International Journal of Gerontology - Articles in Press

Hospital Mortality of Septic Acute Kidney Injury Requiring Renal Replacement Therapy in the Postoperative Elderly - Corrected Proof

2012-05-17

Summary: Background: Septic acute kidney injury (AKI) is a common complication in intensive care units (ICU), it and portends a higher risk of morbidity and death than nonseptic AKI. However, its outcome and prognostic factors among elderly postoperative patients remain unknown. We aimed to determine the risk factors and predictors of mortality among postoperative elderly patients (≥ 65 years) with septic AKI requiring acute dialysis.Methods: The study protocol was based on that of a clinical cohort study of renal failure patients in the database of the National Taiwan University Surgical ICU Acute Renal Failure (NSARF) Study Group. From January 2002 to July 2009, patients (aged > 18 years) with postoperative AKI requiring renal replacement therapy (RRT) were recruited for this study. Each case of septic AKI before operation was identified and patients with end-stage renal disease were excluded.Results: A total of 292 postoperative patients with septic AKI requiring dialysis were identified during the study period. The mean (SD) age was 65.9 (11.9) years and 68.2% were men. Abdominal surgery was the most common type of surgery (42.8%), followed by cardiovascular (28.8%) and chest surgery (15.4%). The most common indications for RRT in this study cohort were azotemia in 223 patients (76.4%) and fluid overload in 62 patients (21.2%); 92 (31.5%) patients had one indication, 170 (58.2%) had two indications, and 30 (10.3%) had more than three indications. The elderly patients (those ≥ 65 years) had anemia, underwent abdominal surgery, and received dialysis for fluid overload more frequently than the young adults. By contrast, the young adults were more likely to present with shock requiring vasopressor use and have abnormal liver functions. In the elderly subgroup, the outcome was found to be associated with mechanical ventilator use, but not with disease severity, comorbidities, types of surgery and the indication for dialysis.Conclusions: The hospital mortality of postoperative elderly patients with septic AKI was more than 60% and was not affected by age. Mechanical ventilator use was the major risk factor and prognostic factor for elderly patients in this clinical setting.

Alendronate-Induced Osteonecrosis of the Jaw in an Elderly Female - Corrected Proof

Bi-Wei Jan, Hui-Wen Liu, Hung Yu, Shen-Chuan Wang, Chung-Ji Liu — 2012-05-10

Summary: In recent years, more and more evidence has demonstrated that a rare symptom, osteonecrosis of the jaw, may be associated with long-term use of bisphosphonates. Bisphosphonate-related osteonecrosis of the jaw (BRONJ) adversely affects the quality of life, producing significant morbidity in afflicted patients. The most common signs and symptoms are swelling, exposed bone, local infection, pathologic fracture of the jaw, etc. We report the case of an elderly female patient with alendronate-induced ONJ. After the patient discontinued taking bisphosphonates and her physician prescribed antiseptic mouthwashes and antibiotic drugs, her uncomfortable symptoms were relieved. This side effect rarely occurs in Taiwan; it causes permanent harm to patients. Moreover, it affects the normal function of taking food. Therefore, this article includes a case report and a list of some related papers systematically providing clinicians with a reference for future prescription of bisphosphonates. Furthermore, we provide suggestions for the Mackay Memorial Hospital and dentists, in anticipation of earlier measures being taken in order to avoid bisphosphonate-related osteonecrosis, and to reduce additional medical expenses resulting from this side effect.

Age Alone May Not Predict Immediate Survival Outcome in Sudden and Unexpected In-hospital Cardiac Arrest - Corrected Proof

Wei-Ren Lan, Shou-Chuan Shih, Chien-Liang Wu, Ming-Jen Peng, Cheng-Ho Tsai — 2012-05-09

Summary: Background: It is unknown whether outcome after unexpected in-hospital cardiopulmonary resuscitation (CPR) differs in the elderly (≥ 65 years) compared to the non-elderly (< 65 years). This study aimed to compare the rate of sustained return of spontaneous circulation (ROSC) in the elderly and those < 65 years old experiencing unexpected in-hospital cardiac arrest (CA).Methods: We conducted a retrospective chart review of all resuscitation attempts in cases that involved 65 years of age or older patients following in-hospital CA, in a medical center during a 3-year study period (January 2007 to December 2009). Patients were stratified a priori by type of CA (sudden and expected) and age groups (< 65 years and ≥ 65 years). The variables that lead to sustained ROSC and those that did not lead to sustained ROSC were analyzed. Logistic regression analyses were calculated separately to identify independent risk factors for ROSC.Results: Altogether, 283 unexpected CA were analyzed and among these 191 patients were ≥ 65 years old. There were no significant differences in terms of the rate of sustained ROSC between unexpected and expected CA regardless of age. Less than half of the patients died immediately; an initial ROSC rate as high as 72% for unexpected CA was established in those < 65 years old and the elderly (p=0.998). However, underlying diseases could affect the rate of sustained ROSC in geriatric patients with unexpected in-hospital CA.Conclusions: Selected geriatric hospitalized patients may benefit from a short resuscitation attempt. Initial successful resuscitation rate was not inferior to those < 65 years, indicating that initiation of resuscitation should not be affected by age. Patients who are unlikely to benefit from CPR should be identified at or during hospital admission and the possibility of DNR (Do Not Resuscitate) orders should be discussed to avoid inappropriate treatment and potential patient suffering.

A Rare Endoscopic Finding in an Elderly Patient: Double Pylorus - Corrected Proof

Adnan Taş, Yusuf Yeşil, Yavuz Beyazıt, Seyfettin Köklü — 2012-05-07

Double pylorus is a relatively unusual endoscopic finding that has been reported in 0.001–0.4% of upper gastrointestinal endoscopies. It can either be congenital or acquired, but in most cases it is an acquired complication of peptic ulcer disease and is associated with stomach malignancy, respiratory system diseases, chronic kidney disease, and diabetes mellitus. It is seen twice as often in males in comparison with females. Here, we present the clinical and endoscopic findings of a case of double pylorus that presented in a 68-year-old woman.

Multidisciplinary Approach for a Relapsing Goiter with Severe Tracheal Stenosis: A Case Report in an Elderly Patient - Corrected Proof

2012-04-05

Summary: Total thyroidectomy is considered the gold standard for thyroid benign pathology treatment. Unfortunately, many partial interventions carried out in the past created many complications due to the tendency of the goiter to relapse and the formation of adherences in the anterior region of the neck. A woman 72 years of age with a relapsing goiter and severe respiratory symptomatology underwent thyroidectomy. After thyroid removal, tracheal stenosis persisted, making the positioning of a T silicon prosthesis (Montgomery’s T-tube) necessary. After 60 days, the prosthesis was replaced with a new made out of the same material but with a larger diameter and a softer consistency, which was removed after 4 months. The patient completely recovered her respiratory function and also maintained normal vocal cord activity without any kind of surgical sequelae. The full success was possible because of the involvement of different specialists.

