Thomas A. Teasdale

Congestive heart failure in the elderly

eart disease is a common cause of disability and death in older people. Of the various clinical syndromes with which heart disH ease presents, congestive heart failure (CHF) is one of the most familiar, so familiar indeed that for many physicians diagnosis and treatment are considered one of their simpler and more rewarding tasks. However, the diagnosis of CHF in its earliest stages is not always simple, and treatment, as measured by survival and frequency of recurrences, is far from satisfactory . CHF may be considered the result of a series of changes beginning with some form of cardiovascular stress (overload) which brings into play compensatory mechanisms, among which cardiac hypertrophy, activation of the sympathetic nervous system (SNS) and use of the Frank-Starling relationship are the most familiar. Continued employment of these compensatory mechanisms leads to another series of changes, “cardiomyopathy of overload,” which further compromises cardiac function and ultimately leads to the syndrome of CHF characterized by edema, dyspnea, limited exercise tolerance, reduced organ perfusion, systemic and pulmonary embolization, cardiac arrhythmias, and sudden death. In the older patient, agerelated changes in the cardiovascular system further impair cardiac compensatory mechanisms, thereby hastening the development of CHF. We will review the relationship between age and the incidence and prevalence of CHF to illustrate the importance of CHF in care of the elderly and discuss the implications of this relationship for the pathophysiology of CHF. Current recommendations for treatment will be discussed. Treatment is now directed against the individual components of the symptom complex and not the antecedent diseaseand age-related changes that produce CHF. Because these changes are still poorly understood, additional research is needed before treatment of CHF will be more effective.

Urinary Incontinence in a Community-residing Elderly Population

A self‐administered postal questionnaire was presented to all attending members (843) of local summer meetings of a national association for retired persons. A 71% response rate (599) revealed that 33% of the total sample population experienced some form of urinary incontinence. Twenty‐three and seven‐tenths percent (142) experienced occasional urine dribbling, 2.3% (14) were unable to prevent involuntary emptying of their bladder, and 7.3% (44) suffered both problems. Eighty‐three percent of the respondents were between the ages of 65 and 85 years. Females accounted for 75% of all respondents. Respondents 75 years of age or older had a higher occurrence of all forms of urinary incontinence (P = .057), and a strong association existed with the same age‐group and uncontrolled emptying of the bladder (P = .02). Thirty‐seven percent of the females and 22% of the males reported having had an incontinent episode (P = .002). High parity (four or more births) was significantly associated with incontinence in females (P = .04). These survey findings provide prevalence estimates of urinary incontinence that are greater than those previously reported and show statistical differences by age and gender. The study population is not representative of all the noninstitutionalized elderly, but consists primarily of individuals who are active, ambulatory, generally healthy and may underestimate the magnitude of the problem. Urinary incontinence is substantiated as a major health problem in even the most functional community‐residing elderly citizens.

A Comparison of Placement Outcomes of Geriatric Cohorts Receiving Care in a Geriatric Assessment Unit and on General Medicine Floors

To assess whether care in a geriatric assessment unit using a multidisciplinary team approach with rehabilitative emphasis impacted on patient placement outcomes, a historical prospective study was initiated using records of geriatric assessment unit patients admitted during a one‐year period (n = 62). A second, diagnostically similar general medicine unit cohort was also sampled (n = 62). Placement outcomes of the two groups were compared. All study patients were 75 years of age or older, stratified by source of admission, and controlled for comparability using diagnostic grouping. The geriatric assessment unit admitted 92 per cent of its patients from home; the general medicine unit, 82 per cent. As a result of expanded rehabilitative, respite, and terminal care promoted by the geriatric assessment unit staff, mean length of stay was 36 days, whereas it was 13 days in the general medicine unit (P < 0.001). There was no significant difference between the two units with respect to hospital deaths, post‐hospitalization discharges to home or nursing homes, or patient locations (home versus nursing home) six months after admission. Although improvements in patient independence may have been achieved through the efforts of a multidisciplinary team approach utilizing the geriatric assessment unit, they were not sufficient to significantly increase the proportion of patients placed at home. Superiority in placement outcome may be demonstrated only by geriatric assessment unit use of selective admission criteria.

Estimation of survival time in terminal cancer patients: an impedance to hospice admissions?

