Screening Of Elderly Patients Research Articles

Clinical profiles and correlates of mortality in nonagenarians with severe aortic stenosis undergoing transcatheter aortic valve replacement

Transcatheter aortic valve replacement (TAVR) is the current standard for nonoperable and high-risk surgical patients with aortic stenosis, including those of advanced age. However, the clinical profiles, procedural characteristics, and outcomes of nonagenarians undergoing TAVR have not been thoroughly reported. A total of 654 patients (n = 107 >90 years old and n = 547 <90 years) with severe aortic stenosis undergoing TAVR were included in this analysis. Baseline characteristics, procedural variables, and in-hospital outcomes and complications at 30 days and 12 months were analyzed. Overall, of the patients included, 46% were high risk and 53% inoperable. Although nonagenarians had a higher Society of Thoracic Surgeons score of 9.2 ± 4 (12.1 ± 4 vs 8.6 ± 4, P < .001), other factors were considerably lower in this group: diabetes (22% vs 36%, P = .008), hyperlipidemia (65% vs 83%, P < .001), prior coronary artery bypass (13% vs 39%, P < .001), and mean body mass index (24.5 ± 5 vs 28.1 ± 7 kg/m(2), P < .001). The correlates for 1-year mortality in nonagenarians were as follows: ≥moderate aortic insufficiency post-TAVR (hazard ratio [HR] 5.07, 95% CI 1.17-22, P = .03), pacemaker implantation after TAVR (HR 6.87, 95% CI 2.32-20.3, P = .001), and peripheral vascular disease (HR 2.35, 95% CI 1.03-5.38, P = .042). Mortality at 30 days (12.1% vs 7.1%, P = .07) and at 1 year (25% vs 21%, P = .35) was similar between groups. Nonagenarians undergoing TAVR had a healthier clinical profile compared with younger patients. Age alone should not be a discriminatory factor when screening elderly patients with aortic stenosis because even the nonagenarians are doing well when compared with the younger elderly population. Transcatheter aortic valve replacement remains a viable option for the treatment of severe symptomatic aortic stenosis for the elderly regardless of their age.

The effectiveness of “Mindfulness based Cognitive Therapy” on psycho-social performance of chronic low back pain patients (CLBP)

The effectiveness of “Mindfulness based Cognitive Therapy” on psycho-social performance of chronic low back pain patients (CLBP)

Cognitive-behavioral screening in elderly patients with new-onset epilepsy before treatment.

Cognitive comorbidity at epilepsy onset reflects disease severity and provides a baseline estimate of reserve capacities with regard to the effects of epilepsy and its treatment. Given the high incidence of epilepsy at an older age, this study analyzed objective and subjective cognition as well as quality of life in elderly patients with new-onset focal epilepsy before initiation of anti-epileptic treatment. A total of 257 untreated patients (60-95 years of age) with new-onset epilepsy underwent objective assessment of executive function (EpiTrack) and performed subjective ratings of cognition (Portland Neurotoxicity Scale) and quality of life (QoL; QOLIE-31). According to age-corrected norms, 58% of patients (N=257) demonstrated deficits in executive function; major determinants were cerebrovascular etiology, neurological comorbidity, and higher body mass index. Subjective ratings indicated deficits in up to 27% of patients. Self-perceived deficits were associated with neurological, cardiovascular, and/or psychiatric comorbidity, whereas poorer QoL was related to neurological comorbidity and female gender. Objectively assessed executive functions correlated with subjective social functioning, energy, motor function, and vigilance. We found a relatively high QoL, a low rate of subjective impairment, but a high incidence of objective executive deficits in untreated elderly patients with new-onset epilepsy. Neurological status and body mass index, rather than seizure frequency or severity, were risk factors for cognitive impairment. Given the relevance of cognition in the course of epilepsy and its treatment, routine screening before treatment initiation is highly recommended.

