Geriatric Medicine Outpatient Clinic Research Articles

The Ghost Of Hip Arthroplasties Past: It Takes A Geriatrician To Mine For Metal

Abstract Background An 84-year-old female presented to Geriatric Medicine out-patient clinic with many years of persistent right hip pain, generalised myalgia; and several months of constipation, weight loss and persistent elevation of C-reactive protein and Erythrocyte Sedimentation Rate. The General Practitioner's concern was occult neoplasm. History of right hip arthroplasty in 2011. 6 years prior, she had wide local excision and adjuvant radiotherapy for a grade 3, “triple negative”, invasive ductal carcinoma of the right breast. Serial imaging identified a right parasternal, internal mammary chain neurofibroma. A Rheumatologist had administered intra-articular steroid to both glenohumeral joints for plain X-ray confirmed osteoarthritis, in the absence of serological vasculitic or autoimmune rheumatological disease. Benefit was transient. Her Oncologist had arranged MRI spine for “sciatica” demonstrating L3/4 and L4/5 stenosis and a large right adnexal cyst. Subsequently, the Gynaecology team assessed and planned interval MRI pelvis as initial MRI suggested a right partial hydrosalpinx, left internal chain lymphadenopathy and nodule adjacent to sacroiliac joint. Methods History, examination and imaging results were checked against the Medical Device Alert number 18 from the Medicines and Healthcare products Regulatory Agency (UK) in 2017. Oxford Hip Score Assessment was 29. Lymphatic drainage from medial hip joint is towards right iliac chain. Results In the absence of Gadolinium based contrast agents within 96hours, metal testing demonstrated: Serum Cobalt was 232nmol/L or 13.7 ug/L; Serum Chromium was 78.8nmol/L or 4.1ug/L; Chromium Urine: Creatinine Urine Ratio was 24.54nmol/mmol; and Cobalt Urine: Creatinine Urine Ratio73.96nmol/mmol. These elevated blood and urine results confirmed metal-on-metal hip disease. Conclusion Consider symptomatic metal-on-metal hip disease with soft-tissue involvement in patients presenting with post-hip arthroplasty joint pain, generalised myalgia and raised inflammatory markers; particularly if there is unexplained ipsilateral internal iliac chain lymphadenopathy and pelvic fluid collections. If confirmed, metalwork explanation is the treatment.

A hand-in-hand phenomenon in older adults: Increased risk of frailty in geriatric outpatients associated with handgrip strength asymmetry and weakness

ObjectivesHandgrip strength (HGS) is accepted as a predictor of overall health status and a biomarker of aging, besides negative health outcomes and mortality. While differences in HGS between the dominant and non-dominant hands are expected, substantial discrepancies may signal impaired muscle function. This study aims to investigate whether handgrip asymmetry can serve as a reliable indicator of frailty in a diverse population of older adults. DesignCross-sectional study Setting and participantsA total of 512 patients aged 65 years and older who were admitted to the geriatric medicine outpatient clinic of a university hospital were enrolled in the study. MethodsThe Clinical Frailty Scale (CFS) was used to assess the overall level of frailty of the study population. The highest recorded HGS values from the non-dominant and dominant hand were used to calculate the HGS ratio. Those with a HGS ratio of dominant and non-dominant hand <0.90 or >1.10 were defined as HGS asymmetry. ResultsOf the whole study group, 61.1% was female and the mean age was 73.2 ± 6.1 years. The ratio of the participants living with frailty was 57.6% (n=219). The number of patients with HGS asymmetry was 264 (51.6%), and 48.4% (n=248) of the study population had symmetric HGS. The normal and symmetric HGS was found in 40.2% of the non-frail group, whereas it was 23.7% in patients living with frailty. Furthermore, the ratio of low and asymmetric HGS was 16.3% in the non-frail group, and 35.0% in the patients living with frailty (p<0.001). The presence of asymmetric and low HGS increased the risk of frailty three times independently of other confounding factors (OR:3.08; 95% CI:1.48-6.43; p=0.003). Conclusions and ImplicationsIdentifying HGS asymmetry along with low HGS as potential indicators of frailty may provide clinicians with a clear and quantifiable criterion for assessing older patients.

