Docetaxel (taxotere, Rhone-Poulenc Rorer)

The oft quoted phrase, "There's no place like home," has no greater meaning than when long-term care decisions are being made. In the midst of ongoing late life changes, one's home is often the only anchor. Through carefully selected home care and nursing and care management services, living at home remains a viable option for older adults and their families. Physicians can serve as a vital link between older adults and the home care system by educating the patient where services can be obtained. Physician input into referral and collaboration with other care managers can help determine the best approach to home care.     

Coronary flow measurements for evaluation of patients after stent implantation

The treatment of "asymptomatic" intestinal malrotation remains controversial, particularly beyond the neonatal period. Two cases illustrate the application of laparoscopy for correction of malrotation: one in an older child and another in an asymptomatic infant. Both patients recovered well and were discharged 2 days after surgery. Laparoscopic appendectomy and duodenocolonic dissociation allows excellent visualization of the duodenocolic and Ladd's bands and easily accommodates appendectomy. The availability of this minimal-access technique should encourage correction of malrotation in the asymptomatic patient.     

Age and Regulatory Focus Determine Preferences for Health-Related Role Models.

The authors hypothesized that the effectiveness of role models varies across the adult life span because of differences in health-related regulatory orientations. Because young adults have strong health-related promotion orientations, they should be motivated by positive models who illustrate the benefits of good health. Because older adults have more balanced health-related promotion and prevention orientations, they should be motivated not only by positive models but also by negative models who illustrate the costs of poor health. Results indicated that both young and older adults perceived positive models to be motivating, but older adults found negative models to be more motivating than did young adults. Age differences in responses to negative models were partially mediated by differences in health-related prevention orientation. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Geriatric assessment in oncology

With the anticipated growth in the numbers of elderly persons, a higher prevalence of cancers among older persons is expected; as a result, oncologists will treat larger numbers of older persons in their practices. Clinicians caring for older persons with cancer must recognize the heterogeneity of the elderly population and focus their assessments and care plans accordingly. The author reviewed literature and drew conclusions regarding geriatric assessment in several key areas: the medical, cognitive, affective, functional economic, and environmental status of patients; social support for patients; and advance directives. They concluded that for younger and healthier seniors, simple probes for the presence of common geriatric problems may suffice, but traditional means of medical assessment should be supplemented by brief screening for common geriatric conditions and nonmedical issues that are of particular relevance to the health of older persons. Assessment instruments can be used to guide these brief evaluations, but results must be interpreted in the context of the limitations of the instruments used. Patients who are frail or at high risk for functional decline or nursing home placement should receive more extensive evaluation by individual practitioners or by a multidisciplinary team of health care professionals who can provide comprehensive geriatric assessment. By broadening their assessment skills to include domains that are beyond traditional internal medicine and oncology training, oncologists can better serve their older cancer patients.     

The importance of geriatrics to family medicine: a position paper by the Group on Geriatric Education of the Society of Teachers of Family Medicine

The role of geriatrics and geriatricians in family medicine remains unsettled. Despite a rapidly aging population, a tremendous shortage now exists of faculty with interest and expertise in geriatrics. Relatively few family practice residents choose to enter geriatric fellowship programs, and federal funding for such programs has been reduced. Despite accreditation requirements, residency programs are not always able to provide the range of geriatric experiences needed to properly prepare graduates to provide care for the broad range of older patients. Medical students' exposure to geriatrics remains limited. The Group on Geriatric Education of the Society of Teachers of Family Medicine believes that family medicine faculty must recognize and be committed to the notion that geriatrics is integral to family medicine. Both undergraduate and residency training programs should emphasize experience with geriatric patients in multiple settings. In particular, the nursing home should not be the main focus of geriatric training. The small number of certified geriatric faculty will be able to provide leadership, but a broad range of faculty must become involved in teaching geriatrics. Faculty development activities and continuing education programs to foster the necessary expertise will be essential to the accomplishment of this task.     

