An overview of the older driver

Although MVC rates are not substantially higher among older drivers after adjusting for mileage and may even be lower, the crash risk of the elderly driver remains a matter of increasing public concern. In part this is due to media attention over isolated cases of fatal MVCs involving older drivers, occasionally with a demented driver. This media attention has led to growing apprehension over the issue of elderly drivers. Physicians are likely to be involved increasingly in the evaluation of older drivers, whether they want to or not. The physician's quandary is the competing interests of the patient's well-being (i.e., continued independence), and the public's welfare (i.e., protection from impaired drivers). Unfortunately, there are no certain guidelines to protect the physician from liability for either of these conflicting duties. At issue is the foreseeability of harm from an elderly driver, either to self or to others. What degree of impairment is necessary before a physician is bound to report a patient to authorities? Although there are no clear answers, the best advice is to follow clinical judgment. One suggestion is to consider the diagnosis as suitable evidence. Thus, if the patient has a dementing illness of sufficient severity to warrant documentation in the medical record as a diagnosis, then perhaps the physician should consider advising the patient not to drive; reporting the patient to the appropriate authorities would be left to the physician's discretion after consultation with the patient's family. This might have the added benefit of obliging physicians to think twice before mislabeling patients with benign forgetfullness as demented, an all-too-frequent phenomenon. In this weighty ethical decision, it is critical for physicians to consider the consequences of removal of driving privileges from their elderly patients as well as their duty to protect the public health. Neither should be taken lightly. Above all else, physicians should not forsake their responsibility for advising either patients or the public regarding the driving privilege. To do so would simply relinquish the decision-making to those without clinical training or evaluative skills relevant to driving tasks. The physician's role in the evaluation of the elderly driver should be regarded as a pivotal challenge in the complicated management of the health of the elderly population.     

The behavior of the general practitioner in dealing with tachycardia

In medical practice the physician may face 3 situations when dealing with tachycardia or arrhythmia: 1) when seen, the patient has tachycardia and the physician has no electrocardiograph: 2) the patient has tachycardia and the physician can take an electrocardiogramm; 3) the patient discloses a history suggestive of tachycardia or arrhythmia. In the first situation the heart rate and rhythm must be carefully observed immediately, as well as jugular venous pulse and heart sounds and murmurs; then the effects of respiration, change in posture, and carotid sinus pressure should be evaluated; finally, a complete physical examination should be carried out and the patient's history taken; for the latter, questions should be asked concerning past episodes, intake of digitalis or other drugs, possible reasons for hypokalemia, and presence of any disease that might play a role. In the second situation, the ECG should be recorded at once by the physician himself (first V1-2 and DII); the subsequent workup is the same as for the first situation. In the third situation a highly detailed patient's history is of the utmost importance. If recurring episodes take place, their ECG recording should be tried by all possible means: the most important factor is the physicians readiness to do so. A hospital stay for observation of an epidose is usually fruitless, as is an exercise ECG. 24 h recording may be useful, as may endocavitary recording and stimulation tests. Any tachycardia should be correctly related to the natural history of the patient's disease.     

Obesity: evaluation and treatment

Obesity as a chronic condition among large numbers of people is a disease of recent origin, often but by no means always associated with dietary habits and sedentary lifestyle. Many obese people want to lose weight, and may have tried to do so numerous times with self-help or proprietary weight-loss programs. When they seek a physician for help in losing weight-or when a physician advises an obese patient to lose weight as part of a clinical strategy-care must be taken to "match" the patient to an appropriate therapeutic program with appropriate therapeutic goals. History and physical examination and psychologic evaluation are essential elements of patient screening. Complications of obesity must be taken into account in any treatment plan. The multidisciplinary management strategy is most likely to succeed in helping the patient lose weight. It also avoids untoward events associated with complications or concomitant disease. The multidisciplinary approach is especially important when the patient does not lose weight, and alternative strategies must be considered, such as surgical approaches.     

Home health care

Home health care is the fastest-growing expense in the Medicare program because of the aging population, the increasing prevalence of chronic disease and increasing hospital costs. Patients and families are choosing the option of home care more frequently. Medicare's regulations are often considered the standard of care for all home health agency interactions, even when a patient does not have Medicare insurance. These regulations require patients who receive home health care services to be under the care of a physician and to be homebound. The patient must have a documented need for skilled nursing care or physical, occupational or speech therapy. The care must be part time (28 hours or less per week, eight hours or less per day) and occur at least every 60 days except in special cases. A detailed referral and specific care plan maximize the care to the patient and the reimbursement received by the physician.     

