International Journal of Gerontology

Current Treatments of Diabetic Macular Edema

Wei-Chun Chan, Shawn H. Tsai, Ai-Ching Wu, Lee-Jen Chen, Chi-Chun Lai — 2012-01-20

Summary: Diabetic macular edema (DME) is a major cause of visual impairment in diabetic patients. Laser photocoagulation is the standard management strategy for macular edema, but its results remain unsatisfactory. Several clinical trials of new treatment modalities for DME have been conducted over the past 10 years. We performed a literature search of English articles, published between 2000 and 2010, by using the PubMed database. The keywords searched included “diabetic macular edema and treatment” with limits set to include only clinical trials and review articles, over 50 articles were reviewed. Among the newer treatment modalities reviewed, therapy with anti-vascular endothelial growth factor (VEGF) antibodies showed significantly better efficacy, with level I evidence. However, multiple injections were required to maintain its efficacy. Therefore, the associated complications and cost implications are the major limitations of this treatment. Several combinations of different modalities have been evaluated in the literature, but none are more efficacious than monotherapy with anti-VEGF antibodies. Since DME is a multifactorial disease, further studies involving combinations of modalities or new treatments modalities may be needed to reduce the number of injections required or improve the visual outcomes in case of DME.

An Analysis of Telemedicine in Taiwan: A Business Model Perspective

Tung-Cheng Lin, Hong-Jer Chang, Chung-Chien Huang — 2012-01-24

Summary: Background: As a useful tool, business model holds the promises to make operations explicitly in terms of what services and benefits the consumer may receive, the ways services may be provided, and what financial benefits the operations may yield. Previous researchers have used business models to examine components of operations for telemedicine in the United States. There exists an omission in the literature concerning its commercial potential consideration. The purpose of this study is to apply business model perspective to generate a framework to analyze six major telemedicine projects in Taiwan.Methods: This study used a business-model perspective and applied case study to examine six major telemedicine projects launched in a commercial operation. These cases encompassed the three major types of players, including hospitals, security firms, and not-for-profit organizations and represented the four models of long-term care service delivers, including home care, community-based care, institutional care, and mobile security care. Data were collected through in-depth interviews with the managers or principal executers of each project.Results: The finding of this study indicate that value proposition, partnership, resource, and capability affect service process and cost structures. This in turn has an impact on customers' acceptance of telemedicine.Conclusions: The framework we proposed serves as a useful tool to obtain more insights into the future development of telemedicine. The cost of operating a telemedicine service system is currently not low. The practitioner could reduce the cost through modifying value proposition, service process or allying with more experienced partner.

Elderly in ‘Super Traders’ Family

Harasankar Adhikari — 2011-12-02

Summary: Background: In this globalized world, societal change has impacted on family structure and the roles and relationships of its family members. In recent times extreme competitiveness amongst family members has given rise to a new structure known as the ‘super trader’ family rather than the traditional nuclear, joint or extended family.Method: One hundred people over 60 years old from rural and urban areas at a ratio 1: 1 through simple purposive random sampling have been studied to examine the current social situation of the elderly. The study was concentrated on the social, educational, occupational and marital background of the elderly people to assess their living situation.Result: The elderly living in urban or rural areas are facing an unhealthy, lonely and unhappy existence. Often they are accommodated in their families, but are mostly separated from the younger family members. They may be psychologically ill and unhappy because their position in the family is not respected and is undervalued. They are often seen as the structural head, but are non-functional in terms of participation in power and decision-making process in the family.Conclusion: In order to protect the elderly and their lifelong experiences it is important that they are respected and their value is recognized by the younger members of the family.

