International Journal of Gerontology

Restless Legs Syndrome Among the Elderly

Pei-Hao Chen, Shih-Jung Cheng — 2009-12-01

Summary: Restless legs syndrome is a sleep and movement disorder that affects 5–15% of the general population, with an increased prevalence among the elderly population. It not only affects quality of life but also increases risk of mortality among older adults. The diagnosis is based on clinical symptoms of the patient by four minimal essential criteria. Restless legs syndrome can be divided into primary or secondary causes. Examination should be performed to rule out potentially treatable illnesses, such as iron deficiency, renal failure or peripheral neuropathy, especially among elderly patients. The initial approach to restless legs syndrome should be nonpharmacologic management, such as good sleep hygiene, regular exercise, cognitive behavioral therapy and avoidance of certain aggravating drugs. An algorithm based on scientific evidence and expert opinion was developed for guidance of treatment. Combination or change of medication can be applied to resistant or difficult cases. Since elderly patients are prone to treatment-related side effects, the best strategy is to start medication cautiously and at the lowest recommended dosage.

Pyogenic Liver Abscess in the Elderly

Yu-Hang Yeh, Yu-Chia Lin, Yu-Jang Su, Yen-Chun Lai — 2009-12-01

Summary: Background: We analyzed the characteristics of elderly patients with pyogenic liver abscess, including clinical features, laboratory analyses and outcomes. Methods: A retrospective review of patient records from January 1, 2007 to June 30, 2008, identified 140 cases of liver abscess hospitalized in a medical center in northern Taiwan. Patients transferred from other hospitals, or those who had amoebic, fungal, traumatic or iatrogenic LA were excluded, and 122 cases were enrolled. We divided patients into two groups: an elderly group aged ≥ 65 years, and a non-elderly group. We collected information on clinical manifestations, laboratory data, imaging, blood and pus culture, and surgical findings for statistical analyses. Results: We compared the elderly and the non-elderly with pyogenic liver abscess with respect to diabetes history (p = 0.03), presence of fever (p = 0.19), days of fever before hospital visit (p = 0.001), abdominal pain (p = 0.08), diarrhea (p = 0.36), shock (p = 0.25), white blood cell count (p = 0.70), serum glucose (p = 0.49), aspartate aminotransferase (p = 0.95), length of hospital stay (p = 0.10), and mortality (p = 0.12). Most positive results in cultures were for Klebsiella pneumoniae, and the positive rates in culture of blood and pus were 43% and 60%, respectively. Conclusion: We found that there was no significant statistical difference between elderly and non-elderly pyogenic liver abscess patients in the presence of fever, abdominal pain, diarrhea, shock, white blood cell count, serum glucose, aspartate aminotransferase, hospital stay, and mortality. The elderly pyogenic liver abscess patients had fewer days of fever before hospital visit (2.2 ± 2.2 vs. 6.3 ± 6.9; p = 0.001). The elderly were taken to hospital earlier, because their families were more concerned about their constitutional symptoms. More cases of diabetes in the elderly pyogenic liver abscess group (44.7% vs. 39.3%) may arise because of more diabetes in the elderly population.

Do Elderly Patients With Non-hematologic Malignancies Have A Worse Outcome in the ICU?

Tzu-Tao Chen, Ming-Jen Peng, Chien-Liang Wu — 2009-12-01

Summary: Background: The aim of this study was to evaluate the difference in outcome between older (≥ 65 years) and younger (< 65 years) cancer patients admitted to the intensive care unit (ICU) with acute life-threatening illness. Methods: A total of 1,881 patients were admitted to the medical intensive care unit (ICU) of Mackay Memorial Hospital, Taipei, from September 2004 to September 2007. We excluded patients diagnosed with cancer and in remission for > 5 years, ICU stay of < 24 hours, and ICU admission for routine postoperative monitoring. A total of 85 patients were included and divided into younger (< 65 years) and older (≥ 65 years) groups for comparison. Results: The mean ages of the younger and older group were 50.7 ± 3.6 years and 76.1 ± 1.9 years, respectively. There was no significance in ICU length of stay (8.6 ± 2.5 days vs. 11.7 ± 2.6 days; p = 0.09), in the proportion of high Adult Comorbidity Evaluation 27 grade (86.1% vs. 77.6%; p = 0.32). The most frequent reasons for ICU admission in the younger and older groups were acute respiratory failure (50.0% vs. 61.2%) and shock (41.7% vs. 24.5%). The elderly had significantly more sepsis (87.8% vs. 58.3%; p = 0.002) and bloodstream or intraperitoneal infection (34.7% vs. 13.9%; p = 0.03), and received earlier conventional mechanical ventilation (−0.3 ± 0.17 days vs. 0.13 ± 0.36 days; p = 0.045) and shorter vasopressor administration (2.07 ± 0.94 days vs. 5.36 ± 2.63 days; p = 0.03). The hospital survival times in younger and older groups were 36.3 ± 16.3 days and 60.9 ± 33.9 days (p = 0.20), respectively, and 1-year survival rates were 2.8% and 12.2% (p = 0.12), respectively. Conclusion: The main cause of death and survival rates, both short-term and long-term, were not worse in elderly patients with non-hematologic malignancies in the ICU, and the main reasons for patient death were sepsis and respiratory failure, rather than the malignancy itself. Therefore, an ICU admission policy should not exclude elderly patients with non-hematologic malignancies merely because of concerns about survival rate or life expectancy.