Postural stability, risk of falls and fear of falling in elderly with diabetic neuropathy who do therapeutic exercises

This study aimed to analyze postural stability, the risk of falls and fear of falling in elderly with diabetic neuropathy (DNP) that perform therapeutic exercises. The authors conducted the screening of elderly patients with DNP using the instruments Neuropathy Symptom Score (NSS) and the Neuropathy Disability Score (NDS). The 50 selected patients were divided into two groups: 24 of G1 (who were performing therapeutic exercises) and 26 of G2 (the control group). To assess postural stability, risk of falls and fear of falling among groups used the pressure platform, the Berg Balance Scale (BBS) and the Falls Efficacy Scale (FES-I). There was no significant difference in the outcome of BBS scales (p=0.16) and FES-I (p=0.15) between the G1 and G2; by the pressure platform, we found differences between G1 and G2 in parameters path length (PL) and stability medio-lateral (ML), with both eyes closed (EC). Elderly people with DNP who perform therapeutic exercise have better stability and ML and PL with EC that sedentary elderly; however, there was no association with therapeutic exercise, risk of falls and fear of falling.

PC-FACS

PC-FACS

Screening Colonoscopy Can Benefit Healthier Elders

Gaithersburg, Md. – The benefits of a transcatheter heart valve outweigh its risks for older patients with severe, symptomatic aortic stenosis who are at a high risk for surgery, voted the majority of an advisory panel to the Food and Drug Administration recently. All panel members also voted that the valve was effective, and 10 of 12 members said that it was safe. The valve entered the U.S. market last November after receiving FDA approval for patients who have severe aortic stenosis and are deemed too sick to undergo surgical heart valve replacement (N. Engl. J. Med. 2010;363:1597-607). On June 12, Edwards Lifescience, the maker of the SAPIEN transcatheter heart valve, said that based on the results of the PARTNER pivotal trial, the valve is also safe and effective in the high-risk cohort. Although FDA officials agreed that the trial met its primary endpoints, they expressed concern with the higher risk of stroke in patients who underwent transcatheter aortic valve replacement (TAVR), compared with those who underwent surgery. They also raised questions about the long-term durability of the device, for which there are no data yet available yet. In his final remarks, Dr. Craig R. Smith, chair of the department of surgery at Columbia University and coprincipal investigator of the PARTNER trial, said that although the risks associated with the procedures must be taken seriously, they should not be an obstacle to the indication’s approval. The main results of the trial showed that all-cause mortality at 30 days favored TAVR at 3.4%, compared with 6.5% for open surgery, and was similar at 1 year (24% and 27%, respectively). The difference at 1 year reached the trial’s prespecified noninferiority margin, yet again, neurologic complications occurred more frequently after TAVR. Surgical valve replacement has evolved over the past 50 years, and although TAVR is radical, it’s the next logical step in that evolution, Dr. Smith told the panel. The results of cohort A of PARTNER, he said, bring the field one step closer to the day that valves can be replaced with no large incisions, no heart-lung machine, and potentially no general anesthesia. The Centers for Medicare & Medicaid Services decided in May that it will cover the procedure in inoperable patients, under certain conditions, including evaluation of the patient by two cardiac surgeons. Dr. Gregory J. Dehmer, professor of medicine at Texas A&M University, said that the field was only at its infancy. Dr. Dehmer disclosed no conflict of interest. Dr. Smith noted that he is an investigator in the PARTNER trial. CfA

Health Status Screening in Elderly Patients — Is this the Way Forward?

The rapid ageing of the European population poses a challenge for healthcare systems. The incidence of cancers will rise as the number of adults aged 65 years and older increases. Moreover, the health status of individuals in this age group is diverse, and thus requires modern oncology to apply an individualised approach to treatment. There is a clear need to develop and validate health assessment tools enabling the identification of specific geriatric issues which might be overlooked by standard assessment methods. The Comprehensive Geriatric Assessment (CGA) is the ‘gold standard’ for geronto-oncology assessment. However, the complexity of this test has stimulated a search for pre-screening methods able to identify individuals with the potential to gain most from full pre-treatment CGA. Such tools consist of specific tests to evaluate health status in the important functional, psychological, social and cognitive domains. The choice of which tests are best to use within the various screening tools is still a subject of debate. This paper presents a review of the most commonly used tests within various health status domains as well as of the most valuable screening tools.