Cause Analysis of Injury-Related Out-of-Hospital Cardiac Arrest in the Elderly - Corrected Proof

2012-04-05

Summary: Background: The purpose of this study was to investigate the causes of injury-related out-of-hospital cardiac arrest (OHCA) in patients; the differences between elderly and younger patients were investigated. We believe that identifying the causes of cardiac arrest in different patient groups, may help emergency physicians to make better decisions and thus improve the development of preventive strategies in the future.Methods: A retrospective review was carried out of injury-related OHCA patients who were > 17 years old, and who were admitted to the emergency department (ED) of a medical center in northern Taiwan, between January 1 and December 31, 2005. Details of demographics, witness reports, mode of transport, outcome, and cause of injury-related OHCA were collected and analyzed.Results: Ninety-four patients met our inclusion criteria; 5 patients (5.3%) survived to hospital discharge, but all had significant neurological deficits. Twenty patients were > 65 years old, and were defined as elderly; 74 patients, who were defined as adults, were between 18 and 64 years old. The survival rate in the elderly group was 15.0% (3/20), and in the adult group was 2.7% (2/74); there was no significant difference between the elderly and adult groups (p=0.063). In the adult group, the leading cause of injury-related OHCA was a traffic accident, but in the elderly group, the leading cause was mechanical airway obstruction (choking); these results are statistically significant.Conclusion: In this study, choking was found to be the leading cause of injury-related OHCA in the elderly and traffic accidents were the leading cause in adults. Five patients (5.3%) survived, but all had significant neurological deficits. Because of the poor outcomes of injury-related OHCA patients, it is proposed that prevention may be the best strategy for these patients' survival.

Choroidal Neovascular Membrane in Age-Related Macular Degeneration is Associated with Increased Interleukin-6 - Corrected Proof

Zuhal Yildirim, Nil Irem Ucgun, Filiz Yildirim, Aylin Sepici-Dincel — 2012-04-05

Summary: Background: Age-related macular degeneration (AMD) is the leading cause of irreversible visual impairment and blindness among persons aged 60 years and older. Although inflammation has been postulated to have a role in the pathogenesis of AMD, epidemiologic studies have not shown a relationship between systemic inflammation or presence of inflammatory markers at AMD. The aim of our study was to evaluate the differences in various types of cytokines and intracelluler signaling molecules for the onset and progression of AMD.Materials and methods: There were two groups in our study; Group 1, which acted as the control group (n=30, mean age 67.60±8.32 years), and Group 2, consisting of AMD patients (n=22, mean age 70.10±10.33 years). From serum samples, vascular endothelial growth factor (VEGF) (pg/mL), interleukin-6 (IL-6) and interleukin-1β (IL-1β) (pg/mL), nitrotyrosine (nmol/L) levels were determined by enzyme linked-immuno-sorbent assay method. Nitrite/Nitrate levels were measured by photometric method (μmol/L).Results: There were no significant differences between the groups with regard to age, VEGF, IL-1β, nitrite/nitrate, and nitrotyrosine. The significant result was the mean IL-6 levels that were higher in the AMD group (55.03±60.03pg/mL) than in the control group (16.08±8.24pg/mL, p<0.001).Conclusion: IL-6 induces an ocular inflammatory response often accompanied by the breakdown of the blood–ocular barrier. The increased levels of IL-6 can support the hypothesis that AMD may be partially mediated through inflammatory mechanisms.

Association between Platelet Count and Components of Metabolic Syndrome in Geriatric Taiwanese Males - Corrected Proof

2012-04-05

Summary: Background: With the growing number of elderly population in Taiwan and many other countries, the role of metabolic syndrome (MetS) has become more important recently. Although had been reported in different age groups, the relationship between platelet and MetS in the geriatric population still remains unknown.Method: We included 1187 Taiwanese males who were older than 65 years. In this study, we excluded individuals with abnormal platelet counts to reveal a more clear relation between platelet counts and MetS. Platelet counts were analyzed among patients with and without MetS. We divided platelet counts into four groups according to quartiles arbitrary of platelet counts (lowest, PC1; highest, PC4). The number of MetS components was compared between platelet groups with analysis of variance. We also used simple correlation and multivariate linear regression to find the relationship between platelet counts and MetS components.Results: We found that the platelet counts were higher in the group with MetS but not significantly different (p = 0.675). The fasting plasma glucose (FPG), total cholesterol, low-density lipoprotein-cholesterol (LDL-C), triglyceride (TG), and Log-triglyceride (Log-TG) were all statistically different across the four platelet groups. These four components were also positively correlated to platelet count in simple correlation. Not surprisingly, FPG, LDL-C, TG, and Log-TG were positively correlated with platelet count in multivariate linear regression.Conclusion: FPG, LDL-C, TG, and Log-TG were positively correlated with platelet count among the MetS components in geriatric Taiwanese males. The role of HDL-C and LDL-C in the definition of MetS should be re-evaluated.

Gastric Variceal Bleeding in the Elderly - Corrected Proof

2012-04-05

Summary: Background: Upper gastrointestinal bleeding of all causes has a higher morbidity and mortality in older patients compared with younger patients. We retrospectively studied gastric variceal bleeding in older patients and compared the complications and outcomes of endoscopic variceal obliteration with younger patients.Methods: From August 2002 to August 2010, a total of 76 patients with gastric variceal bleeding who had received endoscopic variceal obliteration using Histoacryl as an adhesive agent by a single endoscopist were studied. Their chart records were obtained and reviewed with data collection. Patient demographics, laboratory parameters, etiology of liver cirrhosis, Child-Pugh classification, endoscopic findings, complications after endoscopic treatment, and mortality were gathered and analyzed.Results: A total of 26 (34.2%) of the 76 patients were older than 64 years. There were patients who were younger than 64 years who had more variceal bleeding as compared with the older patients. In older patient groups, women were more likely to have gastric variceal bleeding than their male counterparts. The most common type of gastric varices was gastroesophageal varices type 2 (GOV2). Significant difference existed in the etiology of cirrhosis between the two groups, with more hepatitis B and alcoholic hepatitis in the younger patients and more hepatitis C in the older patients. Significantly more Child-Pugh classification B and C cases were noticed in the younger patients. There were no significant differences of mortality and complications after treatment, including recurrent bleeding and sepsis, between the older and younger patients.Conclusion: There was no significant difference in outcomes after endoscopic treatment between the younger and the older patient groups. Endoscopic variceal obliteration using Histoacryl as an adhesive agent could be applied to treat older patients with gastric variceal bleeding just as it is for younger patients.

Bioelectrical Impedance Analysis in a Mathematical Model for Estimating Fat-free Mass in Multiple Segments in Elderly Taiwanese Males - Corrected Proof

2012-04-05

Summary: Background: This research applied bioelectrical impedance analysis (BIA) and Dual-Energy X-ray AbsorptioMetry (DXA) to measure the body composition of Taiwan elderly. We developed the new mathematical estimation model for fat free mass of multiple segments.Methods: The modified BIA instrument with 8 electrodes (BIA8) at 50 kHz and 0.4 mA was used to measure the bioelectrical impedance of whole body and all limb segments of 33 male elderly in Taiwan. The criterion fat free mass (FFM) values in whole body and all limb segments were determined by DXA. After analyzing by linear regression, we obtained the FFM estimation equation for limb segments. The Bland-Altmen analysis were used to evaluate the differences existed between the estimation FFM from equation by BIA and from by DXA.Result: The correlation efficient (R) with standard deviation (SD) of FFM measured by DXA v.s. estimated by BIA in whole body, lower limbs, upper limbs and trunk were 0.942 with 2.660 kg, 0.859 with 0.713 kg, 0.922 with 0.265 kg and 0.884 with 1.917 kg, respectively. The relative high in the weight coefficients of h2/Z for estimation equation implied the critical role played by height and BIA values.Conclusion: In summary, the multiple segments FFM estimated by BIA were highly relative to that of determined by DXA for elderly in Taiwan. It is feasible to apply in monitoring the body composition in elderly by fast, non-invasive and convenient way.

