Influence of thiopental and propofol on postoperative cognitive recovery in the elderly patient undergoing general anesthesia

STUDY OBJECTIVE

To assess mental and psychomotor recovery following induction of anesthesia with thiopental or propofol in elderly patients undergoing general anesthesia.

DESIGN

Randomized, prospective, double-blind study.

SETTING

Large referral hospital.

PATIENTS

40 elderly patients ASA physical status I-III (> 65 years) undergoing abdominopelvic surgery with an estimated surgical time of at least 90 minutes.

INTERVENTIONS

All patients received combined epidural-general anesthesia. After establishing a T6 sensory blockade, patients were randomized to receive either thiopental or propofol for induction of general anesthesia. The induction drug was slowly titrated until loss of eyelash reflex was noted. Thereafter, all patients received desflurane (2% to 3% end-tidal) and 70% nitrous oxide (N2O) in oxygen for maintenance of general anesthesia. To facilitate tracheal intubation, intravenous alfentanil 10 micrograms/kg and atracurium 0.4 mg/kg were administered. Perioperative analgesia was maintained with epidural bupivacaine.

MEASUREMENTS AND MAIN RESULTS

A digit substitution test (DSST) and shape-sorter test, as well as patient-generated 100-mm visual analog score (VAS; 0 = minimal and 100 = maximal) for anxiety, sleepiness, and coordination, were performed during the preanesthetic interview, on postanesthesia care unit admission, and at 15, 45, 90, and 120 minutes thereafter. To induce loss of consciousness, either thiopental 2.5 +/- 1.0 mg/kg or propofol 1.6 +/- 0.6 mg/kg was administered. The mean anesthetic time was 109 +/- 30 minutes and 114 +/- 38 minutes for the thiopental and propofol groups, respectively. Emergence, extubation, and orientation times, as well as time to follow commands, were unaffected by patient randomization. Similarly, the DSST and shape-sorter tests, in addition to the patient-generated VAS for pain, anxiety, and coordination, were similar among groups. However, irrespective of treatment modality, return to baseline digit substitution and shape-sorter scores were significantly delayed (p < 0.01).

CONCLUSION

When compared to thiopental, propofol does not facilitate improved cognitive recovery in geriatric patients undergoing prolonged surgery.

[Left ventricular outflow tract obstruction without left ventricular hypertrophy treated with ACE inhibitors]

We describe a very unusual case of sudden, severe worsening of congestive heart failure which was caused by ACE inhibitors. Diagnosis was made by echocardiogram showing a typical picture of dynamic, left ventricular outflow tract obstruction without left ventricular hypertrophy, which disappeared on discontinuing ACE inhibitors. This phenomenon has already been described as a complication of other drugs such as nitrates, commonly used as provocative tests for latent obstructive cardiomyopathy. To our knowledge ACE inhibitors have not been described as a causative factor.

Creatine kinase MB isoenzyme of noncardiac origin in elderly patients

Increased activity of creatine kinase MB (CKMB) isoenzyme is regarded as highly diagnostic for acute myocardial infarction. We report two cases of elderly patients with increased levels of CKMB but no evidence of cardiac injury. We conclude that numerous factors influence CKMB activity and that the suitability of this test for the diagnosis of cardiac muscle damage in the elderly should be viewed with caution.

[Infective endocarditis presenting as polyarticular septic arthritis]

We report acute polyarthritis in an 86-year-old man which was initially considered to be an exacerbation of osteoarthritis. After a delay of a few days a diagnosis of septic polyarthritis as an initial symptom of infective endocarditis was made. Although rheumatic manifestations in infective endocarditis are common, septic polyarthritis is rarely seen. In our patient the course of the disease was rapidly fatal.