Accurate estimation of survival time in terminal cancer patients is difficult yet may provide useful information. A historical prospective study on 172 patients admitted to a home based hospice service was performed to determine which variables were best correlated with survival time. Mean and median survival were 48 and 22 days, respectively, representing a highly skewed distribution of life span in this sample. As age increased, survival time decreased. All Activities of Daily Living (ADLs) recorded (Bathing, Continence, Dressing and Transfer) as well as other measures of performance (mobility and pulse) and nutrition (appetite and nourishment) were each strongly associated with survival. Multivariate analysis limited significant variables to dressing ability, pulse rate, level of appetite and transferring ability. Outliers (survival greater than 180 days) were differentiated from the remainder of the sample by significant differences in all ADLs recorded as well as the level of appetite. These findings establish the importance of assessing ADLs, a measure of functional status, and reinforce the importance of performance and nutrition measures when estimating length of survival in terminal cancer patients.

Older Nursing Home Residents Have a Cardiac Arrest Survival Rate Similar to That of Older Persons Living in the Community

OBJECTIVE: To determine the survival rates of older nursing home residents after cardiopulmonary resuscitation (CPR) and to compare it with that of older persons who experienced cardiac arrest in an outpatient setting. To identify patient characteristics, arrest characteristics, and effort characteristics that are associated with higher survival rates.

Continuity of Do‐Not Resuscitate Orders Between Hospital And Nursing Home Settings

OBJECTIVE: To determine the relationship between interinstitutional communication and continuity of advance directives from hospital to nursing home (NH) settings.

Effect of a Mandatory Geriatric Medicine Clerkship on Third-Year Students

A nationwide push has increased geriatric medicine instruction within medical school curricula. Some institutions have proceeded with an integrated 4‐year curriculum while others have constructed discrete courses in the third or fourth year of medical school. This paper describes the impact of a new mandatory 4‐week geriatric medicine clerkship on third‐year students developed by the Donald W. Reynolds Department of Geriatric Medicine at the University of Oklahoma Health Sciences Center. In the first year of implementation, 135 students took the course on both the Oklahoma City and Tulsa campuses. Clinical sites included inpatient, VA extended care unit, outpatient clinics, dementia clinics, home care, long‐term care settings, and hospice. Didactic instruction used formal lectures and problem‐based learning. The impact of the clerkship on students was assessed in three areas: knowledge, skills, and attitude using a pre‐ and postknowledge test, student satisfaction survey, and written comments. This article discusses how the clerkship resulted in increased knowledge of geriatric medicine. Student self‐report indicates that the clerkship enhanced clinical evaluation and patient assessment skills. Students indicated that the experience was positive and recognized the importance of geriatric medicine in their development as doctors.

Estimation of severity of illness with APACHE II: age-related implications in cardiac arrest outcomes

The ability to predict outcomes of cardiac arrest before starting cardiopulmonary resuscitation (CPR) would be useful for discussions of resuscitation with elders and their families. We thought CPR outcome might be dependent on the severity of pre-existing illnesses. The APACHE II is a severity-of-illness (SOI) scale based, in part, on physiologic parameters whereby points are given for degree of deviation from normal. Additionally, up to six points are given for increased age. We hypothesized that (1) patients with the highest APACHE II would be least likely to survive, and (2) because of the blunted physiologic responsiveness, the APACHE II would underestimate the SOI of elderly patients who were sufficiently ill to have a cardiac arrest. A retrospective study of 172 arrests was carried out to evaluate these hypotheses. For the young cohort (n = 126; age, < 70; mean age, 59 +/- 8), mean admission APACHE II was 16.5 +/- 7.9 and pre-arrest APACHE II regression analysis.2+ carried out with both APACHE II scores and factors previously correlated with CPR outcome. Witnessed arrests and those requiring a low number of medications were most likely to result in immediate success (restoration of blood pressure) and in a live discharge. APACHE II score (24 h pre-arrest) was associated with live discharge in the regression analysis.(ABSTRACT TRUNCATED AT 250 WORDS)

Development and evaluation of a longitudinal Case Based Learning (CBL) experience for a geriatric medicine rotation.

Abstract The DWR Department of Geriatric Medicine at OUHSC and the OKC VA Medical Center began a mandatory third-year geriatric medicine clerkship in 2003. As part of the didactic sessions, the Department created a longitudinal Case-Based Learning (CBL) experience. The purpose of this paper is to describe the CBL experience, report student satisfaction with the CBL process, and discuss how students value CBL as a teaching method compared to other methods. The results indicate that CBL is highly valued among the students due to the interactive nature of the sessions and longitudinal nature of the cases

Characteristics of Patients Receiving or Forgoing Resuscitation at the Time of Cardiopulmonary Arrest

OBJECTIVE: To compare clinical, functional and social characteristics of DNR patients at the time of their cardiopulmonary arrest with characteristics of patients who receive cardiopulmonary resuscitation.