Music Therapy with Ethnic Music for Dementia Patients - Corrected Proof

Yuki Tanaka, Hiroki Nogawa, Hiroshi Tanaka — 2012-04-04

Summary: Background: Dementia is already critical issues in the world when the society experiences super-aging. This situation requires establishment of rehabilitation methods for relieving symptoms of the patients. We have done research based on our assumption that most effective music therapy differs from culture, because music is dependent on cultural context. Here, we propose a hypothesis that the Japanese music gives better effects to Japanese patients than Classical music.Methods: In this study, we collected 87 volunteers including 79 dementia patients, 5 people <65 years old, 1 early-stage senior (65–74), and 2 late-stage senior (>75). We let the volunteers hear music prepared by us as follows: we selected 2 songs (Major/Minor with the same tonality) from famous nursery songs, 2 songs from famous play songs, and we composed 2 original songs (Major/Minor) with one tonality. We prepared 2 classical music as follows: one has scale of C Major and the other has scale of C Minor. We observed their response in 2 ways: one is physiological response measured by Near-Infrared Spectroscopy (NIRS), which reveals changes of blood flow, and the other is subjective response measured by questionnaires.Results: Our result showed dementia patient has tendency for judging Major on the Japanese music, whereas normal people has tendency judging Minor on them.Conclusion: Our results revealed characteristic responses of dementia patients onto the Japanese music, and we expect our result provides an evidence for better music therapy for dementia patients with Japanese culture.

Impact of Cognitive Impairment in a Multicentric Cohort of Polypathological Patients - Corrected Proof

2012-03-29

Summary: Background: Little is known about the prevalence and impact of cognitive impairment in polypathological patients (PPs).Objectives: To assess the prevalence of cognitive impairment (CI) and delirium, their associated risk factors, and their impact on survival of a multicenter population of PPs.Methods: Prospective cohort study. Descriptive analysis of the prevalence, main clinical features of PPs with basal CI (by means of Short Portable Mental Status Questionnaire), and delirium (Confusion Assessment Method); and bivariate as well as multivariate assessment of the factors associated with both conditions. Survival analysis after 12 months follow-up by means of Kaplan–Meier curves, and multivariate analysis of mortality risk factors in PPs with CI, and those with delirium.Results: CI was present in 39% [28% mild to moderate (3–7 errors), and 11% severe (≥ 8 errors)] of the 1434 PPs assessed [in the remaining 11% (n=198) delirium was detected]; only 26% of them had been previously diagnosed with dementia. One-year mortality was 46%/31.4% in those with/without CI [p<0.0001; relative risk (RR)=1.8 (1.5–2.3)]. Mean survival was 305±4/266±5 days in those with/without CI (p<0.0001). One-year mortality was 54.5%/34.8% in PPs with/without delirium, [p<0.0001, RR=2.25 (1.65–3)]. Mean survival after inclusion was 296±4/241±10 days in those with/without delirium (P<0.0001). Factors independently associated with mortality in PPs with CI were the presence of a concomitant active neoplasm [p=0.007; RR=3 (1.3–6.7)], severe dyspnea (p=0.04; RR=1.6 (1.02–2.6)], higher comorbidity load (p=0.003; RR=1.2 (1.07–1.4)], and ≥ 4 hospital admissions in the previous 12 months [p<0.0001; RR=5.2 (2.4–11.5)]. Factors associated with mortality in PPs with delirium were age ≥ 85 years [p=0.021, RR=2.3 (1.14–4.6)], chronic liver disease (p=0.019, RR=5.9 (1.3–25)], severe dyspnea [p=0.007; RR=2.7 (1.3–5.4)], plasma creatinine levels > 2mg/dL [p=0.003; RR=7.8 (2–26)], and polypharmacy [p=0.0019; RR=3.1 (1.2–8.1)].Conclusion: CI, as well as delirium, is common in PPs. Both play a deleterious role in 12-month survival. A systematic cognitive assessment as well as prevention and early detection of delirium should be included in the clinical care of all PPs.

Functional Decline Over 1-year Follow-up in a Multicenter Cohort of Polypathological Patients: A New Approach to Functional Prognostication - Corrected Proof

2012-03-29

Summary: Background: Little is known about the fitness of the available tools in predicting functional decline of polypathological patients (PPs). Our objective was to assess accuracy of the Triage Risk Screening Tool (TRST), the Variable Indicative of Placement risk (VIP) and to develop a specific functional prognostic index adjusted to this population in a multicenter cohort of hospital-based PP.Methods: Prospective 12-month follow-up study of PPs from 36 hospitals. Functional decline was defined as loss of ≥20 points on Barthel’s index (BI). Accuracy of TRST/VIP was assessed by calibration/discrimination tests. Development of the new score was performed by dividing into a derivation cohort (constructing the index by logistic regression), and a validation cohort (in which calibration/discrimination of the index were tested).Results: Nine hundred and fifty-eight patients from the 1632 included survived during follow-up. Basal/12-month BI was 85/70, respectively. Mean fall in BI score was 11.7±24 points [353 (36.8%) fell by ≥20 points]. The activities for daily living that declined most frequently were toilet use, grooming, dressing and bathing. TRST/VIP fitted well but their discrimination power was poor (area under the curve=0.49 and 0.46, respectively). A simplified PROFUNCTION index was derived containing seven items (≥85 years, neurological condition, osteoarticular disease, III–IV functional class of dyspnea, ≥4 polypathology categories, basal BI<60, and social problems). Functional decline risk ranged from 21% to 24% in the lowest risk group (0 items) to 38–46% in the highest (4–7 items). Calibration as well as discrimination power (area under the curve=0.56–0.59) of this simplified index were good.Conclusion: We developed and validated a new functional prognostic index specifically focused on these patients with better discrimination power than other tools available.

Assessment of Individual Activities of Daily Living and its Association with Self-Rated Health in Elderly People of Taiwan - Corrected Proof

Yu-Ning Hu, Gwo-Chi Hu, Chia-Yu Hsu, Shiau-Fu Hsieh, Chin-Ching Li — 2012-03-29

Summary: Background: Functional status is an important component of health status of the elderly. However, few studies have discussed the correlation between health status and each item of the activities of daily living scales (ADLs). The aim of this study was to investigate both the prevalence of functional disability in each activity of daily living (ADL) item and the association between each ADL item and the self-rated health of the elderly.Methods: A stratified random sample of 302 male and 298 female elderly residents, aged 65 and older, in Miaoli County was drawn. Baseline characteristics, functional status of each ADL item, and self-rated health of the participants were collected.Results: The results showed that the self-rated health status was excellent, good, or fair in 72.3% of the sample, and bad or poor in 27.7%. The most common disability among basic ADLs was transfers (9.3%); the most common disability among instrumental ADLs (IADLs) was transportation (24.7%). Multiple logistic regression analysis revealed that bathing, feeding, dressing, bowel and bladder control, transfers, transportation, and responsibility for own medication, were independently associated factors of self-rated health. Bowel and bladder control (odds ratio, 4.72; 95% confidence interval, 1.76–12.67) and feeding (odds ratio, 4.27; 95% confidence interval, 1.61–11.37) were the leading items correlated with self-rated health.Conclusion: In summary, in terms of self-rated health, the most important ADLs were bowel and bladder control and feeding. Further study is warranted to investigate the effects of restoring specific health-related ADL to improve the health of the elderly.

