Jerry O. Ciocon

Continuous Compared With Intermittent Tube Feeding in the Elderly

The methods of continuous (C) and intermittent (I) nasogastric tube feedings in 60 patients, 54 men and 6 women, with a mean age of 72 +/- 9 years were compared in terms of number of complications, staff time used, and caloric intake. Patients were randomly assigned between these two methods and followed for 7 days. Diarrhea, aspiration pneumonia, clogged tubes, and self-extubation were observed in both groups. Diarrhea was significantly more frequent (96% of 30 patients) in the I group than the C group (66% of 30 patients) (p < .008). Furthermore, diarrhea was more prolonged (4 days or more) in 64% of 30 patients in the I group than the C group (4 days or more) in 58% of 30 patients (p < .02). However, clogged tubes occurred 3 times more often in the C group (p < .01). Self-extubation and aspiration pneumonia tend to be more frequent in the I group but the difference was not significant. The average time used by staff nurses in the maintenance of NGT feedings was not significantly longer in the I group (48.45 +/- 11 min/patient per day) than the C group (46.46 +/- 11 min/patient per day). In the C group the mean calories recommended were 2248 +/- 36 kcal/day but the actual caloric intake was only 1465 +/- 281 kcal/day, a deficiency of 783 +/- 291 kcal/day. The recommended calorie count for the I group was 2021 +/- 5 kcal/day but the amount delivered was only 1226 +/- 254 kcal/day, which resulted in a deficit of 795 +/- 259 kcal/day.(ABSTRACT TRUNCATED AT 250 WORDS)

Caudal Epidural Blocks for Elderly Patients with Lumbar Canal Stenosis

Objective: To determine the efficacy of caudal epidural blocks (CEB) in relieving pain and the duration of pain relief with CEB in elderly patients suffering from degenerative lumbar canal stenosis (LCS).

Cardiovascular outcomes using doxazosin vs. chlorthalidone for the treatment of hypertension in older adults with and without glucose disorders: a report from the ALLHAT study.

Insulin resistance underlies most glucose disorders in adults and is associated with an increased risk of cardiovascular disease. Alpha blockers decrease insulin resistance, whereas diuretics increase insulin resistance.

GAIT TRAINING AND FALLS IN THE ELDERLY

1. Patients with gait and balance disorder, as measured by the Tinetti Mobility Scale, can benefit from physical therapist-assisted gait training. 2. Score in the Tinetti Mobility Scale negatively correlates with the number of recurrences of falls. 3. The nurses role includes identification of those who are at risk for falls, assessment of their response to training in preventing recurrence of falls, and the effect of training in their mobility and independence.

Long‐Term Follow‐Up of Moderately Hypercholesterolemic Hypertensive Patients Following Randomization to Pravastatin vs Usual Care: The Antihypertensive and Lipid‐Lowering Treatment to Prevent Heart Attack Trial (ALLHAT‐LLT)

The authors conducted a randomized, controlled, multicenter trial, in which they assigned well‐controlled hypertensive participants aged 55 years and older with moderate hypercholesterolemia to receive pravastatin (n=5170) or usual care (n=5185) for 4 to 8 years, when trial therapy was discontinued. Passive surveillance using national databases to ascertain deaths and hospitalizations continued for a total follow‐up of 8 to 13 years to assess whether mortality and morbidity differences persisted or new differences developed. During the post‐trial period, fatal and nonfatal outcomes were available for 98% and 64% of participants, respectively. The primary outcome was all‐cause mortality and the secondary outcomes included cardiovascular mortality, coronary heart disease (CHD), stroke, heart failure, cardiovascular disease, and end‐stage renal disease. No significant differences appeared in mortality for pravastatin vs usual care (hazard ratio [HR], 0.96; 95% confidence interval [CI], 0.89–1.03) or other secondary outcomes. Similar to the previously reported in‐trial result, there was a significant treatment effect for CHD in black patients (HR, 0.79; 95% CI, 0.64–0.98). However, the in‐trial result showing a significant treatment by race effect did not remain significant during the entire follow‐up (P=.08). These findings are consistent with evidence from other large trials that show statins prevent CHD and add evidence that they are effective for CHD prevention in black patients.

A Comparison Between Aspirin and Pentoxifylline in Relieving Claudication Due to Peripheral Vascular Disease in the Elderly

Peripheral vascular disease (PVD) commonly presents with leg claudication during walking and eventually limits the walking distance and daily activities. Aspirin or pentox ifylline are commonly prescribed to improve blood flow. Aspirin works through its antiplatelet aggregation mechanism, and pentoxifylline increases the red blood cell flex ibility, which leads to increased tissue perfusion. Data on comparative studies of these drugs for improving claudication in the elderly are limited. The objective of this study was to compare pain relief offered by either aspirin or pentoxifylline for walking leg pain in the elderly with PVD. Patients sixty-five years or older with claudication were randomly assigned to receive aspirin or pentoxifylline. Their reported level of walking claudication pain with use of the visual analogue scale (0-5) and the distance walked during exercises were recorded. Six weeks later the same parameters were recorded and results were compared with Students t test, and a P value less than 0.05 was considered a statistically significant difference. Of the 90 patients who participated, 45 received aspirin (325 mg daily) and 45 were prescribed pentoxifylline (400 mg tid) for six weeks. Both the aspirin and the pentoxifylline groups reported a moderate level of pain (2/5) and remained about the same (2/5 for aspirin and 1/5 for pentoxifylline, P = 0.9, NS) after six weeks. However, the pentoxifylline group reported a farther walking distance of 2 miles compared with the aspirin group of 1.2 miles (P < 0.05). The level of pain did not change significantly with either aspirin or pentoxifylline, but the walking distance was farther with the pentoxi fylline group.