The varicocele and male infertility

Varicocele is accepted as a common cause of male subfertility, even though many men with varicocele appear to have normal fertility. The pathophysiology of the varicocele effect on fertility remains unclear, but the association of varicocele with decreased testicular size, abnormal testicular histology, and abnormal semen parameters is clearly established. Because a small varicocele may impair fertility, it must be diligently sought, and the Doppler stethoscope may be helpful in establishing the diagnosis when a venous thrill is equivocal during the Valsalva maneuver in a standing patient. Abnormal semen parameters should be demonstrated in subfertile males with varicocele prior to advising varicocelectomy. Decreased sperm motility or a "stress pattern" in the semen should be documented; however a decreased sperm count may or may not be present. Various surgical approaches are available. When suprainguinal approaches have been used, failures have been shown to be attributable to secondarily incompetent cremasteric system veins. When high inguinal approaches are used, unsuccessful operations are probably secondary to a failure to identify one of the several venous tributaries that may be present at this level. The surgeon's approach should be based on available data, and his patients should be informed that failures are possible with any method of varicocelectomy until experience indicates otherwise. In most series, improvement in semen quality and pregnancy rates have been reported in a significant percentage of patients undergoing varicocelectomy for infertility. However, prior to subjection of the patient to varicocelectomy, the wife of the varicocele patient should be thoroughly studied (and treated when indicated).     

Current aspects of acute respiratory distress syndrome in children

Acute respiratory distress syndrome (ARDS) is a frequent condition in pediatric intensive care units. The mortality remains high despite advances in conventional mechanical ventilation and aetiological treatment. Several animal studies have documented lung injury during mechanical ventilation with high tidal volume, and clinical investigations have shown that in human ARDS, most ventilation is distributed to the small areas of remaining aerated lung resulting in overdistension of these areas and lung injury ("baby lung" theory). Nevertheless the usefulness of extrapulmonary gas exchange remains much debated. New ventilatory strategies have been developed in order to reduce ventilator-induced lung injury and to improve systemic oxygenation but multicentric randomized clinical trials are needed before these strategies can be validated.     

The effect of age on memory for emotional faces.

Prior studies of emotion suggest that young adults should have enhanced memory for negative faces and that this enhancement should be reduced in older adults. Several studies have not shown these effects but were conducted with procedures different from those used with other emotional stimuli. In this study, researchers examined age differences in recognition of faces with emotional or neutral expressions, using trial-unique stimuli, as is typically done with other types of emotional stimuli. They also assessed the influence of personality traits and mood on memory. Enhanced recognition for negative faces was found in young adults but not in older adults. Recognition of faces was not influenced by mood or personality traits in young adults, but lower levels of extraversion and better emotional sensitivity predicted better negative face memory in older adults. These results suggest that negative expressions enhance memory for faces in young adults, as negative valence enhances memory for words and scenes. This enhancement is absent in older adults, but memory for emotional faces is modulated in older adults by personality traits that are relevant to emotional processing. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

"Personality and risk for Alzheimer's disease in adults 72 years of age and older: A 6-year follow-up": Correction to Duberstein et al. (2010).

Reports an error in "Personality and risk for Alzheimer's disease in adults 72 years of age and older: A 6-year follow-up" by Paul R. Duberstein, Benjamin P. Chapman, Hilary A. Tindle, Kaycee M. Sink, Patricia Bamonti, John Robbins, Anthony F. Jerant and Peter Franks (Psychology and Aging, , , np). This article contains an error in the Discussion, under the Implications, Caveats, Future Directions heading. The third paragraph includes sentences that should have been removed, as they are a variation on similar text immediately following. The sentences that should have been removed are presented in the erratum. (The following abstract of the original article appeared in record 2010-22067-001.) We conducted secondary analyses to determine the relationship between longstanding personality traits and risk for Alzheimer's disease (AD) among 767 participants 72 years of age or older who were followed for more than 6 years. Personality was assessed with the NEO-FFI. We hypothesized that elevated Neuroticism, lower Openness, and lower Conscientiousness would be independently associated with risk of AD. Hypotheses were supported. The finding that AD risk is associated with elevated Neuroticism and lower Conscientiousness can be added to the accumulating literature documenting the pathogenic effects of these two traits. The link between lower Openness and AD risk is consistent with recent findings on cognitive activity and AD risk. Findings have implications for prevention research and for the conceptualization of the etiology of AD. (PsycINFO Database Record (c) 2011 APA, all rights reserved)     

What is the place of peritoneal dialysis in the integrated treatment of renal failure?