Cervical cancer screening in elderly patients: Should we discontinue screening at age 70?

Objectives: Cervical cancer incidence and mortality rates have declined greatly since the introduction of the Papanicolaou smear. The American Cancer Society, the American College of Obstetricians and Gynecologists and the U.S. Preventive Services Task Force recommend discontinuation of cervical cancer screening between 65 and 70years of age in women with no abnormal test results in the preceding 10years. However, the rationale behind those recommendations is unclear. This population-based study was undertaken to determine the incidence of cervical cancer in different age groups as a means to establish if current screening guidelines need re-evaluation.

Sensitive and high sensitivity next generation cardiac troponin assays: more than just a name

In the 20 years that cardiac troponin testing has been available in clinical laboratories, the biomarker has revolutionised testing of patients with acute coronary syndromes. Cardiac troponin I and T testing has become the cornerstone for diagnosis of myocardial infarction and is useful for risk assessment and management of suspected acute coronary syndrome patients. As evidence and knowledge have evolved, it has become clear that even small troponin elevations are associated with adverse health outcomes. As a result there have been several generations of troponin assays, all toward tests that reliably detect lower concentrations of this critical analyte. Guidance for cardiac troponin interpretation has been in the form of myocardial infarction redefinition and evidence-based clinical and analytical guidelines. Although terminology naming generations for cardiac troponin assays has been inconsistent, state-of-the-art cardiac troponin assays are generally referred to as 'sensitive' assays and are in general compliance with analytical guidelines. Evidence shows that use of a sensitive troponin assay can result in diagnosis of myocardial infarction earlier. Next generation cardiac troponin I and T assays will likely be termed 'high sensitivity'; these assays should have the ability to measure troponin with a CV of total error of <10% at concentrations significantly lower than the 99 percentile of the normal reference population. As such, these assays should reliably measure troponin in most normal individuals and detect troponin changes (delta values) below the 99 percentile. This property may result in earlier ACS diagnosis and better management. Utilisation of high sensitivity troponin measurements may be useful for applications other than acute coronary syndromes including risk stratifying patients with renal insufficiency, heart failure, cardiac amyloid and screening elderly patients.

Mini-Mental State Examination score and B-type natriuretic peptide as predictors of cardiovascular and total mortality in an elderly general population

Introduction. The aim of the present study was to examine the power of B-type natriuretic peptide (BNP) and mild cognitive impairment as independent predictors of total and cardiovascular mortality in combination with established cardiovascular risk markers in an elderly general population without severe cognitive impairment.Methods. A total of 499 individuals, aged more than 75 years, were examined and followed up for a median of 7.9 years in a prospective population-based stratified cohort study carried out in eastern Finland. The Cox proportional hazards regression model was used to determine the impact of multiple factors on total and cardiovascular mortality.Results. In a multivariable model including established cardiovascular risk factors and conditions, both continuous BNP (adjusted hazard ratio (HR) 1.44 for a 1-SD change; 95% confidence interval (CI) 1.22–1.77; P < 0.001) and continuous MMSE score (HR 0.81 for a 1-SD change; 95% CI 0.70–0.94; P = 0.007) were independently associated with all-cause mortality. In a multivariable model, BNP remained a significant predictor of cardiovascular mortality, while MMSE score lost its significance.Conclusions. BNP, a measure of cardiovascular burden, and MMSE score 18–23, an indicator of mild cognitive impairment, are both independent predictors of total mortality. BNP and MMSE score may potentially be useful in screening elderly patients for elevated risk of mortality.