Prevalence and general characteristics of dementia: a nationwide population-based study of electronic health records in Türkiye.

Türkiye is a country with an increasing life expectancy and an older adult population in parallel with the rest of the world. Several national small-scale studies were performed regarding the prevalence and characteristics of dementia in Türkiye, and the results of these studies differ from each other. We aimed to determine the prevalence of dementia in Türkiye to present the demographic characteristics, the frequency of use of health services, and the management of dementia. Patients aged 65 years and over with a diagnosis of any type of dementia between January 1, 2019, and December 31, 2020, were retrospectively screened from the electronic health records of the Ministry of Health using ICD-10 codes. In 2019, the total number of dementia cases identified in individuals aged 65 years and older was 247,727, of whom 150,529 (60.8%) were women. In 2020, the total number of dementia cases identified in this age group was 233,949, with 142,878 (61.1%) of these cases being women. The rate of patients admitted to the emergency department was 72.3% and 66.2% of all dementia patients in 2019 and 2020, respectively. In terms of the use of outpatient clinics, most patients with dementia were admitted to neurology (71.0% in 2019 and 62.4% in 2020). The geriatric medicine outpatient clinic was the least used by patients with dementia both in 2019 and 2020. The prevalence of patients living with dementia in Türkiye is lower than the global average. This suggests that most dementia cases are overlooked, highlighting the need to raise dementia awareness both in the community and among primary health care providers who frequently encounter older individuals. The study is significant in that it is the first to show the nationwide frequency of dementia in Türkiye.

Mini Nutritional Assessment-Short Form and Frailty Screening According to 2 Different Frailty Scales

Objective: Mini Nutritional Assessment-Short Form is a malnutrition screening scale that evaluates the patient from different perspectives and is thought to be used in frailty screening. The present study aimed to evaluate the reliability of Mini Nutritional Assessment-Short Form for frailty screening by using 2 frailty scales.&#x0D; Methods: It was a cross-sectional study that included patients admitted to the geriatric medicine outpatient clinic of a university hospital. Mini Nutritional Assessment-Short Form was performed on all patients. The FRAIL Scale and Clinical Frailty Scale were used as reference frailty scales.&#x0D; Results: While 62.2% (n = 61) of the 98 participants were female, the median age was 72 (interquartile range: 10.0). The FRAIL Scale (Spearman rho: −0.64, P &lt; .001) and Clinical Frailty Scale (Spearman rho: −0.55, P &lt; .001) were both correlated inversely and moderately with Mini Nutritional Assessment-Short Form. For both frailty scales, Mini Nutritional Assessment- Short Form cut-off for frailty identification was 11 (for FRAIL Scale, sensitivity: 68.00%, specificity: 87.67%, area under the curve: 0.83, P &lt; .001; for Clinical Frailty Scale, sensitivity: 76.47%, specificity: 83.95%, area under the curve: 0.84, P &lt; .001), and the cut-off was 13 for robust and pre-frail/frail identification (for FRAIL Scale, sensitivity: 71.70%, specificity: 73.33%, area under the curve: 0.80, P &lt; .001; for Clinical Frailty Scale, sensitivity: 71.74%, specificity: 67.31%, area under the curve: 0.74, P &lt; .001).&#x0D; Conclusion: For quick evaluation of frailty and nutritional status concurrently, Mini Nutritional Assessment-Short Form may be an appropriate option.

One Step at a Time: Improving Gait Speed Measurement in a Geriatric Medicine Clinic.

