摘要:

OBJECTIVE: To assess the relation between age, sodium intake, renal blood flow (RBF) and the renal vascular response to an angiotensin converting enzyme (ACE) inhibitor, captopril.DESIGN: Blood flow studies were performed before and during the acute response to an oral 25‐mg dose of captopril, selected to induce a maximal response, after 5 to 7 days on a metabolic ward, sufficient time to have achieved external balance on a fixed low‐salt (10 mEq/day) or high salt (200 mEq/day) diet. Blood flow was measured as radioxenon transit through the kidney.SETTING: The study was performed on a metabolic ward, the Clinical Research Center, and in the Cardiovascular Radiology Laboratories of the Brigham and Women's Hospital in Boston.PARTICIPANTS: The participants, all community dwellers, were potential kidney donors, in a renal transplant program. They were thought to be sufficiently healthy to consider donation of a kidney. The age range was 18 to 69 years.RESULTS: Renal blood flow showed the anticipated decline with increasing age, whether the subjects were on a restricted or a liberal salt intake. Captopril induced an acute increase in RBF, averaging 88 ± 7 mL/100 g/min in subjects on a low‐salt diet, and 49 ± 9 mL/100 g/min in subjects on a high‐salt diet, but no influence of age was identified on the renal vasodilator response on either diet. Increasing age did not limit the renal vasodilator response, although subjects beyond the sixth decade were not studied.CONCLUSIONS: The limited renal vascular response to vasodilators we had documented in earlier studies does not extend to ACE inhibitors. Although ACE inhibitors lack the pharmacological specificity required to prove a role for angiotensin II (Ang II), the data are compatible with a contribution of Ang II to the maintenance of renal vascular tone that does not change with increasing age, at least to 70 yea

ISSN:0002-8614    

DOI:10.1111/j.1532-5415.1994.tb06550.x

出版商:Blackwell Publishing Ltd    

年代:1994

数据来源: WILEY

摘要:

OBJECTIVE: The purpose of this study was fourfold: to determine the rate of delirium among hospitalized older persons, to contrast the clinical outcomes of patients with and without delirium, to identify clinical predictors of delirium, and to validate the predictive model in an independent sample of patients.DESIGN: Two prospective cohort studiesSETTING: Medical and surgical wards of 2 university teaching hospitalsPATIENTS: In the derivation cohort, 432 patients were enrolled from the University of Chicago Hospitals. Patients 65 years of age or older admitted to 1 of 4 wards were eligible. Subjects were excluded if they were discharged within 48 hours of admission, unavailable to the research assistants during the first 2 days of hospitalization, or judged too impaired to participate in the daily interviews. In the test cohort, 323 patients 70 years of age or older admitted to Yale‐New Haven Hospital were studied.MEASUREMENTS: Subjects were screened for delirium daily and referred to experienced clinician investigators if acute mental status changes were observed. The clinician investigators assessed the patient for delirium based on DSM‐III‐R criteria. Duration of hospitalization was adjusted for diagnosis‐related groups (DRG) and mortality rates were determined at discharge and 90 days after discharge. Socio‐demographic characteristics, cognitive and functional status, comorbidity, depression, and alcoholism were examined as predictors of delirium.MAIN RESULTS: The rate of delirium in the derivation cohort was 15%; subjects with delirium had longer hospital stays and an increased risk of in‐hospital death. Cognitive impairment, burden of comorbidity, depression, and alcoholism were found to be independent predictors of delirium. The ability of the model to stratify patients as low, moderate, or high risk for developing delirium was validated in the test cohort in which the rate of delirium was 26%.CONCLUSIONS: This study confirms the high rate of delirium among hospitalized older persons and the associated adverse outcomes of prolonged hospital stays and increased risk of death. Patients can be stratified according to their risk for developing delirium using relatively few clinical characteristics which should be assessed, on all hospitalized ol

ISSN:0002-8614    

DOI:10.1111/j.1532-5415.1994.tb06551.x

出版商:Blackwell Publishing Ltd    

年代:1994

数据来源: WILEY

摘要:

OBJECTIVE: To describe the occurrence of severe gastrointestinal bleeding in community‐dwelling older persons and to examine whether disability is a risk factor for this life‐threatening condition independent of other known predictors.DESIGN: Prospective cohort survey.SETTING: Three communities of the Established Populations for Epidemiologic Studies of the Elderly (EPESE).PARTICIPANTS: 8205 persons age ≥68 years.MEASUREMENTS: The hospital discharge diagnoses provided by the Medicare Provider Analysis and Review files and the death certificates were prospectively surveyed for 3 years. Those with at least 1 discharge diagnosis of gastrointestinal bleeding and who received a blood transfusion or died were identified as cases of severe gastrointestinal hemorrhage. Physical disability, cognitive function, smoking and alcohol intake habits, body mass index, blood pressure, chronic conditions, number of hospital admissions in past year and medications taken were assessed at baseline.RESULTS: The occurrence rate of severe gastrointestinal bleeding was 10.8 per 1000 person‐years (241 events/22,277 person‐years). In proportional hazards regression models, compared with no disability, ≥ 1 disabilities in the Rosow‐Breslau scale (RR = 2.1, 95% CI = 1.5–2.9), and ≥1 ADLs limitations (RR = 3.1, 95% CI = 2.1–4.6) independently predicted gastrointestinal hemorrhage after adjusting for age, gender, body mass index, comorbidity, number of hospital admissions, blood pressure, intake of coumarin, corticosteroids, aspirin and other nonsteroidal antiinflammatory drugs.CONCLUSIONS: In this prospective analysis, disability is an independent predictor of gastrointestinal hemorrhage. Further studies are needed to explain the mechanisms by which disability may cause gastrointestinal hemorrhage. Because physical disability is potentially modifiable, strategies to lower the risk of gastrointestinal bleeding

ISSN:0002-8614    

DOI:10.1111/j.1532-5415.1994.tb06552.x

出版商:Blackwell Publishing Ltd    

年代:1994

数据来源: WILEY

摘要:

OBJECTIVE: To identify age‐related differences in the treatment of patients with acute myocardial infarction.DESIGN: Retrospective cohort study.SETTING: Two university‐affiliated medical centers with integrated clinical programs.PATIENTS: 329 patients admitted with acute myocardial infarction in 1988–1990 for whom complete medical records were available. Study exclusions included patients transferred from other hospitals specifically to undergo angiography or other cardiac procedures, nursing home residents, patients with metastatic cancer or dementia, and patients in whom “do not resuscitate” orders were written during the first 2 hospital days.MEASUREMENTS: Medical records were reviewed to determine socio‐demographic data, comorbidity, admission severity of illness, medications, the use of specific diagnostic and therapeutic modalities during and after hospitalization, treatment limitations, and patient outcomes.MAIN RESULTS: Chronological age of patients was related to the use of several diagnostic and therapeutic modalities. Using logistic regression to adjust for comorbidity, severity, infarct size and location, and other covariates, patients 75 years and older were 12 times less likely to receive thrombolytic therapy, 8 times less likely to undergo coronary angiography, and 7 times less likely to undergo coronary angioplasty than patients less than 65 years of age. However, age was not related to the use of other modalities, including echocardiography or gated blood pool scanning, pulmonary artery catheterization, and transvenous pacing. Finally, in a logistic regression model, the risk of in‐hospital death was 4 times greater for patients 75 years and older than patients less than 65 years.CONCLUSIONS: Physicians' management of patients with acute myocardial infarction differed greatly according to patient age for some diagnostic and therapeutic modalities, but not for others. These findings indicate that generalizations about age‐related practice variations should not be based on analysis of a single procedure. Moreover, judgments about the appropriateness of age‐related differences in management require knowledge of the relative effectiveness of management strategies in older and

ISSN:0002-8614    

DOI:10.1111/j.1532-5415.1994.tb06553.x

出版商:Blackwell Publishing Ltd    

年代:1994

数据来源: WILEY

摘要:

OBJECTIVE: To describe the prevalence and 9‐month incidence of depressive symptoms among a cohort of elderly primary care patients and to determine whether different patterns of depression are associated with different patterns of health services use.DESIGN: Prospective study of depressive symptoms as measured by the Center for Epidemiologic Studies Depression (CES‐D) scale and identification of patients' outpatient health services use through an electronic medical record system.SETTING: An academic primary care group practice at an urban ambulatory care clinic.PATIENTS/PARTICIPANTS: 1711 patients aged 60 and older who completed the CES‐D at baseline and 9 months later; 935 of these patients also completed the CES‐D at 6 months.MEASUREMENT AND MAIN RESULTS: The prevalence of significant symptoms of depression (CES‐D ≥ 16) was 17.1% at baseline and 18.8% at 9 months; 26.8% of patients exceeded the threshold on the CES‐D either at baseline or 9 months, and the 9‐month incidence was 11.7%. Among the patients re‐interviewed at both 6 and 9 months, the 6‐month incidence was 12%, and the incidence between the 6‐ and 9‐month assessments was 10%. Of the 292 patients with depression at baseline, 140 (47.6%) remained depressed at the 9‐month follow‐up. Baseline and 6‐month CES‐D score, in addition to perceived health at 6 months, explained 45% of the variance in the 9‐month CES‐D score. Patients above the threshold on the CES‐D at any time were more likely to rate their health as fair or poor (69.8% vs 43.7%) and more likely to have an emergency room visit (40.4% vs 29.4%). These patients also had 38% more outpatient visits (7.7 vs 5.6) and 61% higher total outpatient charges ($1209 vs $751) than patients who never exceeded the CES‐D threshold over the 9‐month window (allPvalues<0.01).CONCLUSIONS: Depressive symptoms were frequent and often persistent in this patient population. We identified patterns of oscillating severity of symptoms within individuals but relatively stable incidence and prevalence rates over a 9‐month period. Patients who exceeded the threshold on the CES‐D at any time during the study had significantly greater he

ISSN:0002-8614    

DOI:10.1111/j.1532-5415.1994.tb06554.x

出版商:Blackwell Publishing Ltd    

年代:1994

数据来源: WILEY

摘要:

OBJECTIVE: Facilitate primary care physicians' compliance with recommended standards of care for late life depression by reducing barriers to recognition and treatment.DESIGN: Randomized controlled clinical trial of physician‐targeted interventions.SETTING: Academic primary care group practice caring for an urban, medically indigent patient population.PATIENTS/PARTICIPANTS: Patients aged 60 and older who exceeded the threshold on the Centers for Epidemiologic Studies Depression Scale (CES‐D) and the Hamilton Depression Rating Scale (HAM‐D) and their primary care physicians.INTERVENTION: Physicians of intervention patients were provided with patient‐specific treatment recommendations during 3 special visits scheduled specifically to address the patient's symptoms of depression. In general, physicians were encouraged to establish a diagnosis of depression and educate their patient about the diagnosis, discontinue medications that can cause or exacerbate depressive symptoms, initiate antidepressants when appropriate, and consider referral to psychiatry. Guidelines for prescribing antidepressants were provided. Control physicians received no intervention, and control patients received usual care.MAIN OUTCOME MEASURES: Frequency of recording a depression diagnosis, stopping medications associated with depression, initiating antidepressant medication, and psychiatry referral; mean changes in HAM‐D and Sickness Impact Profile (SIP) scores.RESULTS: One hundred three physicians and 175 patients were involved in the clinical trial. Physicians of intervention patients were more likely to diagnose depression and prescribe antidepressants (P<0.01). There were no differences between the groups in the frequency of stopping medications associated with depression or referrals to psychiatry. Medications with the strongest cause and effect relationship to depression were infrequently used in this cohort of patients. Although both groups showed improvement in HAM‐D and SIP scores, we were unable to demonstrate significant differences in HAM‐D or SIP scores between the 2 groups.CONCLUSIONS: Intensive screening and feedback of patient‐specific treatment recommendations increased the recognition and treatment of late life depression by primary care physicians. However, we were unable to demonstrate significant improvement in depression or disability severity among intervention patients despite the informational support provided to their physicians. Efforts to improve the functional status of these patients may require more integrated interventions and more aggressive attempts to target psychosocial stressors traditionally outside the purview

