The safety and efficacy of electroconvulsive therapy in patients over age 75

OBJECTIVES: To examine the safety and efficacy of electroconvulsive therapy (ECT) in patients over the age of 75 years. METHOD: Retrospective study of all patients over 75 years treated with ECT in three hospitals between 1995 and 1997. RESULTS: Ninety-three ECT courses were administered during the study period. Ten patients (10.8%) suffered complications following ECT. The most common adverse events were prolonged confusion and hypomania, all of which resolved within 2 weeks of the cessation of treatment. Eighty-five per cent of patients made a marked or moderate response to treatment. CONCLUSIONS: ECT is a relatively safe and effective procedure in patients over age 75.     

Cancer chemotherapy in patients older than 75 years old--from the aspect of clinical pharmacology

A review concerning cancer chemotherapy in older patients from the aspect of clinical pharmacology was performed. Age-related physiological changes, comorbid disease, polypharmacy, and social issues are major problems in older patients with cancer. Pharmacokinetics of anticancer agents change according to physiological changes, and distribution, metabolism and excretion may change. Resistance to anticancer agents is more common. Side effects are more severe and frequent because of age-related physiological changes and comorbid disease. Since the interindividual difference is large in the elderly, the individual dose of anticancer agents must be determined especially for patients older than 75 years old.     

Management of myocardial infarction in patients over 75 years of age compared to patients under 75 years of age. Apropos of 594 consecutive cases admitted between 1991 and 1994

This study analyses the patients consecutively admitted for myocardial infarction between January 1991 and December 1994. The study population consisted of 594 patients divided into two groups: 446 patients under the age of 75 years and 178 patients over the age of 75 years. The sex-ratio showed a male predominance (84%) before 75 years, and a female predominance (57%) after 75 years. A history of angina was more frequent in elderly patients (45% vs 30%, p < 0.001), who were admitted later (22.5% vs 46.6% before the 6th hour, p < 0.001). Thrombolysis was administered in 49.6% of subjects under the age of 75 years and in 17.3% of elderly patients. The course was uneventful in 56.7% of subjects under the age of 75 years and in 28.2% of elderly patients. Mortality was 6-fold higher in this group (22% vs 3.7%, p < 0.01). The cause of death was usually heart failure with a 10-fold higher frequency of cardiogenic shock (13.5% vs 1.4%, p < 0.001). Coronary angiography was performed in 81.4% of subjects under the age of 75 years and in 30% of the elderly patients. Multi-vessel lesions were more frequent in elderly subjects (78.4% vs 47.5%, p < 0.01). Revascularization by angioplasty or bypass graft was performed with a similar frequency (50%) in the two groups of patients investigated by coronary angiography. The mortality of myocardial infarction was high in the elderly, usually due to heart failure, and partly explained by the severity of the coronary lesions; in contrast, elderly patients were less frequently submitted to active management (thrombolysis-coronary angiography), while recent data of the literature argue in favour of primary angiography in these patients.     

Neoadjuvant (induction) chemotherapy in advanced bladder carcinoma

Many doctors frequently encounter hirsute patients. Quantification of hair growth may be useful for diagnosis and follow-up. To establish the reference range for distribution and density of hair in females, and to determine the regions yielding the best discrimination between normal and hirsute women, we studied the distribution and density of terminal hair on 12 body regions assessed on a scale of 0-4. Prospectively, 81 healthy female volunteers and 71 hirsute patients of child-bearing age and Dutch ancestry, who were not receiving medication, and who had not had a recent pregnancy were studied. The reference hair pattern was established for each body region, and the threshold value yielding the highest sensitivity and specificity to evaluate hirsutism was calculated. None of the women in the reference population displayed a score of more than 1 for chin, upper back, upper abdomen and upper arm, or more than 2 for upper lip, side-burns, chest, lower back, lower abdomen, thighs or forearm. The best discrimination between the reference and hirsute populations was obtained with the sum of the scores for four regions: upper lip, chin, lower abdomen and thighs. Independent assessment of hair growth by two investigators revealed excellent agreement. We conclude that a score of more than 1 for chin, upper back, upper abdomen and upper arm, or more than 2 for upper lip, side-burns, chest, lower back, lower abdomen, thighs or forearm is abnormal for Dutch women, and that assessment of hair growth on the upper lip, chin, lower abdomen and thighs is the most suitable way to evaluate hirsutism.     

