Renato V. Samala

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.

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.

Steroid-induced hallucination following intra-articular administration: a case report and brief review.

Amidst the ubiquitous use of steroids, psychiatric side-effects are not uncommon, though the presentation may be curiously diverse. The case of an elderly lady who had 40 mg of methylprednisolone injected in each knee for treatment of suprapatellar bursitis is presented. After 3 days, she reported visual hallucinations, which resolved without treatment 6 days after the steroid injections. We found considerable interest in this case as there were very few reported cases of adverse psychiatric events triggered by intra-articular steroid administration. We follow with a brief review of the incidence, risk factors, presentation, and treatment of steroid-induced psychiatric side-effects.

REDUCING NURSING HOME POLYPHARMACY USING SYSTEMATIC MEDICATION AND ASSESSMENT REVIEW AND TRACKING: THE SMART PROGRAM

early detection and treatment of the disease. Clinical characteristics of hepatitis E in older adults of influenza-like symptoms were barely observed before hepatitis occurred ( 13.5%). Most patients developed jaundice (92.8%), and 50.5% exhibited severe jaundice, with peak values of total bilirubin (TB) 10 times or more the upper limit of normal (ULN). For these reasons, many patients stayed in the hospital for a long time (54.1% 430 days). In addition, many people had cholestasis (66.7% with conjugated bilirubin (CB)/TB 70%); thus, they were often misdiagnosed with obstructive jaundice and were required to undergo computed tomography or magnetic resonance cholangiopancreatography, which caused unnecessary expenses. Older adults have obvious liver degeneration, with less compensation capacity and slower hepatocyte proliferation than younger people. Our results confirmed that hepatitis E in older adults results in a high incidence of low albumin (46.8%). Hepatitis E is believed to exacerbate diseases in older adults, with high rates of liver failure and mortality, although the current study found that only three individuals (2.9%) had minimal prothrombin activity (PTA) values less than 40%, and mortality was low (n 5 1, 0.9%). Most scholars believe that hepatitis E superinfection will exacerbate hepatitis B, but the current results showed that only one case exhibited a peak value of TB 10 times ULN or greater. This investigation revealed 21 cases of alcohol drinkers with peak values of TB 10 times ULN or greater, and one case showed a minimal PTAvalue of less than 40%. Thirty-five cases without alcohol intake showed peak values of TB 10 times ULN or greater, and two cases showed minimal PTA values less than 40%. No statistically significant difference was observed. Therefore, hepatitis E does not exacerbate alcoholic liver disease. In summary, hepatitis E in older adults in the Wenzhou area of China has its own epidemiological, clinical, and laboratory characteristics.

Nonconvulsive Status Epilepticus in a Palliative Care Unit When Delirium Is a Seizure

The search for an underlying cause of altered mental status not uncommonly becomes more challenging in the hospice and palliative care setting. Due to multiple coexisting conditions that affect mental status and shifting goals of care, discerning that single cause in this venue can become frustrating and even nonbeneficial at times. We present a case of nonconvulsive status epilepticus (NCSE), which multiple reports have shown to be a rarely contemplated cause of impaired consciousness. A concise review of NCSE follows, with emphasis on conditions that present similarly, precipitating factors, diagnostic and therapeutic considerations, and prognostic implications. Nonconvulsive status epilepticus is a reversible cause of altered consciousness, particularly when recognized promptly. In a palliative care unit, treatment should ultimately be guided by the patient’s goals of care.

Efficacy and Safety of a Six-Hour Continuous Overlap Method for Converting Intravenous to Transdermal Fentanyl in Cancer Pain

CONTEXT Managing cancer pain often requires opioid medications, such as fentanyl, which is frequently initiated parenterally, and then converted to transdermal form. Little evidence exists to guide this conversion. OBJECTIVES To observe the efficacy and safety of a six-hour continuous overlap method for converting intravenous fentanyl (IVF) to transdermal fentanyl (TF) in patients with cancer pain. METHODS We switched from IVF to TF using a 1:1 (IVF:TF) conversion ratio and overlapped a continuous, nontapered dose of IVF until six hours after TF placement. Pain intensity by Numeric Rating Scale, number of rescue analgesic doses, and presence and severity of opioid-related adverse events were recorded immediately before TF placement, and at six, 12, 18, and 24 hours thereafter. RESULTS A total of 17 consecutive patients with cancer pain controlled on IVF were converted to TF. Median age was 65 years, 10 were female, and all had Stage IV cancer. Pain intensity at six and 24 hours remained stable; a slight but statistically significant increase in Numeric Rating Scale was noted at 12 and 18 hours (P=0.01 and 0.02, respectively); however, there was no significant increase in number of rescue doses throughout the observation period. Only one patient experienced opioid-related adverse events. CONCLUSION A continuous six-hour overlap method is a safe and effective strategy when converting from IVF to TF in patients with cancer pain. A slight increase in pain intensity may occur, but does not lead to increased rescue doses.