Outcomes and Cost Analysis of Patients With Successful In-Hospital Cardiopulmonary Resuscitation

2012-01-03

Summary: Backgrounds: This study evaluated the outcomes of patients after in-hospital cardiac arrest who were admitted to the intensive care unit (ICU) with successful cardiopulmonary resuscitation (CPR).Methods: Data were extracted from a prospectively maintained database of intubation and mechanical ventilation in a tertiary hospital. Adult patients (age ≥ 18 years) with successful CPR and admitted to the ICU were included for analysis. The characteristics of the patients and the outcomes were analyzed.Results: A total of 313 patients were included from January 1, 2004, to December 31, 2004, with 114 (36.4%) admitted from the emergency department and 199 (63.6%) from the ward. The in-hospital mortality was high (209, 66.8%), with 130 (62.2%) of the patients dying within 24 hours. The nonsurvivors had a significantly higher Acute Physiology and Chronic Health Evaluation II (APACHE II) score and Therapeutic Intervention Scoring System (TISS) score but a lower Glasgow Coma Scale (GCS), a shorter ICU and hospital stay, shorter mechanical ventilation (MV) hours, and fewer expenses. Patients with early mortality (< 24 hours) had a significantly higher APACHE II score and a greater portion were admitted from the ward. Only 73 (23.3%) were discharged home and 31 (9.9%) were transferred to a chronic care center. Patients who were discharged to chronic care centers were older, had a higher APACHE II score, higher medical expenses, more MV hours, longer ICU and hospital stays, but a lower GCS than those who were discharged home. The mean expense for survivors was about threefold that of nonsurvivors, and patients who were discharged to a chronic care center had the highest mean hospital expense, which was about sixfold of the patients with early mortality. Although survivors comprised 33.3% of the in-hospital cardiac arrest patients with return of spontaneous circulation, they have consumed 60% of the total hospital expenses.Conclusions: Given the fact that less than one quarter of the successfully resuscitated patients have a favorable outcome, two-thirds of the mortality cases died within 24 hours, which is a high cost for successful resuscitation, and one-third of the survivors had to stay on chronic respiratory care center. A better prognostic tool to predict outcomes should be developed to avoid futile resuscitation.

Association Between Sleep Duration and Health Outcome in Elderly Taiwanese

Meng-Ting Tsou — 2012-01-24

Summary: Background: The aim was to assess the relationship between sleep duration and self-rated health outcome in the elderly Taiwanese.Methods: The data were drawn from the National Survey on Knowledge, Attitude, and Practice of Health Promotion 2002 (HPKAP 2002) in Taiwan. Three thousand seven hundred and thirty-one elderly participants (≧ 65 years of age) completed this survey, including 1955 men (52.4%) and 1776 women (47.6%). The anonymous questionnaire collected information on demographic data, sleep duration, health status, and health behaviors. After adjusting for various risk factors, a multiple logistic regression model was applied to compare the participants sleeping an average of 6 to 8 hours/night with those sleeping ≦ 5 hours and ≧ 9 hours.Results: A U-shaped relationship was found in elderly participants, with both short and long sleep durations and a higher risk of poor health perception (≦ 5 hours/night: OR = 1.13, 95% CI 0.93–1.36; ≧ 9 hours/night: OR = 1.30, 95% CI 1.01–1.75), depression (≦ 5 hours/night: OR = 1.35, 95% CI 1.02–1.86), chronic diseases (especially heart disease and limited activity), and unhealthy habits (≧ 9 hours/night: smoking – OR = 1.24, 95% CI 1.02–1.46; no exercise – OR = 1.52, 95% CI 1.17–1.97).Conclusion: A U-shaped relationship was observed between the self-reported sleep duration with risk prevalence and health outcome in the elderly population, although not all results showed a significant difference. A progressively higher change was observed during short and long sleep durations in our study.

The Outcome and Predictors of Failed Extubation in Intensive Care Patients—The Elderly is an Important Predictor

Ai-Chin Cheng, Kuo-Chen Cheng, Chin-Ming Chen, Shu-Chen Hsing, Mei-Yi Sung — 2012-01-20