Characteristics of Emergency Services for the Elderly—A Regional Hospital Example

Ching-Lin Huang, Wai-Mau Choi — 2009-12-01

Summary: Background: In Taiwan, the study of emergency medical services for elderly patients is inadequate. Although in recent years there has been more discussion of emergency care, there has been no comprehensive review. In other countries, elderly services have been examined for some years now, but the situation is different in Taiwan. Therefore, this study was performed in a district teaching hospital in Hsinchu County, and the emergency medical treatment of patients aged older than 65 years and its impact were analyzed. Methods: In this study, we used retrospective data from a hospital in Hsinchu City between January and December 2008. We selected 9,692 patients aged older than 65 years and excluded missing data. Results: The elderly patients' emergency condition, symptoms and diagnoses were found to be uncertain. As they tended to be triage levels 2–3, which is very serious, it meant that the elderly patient's status was complicated and emergency medical personnel often could not quickly judge what constituted appropriate treatment within a short time. Conclusion: This study's primary goal was to investigate the most common clinical signs and symptoms of the various diseases most common in elderly patients, who presented to the emergency service, and the care of these patients in Hsinchu County to facilitate a more efficient and useful emergency medical service.

Radiologic Pulmonary Findings, Clinical Manifestations and Serious Complications in Scrub Typhus: Experiences From A Teaching Hospital in Eastern Taiwan

Kun-Ming Wu, Zhe-Wei Wu, Guo-Quan Peng, Jian Liang Wu, Shih-Yi Lee — 2009-12-01

Summary: Background: Scrub typhus (tsutsugamushi disease) is an endemic infectious disease in eastern Taiwan caused by Orientia tsutsugamushi. Methods: A total of 136 cases of scrub typhus were diagnosed from patients' blood samples. Medical records were reviewed and clinical manifestations and chest X-rays were analyzed. Results: Scrub typhus was diagnosed in 136 patients, with a mean age of 40.7 ± 21.5 years. The most common symptom was fever in 134 patients (98.5%), and the most common sign was eschar in 82 (60.3%). Chest X-rays were performed in 115 cases and showed abnormalities in 63 patients (54.8%). Patients with chest X-rays abnormalities had an increased incidence of cough (p < 0.001), septic shock (p = 0.006), congestive heart failure (p < 0.001), acute respiratory failure (p < 0.001), severe jaundice (p = 0.03) and acute renal failure (p = 0.007), and requirement for intensive care unit treatment (p < 0.001) and prolonged length of hospital stay (p = 0.002), compared with patients without chest X-rays abnormalities. Patients aged £ 16 years had an increased incidence of meningoencephalitis (p = 0.006) compared with the others. Patients aged ≥ 65 years had a higher incidence of complications and requirement for intensive care unit care (p = 0.02) compared with the other two groups. Conclusion: Patients with abnormal chest X-rays had higher rates of serious complications. Central nervous system infection was most frequent in pediatric patients. Patients aged ≥ 65 years had a higher incidence of serious complications. Physicians should have increased awareness of scrub typhus when caring for patients with acute febrile illness in endemic areas.

Comparison of the Prevalence of Metabolic Syndrome Between the Criteria for Taiwanese and Japanese and the Projected Probability of Stroke in Elderly Hypertensive Taiwanese

Ta-Chuan Hung, Chun-Yen Chen, Shih-Jung Cheng, Chung-Hsiang Liu, Hung-I Yeh — 2009-12-01

Summary: Background: The cutoff of abdominal circumference for metabolic syndrome (MS) defined by the Bureau of Health Promotion (BHP) of Taiwan for Taiwanese (men, 90cm; women, 80cm) and by the International Diabetes Federation (IDF) for Japanese (men, 85cm; women, 90cm) differs. This study aimed to examine the impact of this difference on the prevalence of MS and the impact of an MS diagnosis on the projected risk of stroke in hypertensive Taiwanese. Methods: MS was examined in a sample of 3,472 hypertensive patients (aged 55–80 years; 1,709 women) across Taiwan. The 10-year probability of stroke estimated from the Framingham equation was compared between MS and non-MS patients. Results: The prevalence of MS using the BHP criteria was 59.2% using the BHP criteria (95% confidence interval, CI, 57.6–60.8%; men, 52.5%; women, 66.1%) and 48.9% by the IDF criteria (95% CI, 47.2–50.5%; men, 61.3%; women, 36.1%). Both criteria showed that, compared with non-MS, MS has higher predicted 10-year probability of stroke (BHP, 0.153 ± 0.115 vs. 0.133 ± 0.105; IDF, 0.159 ± 0.109 vs. 0.132 ± 0.112; both p < 0.001) because of the difference in women (BHP, 0.143 ± 0.124 vs. 0.102 ± 0.091; IDF, 0.147 ± 0.121 vs. 0.118 ± 0.110; both p < 0.001) rather than men (BHP, p = 0.21; IDF, p = 0.29). Conclusion: Both criteria demonstrate that MS is highly prevalent in elderly hypertensive patients in Taiwan. Additionally in women, but not men, the predicted probability of stroke is higher in MS than in non-MS patients. The diagnosis of MS is potentially useful for identifying elderly hypertensive females with an elevated risk of stroke in Taiwan.

