate VT from an artifact are the absence of hemodynamic instability during the event, discrepancy between the pulse rate and the ventricular rate shown on the ECG, the