Clinics in geriatric medicine
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Elderly individuals comprise an increasing proportion of the population and represent a progressively expanding number of patients admitted to the ICU. Because of underlying pulmonary disease, loss of muscle mass, and other comorbid conditions, older persons are at increased risk of developing respiratory failure. Recognition of this vulnerability and the adoption of proactive measures to prevent decompensation requiring intrusive support are major priorities together with clear delineation of patients' wishes regarding the extent of support desired should clinical deterioration occur. ⋯ The SUPPORT investigators observed that clinicians often underestimated the degree of intervention desired by older patients assuming that less care would be desired [13]. Thus, as in other circumstances, effective communication and elicitation of patients' preferences regarding management options is crucial in the management of respiratory failure. The frequent discordance between patient preferences and the wishes of family members or other surrogate decision makers impose major clinical challenges and also mandates further investigation.
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Early and clear discussion and articulation of preferences about interventions with increasing burdens and diminishing benefits is helpful in identifying the goals of care and planning management for patients who have unremitting terminal illnesses. The development of respiratory symptoms such as dyspnea, cough, and hiccups is common and can often be anticipated. Aggressive evaluation and treatment should be pursued and offered to palliate symptoms at the end of life.
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Postoperative pulmonary complications in the elderly are common and are a significant source of morbidity, mortality, and prolonged length of stay. Risk factors differ from the well-known risk factors for cardiac complications and can be divided into patient- and procedure-related factors. Patient-related factors include COPD, recent cigarette use, poor general health status as defined by Goldman or ASA class, dependent functional status, and laboratory parameters including abnormal chest radiograph, renal insufficiency, and low serum albumin. ⋯ Patients who might benefit from preoperative spirometry include those who have unexplained dyspnea or exercise intolerance and those who have COPD or asthma in whom uncertainty exists as to the status of airflow obstruction when compared with baseline. After identifying patients at risk for postoperative pulmonary complications, clinicians can recommend strategies to reduce risk throughout the operative period. In addition to minimizing or avoiding the above risk factors, optimization of COPD or asthma, deep breathing exercises, incentive spirometry, and epidural local anesthetics reduce the risk of postoperative pulmonary complications in elderly surgical patients.
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Clin. Geriatr. Med. · Nov 2002
ReviewIdentifying the elderly at risk for malnutrition. The Mini Nutritional Assessment.
In more than 10,000 elderly persons, the mean prevalence of malnutrition is 1% in community-healthy elderly persons, 4% in outpatients receiving home care, 5% in patients with Alzheimer's disease living at home, 20% in hospitalized patients, and 37% in institutionalized elderly persons. In community-dwelling elderly persons, the MNA detects risk of malnutrition and life-style characteristics associated with nutritional risk while albumin levels and the BMI are still in the normal range. In outpatients and in hospitalized patients, the MNA is predictive of outcome and cost of care. ⋯ The MNA has the following characteristics: * The MNA is a two step procedure: (1) the MNA-SF to screen for malnutrition and risk of mainutrition; (2) assessment of nutritional status with the full MNA. * The MNA is an 18-item questionnaire comprising anthropometric measurements (BMI, mid-arm and calf circumference, and weight loss) combined with a questionnaire regarding dietary intake (number of meals consumed, food and fluid intake, and feeding autonomy), a global assessment (lifestyle, medication, mobility, presence of acute stress, and presence of dementia or depression), and a self-assessment (self-perception of health and nutrition). The MNA-SF comprises 6 items from the 18. * The MNA is well validated. It correlates highly with clinical assessment and objective indicators of nutritional status (albumin level, BMI, energy intake, and vitamin status). * A low MNA score can predict hospital-say outcomes in older patients and can be used to follow up changes in nutritional status. * Because of its validity in screening and assessing the risk of malnutrition, the MNA should be integrated in the comprehensive geriatric assessment. * In more than 10,000 elderly persons, the prevalence of undernutrition assessed by the MNA is 1% to 5% in community-dwelling elderly persons and outpatients, 20% in hospitalized older patients, and 37% in institutionalized elderly patients.
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The poor response to hypercaloric feeding in ill adults may be caused by failure to distinguish cachexia from starvation (Table 1). The chief difference between starvation and cachexia is that refeeding reverses starvation but is less effective for cachexia. ⋯ Simple starvation should respond to voluntary or involuntary hypercaloric feedings. The failure to demonstrate a more positive response may be caused by underlying cachexic states.