The impact and cost of influenza in the elderly

BACKGROUND: Traditional methods of measuring the impact and cost of influenza virus have focused on epidemic years and morbidity and mortality due to pneumonia and influenza. METHODS: Annualized age-sex-race adjusted rates of hospitalization for pneumonia and influenza and other diagnoses among elderly Medicare beneficiaries during the epidemic influenza season of 1989 to 1990 and the nonepidemic season of 1990 to 1991 were compared with an interim period in 1990 without influenza virus circulation. RESULTS: The rates of hospitalization for pneumonia and influenza, acute bronchitis, chronic respiratory disease, and congestive heart failure were significantly greater during each influenza period compared with the interim period. The highest rates were found in the epidemic season of 1989 to 1990. The amount reimbursed by Medicare to hospitals to 1990. The amount reimbursed by Medicare to hospitals for the treatment of excess hospitalizations during periods of influenza activity was more than $1 billion in 1989 to 1990 and almost $750 million in 1990 to 1991. CONCLUSIONS: Measures of the impact and cost of influenza in elderly Americans should include all of the diagnoses listed above and should recognize that the impact of influenza virus is significant even in nonepidemic years. There are great opportunities for cost savings if effective control programs are implemented.     

Fibronectin in host defense: implications in the diagnosis, prophylaxis and therapy of infectious diseases

A polymerase chain reaction (PCR) was developed for the detection of Clostridium botulinum type A, a cause of human botulism. A two primer set and an oligonucleotide detection probe were used to specifically detect Cl. botulinum type A neurotoxin gene (BoNT/A). After 40 cycles of amplification, detection of a 798 bp amplified DNA fragment was carried out by agarose gel electrophoresis and Southern blot hybridization. This assay was able to detect 12.5 fg of purified target DNA or five bacteria per reaction. The sensitivity in artificially contaminated food samples after an 18 h enrichment step ranges from 10 to 10(3) bacteria per g according to the type of food samples. No cross-reactions were observed with the other Cl. botulinum toxinotypes and other bacteria found routinely in food. This PCR method may provide a suitable and rapid alternative to standard techniques for detection of Cl. botulinum type A in food samples.     

Renal replacement therapy in the elderly

Before 1980 few patients over the age of 65 started chronic dialysis, despite the fact that the incidence of advanced chronic renal failure was approximately ten times greater in this group compared to young and middle aged adults. Since that time the number of elderly patients starting renal replacement has increased markedly and accounted for 38% of new dialysis patients in Scotland in 1995. (Data supplied by the Scottish Renal Registry). In order to meet the needs of older patients with chronic renal failure there has been considerable expansion in renal services and it has been predicted that this will continue to increase in Scotland until 2010.     

Vitamin supplementation therapy in the elderly

Vitamin supplementation in large dosages is increasingly common in the older population. Often, such supplementation is used in an attempt to improve an individual's health status. There have been claims that the effects of vitamins halt the normal aging process or prevent and cure disease. However, several recent studies have failed to demonstrate the efficacy of vitamin supplementation in preventing several types of cancer. In moderate dosages, supplementation with vitamin E (tocopherols) shows promise as a lipid antioxidant, and may reduce the risk of coronary heart disease. However, before vitamin E becomes an accepted medical therapy, further long term studies must be undertaken to examine the safety and efficacy of such therapy. An adequate intake of vitamins should be ensured by adherence to a well balanced diet. However, the elderly are prone to circumstances that may prevent them from eating a balanced diet. In addition, there are several age-related medical conditions that may predispose individuals to dietary and vitamin deficiencies. To prevent vitamin deficiency diseases and their associated morbidity, modest vitamin supplementation may be necessary. However, supplementation should be reserved for individuals with documented deficiency or who are at risk of developing such deficiencies, especially those who are homebound or institutionalised. Vitamins taken in large dosages should be considered as drugs. These medicines, which are obtainable over-the-counter, should be carefully regulated to prevent toxicity.     

Characteristics of antibiotic therapy in the elderly

In the elderly, the morbidity and mortality rates of infections are significantly increased. Atypical or nonspecific symptoms or their absence often delay the diagnosis. When providing treatment, in addition to microbiological specifics of infections in the aged, consideration must also be given to pharmacokinetic aspects when choosing a suitable antibiotic. Furthermore, any existing medication must be taken into account in order to avoid interactions and undesirable drug effects. In view of the elevated mortality and multimorbidity rates, the early use of antibiotics is of considerable importance. If no specific etiological diagnosis is available, a broad-spectrum antibiotic should be administered.     