Comments on emergency treatment of biliary lithiasis in patients over 75 years of age. Apropos of 157 cases]

Surgery remains the ideal emergency treatment for biliary lithiasis in elderly subjects despite perioperative morbidity and mortality. Minimally invasive techniques appear promising but require assessment. The aim of this work was to determine the usefulness of these techniques and evaluate outcome in a series of 157 patients over 75 years of age who were hospitalized in an emergency setting of complicated biliary lithiasis from January 1990 to December 1996. There were 103 women and 54 men, mean age 82 years. The patients' general status was evaluated according to the ASA classification; 66% of the patients were ASA III, IV or V. Diagnoses at admission were acute cholecystitis (n = 71, 45%), angiocholitis (n = 50, 31%) subintrant hepatic colic (n = 17, 10.8%), pancreatitis (n = 10, 6%), isolated jaundice (n = 2), peritonitis (n = 2) and occlusion (n = 5). Within 24 hours of admission, 7 patients underwent emergency surgery, and the 150 others were given medical treatment. Among these 150 patients, cure was considered to have been achieved with medical treatment alone in 41 (subsequent surgery being required in only one 6 months later), semi-emergency was performed in 17, and a minimally invasive procedure was performed in the 92 others (echo-guided percutaneous cholecystostomy in 42, endoscopic sphincterotomy in 50) followed by a subsequent operation in 29. In the 103 patients (65.5%) in this series who did not undergo surgery, mortality was 3.8% and in the 54 patients (34.5%) who did, mortality was 15%, but this rate was only 6.9% when the open procedure followed a minimally invasive technique. Surgical treatment of complicated biliary disease remains the ideal therapy but indications should be carefully weighed in these elderly fragilized subjects. Under surgical observation, abstention from surgery or use of minimally invasive techniques can play an important role in the therapeutic strategy aimed at lowering perioperative mortality.     

Insulin dependent (type 1) diabetes mellitus in advanced age

In everyday praxis diabetes mellitus diagnosed over the age of fifty years, means generally type 2 diabetes. Authors present cases where diabetes, beginning in advanced age, showed typical classical diabetic symptoms, like polyuria, polydipsia, loss of bodyweight. Apart from these signs a rapid decompensation of carbohydrate metabolism characterises this diabetes form. The most significant features are the rapid decrease of serum immunoreactive insulin and C-peptide levels, what is characteristic for the diminishing insulin secretory capacity. The patients had to be switched to insulin therapy within maximum 6 weeks. These patients can be easily differentiated both from type 2 and from the slowly progressing type 1 subtype. We suppose that the pathomechanism of this type of diabetes differs from the classical insulin-dependent form, beginning in young age.     

Aortic valve replacement in patients older than 75 years of age

From 1988 to 1992, 16 patients older than 75 years underwent AVR (14 cases) or AVR+MVR (two cases). All patients were followed up for an average of 2.4 years after the operation and follow-up totaled to 38 patient-years. There were no hospital death and one late death. The survival rate was 93.8% through 1 to 5 years and 15 patients are now in NYHA class I or II. The problems of AVR for elderly patients were calcification and small annulus. Decalcification using CUSA was effective technique and supraannular fixing of bioprosthetic valve avoided from aortic annular enlargement. The improved quality of life after AVR supports the aggressive surgery in elderly population.     