A Stuttering Discovery of Lithium Toxicity

An 86-year-old female nursing home resident was typically described by the nursing staff as alert, pleasant, and conversant, although disoriented to time and place at times. She was frequently seen in the hallways, often breaking into song with her melodious voice. Her past medical history was significant for dementia, epilepsy, and bipolar disorder, for which she took lithium carbonate. One day, she complained to her nurse that she had been stuttering, finding it difficult to complete a sentence, as well as sing. This persisted for 3 more months until a lithium level was checked, and came back elevated at 2.0 mmol/L (0.6 to 1.2 mmol/L). Lithium carbonate was promptly stopped and after about 2 weeks, her stuttering had completely resolved. We found considerable interest in this case, as lithium has rarely been associated with drug-induced stuttering. We reviewed drug-induced stuttering, enumerated the medications implicated in various case reports, and discussed its mechanisms and management.

Characteristics of patients referred to a community-based palliative care consultation service.

132 Background: Home-based palliative care programs by multi-disciplinary providers improve patient and caregiver satisfaction, enhance symptom control, increase hospice use, and decrease acute care encounters. We launched a community-based consultation service to deliver high-quality palliative care to patients who are homebound or staying in various post-acute care facilities. The study described the characteristics of our patients, and determined the relationship between certain demographic features and outcomes. METHODS We conducted a restrospective chart review of patients seen on initial consultation and subsequent visits between January 1, 2011 and December 31, 2011. All patient encounters were done by 4 palliative care physicians. Data pertaining to demographics, diagnosis, hospice use, and death were obtained and analyzed. RESULTS A total of 221 patients were evaluated. The median age was 75 years, 61.1% were female, 51.1% had cancer, 79.1% were seen at home, and 57% possessed advance directives at initial consultation. Almost half (45.2%) of the referrals were made by primary care physicians. Majority (82.4%) of the referrals were for symptom management, while 37.6% were for goals of care discussion. Many patients had several reasons for consultation, as well as multiple symptoms, such as pain (65%), fatigue (54.8%), and dyspnea (22.6%). The mean number of follow-up visits was 0.62 + 1.08. During the study period, 33.5% of patients died, and 42.5% enrolled in hospice. Of the deaths, 48.7% occurred within 30 days of initial consultation, and 50.0% died at home. Age, gender, race and marital status were not related to hospice enrollment, death, and time and site of death. Patients with advance directives were more likely to enroll in hospice (50.0% vs 32.2%, p=0.009), while those seen at home were more likely to die at home rather than in a facility or hospital (61.0% vs 16.9% vs 22.0%, p<0.001). CONCLUSIONS Patients referred to our community-based palliative care consultation service were mostly homebound older adults needing symptom management and goals of care discussion. Our program may have been helpful in providing quality end-of-life care by facilitating hospice enrollment and death at home.

A 91-YEAR-OLD WOMAN WHO SUDDENLY TALKED MORE AND SLEPT LESS

incidence of pyometra in those with uterine malignant lesions (1.5–4.0%) is higher than in the overall population ( 0.2%), although in premenopausal women, pyometra is rare and is usually caused by traumatic damage to the uterine cervix or a congenital anomaly of the genital tract rather than malignancy. Approximately half of individuals with pyometra are aged 65 and older. The classic symptoms of pyometra are postmenopausal bleeding, vaginal discharge, and uterine enlargement or cramps. Vaginitis and fever may occur, but individuals with pyometra are usually afebrile and have normal white counts. Anaerobic or aerobic bacterial infections may occur. Pyometra was reported to occur in approximately 0.89% of individuals with cervical cancer. Clinicians should examine the uterine cervix of older women with vaginal discharge. In women aged 100 and older, cervical cancer is a common gynecological problem and a differential diagnosis for postmenopausal vaginal bleeding or discharge. Approximately 41.7% of the specimens in older women undergoing gynecological surgery were diagnosed or genital malignancy, with the major origins being the endometrium, ovaries, and cervix, in descending order. In developed countries, life expectancy decreases with age, to 2.5 years at the age of 100 in women, and the risk of dying from cervical cancer in the remaining lifetime for patients at average risk also decreases markedly with advancing age (0.26% at 50, 0.15% at 70, and 0.05% at 90). The American Cancer Society recommends cessation of screening for cervical cancer using the Papanicolaou test in women aged 70 and older if all of their Papanicolaou tests have been negative in the past 10 years. The American Geriatrics Society does not recommend for or against screening for cervical cancer in women aged 70 and older who have been screened regularly in previous years. Once diagnosed with cervical cancer, older women are more likely to die of this disease within 3 years because they are likely to be at an advanced stage of cancer at diagnosis. Radiotherapy is applicable to such women aged 90 and older with good performance status. Pyometra complicating cervical cancer may mimic a pelvic cystic mass or abscess on MDCT because chronic obstruction of the cervical canal causes distention of the uterine cavity and thinning of the uterine wall. Differential diagnoses of pelvic cystic mass include ovarian cystic tumor, intraperitoneal pelvic abscess, and pyometra. In the absence of an identifiable atrophic uterus and fever, pyometra should be suspected for a pelvic cystic mass in a geriatric woman. Pyometra complicating cervical cancer, a potentially lethal pelvic abscess, should be safely managed using transvaginal drainage after manual dilation of the endocervical canal. Appropriate antibiotics are given to cover anaerobic and aerobic bacteria.

HIGHLIGHTING THE IMPORTANCE OF PHYSICAL EXAMINATION IN DISEASE DETECTION

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