Hepatitis C virus infection in the elderly. Epidemiology, prophylaxis and optimal treatment

Chronic infection with the hepatitis C virus (HCV) occurs throughout the world and appears to be the main cause of hepatocellular carcinoma. Studies have shown that, in areas of high endemicity, the prevalence of HCV infection is low in children but high in people aged > 60 years. Medical interventions were found to play an important role in the spread of HCV infection, because elderly patients became infected via contaminated blood transfusions or when contaminated syringes and needles were used. Maternal and sexual transmission do not appear to be the main routes of HCV infection. Interferon treatment eliminates HCV in 20 to 30% of patients with chronic HCV infection. The response to interferon therapy is usually complete in 70 to 80% of people with low levels of HCV RNA, HCV of genotype 2 and young women, but poor in elderly patients. Because liver disease can be severe in elderly patients, more effective therapies are clearly needed.     

Tianeptine therapy for depression in the elderly

PURPOSE: Data on patients with cancer of the larynx are analyzed using statistical models to estimate the effect of gaps in the treatment time on the local control of the tumor. METHODS AND MATERIALS: Patients from four centers, Edinburgh, Glasgow, Manchester, and Toronto, with carcinoma of the larynx and treated by radiotherapy were followed up and the disease-free period recorded. In all centers the end point was control of the primary tumor after irradiation alone. The local control rates at > or = 2 years, Pc, were analyzed by log linear models, and Cox proportional hazard models were used to model the disease-free period. RESULTS: T stage, nodal involvement, and site of the tumor were important determinants of the disease-free interval, as was the radiation schedule used. Elongation of the treatment time by 1 day, or a gap of 1 day, was associated with a decrease in Pc of 0.68% per day for Pc = 0.80, with a 95% confidence interval of (0.28, 1.08)%. An increase of 5 days was associated with a 3.5% reduction in Pc from 0.80 to 0.77. At Pc = 0.60 an increase of 5 days was associated with an 7.9% decrease in Pc. The time factor in the Linear Quadratic model, gamma/alpha, was estimated as 0.89 Gy/day, 95% confidence interval (0.35, 1.43) Gy/day. CONCLUSIONS: Any gaps (public holidays are the majority) in the treatment schedule have the same deleterious effect on the disease free period as an increase in the prescribed treatment time. For a schedule, where dose and fraction number are specified, any gap in treatment is potentially damaging.     

Use of antihypertensive drugs and trends in blood pressure in the elderly

BACKGROUND: During the 1980s data became available from randomized trials concerning the clear benefits of treating hypertension in the elderly. In three large communities, we examined the impact of these findings on rates of treatment, use of specific antihypertensive drugs, and rates of elevated blood pressure as well as distributions of levels. METHODS: In 1981 the National Institute on Aging initiated population-based cohort studies in the residents of three communities who were 65 years and older. East Boston, Mass; Washington and Iowa counties, Iowa; and New Haven, Conn. Participation rates ranged from 80% to 85% across sites with 10,294 community-dwelling participants in the combined cohorts. Baseline evaluation included inhome blood pressure assessment and medication inventory. Repeated in-home evaluations occurred 3 and 6 years after baseline and follow-up rates ranged from 71% to 88%. RESULTS: Use of antihypertensive drugs increased over time in all three communities: the age- and sex-adjusted rates of use were between 14% and 32% higher in 1988 and 1989 relative to 1982 and 1983. Parallel declines in the use of thiazide diuretics occurred in all three populations along with large increases in the use of angiotensin-converting enzyme inhibitors and calcium channel blockers. In East Boston and New Haven mean systolic blood pressure decreased substantially over time and the prevalence of elevated systolic pressure (> or = 160 mmHg) decreased overall as well as by age and sex. In Iowa the mean levels of systolic blood pressure were lowest at baseline and increased slightly. CONCLUSIONS: The reported evidence about the benefits of treatment for hypertension in the elderly was followed by substantial increases in treatment rates. The use of drugs with proven efficacy declined while the use of newer agents with theoretical advantages, not yet tested in clinical trials of mortality, increased. In the United States, the ongoing therapeutic efforts to lower elevated blood pressure in elderly populations may be contributing to the continuing decline in cardiovascular and stroke mortality.     