(1) Background: Mobility assessment is a key component of the assessment of an older adult as a part of the Age-Friendly Health System (AFHS) "geriatric 4Ms" framework. Several validated tools for assessing mobility and estimating fall risk in older adults are available. However, they are often under-utilized in daily practice even in specialty geriatric medicine care settings. We aimed to increase formal mobility assessment with brief gait speed measurement in a geriatric medicine outpatient clinic using phased change interventions. (2) Methods: This quality improvement (QI) initiative was conducted in a single outpatient geriatric medicine clinic. All clinic attendees who could complete a gait speed measurement were eligible for inclusion. The outcome measure was the completion of a 4 m gait speed. Several change interventions were implemented on a phased basis using the Model for Improvement methodology during the period from December 2018 to March 2020. Statistical process control charts were used to record gait speed measurements and detect non-random shifts. (3) Results: During this QI initiative, 80 patients were seen, accounting for 142 clinic visits. In response to change interventions, gait speed measurement at clinic visits increased from a median of 25% of visits to 67% by March 2020. (4) Conclusions: Adopting an AFHS care model is an urgent and challenging task to improve the quality of care for older adults. This initiative details how to effectively incorporate a brief, validated assessment of mobility using gait speed measurement into every geriatric medicine outpatient visit and progresses implementation of the AFHS "geriatric 4Ms". Mobility assessment can aid in identifying older adults at increased fall risk.

Factors Associated with Nonattendance to a Geriatric Clinic among Mexican Older Adults

Introduction: Outpatient appointment nonattendance (NA) represents a public health problem, increasing the risk of unfavorable health-related outcomes. Although NA is significant among older adults, little is known regarding its correlates. This study aimed to identify the correlates (including several domains from the geriatric assessment) of single and repeated NA episodes in a geriatric medicine outpatient clinic, in general and in the context of specific comorbidities. Methods: This is a cross-sectional study including data from 3,034 older adults aged ≥60 years with ≥1 scheduled appointments between January 1, 2016, and December 31, 2016. Appointment characteristics as well as sociodemographic, geographical, and environmental information were obtained. Univariate and multivariate multinomial regression analyses were carried out. Results: The mean age was 81.8 years (SD 7.19). Over a third (37.4%) of participants missed one scheduled appointment, and 14.4% missed ≥2. Participants with a history of stroke (OR 1.336, p = 0.041) and those with a greater number of scheduled appointments during the study time frame (OR 1.182, p < 0.001) were more likely to miss one appointment, while those with Parkinson’s disease (OR 0.346, p < 0.001), other pulmonary diseases (OR 0.686, p = 0.008), and better functioning for activities of daily living (ADL) (OR 0.883, p < 0.001) were less likely to do so. High socioeconomic level (OR 2.235, p < 0.001), not having a partner (OR 1.410, p = 0.006), a history of fractures (OR 1.492, p = 0.031), and a greater number of scheduled appointments (OR 1.668, p < 0.001) increased the risk of repeated NA, while osteoarthritis (OR 0.599, p = 0.001) and hypertension (OR 0.680, p = 0.002) decreased it. In specific comorbidity populations (hypertension, type 2 diabetes mellitus, and cancer), better ADL functioning protected from a single NA, while better mobility functioning protected from repeated NA in older patients with hypertension and cancer. Discussion/Conclusion: Identifying geriatric factors linked to an increased probability of NA may allow one to anticipate its likelihood and lead to the design and implementation of preventive strategies and to an optimization of the use of available health resources. The impact of these factors on adherence to clinical visits requires further investigation.

The Feasibility of Using N-Of-1 Trials to Investigate Deprescribing in Older Adults with Dementia: A Pilot Study.

N-of-1 trials may provide insights into the impact of deprescribing medications in populations where evidence is currently lacking, such as the effect of statins on cognition in people with dementia. For this pilot, N-of-1, double-blinded, deprescribing trial, adults over 80 years of age with dementia taking statins for at least 6-months were recruited from a hospital’s geriatric medicine outpatient clinic in Sydney, Australia. Participants discontinued and restarted statins over the study period. At enrolment, the hospital pharmacy—using a random number generator, randomised recruited participants to their usual statin or placebo regimen, with assessment and switching of treatment every 5 weeks from baseline (0-weeks) until Visit 4 (15-weeks). Primary outcome was measured using the rate of change in Alzheimer’s Disease Assessment Score-Cognitive Subscale (ADAS-CoG). Over 6-months, 81 participants were screened, 14 were eligible, and four were randomised. One participant (female, 88 years) completed all four assessments with no major harms reported. Cognitive impairment, as measured by ADAS-CoG score, was similar on placebo (15.5/70) compared to statin (15/70). This study suggests there are significant challenges in performing N-of-1 trials and recruiting people with dementia into deprescribing trials from outpatient settings.