Myocardial infarction in the elderly. Comparison between 2 groups of patients over 75 and under 65 years of age

To define the clinical characteristics, prognosis and treatment of myocardial infarction (MI) in the elderly, we retrospectively compared the files of 101 patients aged > or = 75 years (mean: 82 +/- 4 years) and of 120 others aged < or = 65 years (mean: 55 +/- 4.7 years). The figures corresponding to younger patients are presented in brackets. The elderly group included 60.4% women (5%: p < 0.001), 58.9% hypertensive subjects (38.3%: p = 0.005); 30.4% diabetics (11.7%: p = 0.0013) and 12.6% smokers (66.1%: p < 0.001); 20.8% of the elderly had a history of MI (10%: p = 0.002), 15.8% of arteriopathy of the lower limbs (8.3%: p = 0.001) and 6.9% of cerebrovascular accident (1.7%: p = 0.02). Elderly patients were admitted after an average of 26.6 hours (10.4 hours: p < 0.001). Only 56.4% (79.2%) reported typical MI pain, 22.8% (7.5%) had a painless form, 31.8% (4.2%) an initial left ventricular failure, 21.8% (7.5%) a global cardiac dysfunction and 20.8% (4.2%) a cardiogenic shock (p < 0.001 for all comparisons). 63.4% had an anterior MI (40.8%: p < 0.001), 40.6% a Q-form (29.6%: p = NS) and 22.2% an atrial fibrillation (0.8%: p < 0.001). Serum myoglobin and total CK concentrations were significantly lower in elderly subjects. 20.8% of them received beta-blockers (86.7%), 43.6% aspirin (80%), 14.6% oral anticoagulant (56.7%), but 63.4% were given diuretics (25.2%) and 31.7% digitalis alkaloids and positive inotropic drugs (6.7%) (p < 0.001 for all these comparisons). Heparin, nitrates, calcium channel blockers, ACE inhibitors and antiarrhythmics were prescribed as often regardless of age. Only 10 elderly patients (9.9%) were treated with thrombolytics (77: 65%: p < 0.001); 6 (5.9%) underwent coronary angiography (43: 35.8%: p < 0.001), 2 (2%) angioplasty (11: 9.2%) and one (1%) coronary bypass surgery (12: 10%). 35 elderly patients (34.7%) died while in hospital (5: 4.2%), 22 suddenly, 10 in cardiogenic shock and 3 due to arrhythmias. 38 cases (37.8%) of heart failure (21: 17.5%), 21 (20.8%) recurrences of coronary insufficiency (8: 6.7%) and 11 (10.9%) mechanical complications of MI (4: 3.3%) were also observed (p < 0.001 for all these comparisons). Due to lack of sufficient data, we could not define the status of the surviving patients discharged from hospital. The wider use of thrombolytics, angiography and angioplasty (coronary bypass surgery still having a heavy mortality and morbidity) is probably the best way to improve the prognosis of MI in the elderly.     

Bone density, bone turnover, and hormone levels in men over age 75

BACKGROUND: Osteoporosis is a substantial problem in older men, with 25% of all hip fractures occurring in men. The mechanisms of bone loss in older men are unknown, but elevated parathyroid hormone (PTH) and diminished testosterone (T) levels are postulated as contributing factors. METHODS: We measured bone mineral density (BMD), sex hormones, bone turnover markers, and calcium regulating hormones in a group of community-living men over the age of 75. RESULTS: Thirty-five men (mean age 79; range 75-88 years) without disease or medication known to affect bone metabolism participated in the study. Whole body BMD was 1.21+/-.15 g/cm2; lumbar spine BMD (L1-L4) was 1.10+/-.15 g/cm2; femoral neck BMD was .77+/-.14 g/cm2; and trochanteric region was .71+/-.13 g/cm2. The femoral neck and trochanteric region values were more than 1 SD below the mean for adult men (age 25-33 years) in 28/35 and 15/35 men, respectively. Deoxypyridinoline levels were above the normal range for premenopausal women in 23% of the men; N-telopeptide and C-telopeptide demonstrated a wide scatter, but the values remained in the normal range. T levels were found to be below normal range for adult men in 12 of 32 (38%) subjects and the PTH levels above the normal range in 8 of 35 (23%) subjects. Bone resorption markers correlated inversely with BMD of the whole body, femur, and spine (r=-.22 to -.48). There was an inverse correlation between total T and spine BMD which became insignificant after correcting for body mass index (BMI). In addition, there was no correlation between free or bioavailable testosterone and BMD. 1,25-(OH)2D levels correlated inversely with BMD at the femur and whole body, but no association was found with PTH or 25 OH-D. CONCLUSIONS: Men over 75 years of age had a wide range of BMD but frequently had low values at femoral sites. T levels were below the normal range in 38% of men, and PTH levels were elevated in 23% of men. There was an inverse correlation between total T and spine BMD which may have been dependent on the common effect of BMI. Bone mineral density was inversely related to markers of bone resorption.     