The role of peritoneal dialysis (PD) in renal replacement therapy (RRT) remains unclear. There are no controlled trials to provide hard evidence of its efficacy. Comparative studies with haemodialysis from different centres and countries have given conflicting results even when allowing for case mix. Data from the United States on patients starting or receiving treatment in the late 1980s suggested a worse prognosis for older patients, particularly diabetics receiving PD as compared to HD. Analysis of the USRDS data base for patients starting in the early 1990s shows an improvement in outcome but with no difference in overall mortality. The Canadian registry has recently published data showing a better survival with PD than with HD in the first two years of RRT. Morbidity is similar with both therapies, although hospitalization is increased with PD. Unfortunately long-term technique survival is not as good with PD. However, PD has certain medical advantages, particularly the maintenance of residual renal function that contributes to solute and fluid removal. It may also postpone the onset of amyloidosis. Patients transplanted after previous PD have a decreased risk of early acute renal failure and equally good long-term results when compared to those patients who were on HD before transplantation. The quality of life is as good with PD as with center HD, and there are social advantages to PD including an increased chance of employment, more flexible holidays and avoidance of thrice weekly travel to a dialysis center. PD also has logistical advantages and can be utilized by the majority of new patients. We therefore conclude that PD has potential advantages early in the course of RRT, and should therefore be offered as a first option to all suitable new patients. Whether PD has a major or minor role in later years (> 5) remains unclear.     

Reflections on replacement

In the United States, the total fertility rate is about 1.9 births per woman, down from a peak of 3.2 a generation ago and below the replacement level of 2.1 children. The proportion of women who will never have children has risen from 8% a generation ago to approximately 18% in 1993. The increase in the proportion of women in the labor force, a proximate explanation of the recent decline in intended fertility, is expected to continue. The demographic consequence is declining population with an older age structure. A pronatalist policy to alleviate this outcome, through monetary transfers from taxpayers to potential parents, is not only unlikely to succeed, it is politically unfeasible. An alternative solution, immediately effective but politically unpalatable, would be a generous immigration policy. Even with replacement level fertility, the population is destined to become much older. This inevitable aging of the population should be countered by appropriate institutional transformations: 1) with lower fertility, a larger proportion of women will be available to participate in the labor force to generate taxes needed to support a larger number of pensioners; 2) the institutional practice of ascribing a dependent status to anyone above a particular age can be changed; 3) concerns that an older labor force will have an obsolete education (and fewer years of it) can be countered by changing access to education. Yet, the most serious question is not merely the net reproduction rate, but producing adequate numbers of new adult citizens with responsibility and technical training in the modern world. The fundamental process of socializing children may be jeopardized by replacing the full-time parent with the hired care-giver, the peer group, and the television set. The attenuation of the bonds between parent and child may devalue the worth of childbearing itself. These portentous consequences deserve consideration.     

"Affect dynamics, affective forecasting, and aging": Correction to Nielsen, Knutson, and Carstensen (2008).

Reports an error in "Affect dynamics, affective forecasting, and aging" by Lisbeth Nielsen, Brian Knutson and Laura L. Carstensen (Emotion, 2008[Jun], Vol 8[3], 318-330). The first author of the article was listed as being affiliated with both the National Institute on Aging and the Department of Psychology, Stanford University. Dr. Nielsen would like to clarify that the research for this article was conducted while she was a postdoctoral fellow at Stanford University. The copyright notice should also have been listed as "In the Public Domain." (The following abstract of the original article appeared in record 2008-06717-002.) Affective forecasting, experienced affect, and recalled affect were compared in younger and older adults during a task in which participants worked to win and avoid losing small monetary sums. Dynamic changes in affect were measured along valence and arousal dimensions, with probes during both anticipatory and consummatory task phases. Older and younger adults displayed distinct patterns of affect dynamics. Younger adults reported increased negative arousal during loss anticipation and positive arousal during gain anticipation. In contrast, older adults reported increased positive arousal during gain anticipation but showed no increase in negative arousal on trials involving loss anticipation. Additionally, younger adults reported large increases in valence after avoiding an anticipated loss, but older adults did not. Younger, but not older, adults exhibited forecasting errors on the arousal dimension, underestimating increases in arousal during anticipation of gains and losses and overestimating increases in arousal in response to gain outcomes. Overall, the findings are consistent with a growing literature suggesting that older people experience less negative emotion than their younger counterparts and further suggest that they may better predict dynamic changes in affect. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Pharmacotherapy: strategies to control drug costs in managed care

Pharmacotherapy remains one of the most cost-effective interventions physicians can provide to manage the medical conditions of older patients. Because many older Americans have multiple diseases, the practitioner's goal is to maximize appropriate drug use while avoiding duplicative or interacting medications. Medicare managed care plans seek to provide appropriate medication for the older patient at a reasonable cost through such strategies as formularies, prior authorization, generic and therapeutic substitution, and drug utilization review. Yet, like the medications themselves, these strategies require careful attention to their risks and benefits to the individual patient.     