Electroconvulsive therapy in therapy refractory depression in the elderly. Report of experiences

The aetiology of idiopathic facial nerve palsy (Bell's palsy) and sudden deafness are not known, although viruses have been suspected as a cause of them. We investigated the relationship between Bell's palsy or sudden deafness, and reactivation of cytomegalovirus, human herpesvirus 6 (HHV-6) and 7 (HHV-7). Paired sera were collected from 22 patients with Bell's palsy and 24 patients with sudden deafness. IgG antibody titres to HHV-7 were increased in one patient with Bell's palsy. IgG antibody titres to HHV-6 were increased in one patient with Bell's palsy and two with sudden deafness. IgG antibody titres to cytomegalovirus were increased in one patient with sudden deafness. Titres of the three viral antibodies were not increased simultaneously in any patients. These viruses may contribute to the development of Bell's palsy or sudden deafness in some cases. It is, however, unlikely that these viruses are the main cause of Bell's palsy and sudden deafness in the majority of patients.     

Qualitative interview study on acceptance of influenza vaccination among the elderly

Nine elderly men and women were interviewed in order to discover factors of importance in accepting influenza vaccinations. The study demonstrated that the fee to be paid by the patients was a considerable barrier to an improvement of the vaccination rate. The elderly informants were all aware that influenza vaccine is available. Some informants expressed uncertainty whether they themselves belonged to the risk groups who should be vaccinated. Sources of information were the general practitioner (GP), relatives, and the mass media. More personal information from the GP to persons at risk was wanted. Influenza vaccination behaviour was found to be consistent with the Health Belief Model. The present organization of influenza vaccinations does not promote a sufficient immunization rate. The threshold for accepting influenza vaccinations appears to be too high for the elderly population.     

Risk of ulcer and its prophylaxis in therapy with non-steroidal antirheumatic drugs

Nonsteroidal antiinflammatory drugs (NSAIDs) are among the most frequently prescribed drugs in western countries. The high incidence of adverse gastrointestinal effects which are potentially life-threatening require steps for prevention. The use of NSAIDs should be restricted to patients with inflammatory rheumatic diseases. If NSAIDs are indicated it is important to identify patients who are at high risk to develop serious gastrointestinal side effects. These patients should receive Misoprostol at a dose of 2 to 3 x 200 micrograms per day. Up to date Misoprostol is the only drug with proven efficacy with respect to the prevention of gastroduodenal ulcer and its complications. NSAIDs inhibit the key enzyme of prostaglandin synthesis, the cyclooxygenase. Recently published data show that 2 isoenzymes of the cyclooxygenase exists. Cyclooxygenase-1 is primarily involved in the maintenance of organ function whereas cyclooxygenase-2 is expressed in inflamed tissue. Specific cyclooxygease-2 inhibitors have been developed. Clinical trials have to prove if the concept of a selective cyclooxygenase-2 inhibition with high antiinflammatory potency but lack of gastrointestinal side effects holds true in humans.     

Play therapy with the elderly: A case study.

This article reviews a project conducted with nursing home residents using child-centered play therapy. Play therapy was chosen as a therapeutic modality in order to reach this population more creatively. Three case studies are presented. Therapeutic changes were reported by the social worker, staff members, the elderly participants, and the author. Observed outcomes of therapy reported were decreased depression, heighten self-esteem, improved socialization skills, and what appeared to be resolution of difficult issues. A discussion of limitations, selection of clients, and suggestions for future use of play therapy with this population are included. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The choice of the optimal schedules in the vaccination procedure against influenza in elderly subjects

The paper describes a clinical case of the cerebral hyperperfusion syndrome, a rare complication of carotid endarterectomy. The syndrome appeared as the generalized convulsive syndrome in the patient in the early postoperative period. In the context of clinical observation, the results of analysis of the literature are presented and the pathogenesis, diagnosis, therapy, and prevention of the cerebral hyperperfusion syndrome considered.     

Cefotaxime prophylaxis in major non-contaminated head and neck surgery: one-day vs. seven-day therapy

Exfoliated cervical epithelial cells from women 6 weeks postpartum were analyzed for human papillomavirus (HPV) DNA using the polymerase chain reaction, and results were compared with those from buccal mucosal smears from their babies. Eleven mothers had genital genotypes of HPV in their cervical smears, and the children of 8 of these had HPV of the same genotype in buccal mucosal cell samples. Nineteen mothers had no HPV DNA detected in their cervical smears, and 1 of the buccal mucosal cell samples from their children was positive for HPV DNA (p < 0.0001). Contamination of a child's mouth with 'genital' HPV from a mother's cervix appears to occur commonly at birth or in the perinatal period, and to persist for at least 6 weeks. This observation has implications for the epidemiology and management of HPV associated cancer and precancerous conditions in the cervix and the mouth.     

