Calcium antagonists in the elderly. A risk-benefit analysis

Calcium antagonists are effective in lowering blood pressure, relieving anginal symptoms and improving exercise tolerance in older and younger patients with coronary artery disease. Verapamil and diltiazem are effective in slowing ventricular response rates to supraventricular arrhythmias in both older and younger patients. Although they belong to at least 3 distinct chemical classes, a moderate decrease in the clearance of all calcium antagonists occurs with aging. Most clinical trials of these drugs have used the same dosages in older and younger patients, confounding analyses of sensitivity in older compared with younger patients. Greater reductions in blood pressure usually occur in older compared with younger patients receiving the same dosages of calcium antagonists; similarly, the dosage required to reduce blood pressure to a certain level is usually lower in older compared with younger patients. Drug acquisition costs are generally higher for calcium antagonists than for beta-blockers or diuretics. Compared with younger patients, greater heart rate suppression may be seen in older patients treated with verapamil and diltiazem; conversely, heart rate increases are usually seen with dihydropyridines. Calcium antagonists have not been shown to provide long-term benefits or decreased morbidity or mortality in elderly patients with hypertension. Verapamil, but not dihydropyridines, decreases mortality after myocardial infarction in patients without congestive heart failure. Calcium antagonists have not been shown to be beneficial in the treatment of acute stroke. Adverse effects, such as a postural hypotension, may be more frequent in elderly compared with younger patients. In addition, the elderly are at greater risk for drug interactions with calcium antagonists due to the higher likelihood that they are receiving other drugs.     

Restorative dental care of the geriatric patient

Dental care of the elderly generally does not form a major area of study in the undergraduate curriculum, and seldom forms the main attraction at dental conferences. All too often treatment of the elderly is considered to be a backwater of prosthetic dentistry and little attention is paid to the restorative needs of this rapidly growing section of society. The aim of this paper is to identify the dental needs of an ageing population, and to focus the attention of the profession on these needs as well as to explore certain myths and prejudices associated with the treatment of patients in senescence.     

A review of water balance in ageing in health and disease

The elderly are at increased risk of changes in body water and sodium, often accompanying comorbid disease states, which are associated with increased mortality. The clinical assessment of the hydration status of an elderly patient is difficult and the elderly care physician relies on both the clinical picture and laboratory investigation. Although still contentious, research suggests that the elderly may appreciate thirst less readily. However, healthy elderly may be able to produce an enhanced vasopressin response to osmotic stimulation compared to their younger counterparts, possibly in response to reduced renal function. The changes in these systems, when combined with coincident disease, place elderly patients at risk of water imbalance and electrolyte disturbance.     

Potential importance of antileukotrienes in the treatment of asthma and other inflammatory diseases: apropos of a new pharmacological class

Like their younger counterparts, older adults with diabetes need individualized treatment and educational programs based on personal glucose goals. Although most of the tools and therapies available to younger adults are also appropriate for the elderly, additional considerations and strategies are needed to meet the needs of this population for whom diabetes is a frequent and serious problem. To be effective, the therapeutic approach needs to take into consideration the aging process, other health problems, and the functional, psychosocial, cultural, and educational status of each patient. Along with these considerations, this article provides an overview of the treatment of diabetes for this age group and offers strategies for working with older adults.     

Caring for the older patient, Part I: The relationship of theory to practice

This is the first article of a four-part series on gerontology and its applications to the care of elderly patients in nuclear medicine. The series includes discussions about the theories of aging, approaches to meeting the special needs of the elderly and ethical dilemmas in caring for the elderly. It also reviews anatomical and physiological changes associated with aging and the role of nuclear medicine studies in caring for the elderly. Upon completion of this article, the reader should be able to: (a) describe the aging U.S. population by citing demographic data; (b) identify the theories of aging and distinguish their major characteristics; (c) differentiate a gerontologic approach from a geriatric approach in caring for the elderly; and (d) recognize factors important to the delivery of effective care for the elderly.     

The elderly in a coronary unit

The clinical features of myocardial infarction were compared in 104 patients over the age of 70 and 399 younger patients admitted to a coronary care unit. Absence of an age bar at 70 years has increased the number of admission to the unit by 24%, and the number of patients with proved infarcts by 26%. Severe complications are more common and mortality is doubled in the elderly. Although immediate management of primary ventricular fibrillation is as successful in older as in younger patients, treatment of the elderly with less dramatic conditions is less successful. The elderly survivors tend to spend longer in the coronary unit and subsequently in the general medical ward.     