Is angiodiathermocoagulation an outmoded operation?

It would be impossible to devise a complete list of "Do's and Don'ts" for the physician to follow in preventing legal involvement. Indeed, such a list, even if considered complete, would not benefit the physician as much as would an overall feel for this whole area of patient interaction. When about to engage in some specific activity, the physician should consult the helpful medical-legal articles in publications that are readily available, e.g., articles on artificial insemination (1, 10), sex therapy (12), and human experimentation (9, 11, 15, 17). The physician must never undertake an action for which he/she does not have the training, the experience, and the emotional security to perform. If complications occur, exact and detailed documentation of the circumstances and the steps taken to correct the complication should be made. All this should be explained to the patient, if she is in a condition to understand, or to relatives. The physician needs to assume a humble attitude, but should not be defensive or make guiltridden admissions. When surgical procedures are undertaken, there should always be adequate pathology to justify the procecure. The physician should avoid pressuring the patient for a quick consent and should avoid statements that might invoke excessively optimistic expectations on the part of the patient (7).     

Billing fraud from the viewpoint of the state attorney

The so-called settlement fraud includes not only charging for unrealized services but also the charging of realized services that must not be charged as well as intended uneconomical behavior. Victim of this kind of fraud is either the privately paying patient or the society of panel doctors and, thus, every correctly charging physician when legal health insurances are involved. The perpetrator may be fined or imprisoned. Other punishments may include professional ban, revocation of the license, and compensation. Weak spots of the system encourage fraud. Without effective control mechanisms and self-administration, more and more physicians do not meet the confidence and the special responsibility necessary for the settlement system of our health insurances.     

Consumer information, patient satisfaction surveys, and public reports

This article describes information useful for consumers and purchasers in making choices about health care services. Two types of information are described, patient satisfaction surveys and public reports about the price and outcomes of health care services such as those published by the Pennsylvania Health Care Cost Containment Council. Patient satisfaction surveys can be used to provide valuable information about health care. The goal of patient satisfaction reporting is to incorporate the patient's perspective to improve care. Public reports about the price and outcome of hospital and physician services not only facilitate consumer and purchaser choice, they also encourage continuous quality improvement by providers.     

Introduction of insurance system for long-term care

The newly proposed insurance system for long-term care aims at providing elderly persons with quality care for their self-reliance. Under the proposed system, elderly persons themselves would choose services. Therefore, for its efficient use of services utilization, more coordination between health and welfare sectors will be required. To fulfill its purpose, specialists in geriatric medicine should take a major role, too. Health care providers will have to take into consideration each elderly person's whole life-style for self-reliance despite their health problems. The medical sector will also need to be familiar with the various procedures which would be essential for the smooth implementation of the system. These include not only the providing of care but also the documentation of care need which is one of the essential materials for the certification of care need which determines the reimbursement for the care.     

Mucopolysaccharidosis. Radiological and clinical aspects

These are congenital diseases that may be seen occasionally, both in males as in females with the exception of Hunter's syndrome which is exclusive of the male sex. This possibility should be suspected before a patient with or without mental retardation and bony malformations. It must be kept in mind there is no medical treatment for their relief. However, recent studies have established a cause of effect relationship of metabolic disturbances of cycopolysaccharides and their accumulation in different tissues of the body, amongst them cartilages (chondrocytes), which would be responsible for the corresponding disturbances seen. Bony age was always found to be less than the chronological. Bony malformations may be corrected if disableness is prevented. Mental retardation was not present in every case and heart disease was diagnosed in only one case, although heart catheterism was practiced in 50% of all cases. Since heart lesion is the main cause of death, it should always be investigated. Clinics, x-rays and laboratory should always be the basis of the diagnosis.     

Arterial ulcers: assessment and diagnosis

Arterial ulcers occur because of inadequate perfusion of skin and subcutaneous tissue at rest. Arterial occlusive disease, common among smokers, diabetics and the elderly, can lead to claudication, rest pain and gangrene, in addition to localized ulceration. Other processes, such as venous stasis, pressure, trauma, and vasculitis, can also cause ischemia. However, a thorough patient history and physical assessment can help discriminate between ischemic ulcers caused by arterial disease and other types of ulcers. The key to the diagnosis of arterial occlusive disease is the patient history. Pain while walking is the most common presenting complaint and can indicate intermittent claudication. Physical assessment should include both a general exam, looking for problems relating to lungs, heart and nervous system, and a focused exam of the affected extremities and arterial pulses. Vascular laboratory findings can also help confirm a diagnosis of arterial ischemic ulceration. The key to treatment is improvement in the vascular perfusion to the affected area. Surgical revascularization is the mainstay of treatment, with some interventional procedures becoming accepted. Medical options, in addition to correction of underlying medical problems, include good wound and supportive care, but pharmaceutical interventions have generally not proven effective, and should be considered only if interventional procedures are not possible. With an adequate blood supply reestablished, most arterial ulcers will progress to healing unless there are complicating factors.     