Duration of antiviral prophylaxis during nursing home outbreaks of influenza A: a comparison of 2 protocols

BACKGROUND: We performed a randomized trial of 2 protocols guiding the duration of antiviral chemoprophylaxis during outbreaks of influenza A in a rural, 700-bed nursing home for veterans and their spouses with 14 nursing units in 4 buildings. METHODS: Half of all residents volunteered to participate. Nursing units were randomized, and the effectiveness of short-term (minimum, 14 days and 7 days without the onset of a case in the building) vs long-term (minimum, 21 days and 7 days without the onset of a case in the 4-building facility) prophylaxis was compared using amantadine hydrochloride in the influenza seasons of 1991-1992 and 1993-1994 and rimantadine hydrochloride in the influenza season of 1994-1995. A "case" is defined as an incident of a respiratory tract illness and the isolation of an influenza virus organism. We compared the number of cases after the discontinuation of short- vs long-term chemoprophylaxis. Prospective surveillance identified residents with new respiratory tract symptoms, and specimens for viral cultures were obtained even in the absence of temperature elevation. RESULTS: We documented influenza A virus activity during 3 seasons (32, 68, and 12 patients, respectively). During the 1991-1992, 1993-1994, and 1994-1995 influenza seasons, the patients on 11 floors were assigned to receive short-term chemoprophylaxis and those on 10 floors were assigned to long-term chemoprophylaxis. Only in 1993-1994 did chemoprophylaxis extend beyond 14 or 21 days when new cases continued beyond 14 days. Amantadine-resistant strains were circulating at that time. None of the participants in the prospective, controlled study had influenza develop after the termination of short- or long-term chemoprophylaxis. CONCLUSION: Antiviral chemoprophylaxis can be administered for the longer duration of 14 days or, in the absence of new culture-confirmed illness in the nursing building, for 7 days.     

Efficacy of an influenza hemagglutinin-diphtheria toxoid conjugate vaccine in elderly nursing home subjects during an influenza outbreak

OBJECTIVE: To compare the efficacy of an influenza hemagglutinin-diphtheria toxoid conjugate vaccine with the commercially available influenza hemagglutinin-subunit vaccine in preventing influenza in older adults living in a nursing home. DESIGN: A prospective, randomized, double-blind vaccine trial with 5 months of follow-up after vaccination. SETTING: Fourteen Wisconsin nursing homes. PARTICIPANTS: Nursing home residents at least 65 years old who were able to give informed consent and were free of malignancy and not receiving immunosuppressive therapy. INTERVENTIONS: Participants received, by intramuscular injection, 0.5 mL of a trivalent influenza vaccine containing 15 micrograms each of A/Leningrad/360/86 (H3N2), A/Taiwan/1/86 (H1N1), and B/Ann Arbor/1/86 (HA) or 0.5 mL of an influenza vaccine containing the same antigens conjugated to diphtheria toxoid (HA-D). MEASUREMENTS: Blood was obtained pre- and 1 month post-vaccination to assess for any vaccine-induced antibody titer change. Clinical surveillance for respiratory illness was performed twice weekly for 5 months. A record was kept of all signs and symptoms of new respiratory illness, and a viral culture and acute and convalescent sera were obtained. RESULTS: 204 participants received HA and 204 received HA-D. Both groups had similar baseline antibody levels to all influenza antigens. HA-D recipients seroconverted more frequently based on serum neutralizing activity (P < 0.05), had a greater increase in geometric mean titer (GMT), and sustained the increase in antibody titer longer than HA recipients. Vaccine hemagglutinin recall was greater in a subset of HA-D recipients as measured by lymphocyte proliferative assays (P < 0.05). During an outbreak of influenza A (H3N2 A/Shanghai/11/87-like and A/Victoria/7/87-like), fewer HA-D (29/195) than HA (43/204) recipients had laboratory-confirmed infection (P = 0.053), and, of these, fewer HA-D-treated subjects had lower respiratory tract involvement (5/29 HA-D and 17/43 HA) (P = 0.022). CONCLUSIONS: HA-D was more immunogenic in institutionalized elderly recipients and produced greater protection from influenza infection. Superior protection may be due to HA-D's ability to stimulate and recruit antigen-presenting cells, thus enabling the recipient to achieve and maintain functional antibody titers.