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Management of Complications of Hematologic Malignancies in the Elderly

Management of Complications of Hematologic Malignancies in the Elderly

Teaser: 

Jeffrey Zonder, MD
Ulka Vaishampayan, MD
Division of Hematology/Oncology,
Department of Medicine
Wayne State University School of Medicine/Barbara Ann Karmanos Cancer Institute
Detroit, MI, USA.

 

Introduction
The incidence of hematologic malignancies, especially lymphoma, is steadily rising in the elderly. These diseases and their complications pose specific problems for older patients. Factors that contribute to increased toxicity in the elderly include diminished marrow reserve, impaired renal and hepatic metabolism and, perhaps most importantly, poor performance status as a result of comorbidities.1 This article will focus on the management of common complications of hematologic malignancies, particularly as they pertain to older patients.

Febrile Neutropenia

Risk of Neutropenia in the Elderly
The incidence of life-threatening neutropenia (absolute neutrophil count, ANC, <0.5x 109/L) in elderly patients following chemotherapy for hematologic malignancies is 40% or higher.2 The risk of infection is affected by the duration and severity of neutropenia with a steep rise in infection incidence at a neutrophil count of less than 0.5x 109/L.

Diagnosis and Management of Acute Coronary Syndromes

Diagnosis and Management of Acute Coronary Syndromes

Teaser: 

Diagnosis and Management of Acute Coronary Syndromes

Nariman Malik, BSc, MD
Medical Writer,
Geriatrics & Aging

Coronary heart disease (CHD) is one of the leading causes of death in individuals over the age of 651 and, through a variety of syndromes, is responsible for symptomatic and asymptomatic functional abnormalities. The prevalence of cardiovascular disease increases with age and is a major cause of death and disability in the elderly population.2 CHD is the most prevalent cardiac illness in this population: it accounts for 85% of all deaths due to heart disease in persons over the age of 65.3 By age 70, 15% of men and 9% of women have coronary artery disease (CAD) and are at an increased risk of suffering an acute coronary syndrome (ACS).4 By age 80, the severity of lesions becomes nearly equal for men and women.4 An estimated 40% of all individuals over the age of 80 have symptomatic cardiac disease.2

Despite advances in cardiology, CHD is still the leading cause of death in older individuals, especially those aged over 75.1 Nevertheless, there is wide variation in the severity of coronary illness and in the functional status of elderly patients.

Management of Postoperative Pain in the Elderly Client

Management of Postoperative Pain in the Elderly Client

Teaser: 

 

Pamala D. Larsen, PhD, CRRN
Associate Dean for Academic Affairs,
College of Nursing and Health Professions,
The University of North Carolina at Charlotte, NC, USA.

 

Although the elderly compose a significant percentage of the surgical patient population, postoperative pain management for this population has received little attention.1 According to 1990 data, more than 4,000 documents are published annually about pain, but fewer than 1% focus on pain in the older adult.2 Lack of published information and research about geriatric pain results in most patients' pain being managed by trial and error.

Considerable evidence suggests that pain is undertreated in older patients. This may be due in part to the misconception that pain sensation diminishes with increasing age or that the elderly patient cannot tolerate narcotic analgesia.3 The perception that older adults have less pain sensitivity than do younger patients is influenced somewhat by the silent myocardial infarctions and emergent 'painless' intra-abdominal surgical events that frequently occur in older adults.4 The research involving pain perception in the elderly client provides mixed results. These conflicting results make it difficult to fully establish the relationship or connection between aging and the sensory pain component.

Perioperative Evaluation and Management in the Elderly

Perioperative Evaluation and Management in the Elderly

Teaser: 

 

Laurie G. Jacobs, MD
Head, Unified Division of Geriatrics,
Albert Einstein College of Medicine & Montefiore Medical Center,
Bronx, NY, USA.

 

Introduction
Increasingly, older adults are undergoing invasive procedures and surgery. Surgery in the elderly has been associated with a greater morbidity and mortality than in younger patients due to the physiologic changes of aging, concurrent medical conditions and an increased rate of emergency procedures. Age alone is often a determining factor in whether a procedure or surgery should even be undertaken. Preoperative evaluation and perioperative care of the elderly patient requires evaluating the risk of complications, maximizing functional and physiologic parameters, instituting preventative measures, and focused management to assess potential risk and benefit for an individual patient.

