[Collagen diseases and recurrent meningitis in an 88 year old patient]

Recurrent aseptic meningitis (RAM) infrequent in elderly patients and generally secondary to drugs. Its association with rheumatologic diseases is also seldom reported in the elderly. Sjögren Syndrome (SS) sometimes affects the central nervous system, but the association between recurrent meningitis and SS is rare, specially in this age-group. We present an 88 year-old auto-valid patient, with a history of xerostomia, xerophthalmia, Raynaud, dysphagia, and recurrent parotid enlargement. In 2001 she developed a lymphocytic meningitis with a complete remission. A year later, she developed again an aseptic lymphocytic meningitis. We ruled out infectious causes. We found a FAN titer 1/160 with a nucleolar-mottled pattern, positive anti Ro and anti RNP antibodies and a positive lupus anticoagulant. We confirmed the ocular dryness and the lip biopsy was compatible with the diagnosis of SS. She had a good outcome with a complete remission without treatment in 10 days. We believe that this is a case of mixed connective tissue disease (MCTD) with predominant symptoms of SS, that developed a recurrent meningitis in its pure form. MCTD and SS should be considered in the differential diagnoses of RAM, also in the elderly.

Gait velocity in senior people. An easy test for detecting mobility impairment in community elderly

BACKGROUND

Functional assessment is an important part of the evaluation of elderly patients. Mobility problems detected by functional tests predict the development of more severe disability and injurious events such as falls and hip fractures. Several tests to evaluate mobility have been described, but most of them are difficult to perform by a primary care physicians or take much time in the ambulatory setting.

PURPOSE

To evaluate different mobility test to detect mobility impairment in community senior people. Select an easier test to perform on the ambulatory ward by a GP with the hypothesis that gait velocity could be an easier test to detect early mobility impairment.

METHODS

A cohort of 100 elderly subjects of 75 year and older were selected from our database and contacted by phone. The subjects were appointed and assessed by three geriatricians from January to May 2000. The measures including MMSE, Yesavage Test, ADL (Barhtel) and IADL (Lawton), the Get Up and Go test, the POMA, one leg balance test and the Gait Velocity (GV). A gait velocity of 0.8 m/s or lower was defined as a pathological gait velocity (PGV).

RESULTS

95 subjects, mean age 79.63 (+/- 4) ranged form 75 to 95. Women in 71.3%. The ADLs were normal on 85% of the patients and the MMSE was normal on 78%. There was a significant association between pathological gait velocity (<0.8m/sec) and impairment on Get up and Go (OR 2.20; 95% CI 1.44-3.34), incapacity to perform the one leg balance test (OR 2.20; 95%CI: 1.43 - 4.71) and abnormal POMA test (OR 4.60; 95 %CI 1.5-14.7). Only 15% of the subjects with normal gait velocity reported recurrent falls in the previous 6 months while 35% of subjects with pathological gait velocity did. (OR 0.32 CI95% 010-099 p < 0.044).

CONCLUSION

The pathological gait velocity (<0.8m/sec) correlates with a pathologic performance of Get Up and Go test and POMA and with the incapacity to perform the One Leg Balance test. Also correlate with previous repeated falls in the last 6 (p <0.04). The gait velocity could be a test easy to perform, no time consuming, and an operative tool to apply in the ambulatory care to detect elderly patients with mobility impairment.

[Polymyalgia rheumatica revisited]

Polymyalgia rheumatica is an inflammatory disorder that usually affects persons over the age of 50 causing proximal muscle pain and stiffness, and an elevated erythrocyte sedimentation rate. Although increasingly recognized in this age group, it remains a diagnosis of exclusion and although several diagnostic criteria have been proposed, none has been clearly accepted. While polymyalgia rheumatica is associated with giant cell arteritis, obtaining a temporal artery biopsy is not recommended in patients with polymyalgia rheumatica without symptoms of giant cell arteritis. Early diagnosis and low dose corticosteroid therapy improve patients' clinical features and functional status. Treatment usually lasts between 12 and 24 months and the majority of patients manage to discontinue treatment completely.

Prevalence of hyperhomocysteinemia in an elderly population

BACKGROUND

Currently, total hyperhomocysteinemia (tHHcy) is a well-known condition linked to a higher risk of vascular disease. Prevalence of HHcy increases in elderly persons as the risk associated with it persists. Because factors can be potentially reduced in the elderly, it is important to carry out epidemiologic studies of HHcy.

PROCEDURE

Previously we described the prevalence of hypertension control in an elder population; now, in an observational cross-sectional simple blind study, total homocysteine (tHcy) concentration was determined in 196 of 400 patients from the original cohort.

RESULTS

Mean Hcy concentration was 13.2 ,amol/L (95% confidence interval 12.4-14.0; range, 5.0 to 48.9); 15.0 ,imol/L for men and 12.3 pAmol/L for women. Mean serum folic acid levels were 4.9 + 3.1 ng/mL (range, 2.0 to 20.0 ng/mL), and vitamin B12 levels were 384.8 314.1 pg/mL (range, 48.0 to 1500.0 pg/mL). Taking into account the reference values established by the Third National Health and Nutrition Examination Survey III study, HHcy was detected in 69.8% of all the subjects evaluated. The study showed that 76.2% of the men and 66.4% of the women had high Hcy levels.

CONCLUSIONS

The very high prevalence of tHHcy in the elderly population, and the consequent risks associated with it suggest that although there are no trials that effectively prove the benefit of tHcy decrease, nutritional intervention is still justified.