Characteristics of Pulmonary Tuberculosis in Elderly People

Results: There was no difference in the prevalence of typical symptoms between the younger and the elderly group. Dypsnea was the only symptom that occurred more frequently in the elderly group (16.8% vs 5.5%, p=0.008). On radiological study, pneumonic infiltration type was more common in the elderly group (28.6% vs 16.8%, p=0.035). Sputum Acid fast bacilli smear positivity rate was si milar between the 2 groups. Elderly patients with anti-tuberculosis medication had more frequent adverse drug reactions; however, there was no significant difference between the 2 groups in the number of patients required to stop medication due to an adverse drug reaction. There were more patients lost to follow-up in the elderly group (22/112, 19.6% vs 11/113, 9.7%, p=0.036). Conclusion: The majority of elderly patients did not complete the treatment, resulting in a poorer outcome. Therefore, we need to make an effort to support the continued screening of elderly patients by making this economically feasible.

The Safety of Anti-TNF Agents in the Elderly

Rheumatoid arthritis, ankylosing spondylitis and psoriatic arthritis are commonly thought of as inflammatory diseases that affect younger individuals. Although the initial presentation of these diseases is common in a patients twenties or thirties, they usually persist for the duration of the patients life. In addition, up to one-third of patients with RA have disease onset after 60 years of age. Anti-TNF-a therapies now have well-recognized safety profiles that have been demonstrated in the usual clinical trial populations for these diseases, but such populations under-represent patients > or =65 years of age. This retrospective study aims to determine the safety profiles for etanercept, infliximab and adalimumab in patients of 65 years or more, undergoing anti-TNF treatment for an active inflammatory disease such as rheumatoid arthritis, ankylosing spondylitis or psoriatic arthritis, or skin disease like psoriasis. Our data show that admitting elderly patients into anti-TNF therapeutic regimens is a safe option and that it grants these patients access to the best current therapeutic option, possibly leading to better disease outcome. Quality of life in elderly patients affected by arthritis or psoriasis, often reduced by comorbidities, is as important as quality of life in younger patients. Applying the recommended screening before using biological treatment helps to reduce adverse events related to the therapy, and the application of the same screening in elderly patients seems to lead to comparable results.

Risk analyses for screening sigmoidoscopy based on a colorectal cancer (CRC) population

Objective. Although colonoscopy can be effective in the prevention of colorectal cancer (CRC), it requires many endoscopic facilities, has a high patient burden and risk of complications, and it is expensive. The aim of this study was to determine the risk for proximal CRC and to identify subgroups in which screening sigmoidoscopy can be effective. Material and methods. A database search was carried out on all patients who underwent endoscopy of the lower gastrointestinal (GI) tract between 1997 and 2005. All patients diagnosed with CRC were included. Variables including age, gender and the presence of distal colonic neoplasia were used for risk analyses. Results. In total, 783 patients were diagnosed with CRC. Tumour was located in the proximal colon in 68/255 (27%) of the patients <65 years. Of the patients <65 years, 22% (57/255) had proximal CRC without synchronous distal lesions and would thus have been missed by sigmoidoscopy screening. Among patients >65 years, 41% (216/528) were diagnosed with proximal CRC, significantly more often in women than in men (p <0.001). In 35% of patients (185/528) proximal CRC without distal colonic neoplasia was found, significantly more than in those under 65 years of age (p <0.001). Conclusions. Significantly more proximal localized CRC would have been missed by sigmoidoscopy screening in elderly patients, especially in women. In subjects <65 years of age, sigmoidoscopy screening allows detection of almost 80% of CRC cases and might suffice as a screening method.

