Manuel Rodstein

[Ballistocardiography; an appraisal of technic, physiologic principles, and clinical value].

T HE various modalities used in the study of the heart and circulation contribute different types of information. Some, such as electrocardiography and fluoroscopic or roentgenographic study, have such broad spheres of usefulness that they are almost routinely employed. Other diagnostic procedures have not gained wide usage either because of expense of equipment, difficulty in clinical application, specialized nature and limited value of information provided, or because such information as is provided unnecessarily duplicates what may be learned in simpler fashion. It is the object of this survey to appraise the clinical usefulness of ballistocardiography, a technic which records the movements imparted to the body by the forces associated with contraction of the heart, and acceleration and deceleration of blood as it is ejected and moved in the large vessels. Parenthetically it may be remarked that the ballistocardiogram provides, in simple and routinely applicable fashion, a considerable body of useful information not otherwise obtainable; and hence fulfills the criteria of a valuable adjunct in examination of the heart.

Mortality of the Aged with Chronic Brain Syndrome

ABSTRACT: The five‐year survival rates for a group of aged persons in a home and hospital for the aged showed that those with chronic brain syndrome (CBS) died at a much higher rate than those without CBS. Bronchopneumonia predominated as the cause of death among those with CBS but not among those without CBS. The mortality for 145 subjects was computed by relating the actual number of deaths to the expected (life tables) number of deaths as a function of age and sex of residents in the same institution. Differences, on the basis of presence or absence of CBS, were statistically significant for females irrespective of whether they were in relatively poor, or relatively good physical condition.

Initial Adjustment to a Long‐Term Care Institution: Medical and Behavioral Aspects

ABSTRACT: One hundred elderly persons consecutively admitted to the Jewish Home and Hospital for Aged were studied during the first month after admission. Medical changes (chiefly cardiovascular) and behavioral changes were analyzed independently and then correlated. Four subgroups were found: 1) smooth adjustment and no significant medical changes (33 subjects); 2) smooth adjustment with significant medical changes (17 subjects); 3) severe adjustment problems but no significant medical changes (31 subjects); and 4) severe adjustment problems with significant medical changes (19 subjects). The aged persons most likely to have initial adjustment difficulties usually had poor capacity for interpersonal relationships, were socially isolated, were either single or divorced, had a dependent personality, had severe chronic brain syndrome, had a negative or ambivalent attitude toward admission, and often had been referred for psychiatric evaluation before admission. Major patterns of reaction were anxiety, aggressiveness and depression. Significant medical changes were more likely to develop in those with previous poor health who manifested an advanced state of confusion and depressive trends. Depression was related to concomitant medical changes rather than to the previous health status; it exacerbated the reaction to medical illness, which resulted in a decline in the level of functioning. In 58 per cent of the 50 patients with initial adjustment difficulties, a satisfactory level of adaptation was reached during the first six months after admission.

Mortality of the aged with chronic brain syndrome: further observations in a five-year study.

ABSTRACT: In order to pursue the question of excess mortality due to chronic brain syndrome (CBS), 330 residents of a home for the aged were independently evaluated prior to admission by psychiatrists and by general physicians. Five years later, their medical records were searched to determine: 1) age on admission, 2) diagnosis of CBS on admission, 3) physical status on admission, and 4) if death had occurred, the age at death and the cause of death. Women outnumbered men by 3:1. Subjects with CBS outnumbered those without CBS by 2:1. A previous mortality study on 145 aged subjects at the same institution provided an excellent frame of reference for this investigation. Among the men there was no difference between the mortality rates for those with CBS and those without. Among the women a statistically significant difference in mortality was found between those with CBS and those without. Women with CBS and a “poor” physical status had the highest mortality rate. Those who initially had CBS died significantly sooner even if their admission physical status had been “good.” Their mortality rate exceeded that for women with a “poor” physical status who did not have CBS. Bronchopneumonia caused death twice as often in subjects with CBS as in those without CBS, both among men and women. It is concluded that CBS per se is a significant factor in increasing mortality in the aged.

Cardiovascular side effects of long-term therapy with tricyclic antidepressants in the aged.

ABSTRACT: In a study to determine the nature and frequent cy of cardiac side effects during long‐term administration of tricyclic antidepressant drugs in usual dosages in the aged, 32 geriatric patients were followed for an average of 36.6 weeks. Ten of them received amitriptyline in a daily dosage of 20–75 mg for 53 weeks (average); in 2, electrocardiographic side effects developed, viz, inversion of the T waves or evidence of acute coronary insufficiency. Imipramine was administered to 21 patients in a daily dosage of 20–100 mg (average, 66 mg) over a period of 40 weeks; in 3 instances major side effects developed‐intermittent left bundle‐branch block, acute coronary insufficiency with node dysfunction, or T‐wave inversion with sinus tachycardia; in 1 instance there was a minor side effect, viz, tachycardia only. In 1 patient, acute myocardial infarction developed after two 10‐mg doses of nortriptyline. Five of the 7 patients with cardiac side effects had prior organic heart disease. It was concluded that the incidence of cardiac side effects in aged persons given tricyclic antidepressant drugs in the usual therapeutic dosages for a prolonged period is great enough to warrant frequent careful monitoring of cardiac status during therapy.