Summary: Background: Weaning off the ventilator and removal of the endotracheal tube requires appropriate timing and supportive care in order to avoid reintubation. In this study, the incidence, outcome, and factors predictive of failed extubation (reintubation within 48 hours), as well as the associated mortality in critically ill patients on mechanical ventilation in the adult intensive care unit (ICU), were studied.Methods: The medical records of all patients who experienced planned extubation in the ICUs of Chi-Mei Medical Center in 2008 were reviewed. The primary endpoints were factors predicting failed extubation and mortality. The secondary endpoint was the outcome of failed extubation.Results: Among the 1794 patients experiencing planned extubation, 167 patients (9.3%) required reintubation within 48 hours. The overall mortality rate was 8.1%. Using multivariate analyses, the factors predicting failed extubation were age ≥65 years and medical patients. The predictors of mortality included age ≥65 years, higher Acute Physiology and Chronic Health Evaluation II scores, and failed extubation. The patients with failed extubation had significantly longer ICU and hospital stays (15.2 vs. 6.6 days, and 40.3 vs. 24.0 days, respectively), increased incidence of tracheostomy (21.6% vs. 1.5%), a higher hospital mortality (45.5% vs. 4.2%), and higher hospital costs (52.3 vs. 30.4×104 New Taiwan dollars) when compared with patients who had successful extubation.Conclusion: Our study indicated that patients with failed extubation experienced significantly increased admission expenditure, increased tracheostomy rate, and higher hospital mortality. Advanced age should be considered an important risk factor for failed extubation and overall mortality when planning extubation in critically ill ICU patients.

Hypertension and Cognitive Impairment: Kahrizak Elderly Study

2012-01-09

Summary: Background: Dementia is a major cause of cognitive impairment in the elderly. Numerous studies have investigated the association between hypertension and cognitive disorders in elderly persons, with inconsistent results. The goal of the study was to investigate the association between hypertension at baseline and cognitive impairment after 24 months’ follow-up in the elderly residents of the Kahrizak Charity Foundation (KCF) in Iran.Methods: There were 211 elderly residents of KCF aged 65 years or older with a Mini Mental State Examination (MMSE) score greater than 10. The MMSE score was assessed at the end of the study. Blood pressure was measured in all of the participants at the beginning of study. Data were compared between hypertensive and normotensive patients.Results: A total of 63.5% of patients had impaired cognition (61% and 63.9% in normotensive and hypertensive patients, respectively). Cross sectional analysis of baseline data in a multiple regression model has revealed that diastolic high blood pressure was a risk factor for cognitive impairment even after adjustment for confounding factors (odds ratio: 2.42, 95% CI: 1.01-5.78). In the cohort follow-up analysis, the relative risk of cognitive impairment for patients aged 75 years or older with final diagnosis of hypertension was 0.72 (0.57–0.92). The relative risk of patients with systolic high blood pressure and history of hypertension was 19% and 10%, respectively, which was lower than normotensive group but such differences were not significant.Conclusions: High systolic blood pressure in very old persons may have a preventive effect on development and progression of cognitive impairment. However, diastolic high blood pressure perhaps may be a risk factor for cognitive impairment in elderly persons.

Ultrathin Transnasal Esophagogastroduodenoscopy in Geriatric Patients: A Prospective Evaluation

Qing Zhang, An-Hua Xiao, Xiao-Ping Tan, Wei-Zheng Wang, Chang-Hua He — 2012-01-04

Summary: Background: Ultrathin transnasal EGD is a very safe technique in common people. This study was conducted to explore the safety and tolerance of ultrathin transnasal esophagogastroduodenoscopy (EGD) in geriatric patients.Methods: A total of 327 patients referred for diagnostic transnasal EGD were allocated to three groups on the basis of age: group A (between 70 and 85 years), group B (older than 85 years), and control (younger than 70 years). Pre-EGD anxiety was measured using the 100-mm visual analog scale (VAS). After EGD, patients were required to complete a questionnaire on pain, nausea, choking, overall discomfort, and quality of the examination either using VAS or answering some questions. The duration of EGD was timed. Blood pressure (BP), oxygen saturation (SpO2), and heart rate (HR) were monitored before, during, and after EGD.Results: There was no statistically significant association with age, gender, baseline VAS, SpO2, BP, HR, and duration of the procedure among all groups. Transnasal EGD was successfully completed in all patients. No severe complication(s) occurred in all groups. Compared to baseline data, systolic BP (SBP), diastolic BP (DBP), and HR gradually rose before endoscopy was initiated, but they decreased 5 minutes after endoscopic insertion. However, the change in SpO2 showed a contrary trend during the whole procedure. There was no statistical significance with the differential value compared to the baseline of DBP, HR, and SpO2 during the different stages between groups A, B, and control. Compared to baseline data, only SBP during following endoscopic insertion and endoscopy in group B increased with statistical significance. On the basis of the patients’ evaluation, no difference was found in intubation pain, overall discomfort, choking, nausea/vomiting, or overtolerance among the three groups.Conclusion: Ultrathin transnasal EGD has good technical performances, has high security and reliability, and is generally well accepted and preferred by geriatric patients.

