Yaffa Lerman

Intervention with the Screening Tool of Older Persons Potentially Inappropriate Prescriptions/Screening Tool to Alert Doctors to Right Treatment Criteria in Elderly Residents of a Chronic Geriatric Facility: A Randomized Clinical Trial

To assess the effect of a Screening Tool of Older Persons potentially inappropriate Prescriptions/Screening Tool to Alert doctors to Right Treatment (STOPP/START) medication intervention on clinical and economic outcomes.

Admission Norton scale scores (ANSS) and postoperative complications following hip fracture surgery in the elderly.

We sought to determine if low ANSS, usually associated with high pressure ulcer risk, are also associated with postoperative complications and in-hospital mortality following hip fracture surgery in the elderly. This was a retrospective cross-sectional study conducted in a tertiary medical center. The medical charts of consecutive elderly (≥ 65 years) patients admitted for hip fracture surgery were studied for the following measurements: ANSS, demographic data, co-morbidities, postoperative complications, the need for revision procedures, and in-hospital mortality. Except for pressure ulcers, postoperative complications included: acute coronary syndrome, acute renal failure, confusion, pneumonia, urinary tract infection, venous thromboembolism, and wound infection. The final cohort included 269 patients: 198 (73.6%) females and 71 (26.4%) males. Mean age for the entire cohort was 82.8 ± 0.4 years. Most patients underwent an internal fixation (n=146; 54.3%) or hemiarthroplasty (n=92; 34.2%). Overall, 110 (40.9%) patients had low (<15) ANSS. Patients with low ANSS had significantly more postoperative complications relative to patients with high ANSS (0.77 ± 0.09 vs. 0.23 ± 0.04; p<0.0001). Among all postoperative complications, urinary tract infection was independently associated with low ANSS (p<0.0001). ANSS were independently associated with postoperative complications (p<0.0001), the need for revision procedures (p=0.019), and in-hospital mortality (p=0.016). We conclude that the Norton scoring system may be used for predicting postoperative complications and in-hospital mortality following hip fracture surgery in the elderly.

Admission Norton scale scores (ANSS) correlate with rehabilitation outcome and length in elderly patients following hip arthroplasty

We sought to determine if ANSS used for evaluating pressure sore risk also correlate with rehabilitation outcome and length following hip arthroplasty in elderly patients. This was a retrospective study conducted in a geriatric rehabilitation department during 2009. ANSS, admission albumin serum levels, mini-mental state examination (MMSE) scores, discharge walking functional independence measure (FIM) scores, and rehabilitation length were studied. The final cohort included 201 patients: 160 (79.6%) females and 41 (20.4%) males. Mean age was 82.7±6.5 years. Mean discharge walking FIM score was 5.2±0.9. Mean length of rehabilitation was 19.9±7.8 days. ANSS correlated with discharge walking FIM scores (r=0.28; p=0.002), and with length of rehabilitation (r=-0.22; p=0.014) following adjustment for age, admission albumin serum levels, and MMSE scores. Linear regression analysis showed that ANSS were associated with the discharge walking FIM scores (p<0.0001) and rehabilitation length (p=0.027) independent of age, admission albumin serum levels, gender, type of hip surgery, and the appearance of pressure sores. We conclude that the Norton scoring system may be used for predicting the outcome and the duration of rehabilitation in elderly patients following hip arthroplasty.

Admission Norton scale scores (ANSS) correlate with rehabilitation outcome and length in elderly patients with deconditioning

We sought to determine if admission Norton scale scores (ANSS) used for evaluating pressure ulcer risk also correlate with rehabilitation outcome and length in elderly patients with deconditioning. This was a retrospective study conducted in a geriatric department between June 2008 and June 2010. The medical charts of consecutive elderly (≥65 years) patients admitted for rehabilitation due to deconditioning were studied for the following measurements: ANSS, admission albumin serum levels, mini-mental status examination (MMSE) scores, discharge walking functional independence measure (FIM) scores, discharge transfer FIM scores, and rehabilitation length. The cohort included 152 patients: 79 (52%) females and 73 (48%) males. Mean age was 83.6±6.5 years. The three most common causes of deconditioning were pneumonia, congestive heart failure exacerbation, and falls. ANSS correlated with discharge walking FIM scores (r=0.32; p=0.003), discharge transfer FIM scores (r=0.30; p=0.005), and length of rehabilitation (r=-0.37; p<0.0001), following adjustment for age, albumin serum levels, and MMSE scores. Linear regression analysis showed that ANSS were independently associated with discharge walking FIM scores (p=0.004), discharge transfer FIM scores (p=0.006), and rehabilitation length (p<0.0001). We conclude that the Norton scoring system may be used for predicting the outcome and the length of rehabilitation in elderly patients with deconditioning.