[Epidemiology of delirium in elderly inpatients]

Our objective was to determine delirium incidence and risk factors in a cohort of elderly inpatients. We randomly selected 149 patients, aged 65 years or older, from admission to general wards, without evidence of delirium. They were evaluated daily with the Confusion Assessment Method, an instrument validated for the diagnosis of delirium. We obtained relative risks for delirium and those independently associated were included in a logistic regression model. We used the chi-square test with Yate's corrections for univariate analysis, and t-test for comparisons of means. We observed that 51 patients (20.5%) developed delirium during their hospital stay. Severity of disease (RR 1.28, 1.14-1.43), having chronic diseases (RR 3.45, 2.4-4.96), and having fever at admission (RR 1.84, 1.33-2.56) were found independently associated with delirium. Patients who developed delirium had longer hospital stay (9.87 days +/- 3.48 vs 6.95 days +/- 2.45, p < 0.05) and higher mortality (RR 2.19, CI 1.26-3.79). We conclude that delirium in our setting is very frequent and has negative effects on resource utilization and mortality in elderly inpatients. Its association with the severity of the disease seems interesting. Appropriate prospective identification of patients at risk for delirium may allow the implementation of preventive strategies in order to minimize the impact of this complication.

Lack of effective blood pressure control among an elder hypertensive population in Buenos Aires

Our purpose was to determine the level of awareness, treatment, and control of hypertension in a population of subjects aged 65 or more. We studied a random sample from the national health care program in Buenos Aires. Letters were mailed to 1000 selected individuals. Among those eligible, 41.4% (n = 414) were enrolled. The mean age was 73.8 years and 68% were women. Prevalence of hypertension in our sample was 77.5% (n = 321). Awareness of hypertension was 60.7% (n = 195). Fifty-four percent (n = 173) of the hypertensive subjects were receiving pharmacologic treatment and only 18.5% (n = 32) of them were controlled. These results show that there is a low level of awareness, pharmacologic treatment, and control of hypertension in the studied elderly subjects.

Diastolic pressure underestimates age-related hemodynamic impairment

It has been hypothesized that as large arteries become more rigid with age, the pattern of hypertension changes from diastolic to systolic. Thus, diastolic blood pressure (DBP) may lose its ability to reflect the increase in vascular resistance with age. To assess this, we studied the age-related changes in blood pressure pattern and its steady-state and pulsatile determinants. We performed an epidemiological analysis based on a national survey of 10,462 subjects from Argentina. A hemodynamic analysis (impedance cardiography) was then carried out in 636 consecutive hypertensive patients (age, 25 to 74 years). Whereas the rate of increment in the prevalence of mild to moderate hypertension (MMH) reached a plateau after the sixth decade, isolated and borderline systolic forms of hypertension began a steep and sustained rise. Among patients with MMH, DBP remained stable from the third to the seventh decade, whereas SBP maintained a sustained increase. Despite similar DBP, the systemic vascular resistance index increased 47% (P<.01) and the cardiac index decreased 27% (P<.01), whereas the ratio of stroke volume to pulse pressure, an index of arterial compliance, decreased 45% (P<.01). However, there were no significant differences between older patients with MMH and those with isolated systolic hypertension in the level of SBP, vascular resistance, stroke volume, and cardiac index. Compared with age-matched normotensive control subjects, the ratio of stroke volume to pulse pressure was much more reduced in isolated systolic hypertension (48%) than in MMH (30%). In summary, the present study, carried out in a large sample of hypertensive subjects with a wide age range, showed a simultaneous impairment in vascular resistance and arterial compliance associated with aging in different patterns of hypertension. The magnitude of these changes, with opposite effects on DBP but additive effects on SBP, suggests that a hemodynamic mechanism could determine the transition in the prevalence of diastolic hypertension toward a systolic pattern of hypertension with aging. Also, the results suggest that SBP, but not DBP, is a reliable indicator of the underlying hemodynamic abnormalities (high resistance and low arterial compliance) in the elderly.

Relationship between systemic hemodynamics and ambulatory blood pressure level are sex dependent

Sex-related differences in systemic hemodynamics were analyzed by means of cardiac index and systemic vascular resistance according to the level of daytime ambulatory blood pressure. In addition, we assessed the relations between ambulatory blood pressure measurements and systemic hemodynamics in male and female patients. We prospectively included 52 women and 53 men referred to our unit for evaluation of arterial hypertension. Women and men were grouped according to the level of daytime mean arterial pressure: < 110 or > or = 110 mm Hg. Patients underwent noninvasive evaluation of resting hemodynamics (impedance cardiography) and 24-hour ambulatory blood pressure monitoring. Compared with women men with lower daytime blood pressure had a 12% higher systemic vascular resistance index (P = NS) and a 14% lower cardiac index (P < .02), whereas men with higher daytime blood pressure had a 25% higher vascular resistance (P < .003) and a 21% lower cardiac index (P < .0004). Furthermore, in men systemic vascular resistance correlated positively with both daytime and nighttime systolic and diastolic blood pressures, whereas cardiac index correlated negatively only with daytime diastolic blood pressure. In contrast, women did not exhibit any significant correlation between hemodynamic parameters and ambulatory blood pressure measurements. In conclusion, sex-related differences in systemic hemodynamics were more pronounced in the group with higher daytime hypertension. The relations between systemic hemodynamics and ambulatory blood pressure level depended on the sex of the patient. In men a progressive circulatory impairment underlies the increasing level of ambulatory blood pressure, but this was not observed in women.

Magnesium plus nifedipine: potentiation of hypotensive effect in preeclampsia?

Two women with preeclampsia treated unsuccessfully with alpha-methyldopa and magnesium sulfate became profoundly hypotensive when oral nifedipine was added. Blood pressure returned to previous levels without changes in fetal vitality. Awareness of this potentiation is important because nifedipine is being used increasingly in the treatment of pregnancy-related hypertension.