Aortic Dissection Mimics Acute Abdomen in an Older Patient - Corrected Proof

Chi-Hung Lo, Chun-Chang Chen, Chao-Wen Hsueh, Hsien-Kuo Chin, Nang-Hsiung Feng — 2012-03-27

Summary: Aortic dissection is a relatively uncommon illness, but it often presents with acute hemodynamic compromise and severe chest pain. Early diagnosis and treatment are crucial for survival. Patients with an aortic dissection typically present with an acute, severe, sharp, or “tearing” posterior chest or anterior chest pain or back pain. We describe one example of ascending aortic dissection show atypical symptoms. And the symptoms are similar to acute abdomen initially. We should always keep in mind that the possibility of aortic dissection when a widened mediastinum is noted despite of atypical symptoms for aortic dissection.

Development of a New Fall Risk Assessment Index for Older Adults - Corrected Proof

2012-03-26

Summary: Background: Falls are the third-leading cause of a bedridden state and are a major cause of morbidity in elderly people. Therefore, it is important to determine an older person’s risk of falling using a simple and reliable method. The aim of the present study was to examine whether our newly developed index for the assessment of complex-task locomotion can predict falls in robust elderly people.Methods: The new index consisted of four items (stand-up, turn, walk and trip tests). It was used to assess 780 community-dwelling elderly Japanese people (mean age 76.0±7.4 years, 300 men and 480 women) who could complete a Timed Up and Go test in less than 13.5 seconds. We used receiver operating characteristic curves (ROC) to validate the index and to determine its cut-off point to predict falls.Results: The area under the curve was 0.15 (p<0.001, 95% CI: 0.675-0.755). The ROC curve analysis enabled the best cut-off (1 point) to discriminate fallers from non-fallers (sensitivity 80.8%, specificity 60.6%).Conclusion: We have demonstrated that the new index is a reliable indicator for falls in elderly people who have higher levels of functional capacity. Our data suggest that a score of more than 1 point by the new index can predict falls in robust elderly people.

Geriatric Inpatient Units in the Care of Hospitalized Frail Adults with a History of Heart Failure - Corrected Proof

2012-03-23

Summary: Background: Frail hospitalized older adults are at risk for adverse outcomes. Previous studies have suggested benefits for inpatient geriatric management (GEM). We sought to determine whether hospitalized patients with a history of heart failure (HF) benefitted from inpatient GEM or not.Methods: We studied 309 inpatients previously diagnosed with HF who were participants in a randomized trial of geriatric evaluation and management (GEM) versus usual care (UC). The intervention involved multidisciplinary teams that provided comprehensive geriatric assessment. We evaluated health-related quality of life (HRQOL), basic activities of daily living (ADLs), health service utilization, and survival at discharge, 6 months, and 1 year post randomization.Results: GEM patients had higher mean change scores for physical function (unadjusted means: 0.17 vs. –4.67, p = 0.046) and basic ADLs (1.25 vs. 0.67, p = 0.003) at hospital discharge, which remained significant after adjusting for baseline HRQOL scores and in-hospital days. Outcomes were not significantly different at 1 year. Length of stay for GEM was greater than UC (24 days vs. 17 days, p = 0.03), but total costs at 1 year were not different (p = 0.9). Mortality rates at 1 year were high and similar (GEM 29.0%, UC 27.3%, p = 0.73) in both the groups.Conclusion: Inpatient GEM was associated with better maintenance of physical function and basic ADLs at hospital discharge; however, no differences in HRQOL or survival were observed between GEM and UC at 1 year post randomization. Restructuring inpatient care models to incorporate inpatient GEM principles may be one method to optimize health-care delivery.

Association Between Platelet Count and Components of Metabolic Syndrome in Geriatric Taiwanese Women - Corrected Proof

2012-03-23

Summary: Background: The growing elderly population in Taiwan, as in many other countries, has resulted in increased importance of the metabolic syndrome (MetS). Although it has been reported in different age groups, the relationship between platelets and MetS remains unknown in geriatric patients.Patients and Methods: We enrolled 1460 women >65 years old. Women with a known history of diabetes, hyperlipidemia or hypertension or those taking medication for these conditions were all excluded. The women were further divided into quartiles arbitrarily according to platelet count (PC) (PC1–PC4, lowest to highest accordingly).Results: Among the MetS components, body mass index (BMI), total cholesterol, low-density lipoprotein cholesterol (LDL-C) and log transformation triglyceride (Log TG) were all significantly higher in the PC4 group (p < 0.05), and they were also positively correlated with PC. However, in multiple regression, BMI became nonsignificant. Both LDL-C and Log TG were the only two factors that remained positively and independently correlated with PC. Compared to PC1, all the other three groups had significantly higher odds ratios for having MetS (2.013, 1.473–2.751; 1.486, 1.081–2.042; 1.537, 1.117–2.114; odds ratios and 95% confidence intervals for PC4, PC3 and PC2, respectively).Conclusion: Elderly women with MetS had higher PC. Among the five components, TG was positively correlated with PC. There was a positive correlation between PC and LDL-C but not high-density lipoprotein cholesterol. The importance of both lipids might be re-evaluated in the future in older women.

Erythrocytosis Secondary to Testosterone Therapy in a Male with Cryptorchidism: A Case Report - Corrected Proof

2012-03-22

Summary: Hypogonadism is association with aging (andropause) can now be recognized earlier and treated with testosterone, thus resulting in the relief of symptoms and better quality of life. However, any patients that are treated with testosterone must be closely monitored in order to avoid the development of sleep apnea, cardiovascular diseases, hepatic dysfunction, plasma lipid disorders, or erythrocytosis, all of which are potential side effects of treatment. Herein, we present a case of erythrocytosis secondary to testosterone treatment in a patient with cryptorchidism. Hemoglobin levels returned to normal soon after phlebotomy and discontinuation of testosterone therapy. Physicians should be aware of the side effects of testosterone replacement therapy and cautiously monitor patients in order to avoid these side effects and cumbersome and expensive laboratory tests.

Small Bowel Obstruction Secondary to a Mushroom Bezoar: Case Report - Corrected Proof

Cuiping Liu, Haijun Deng, Zhenshu Zhang, Lan Bai — 2012-03-22

Summary: A bezoar is an accumulation of indigestible exogenous matter in the stomach and the intestine. The clinical diagnosis of bezoar is challenging, and initial radiographs are frequently nondiagnostic. Computed tomography (CT) has become a useful method in diagnosing the presence and cause of small bowel obstruction. The most common CT finding of phytobezoars includes a round or ovoid mass containing mottled gas at the obstructed site. We report one case of small bowel obstruction secondary to bezoar that is composed of mushroom, but without a characteristic bezoar CT imaging.

Sigmoid Pseudovolvulus in the Elderly - Corrected Proof

Huan-Lin Chen, Ming-Jong Bair — 2012-03-22

One 73-year-old woman suffering from dementia presented with general weakness, poor appetite, and abdominal pain that had been manifesting for 1 week. The other symptoms included diarrhea and fever. Physical examination revealed diffuse abdominal distension without tenderness. An abdominal plain film showed dilatation of the sigmoid colon, including the presentation of the coffee bean sign. A diagnosis of sigmoid volvulus was considered (, arrow). Computed tomography demonstrated bowel wall thickening that involved the rectum and sigmoid colon with proximal megacolon. Significant laboratory data demonstrated hypoalbuminemia (2.3g/dL albumin; normal range: 3.4–4.8g/dL). Human immunodeficiency virus was not detected. Colonoscopy revealed multiple broad-based longitudinal ulcers with multiple papules on the bases in the rectum and sigmoid colon (). Pathological results revealed colonic mucosa with ulcers and acute and chronic inflammatory infiltration. Some cells were positive for cytomegalovirus, which is compatible with a diagnosis of cytomegalovirus colitis. After receiving nutritional supplements and supportive treatment, her bowel condition improved and she was symptom-free for half a year.