Synchronous Isolated Distant Metastasis to Spleen From Colon Adenocarcinoma

2009-12-01

Summary: The most common site of metastasis from colorectal carcinoma is the liver. Isolated splenic metastasis from colorectal carcinomas is uncommon. We report a case of an 84-year-old man with synchronous isolated splenic metastasis from colon carcinoma. The splenic tumor was incidentally found by ultrasound and computer tomography. The patient underwent left hemicolectomy and splenectomy, and histology of spleen confirmed a metastatic adenocarcinoma from colonic carcinoma. The literature recommends close attention to the spleen in the patients with colonic carcinoma, and surgery may be possible in patients with isolated splenic metastasis.

Atypical Presentation of Spinal Epidural Abscess—Prolonged and Intractable Abdominal Pain

2009-12-01

Summary: Despite advances in medicine, early diagnosis of spinal epidural abscess remains a challenge to clinicians. The most common symptoms of spinal epidural abscess include back pain, fever, and neuralgic deficits. However, spinal epidural abscess can also present with vague and nonspecific symptoms. In this case, a 68-year-old male had abdominal pain in the right upper quadrant lasting 3 weeks and was diagnosed with a gastric ulcer. After treatment, his symptoms did not resolve. Fever and back pain became evident as his disease progressed, followed by right lower limb weakness and the inability to walk. He was taken to the emergency department of our hospital, and the weakness of his lower extremities worsened during hospitalization. His right leg became completely paralyzed despite the use of intravenous antibiotics. A spinal computed tomography scan was performed emergently (magnetic resonance imaging was unavailable) and revealed an epidural abscess involving T5–6 with adjacent osteomyelitis. The patient underwent posterior decompressive laminectomy with pus drainage in the T4–7 region. His neuralgic examinations improved soon after the operation, but ambulation remained limited. Early diagnosis is crucial to the prognosis of spinal epidural abscess, because delayed diagnosis usually results in complete paralysis even death. Thus, clinicians should be aware of atypical presentations of spinal epidural abscess.

Cholestasis and Acute Cholecystitis in Hyperthyroidism Treated With Methimazole

Wei-Che Chen, Zheng-Xin Zhu, Chao-Hung Wang, Ming-Nan Chien — 2009-12-01

Summary: Hepatic dysfunction and jaundice are usually present in patients with hyperthyroidism. It may be the clinical manifestation of the disease or the adverse effect of antithyroid therapy. We report a 69-year-old male with hyperthyroidism who developed cholestasis and acute cholecystitis after a 4-day course of methimazole. After withdrawal of methimazole, his cholestasis subsided.

Acute Pulmonary Embolism Mimics Acute Coronary Syndrome in Older Patient

Chun-Chieh Liu, Ta-Chuan Hung, Charles Jia-Yin Hou, Cheng-Ho Tsai — 2009-12-01

Summary: Acute pulmonary embolism is a fatal disease and an often missed diagnosis. There are no specific symptoms or signs. Accurate diagnosis followed by effective therapy can reduce mortality. We report on a 67-year-old man who underwent lumbar laminectomy and developed an acute anterior compressive-like chest pain and jaw numbness rather than dyspnea on the fifth postoperative day. Owing to refractory chest pain with suspicious posterior myocardial infarction or unstable angina on surface electrocardiogram, the patient received emergency coronary catheterization, which demonstrated normal coronary arteries. Further investigation provided a final diagnosis of acute pulmonary embolism. Acute pulmonary embolism with simultaneous recent neuro-surgery was a therapeutic dilemma because of the risk of postoperative hemorrhage threatening neurologic function. After treatment with enoxaparin and close monitoring of his neurologic condition, his symptoms were eliminated. Clinicians must keep in mind a differential diagnosis of pulmonary embolism in a postoperative high-risk patient.

The Advantage of Contrast-enhanced Helical Computed Tomography in the Diagnosis of Arterio-enteric Fistula in an Elderly Patient

2009-12-01

Author Index

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Key Word Index

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Title Index

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