Turkish validation of a new scale from older people’s perspectives: Older people’s quality of life-brief (OPQOL-brief)

IntroductionThere are various ‘quality of life’ scales developed for older people. Although quality of life is a subjective concept, most of these scales are based on expert opinions rather than perspectives of older people. The aim of this study is to evaluate validity and reliability of Older People’s Quality of Life-brief scale (OPQOL-brief), which is based on perspectives of older people, in Turkish population. MethodsA cross-sectional study was implemented in a Geriatric medicine outpatient clinic. Total number of 168 older patients who speak in Turkish fluently were recruited. Comprehensive geriatric assessment and OPQOL-brief was applied to all participants together with another quality of life scale validated in Turkish population, CASP-19 (Control, Autonomy, Self-realization, Pleasure). Validity was evaluated with construct validity, convergent validity and discriminant validity. Reliability was assessed with internal consistency and test-retest reliability. ResultsMean age of the study population was 73.3 ± 5.9 years. Female participants were 64.9% (n = 109). Internal consistency was assessed by Cronbach’s α coefficient. OPQOL-brief scale demonstrated high internal consistency (Cronbach’s α = 0.876). Test-retest reliability was assessed by interclass correlation coefficient (ICC) and showed high reliability (ICC = 0.98, 95%CI = 0.96-0.99, p < 0.001). Strong and significant correlation was detected between OPQOL-brief and CASP-19 scales (r = 0.763, p < 0.001). ConclusionTurkish version of OPQOL-brief has acceptable validity and reliability in Turkish population. The scale can be used to measure quality of life of older people.

An important problem in an aging country: identifying the frailty via 9 Point Clinical Frailty Scale-

ABSTRACTObjectives: Frailty is a geriatric syndrome which develops as a result of cumulative decline in many physiological systems and results in an increased vulnerability and risk of adverse outcomes. The Clinical Frailty Scale (CFS) was validated as a predictor of adverse outcomes in community-dwelling older people and evaluates items such as comorbidity, cognitive impairment and disability. We aimed to study the concurrent and construct validity and reliability of the 9 point CFS in Turkish Population.Methods: This study was designed as a cross-sectional study. Participants, who were admitted to a geriatric medicine outpatient clinic, were included. Validity of 9 point CFS was tested by its correlation with the assessment and opinion of an experienced geriatric medicine specialist and Fried frailty phenotype. Test-retest and inter-rater reliability analyses were also performed.Results: Median age of the 118 patients was 74.5 years (min: 65 max: 88) and 64.4 % were female. The concordance of CFS and experienced geriatric medicine specialist’s opinion was excellent (Cohen’s K: 0.80, p < 0.001).The concordance of CFS and Fried Frailty phenotype was moderate (Cohen’s K: 0.514, p < 0.001).CFS inter-rater reliability and test-retest reliability was very strong (Cohen’s K: 0.811, p < 0.001 and Cohen’s K: 1.0, p < 0.001, respectively).Conclusions: CFS appears to be a quick, reliable and valid frailty screening tool for community-dwelling older adults in the Turkish population.

Masked Hypertension is Associated With Cognitive Decline in Geriatric Age-Geriatric MASked Hypertension and Cognition (G-MASH-cog) Study.

