ITEMS IN AFP WITH MESH TERM:
ABSTRACT: Compression fracture of the vertebral body is common, especially in older adults. Vertebral compression fractures usually are caused by osteoporosis, and range from mild to severe. More severe fractures can cause significant pain, leading to inability to perform activities of daily living, and life-threatening decline in the elderly patient who already has decreased reserves. While the diagnosis can be suspected from history and physical examination, plain roentgenography, as well as occasional computed tomography or magnetic resonance imaging, are often helpful in accurate diagnosis and prognosis. Traditional conservative treatment includes bed rest, pain control, and physical therapy. Interventional procedures such as vertebroplasty can be considered in those patients who do not respond to initial treatment. Family physicians can help patients prevent compression fractures by diagnosing and treating predisposing factors, identifying high-risk patients, and educating patients and the public about measures to prevent falls.
Vasomotor Rhinitis - Article
ABSTRACT: Vasomotor rhinitis affects millions of Americans and results in significant symptomatology. Characterized by a combination of symptoms that includes nasal obstruction and rhinorrhea, vasomotor rhinitis is a diagnosis of exclusion reached after taking a careful history, performing a physical examination, and, in select cases, testing the patient with known allergens. According to a 2002 evidence report published by the Agency for Healthcare Research and Quality (AHRQ), there is insufficient evidence to reliably differentiate between allergic and nonallergic rhinitis based on signs and symptoms alone. The minimum level of diagnostic testing needed to differentiate between the two types of rhinitis also has not been established. An algorithm is presented that is based on a targeted history and physical examination and a stepwise approach to management that reflects the AHRQ evidence report and U.S. Food and Drug Administration approvals. Specific approaches to the management of rhinitis in children, athletes, pregnant women, and older adults are discussed.
ABSTRACT: Clostridium difficile infection is responsible for approximately 3 million cases of diarrhea and colitis annually in the United States. The mortality rate is 1 to 2.5 percent. Early diagnosis and prompt aggressive treatment are critical in managing C. difficile-associated diarrhea. Major predisposing factors for symptomatic C. difficile colitis include antibiotic therapy; advanced age; multiple, severe underlying diseases; and a faulty immune response to C. difficile toxins. The most common confirmatory study is an enzyme immunoassay for C. difficile toxins A and B. The test is easy to perform, and results are available in two to four hours. Specificity of the assay is high (93 to 100 percent), but sensitivity ranges from 63 to 99 percent. In severe cases, flexible sigmoidoscopy can provide an immediate diagnosis. Treatment of C. difficile-associated diarrhea includes discontinuation of the precipitating antibiotic (if possible) and the administration of metronidazole or vancomycin. Preventive measures include the judicious use of antibiotics, thorough hand washing between patient contacts, use of precautions when handling an infected patient or items in the patient's immediate environment, proper disinfection of objects, education of staff members, and isolation of the patient.
ABSTRACT: Compared with community-dwelling persons, residents in long-term care facilities have more functional disabilities and underlying medical illnesses and are at increased risk of acquiring infectious diseases. Pneumonia is the leading cause of morbidity and mortality in this group. Risk factors include unwitnessed aspiration, sedative medication, and comorbidity. Recognition may be delayed because, in this population, pneumonia often presents without fever, cough, or dyspnea. Accurate identification of the etiologic agent is hampered because most patients cannot produce a suitable sputum specimen. It is difficult to distinguish colonization from infection. Colonization by Staphylococcus aureus and gram-negative organisms can result from aspiration of oral or gastric contents, which could lead to pneumonia. Aspiration of gastric contents also can produce aspiration pneumonitis. This condition is not infectious initially and may resolve without antibiotics. Antibiotics for the treatment of pneumonia should cover Streptococcus pneumoniae, Haemophilus influenzae, gram-negative rods, and S. aureus. Acceptable choices include quinolones or an extended-spectrum beta-lactam plus a macrolide. Treatment should last 10 to 14 days. Pneumonia is associated with significant mortality for up to two years. Dementia is related independently to the death rate within the first week after pneumonia, regardless of treatment. Prevention strategies include vaccination against S. pneumoniae and influenza on admission to the care facility. This article focuses on recent recommendations for the recognition of respiratory symptoms and criteria for the designation of probable pneumonia, and provides a guide to hospitalization, antibiotic use, and prevention.
ABSTRACT: Chronic kidney disease affects approximately 19 million adult Americans, and its incidence is increasing rapidly. Diabetes and hypertension are the underlying causes in most cases of chronic kidney disease. Evidence suggests that progression to kidney failure can be delayed or prevented by controlling blood sugar levels and blood pressure and by treating proteinuria. Unfortunately, chronic kidney disease often is overlooked in its earliest, most treatable stages. Guidelines from the National Kidney Foundation's Kidney Disease Outcomes Quality Initiative (KDOQI) recommend estimating glomerular filtration rate and screening for albuminuria in patients with risk factors for chronic kidney disease, including diabetes, hypertension, systemic illnesses, age greater than 60 years, and family history of chronic kidney disease. The glomerular filtration rate, calculated by using a prediction equation, detects chronic kidney disease more accurately than does the serum creatinine level alone; the glomerular filtration rate also is used for disease staging. In most clinical situations, analysis of random urine samples to determine the albumin-creatinine or protein-creatinine ratio has replaced analysis of timed urine collections. When chronic kidney disease is detected, an attempt should be made to identify and treat the specific underlying condition(s). The KDOQI guidelines define major treatment goals for all patients with chronic kidney disease. These goals include slowing disease progression, detecting and treating complications, and managing cardiovascular risk factors. Primary care physicians have an important role in detecting chronic kidney disease early, in instituting measures to slow disease progression, and in providing timely referral to a nephrologist.