The decision-making process in cancer screening of elderly patients in primary care: a systematic review

The decision-making process in cancer screening of elderly patients in primary care: a systematic review

The hospital appropriateness evaluation protocol in elderly patients: a technique to evaluate admission and hospital stay

Aging of the population represents one of the main challenges for health systems because of the increase in the demand for hospital services. To be able to count on tools that allow an objective evaluation of hospital-resource use becomes indispensable for health systems. To evaluate the reliability and validity of the Appropriateness Evaluation Protocol (AEP) regarding the appropriateness of admissions and hospital stays in elderly patients. In a scenario of scarce resources, to have a valid instrument will make it possible to evaluate the process of care in our growing elderly population in a standardized way. We carried out a retrospective study of 144 randomly chosen elderly patients admitted to the hospital with 394 even-numbered hospital-stay days. For the reliability analysis between the pair of nurses with the AEP and the pair of specialists, the details of the hospital admissions and the stay days were obtained from the clinical files. Criteria validity was conducted by pairs of physicians, including two internists, two general surgeons and two geriatricians. Only the agreements were compared with agreements of the AEP-trained nurses. Disagreements were excluded from the final analysis. Inter-rater (inter-reviewer) agreement of hospital admissions and days spent by the patient presented a kappa coefficient of >0.70, while these admissions and hospital-stay days was >0.70. Sensitivity and positive predictor value to detect inappropriate admissions were not calculated because no agreement existed on inappropriate admissions. Specificity and negative predictive value to detect appropriate admission was >94.0% and >98.0%. Sensitivity and positive predictor value to detect inappropriate hospital-stay days was >44.0% and >10.0%, while specificity and negative predictor value for detecting appropriate hospital-stay days was >79.0% and >88.0%. AEP's high-reliability and moderate-validity results with regard to clinical judgement positions it as a useful instrument for appropriate hospitalization screening in elderly patients.

When to stop screening for colorectal cancer

When to stop screening for colorectal cancer

Comparing Risks and Benefits of Colorectal Cancer Screening in Elderly Patients

Comparing Risks and Benefits of Colorectal Cancer Screening in Elderly Patients

Comparing Risks and Benefits of Colorectal Cancer Screening in Elderly Patients

In patients with limited life expectancy, the risks of colorectal cancer screening may outweigh the benefits. The aim of this study was to quantify risks and benefits of different screening strategies in elderly patients with varying life expectancies. We examined risks and benefits of screening in patients aged 70-94 years with differing health status using 3 strategies: annual fecal occult blood tests, flexible sigmoidoscopy every 5 years, or colonoscopy every 10 years. We compared the number needed to screen to prevent one cancer-related death and the number needed to encounter one screening-related complication for different strategies. The potential benefit from screening varied widely with age, life expectancy, and screening modality. One cancer-related death would be prevented by screening 42 healthy men aged 70-74 years with colonoscopy, 178 healthy women aged 70-74 years with fecal occult blood tests, 431 women aged 75-79 years in poor health with colonoscopy, or 945 men aged 80-84 years in average health with fecal occult blood tests. Colonoscopy screening had the greatest benefit but the highest risk of complications. The potential for screening-related complications was greater than estimated benefit in some population subgroups aged 70 years and older. At all ages and life expectancies, the potential reduction in mortality from screening outweighed the risk of colonoscopy-related death. The potential benefits and risks of screening vary in elderly patients of different life expectancies. For any individual patient, the potential for harm from screening must be weighed against the likelihood of benefit, especially with shorter life expectancy.

This Month in Gastroenterology

This Month in Gastroenterology

Letter Regarding Article by Masoudi et al, “National Patterns of Use and Effectiveness of Angiotensin-Converting Enzyme Inhibitors in Older Patients With Heart Failure and Left Ventricular Systolic Dysfunction”

To the Editor: We read with great interest the article by Masoudi et al,1 in which “a stubborn, persistent gap between ideal practice and actual use of ACE inhibitors for heart failure” was shown. The editorial by Mark Hlatky2 also stimulated our reflections. The gap between ideal and practical use in the cardiovascular field and other fields of medicine may have various explanations. Data have shown that the “real patient” is different from the “trial patient”; in fact the latter, even if old, is usually in good general condition, without comorbidities and cognitive and physical impairments. This patient may be considered a “robust” or an “intermediate” subject.3 In the real world, however, many patients are frail, with severe comorbidities, polypharmacy, cognitive or physical disabilities, and …