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.     

Preoperative evaluation and postoperative care of the elderly patient undergoing major surgery

As the population ages and as surgical and anesthetic techniques advance, more and more elderly patients are referred for surgery. As a result, the physician must be increasingly aware of the aged response to surgery and the management of the geriatric surgical patient in the perioperative period. Elderly patients are prone to cardiac, respiratory, and infectious complications, and thus, they need to be screened for the presence of pre-existing disease. In addition, the geriatric patient needs to be carefully monitored in the proper postoperative environment to guard against untoward sequelae.     

Percutaneous drainage of pancreatic necrosis: is it ecstasy or agony?

The above comments are meant to help the reader further analyze the fine study of Freeny et al. [1]. To my knowledge, this is the first series to specifically define its patients correctly as having pure pancreatic necrosis. This work represents a thorough analysis of a difficult problem and points out how to treat these patients if one wants to be successful. This template is important to radiologists who wish to get involved with this type of patient. What Freeny et al. truly describe is the agony and ecstasy involved with this difficult undertaking. Radiologists can obtain a lot of satisfaction in taking care of this type of patient, but they and the referring physicians must be committed. The patient, the referring physician, and the radiologist must also face the agony in dealing with the illness. They must be ready to handle the number of catheters, the number of catheter changes, the number of CT scans, and the duration of drainage. In some cases percutaneous drainage will work; in some cases it is the only alternative for a patient with this disease. In other cases a catheter or two can be placed, but they might not be as beneficial to the patient as surgery. Clearly, percutaneous drainage of pancreatic necrosis can be done, and radiologists must work with their clinical colleagues to decide whether it is in the patient's best interest.     

Electrocardiographic left ventricular hypertrophy in chest pain patients: differentiation from acute coronary ischemic events

Electrocardiographic left ventricular hypertrophy (LVH) and related repolarization changes alter the morphology of the ST segment and/or the T wave. Such electrocardiographic abnormalities--all features that are encountered in patients with acute ischemic heart disease--may confound the early emergency department evaluation of the chest pain patient. In the instance of the chest pain patient demonstrating ST segment/T wave abnormality, the correct electrocardiographic diagnosis must be made not only to offer appropriate management for that particular illness but also to avoid the incorrect application of potentially dangerous therapies such as thrombolysis. This report presents two cases in which the electrocardiogram demonstrated significant repolarization changes consistent with LVH, and focuses on the recognition of the expected ST segment/T waves changes and their differentiation from the primary ST segment/T wave changes associated with acute ischemic heart disease.     

Pentobarbital modulatory effect on GABA binding sites in developing chick optic lobe

The care for elderly patients is traditionally a task of the general practitioner and will be of increasing importance in the future. Medical considerations focus on the patient's functional abilities which should play a primary role. These should, however, not neglect the patient's resources for the development of social and mental competence. Medical interventions so far will also need social indications evaluating their importance in the every day life context of the individual patient. Based on scientific knowledge of geriatrics and gerontology there should be a wide-spread introduction of standardized instruments into geriatric diagnostics and evaluation. Geriatric screening may be one example. This will support the development of a special geriatric quality management in general practice. There is a need for further development of ambulatory rehabilitation for the elderly. The general practitioner in this field will have to control the teamwork with rehabilitation-professionals and professionals from the social support services.     

On-duty medical service regulation in Norway, Sweden, Finland and Denmark

Out of hours services are under discussion in the Nordic countries, and their organisations in Norway, Sweden, Finland and Denmark are compared in the article. Only in Denmark all such services are free of charge. In Denmark and in most parts of Norway, the patient must first phone a call-in service manned by a physician who acts as receptionist cum dispatcher. House calls are very rarely made in Sweden and Finland but account for approximately 20 percent of the out of hours workload in Norway and Denmark.     