Surgical Stress and Operative Risk
Noncardiac surgery in adults is associated with an incidence of postoperative myocardial infarction of 1-2%. Those with known heart disease, advanced age and serious comorbid conditions have a significantly greater risk for MI and other serious complications. Cardiovascular complications represent 50% of the causes of postoperative morbidity and mortality. In older adults, pulmonary, renal, infectious and cognitive adverse events are also extremely common.

Diagnosis and Management of Dysphagia After Stroke

Diagnosis and Management of Dysphagia After Stroke

Teaser: 

Lin Perry, MSc, RGN, RNT,
Faculty of Health & Social Care Sciences,
Kingston University and St. George's Hospital Medical School:
Sir Frank Lampl Building, Kingston University,
Kingston upon Thames, Surrey, UK.

 

Introduction
Stroke is a major cause of mortality and morbidity in all industrialized countries1--incidence of a first-in-a-lifetime stroke in the UK is estimated at 2.4 per 1,000 population per year, with all strokes combined having an incidence 20-30% higher.2

Dysphagia is a frequent accompaniment to stroke.3-5 Depending upon manner and timing of assessment, dysphagia is detected in 30-65% of acute stroke patients6-10 with a small proportion experiencing clinically 'silent' aspiration of food/ fluids.9,10 Dysphagia is associated with increased morbidity and mortality. Whilst this may partly be explained by its relationship with increased stroke severity, dysphagia also exerts an independent effect revealed by the tripling of mortality rates in alert dysphagic stroke patients compared to similar groups with intact swallow.8 It is associated with chest infection independent of aspiration7 which also risks chemical pneumonitis, infection and airway obstruction.11,12 Although dysphagia frequently resolves rapidly, for a minority it produces enduring disability and handicap. Stroke-related impaired swallowing has been found in 5.

Managing Behavioural Disorders in Dementia

Managing Behavioural Disorders in Dementia

Teaser: 

A. Mark Clarfield

The fact that dementia is finally beginning to receive the attention that it deserves is evidenced by the editors of Geriatrics & Aging wisely deciding to devote most of this issue to the subject. Dementia is primarily associated with memory loss; this means, unfortunately, that professionals often pay far less attention to the other symptoms that can accompany the syndrome. In fact, caregivers tell us that their loved one's problem with memory is usually far less burdensome than are the behavioural symptoms. Two of these symptoms are featured in this issue: agitation, by Dr. Elizabeth Sloan (a resident in Psychiatry at the U of T); and wandering, written by Dr. Bob Chaudhari, of the same department.

Dr. Sloan reminds us that agitation--sometimes accompanied by other symptoms such as screaming and aggression--is not a diagnosis per se but rather consists of a "constellation of symptoms." In geriatric care we are not afraid of such terminology, even if the terms are not always easily found in the index of Harrison's Textbook of Medicine. The same, of course, would hold for falls or incontinence.

As is the case with many of the non-specific ("atypical") presentations of disease in the elderly, Sloan points out, an underlying medical illness must never be overlooked as a possible causal factor. As I like to teach my medical students, "Take a history before prescribing haldol." (Unfortunately, now that the older anti-psychotic medications are increasingly being replaced by less toxic molecules, I'll have to figure out a new alliteration to go with, for example, risperidone--now what starts with an "r"? "rectum", no; "respiratory system"--doesn't ring true.) But I digress.

Dr. Sloan goes on to offer a great deal of good advice and the interested reader is advised to consult the references in her comprehensive bibliography.

Dr. Chaudhuri tackles the related problem of wandering, where he offers an interesting tri-partite classification which I admit that I have not seen before: volitional (depressive), motivational (anxious) and repetitive behavioural (irritable) wandering. Perhaps as a geriatrician, I am used to a more "medical" classification; but the author, not surprisingly as he is a psychiatrist, offers a more psychodynamic approach.

Like Sloan, Dr. Chaudhuri points out that management must take into account the patient's environment. Appropriately, he does not spend much time on a pharmacological approach, which is not usually an effective method unless, of course, your aim is to drug the patient into a stupor.