Cancer surgery in the elderly

Cancer surgery is safe for older patients and should not be denied on the basis of chronological age. The curability of cancer in the elderly is predicated on the individual's tolerance of major surgery. We present the physiologic changes that occur with aging and focus on their influence upon surgical decision making, the risk factors associated with cancer surgery in the elderly, the preoperative assessment, and perioperative care of the elderly cancer patient, as well as surgical considerations for specific neoplasms.     

Treatment of myocardial ischemia and myocardial infarction in the elderly

The diagnosis of coronary artery disease in the elderly is problematic because older patients often present atypical symptoms or are asymptomatic. Once coronary disease is diagnosed, the proper course of treatment is not always clear, since few studies have focused on patients older than 65 years. Moreover, older patients often have medical conditions that may aggravate coexisting cardiovascular problems or interfere with conventional pharmacotherapy. For these reasons many physicians who treat cardiovascular problems aggressively in younger patients are reluctant to do so in older individuals. There is considerable evidence, however, that older patients could benefit as much or more from aggressive therapy because of their greater risk of mortality from myocardial ischemia and infarction.     

Revisiting the O complex: urinary incontinence, delirium and polypharmacy in elderly patients

Urinary incontinence, delirium and polypharmacy are common, challenging problems encountered in elderly patients. Review of the literature shows that these conditions are interrelated. For example, polypharmacy can lead to delirium, which, in turn, can lead to urinary incontinence. The drugs prescribed for urinary incontinence can precipitate delirium or contribute to polypharmacy. The underlying causes for these problems in elderly patients are frequently complex, and management in turn must often be multifactorial. The occurrence of these problems should lead to careful evaluation followed by thoughtful, responsive treatment. Brief updates are given with recommendations for management directed at primary care physicians.     

Successful behavioral treatment for reported sleep problems in elderly caregivers of dementia patients: a controlled study

Although sleep problems are common among dementia caregivers, there has been no research thus far describing treatment of such problems using behavioral techniques. In this study, 36 elderly dementia caregivers with disturbed sleep were randomly assigned to either a brief behavioral intervention or a wait list control. The active treatment consisted of standard sleep hygiene, stimulus control, and sleep compression strategies as well as education about community resources, stress management, and techniques to reduce patient disruptive behaviors. Caregivers in active treatment showed significant improvements in sleep at post-treatment and 3-month follow up. No significant differences between groups were observed for caregiver mood, burden, or patient behavior problems, suggesting that sleep improvements were not an artifact of depression treatment. Treatment responders tended to be younger and more compliant with treatment recommendations than non-responders. Results suggest that behavioral techniques may well be a viable alternative to medication for sleep problems in aging caregivers.     

Heart failure in elderly patients

The incidence and prevalence of congestive heart failure increase exponentially with advancing age. Congestive heart failure in the elderly is characterized by a multifactorial etiology, a high proportion of accompanying degenerative changes of the cardiovascular system and age-specific problems regarding diagnosis and treatment. The treatment strategy is the same as in younger patients, but the higher incidence of adverse effects and complications demands special awareness. The majority of decompensations leading to hospitalization are precipitated by insufficient compliance in life style change and drug intake.     

In situ monitoring with the Tradescantia bioassays on the genotoxicity of gaseous emissions from a closed landfill site and an incinerator

The aging process introduces many changes that affect the whole person, including sleep. Age-related changes in the nervous system, acute and chronic illnesses, medications, primary sleep disorders, and factors associated with hospitalization in the critical care unit are elements identified with sleep disturbance in the elderly patient hospitalized in the critical care unit. One of the most important challenges for critical care nurses is to promote a healing environment for elderly patients where they can obtain the sleep necessary for recovery. Potentially effective nursing interventions for sleep promotion are those caring interventions that focus on the body-mind connection, such as back massage, relaxing music, imagery, and muscle relaxation. Investigations of the effectiveness of nursing interventions for sleep promotion are needed.     

Use of interferon for the treatment of chronic hepatitis C in the elderly

Hepatitis C virus is a worldwide health care problem. It affects all age groups. Many patients have had the infection for 20-30 years before they present for therapy. With a peak incidence of disease in the 30-40 year age group, it is obvious that a large number of cases must occur in the elderly (age > 65 years). Of these, a fraction progress to cirrhosis and hepatocellular carcinoma. Interferon is the only agent approved for use in patients with chronic hepatitis C. The efficacy of interferon in younger patients is reported to be 50%. Half of these will experience a relapse within 1 year. There are few studies assessing the role of interferon used for elderly patients with chronic hepatitis C. The reported response rate to interferon in elderly patients was 60%, with 30% having a virologic/complete response. These studies demonstrate that the elderly tolerate interferon reasonably well. No significant differences have been reported between elderly and young treatment groups.     

