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P005: Swallowing syncope in the elderly: a case report
S84
Poster presentations, Thursday 18 September 2014 / European Geriatric Medicine 5S1 (2014) S83–S158
P003 Elderly complexity: one complaint, several hypothesis, more than one cause A.P.P. Mendes, D.C.M. Ferreira, M.D. Lopes, A. Clemente, J.P.F. Fonseca, R.V. Ferreira, P.D.M.T. Pina, T.M. Verissimo, S.P. Carvalho Centro Hospitalar e Universit´ ario de Coimbra – P´ olo HUC, Coimbra, Portugal Introduction: Elderly show atypical presentation of diseases and consequent difficulties in differential diagnosis. Goal: We purpose to report a clinical case of an elder woman who presented at the Emergency Department (ED) with lipothymia and head trauma. Clinical case: APHP, female, 88-year-old, previously independent to the daily life activities (DLA). Brought to our ED with lipothymia and head trauma, progressive prostration and DLA dependence evolving for two weeks. Past medical history: essential hypertension, depression disorder and atrial fibrillation. Drug history: amiodarone, sertraline, furosemide, perindopril, verapamil, nifedipine and omeprazole. She presented pale, lethargic, with depressed humour, hypotensive, afebrile, bradycardic, with hypophonesis of cardiac sounds and generalized oedemas. Lab results: mild leukocitosis, moderate macrocytic anaemia with normal values of folic acid and elevated B12 vitamin, severe thrombocytopenia, hypokalaemia, elevated TSH (115UI/ml) and decreased free T4 (<0.3 ng/ml), elevated inflammation markers. Positive tiroglobuline antibodies. Chest x-ray had right perihilar hypotransparency. Head CT showed generalized encephalic atrophy. Bone marrow aspirate with immunophenotyping was compatible with myelodysplastic syndrome and had 0.5% of clonal B cells, similar to those of splenic marginal zone lymphoma. Abdominal echography had no alterations. We assumed three diagnosis: community acquired pneumonia, iatrogenic hypothyroidism and myelodysplastic syndrome. She was given amoxicillin and clavulanic acid for 10 days and initiated levothyroxine and physical rehabilitation with some improvement in her clinical condition. Conclusions: Sometimes it is not possible to suit every evidence into a unique diagnosis. Elderly are complex individuals with many confounding factors, including iatrogeny.
Figure: The lethargic face of the elder – capture from a video.
P004 Efficacy and tolerability of oxycodone/naloxone in the treatment of chronic pain from multiple diabetic skin ulcers F. Guerriero1 , M. Rollone2 , G. Ricevuti1 , C. Alfano3 , S. Perna3 , M. Rondanelli1 , C. Sgarlata3 1 University of Pavia, Azienda di Servizi alla Persona of Pavia, Italy; 2 Azienda di Servizi alla Persona of Pavia, Pavia, Italy; 3 University of Pavia, Pavia, Italy Introduction: The prevalence of chronic skin ulcers increases with age, reaching very high levels in the geriatric population. The underlying mechanisms include a physiological loss of trophic dermo-epidermal elasticity and a large number of other factors closely related to the presence of comorbidities in the elderly. The pain associated with skin ulcers is often a not negligible factor, impacting negatively on both mood and wound healing.