Masked hypertension is described as high ambulatory blood pressure measurements (ABPM) where office blood pressure measurements are normal. Effect of hypertension on cognitive functions is well known. However, the effect of masked hypertension on cognitive functions is unclear. The aim of this study is to examine the relationship between masked hypertension and cognitive functions. One hundred-two normotensive patients admitted to the Geriatric Medicine outpatient clinic were included. Exclusion criteria were hypertension, dementia, major depression, and usage of antihypertensive medication. All patients underwent ABPM procedures and average daytime blood pressure, mean blood pressure at night and the 24-hour average blood pressure measurements were recorded. Comprehensive geriatric assessment tests and neuropsychological tests were administered. The diagnosis of masked hypertension was based on the definitions in the 2013 guideline of the European Society of Cardiology. Forty-four patients (43%) were diagnosed with masked hypertension. Patients with masked hypertension had significantly lower scores on Mini-Mental State Examination (MMSE) test, Quick Mild Cognitive Impairment Test (QMCI), and Categorical Fluency Test than the normotensive patients (p = .011; p = .046; and p = .004; respectively). Montreal Cognitive Assessment Scale test score was lower in masked hypertension, although this was not statistically significant. This study may indicate that geriatric patients with masked hypertension, compared to normotensive patients have decreased cognitive functions. Masked hypertension should be kept in mind while assessing older adults. When masked hypertension is detected, cognitive assessment is essential to diagnose possible cognitive dysfunction at early stage.

Which parameters affect long-term mortality in older adults: is comprehensive geriatric assessment a predictor of mortality?

Determining predictors of mortality among older adults might help identify high-risk patients and enable timely intervention. The aim of the study was to identify which variables predict geriatric outpatient mortality, using routine geriatric assessment tools. We analyzed the data of 1141 patients who were admitted to the geriatric medicine outpatient clinic between 2001 and 2004. Comprehensive geriatric assessment was performed by an interdisciplinary geriatric team. Mortality rate was determined in 2015. The parameters predicting survival were examined. Median age of the patients (415 male, 726 female) was 71.7years (53-95years). Mean survival time was 12.2years (95% CI; 12-12.4years). In multivariate analysis, age (OR: 1.16, 95% CI: 1.09-1.23, p<0.001), smoking (OR: 2.51, 95% CI: 1.18-5.35, p=0.017) and metabolic syndrome (OR: 2.20, 95% CI: 1.05-4.64, p=0.038) were found to be independent risk factors for mortality. MNA-SF scores (OR: 0.84, 95% CI: 0.71-1.00, p=0.050) and free T3 levels (OR: 0.70, 95% CI: 0.49-1.00, p=0.052) had borderline significance. The present study showed that the risk conferred by metabolic syndrome is beyond its individual components. Our findings confirm previous studies on the prognostic role of nutritional status, as reflected by MNA-SF. Serum fT3, a simple laboratory test, may also be used in geriatric outpatient clinics to identify individuals at risk. The results of the study demonstrated the need for addressing modifiable risk factors such as smoking, metabolic syndrome, and undernutrition in older adults.

Hypovitaminosis D is an independent associated factor of overactive bladder in older adults

Aim of the studyUrinary incontinence and vitamin D deficiency are common problems encountered in geriatric population. We aimed to investigate if there is a relationship between these conditions. Subjects and methodAmong 2281 patients who were admitted to our geriatric medicine outpatient clinic spanning the last three years, 705 patients with known vitamin D status, urinary incontinence and subtype, and calcium plus vitamin D therapy data were included in statistical analysis. Patients who are using calcium plus vitamin D therapy were excluded. SPSS (Statistical Package for Social Sciences) version 15.0 for Windows was used for statistical analysis and p<0.05 was considered as statistically significant. ResultsMean age of the study population was 72.3±6.4years and 62.8% were female. Plasma vitamin D level (OR: 0.968, 95%CI: 0.943–0.993, p=0.013), MMSE (Mini Mental State Examination) score (OR: 0.944, 95%CI: 0.902–0.989, p=0.014), and serum ALP (Alkaline Phosphatase) level (OR: 0.995, 95%CI: 0.992–0.998, p=0.001) were found to be inversely correlated factors, and serum calcium level (OR: 1.772, 95%CI: 1.008–2.888, p=0.022) was found to be a positively correlated factor of overactive bladder. Considering the different clinical subtypes of urinary incontinence, only urgency incontinence was associated with lower plasma vitamin D level (p=0.013). ConclusionsVitamin D deficiency and insufficiency are independent associated factors for overactive bladder in older adults. This is explicable by effects of vitamin D on muscle growth and function.

