Items in AFP with MESH term: Aged
ABSTRACT: Constipation is a common complaint in older adults. Although constipation is not a physiologic consequence of normal aging, decreased mobility and other comorbid medical conditions may contribute to its increased prevalence in older adults. Functional constipation is diagnosed when no secondary causes can be identified, such as a medical condition or a medicine with a side effect profile that includes constipation. Empiric treatment may be tried initially for patients with functional constipation. Management of chronic constipation includes keeping a stool diary to record the nature of the bowel movements, counseling on bowel training, increasing fluid and dietary fiber intake, and increasing physical activity. There are a variety of over-the-counter and prescription laxatives available for the treatment of constipation. Fiber and laxatives increase stool frequency and improve symptoms of constipation. If constipation is refractory to medical treatment, further diagnostic evaluation may be warranted to assess for colonic transit time and anorectal dysfunction. Alternative treatment methods such as biofeedback and surgery may be considered for these patients.
Extrapulmonary Tuberculosis: An Overview - Article
ABSTRACT: In the 1980s, after a steady decline during preceding decades, there was a resurgence in the rate of tuberculosis in the United States that coincided with the acquired immunodeficiency syndrome epidemic. Disease patterns since have changed, with a higher incidence of disseminated and extrapulmonary disease now found. Extrapulmonary sites of infection commonly include lymph nodes, pleura, and osteoarticular areas, although any organ can be involved. The diagnosis of extrapulmonary tuberculosis can be elusive, necessitating a high index of suspicion. Physicians should obtain a thorough history focusing on risk behaviors for human immunodeficiency virus (HIV) infection and tuberculosis. Antituberculous therapy can minimize morbidity and mortality but may need to be initiated empirically. A negative smear for acid-fast bacillus, a lack of granulomas on histopathology, and failure to culture Mycobacterium tuberculosis do not exclude the diagnosis. Novel diagnostic modalities such as adenosine deaminase levels and polymerase chain reaction can be useful in certain forms of extrapulmonary tuberculosis. In general, the same regimens are used to treat pulmonary and extrapulmonary tuberculosis, and responses to antituberculous therapy are similar in patients with HIV infection and in those without. Treatment duration may need to be extended for central nervous system and skeletal tuberculosis, depending on drug resistance, and in patients who have a delayed or incomplete response. Adjunctive corticosteroids may be beneficial in patients with tuberculous meningitis, tuberculous pericarditis, or miliary tuberculosis with refractory hypoxemia.
ABSTRACT: A combination of aerobic activity, strength training, and flexibility exercises, plus increased general daily activity can reduce medication dependence and health care costs while maintaining functional independence and improving quality of life in older adults. However, patients often do not benefit fully from exercise prescriptions because they receive vague or inappropriate instructions. Effective exercise prescriptions include recommendations on frequency, intensity, type, time, and progression of exercise that follow disease-specific guidelines. Changes in physical activity require multiple motivational strategies including exercise instruction as well as goal-setting, self-monitoring, and problem-solving education. Helping patients identify emotionally rewarding and physically appropriate activities, contingencies, and social support will increase exercise continuation rates and facilitate desirable health outcomes. Through patient contact and community advocacy, physicians can promote lifestyle patterns that are essential for healthy aging.
ABSTRACT: Acute abdominal pain is a common presenting complaint in older patients. Presentation may differ from that of the younger patient and is often complicated by coexistent disease, delays in presentation, and physical and social barriers. The physical examination can be misleadingly benign, even with catastrophic conditions such as abdominal aortic aneurysm rupture and mesenteric ischemia. Changes that occur in the biliary system because of aging make older patients vulnerable to acute cholecystitis, the most common indication for surgery in this population. In older patients with appendicitis, the initial diagnosis is correct only one half of the time, and there are increased rates of perforation and mortality when compared with younger patients. Medication use, gallstones, and alcohol use increase the risk of pancreatitis, and advanced age is an indicator of poor prognosis for this disease. Diverticulitis is a common cause of abdominal pain in the older patient; in appropriately selected patients, it may be treated on an outpatient basis with oral antibiotics. Small and large bowel obstructions, usually caused by adhesive disease or malignancy, are more common in the aged and often require surgery. Morbidity and mortality among older patients presenting with acute abdominal pain are high, and these patients often require hospitalization with prompt surgical consultation.
ABSTRACT: Polymyalgia rheumatica and giant cell arteritis are common, closely related vasculitic conditions that almost exclusively occur in patients older than 50 years. They may be manifestations of the same underlying disease and often coexist. Patients with polymyalgia rheumatica usually present with acute onset of stiffness and pain in the shoulder and pelvic musculature, which may be accompanied by fever, malaise, and weight loss. If untreated, polymyalgia rheumatica may result in significant disability. Giant cell arteritis may manifest as visual loss or diplopia, abnormalities of the temporal artery such as tenderness or decreased pulsation, jaw claudication, and new-onset headaches. Erythrocyte sedimentation rate and temporal artery biopsy help make the diagnosis. Giant cell arteritis requires urgent diagnosis because without treatment it may lead to irreversible blindness. Patients with either condition also may have nonspecific symptoms. Corticosteroids are the mainstay of therapy for both conditions, with higher doses required for treatment of giant cell arteritis. Duration of corticosteroid therapy can be five years or longer before complete clinical remission is achieved. Monitoring for corticosteroid-associated side effects such as osteoporosis and diabetes, as well as for relapses and flare-ups, is key to chronic management. The prognosis for either condition, if treated, is good.