Raised Leg Exercises for Leg Edema in the Elderly

Leg edema is a common problem in the elderly and requires further evaluation and management. Method: From October 1990 to July 1992, 245 patients presented to the Cleveland Clinic Florida with leg edema. All patients were counseled about the benefits of twenty-minute, three-times-a-day raised-leg exercises. Fifty seven (57) of the 245 patients were not compliant with this regimen (nonexercise group). Although not true controls, they formed a comparison group for those who performed the exercise regimen. The exercise group was composed of 188 patients with a mean age of 73 ±6.8 years, 25 (13%) men and 163 (87%) women; the nonexercise group was composed of 57 patients with a mean age of 71.9 ±4.3, 19 (33%) men and 38 (67%) women. Workup for leg edema included: comprehensive history, clinical examination including prostate or pelvic examination, complete blood count, chemistry profile, thyroid profile, electrocardiogram, chest radiograph, and, when indicated, pelvic or leg ultrasound and pelvic computed tomographic scan. The circumference of the leg with the maximum amount of edema was measured initially and on the fourth week. Results: In this study, the common causes of leg edema in the elderly population were venous stasis (63.2%), drug induced (13.8%), and heart failure (15.1%). Postphlebitic syndrome, cirrhosis, lymphedema, lipedema, prostate carcinoma (CA), and ovarian mass were the less frequent findings. Upon comparison of the circumference of leg edema on initial visit and four weeks after, both the exercise and nonexercise groups showed significant decreases in the measurement of the leg edema (P < .001) except those caused by lymphedema. The amount of change when compared between those who exercised and those who did not was significant only in venous stasis. Conclusion: Causes of leg edema in the elderly are multiple. Twenty-minute, three-times-a-day raised-leg exercises were significantly more effective in the management of leg edema due to venous stasis (P < 0.0001) but did not produce significant differences in other etiologies such as heart failure, drug induced, and other conditions, which include lymphedema, prostate and ovarian CA, and postphlebitic syndrome. Successful management of leg edema is based on adequate and thorough assessment to identify the cause.

Heart failure in frail, older patients: We can do 'MORE'

A comprehensive approach is necessary in managing heart failure in frail older adults. To provide optimal care, physicians need to draw on knowledge from the fields of internal medicine, geriatrics, and cardiology. The acronym “MORE” is a mnemonic for what heart failure management should include: multidisciplinary care, attention to other (ie, comorbid) diseases, restrictions (of salt, fluid, and alcohol), and discussion of end-of-life issues. A comprehensive approach is necessary in managing heart failure in frail older adults. Physicians need to draw from the fields of internal medicine, geriatrics, and cardiology.

Arm Edema, Subclavian Thrombosis, and Pacemakers: A Case Report

This reports an arm edema that was initially treated as cellulitis and later diagnosed to be subclavian thrombosis due to pacemaker wire irritation. We present an 87-year-old Caucasian man with 5 weeks duration of left arm swelling and pain that was treated with two courses of antibiotics. An axillary venous Doppler study was interpreted as normal with no evidence of venous thrombosis. However, a venogram showed evidence of thrombosis involving the left innominate, subclavian, and axillary veins with multiple collateral veins diverting the blood to the contralateral side and into the superior vena cava. Intravenous anticoagulation was initiated and subsequently the patient was main tained on warfarin (Coumadin). The thrombosis subsequently improved and the original pacemaker was maintained. Arm edema are commonly mistaken for cellulitis, causing a delay in a more definite diagnosis of subclavian thrombosis. In a setting of a patient with pacemaker, subclavian thrombosis should be considered even with a normal screening venous ultrasound test. The incidence, manifestation, venous Doppler, and venogram findings are reviewed and discussed. Upper arm edema and superior vena cava syndrome are the most common presentation of this subclavian thrombosis associated with pace makers. Venous ultrasound tests may be normal and a venogram is usually required to establish a diagnosis.

Nocturia in the elderly: a wake-up call.

Nocturia is a condition that health providers must seek out and address in older adults. Since it adversely affects quality of life and carries a risk of morbidity and of death (often because of falling), this symptom must be elicited during the physician-patient encounter. Understanding its underlying causes, risk factors, and consequences is essential in formulating the most suitable management strategy. Drug and nondrug treatments target the individual disorders that contribute to nocturia. Nocturia is common, but elderly patients infrequently volunteer this complaint, and even when they do, some clinicians may dismiss it.