Validation of Katz index of independence in activities of daily living in Turkish older adults

ObjectiveKatz Index of Independence in Activities of Daily Living Scale (Katz ADL) is a widely used tool to assess the level of independency in older adults. The objective of this study was to assess the validity and reliability of the Turkish version of the six item Katz ADL in geriatric patients aged 65 years and older. MethodsThe participants were recruited in a geriatric medicine outpatient clinic (n=211). The Katz ADL was translated to Turkish and it was administered with the Barthel index (BI) and SF-36 physical functioning subscale (SF-36 PF) which are already validated in Turkish. Reliability was assessed by internal consistency, interrater and test–retest analysis. Construct validity was assessed by Spearman correlations between the Katz ADL and other functional status indices. ResultsThe internal consistency was high (Cronbach’s α=0.838). The test–retest reliability and inter-rater reliability were excellent (ICC 0.999 [0.999–1.000 95% CI]). Regarding the convergent validity strong associations between Katz ADL, BI and SF-36 PF were demonstrated (rs=0.988, p<0.001 and rs=0.674, p<0.001). ConclusionValidating an instrument, which has originally been developed in a different culture, is a complex but neccessary task. It provides an opportunity for comparison of information across different cultures. To our knowledge, this is the only study to demonstrate reliability and validity of the Katz ADL-six item version in the geriatric population living in Turkey. Turkish version of the Katz ADL is a valid and reliable scale to detect the disability status in the basic activities of daily living in older adults.

Mini nutritional assessment test long and short form are valid screening tools in Turkish older adults

BackgroundMalnutrition is a pitfall in older adults despite its high prevalence and serious consequences. There are various screening tests however, none of them have been validated for our country. In this study, we aimed to test the hypothesis that MNA (long form of MNA) and MNA-SF (short form of MNA) are applicable to screen malnutrition in Turkish geriatric patients. Materials and methodsTwo hundred and thirty-six patients aged 65 years and over who were admitted to our geriatric medicine outpatient clinic were enrolled in the study. Four groups of data (anthropometric measurements, biochemical markers, three-day diet record and geriatric assessment scales) were recorded. Long and short forms of MNA test were performed. Two different geriatricians interpreted the patients’ nutritional status with the aid of aforementioned data. Patients were divided into three groups which were patients with malnutrition, with malnutrition risk and well-nourished. Concordance between the two geriatricians’ clinical assessment was analyzed by kappa statistics. Excellent concordance was found, therefore the first specialist's decisions were accepted as gold-standard. A third physician performed the long and short forms of MNA test. The concordance between the first clinician's assessment and MNA test results were compared subsequently. ResultsMNA and MNA-SF results were compared with first clinician's decision of malnutrition and kappa coefficients were 0.68 and 0.66, respectively. Sensitivity analysis indicated that MNA was 92% sensitive and 86% specific, whereas MNA-SF was 94% sensitive and 81% specific. ConclusionMNA and MNA-SF are suitable for malnutrition screening in Turkish older adults.

Influence of antimuscarinic therapy on cognitive functions and quality of life in geriatric patients treated for overactive bladder