[Comprehensive geriatric assessment--its clinical, social and economic importance and prospects]

It is well known that many elderly patients are referred to nursing homes because of "functional decline" without being thoroughly investigated. We studied 9 elderly patients, all referred to hospital due to functional decline and diagnosed as follows: spinal stenosis--2 cases, depression--3, thyrotoxicosis--1, Parkinson--1, polypharmacy and congestive heart failure--1 patient each. Proper diagnosis and appropriate treatment prevent unnecessary hospitalization in nursing homes. Our study is meant to draw attention to this crucial aspect of geriatric medicine.

[Nursing home-acquired pneumonia--guidelines for hospitalization]

To determine if there are any specific features of nursing-home acquired pneumonia we carried out a retrospective study in a nursing home between 1995-1996, based on clinical and laboratory data. We found no correlation between these findings and the severity of pneumonia, so it would be hazardous to determine rigid guidelines. These patients should be treated in the nursing home as long as conditions allow, in order to avoid hospitalization.

[Rheumatoid arthritis in the elderly]

Opinions differ as to whether late onset rheumatoid arthritis (RA) represents a clinical subset and whether age at onset involves differences in therapy and prognosis. In this retrospective study we compared 23 patients with early onset RA (average onset 52.8 years; 91.3% of them women), with 36 with late onset (average onset 70.3 years; 67% of them women). No statistically significant differences were found as to demographic, clinical, laboratory or radiographic characteristics.

Clay as a therapeutic tool in group processing with the elderly

Geriatric rehabilitation includes medical treatment, physical therapy, and therapy in both the psycho-social field and the activities of daily living (ADL). Its objective is to return the individual to independent functioning. This may be achieved through art therapy, which enables verbal and non-verbal communication; the expression of personal feelings; and physical, sensorimotor, and cognitive therapy. Group work with hospitalized elderly people is general limited, and art therapy using clay is particularly so. Yet it can stimulate feelings of fellowship and evoke a sense of cooperation and support. This article reviews group work with clay as an additional form of therapy with a group of 8 patients with Cerebrovascular Accident (CVA), or stroke, and femur neck fractures. The objective of the therapy was to combine bilateral sensorimotor activities of the upper limbs with social interaction directed towards future leisure-time activity. The subject of the clay work was "the home," which is central in the life of the elderly person. The article describes initial group activity with two groups of patients. Analysis of the activity was through retrospective observation--examining videotapes, photographs, and questionnaires at the end of each session.

Slowly progressive aphasia, a left temporal variant of probable Pick's disease: 15 years of follow-up

It is known that word-finding difficulties or anomia are the first signs observed in Pick's disease. We report a 15 year follow-up of a woman who at the age of 52 suddenly developed a speech impairment and only 6 years later showed other cognitive disturbances compatible with Pick's disease. This case demonstrates that nonfluent aphasia and agrammatic aphasia may constitute the first signs of this disease, stressing the importance of prolonged follow-up in such cases.

Primary visual memory of stroke patients

This matched control group study assesses primary visual memory of stroke patients using the GEMAT visual-memory test. Primary visual memory of 29 stroke patients who scored 24 or more on the MMSE was compared with that of 33 age and sex-matched controls. Patients were recruited from physiotherapy outpatient clinics. Measured variables were the total time needed to complete the test (GTT) and the number of correct answers (GCA). Patients were slower (p < 0.01) and made more mistakes (p < 0.01) than controls. 'Young' (60-71) subjects made fewer mistakes (p < 0.01) than old subjects (72-89) and patients who scored 24-26 on MMSE were slower than patients who scored 27-30. It should be taken into consideration that stroke patients whose cognitive function is within a normal range of the MMSE might have impaired primary visual memory.