ISSN:0002-8614    

DOI:10.1111/j.1532-5415.1994.tb06555.x

出版商:Blackwell Publishing Ltd    

年代:1994

数据来源: WILEY

摘要:

OBJECTIVE: To identify the prevalence and character of psychological disorders accompanying chronic dizziness in older patients.DESIGN: Case series of patients from a geriatric dizziness clinic, with comparison data from age‐ and sex‐matched healthy community controls. Both cases and controls received screening psychological testing; all cases were evaluated by a clinical psychologist as part of the dizziness clinic evaluation.SETTING: Multidisciplinary Geriatric Dizziness Clinic.PARTICIPANTS: Fifty six consecutive patients with chronic dizziness, evaluated by a multidisciplinary Geriatric Dizziness Clinic, and 68 healthy volunteers whose age and sex distribution matched that of the dizziness clinic patients.MEASUREMENTS: Standardized questionnaire for medical, functional, and demographic data; the anxiety, depression, somatization, and phobic anxiety subscales of the Symptom Checklist‐90 (SCL‐90‐R); the Tinetti gait and motor screen; a physical therapy evaluation; selected laboratory tests; evaluation by a geriatrician; and a formal evaluation by a clinical psychologist, including a semi‐structured interview. Psychological diagnoses were assigned based on DSM‐III‐R criteria.MAIN RESULTS: Of these patients with chronic dizziness, 37.5 percent had a psychological diagnosis causing or contributing to their dizziness problem. Of these, only 3 were felt to have a primary psychological cause of their dizziness, and 18 had secondary psychological diagnoses. Anxiety disorders, depression, and adjustment reactions were the most common diagnoses. On multivariate analysis, factors predicting a psychological diagnosis were a positive response to hyperventilation testing, a high score on the SCL‐90 anxiety subscale, and fatigue as a precipitant of dizziness. In addition, dizziness clinic patients scored significantly higher (P<0.001) on all 4 subscales of the SCL‐90 when compared with the healthy elderly, suggesting a greater degree of psychological distress among these elderly with chronic dizziness.CONCLUSIONS: Psychological disorders are rare as primary causes but are common as contributing or modulating factors in older per

ISSN:0002-8614    

DOI:10.1111/j.1532-5415.1994.tb06556.x

出版商:Blackwell Publishing Ltd    

年代:1994

数据来源: WILEY

摘要:

PURPOSE: To identify medical care indicators for nursing home terminal care.DATA SOURCES: Studies examining care of terminally ill patients were identified using computer, bibliography, and expert searches; input from nursing home medical directors in Maryland; and input from expert geriatricians.STUDY SELECTION: More than 900 articles, books, and abstracts from meetings covering medical care for terminally ill patients were reviewed. Information from more than 100 publications is included.DATA EXTRACTION: Indicators of medical care for terminally ill patients, which can be used to quantify performance with respect to standards, guidelines, and options, were identified initially through review of the literature.DATA SYNTHESIS: Indicators were refined by input from medical directors of Maryland long‐term care facilities and subsequent review by expert geriatricians.CONCLUSIONS: Minimum standards for which 100% performance is expected are communication of advance directives, attention to pain control, and attention to relief of dyspnea. Performance indicators for medical care guidelines and options in terminal care of nursing home patients are also describe

ISSN:0002-8614    

DOI:10.1111/j.1532-5415.1994.tb06557.x

出版商:Blackwell Publishing Ltd    

年代:1994

数据来源: WILEY

ISSN:0002-8614    

DOI:10.1111/j.1532-5415.1994.tb06558.x

出版商:Blackwell Publishing Ltd    

年代:1994

数据来源: WILEY

ISSN:0002-8614    

DOI:10.1111/j.1532-5415.1994.tb06559.x

出版商:Blackwell Publishing Ltd    

年代:1994

数据来源: WILEY