Plasma Uric Acid is Associated with Postinfarction Cardiac Remodeling in Elderly with Old Myocardial Infarction - Corrected Proof

Gang Li, Zhi-Hua Wang, Bing-Bao Zhu, Can-Jing Zhang — 2012-03-22

Summary: Background: The increased plasma uric acid has been documented in ischemic cardiomyopathy (ICM) and heart failure in other age ranges in human and in animal models. However, it remains incompletely clear whether plasma uric acid is associated with cardiac remodeling, ischemic cardiomyopathy and heart failure in elderly. So, the objective of the study was to investigate whether plasma uric acid was associated with postinfarction cardiac remodeling in elderly with a previous myocardial infarction.Methods: Data of 246 elderly aged 60 years and older with angiography-confirmed coronary heart disease and myocardial infarction were analyzed. Among the patients, 89 had ICM defined as left ventricular end-diastolic diameter [men > 55mm, women > 50mm (60.74±5.79mm)] measured by echocardiography. Difference in plasma uric acid was analyzed between patients with and without ICM.Results: There was significant increase in plasma uric acid in ICM compared with non-ICM (444.66±160.97umol/L vs. 372.59±131.31umol/L, p=0.000), and plasma uric acid was significantly positively related to left ventricular end-diastolic diameter (r=0.312, p=0.000).Conclusions: Plasma uric acid is significantly increased in elderly with ICM complicated with previous myocardial infarction as well as with those elderly patients who have postinfarction cardiac remodeling and previous myocardial infarction.

Pneumoperitoneum Presenting as Minimal Left Subphrenic Air in an Elderly Patient - Corrected Proof

Ding-Kuo Chien, Wen-Han Chang, Shu-Tien Huang — 2012-03-22

A 68-year-old man visited the emergency department complaining of sudden onset of epigastric pain within 1h, but he felt the pain had subsided on arrival at the emergency department. The patient reported an 8-year history of a gastric ulcer, but otherwise he had never been hospitalized before. Upon physical examination, the patient appeared to be in mild distress but he had normal vital signs. His upper abdomen was mildly tender and soft and had normal bowel sounds. Laboratory data showed a white cell count of 8800/μL with 83% segmented neutrophils. Supine chest () and abdominal () radiographs were considered unremarkable initially. Unfortunately, the patient’s epigastric pain became worse 4h later. Minimal left subphrenic free air between the left diaphragm and the stomach was found after a careful review of these radiographs, and the presence of pneumoperitoneum was confirmed by computed tomography (). The patient began to receive intravenous antibiotics immediately before emergency surgery, during which a gastric ulcer with perforation was found. He recovered well and was discharged uneventfully 2 weeks later.

The Body Mass Index and Related Factors of Aged Living in a District of Istanbul, Turkey - Corrected Proof

2012-03-22

Summary: Background: To determine the nutritional status of elderly by body mass index (BMI) and to investigate associated factors.Methods: This is a cross-sectional, descriptive and analytic study done among 309 elderly, in the Besiktas district of Istanbul from January to December 2008. The interviews were performed face-to-face. Anthropometric measurements (height, weight) were taken and BMI was calculated and classified according to World Health Organization standards.Results: According to BMI classification, 1.6% were underweight, 15.2% were normal, 32.4% were overweight, 46.3% were obese and 4.5% were morbidly obese. A gradually lower BMI was observed with the progression of age. According to the study, obesity rates tended to be higher in those with inferior educational background. The study also revealed that diabetes mellitus is more prevalent in those that are overweight, obese and morbidly obese than those that are underweight and normal. In addition, hypertension is a more common ailment along obese and morbidly obese elders. On the contrary, osteoporosis is more prevalent among underweight and normal elders than those that are classified as obese and morbidly obese.Conclusion: BMI provides valuable insight in lieu of nutritional status and health state of the elderly in the primary health care unit.

Bloodstream Infections in the Elderly: Effects of Nursing Homes on Antimicrobial-Resistant Bacteria - Corrected Proof

2012-03-22

Summary: Objectives: Emergency room visits by nursing home patients with bloodstream infections (BSIs) are not uncommon and pose challenges to clinicians when selecting appropriate antimicrobial agents. This research aims to discover distinct bacteriology in nursing home patients by focusing particularly on antimicrobial-resistant bacteria.Methods: This retrospective study enrolled patients aged 65 years or older who had documented positive blood culture reports between May 2006 and June 2008. Patients were further categorized into subgroups according to nursing home history and the timely trend of hospital exposure.Results: The adjusted risk of BSIs associated with nursing home exposure was significantly higher in Methicillin-resistant Staphylococcus aureus (odds ratio (OR) 2.0; 95% CI 1.5–2.8), Methicillin-resistant coagulase-negative Staphylococcus species (OR 1.7; 95% CI 1.2–2.5), and Enterobacteriaceae-extended spectrum β-lactamase-producing Enterobacteriaceae (OR 2.4; 95% CI 1.5–3.9), but not in Pseudomonas aeruginosa (OR 1.4; 95% CI 0.9–2.2) or Acinetobacter baumannii (OR 0.9; 95% CI 0.5–1.5).Conclusion: Host environments—nursing home or hospital exposure—were shown to be more significant than medical comorbid conditions for acquiring antimicrobial-resistant pathogens. Each unique environment increased the risk for acquiring some pathogens, but not all. In addition, these environmental factors may also exert cumulative effects toward some specific pathogens.

Assessment of a New Method to Verify Feeding Tube Placement by Syringe Aspiration in a Porcine Model - Corrected Proof

2012-03-22

Summary: Background: Malpositioned feeding tubes carry the risk of serious complications. However, common bedside methods of differentiating tracheal from gastric feeding tube placement are neither accurate nor practical. Therefore, we conducted an animal study to verify feeding tube placement by syringe aspiration test.Methods: A total of 26 pigs were anesthetized and intubated with tracheal tubes in the trachea and the esophagus. The animals were divided into two groups. The animals in the mechanical ventilation group were paralysed and received mechanical ventilation. The animals in the spontaneous breathing group maintained spontaneous breathing. The feeding tubes were then inserted through the tracheal tubes, into the trachea and esophagus, so that the anterior openings of the feeding tubes were located in the trachea and esophagus. A feeding syringe was then attached and 30ml of air was aspirated into the syringe. The ability to aspirate air without resistance was defined as a positive syringe aspiration test. If there was resistance as air was aspirated, it was defined as a negative syringe aspiration test. In the next step, 20 esophageal ventilations were given to create a distended stomach in the experimental animals, and the syringe aspiration test was repeated in the same manner described above.Results: The syringe aspiration test was positive for feeding tubes placed in the trachea and was negative for feeding tubes located in the esophagus in both the mechanical ventilation group and the spontaneous breathing group.Conclusion: The syringe aspiration test is an effective method of differentiating tracheal from esophageal feeding tube placement.