Colorectal cancer in patients over 80 years of age

BACKGROUND/AIMS: The aim of the study was to compare the short- and long-term outcome of older and younger patients treated for colorectal cancer. We also wanted to study whether age was independently associated with post-operative mortality. METHODOLOGY: We conducted a retrospective study of 503 consecutive patients treated for colorectal cancer. One hundred and six (21%) were 80 years of age or older. The median follow-up was 5.5 years (2-16.8 years) or until death. RESULTS: Post-operative mortality was 6% (0.7% in patients less than 65 years and 16% in patients over 80 years). Multiple logistic regression analysis showed that age, emergency operation, advanced T-stage, and ASA-class were each independently related to post-operative mortality. The overall estimated 5-year survival rate was 59% in patients less than 65 years and 24% in patients over 80 years. The cancer specific 5-year survival was 62% in patients less than 65 years and 45% in patients over 80 years. CONCLUSIONS: The study demonstrated that age was an independent risk factor for post-operative mortality. In very old patients surviving the post-operative period, the long-term outcome was good. Advanced age alone should not be used as a criterion to deny surgery for colorectal cancer.     

Weekly CAF chemotherapy for advanced breast cancer patients

BACKGROUND: Seromas and impaired shoulder function are well-known complications after modified radical mastectomy for breast cancer. Early postoperative physiotherapy is a common treatment to avoid shoulder dysfunction. The aim of this study was to evaluate if the frequency of postoperative seromas could be reduced, without increasing shoulder dysfunction, by delayed postoperative shoulder exercises. METHODS: In a prospective study 163 patients with breast cancer undergoing modified radical mastectomy were randomized to physiotherapy starting on postoperative day 1 or day 7. Patients were seen by the surgeons and the physiotherapists during hospital stay and in the outpatient department. Seromas and other complications were registered by the surgeons. The physiotherapists instructed the patients pre- and postoperatively and assessed shoulder function. RESULTS: There was a significantly higher incidence of postoperative seromas in the group of patients that started physiotherapy postoperative day 1 (38%) compared to the group that started physiotherapy postoperative day 7 (22%) (p < 0.05). There was no significant difference between the groups in the late outcome of shoulder function. CONCLUSION: The incidence of seromas after modified radical mastectomy for breast cancer is reduced by delaying shoulder exercises one week postoperatively. Earlier postoperative physiotherapy is not necessary to avoid impaired shoulder function.     

Hospital infections and their consequences in patients of advanced age

On the basis of a representative survey of more than 66,000 patients in German acute hospitals from 1978 to 1989 the incidence and consequences of nosocomial infections on length of hospital stay and mortality for patients above age 60 are discussed. Infection rates are higher for female patients and increase with age for both sexes. Surprisingly the length of stay differences due to nosocomial infections are smaller in absolute and relative terms for older patients. The consequences on mortality, however, strongly concentrate on older patients. Using realistic assumptions on incidence and mortality and on possible degrees of infection the number of "preventable deaths" due to nosocomial infections are calculated. For 1990 the results sum up to more than 6000 deaths at ages above 60 alone for the Federal Republic of Germany within its former borders.     