ABSTRACT: Antihypertensive therapy has been shown to reduce morbidity and mortality in older patients with elevated systolic or diastolic blood pressures. This benefit appears to persist in patients older than 80 years, but less than one third of older patients have adequate blood pressure control. Systolic blood pressure is the most important predictor of cardiovascular disease. Blood pressure measurement in older persons should include an evaluation for orthostatic hypotension. Low-dose thiazide diuretics remain first-line therapy for older patients. Beta blockers, angiotensin-converting enzyme inhibitors, angiotensin-receptor blockers, and calcium channel blockers are second-line medications that should be selected based on comorbidities and risk factors.
ABSTRACT: Medications for treating alcohol dependence primarily have been adjunctive interventions, and only three medications--disulfiram, naltrexone, and acamprosate--are approved for this indication by the U.S. Food and Drug Administration. Disulfiram, an aversive agent that has been used for more than 40 years, has significant adverse effects and compliance difficulties with no clear evidence that it increases abstinence rates, decreases relapse rates, or reduces cravings. In contrast, naltrexone, an anticraving agent, reduces relapse rates and cravings and increases abstinence rates. Acamprosate also reduces relapse rates and increases abstinence rates. Serotonergic and anticonvulsant agents promise to play more of a role in the treatment of alcohol dependence. Although not approved by the U.S. Food and Drug Administration for this indication, the anticonvulsant topiramate and several serotonergic agents (e.g., fluoxetine, ondansetron) have been shown in recent studies to increase abstinence rates and decrease drinking.
ABSTRACT: The recognizable appearance and the dermatomal distribution of herpes zoster lesions usually enable a clinical diagnosis to be made easily. Herpes zoster and postherpetic neuralgia occur mainly in older patients. The role of the varicella vaccine in preventing herpes zoster is uncertain, but is being studied. There is evidence to support using antiviral therapy and possibly low-dose tricyclic antidepressants to prevent postherpetic neuralgia. There is good evidence that treating herpes zoster with antiviral medication is beneficial, particularly in patients older than 50 years with severe outbreaks. The use of steroids has an unfavorable risk-benefit ratio. In patients who develop postherpetic neuralgia, there is good evidence to support treatment with gabapentin and tricyclic antidepressants. More evidence for treatment with capsaicin cream, lidocaine patch, and opioids is needed. Intrathecal methylprednisolone is an option for patients with persistent pain.
ABSTRACT: Coronary heart disease remains a leading cause of mortality in the United States, with 84 percent of persons 65 years or older dying from this disease. Secondary preventive measures, including lifestyle modification and pharmacotherapy, are important for elderly patients because of the variable impacts on morbidity and mortality rates and quality of life. Participating in light to moderate activities significantly decreases mortality rates in elderly patients. Smoking cessation translates into a reduction in overall mortality and morbidity rates at least equal to that of other preventive measures such as aspirin or beta-blocker therapy. Recent studies on the effects of lowering low-density lipoprotein cholesterol levels to below 100 mg per dL have shown a substantial reduction in coronary heart disease mortality and nonfatal myocardial infarction rates, with a persistent effect in patients older than 75 years. Hypertension, manifesting mostly as isolated systolic blood pressure elevation, also should be treated aggressively. Conventional medical therapies for hypertension (e.g., diuretics, beta blockers) and newer agents (e.g., calcium channel blockers, angiotensin-converting enzyme inhibitors), together with sodium restriction, have had a positive effect on cardiovascular mortality and morbidity rates in older patients. With the increasing prevalence of obesity, insulin resistance, and type 2 diabetes, interventions targeting weight reduction and glucose control should be emphasized. Whereas weight-loss strategies are poorly defined in this population, the management of diabetes through dietary modification, exercise, and medications is similar across age groups. The target hemoglobin A1C level is less than 7 percent. Elderly patients are prone to depression and social isolation, and they are more likely to have a lower socioeconomic status than younger patients, which may negatively affect participation in rehabilitation programs and compliance with medical advice and therapy. Strategies aimed at these factors have shown variable results and remain ill-defined.
Prevention of Falls in Older Patients - Article
ABSTRACT: Falls are one of the most common geriatric syndromes threatening the independence of older persons. Between 30 and 40 percent of community-dwelling adults older than 65 years fall each year, and the rates are higher for nursing home residents. Falls are associated with increased morbidity, mortality, and nursing home placement. Most falls have multiple causes. Risk factors for falls include muscle weakness, a history of falls, use of four or more prescription medications, use of an assistive device, arthritis, depression, age older than 80 years, and impairments in gait, balance, cognition, vision, and activities of daily living. Physicians caring for older patients should ask about any falls that have occurred in the past year. Assessment should include evaluating the circumstances of the fall and a complete history and physical examination, looking for potential risk factors. The most effective fall prevention strategies are multifactorial interventions targeting identified risk factors, exercises for muscle strengthening combined with balance training, and withdrawal of psychotropic medication. Home hazard assessment and modification by a health professional also is helpful.