Abstracts from Medical Literature for the Geriatrics Practitioner

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CARDIORESPIRATORY FITNESS AND THE RISK FOR STROKE IN MEN Previous studies have shown that physical activity and good cardiorespiratory fitness have protective effects on atherosclerotic cardiovascular disease, including coronary heart disease and hypertension. Physical activity may also protect against future stroke. However, low cardiorespiratory fitness is a major public health problem. In a population-based cohort study with an average follow-up of 11 years, 2011 men with no stroke or pulmonary disease at baseline from Kuopio and the surrounding communities of eastern Finland, the authors examined the relationship of cardiorespiratory fitness, as indicated by maximum oxygen consumption (VO2max), with subsequent incidence of stroke. They compared VO2max with conventional risk factors as a predictor for future strokes. Among the participants, 110 strokes occurred, of which 87 were ischemic. The VO2max was measured directly during exercise testing at baseline. The relative risk for any stroke in unfit men was 3.2, and for ischemic stroke it was 3.50, compared with fit men after adjusting for age and examination year. After further adjustment for smoking, alcohol consumption, socioeconomic status, energy expenditure of physical activity, prevalent coronary heart disease, diabetes, systolic blood pressure, and serum low-density lipoprotein cholesterol level for any strokes or ischemic strokes, the associations remained statistically significant. Low cardiorespiratory fitness was comparable to systolic blood pressure, obesity, alcohol consumption, smoking, and serum low-density lipoprotein cholesterol level as a risk factor for stroke. The authors concluded that low cardiorespiratory fitness was associated with an increased risk for any stroke and ischemic stroke. The VO2max was one of the strongest predictors of stroke, similar to other modifiable risk factors.

Kurl S, Laukkanen JA, Rauramaa R, Lakka TA, Sivenius J, Salonen JT. Cardiorespiratory fitness and the risk for stroke in men. Arch Intern Med 2003;163:1682-1688.

DEEP VEIN THROMBOSIS IN ELDERLY PATIENTS HOSPITALIZED IN SUBACUTE CARE FACILITIES Venous thromboembolism is a common clinical problem among hospitalized patients. Comprehensive scientific data are lacking in providing evidence of the efficacy of venous thromboembolism prophylaxis in elderly patients hospitalized in subacute care facilities. The authors of this study sought to determine risk factors and physician practices in the prevention of venous thromboembolism and to estimate the prevalence of deep vein thrombosis. They conducted a multicenter cross-sectional study in the subacute care departments of 36 French hospitals, including 852 inpatients over 64 years of age. Angiologists performed systematic ultrasound examinations, and found that 178 patients (20.9%) had three or more risk factors other than age, while 144 patients (16.9%) had no risk factors. The rate of prophylactic anticoagulant treatment was 56.1%, ranging from 20.0-86.9%, depending on the department. Prophylaxis use was found to be associated with acute immobilization, chronic immobilization, major surgical procedure, and congestive heart failure, and was low in patients who had cancer or myocardial infarction. It was not significantly associated with paralytic stroke or history of venous thromboembolism. Deep vein thrombosis was detected in 135 patients: 50 with proximal vein thrombosis and 85 with calf vein thrombosis. The authors determined that the prevalence of deep venous thrombosis is high in elderly patients hospitalized in subacute care facilities, despite wide use of prophylaxis. Further prospective studies are needed to assess the clinical benefit of extended-duration prophylaxis in this population.

Bosson JL, Labarere J, Sevestre MA, Belmin J, Beyssier L, Elias A, Franco A, Le Roux P. Deep vein thrombosis in elderly patients hospitalized in subacute care facilities: A multicenter cross-sectional study of risk factors, prophylaxis, and prevalence. Arch Intern Med 2003;163:2613-2618.

ADVANCES IN NEUROPATHIC PAIN Chronic neuropathic pain is common in clinical practice. It is caused by lesions in the peripheral or central nervous system and can appear in many forms. Patients with such conditions as diabetic polyneuropathy, HIV, and multiple sclerosis often experience daily pain that has a significant impact on their quality of life. It is possible that more than 3 million people in the U.S. have painful diabetic neuropathy and about 1 million people have postherpetic neuralgia. This review describes current approaches to the diagnosis and assessment of neuropathic pain and discusses the results of recent research on its pathophysiologic mechanisms. Randomized controlled clinical trials of gabapentin, the 5% lidocaine patch, opioid analgesics, tramadol hydrochloride, and tricyclic antidepressants provide evidence-based treatment recommendations for neuropathic pain and the use of these medications, taking into account clinical effectiveness, adverse effects, influence on quality of life, and cost. Continued advancement in basic and clinical research on the pathophysiologic mechanisms of neuropathic pain will help to predict effective treatments for individual patients by applying a pain mechanism–based approach.

Dworkin RH, Backonja M, Rowbotham MC, Allen RR, Argoff CR, Bennett GJ, Bushnell MC, Farrar JT, Galer BS, Haythornthwaite JA, Hewitt DJ, Loeser JD, Max MB, Saltarelli M, Schmader KE, Stein C, Thompson D, Turk DC, Wallace MS, Watkins LR, Weinstein SM. Advances in neuropathic pain: Diagnosis, mechanisms, and treatment recommendations. Arch Neurol 2003;60:1524-1534.

CONTEMPORARY MANAGEMENT OF CHRONIC OBSTRUCTIVE PULMONARY DISEASE: CLINICAL APPLICATIONS Chronic obstructive pulmonary disease (COPD) usually has an insidious presentation, and many patients are undiagnosed until the disease is far advanced. Early use of spirometry provides the proper documentation of the presence and severity of airflow obstruction and is recommended for anyone who is suspected to have COPD. The patient presents as mildly symptomatic in the early stages of the disease, with cough and sputum production. As COPD advances, functional impairment (chronic dyspnea) occurs and acute exacerbations of symptoms become more frequent, contributing to overall morbidity and mortality. Since cigarette smoking is the single most important known risk factor for COPD, smoking cessation is the basis of therapy. Patients with advanced disease should receive symptomatic single- or combination-therapy treatment with regular use of either short- or long-acting sympathomimetic and/or anticholinergic bronchodilators, in addition to smoking cessation and influenza and pneumococcal vaccinations. An inhaled corticosteroid, either alone or in combination with a long-acting bronchodilator, can further reduce exacerbations and improve the health status of these patients. Patients with severe COPD, particularly those who are debilitated, should be considered for pulmonary rehabilitation, as these programs have proved useful in maintaining or improving patient health. Finally, correction of resting arterial hypoxemia with oxygen therapy for more than 15 hours a day can prolong the survival of patients with COPD with a PaO2 lower than 55-60 mm Hg.

Man SF, McAlister FA, Anthonisen NR, Sin DD. Contemporary management of chronic obstructive pulmonary disease: Clinical applications. JAMA 2003;290:2313-2316.

Annals of Long-Term Care: Clinical Care and Aging 2004;12[5]:38-40

Annals of Long-Term Care - ISSN: 1524-7929 - Volume 12 - Issue 05 - May 2004