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We report the case of a 67-year-old male who presented with a six-week history of progressive unsteadiness, cognitive impairment and weight loss, in the context of a recent bereavement. Magnetic resonance imaging (MRI) performed several weeks earlier excluded acute stroke. Examination revealed gross bilateral ataxia, bradyphrenia and physical manifestations of depression. Collateral history suggested rapidly progressing symptoms over three months. Repeat MRI head showed features suggestive of Creutzfeldt-Jakob disease (CJD) including T2 hyperintensities in the basal ganglia. Cerebrospinal fluid (CSF) samples were positive for 14-3-3 protein, S100b and real-time quaking-induced conversion (RT-QuIC) proteins confirming the diagnosis of sporadic CJD (sCJD). [ABSTRACT FROM AUTHOR]

A letter to the editor is presented in response to the article about the assessment of diseases and screening of older people in the August 1994 issue.

Merkel cell carcinoma (MCC) is a rare, aggressive skin tumor that mainly occurs in the elderly with a generally poor prognosis. Like all skin cancers, its incidence is rising. Despite the poor prognosis, a few reports of spontaneous regression have been published. We describe the case of a 89-year-old male patient who presented two MCC lesions of the scalp. Following biopsy the lesions underwent complete regression with no clinical evidence of residual tumor up to 24 months. The current knowledge of MCC and the other cases of spontaneous regression described in the literature are reviewed. [ABSTRACT FROM AUTHOR]

Background: Criteria are needed for primary care providers such that they can evaluate age-related knee pain in a cost-effective manner. This study examined (1) in what percentage of patients are appropriate radiographic views of the knee ordered before magnetic resonance imaging (MRI) for knee pain, (2) specialists' retrospective evaluation for appropriate utilization of MRI in knee pain, and (3) in what manner would the MRIs have altered diagnosis and management of knee disorders.Hypothesis: Primary care providers underuse appropriate radiographs-especially, flexion weightbearing posteroanterior films-and overuse MRIs when evaluating older patients with knee pain.Study Design: Case control.Methods: The authors performed a retrospective analysis of 100 patients older than 40 years with knee MRIs. Patient encounters with primary care physicians were reviewed. Given available information, specialists then formulated a pre- and post-MRI diagnosis and treatment plan and indicated whether the MRI would have altered their treatment.Results: Only 12 of 100 MRIs would have been ordered by an orthopaedist given the documented data. No MRIs would have been ordered in the 19 patients aged 60 years or older. Among 44 radiographs ordered, only 7 were flexion weightbearing. The most common pre-MRI diagnoses made by primary care providers were joint pain (22%) and meniscus injury (24%); the most common post-MRI diagnoses were osteoarthritis (40%) and degenerative meniscus injury (23%). In contrast, the 2 most common pre- and post-MRI diagnoses by specialists were osteoarthritis (28% and 37%, respectively) and degenerative meniscus injury (23% and 24%, respectively). Also, referrals to specialists increased from 9% pre-MRI to 76% post-MRI.Conclusion: Primary care providers may be overusing knee MRIs and underusing flexion weightbearing posteroanterior radiographs in patients older than 40 years with knee pain.Clinical Relevance: Primary care providers should strongly consider not ordering knee MRI in patients with radiographic evidence of degenerative changes. [ABSTRACT FROM AUTHOR]

Background: Osteoarthritis is a widespread condition affecting the elderly where ~70-90% of over 75 year olds are affected, representing one of the largest cost burdens to healthcare in the western world. The monosodium iodoacetate (MIA) osteoarthritis model has been well described in the rat especially in terms of the pathological progression of the disease and more recently pain behaviour. In this study, we characterise, for the first time, MIA induced osteoarthritis in mice and compare it with nerve-injured mice (partial sciatic nerve injury), using both behavioural and in vivo electrophysiological measurements. These approaches uniquely allow the threshold and suprathreshold measures to many modalities to be quantified and so form a basis for improving and expanding transgenic studies. Results: Significant mechanical hypersensitivity was observed in the ipsilateral hindpaw in MIA injected mice at all observed time points following infrapetellar MIA injection (p < 0.05). The mechanical hypersensitivity exhibited a partial biphasic temporal pattern, but thermal hypersensitivity was absent. Electrically-evoked dorsal horn neuronal responses in MIA injected mice were significantly elevated (p < 0.05) with respect to A- and C-fibre firing, input, pinch and noxious von Frey (26 and 60 g). No significant changes in A- or C-fibre thresholds were observed. Nerve-injured mice displayed significant behavioural thermal and mechanical hypersensitivity (p < 0.05) and evoked dorsal horn responses were significantly increased with respect to C-fibre firing, pinch and wind-up (p < 0.05). Conclusion: The MIA model of osteoarthritic pain in mice displays behavioural characteristics similar to those observed in rats. Changes in both behavioural measures and neuronal activity from the paw, suggest that central changes are involved in this pain state, although a role for peripheral drives is also likely. Moreover, the behavioural and neuronal measures in these two pain models showed overlapping alterations in terms of certain neuronal measures and mechanical sensitivity despite their very different pathologies and a loss of input in neuropathy, suggesting some commonalities in the central processing of different peripheral pain states. This murine model of osteoarthritis will allow the exploitation of knock out animals to better understand underlying mechanisms and identify novel molecular targets. [ABSTRACT FROM AUTHOR]