Outcome and cost of trauma among the elderly: a real-life model of a single-payer reimbursement system

BACKGROUND: As our population ages, the number of elderly trauma patients (age > or = 65 years) increases. Studies have demonstrated increased mortality and cost for a given injury severity in the elderly compared with younger patients. The financial viability of trauma centers in the United States has been an area of concern for many years. As reimbursement diminishes for privately insured patients, the ability to finance the care of the indigent is jeopardized. Medicare, the single-payer insurance plan for the elderly, reimburses at a lower rate than standard private insurance carriers. We examined the differences in outcome and cost between the elderly and younger patients and the financial burden imposed by care for elderly trauma. Our hypothesis was that elderly trauma patients would have poorer outcomes, higher cost, and generate greater financial losses than younger patients. METHODS: All patients admitted to the University of Virginia Trauma Service from July 1, 1994, to July 1, 1997 were included. Trauma registry and patients records were examined. Patients with incomplete financial data (cost, reimbursement, and payer source) were excluded. Patients were grouped by age (18-64 and > or =65 years), Injury Severity Score, and payer source. RESULTS: One thousand one hundred twenty-seven patients met the entry criteria. One hundred forty patients had incomplete financial or patient data and were excluded. Nine hundred eighty-seven patients were included in the study, of which 159 were elderly and 828 were 18 to 64 years of age. Injury Severity Scores were significantly higher in the elderly group. Only 2% of elderly patients were uninsured (76% were insured by Medicare), whereas 25% of younger patients were uninsured. Medicare reimbursement rates actually exceeded those of all other carriers (114% of costs). Elderly patients had a higher mortality rate, but the z score did not reach significance. The W score, however, indicated that there were more unexpected, negative outcomes among elderly patients. As injury severity increased, profit per case increased in the elderly and decreased in the younger group. CONCLUSION: Despite higher injury severity and lower survival probability for the elderly, the length of hospital and intensive care unit stays, as well as the percentage of admissions to the intensive care unit, were similar. The per capita cost of hospital care for the elderly was lower than for younger patients, whereas reimbursement was higher, primarily because 98% of elderly patients were insured. Medicare, the single-payer insurance plan for the elderly, adequately reimburses for elderly trauma care. This implies that universal insurance coverage for all trauma patients would be desirable, even if reimbursement rates decreased significantly. The increased mortality in the elderly requires continued study and diligence.     

An analysis of the outcomes of treatment of small cell lung cancer in the elderly

BACKGROUND: Many cases of small cell lung cancer will occur in the elderly population but optimal management of the disease in this age group remains uncertain. AIMS: To evaluate treatment of small cell lung cancer in the elderly in Australia and to compare treatment received and outcomes with those of younger patients. To draw insights from these observations into the optimal management of small cell lung cancer in the elderly. METHODS: A retrospective review of treatment charts and case notes for 51 elderly patients and 102 younger patients was undertaken. RESULTS: Elderly patients had similar baseline parameters with respect to disease stage and performance status. Elderly patients were mostly treated uniformly with combination chemotherapy, but suffered more dose reductions than younger patients. Benefits of chemotherapy were seen even in patients with poor performance status. Despite the dose reductions, response rates and survival times for elderly patients were usually similar to younger patients. CONCLUSIONS: Combination chemotherapy is beneficial to elderly patients with small cell lung cancer. Optimal therapy for the elderly may be different from that for younger patients and should be defined through prospective randomised clinical trials.     

Endodontic considerations in the geriatric patient

Endodontic needs of today's and tomorrow's growing older adult population present increasing challenges for dental care providers. Biologic and anatomic differences in the dental tissues between older and younger patients must be understood and considered in treatment planning and performance for appropriate endodontic procedures. These differences generally do not contraindicate treatment, which, when performed correctly, will be successful in the elderly patient.     