Acquired Aplastic Anemia After Nosocomial Serratia marcescens Bone Marrow Infection in an Elderly Patient

Hsiao-Wei Wang, Chang-Pan Liu, Kuo-Ming Chuang, Chun-Ming Lee — 2012-01-05

Summary: A 76-year-old female patient with a multiple medical history developed refractory pancytopenia during treatment for peptic ulcer, bacteremia, pneumonia, and respiratory failure. Bone marrow biopsy revealed hypocellularity with few hematopoietic cells, which was indicative of aplastic anemia. Common causes including viral infection, mycobacterial infection, environmental exposure, congenital bone marrow disorder, and hematologic malignancy were primarily excluded. Identical Serratia marcescens cultures were isolated from the central venous catheter tip and bone marrow, and the pancytopenia improved gradually with proper antibiotics treatment. This case indicates that nosocomial S. marcescens infection may cause potentially fatal acquired aplastic anemia. Crucial issues in avoiding aplastic anemia include confronting increasing mortality and morbidity caused by nosocomial infection, improving environmental hygiene, early diagnosis of proper etiology, and adequate antibiotics treatment.

Live Fish Impaction in Hypopharynx in an Elderly Patient

2012-01-09

Summary: Successful removal of a live fish impacted in the hypopharynx of a 65-year-old male is reported to emphasize the importance of the speed with which it has to be recognized and intervened. The present report also highlights the altered sensory perception in the oral cavity of elderly people as a potential risk factor for airway obstruction due to a foreign body. Moreover, the possibility of a foreign body has to be suspected, if an elderly patient without any cardiorespiratory illness presents with an acute onset of progressive respiratory distress.

Atraumatic Urineous Peritonitis Caused by Bladder Rupture

Chia-Lin Chiang, Wei-Ning Du — 2012-01-06

A 72-year-old man lived independently in a nursing home for >10 years because of a stroke leading to a bed-ridden state. Because of blood-stained and coffee-ground coloured vomitus, he was referred to the gastroenterology service at our institution for further evaluation. Upper gastrointestinal endoscopy revealed fresh blood in the lower part of the oesophagus; he was diagnosed with a bleeding ulcer and Mallory–Weiss tear. However, epigastric and low abdominal pain simultaneously persisted. He developed severe sepsis and peritonitis in 1 day. Contrast-enhanced computed tomography (CT) revealed urinary bladder rupture with massive ascites (A transaxial view and B sagittal view). A laparotomy and surgical repair of the ruptured bladder was performed on the same day after the CT. Perforation of the augmented bladder, without a history of preceding trauma, is a rare but life-threatening complication (mortality rate, 23–25%). Diagnosis can be difficult, particularly in paralytic patients with inapparent symptoms and signs.

Incarcerated Incisional Hernia Complicated by Abdominal Wall Abscess in an Elderly Patient

Min-Po Ho, Wing-Keung Cheung, Wen-Han Chang — 2012-01-11

Incisional hernia, the abdominal viscera’s protrusion at a previous surgical incisional site, occurs in about 10% of patients after laparotomy and 0.1–0.3% after a laparoscopic procedure. If the incisional hernia cannot be reduced, it is called an incarcerated hernia, which can obstruct the bowel and possibly strangle or impede the blood supply to the herniated bowel. These latter findings require an immediate surgical decision to reduce the possibility of ischemia of the bowel and to prevent further morbidity and mortality. Herein, we report a case of an incarcerated incisional hernia complicated by an abdominal wall abscess in a 78-year-old obese female patient.

Author Index

2011-12-01

Keyword Index

2011-12-01

Title Index

2011-12-01