Aging, dementia and automobile driving

According to Norwegian law, drivers 70 years and older must carry a health certificate. This is issued by a general practitioner. If the patient is not supposed to drive because of a medical condition, the doctor should report this to the County Health Officer. This can be problematic, not only because assessing whether a patient fulfills the criteria for driving is difficult, but also because the doctor has obligations to both the public and his patient. These problems are discussed, based on assessment of available literature and on personal experience. Dementia is common in old age and affects approximately 15% of persons aged 75 and older. Patients with moderate and severe dementia should certainly not drive. However, some patients with mild dementia can nevertheless be safe drivers. The problem, however, is to identify the safe drivers among patients with mild dementia. The current regulations on dementia and driving are presented briefly.     

Usefulness of detection of breast cancer: the part played by the internist

The prognosis of breast cancer is the result of many factors, among which the mass of the tumor at the time of diagnosis remains the most significant: small tumors have a better prognosis than larger ones and are less often accompanied by positive lymph nodes. It is therefore justifiable to search for them systematically by breast examination of all patients over 30. Large-scale mass screening campains in the USA, with clinical and mammographic examination of tens of thousands of women, have proven that it is possible to detect more "early" cancers and reduce general mortality in the groups studied. The number of cancers thus detected is nevertheless so small that it does not justify the investment of so much labour and money in this kind of campaign. Systematic breast examination at regular intervals (6 months to 1 year) with regular mammographies should be confined to patients in the high risk groups: women who have already undergone surgery for cancer of one breast, and patients with a marked family history of breast cancer. For the rest of the female population, the solution seems obvious: every physician should get into the habit of performing regular clinical examination of the breasts. Most gynecologists are already doing so, but they only examine a small part of the population. The most important role in the detection of breast cancer falls to the internists and the general practitioners: they should assume responsibility for all their patients' breasts, in the same manner as they do for heart and lung examinations. They will then request additional examinations (mammography, thermography) as soon as clinical examination reveals a pathological finding. The results of GILBERTSEN [5] confirm that clinical examination remains the most valuable and least expensive method for breast cancer detection.     

"Ocular fixation control as a function of age and exposure duration": Correction to Kosnik et al.

Reports an error in "Ocular fixation control as a function of age and exposure duration" by William Kosnik, Donald Kline, John Fikre and Robert Sekuler (Psychology and Aging, 1987[Sep], Vol 2[3], 302-305). In the aforementioned article, the following corrections should be made: 1. The title of Table 1 should be changed to Mean Bivariate Areas (min-arc2) and Mean Horizontal and Vertical Standard Deviations (min-arc) of Fixations of Older and Younger Groups. 2. The equation on page 304 should have used the natural log rather than the log base 10. The corrected equation is provided in the erratum. (The following abstract of the original article appeared in record 1988-01066-001.) In previous work we reported that fixation stability did not deteriorate in older adults over relatively long viewing durations. In the present study we reanalyzed the data to examine potential aging effects on fixational control for viewing durations typically used in psychological experimentation. Monocular eye movements were recorded in 12 older and 12 younger observers using a dual Purkinje image technique, while observers fixated a stationary target. The two-dimensional scatter of eye positions was measured during nine viewing durations ranging from 100 ms to 12.8 s. Fixational control of the two groups was comparable at all of the viewing durations. Both younger and older observers were able to maintain fixation within an area several times smaller than the size of the fovea. Implications for aging studies that use briefly presented visual stimuli are discussed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