Admission Norton scale scores correlate with rehabilitation outcome and length in elderly patients following cerebrovascular accident

Aims: To determine whether Norton scale scores used for evaluating pressure sore risk also correlate with rehabilitation outcome and length following cerebrovascular accident (CVA) in elderly patients. Methods: A retrospective study was conducted at a geriatric rehabilitation department in a tertiary medical center during 2009. The medical charts of consecutive elderly (≥65 years) patients admitted for rehabilitation after CVA were studied for the following measurements: admission Norton scale scores, admission albumin serum levels, mini-mental status examination (MMSE) scores, discharge walking functional independence measure (FIM) scores, discharge transfer FIM scores, and rehabilitation length in days. Results: The cohort included 110 patients, 64 (58.2%) women and 46 (41.8%) men. The mean age of the entire group was 80.5±7.4 years. Most patients had ischemic CVA (90.9%) and a first CVA (79.1%). The mean discharge walking FIM score was 4.7±1.4, the mean discharge transfer FIM score was 5.0±1.4, and the mean length of rehabilitation was 28.2±15.3 days. Admission Norton scale scores correlated with discharge walking FIM scores (r=0.51; p<0.0001), discharge transfer FIM scores (r=0.43; p<0.0001), and length of rehabilitation (r=-0.45; p<0.0001) after adjustment for age, albumin serum levels, and MMSE scores. Linear regression analysis showed that admission Norton scale scores were associated (p<0.0001) with the discharge walking FIM scores, the discharge transfer FIM scores and rehabilitation length, independent of age, gender, albumin serum levels, MMSE scores, type of CVA, and the appearance of pressure sores. Conclusions: The Norton scoring system may be used to predict the outcome and duration of rehabilitation in elderly patients after CVA.

Symptomatic venous thromboembolism in elderly patients following major orthopedic surgery of the lower limb is associated with elevated vitamin B12 serum levels

BACKGROUND Elevated vitamin B12 serum levels are associated with systemic inflammation and mortality. Since venous thromboembolism (VTE) is associated with systemic inflammation and mortality as well, we have hypothesized that it is also associated with elevated vitamin B12 serum levels in elderly patients following major orthopedic surgery of the lower limb. METHODS This is a retrospective study. Medical charts of consecutive elderly (≥65 years) patients admitted for rehabilitation following major orthopedic surgery of the lower limb during 2007-2009 were reviewed. The study group included symptomatic VTE patients. The control group included patients in whom VTE was excluded. Demographics, co-morbidities, VTE risk factors, vitamin B12 serum levels, and 1-year mortality were studied. RESULTS The cohort included 197 elderly patients (median age: 82 years): 140 (71.1%) women and 57 (28.9%) men. Overall, 20 (10.2%) patients had VTE (study group) and in 177 (89.8%) patients VTE was excluded (control group). Vitamin B12 serum levels were higher in the study group compared with the control group (median: 634 vs. 409 pg/dL, p=0.024). The incidence of elevated vitamin B12 serum levels (≥500 pg/dL) was higher in the study group compared with the control group (odds ratio 3.1, p=0.031). Elevated vitamin B12 serum levels were associated with VTE (odds ratio 5.3, p=0.011) and with 1-year mortality (odds ratio 6.6, p=0.015) independent of demographics, co-morbidities, and VTE risk factors. CONCLUSIONS Symptomatic VTE is associated with elevated vitamin B12 serum levels in elderly patients following major orthopedic surgery of the lower limb.

Cytomegalovirus colitis associated with arterial thromboembolism in an immunocompetent elderly man.

ACKNOWLEDGMENTS Conflict of Interest: The editor in chief has reviewed the conflict of interest checklist provided by the authors and has determined that the authors have no financial or any other kind of personal conflicts with this paper. This study was conducted within the CAALYX project, funded by the Commission of the European Union as part of its Sixth Framework Program (IST-2005-045215). Author Contributions: Alejandro Rodrı́guez-Molinero conceived the study and participated in study design, data analysis, interpretation of data, and preparation of the manuscript. Antonio Yuste participated in study design, interpretation of data and preparation. José R. Banegas contributed to the study design, interpretation of data and preparation of the manuscript. Sponsor’s Role: None.

Long-Term Outcomes of Medication Intervention Using the Screening Tool of Older Persons Potentially Inappropriate Prescriptions Screening Tool to Alert Doctors to Right Treatment Criteria

To compare 24‐month outcomes of participants of a prospective randomized controlled trial (RCT) assigned to undergo a medication intervention of orally communicated recommendations based on Screening Tool of Older Persons potentially inappropriate Prescriptions (STOPP) and Screening Tool to Alert Doctors to Right Treatment (START) (intervention group) with outcomes of those assigned to undergo written medication review (control group).