Materials and Methods: Our patient – 82 yrs old – suffering from type 2 diabetes, presented multiple painful skin ulcers of the lower extremities. Despite the analgesic treatment (acetaminophen 3 g/die) pain control was entirely unsatisfactory limiting strongly the local dressing procedures of the ulcers. It was initiated a pain therapy with oxycodone/naloxone (PR/OXN) at the starting dose of 5/2.5 mg day. To evaluate the effectiveness and tolerability of the PR/OXN we assessed: pain through NRS, cognitive function through MMSE, opiods related constipation through Bowel Function Index (BFI) and the incidence of common opioids related adverse events (nausea, vomiting, dizziness, drowsiness, dry mouth and itch). Results: 10/5 mg of PR/OXN has proved sufficient in obtaining a more than satisfactory analgesic efficacy (NRS < 4). No adverse effects were observed confirming the good tolerability of this combination in the elderly. In particular no changes were observed in the BFI score. Conclusions: In our case PR/OXN demonstrated high efficacy and tolerability in the treatment of pain due to diabetic lower limbs ulcers showing at the same time to increase the patient’s compliance to ulcers dressing procedures. P005 Swallowing syncope in the elderly: a case report C. Sgarlata1 , M. Rollone2 , G. Ricevuti3 , C. Alfano1 , S. Perna1 , M. Rondanelli3 , F. Guerriero3 1 University of Pavia, Pavia, Italy; 2 Azienda di Servizi alla Persona of Pavia, Pavia, Italy; 3 University of Pavia, Azienda di Servizi alla Persona of Pavia, Pavia, Italy Introduction: The prevalence of syncope in the elderly is high and this symptom recognizes multiple possible causes, whose prognosis is extremely variable. Swallowing (or deglutition) syncope is an uncommon vagally-mediated syncope, whose mechanism involves afferent impulses from the upper gastrointestinal tract and efferent impulses to the heart, that can produce bradyarrhythmias. The diagnosis of this condition is important because it is often treatable. Materials and Methods: We describe the case of a female 78 years old patient, who was admitted to our department of geriatric medicine for rehabilitation after the fracture of left femur due to a syncope related fall occurred while the patient was eating. A 24-hours dynamic ECG recording showed recurrent episodes of severe bradycardia with atrio-ventricular block associated with the ingestion of solid bolus of food, while no ECG alterations has been showed by the swallowing of liquids. In addition to that the patient reported to had several syncopal episodes previously during meals. Barium swallowing study and head and neck computer tomography did not show any pathological findings. Results: The patient was then sent to the attention of the cardiologists, who have placed a permanent pacemaker achieving the complete resolution of symptoms. Conclusions: In evaluating patients with syncope, a history of a temporal relationship to eating or drinking should be sought. While changes in eating habits may be effective in some cases, permanent pacemaker placement is often indicated and is curative. P006 Multimorbidity: development of organisation models and integrated health assessment for frail patients at home D. Salerno, G. Cosenza, L. Cesari, A.M. Lussiana, M.P. Boscolo, G.P. Richetto, A. Calaon Public Health System, Collegno (Turin), Italy Evaluation of feasibility, effectiveness of new healthcare model which provide specialized continuity of care at home with
Poster presentations, Thursday 18 September 2014 / European Geriatric Medicine 5S1 (2014) S83–S158
P003 Elderly complexity: one complaint, several hypothesis, more than one cause A.P.P. Mendes, D.C.M. Ferreira, M.D. Lopes, A. Clemente, J.P.F. Fonseca, R.V. Ferreira, P.D.M.T. Pina, T.M. Verissimo, S.P. Carvalho Centro Hospitalar e Universit´ ario de Coimbra – P´ olo HUC, Coimbra, Portugal Introduction: Elderly show atypical presentation of diseases and consequent difficulties in differential diagnosis. Goal: We purpose to report a clinical case of an elder woman who presented at the Emergency Department (ED) with lipothymia and head trauma. Clinical case: APHP, female, 88-year-old, previously independent to the daily life activities (DLA). Brought to our ED with lipothymia and head trauma, progressive prostration and DLA dependence evolving for two weeks. Past medical history: essential hypertension, depression disorder and atrial fibrillation. Drug history: amiodarone, sertraline, furosemide, perindopril, verapamil, nifedipine and omeprazole. She presented pale, lethargic, with depressed humour, hypotensive, afebrile, bradycardic, with hypophonesis of cardiac sounds and generalized oedemas. Lab results: mild leukocitosis, moderate macrocytic anaemia with normal values of folic acid and elevated B12 vitamin, severe thrombocytopenia, hypokalaemia, elevated TSH (115UI/ml) and decreased free T4 (<0.3 ng/ml), elevated inflammation markers. Positive tiroglobuline antibodies. Chest x-ray had right perihilar hypotransparency. Head CT showed generalized encephalic atrophy. Bone marrow aspirate with immunophenotyping was compatible with myelodysplastic syndrome and had 0.5% of clonal B cells, similar to those of splenic marginal zone lymphoma. Abdominal echography had no alterations. We assumed three diagnosis: community acquired pneumonia, iatrogenic hypothyroidism and myelodysplastic syndrome. She was given amoxicillin and clavulanic acid for 10 days and initiated levothyroxine and physical rehabilitation with some improvement in her clinical condition. Conclusions: Sometimes it is not possible to suit every evidence into a unique diagnosis. Elderly are complex individuals with many confounding factors, including iatrogeny.