ABSTRACT: Cardiovascular disease (CVD) has been the primary cause of death in women for almost a century, and more women than men have died of CVD every year since 1984. Although CVD incidence can be reduced by adherence to a heart-healthy lifestyle and detection and treatment of major risk factors, preventive recommendations have not been consistently or optimally applied to women. The American Heart Association guidelines for CVD prevention in women provide physicians with a clear plan for assessment and treatment of CVD risk and personalization of treatment recommendations. The emphasis of preventive efforts has shifted away from treatment of individual CVD risk factors in isolation toward assessment of a woman's overall or "global" CVD risk. In addition to accounting for the presence or absence of preexisting coronary heart disease or its equivalents (e.g., diabetes, chronic kidney disease), cardiovascular risk can be further calculated with the Framingham risk score, which is based on age, sex, smoking history, and lipid and blood pressure levels. Intervention intensity and treatment goals are tailored to overall risk, with those at highest risk receiving the most intense risk-lowering interventions. Women at high risk for CVD and without contraindications should receive aspirin, beta blockers, and an angiotensin-converting enzyme inhibitor or angiotensin receptor blocker in addition to pharmacologic therapy for hyperlipidemia, hypertension, and diabetes. Women who already are at optimal or low risk for CVD should be encouraged to maintain or further improve their healthy lifestyle practices. Optimal application of these preventive practices significantly reduces the burden of death and disability caused by heart attack and stroke in women.
ABSTRACT: Approximately 20 to 40 percent of patients at high risk of cardiac-related morbidity develop myocardial ischemia perioperatively. The preferred approach to diagnostic evaluation depends on the interactions of patient-specific risk factors, surgery-specific risk factors, and exercise capacity. Stress testing should be reserved for patients at moderate to high risk undergoing moderate- or high-risk surgery and those who have poor exercise capacity. Further cardiovascular studies should be limited to patients who are at high risk, have poor exercise tolerance, or have known poor ventricular function. Medical therapy using beta blockers, statins, and alpha agonists may be effective in high-risk patients. The evidence appears to be the strongest for beta blockers, especially in high-risk patients with proven ischemia on stress testing who are undergoing vascular surgery. Many questions remain unanswered, including the optimal role of statins and alpha agonists, whether or not these therapies are as effective in patients with subclinical coronary artery disease or left ventricular dysfunction, and the optimal timing and dosing regimens of these medications.
ABSTRACT: Adverse drug events are common in older patients, particularly in those taking at least five medications, but such events are predictable and often preventable. A rational approach to prescribing in older adults integrates physiologic changes of aging with knowledge of pharmacology. Focusing on specific outcomes, such as the prompt recognition of adverse drug events, allows the family physician to approach prescribing cautiously and confidently. Physicians need to find ways to streamline the medical regimen, such as periodically reviewing all medications in relation to the Beers criteria and avoiding new prescriptions to counteract adverse drug reactions. The incorporation of computerized alerts and a multidisciplinary approach can reduce adverse drug events.
The Visually Impaired Patient - Article
ABSTRACT: Blindness or low vision affects more than 3 million Americans 40 years and older, and this number is projected to reach 5.5 million by 2020. In addition to treating a patient's vision loss and comorbid medical issues, physicians must be aware of the physical limitations and social issues associated with vision loss to optimize health and independent living for the visually impaired patient. In the United States, the four most prevalent etiologies of vision loss in persons 40 years and older are age-related macular degeneration, cataracts, glaucoma, and diabetic retinopathy. Exudative macular degeneration is treated with laser therapy, and progression of nonexudative macular degeneration in its advanced stages may be slowed with high-dose antioxidant and zinc regimens. The value of screening for glaucoma is uncertain; management of this condition relies on topical ocular medications. Cataract symptoms include decreased visual acuity, decreased color perception, decreased contrast sensitivity, and glare disability. Lifestyle and environmental interventions can improve function in patients with cataracts, but surgery is commonly performed if the condition worsens. Diabetic retinopathy responds to tight glucose control, and severe cases marked by macular edema are treated with laser photocoagulation. Vision-enhancing devices can help magnify objects, and nonoptical interventions include special filters and enhanced lighting.
ABSTRACT: Benign prostatic hyperplasia is a common condition affecting older men. Typical presenting symptoms include urinary hesitancy, weak stream, nocturia, incontinence, and recurrent urinary tract infections. Acute urinary retention, which requires urgent bladder catheterization, is relatively uncommon. Irreversible renal damage is rare. The initial evaluation should assess the frequency and severity of symptoms and the impact of symptoms on the patient's quality of life. The American Urological Association Symptom Index is a validated instrument for the objective assessment of symptom severity. The initial evaluation should also include a digital rectal examination and urinalysis. Men with hematuria should be evaluated for bladder cancer. A palpable nodule or induration of the prostate requires referral for assessment to rule out prostate cancer. For men with mild symptoms, watchful waiting with annual reassessment is appropriate. Over the past decade, numerous medical and surgical interventions have been shown to be effective in relieving symptoms of benign prostatic hyperplasia. Alpha blockers improve symptoms relatively quickly. Although 5-alpha reductase inhibitors have a slower onset of action, they may decrease prostate size and alter the disease course. Limited evidence shows that the herbal agents saw palmetto extract, rye grass pollen extract, and pygeum relieve symptoms. Transurethral resection of the prostate often provides permanent relief. Newer laser-based surgical techniques have comparable effectiveness to transurethral resection up to two years after surgery with lower perioperative morbidity. Various outpatient surgical techniques are associated with reduced morbidity, but symptom relief may be less durable.