Objectives: Incidences of overactive bladder (OAB) and cognitive dysfunction increase with aging. Treatment of OAB with antimuscarinic agents may result in cognitive decline, especially in patients with Alzheimer's disease (AD). The aim of this study is to evaluate the effect of antimuscarinic treatment on cognitive functions, depression, and quality of life (QOL) of patients with OAB.Methods: This non-interventional prospective observational study was conducted in a geriatric medicine outpatient clinic. Overall, 168 OAB patients were enrolled. Patients were followed up in five groups: oxybutynin, darifenacin, tolterodine, trospium, and control groups. Follow-up visits were done at second, third, and sixth months. Comprehensive geriatric assessment, cognitive and mood assessment, QOL scales (IIQ-7, UDI-6) were performed.Results: Mean age of the patients was 73.5 ± 6.1. Of the 168 patients, 92.3% were female, 83.3% benefited from the treatment, and 37.1% discontinued the medication. Discontinuation rate and frequency of side effects were more frequent in the oxybutynin group. Mini Mental State Examination scores did not decline after treatment, even in AD patients. Geriatric Depression Scale scores, Activities of Daily Living scores, and QOL scores significantly improved after treatment.Conclusion: Antimuscarinic agents are effective in OAB treatment. They have a positive impact on daily life activities, depression, and QOL indices. Furthermore, they do not have a negative effect on cognitive function in older adults with or without AD.

The relationship between metabolic bone diseases and fingernail calcium levels in the elderly

PurposeMetabolic bone disorders are very common in the elderly population. As fingernail clippings are easily available for analysis, this makes them an interesting screening instrument for stored mineral components in the body. Measurements of calcium concentrations in fingernail clippings are thought to give some insight into their value as an alternative screening test for metabolic bone disorders and our aim was to determine whether fingernail calcium concentrations could be used for this purpose. Patients and methodsThis is a cross-sectional study, carried out in a Geriatric medicine outpatient clinic of a university hospital. A total of 159 patients with a mean age of 72.1±5.8 years were involved. Fingernail calcium levels were analyzed with atomic absorption spectrophotometry. ResultsThere was no statistically significant difference in nail calcium levels between osteoporotic and non-osteoporotic patients and similarly between vitamin D deficient and normal patients. The correlation between nail calcium concentrations and femur neck t-score and serum 25-OH vitamin D levels was very weak and non-significant. ConclusionWe found no change in nail calcium concentrations in osteoporosis and vitamin D deficiency, and therefore nail calcium measurements do not seem to be a good alternative screening instrument for metabolic bone disorders in the elderly.

Increased ferritin levels could reflect ongoing aging-associated inflammation and may obscure underlying iron deficiency in the geriatric population

Background and aimFerritin level is decreased in iron deficiency (ID) and increased in inflammation as an acute-phase reacting protein. In the case of inflammation ferritin, level may not decrease even if ID is present. Inflammation is regarded as one of the mechanisms of aging. This subclinical systemic inflammatory state is named as “inflammaging”. The aim of this study is to assess whether serum ferritin levels could indicate aging-associated inflammation rather than ID in older adults. MethodsConsecutive 1310 patients admitted to the geriatric medicine outpatient clinic were enrolled. The clinical conditions, which could alter acute-phase reactants, were excluded. ID diagnosis was made by transferrin saturation (<15%), MCV and serum iron. Patients with increased levels of either one of Erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), white blood cell (WBC), or decreased level of albumin were diagnosed as having subclinical inflammatory state. The correlations of ferritin with those groups were analyzed. ResultsMean age was 71.8±6.9 years and 827 (63.1%) were female. Ferritin levels were significantly higher in patients with subclinical inflammatory state and significantly lower in patients with ID. The interrelationships of the ferritin with acute-phase reactants were stronger than its relationship with the ID. ConclusionThe results of this study suggested that the ferritin level can increase with aging as a part of the ongoing asymptomatic chronic systemic inflammatory state called inflammaging. Inflammaging can result with increased ferritin levels, even if there is ID. Normal or elevated levels of ferritin in the geriatric population should not exclude ID in clinical practice.

Blunted baroreflex sensitivity: An underestimated cause of falls in the elderly?