Long known as an uncommon but serious medical disorder requiring medical management, vitamin B12 deficiency is now seen to be common worldwide, but it is in a quite different form than traditionally envisioned. Most of the newly recognized deficiency is subclinical in nature, its health impact and natural history are uncertain, and its prevalence has been greatly inflated by also including persons with "low-normal" vitamin B12 levels, few of whom are deficient. The spread of folic acid fortification has also introduced concerns about folate's potentially adverse neurologic consequences in persons with undetected vitamin B12 deficiency. Fortification with vitamin B12 may prove more complicated than fortification with folic acid, however, because the bioavailability of vitamin B12 is limited. Bioavailability for those who need the vitamin B12 the most is especially poor, because they often have malabsorption affecting either classical intrinsic factor-mediated absorption or food-vitamin B12 absorption. Moreover, new evidence shows that many elderly persons respond poorly to daily oral doses under 500 μg (1 μg = 0.74 nmol), even if they do not have classical malabsorption, which suggests that proposed fortification with 1 to 10 μg may be ineffective. Those least in need of vitamin B12 usually have normal absorption and are thus at greatest risk for whatever unknown adverse effects of high-dose fortification might emerge, such as the effects of excess accumulation of cyanocobalamin. Studies are needed to define the still unproven health benefits of vitamin B12 fortification, the optimal levels of fortification, the stability of such fortification, interactions with other nutrients, and any possible adverse effects on healthy persons. The answers will permit formulation of appropriately informed decisions about mandatory fortification or (because fortification may prove a poor choice) about targeted supplementation in subpopulations with special needs for additional vitamin B12, such as vegetarians, nursing mothers, and the elderly. [ABSTRACT FROM AUTHOR]

Some 20 million Americans over the age of 60 will soon be obese. As a result, they will likely suffer lower life-expectancy, higher disability, and higher health care costs. How much time do physicians spend with elders, especially obese elders, in helping them plan weight loss? This study, which analyzed 352 videotaped visits with elderly patients and their provider, has found that only a third of the visibly obese patients were counseled, and that the average time spent discussing the subject - if discussed - was 103 seconds. This is probably less than a fifth of the time needed to adequately counsel patients about weight loss. In addition, the study has found that both provider and patient characteristics determine if and how long discussion lasts. [ABSTRACT FROM AUTHOR]

Objectives To compare attendance and prevalence of abdominal aortic aneurysm (AAA) in population based randomised trials of sonographic screening in the United Kingdom, Western Australia, and Denmark. Methods 65 290 men were randomised to screening in the four trials, and data were collected and analysed from 46 397 aortic scans for men aged between 64 and 83 years who attended one of four community screening programmes. Comparisons were made for age standardised populations (65–74 years). Results Age standardised attendance varied between 74% and 81%, and was highest in the United Kingdom and lowest in Western Australia. Age standardised prevalence of AAAs of 3.0 cm or more varied significantly between 4.5% and 7.7%, and was highest in the United Kingdom and lowest in Denmark. Conclusions Participation in the four programmes compares favourably with other reported screening studies. The possibility that variations may reflect the different recruitment methods used is discussed. The prevalence of AAA in central Denmark would appear to be significantly different from that in southern England and Western Australia. [ABSTRACT FROM AUTHOR]

The article reports on the highlights of the results of the studies of tachycardias in the elderly. It describes the results of the 12-lead electrocardiogram performed on the healthy normal elderly population. The studies showed that supraventricular arrhythmias are almost universal as are ventricular premature beats.

The aging population in Japan has recently resulted in a rapid increase in elderly individuals. Airway management is thus being required more and more often. Aspiration pneumonia is a life-threatening problem among patients with swallowing problems. Several new surgical methods of laryngeal closure that are easier and safer than previous methods have been developed. Among these new methods, we have performed the Kano method as closure of the larynx using double flaps of the divided craniad vocal folds and the divided caudad vocal folds with partial resection of the thyroid and cricoid cartilages for patients with intractable aspiration. We encountered minor leakage in two patients, but these soon closed spontaneously. This procedure is less invasive than other methods such as total laryngectomy and tracheal separation and has great advantages in terms of low blood loss and short duration of the operation. [ABSTRACT FROM AUTHOR]