Aneurysm surgery in patients over the age of 80 years

Three cases of cerebral aneurysm in patients over the age of 80 years are reported. Clipping of the aneurysms was successfully performed in all cases, and the patients have continued to lead normal lives thereafter. Aneurysmal surgery should not be withheld merely because patients are elderly.     

Retrospective study of radiotherapy for lung cancer in patients aged 75 years and over

Plasma levels of C-reactive protein were measured 72 hours after successful coronary artery stenting in 76 patients with stable angina pectoris. At 12-month follow-up, the cumulative event rate was higher in patients with abnormal levels of C-reactive protein than that observed in patients with normal C-reactive protein who were event free.     

Acute appendicitis in advanced age

In the elderly, both the diagnosis and treatment of acute appendicitis require particular attention. The diagnosis is often made very late with 40% to 80% of the cases already having perforated. Reasons for the delayed hospitalisation include atypical course, reduction in sensitivity to pain in old age, and an inadequate ability to communicate. The prognosis of uncomplicated appendicitis is just as good in the old as in the young patient, but perforation and concomitant diseases worsen the situation appreciably. Early operation is therefore desirable. The preference of the author is for open, rather than laparoscopic, appendectomy.     

Kidney transplantation in patients over 60 years of age. Study of 37 patients

Between February 1975 and September 1993, 735 renal transplantations have been performed 37 of which took place in 60+ year-old subjects. All grafts were from corpse donors. 34 were first time transplants and 3 were re-transplants. In general, immunosuppression has been accomplished with Cyclosporin, Azathioprine, and Prednisone. Annual patient and graft survival is 87% and 69%, respectively. A review is made of the complications developed and the success rate with and without a functioning graft. Considering long-term results, many patients lead a normal live with stable renal function.     

Do patients with advanced breast cancer benefit from chemotherapy?

This study aimed to assess the proportion of patients with advanced breast cancer who report benefit from first-line palliative chemotherapy using a simple global measure of wellbeing and to identify factors predicting benefit. A consecutive series of women with advanced breast cancer undergoing first-line palliative chemotherapy was evaluated. The main outcome measure was patient report of overall wellbeing assessed at post-treatment interview. Physical, psychological and functional status were assessed using the Rotterdam Symptom Checklist (RSCL) on three occasions (pretreatment, at the start of the third cycle and post treatment). It was planned that treatment would be discontinued after six cycles (i.e. 18-24 weeks). One hundred and sixty patients started treatment, of whom 155 were assessable for quality of life. After treatment, 41 (26%) patients reported they felt better, 29 (19%) felt the same and 34 (22%) felt worse than they did before treatment. The other 51 (33%) patients either died or stopped attending the hospital before the post-treatment interview and were assigned as treatment 'failures'. Patients who reported feeling better after treatment had improvements in psychological distress (P < 0.0001), pain (P = 0.01), lack of energy (P = 0.02) and tiredness (P = 0.02), as well as improvement in functional status (P = 0.07). Feeling better was also correlated with disease response (P = 0.03). Feeling worse after treatment or treatment 'failure' was predicted by the pretreatment presence of a dry mouth (P = 0.003) and high levels of psychological distress (P = 0.03). Pretreatment lack of energy (P = 0.01), dry mouth (P = 0.02), presence of liver metastases (P = 0.03) and breathlessness (P = 0.03) predicted treatment 'failures'. The results of this study suggest that first-line palliative chemotherapy for advanced breast cancer confers benefit on a substantial proportion of patients, with about one-quarter feeling better after treatment and nearly a half feeling better or the same some 4-6 months after the start of treatment. Factors identified in this study may assist clinicians in deciding which patients should not be offered treatment, because of high risk of feeling worse or treatment 'failure'. This work now needs to be validated on a further cohort of women receiving chemotherapy for advanced breast cancer.