Effect of 3-Month Tai Chi Chuan on Heart Rate Variability, Blood Lipid and Cytokine Profiles in Middle-Aged and Elderly Individuals - Corrected Proof

Wan-An Lu, Cheng-Deng Kuo — 2012-03-22

Summary: Background: To investigate the effect of 3 months of Tai Chi Chuan (TCC) training on heart rate variability, blood lipids and cytokine production in elderly people.Methods: This was a longitudinal study with 3 months of follow-up. Participants were recruited from the community and divided randomly into two groups. The TCC trainees exercised the classical Yang's TCC for 40 minutes/session, seven times/week over a course of 3 months. Twenty-five TCC trainees (median age=57.0 years, range=50.0–67.0 years) and 25 control individuals (median age=53.0 years, range=46.5–58.5 years) were included in this study.Results: TCC training for 3 months significantly increased the fasting blood sugar (p<0.001), ratio of forced expiratory volume in the first second to the forced vital capacity (FEV1/FVC) (p<0.05), high-density lipoprotein-cholesterol (HDL-C) (p<0.05), tumor necrosis factor-α (TNF-α) (p<0.001), and interferon-γ (IFN-γ) (p<0.001) in the TCC trainees. In contrast, the total cholesterol (TC) and the ratio of TC to HDL-C (TC/HDL-C) of the TCC trainees were all significantly decreased after 3 months of TCC training (p<0.001). However, all heart rate variability (HRV) measures were not significantly changed after 3 months of TCC.Conclusion: Three months of TCC training can improve the pulmonary function, glucose availability and blood lipid profile, as well as increase the cytokine production, in middle-aged and elderly individuals. TCC may be beneficial to middle-aged and elderly people as a health-promoting calisthenics.

Tuberculous Pleural Effusion in the Elderly - Corrected Proof

2012-03-22

Summary: Background: Tuberculous pleural effusion is the second most common form of extrapulmonary tuberculosis. The relationship between the geriatric population and tuberculous pleural effusion has rarely been studied.Methods: This is a retrospective study. From January 2005 through February 2009, we retrospectively enrolled 51 patients older than 18 years of age that were diagnosed with tuberculous pleurisy. We analyzed the clinical presentations and laboratory data of pleural effusion in elderly and adult groups.Results: Of these patients, 32 were more than 65 years of age (elderly group) and 19 were less than 65 years of age (adult group). Chest pain occurred more frequently in the adult group than the elderly group (52.6 % vs. 15.6 %; p < 0.01). Ziehl-Neelsen stain and Lowenstein-Jensen culturing of the pleural fluid demonstrated similar diagnostic sensitivities between the adult and elderly groups. The pleural fluid consists almost exclusively of exudates, with lymphocytes being the most predominant finding. Regardless, lower lactate dehydrogenase (LDH) and protein contents in the pleural effusion of the elderly group were noted. The duration between thoracentesis and administration of antituberculous therapy was significantly longer in elderly group (12.4 ± 15.4 vs. 4.4 ± 5.5 days; p = 0.03).Conclusion: Tuberculous pleurisy in elderly patients has less specific symptoms and laboratory findings. It may require a longer time to confirm diagnosis and start treatment.

Characteristics and Outcome for Very Elderly Patients (≥ 80 years) Admitted to a Respiratory Care Center in Taiwan - Corrected Proof

Jian Su, Chang-Yi Lin, Shiow-Kwan Chen, Ming-Jen Peng, Chien-Lien Wu — 2012-03-22

Summary: Background: The aim of the study was to assess the characteristics of and outcomes for very elderly patients (≥ 80 years) with prolonged mechanical ventilation (PMV) under the mandatory integrated delivery system (IDS) in Taiwan.Method: This was a retrospective observational study conducted in a step-down respiratory care center (RCC) among adult patients aged > 45 years on prolonged mechanical ventilation (≥ 21 days) between January 2006 and December 2008.Results: A total of 288 patients (63 aged 45–65 years, 115 aged 66–79 years, and 110 aged ≥ 80 years) were included in the study. There were more female patients in the oldest group (p<0.01). A cardiovascular disorder as the main reason for ventilator dependence was associated with increasing age (p<0.01). A longer RCC stay in the oldest compared to the youngest group was noted (30 vs 25 days, p=0.02). Some 126 patients (43.8%) were weaned; there was a trend for successful weaning in relation to age group (p=0.04). However, RCC mortality was not associated with age (p=0.44). For weaned patients, those in the oldest group had higher mortality in long-term follow-up (p=0.03). For patients with weaning failure, age had no influence on long-term weaning outcome or mortality rate (p=0.56 and 0.69, respectively).Conclusion: The oldest PMV patients (≥ 80 years) had lower weaning probability and a poorer outcome even if they were weaned from the ventilator in the RCC. For patients with weaning failure, age had no impact on weaning outcome and long-term survival rate after they were transferred to a step-down care facility.

Predicting Comorbidities, Nutritional Status, and Neuropsychological Performance of Depressed and Nondepressed Geriatric Communities: A Comparative Study - Corrected Proof

Lai Kuan Lee, Suzana Shahar, Ai-Vyrn Chin — 2012-03-22

Summary: Background: The understanding of the relationship between comorbidities, nutritional status, and cognitive manifestations in depression is limited. This study investigated and compared the association between comorbidity status, nutritional status, and neuropsychological performance in depressed and nondepressed community-dwelling older adults.Methods: This cross-sectional study recruited 318 elderly people aged 60 years and above from 15 low-cost public residential buildings located in the Cheras area, Malaysia. Structured in-person questionnaires were administered to obtain information regarding demographic, socioeconomic, and psychosocial characteristics. The GDS-15 Geriatric Depression Scale was used to measure depressive symptomatology with a threshold of ≤4/≥5. Comorbidity status was confirmed by examination of medical records. Indication of nutritional status included anthropometric measurements, nutritional intake assessments, and biochemical analyses. Comprehensive neuropsychological assessments were conducted to assess cognitive function. All tested parameters were compared with the symptoms of depression.Results: The prevalence of depressive symptoms was 30.2%. Subjects who were lacking habitual exercise were two-fold more likely to have symptoms of depression (adjusted odds ratio: 2.163; 95% confidence interval: 1.236–3.788; p < 0.01). Depressed and nondepressed patients had the same trends in comorbidity status, and no significant differences were noted between the groups on any of the nutritional assessments. However, depressed patients had poorer global cognitive functions (F = 4.740, p < 0.05) and verbal immediate verbal learning and memory (F = 4.113, p < 0.05) compared with the nondepressed patients.Conclusion: This study found that less exercise is an independent predictor of depressive symptomatology. Cognition-enhancing interventions are needed for the at-risk elderly with depressive symptoms in order to prevent the progression to severe depression.

Torsades de Pointes in an Elderly Patient with “Broken Heart Syndrome” - Corrected Proof

Yi-Chun Lai, Pai-Feng Hsu — 2012-03-21

Summary: Broken heart syndrome, also called transient left ventricular apical ballooning syndrome (TLVABS), is described as an acute cardiomyopathy characterized by acute, but rapidly reversible, left ventricle systolic dysfunction in the absence of atherosclerotic coronary artery disease which appears to be triggered by intense psychological and physical stress. The syndrome is also named takotsubo syndrome, ampulla cardiomyopathy, or stress-induced cardiomyopathy. We report a woman aged 75 years with dyspnea, ST-segment elevation in the precordial leads, elevation of cardiac enzymes, and normal coronary arteriography. Transient apical systolic left ventricular dysfunction and pneumonia were suspected. Gradual prolongation of QT interval and torsades de pointes (TdP) subsequently occurred. Patients had a complete recovery of cardiac function, normalization of QT interval, and normal apical cardiac wall motion in a few days after lidocaine pump and empiric antibiotics use. Since TdP is rarely reported with TLVABS, we should pay more attention to postmenopausal women with chest pain and elevated cardiac enzymes. We should keep TLVABS in mind and use convenient tools, such as bedside echocardiography, for diagnosis.