Functional recovery after operative treatment of femoral neck fractures in an institutionalized elderly population

Agreement that hip fracture is best treated surgically stems from the fact that early mobilization of the patient reduces morbidity and mortality. This concept was tested in 54 elderly, institutionalized patients with femoral neck fractures who were operatively treated. The patients were reviewed within 12 months after being injured. Their average age was 81.2 years, and 94% of the patients were women. Seventy-five percent of the study population had neurological disease or heart disease and were thus limited in their motivation or ability to participate in a rehabilitation program. Only 16.7% of the patients regained their overall functional ability and only 12.9% returned to their pre-injury, ambulatory status. The therapeutic concept should be reviewed and the conservative approach be given serious consideration.     

Psychologic adjustment to coronary artery disease

As improvements in therapy have extended the survival rate of patients with ischemic heart disease, increasing attention to the quality of survival has resulted in an appreciation of the profound effect of psychologic factors on the patient's life. A multidisciplinary approach, including evaluation and management of pertient psychologic factors, should be part of the treatment of all patients with coronary heart disease. Ischemic heart disease often requires both patient and family to make difficult changes in personality and life-style. As soon as the physiologic stress begins to subside, the physician should begin to provide sympathetic, specific guidelines toward acceptance of the disease and accommodation to its limits. Potential problems and their management are discussed within the framework of the three stages of chronic illness.     

Acute hormone responses to heavy resistance lower and upper extremity exercise in young versus old men

In the final stage of amyotrophic lateral sclerosis (ALS) the majority of patients develop chronic respiratory failure due to respiratory muscle weakness. The interaction between the patient with ALS and the physician should be characterized by continuous communication, especially with respect to the prospect of ventilatory failure and for support. The patient and his family must be informed thoroughly about the natural history and the prognosis of ALS, depending on the individual disease process. Already in the early stage of the disease coping strategies should be discussed so that imminent respiratory emergencies can be handled. If ALS patients are not informed about the acute respiratory insufficiency they run the risk of having to be intubated and mechanically ventilated over a long term. If dyspnea and hypersecretion dominate the final stage of ALS, the therapeutic strategy consists of the administration of morphine, insufflation of oxygen and bronchoscopic suction. Mechanical ventilation should only be initiated in the exceptional case. However, if dyspnea occurs in the early stage of the disease, when there is no bulbar paralysis and peripheral muscle function is intact, then noninvasive mechanical ventilation via mask may improve the quality of life substantially. Nevertheless, invasive mechanical ventilation via a tracheostomy should be avoided.     

Managing the elderly hypertensive patient beyond blood pressure reduction

ANTIHYPERTENSIVE TREATMENT OF THE ELDERLY: Several prospective, randomized, long-term trials on antihypertensive drug treatment have shown that elderly patients with systolic and diastolic or isolated systolic hypertension benefit from a reduction in blood pressure. Antihypertensive treatment reduces the overall mortality by 20%, cardiovascular mortality by 33%, the incidence of fatal and non-fatal cerebrovascular events by 40% and the complications of coronary heart disease by 15%. In addition, elderly patients have a high risk of overt or latent and asymptomatic cardiovascular diseases. For this reason, not only antihypertensive treatment, but also risk factor modification (such as cholesterol reduction therapy) is, in absolute terms, more beneficial in elderly patients than in middle-aged patients, particularly in patients with concomitant cardiovascular diseases and other risk factors. QUALITY OF LIFE: Although the randomized trials have focused on mortality and morbidity as main endpoints, it is questionable whether longevity is a worthwhile social objective in itself. Quality of life is an important aspect of antihypertensive treatment, since hypertension is generally symptomless while drug therapy may have adverse effects on the quality of life. The frequency of adverse effects is similar in both middle-aged and elderly hypertensive patients, with about 2% of patients per year in both age groups withdrawing from randomized treatment due to objectively assessed adverse effects. The rate of subjectively assessed adverse effects during treatment is also similar in younger and elderly patients. In general, clinical studies have suggested that a blood pressure reduction does not influence the well-being of elderly patients, whether measured in physical, emotional or social terms. Both calcium antagonists and diuretics have shown an age-dependent effect in comparative trials, with a higher blood pressure reduction in elderly than in younger patients. CONCLUSION: Antihypertensive therapy in elderly hypertensives adds longevity and need not compromise quality of life. Although the reduction and normalization of blood pressure is the primary goal, the increased availability of antihypertensive preparations and drugs for treating concomitant diseases and risk factors allows the physician to tailor treatment of the elderly to the needs of the individual patient.