Geriatric Abstracts - August 2005

ACUTE MESENTERIC ISCHEMIA

Acute mesenteric ischemia is a life-threatening vascular emergency with an overall mortality of 60-80%. This condition comprises a group of pathophysiologic processes that lead to bowel necrosis. Early diagnosis and intervention can adequately restore mesenteric blood flow and prevent bowel necrosis and patient death. Since it is difficult to recognize the condition before bowel infarction occurs, the survival rate has not improved significantly in the past 70 years. Clinical presentation of this illness is usually nonspecific, and is characterized by a discrepancy between severe abdominal pain and minimal clinical findings. The underlying cause is varied, and the prognosis depends on the precise pathologic findings. Despite the progress in understanding the pathogenesis of mesenteric ischemia and the development of modern treatment modalities, acute mesenteric ischemia remains a diagnostic challenge for clinicians. The timely use of diagnostic and therapeutic methods and the prompt, effective treatment to quickly restore blood flow are essential in reducing the high mortality rate and improving the clinical outcome.

Oldenburg WA, Lau LL, Rodenberg TJ, Edmonds HJ, Burger CD. Acute mesenteric ischemia: A clinical review. Arch Intern Med 2004;164: 1054-1062.

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DIABETES MELLITUS AND RISK OF ALZHEIMER’S DISEASE AND DECLINE IN COGNITIVE FUNCTION

Diabetes mellitus affects approximately 20% of people over age 65 years. It is a condition that has been associated with various adverse health effects in cross-sectional studies, including cognitive decline. This correlation of diabetes to impaired cognitive function suggests that the condition may contribute to Alzheimer’s disease. However, few prospective studies have assessed diabetes mellitus as a risk factor for incident Alzheimer’s disease and decline in cognitive function. Therefore, the authors used data from the Religious Orders Study, a longitudinal cohort study, to evaluate the relationship of diabetes to risk of Alzheimer’s disease and change in different cognitive abilities. Detailed annual clinical evaluations were conducted for up to 9 years on 824 Catholic nuns, priests, and brothers over age 55 years. The evaluations included the clinical classification of Alzheimer’s disease and detailed testing of changes in global and specific measures of cognitive function. Diabetes mellitus was present in 127 (15.4%) of the participants. During a mean of 5.5 years of observation, 151 individuals developed Alzheimer’s disease. In a proportional hazards model adjusted for age, sex, and educational level, those with diabetes had a 65% increase in the risk of developing Alzheimer’s disease compared with those without diabetes (hazard ratio, 1.65; 95% confidence interval, 1.10-2.47). In random effects models, diabetes was correlated with lower levels of global cognition, episodic memory, semantic memory, working memory, and visuospatial ability at baseline. Diabetes was also associated with a 44% greater rate of decline in perceptual speed (P = 0.02), but not in other cognitive systems. Study investigators concluded that diabetes mellitus may be associated with an increased risk of developing Alzheimer’s disease and may affect cognitive systems differentially.

Arvanitakis Z, Wilson RS, Bienias JL, Evans DA, Bennett DA. Diabetes mellitus and risk of Alzheimer disease and decline in cognitive function. Arch Neurol 2004;61(5): 661-666.

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SOCIOECONOMIC STATUS AND OUTCOME FOLLOWING ACUTE MYOCARDIAL INFARCTION IN ELDERLY PATIENTS

Although the Medicare Part A federal program provides universal hospital care coverage for elderly Americans, socioeconomic disparities exist in the medical and invasive treatment of acute myocardial infarction. It remains unclear whether these disparities account for increased mortality among elderly poor patients. The authors of this study sought to determine the association between socioeconomic status and acute myocardial infarction treatment, procedure use, and 30-day and 1-year mortality. They analyzed data from 132,130 elderly Medicare beneficiaries who were hospitalized for acute myocardial infarction between January 1994 and February 1996. Patients were categorized into 10 groups of increasing income using the median income of the zip code of residence. Investigators found that the highest-income beneficiaries received higher rates of evidence-based medical therapy and had lower adjusted 30-day and 1-year mortality rates, as compared with the middle-income beneficiaries (30-day relative risk [RR], 0.89 [95% confidence interval (CI), 0.85-0.94]; and 1-year RR, 0.92 [95% CI, 0.88-0.97]). Conversely, the lowest-income beneficiaries received lower rates of evidence-based medical treatment and had higher adjusted 30-day and 1-year mortality rates, as compared with the middle-income beneficiaries (30-day RR, 1.09 [95% CI, 1.04-1.13]; and 1-year RR, 1.05 [95% CI, 1.00-1.10]). Coronary revascularization rates were similar among income groups. These data reveal that despite the Medicare entitlement, there remain significant socioeconomic disparities in medical treatment and mortality among elderly patients following acute myocardial infarction. Income is independently associated with short- and long-term mortality. The authors conclude that more research is needed to determine the mechanisms contributing to adverse outcomes among poor elderly patients and to determine whether expanding Medicare coverage will alleviate these disparities.

Rao SV, Schulman KA, Curtis LH, Gersh BJ, Jollis JG. Socioeconomic status and outcome following acute myocardial infarction in elderly patients. Arch Intern Med 2004; 164(10):1128-1133.

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PALLIATIVE CARE FOR PATIENTS WITH HEART FAILURE

Heart failure is the leading cause of hospitalization for Medicare beneficiaries. The symptoms, including shortness of breath, fatigue, and edema, can be frightening and diminish quality of life. Heart failure remains a leading cause of death in the United States despite advances in treatment that have allowed patients to live longer with a better quality of life. Half of patients with heart failure die within 5 years of being diagnosed, and for many, death is sudden. Given the availability of effective treatments, the prevalence of distressing symptoms, and a persistent high risk of death that may occur suddenly, physicians must simultaneously treat the underlying condition while helping patients plan for future needs and complete advance directives. This article uses the case of a 74-year-old patient with heart failure to illustrate ways that physicians can address these issues to improve the care of patients with heart failure, including symptom management and discussion of advance directives, prognosis, and hospice care. Optimal medical management combined with palliative care helps physicians to provide the best care for patients with heart failure and their families.

Pantilat SZ, Steimle AE. Palliative care for patients with heart failure. JAMA 2004;291(20):2476-2482.