Figure: The lethargic face of the elder – capture from a video.
P004 Efficacy and tolerability of oxycodone/naloxone in the treatment of chronic pain from multiple diabetic skin ulcers F. Guerriero1 , M. Rollone2 , G. Ricevuti1 , C. Alfano3 , S. Perna3 , M. Rondanelli1 , C. Sgarlata3 1 University of Pavia, Azienda di Servizi alla Persona of Pavia, Italy; 2 Azienda di Servizi alla Persona of Pavia, Pavia, Italy; 3 University of Pavia, Pavia, Italy Introduction: The prevalence of chronic skin ulcers increases with age, reaching very high levels in the geriatric population. The underlying mechanisms include a physiological loss of trophic dermo-epidermal elasticity and a large number of other factors closely related to the presence of comorbidities in the elderly. The pain associated with skin ulcers is often a not negligible factor, impacting negatively on both mood and wound healing.
Materials and Methods: Our patient – 82 yrs old – suffering from type 2 diabetes, presented multiple painful skin ulcers of the lower extremities. Despite the analgesic treatment (acetaminophen 3 g/die) pain control was entirely unsatisfactory limiting strongly the local dressing procedures of the ulcers. It was initiated a pain therapy with oxycodone/naloxone (PR/OXN) at the starting dose of 5/2.5 mg day. To evaluate the effectiveness and tolerability of the PR/OXN we assessed: pain through NRS, cognitive function through MMSE, opiods related constipation through Bowel Function Index (BFI) and the incidence of common opioids related adverse events (nausea, vomiting, dizziness, drowsiness, dry mouth and itch). Results: 10/5 mg of PR/OXN has proved sufficient in obtaining a more than satisfactory analgesic efficacy (NRS < 4). No adverse effects were observed confirming the good tolerability of this combination in the elderly. In particular no changes were observed in the BFI score. Conclusions: In our case PR/OXN demonstrated high efficacy and tolerability in the treatment of pain due to diabetic lower limbs ulcers showing at the same time to increase the patient’s compliance to ulcers dressing procedures. P005 Swallowing syncope in the elderly: a case report C. Sgarlata1 , M. Rollone2 , G. Ricevuti3 , C. Alfano1 , S. Perna1 , M. Rondanelli3 , F. Guerriero3 1 University of Pavia, Pavia, Italy; 2 Azienda di Servizi alla Persona of Pavia, Pavia, Italy; 3 University of Pavia, Azienda di Servizi alla Persona of Pavia, Pavia, Italy Introduction: The prevalence of syncope in the elderly is high and this symptom recognizes multiple possible causes, whose prognosis is extremely variable. Swallowing (or deglutition) syncope is an uncommon vagally-mediated syncope, whose mechanism involves afferent impulses from the upper gastrointestinal tract and efferent impulses to the heart, that can produce bradyarrhythmias. The diagnosis of this condition is important because it is often treatable. Materials and Methods: We describe the case of a female 78 years old patient, who was admitted to our department of geriatric medicine for rehabilitation after the fracture of left femur due to a syncope related fall occurred while the patient was eating. A 24-hours dynamic ECG recording showed recurrent episodes of severe bradycardia with atrio-ventricular block associated with the ingestion of solid bolus of food, while no ECG alterations has been showed by the swallowing of liquids. In addition to that the patient reported to had several syncopal episodes previously during meals. Barium swallowing study and head and neck computer tomography did not show any pathological findings. Results: The patient was then sent to the attention of the cardiologists, who have placed a permanent pacemaker achieving the complete resolution of symptoms. Conclusions: In evaluating patients with syncope, a history of a temporal relationship to eating or drinking should be sought. While changes in eating habits may be effective in some cases, permanent pacemaker placement is often indicated and is curative. P006 Multimorbidity: development of organisation models and integrated health assessment for frail patients at home D. Salerno, G. Cosenza, L. Cesari, A.M. Lussiana, M.P. Boscolo, G.P. Richetto, A. Calaon Public Health System, Collegno (Turin), Italy Evaluation of feasibility, effectiveness of new healthcare model which provide specialized continuity of care at home with