BackgroundAutonomic nervous system disturbance and cardiovascular disorders may be underestimated causes of falls. Heart rate turbulence (HRT), heart rate variability (HRV) and QT dynamicity parameters are noninvasive cardiac autonomic activity markers. The aim of this study was to evaluate autonomic cardiovascular markers in falling older adults. MethodsThis was a case-control study conducted at a geriatric medicine outpatient clinic of a university hospital. Study group consisted of 33 older adults who had falls in the last 12months and the control group included 31 subjects who had never experienced falls. The patients in the study group were examined with 24-hour Holter electrocardiogram (ECG) and carotid sinus massage was done under monitorization. The 24-hour Holter ECG data were recorded and assessed with the ELATEC software. HRV, QT dynamicity and HRT parameters were analysed. ResultsThirty-three faller and 31 non-faller patients were examined in this study. Age and gender were similar between groups. All patients and control subjects had normal ejection fraction. Carotid sinus massage was done to the patients in the study group and three of 33 were positive (9.09%). There was no significant difference in HRV and QT dynamicity parameters between groups. Both HRT onset (2.51±1.48 vs. 7.29±3.28 P<0.001) and turbulence slope (0.15±1.10 vs. −0.73±1.89; P=0.031) were significantly different between the groups. ConclusionElderly subjects with recent falls have significantly worse HRT parameters than matched non-falling counterparts. Blunted baroreflex sensitivity and impaired cardiac autonomic function can be an important reason for falls in the geriatric age group.

Iron deficiency can cause cognitive impairment in geriatric patients.

Deficiency of iron, which plays an important role in oxygen transport and storage, may lead to cerebral hypoxia and cognitive decline. This relationship which was studied in children and adults was not evaluated in the elderly. The objective of this study is to examine the effect of iron deficiency on cognitive function in the elderly. This is a cross-sectional study conducted in a geriatric medicine outpatient clinic of a university hospital. Consecutive 2009 patients admitted to Geriatric Medicine outpatient clinic were examined and 622 patients who fulfilled the inclusion criteria were enrolled in the study. Comprehensive geriatric assessment, cognitive assessment and laboratory analysis including blood count, iron, total iron binding capacity, ferritin, and transferrin saturation were performed. Mean age of the study group was 72.5±6.5 and 439 (70.6%) were women. MMSE scores were moderately and significantly correlated with iron levels (r=0.33, p<0.001) and transferrin saturation (r=0.32, p<0.001). Transferrin saturation was significantly lower in the patients with dementia (p=0.040). It was found that patients with iron deficiency had lower MMSE scores (p<0.001) and this relationship was also present in patients without anemia (p=0.004). The results of this study revealed a negative influence of iron deficiency on cognitive function and this influence was independent from the presence of anemia. As iron deficiency can be easily diagnosed and treated, detecting its effect on cognitive function is of importance. Screening for iron deficiency and initiating appropriate treatment should be a routine part of comprehensive geriatric assessment.

Potential biomarkers for vascular damage in Alzheimer's disease: thrombomodulin and von Willebrand factor.

Evidence regarding the vascular basis of Alzheimer's disease (AD) is growing. In vascular damage thrombomodulin tears of the cell wall and its level increases in the plasma. von Willebrand factor (vWF) is also thought to be a biomarker for vascular damage. The aim of this study was to examine the levels of vWF and thrombomodulin in AD as possible markers for vascular damage and to test their utility as an early biomarker in AD. Case-control study. Geriatric medicine outpatient clinic of a university hospital. Twenty Alzheimer's disease patients free from vascular risk factors and 20 controls were enrolled in the study. Thrombomodulin and VWF levels of 20 AD patients and 20 controls were analyzed by commercial kits. Thrombomodulin levels were not different between Alzheimer's disease and control groups [median (range) = 4.25 (2.27-37.00) ng/ml in Alzheimer's disease and 3.55 (2.27-14.00) in control group, p=0.15]. Von Willebrand Factor antigen (%) levels were 188.5 (96-306) in Alzheimer's disease, and 181 (112- 284) in control group (p=0.74). Although vascular damage is thought to play role in the pathogenesis of AD, vWF and thrombomodulin failed to demonstrate the vascular damage in AD. Their utility to be used as early biomarkers of AD could not be shown.