Am Fam Physician. 1999;60(5):1555
Bipolar Disease in Elderly Persons
(Canada—Canadian Family Physician, May 1999, p. 1229.) Bipolar disease is uncommon in community-based elderly persons, but it is associated with significant morbidity and mortality. The prevalence in this group is estimated to be less than 0.1 percent, compared with at least 1.5 percent in adolescents. Few elderly patients with bipolar illness have a history of episodes earlier in life; the average age of onset of mood disorder in these patients is 50 years. Symptoms in older patients may be less intense than in younger patients and may be combined with cognitive dysfunction. Mania has been associated with cerebrovascular lesions of the right hemisphere and orbitofrontal areas, steroid therapy, trauma to the head and some forms of dementia. No specific trials of therapy have been conducted in elderly persons, so treatment is based on studies of younger patients. The prognosis is poor—one half of elderly patients suffering from mania die within six years, and significant morbidity is also reported.
Optic Nerve Pit
(Canada—Canadian Family Physician, May 1999, p. 1185.) Disturbances in the development of the epithelial papilla can result in the formation of an optic nerve pit. Pits are usually unilateral, appearing as gray lesions within the optic disc. They may be associated with visual field defects and symptoms similar to those of glaucoma. Serous retinal detachment develops in the macular area in approximately one half of patients with optic pits. In fewer than 20 percent of these patients, the detachments spontaneously reattach. The long-term outlook for patients with serous retinal detachment is poor; more than 80 percent of these patients eventually have visual acuity of 6/60 or worse.
(Great Britain—The Practitioner, April 1999, p. 321.) Diverticulae and associated hypertrophy of the bowel musculature are believed to result from disordered peristalsis. The prevalence of diverticulosis in Westerners is thought to be related to a diet low in fiber. Although approximately one third of persons older than 50 years have diverticulae, only 20 percent of these persons ever develop symptoms. The clinical picture may range from vague colicky pain, flatulence and distention to severe infection, formation of abscesses and fistulae, and bowel perforation. The diagnosis can be confirmed by colonoscopy, computed tomographic scanning or barium enema studies, although the latter should not be performed during acute episodes of diverticulitis. Uncomplicated diverticulosis may be managed by increasing fiber and fluid in the diet. Patients should be cautioned that fiber may initially increase bloating and cramping but that these symptoms subside with perseverance. Antispasmodic agents may be used to relieve severe cramping. Surgery should be reserved for severe complications.
(Australia—Australian Family Physician, April 1999, p. 369.) Lichen planus is an uncommon skin condition that can occur in the genital area, on the arms, legs, trunk and in the mouth. The cause is unknown, but it is believed to be autoimmune, possibly triggered by viral infection. The condition is more common in women and usually affects persons 30 to 60 years of age. The onset is slow, with pruritic plaques developing over several months and resolving within 18 months. The “four P's” describe the lesions—purple, polygonal and pruritic papules. White surface lines known as Wickham's striae are characteristic of lichen planus. Treatment may not be necessary unless erosion or secondary infection occurs. Topical corticosteroids are frequently used to reduce itching and induce regression of the lesions. Hyperpigmented areas may persist after the lesion has resolved.
(Great Britain—The Practitioner, May 1999, p. 386.) Up to 15 percent of cases of asthma in adults in industrialized countries are related to occupation. Airborne dust, gases, vapors or fumes generated in the workplace cause narrowing of the airways. This narrowing is initially reversible, but persistent exposure to the allergen may result in permanent symptoms of asthma. Patients may have an initial latent period of up to several years during which they are asymptomatic despite exposure. Early symptoms are often nasal congestion, sneezing, watering of the eyes, itching and burning. Many agents can cause occupational asthma. High-molecular-weight agents are often biological materials such as animal products, flour, fungi, proteins and enzymes. Low-molecular-weight agents include isocyanates, chemicals and platinum salts. Occupational asthma should be suspected when symptoms resolve during holiday periods.