Relation of Long-Term Electronic Cardiac Pacing to Mental Status and Adaptation in the Institutional Aged

The long‐term effects of cardiac pacemakers on the mental status and adjustment of an aged population were investigated. In an institution for the aged, 25 residents (average age, 85) in whom pacemakers had been implanted for an average of 53 months were compared to 18 residents of the same age and sex who had a slow heart rate. A semistructured interview was given to determine mental status, affective condition, perceived health, and other concerns. Cardiac status was rated for all subjects according to the criteria of the New York Heart Association. By the measures of adjustment and mental status, no differences were found between pacemaker patients and those with a slow heart rate. Cardiac status was somewhat poorer in the pacemaker group. When comparison was made between the pacemaker patients with uncompromised or only slightly compromised cardiac status and subjects with a slow heart rate and similar cardiac status, no significant differences were found in the foregoing measures. These findings suggest that although there may be changes in functioning in the acute phase following implantation of a pacemaker, there are no long‐term effects on adjustment in subjects of advanced age. Adaptation in an institution for the aged may be more related to personality factors than to specific health problems.

The natural history of intraventricular conduction disturbances in the aged: an analysis of the magnitude of risk of developing second and third degree heart block with clinical pathological correlations

A group of 300 institutionalized individuals, average age, 82 years, was followed from the onset or discovery of an intraveritricular conduction disturbance to death over an average period of more than five years. They included 143 cases with left anterior hemiblock, 60 cases with left bundle branch block, and 97 cases with right bundle branch block with and without left anterior or posterior hemiblock. Twenty-two cases developed second or third degree heart block. The magnitude of risk of developing second or third degree heart block averaged 1.5% per year for the first five years of follow-up and 2.5% per year for the next four years of follow-up. For the first five-year period of follow-up the magnitude of risk was 6.9%, and for the entire nine-year period of follow-up 15.7%. An intraventricular conduction disturbance was found before death in 20% of those dying in the institution. The causes of death among those with intraventricular conduction disturbances were similar to those of comparable age and sex without these conditions. Sudden death among those with second and third degree heart block was due in the majority of cases to other cardiac conditions, such as acute myocardial infarction and acute pulmonary embolization. It was concluded that the presence of an intraventricular conduction disturbance in the aged, uncomplicated by the development of second or third degree heart block, is not an indication for the insertion of a cardiac pacemaker in the aged.

Ischemic and Hypertensive Heart Disease in the Aged: Prognostic and Therapeutic Factors†

The prognostic significance of risk factors for ischemic and hypertensive heart disease in the aged differs in many respects from that in younger persons. In old age, most risk factors for ischemic heart disease such as an elevated level of total serum cholesterol, cigarette smoking, obesity, Type A personality and abnormal glucose tolerance have a less adverse effect on morbidity and mortality from ischemic heart disease, while an elevated level of high‐density lipoprotein, and moderation in the use of alcohol each have a favorable effect. A high level of low‐density lipoprotein cholesterol exerts an adverse effect. Both systolic and diastolic hypertension have an adverse influence on morbidity and mortality from ischemic and hypertensive heart disease, as does the electrocardiographic pattern of left ventricular strain. Long‐term controlled studies are needed to determine the effects on mortality and morbidity of the modification of risk factors by means of drugs, diet, and change of lifestyle. Such studies are necessary if we are to determine whether hoped‐for favorable changes are offset by potential side effects on physical and mental health.

The ballistocardiographic findings in a case of coarctation of the aorta with a bicuspid aortic valve and aortic insufficiency.

E. ~~T., a 23 year old white male, was admitted to Montefiore Hospital on May ’7, 19~2 for surgery for coarctation of the aorta. Dyspnea and easy fatigability had been present since early childhood. For two years prior to admission occasional palpitations and episodes of transient substernal pain and headache had been present. At the age of 12 years hypertension was noted and at that time angiocardiography revealed coarctation of the aorta at the junction of the aortic arch and its descending portion. The patient was a well developed, well nourished young man. The left border of the heart was in the 6th left intercostal space, just beyond the mid-clavicular line. The aortic second sound was loud and snapping and louder than the pulmonic second sound. Over the aortic area there was a loud, harsh systolic murmur and a loud diastolic blowing murmur was heard maximally in the 3rd interspace to the left of the sternum. The blood pressure was 190/86 in the right arm and 174/84 in the left arm and was unobtainable in the lower extremities. The

Contributions of the Long-Term Care Facility to the Medical Care of the Aged

Care of the aged in the United States by advanced long‐term care institutions has resulted in many important contributions to our knowledge of the aging process and disease over the past four decades. These institutions are characterized by well organized medical staffs, with full‐time medical directors who also serve as chiefs of the Medical Department and as stimulators and coordinators of research and teaching. These institutions provide comprehensive management, with laboratory, x‐ray and necropsy capabilities and multiple levels of care. Many serve as teaching centers and have affiliations with medical schools and university hospitals for house staff and postgraduate medical training. Several contributions to the medical literature on aging are described, among them being the earliest published in this country concerning pneumonia, cancer, arcus senilis, atypical and silent myocardial infarction, digitalis therapy, subacute bacterial endocarditis, calcific aortic stenosis and congenital heart disease. Fundamental papers have been published on a system of functional classification, attitudes toward death and dying, evaluation of mental status, the diagnosis and care of chronic brain syndrome, psychologic evaluation, the diagnosis and care of many ophthalmologic disorders, and the causes, incidence and prevention of accidents among the aged. The long‐term care institution, under proper circumstances, is an excellent site for good medical care, and significant contributions to research and teaching.