Acute Ischemic Stroke with Multiple Infarctions in the Posterior Circulation Complicating Diagnostic Coronary Angiography in an Octogenarian: A Case Report - Corrected Proof

Wai-Kin Wong, Yen-Wei Hsu, Yi-Lan Lin, Wen-Ko Su — 2012-03-21

Summary: Diagnostic coronary angiography is sometimes complicated by acute stroke. An 82-year-old woman suddenly became unresponsive shortly after undergoing coronary angiography. Both of her pupils were dilated and unresponsive to light, and doll’s eye movements were absent. An emergency computed tomography showed no intracranial hemorrhage. Magnetic resonance imaging performed the following day revealed an acute infarction of the left thalamus, mid-brain, and cerebellum. Computed tomographic angiography showed total occlusion of the tip of the basilar artery. Multiple infarctions secondary to occlusion of the basilar artery tip as a complication of coronary angiography has not been reported in an octogenarian.

Spontaneous Intramural Small-Bowel Hematoma: A Rare Complication of Anticoagulant Therapy in an Elderly Patient - Corrected Proof

Chih-Cheng Lai, Chu-Hsin Chuang, Chien-Ming Chao, Wei-Lun Liu, Ching-Cheng Hou — 2012-03-21

Summary: Intramural hematoma of the small bowel is an infrequent complication of the use of oral anticoagulants. Here, we describe the case of a 74-year-old man who was undergoing anticoagulant therapy and presented with abdominal pain, nausea, vomiting, and a prolonged prothrombin time (INR > 8). Computed tomography of the abdomen showed a thickened small-bowel wall that involved efferent bowel loops. Exploratory laparotomy confirmed ecchymosis and edematous changes to several segments of the small bowel that resulted in obstruction. In conclusion, the incidence of this clinical entity is believed to be on the rise in the growing number of elderly patients currently on anticoagulant therapy, and physicians must keep this rare clinical entity in mind when treating patients.

Cutaneous Type of Nocardiosis Caused by Nocardia brasiliensis in an Elderly Patient - Corrected Proof

Chen-Yi Su, Chung-Shu Lin, Sui-Hing Yan, Chung-Kwe Wang — 2012-03-21

Summary: Acute soft tissue infection with Nocardia brasiliensis is an uncommon manifestation in the elderly. A case of cellulitis and an abscess on the foot due to N. brasiliensis in a 77-year-old man with chronic obstructive pulmonary disease is reported. N. brasiliensis was isolated from fluid from the bulla. Treatment with trimethoprim–sulfamethoxazole for 6 months led to complete resolution and no evidence of recurrence was noted. Nocardia infection must be considered in the differential diagnosis for elderly patients with soft tissue infection, especially in those with severe underlying diseases, and we suggest that trimethoprim–sulfamethoxazole is an effective and safe treatment.

Comparison of Pulmonary Embolism and Subsequent Cardiovascular Events Between Elderly and Young Patients in the Emergency Department - Corrected Proof

Yen-Yi Feng, Wen-Han Chang, Shu-Tien Huang, Ming-Yuan Huang — 2012-03-21

Summary: Background: Pulmonary embolism (PE) has been associated with the risk of arterial cardiovascular events, with diagnosis being difficult in older adults. Multiple factors contribute to mortality and morbidity in older adults. Hence, we aimed to investigate the difference of subsequent cardiovascular events (SCVE) and demography between younger and older adults.Methods: We undertook a retrospective cohort study using data from a 1100-bed urban medical center in Taipei, Taiwan. All patients who presented to the emergency department with a documented diagnosis of PE (ICD-9 of 415.19), from January 2003 to December 2008, were enrolled and specified into two age groups. Clinical follow-up was conducted until December 2009, with a median time of 3.5 years. The SCVE included new onset of ischemic stroke or heart attack and recurrence of PE. The time between when a patient was presented to the ER and when the diagnosis took place was assessed.Results: A total of 104 patients were studied, among which 58 patients were placed in the elderly group (≥ 65 years old) and 46 were placed in the young group (< 65 years old). There were significantly more females in the elderly group (n=43; 74.1%; p<0.05). Underlying morbidities including diabetes mellitus (DM), chronic renal failure, hypertension, ischemic stroke, ischemic heart disease, and heart failure were significantly more predominant in the elderly group. There was no significant difference between the two groups in terms of clinical presentation and the incidence of massive PE. A total of 9 patients (8.7%) expired during their hospital stay, with no difference between the two groups. SCVE showed only a significant difference among new ischemic heart disease (n=6; 10.3%). There was a significant difference in diagnosis intervals between the two groups (elderly=48.5±83.9hours; young=21.4±38.5 hours; < 0.05).Conclusion: Diagnosis intervals in the elderly were widely variable. Rapid and precise diagnosis of PE in the emergency department remains a challenge. Clinical presentations gave less useful information to make a correct diagnosis of PE, especially in the elderly. There are more new episodes of ischemic heart disease in the elderly followed by PE, but no significant difference in the overall SCVE between the two groups. The relationship between SCVE and age in patients with PE may need further evaluation.

Relationship between Orthostatic Blood Pressure Changes and Postural Sway When Standing up from a Chair in Older Adult Females - Corrected Proof

Jun Murata, Shin Murata, Jun Horie, Hiroshi Ohtao, Junya Miyazaki — 2012-03-21

Summary: Background: Orthostatic reductions in blood pressure upon standing are common among the elderly. This orthostatic blood pressure changes may relate to the augmentation of postural sway and may be an important risk factor for falls. Thus, to clarify whether orthostatic blood pressure change on standing up from a chair is relevant to postural sway, we simultaneously measured changes in blood pressure and the movement of a weighted center upon standing.Methods: A total of 63 older adult females were investigated. Blood pressure [systolic blood pressure (SBP), diastolic BP] measured in a sitting position were defined as the baseline levels. The movement of center of pressure (COP) was measured using a stable force platform to quantify postural stability. Participants were instructed to stand up from a chair on the platform and maintain an upright position with their eyes open for 40 seconds. Upon standing, the participant’s blood pressure and the movement of COP were recorded. Pearson’s correlation was performed to determine relationships between the changes in BP and the movement of COP [distance of the movement of COP (LNG), envelopment area traced by the movement of COP (AREA)].Results: SBP was reduced while maintaining an upright position for 40 seconds (–5.0 ± 8.6 mmHg), but not diastolic BP (0.6 ± 4.3 mmHg). Moreover, the change in SBP showed a negative relationship with LNG (r = –0.43, p < 0.01) and AREA (r = –0.31, p < 0.05).Conclusion: These results suggested that postural change influenced SBP, and that the drop of SBP was associated with augmentation of postural instability in older adult females.