[Multiple myeloma: a geriatric dilemma]

Asymptomatic multiple myeloma was diagnosed in an 80-year-old woman with ischemic heart and cerebrovascular disease. The diagnosis was based on the finding of a rapid sedimentation rate (120 mm in the first hour), paraproteinemia with high levels of monoclonal IgA (4,582 mg%) and the characteristic findings on bone marrow aspiration. There was neither Bence-Jones protein nor hypercalcemia, nor clinical signs of multiple myeloma, such as bone pain, pathological fractures, or recurrent infections. We faced a dilemma in deciding whether or not to treat this elderly, asymptomatic woman. Chemotherapy in an elderly patient can be hazardous, and even life-threatening, due to adverse effects. On the other hand, untreated myeloma may be followed by rapid deterioration. It was decided not to start chemotherapy unless the clinical picture were to change for the worse. Although the hyperviscosity syndrome in this condition is usually due to elevated IgM paraprotein, it has been caused by IgG, or as in this case, by IgA hyperparaproteinemia.

[Nosocomial acquisition of Clostridium difficile infections]

Clostridium difficile (CD) is associated with diarrhea in hospital patients receiving antibiotic therapy and may be nosocomially acquired. An outbreak of CD diarrhea was observed among elderly patients in acute hospital and geriatric rehabilitation wards. All but 1 patient presenting with diarrhea had a toxin-positive stool culture. Of patients with CD toxin-positive cultures, 4 died, 5 recovered completely and 1 became a chronic carrier. Effective preventive measures are needed to reduce nosocomial acquisition of CD.

Is renal biopsy justified for the diagnosis and management of the nephrotic syndrome in the elderly?

During the past decade, controversy has raged about the necessity of renal biopsy for the management of the idiopathic nephrotic syndrome. The debate has centered on whether a precise diagnosis is imperative for steroid treatment or whether such therapy can be given blindly. The above question has not been addressed in the elderly. In this retrospective study 30 patients aged > 60 years, all of whom underwent a renal biopsy for an unexplained nephrotic syndrome, were categorized according to histological findings and clinical evolution of their disease. The spectrum of histology was diverse, the most common renal lesion diagnosed being membranous glomerulopathy (MGN) (23%). At variance with other works is the relatively high incidence of membranoproliferative glomerulonephritis (MPGN) (20%) found by us. Minimal change disease (MCD) and amyloidosis were encountered in 5 (17%) and 4 patients (13%), respectively. Specific therapy (steroids) was administered in 11 patients. No benefit of steroid treatment was shown in patients with either MGN or MPGN. The only lesion which responded to steroids was MCD (3 complete remissions, 1 partial). Only one biopsy was complicated by a clinically significant perirenal hematoma requiring blood transfusion. No surgical intervention was necessary. Our findings tend to favor a positive approach to the performance of a renal biopsy in the management of the nephrotic syndrome in the elderly.

[Falls in elderly patients in an institution]

Falls among the elderly are a major concern of those caring for them. We studied the incidence of falls in institutionalized elderly, as well as the characteristics of those who fell and the causes of the falls, to determine how to prevent falling. A 2-month survey was conducted in Mishan, an institution in Raanana, and included 144 falls in 108 patients (447 women and 162 men, mean age 84) out of a total of 609 elderly. The prevalence of falls was 1426 per 1000 per year. Most cases of falls were first seen in the emergency room or wards for demented patients. The prevalence of falls among those receiving physiotherapy was only 1/3 that of those who did not. Old institutionalized patients tend to fall mainly while getting in and out of bed. Falls may result from medication such as sleeping pills and psychotropic drugs, but not diuretics. Falls are not inevitable, and measures can be applied to prevent them and thus reduce their frequency.

T lymphocytes of rheumatoid arthritis patients show augmented reactivity to a fraction of mycobacteria cross-reactive with cartilage

An acetone-precipitable fraction of Mycobacterium tuberculosis cross-reacts with human cartilage. Immune responses to this antigen were assessed in 34 patients with rheumatoid arthritis, 16 patients with degenerative joint disease, and 15 healthy controls. The RA patients differed from the other two groups in having more pronounced T lymphocyte responses to the antigen; their serum antibody levels were not higher. The responses of RA patients varied with duration of disease. In the first year (7 patients) T lymphocyte reactivity was increased in the synovial exudates of affected joints but not in peripheral blood, whereas the 19 with disease of 1-10 years' duration showed high reactivity in peripheral blood; in the 8 with disease for more than 10 years, lymphocyte reactivity did not differ from that in the patients with degenerative joint disease or the healthy controls. The observation that the three groups did not differ in their responses to streptococci and a T-cell mitogen indicates that reactivity of the RA patients to the mycobacterial fraction was specific. These results raise the possibility that bacterial antigens cross-reactive with cartilage proteoglycans may be relevant to the pathogenesis of RA.