What's different about older people

Older people can be regarded as a marginalised group within society from a number of perspectives including that of health. When it comes to the use of medication older people have suffered from a double whammy. Not only are they more at risk from the adverse effects of drugs but also their involvement in clinical trials has been limited so that rational prescribing both to maximise benefit and to reduce risk has been problematic. Their special problems have been recognised formerly by the Department of Health in its NSF for Older People [National Service Framework for Older People. Department of Health, London (2001a)], [Medicines and Older People. Implementing medicines-related aspects of the NSF for Older People. Department of Health (2001b)]. Early studies focussed on compliance, the avoidance of poly-pharmacy and the high prevalence of adverse effects of drugs and the reasons for this. Studies in long-stay patients showed dramatic differences in pharmacokinetics between such older people and young healthy volunteers. Initially such differences were ascribed to age alone and the overall message became "start low and go slow". Studies in healthy older people then revealed that age differences in drug metabolism were, as a rule, not so marked although clearance of renally excreted drugs was reduced in line with the age associated decline in renal function. Including older people in clinical trials poses challenges. Many traditional trialists do not have ready access to older people, co-morbidity and poly-pharmacy are common and most people feel reluctant to ask older people to take part in complex and potentially hazardous trials. Concern about compliance is unwarranted. Adverse events may be more serious. Thus in a younger patient postural hypotension may make a subject unsteady but in an older subject the unsteadiness may lead to a fall, the fall to a fracture, and the fracture to poor recovery. The choice of end-points is crucial. Although reduction of clinical events is clearly important, effects on quality of life become more important as natural life expectancy reduces. Although regulatory bodies state that they now evidence of effectiveness in older people before registration there are still many examples of arbitrary and illogical upper age limits in clinical trials.     

Estrogen-receptor expression and function in thymocytes in relation to gender and age

INTRODUCTION: The mechanism of action of N-acetylcysteine in early acetaminophen poisoning is well understood, but much remains to be learned of the mechanism of its possible benefit in acetaminophen poisoning presenting beyond 15 hours. METHODS: Selective review of medical literature. N-acetylcysteine should be used in all cases of early acetaminophen poisoning where the plasma acetaminophen concentration lies "above the line;" which line is chosen depends on individual preference and whether enzyme induction is suspected. Particular care should be taken with the use of the nomogram for patients with chronic excess ingestion of acetaminophen or for those who have taken slow-release formulations. CONCLUSIONS: While there is a trend suggesting a beneficial effect of N-acetylcysteine in some patients presenting beyond 15 hours, further research is necessary to establish just how effective N-acetylcysteine is, particularly in patients presenting with fulminant hepatic failure. Candidate mechanisms for a beneficial effect in-clude improvement of liver blood flow, glutathione replenishment, modification of cytokine production, and free radical or oxygen scavenging. Hemody-namic and oxygen delivery and utilization parameters must be monitored carefully during delayed N-acetylcysteine treatment of patients with fulminant hepatic failure, as unwanted vasodilation may be deleterious to the maintenance of mean arterial blood pressure.     

Correction to Kanayama et al. (2007).

Reports an error in "Testosterone supplementation for depressed men: Current research and suggested treatment guidelines" by Gen Kanayama, Revital Amiaz, Stuart Seidman and Harrison G. Pope Jr. (Experimental and Clinical Psychopharmacology, 2007[Dec], Vol 15[6], 529-538). In the "Recent Studies" section (pp. 531-532), citations to Pope and Katz (2003) should have been to Pope, Kanayama, Cohane, Siegel, and Hudson (2003) to reflect the following source, which was omitted from the reference list: "Pope, H. G., Jr., Kanayama, G., Cohane, G., Siegel, A., & Hudson, J. I. (2003). Testosterone gel supplementation for men with refractory depression: A randomized placebo-controlled trial. American Journal of Psychiatry, 160, 105-111". (The following abstract of the original article appeared in record 2007-18976-003.) Several lines of accumulating evidence suggest that testosterone might be effective for the treatment of depression, especially in older men who exhibit low testosterone levels. However, despite the potential promise of this approach, the available literature of controlled studies of testosterone in depression remains extremely limited. Therefore, testosterone treatment of depression must still be considered an experimental procedure. At the present state of research, it appears that testosterone might most likely show benefit as an augmentation strategy in men who exhibit low or borderline testosterone levels and who show only a partial response to conventional antidepressants. In this article, we provide some suggested practical guidelines for the treatment of such individuals. However, it should be recognized that these suggestions are tentative and will likely require revision as additional data become available. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Therapy and self-actualization in the later years via nontraditional approaches.

A substantial minority of older people have mental health problems, but several studies agree that less than 5% seek treatment from private practitioners or community clinics. Nontraditional therapists have devised various new approaches to circumvent this resistance: groups for the widowed, assertiveness training courses, and peer counseling programs. It is noted that few clinical psychologists have been trained to work with the aging. Training should include life-span development and community psychology. Older people are not likely to make up a large part of a psychologist's private practice, but an expressed interest in the over-50 age group could bring in referrals. Nontraditional approaches can aid the psychologist in reaching and helping older people. Psychologists can also function as trainers of volunteers, as consultants to agencies for seniors, as teachers and speakers, and as key persons in research studies of work with the aging. (33 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)