Changes in CD4+CD25+Foxp3+ Regulatory T Cells in Relation to Aging and Lung Tumor Incidence - Corrected Proof

2012-03-21

Summary: Background: CD4+CD25+Foxp3+ regulatory T (Treg) cells mediate immunosuppression and play an important role in tumor immune evasion. Studies have demonstrated that this cell population represents an aging-related change. It is not clear whether this change leads to higher tumor incidence in the elderly. We investigated changes in CD4+CD25+Foxp3+ Treg cells in relation to aging and tumor incidence.Methods: We set up a Lewis lung cancer model with 26 C57BL/6 female mice. The animals were divided into six groups: young healthy, middle-aged healthy, elderly healthy, young tumor, middle-aged tumor and elderly tumor. We evaluated changes in CD4+CD25+Foxp3+Treg cells in the spleen of all animals using a flow cytometry method. Levels of Foxp3 m RNA in splenocytes were measured using a real-time RT-PCR method.Results: The CD4+CD25+Foxp3+/CD4+T cell ratio (t=2.23, p=0.032) and Foxp3 mRNA levels (t=3.26, p=0.0042) were higher in the tumor groups than in the healthy groups. In the healthy groups, there was a significant increase in CD4+CD25+Foxp3+ Treg cells on aging (F=47.70, p=0.000); elderly mice had a significantly greater population of CD4+CD25+Foxp3+ Treg cells in spleen compared to the younger groups. The highest population was observed in the elderly tumor group. The same trend was evident for Foxp3 mRNA (F=6.56, p=0.0090).Conclusions: The results suggest a close relationship between changes in CD4+CD25+Foxp3+ Treg cells and aging and lung tumor genesis and development.

Mortality Factors Regarding the Injury Severity Score in Elderly Trauma Patients - Corrected Proof

2012-03-21

Summary: Introduction: Mortality of trauma patients is strongly associated with Injury Severity Score (ISS). However, the interaction between ISS and age has not been studied extensively. We evaluated ISS in different age groups in relation to mortality rate.Materials and methods: This was a retrospective review of 955 trauma patients who visited Mackay Memorial Hospital during January–December 2009. Age, sex, emergency department (ED) stay time, hospital stay time, out-of-hospital cardiac arrest, in-hospital cardiac arrest, ED survival rate, emergency operation, and mortality were analyzed. Patients were separated into two groups by age below or above 65 years, and hospital courses and mortality rate were compared.Results: Nine hundred and fifty-five trauma patients visited our ED in 2009: 212 in the aged group (99 male patients; 46.7%) and 743 in the young group (472 male patients; 63.5%). The mean age of the elderly group was 77±8 years (mean±standard deviation), and 38±16 years in the young group. Mean ISS was 12±12 in the elderly group and 10±13 in the young group. The mean ED stay time was 2.9±3.8 hours for the elderly group and 3.0±4.6 hours for the young group. One hundred and sixty-three patients were admitted and the mean hospital stay time was 12.7±13.6 days in the elderly group, whereas 559 patients were admitted and the mean hospital stay time was 9.9±13.7 days in the young group (p=0.018). The mortality rate among hospitalized patients was 3.1% in the elderly group and 2.9% in the young group. On receiver operating characteristic curve analysis, the optimal cut-off ISS for mortality rate among young patients (area under the curve: 0.899) and elderly patients (area under the curve: 0.782) was 17 (sensitivity: 81.3%; specificity: 88.7%) and 14 (sensitivity: 80%; specificity: 82.3%), respectively.Conclusion: The elderly group seemed to have no significant difference from the younger group for mortality rate, ED stay time and hospital stay time. In the elderly group, lower ISS predicted a higher mortality than in the younger group.

Knowledge and Attitude toward Hospice Palliative Care among Community-Dwelling Aged Taiwanese—Analysis of Related Factors - Corrected Proof

Ching-Ping Hsu, Hong-Wen Chen, Shih-Yi Lee, Meng-Ting Tsou — 2012-03-21

Summary: Background: This study was conducted to investigate the knowledge and attitude toward hospice palliative care (HPC) among the elderly, defined as 65 years of age and older, living in the metropolitan area of Taiwan.Methods: A cross-sectional questionnaire survey was conducted among the elderly people who received a senior citizen health examination from March to November 2009. A total of 1332 valid questionnaires were returned.Results: Among these individuals, 57.0% recognized the term HPC, of which only 11.7% had heard it from healthcare personnel; 15.2% would like to endorse “Do-Not-Resuscitate” (DNR) on the National Health Insurance Integrated Circuit Card (NHI IC card); and among the 477 participants considering themselves to understand HPC, 65.1% did not think that HPC meant “DNR.” The analysis of t-test and analysis of variance indicates that better knowledge of HPC is more likely present among the participants with higher education levels, those who adopt healthy behaviors, individuals who are aware of HPC, and those who believe that they understand the concept of HPC. The logistic regression analysis demonstrated that a high percentage of the participants who were younger and had higher education levels and who paid attention to news related to health and medicine chose to endorse DNR on the NHI IC card.Conclusion: Providing information to those who are less educated and do not adopt healthy behaviors can improve overall HPC-related knowledge and the endorsement rate of “DNR” on the NHI IC card. Meanwhile, healthcare personnel are encouraged to discuss end-of-life care with elderly people at the proper time.

Variations of Aripiprazole-Induced Dyskinesia Existing with Concurrent Use of Amantadine and an Anticholinergic Agent in an Elderly Patient - Corrected Proof

I-Wen Sun, Ying Lin, Shen-Ing Liu, Chau-Shoun Lee — 2012-03-16

Summary: Elderly patients are vulnerable to the adverse neurological effects of antipsychotics, particularly Parkinsonian symptoms and tardive dyskinesia. This vulnerability in the elderly becomes complex and unpredictable when aripiprazole is prescribed to replace other second-generation or first-generation antipsychotics. This report describes a 69-year-old female schizophrenic patient, who received aripiprazole after using a few antipsychotics, including the first- and second-generation ones. The tardive dyskinesia developed 6 weeks after switching to aripiprazole but subsided 4 weeks later when stopping the concurrent amantadine and decreasing the dosage of trihexyphenidyl. However, Parkinsonian symptoms developed insidiously thereafter, which remitted after the dosage of trihexyphenidyl was increased again. The possible mechanisms of the alternated adverse neurological events after a switch to aripiprazole in the chronic elderly psychosis are discussed.

A Case of Sporadic Creutzfeldt–Jacob Disease with Unusually Long Survival: Correlation with Clinical Features, Electroencephalogram, and Brain Magnetic Resonance Imaging - Corrected Proof

Chih-Hao Jason Lin, Lu-An Chen, Pei-Hao Chen, Shih-Jung Cheng — 2012-03-16

Summary: Dementia in the elderly is the most common neurodegenerative disease and places a huge burden on public health. Sporadic Creutzfeldt–Jacob disease (sCJD) is sometimes diagnosed in people with dementia; it develops in a rapid and progressive manner and has a short survival duration. The critical issue for sCJD is its transmissible nature. Besides rapid and progressive dementia, two out of four motor symptoms are assessed for a definitive diagnosis, including myoclonus, cerebellar problems, extrapyramidal/pyramidal features, and akinetic mutism. Here we report on a 77-year-old woman with initially pure dementia. Sequential neuroimaging revealed progressive isolated cortical effects over a period of 3 years. Basal ganglia involvement on neuroimaging and generalized periodic sharp wave complexes on electroencephalogram were delayed until the onset of reflex myoclonic jerks occurred 3 years after the onset of dementia. The patient survives, with an unusually long duration for sCJD. According to the clinical and laboratory features observed in this case, awareness of pure dementia with delayed onset of characteristic electroencephalogram features and isolated cortical effects on neuroimaging may predict unusually long survival in sCJD.