My own experience is that the wandering (pacing) patient with dementia must be allowed his/her own space. Obviously, as is also the case at the other end of the age spectrum with the toddler, wanderers must be protected against the obvious dangers involved. However, when all is said and done, the milieu extérieur seems to me to be of more importance than the milieu intérieur.

Dr. Clarfield is the Chief of Academic Affairs at the Herzog Hospital in Jerusalem, Director of Geriatrics in the Ministry of Health, and on staff in the Division of Geriatric Medicine, Sir Mortimer B. Davis-Jewish General Hospital, McGill University, Montreal.

‘Remembering’ Dementia Management

‘Remembering’ Dementia Management

Teaser: 

It is a particular pleasure for me to write the editorial for this month's edition of Geriatrics & Aging. I recently had a mini- reunion with some friends from medical school whom I had not seen in several years. We spent a wonderful evening reminiscing, and I was thrilled to find that my colleagues knew of G&A, and found it very helpful in their clinical practice! I had no idea that the things in which I am involved actually make a difference, although the real credit goes to the full-time editorial staff and the knowledgeable contributors who are so willing to share their expertise. Next, the topic, dementia, is one that is close to my heart. For the last three years, I have been working in the Memory Clinic at the Toronto General Hospital. At first I was shocked at how little I really knew about dementia, but I think I have learned a fair amount in the interim. Now I realize how little anybody really knows about dementia. I have also learned, through personal experience, how different are the professional and personal roles in dementia care. The professionals have it easy!

However, what thrills me most about this edition is our guest editor, A. Mark Clarfield. Mark and I trained together (too many years ago to count), and I still use the example of his dedication to demonstrate what commitment to patient care really means. Prior to his 'half day back for clinic', Mark would come in to the hospital at 6:00 a.m. to ensure that all the needs of his patients had been met. He also left detailed instructions on what his colleagues should do while he was away. I knew Mark would be successful in whatever he decided to do, and it was a thrill that both of us selected careers in geriatric medicine--perhaps inspired by the chief medical resident, Michael Gordon. A decade after training together, we both shared in the Munk Geriatric Award, which was instrumental in shaping our respective careers. Within three years of that award being presented, Mark had written his breakthrough article in the Annals of Internal Medicine, puncturing the myth of the reversible dementia. Mark's work changed the focus in this field from one simply of diagnosis, to one of diagnosis and then the provision of appropriate care, whether the cognitive impairment was reversible or not. This theme of management, regardless of whether the underlying process is modifiable or not, runs through this entire issue of G&A. In our society, health care looks to either high technology or 'magic' bullets. An example of this is the famous article in JAMA several years ago that showed a positive effect for Gingko Biloba in patients with dementia. Although it was a very flawed study, it received widespread media coverage, while an excellent adjacent article on occupational therapy interventions in dementia was completely ignored. Similarly, the possible benefits of vitamin E in preventing nursing home placement has received widespread attention, while the more robust research finding of caregiver education to prevent premature institutionalization is all but ignored.

This edition of G&A has some excellent articles on managing the behavioural problems associated with dementia. Dr. Bob Chaudhuri talks about the treatment of wandering in demented patients, while Dr. Eileen Sloan talks about screaming and agitation. Currently, we try to remember that people with dementia are still people. This means that they must be treated with the same respect for ethical standards that are applied to non-demented people. However, there are specific issues particular to patients with dementia (e.g. to tell or not to tell the diagnosis), that are addressed by Dr. Michael Gordon and Dr. David Goldstein. Dr. Clarfield addresses the issue of treatment in Alzheimer's disease, and Dr. Chris MacKnight highlights the role of the treatment of hypertension in preventing dementia. Margaret MacAdam, from the Baycrest Centre, discusses housing options for patients with dementia. This is particularly appropriate since Baycrest is a world leader in the field. As well, we have our usual assortment of articles. There is an interview with Dr. Judes Poirier, Director of the McGill Centre for Studies in Aging, and articles on the genetics of ALS, atrial fibrillation and hepatocellular carcinoma in the elderly. Enjoy.