Listeria monocytogenes pericarditis in a chronically hemodialyzed patient

We describe the third documented case of Listeria monocytogenes pericarditis. This occurred in a 54-year-old woman with end-stage renal failure on chronic hemodialysis. Her initial presentation was one of Listeria monocytogenes bacteremia, which apparently responded to two weeks of cefazolin sodium therapy. After cessation of therapy the patient returned with Listeria monocytogenes pericarditis, this responding completely to four weeks of erythromycin therapy. We could not rule out coexisting endocarditis, especially since we found high levels of circulating immune complexes which subsided as the patient's condition improved. Further immunological studies displayed a decrease in cellular functions. This case illustrates the importance of Listeria monocytogenes as a human pathogen in immunocompromised patients. Listeria should be included among the potential causative agents of pericarditis in such patients.

Angioimmunoblastic lymphadenopathy with paraproteinemia: a T- and B-cell disorder

A case is reported of angioimmunoblastic lymphadenopathy (AILD), in which a IgM Kappa monoclonal gammopathy developed. On the first admission the immunoblasts were shown to be T cells by surface-marker studies. Although the number of circulating T cells was normal, their functional capacities were markedly reduced. The patient was followed for two months at the end of which she died with hematologic features of immunoblastic plasma cell leukemia.

Pancreatitis in systemic lupus erythematosus--a case report and review of the literature

A young woman with a past history of haemolytic anaemia was admitted to the hospital for pancreatitis and found to have serological evidence of systemic lupus erythematosus (SLE). The occurrence of pancreatitis as a complication of SLE is reviewed.

Detection of anti-red blood cell antibodies by treatment of the cells with neuraminidase

Neuraminidase treated RBC were used to detect incomplete unbound anti RBC antibodies in the plasma of patients with immune diseases. 80% (48 out of 60) of the examined patients gave positive results with this method while all the 50 normal controls were negative. The indirect antiglobulin test was negative in all the patients. In the direct antiglobulin test only two RBC samples, whether treated with neuraminidase or not, gave positive results. The present study indicates that the assay of plasma on neuraminidase treated RBC may serve as a sensitive method for the detection of the presence of anti RBC antibodies in various immunological diseases.

The intracavitary electrocardiogram: a routine bedside procedure elucidating obscure arrhythmias. A study in 60 patients

Right heart intracavitary ECG were studied in 60 patients. The procedure is performed by means of a nonmetallic saline-filled catheter introduced percutaneously. It is a simple, quick bedside method requiring minimal equipment. The intracavitary recording visualizes clear and high-voltage P waves, so that a more precise interpretation of complicated rhythm disturbances is possible. It has a distinct advantage over the esophageal lead recording in the differentiation between atrial and ventricular ectopic rhythms. The precise localization of the tip of the catheter used for central venous pressure monitoring can be determined. In 10 patients, doubtful surface ECG diagnoses were confirmed and in 10 others the original ECG interpretation was changed following intracavitary recording. In the remaining 40 patients, the method was used in order to avoid aberrant placement of the central venous pressure catheter.

Acute lymphoblastic crisis in a patient with chronic lymphatic leukemia

A case of chronic lymphatic leukemia terminating in a lymphoblastic crisis is described. The small lymphocytes were demonstrated to be B cells, they carried immunoglobulins on their surface and formed EAC rosettes. The lymphoblasts had no immunoglobulins on their surface and only 18% of them formed EAC rosettes, none formed E rosettes. The lymphoblasts could be either immature B cells or Null cells.