Acute Stooped Position in Elderly with Alzheimer's Disease

To the Editor-Numerous physical signs and neurological phenomena in patients with Alzheimer Type Dementia (ATD) have recently drawn attention. The abnormal changes include impaired motor skills and disturbances of gait and posture.’ Among all these, changes in posture are the least well known. When mentioned at all, the description has been rigidity and flexed position appearing insidiously and sometimes parallel to the deteriorating course of the disease.’ Acute stooped position has never been described in ATD. We would like to present five cases in which flexed posture occurred acutely and dramatically in Alzheimer patients shortly after their adrmssion to a psychogeriatric ward. In the five cases, age ranged from 68 to 84; two subjects were male and three female; duration of disease after diagnosis was between 3 and 4 years; dementia was severe; the flexed posture first appeared between 2 and 4 days after admission; and brain CT scan showed only atrophy. All patients were at home before admission, took no medications, and walked erect. After the onset of stooping, patients continued to walk, and this may have caused the falls that occurred in two of them. The diagnosis of ATD was made according to NINCDS-ADRDA working rite ria.^ Blood tests including glucose, urea, creatinine, electrolytes, calcium, phosphorus, uric acid, cholesterol, triglycerides, liver function tests, erythrocyte sedimention rate, complete blood count, VDRL, BI2, TSH, and Free T4 were all in the normal range. The presence of abnormal neurological findings in the advanced states of ATD patients is well established;’ these include glabellar, snout and grasp reflexes, impaired sensation and gait abnormalities. Extrapyramidal signs, such as tremor or rigidity, are present in about 12% of patients.* Changes in posture are also seen (Figure l).’ The most distressing posture is a flexed position with rigidity leading insidiously to an end-stage fetal position. In the past, flexed posture has not been described as an acute phenomenon, but rather as a gradual process, parallel to the gradual deterioration of the disease. What is the pathophysiology of this unusual phenomenon? It is tempting to explain the mechanism as an accompanying extrapyramidal disorder, which is not rare in ATD.6 Molsa et a16 described a flexed position in 56% of 143 patients with ATD, but his review included severely demented bedridden patients. The flexed posture was mild (71%) to moderate (25%), and only 4% showed marked flexion. Richter’ demonstrated destruction of the globus pallidum in monkeys subjected to chronic administration of carbon disulfide. The monkeys showed a stooped position of abrupt onset on the background of chronically developing extrapyramidal disease. Our patients experienced the acute onset of flexed posture in chronic ATD, but none of them showed extrapyramidal signs at any time. Since our psychogeriatric department accepts only mobile patients, the stress of moving from a small familiar apartment to a big open space like our department could have contributed to the phenomenon. Torticollis of similar pathogenesis has been described.’ Flexed posture is a well recognized feature of institutional neurosis. The patient often adopts a characteristic posture with the body bent forward. It may be that this posture develops through prolonged sitting and too little exercise.’ This was not the situation in our cases.

Risk Factors for Urinary Retention Following Surgical Repair of Hip Fracture in Female Patients

Background/Objectives: Postoperative urinary retention (POUR) is a common event following surgical procedures. An increase in the number of elderly individuals who undergo hip fracture repair procedures is inevitable due to the aging of population. Postoperative urinary retention is associated with both early (infections, delirium) and late complications (urinary incontinence) of surgery. The objective of the current study is to direct attention to the less studied population of patients admitted to a geriatric rehabilitation ward following hip fracture repair who are at risk of POUR. Design: Prospective single-center cohort study. Setting: Academic tertiary hospital. Measurement: Postvoid bladder volume by ultrasonography (US). Results: Postvoid bladder volume was measured by US in 88 consecutive female patients on the morning following their admission to the geriatric rehabilitation department. The mean age of the patients was 82.5 ± 6.5 years, and the frequency of POUR (defined as postvoid bladder volume ≥200 mL) was 37.5%. The POUR (n = 33) and non-POUR (n = 55) groups were similar with respect to most demographic and disease states. Multivariable stepwise logistic regression revealed a significant effect for opioid use (relative risk [RR] = 8.0, P < .001) and for treatment with anticholinergic medication (RR = 1.3, P = .046). There was an unexpectedly high proportion of patients with asymptomatic urinary retention (29 of the 33 patients, 88%). Conclusion: The high incidence of asymptomatic POUR in elderly patients calls for the need for improved screening tools for early identification and treatment.