Physiological aspects of aging. Implications for the treatment of cancer

The aging of the population has focused attention on the special needs of elderly patients. The increasing number of elderly people in the world's population has led to a parallel increase in the number of older cancer patients. Bias against older patients for screening and treatment of cancer exists, whereby effective therapies are withheld in the mistaken belief that these patients cannot tolerate them. Physiological changes which occur with aging include decreased cardiovascular performance, decreased haematopoietic tissue, a respiratory system which has been affected by life-long exposure to infection and toxins, decreasing renal function and a compromised nervous system. These changes have implications for drug toxicity such as possible increased sensitivity to cardiotoxins and increased haematological toxicity from myelosuppressive therapy. With the physiological decline in renal function with age, drug dosages must be carefully evaluated to avoid chemotherapy toxicity and its sequelae. Older patients may have increased sensitivity to oral toxicity, in particular, mucositis. There are also issues regarding tolerance of the older patient to radiation therapy. The haematopoietic growth factors and new antiemetics now available will allow chemotherapy to be administered with greater safety while maintaining quality of life. Overall, the healthy elderly are appropriate candidates for standard and experimental antineoplastic therapy. Careful assessment of end-organ function needs to be performed before a decision regarding the proper treatment regimen can be made. Clinical trials have rarely included the elderly, making data scarce. More research is needed in this age group.     

T- and B-cell responses of malaria immune individuals to synthetic peptides corresponding to non-repeat sequences in the N-terminal region of the Plasmodium falciparum antigen Pf155/RESA

OBJECTIVE: This study was conducted in order to determine whether the effects of tamoxifen in elderly, frail nursing home residents are similar to those that have been previously reported for younger postmenopausal women. DESIGN: A chart review study. SETTING: The Jewish Home and Hospital for Aged (JHHA), a subacute long-term care facility. PARTICIPANTS: One hundred fifty-eight women who had been at the JHHA at any time since 1986. One hundred ten had a history of breast cancer; 43 of these had been treated with tamoxifen while at the JHHA (Group I), and 66 had not (Group II). The remaining 49 women had no history of breast cancer (Group III). MEASUREMENTS: Data were collected from the time of admission to the JHHA through August, 1994 on: chemistry profiles, bone fractures apparently not a consequence of metastasis, gynecological parameters, and thromboemboli. RESULTS: The lack of pre-admission clinical information presented problems regarding research design and the interpretation of our findings. Nevertheless, compared to women who had not been treated with tamoxifen, treated women had a significantly elevated incidence of vaginal discharge (P = 0.01) and a lower prevalence of elevated total cholesterol (P = 0.04). Although not statistically significant, they also had decreased levels of low density lipoprotein cholesterol and an increased incidence of thromboemboli and bone fractures. CONCLUSIONS: While some of the effects of tamoxifen in elderly, frail women are similar to those observed in younger, postmenopausal women, others may be different. Our results suggest a need for further innovative studies that focus on the consequences of tamoxifen treatment in the elderly, frail population.     

Low vision: physician screening helps to improve patient function

Low vision is a common problem of older patients. As a primary care practitioner, you are not expected to treat most ocular problems, but you can play an important role by identifying patients with visual impairment. Familiarize yourself with the normal visual changes that occur with aging as well as the more common age-related ocular diseases, including glaucoma, cataracts, age-related macular degeneration, and diabetic retinopathy. You can identify patients with visual problems with a careful history and basic in-office tests of visual acuity. Refer patients found to have visual impairment to an eye care specialist for further evaluation.     

Effect of age on pharmacokinetics and pharmacodynamics in man

Elderly patients represent an increasing part of our population who consume disproportionately high amounts of drugs. During aging physiological and disease-induced changes occur which might affect PK and/or PD of many drugs. The calcium channel blocker verapamil and the benzodiazepine midazolam were taken as examples to illustrate some problems and open questions in research pertaining to the elderly. Following an acute i.v. dose of racemic verapamil and during steady-state (120 mg bid p.o.) no significant differences of the stereoselective disposition of S- and R-verapamil could be found between younger and older healthy subjects. Concomitant intake of rifampicin (600 mg/die) induced especially the presystemic (prehepatic) metabolism of verapamil so that oral bioavailability approached zero and PD effects almost diminished. Intestinal metabolism and inducibility were well preserved in the elderly. The PK and PD of midazolam were investigated in young and older patients who received an i.v. bolus of 0.05 and 0.03 mg/kg, respectively, for premedication prior to third molar teeth extraction. Again, no significant differences in the PK parameters were found between both groups. However, the sedative effects were much more pronounced in the elderly and this population demonstrated a significantly higher CNS-sensitivity to midazolam. All physicians should be aware that for various reasons drug response can be age-dependent and therefore more PK-PD data are needed for the elderly.