BACKGROUND: Phenytoin (PHT) is widely used to treat epilepsy in elderly patients, but information on its pharmacokinetics in this population is limited. OBJECTIVE: The purpose of this study was to investigate the effects of age and sex on PHT pharmacokinetics using stable-labeled (SL) isotopes of PHT or fosphenytoin (FOS) administered IV or IM while patients remained on their oral maintenance regimen. METHODS: Subjects were patients 18 years or older with epilepsy, but otherwise healthy, on a maintenance regimen of PHT who were not taking interacting medications. Subjects were given a single injection of a 100 mg dose of SL-PHT or SL-FOS followed by their usual morning PHT dose less 100 mg. Serial blood samples were collected up to 196 hours after the SL dose. Plasma PHT and SL-PHT concentrations were measured by a gas chromatographic-mass spectrometric assay. PHT pharmacokinetics were characterized using a population-based, nonlinear, mixed-effects model. RESULTS: Sixty-three subjects completed the study, 45 of whom were 65 years or older. There was no difference between adult and elderly or men and women in PHT clearance, distribution volume, and elimination half-life. The mean elimination half-life was 40 hours. CONCLUSIONS: Healthy elderly adults appear to have the same phenytoin (PHT) pharmacokinetics as younger adults. Reduced PHT dosage requirements may be due to age-related changes in patients’ sensitivity to the therapeutic and toxic effects of the drug. The prolonged elimination half-life suggests that most patients can take PHT once daily and the time to reach steady-state may extend to 2–3 weeks. [ABSTRACT FROM AUTHOR]

The article discusses the important factors to consider in using insulin to treat elderly patients with diabetes. The benefits and disadvantages of the insulin must be explained to and understood by patients and carers. Insulin is usually started at home when full doses of oral hypoglycemic agents are not achieving acceptable glycemic control or wellbeing. Information regarding choice of insulin regimen, mode of insulin delivery and education and glycemic monitoring is discussed.

The article discusses the carotid sinus syndrome as an overlooked cause of syncope and presyncope in the elderly. Several indications of the syndrome include exaggerated baroreceptor-mediated reflexes resulting in episodic hypotension with or without bradycardia. The article provides the historical aspects of carotid sinus syndrome.

The article reports on the effect of the co-existence of dementia and diabetes in the old age to management and administration of diabetic care. It traces the association of glucose tolerance and diabetes prevalence to causes of dementia while emphasizing the unmet needs of elderly dementia and diabetic patients.

The article presents the diabetes care models for elderly diabetics. It defines the aims of diabetic health care for the aged as well as therapeutic targets considered in the development of the care models. Diabetes care models includes self-care only, primary care only, hospital service on and shared care. Shared care diabetes care model addresses the shortcomings of the other three models which considers the patient, primary and secondary health care as areas of responsibility.

There are a range of therapeutic options available for the management of type 2 diabetes in the elderly. Diet remains the mainstay of treatment although this must be realistic. If diet alone is unsuccessful then, for most patients, short-acting sulphonylurea agents are the treatment of choice. Second line agents include the biguanide, metformin, or an α-glucosidase inhibitor. A significant proportion of type 2 diabetic patients will, however, eventually require insulin to alleviate symptoms of poor control and improve glycaemia. In this article I discuss the therapeutic options available for diabetic management in the elderly, with particular emphasis on the pros and cons of insulin treatment. [ABSTRACT FROM AUTHOR]

The article details the assessment and screening of older people in north London, England. It examines the prevalence of disease and disability of older people within the health district and their needs for health care. The article reports on the implications of the increasing number of older people for the purchasing of health care in the future.

The article cites a research study on the falls in the elderly age. Falls in old age are considered as a major cause of morbidity and mortality. Despite an elaborate study made on the natural history of falls, little is understood about the effects of ageing on the basic neuromuscular mechanisms involved in postural control. Cervical spine pathology, common in the elderly, has been considered a potential cause of postural instability in older people.

The article discusses a medical case involving an old patient who experienced heart failure due to giant cell arteritis. Diagnostic examination revealed an elevated jugular venous pressure, hepatomegaly, gallop rhythm, apical systolic murmur, extensive basal lung crepitations and hypotension. The patient's right iliac fossa has a smooth, non-tender, mobile mass.

The article presents a case study of a 58-year-old man with a history of Buerger's disease for 12 years and presented with painful acral gangrene in fingers. He underwent an initial non-invasive vascular work-up which has demonstrated weak pulses in radial artery and absent ulnar. It states the healing of the patient after receiving phosphodiesterase inhibitor sildenafil in his therapy. The article discusses the definition and pathogenesis of uerger's disease.

Three cases of atypical (endometrial) carcinoma of the prostate are reported. In the light of the uncertain response to oestrogen therapy, all three patients were treated with radical radiotherapy. [ABSTRACT FROM AUTHOR]

The article presents a discussion on the cases of diabetes among elderly Asians. It mentions the prevalence of the disease in the Asian community as well as the growing number of diabetic elderly Asians. Problems in education and compliance result to Asian's poor glycaemic control though they explicit good management of insulin therapy. Elderly Asians are prone to complications such as large vessel diseases and developing lens opacities and retinopathy.

The article offers information on the case of a 73-year-old man who was diagnosed with calcific uremic arteriolopathy (CUA), which formerly known as calciphylaxis. It mentions that the patient received cinacalcet and sevelamer for his high levels of phosphorus and parathyroid hormone. It notes that CUA involves distal extremities, buttocks, and thighs, and occurs mainly in patients with advanced stage renal failure.