Geriatrics

Tuesday, October 28, 1997 Exercise, continued Methods: An ergom eter to evaluate patien ts on whee lchair (EWC) was designed , which has a parabolic response to contro lled and graded load (r.p.m!load). Ten patients were selected to undergo throu gh stress test with the above menti oned ergomete r and with a cycloergometer (CE) for upp er extremities (Monark 881). Maximal oxygen consumption (V0 2 max), inspiratory pattern (Tifftot, Vt/Ti), heart rate (H R) and Vo,jHR were measured. Results: Since CE has a linear response between the load and the physiological variables studied, a correlation was then established with EWC, which should accomplish the same prem ise. Th e linear correlation indices (r) were 0.78 for Tifftot, 0.93 for Vt/Ti, 0.93 for V0 2 max, 0.97 for HR and 0.76 for VO/ HR . Conclusions: The new designed EWC is able to indu ce measurable, repro ducible and reliable physiologic changes, comparable with tho se obtain ed with other known ergome ter. Clinical Implications: The EWC is an adequate tool to evaluate parapl egic patients under physical stress. This device would be very useful in rehabi litation programs as well as for training when parapl egics engage sports on whee l chairs.

Geriatrics QUALITY OF LIFE IN ELDERLY HEART FAILURE PATIENTS IS RELATED TO LOWER BODY WEIGHT Lawrence P Cahalin , M Semigran, R Kacmarek, C Certo, GW Dec.Massachusett s General Hospital and Boston University, Boston, MA, USA Purpose: Previous investigations have observed Significant relationships between the quality of life (QOL) and measures of exercise per formance in middle-aged patients with heart failure (HF ). Th e purpose of this study was to investigate if a similar relationship exists in eld erly HF patient s. Methods: We evaluated the relation ship of submaximal exercise performance (via the 6 minute walk test (6' \ VT)) and 6 physical characteristics (age, height, weight, body mass index, LVEF, and NYHA class) to QOL (via the Minnesota Living With Heart Failure Questionnaire (MLWH FQ) ) in 40 elder ly HF patient s (22 males, 18 females; mean :!:SD, age =72:!:9 yrs, height= 168:!:8 em, weight = 67 :!:15 kg, body mass index=23:!:4, LVEF = 30:!:8%, NYHA=2.3:!:0.8). Results: The mean 6'\VT distance ambulated was 183:!:110 meters and the mean MLWH FQ score was 48:!:22. Significant univariate relation ships were observed between MLWH FQ score and height (r = 0.36) and weight (r = 0.37). Body weight was the only multivariate predictor of QOL (model r=0.14, coeff=0.53). In separa te analyses of males and fem ales, NYI-IA class and LVEF were identified as Significant univariate and multivariate predictors of QOL in males and females, respec tively (r= 0.37 and 0.44, respectively). Conclusions: In this elde rly cohort, subm aximal exercise was unrelated to QO L, but lower body weight was related to an improved QOL. Clinical Implications: Management of elde rly HF patie nts should focus on therapies to decrease body weight. EFFECT OF BODY POSITION (BP) ON PULMONARY MECHANICS, GAS EXCHANGE, AND LUNG VOLUMES IN ELDERLY SUBJECTS WITHOUT LUNG DISEASE Jay A Johannigman , RS Campbell, RD Branson, M Rashkin,* K Davis Jr, Y Ploysongsang*.- De partments of Surgery and Pulmon ary Medicine , University of Cincinnati, Cincinnati , OH Purpose: Evaluate the effect of three BP [sitting with feet down (ST), semi-fowlers with feet level (SF), supin e with feet level (SP)] available on a prototyp e hospital bed (Hill-Rom) on pulmona ry function and gas exchange in elde rly subjects (SUB) without lung disease (LD ). Methods: Ten SUB olde r than 50 (mean age 59) were enrolled. Mean height was 65 inches, 6 females, and 4 males were studied (all Cauc). SUB were rando mly placed in each BP for a 30" acclimation period, after which the following measurem ents were made: deadspace to tidal volume ratio (VDN T), arterial blood gas on 21% and 100% 0 2' closing volume (CV), lung volumes (LV) and subdivisions (TLC, VC , VT, FR C, RV), and forced expiratory volume in 1 second (FEV,). Values for each BP were compared using ANOVA.

Results: Table 1 shows mean (SD ) values for FEV " TL C, FR C, RV, CV, Pa0 2 on 21% and 100% 0 2' and VDNT at each BP tested . Table 1

TLC (L) FR C (L) RV (L) CV(L) Pa0 2-·21 Pa0 2-1.0 VnNT (%) FEV, (L)

ST (75°)

SF (45°)

SP (0°)

5.26 (.98)1* 2.1 (.35)1* 1.67 (.27)* .543 (.16) 88.6 (7.3) 542 (33)* 30.7 (204) 2.7 (.52)*

5.03 (1.0)* 1.84 (041) 1.56 (.35) .519 (.18)* 87.1 (11.9) 530 (30) 30.9 (1.6) 2.58 (.55)

4.85 (1.1) 1.72 (047) 1.43 (.35) .581 (.19) 8404 (10.1) 514 (38) 32.2 (3.2) 2.53 (.55)

*=p<0.05 vs. SP. l = p < 0.05 Conclusions: Pulmo nary mechanics and gas exchange are best whe n ST at 75° with feet down . CV was highest in the SP BP, all other LV were best when ST. Clinical Implications: Elderly pts may benefit from a bed capable of ST BP with feet down in terms of improved pul monary mechani cs and oxygenation . Differenc es may be greater in elde rly pts with LD . Risks to pts and hospit al staff associate d with changing BP may be lower with use of this bed .

MANAGEMENT AND OUTCOMES OF A GERIATRIC ANTICOAGULATION CLINIC PROTOCOL DP Schroeder, C Cunningham, L Vignes.-Emory University School of Medicin e and Wesley Woods Geriatri c Hospital , Atlanta , Georgia Purpose: To analyze the efficacy and adverse effects of a protocol directed anticoagulation clinic for 200 geriatric patient s. Methods: 51 male patient s (mean age 79 years ) and 149 female patient s (mean age 81 years ) were monitore d with monthly INR ratios (IN R) and for adverse events (AE) duri ng warfarin (W) anticoagulation over 29 month s. The pro tocol was developed by a multidi sciplinary team of geriatric clinicians and nurses . W dosing schedules were based on the INR and INR ranges (R) and dosages were prescribed by the pati ent's ph ysician . Monthl y team meetings reviewed AE, per cent age (%) of patients in and out of established R, and medication and dietary changes. If any INR was greater than :!:1 from the R or if 2 out of 3 IN Rs are greate r than :!:.5 from the R, the physician was contacted by the nurs e coordinator. Results: Major hemorrhagic AE were 3% and major thr omboembolic AE were 1.5%. All cause mortality was 8.5% and mortali ty directly relat ed to anticoagulation was 1.5%. In a typical month 91% of the patient s are within and 9% fall outside the R. Conclusions: Protocol parameters enable the nu rse coordin ator to continue patient dosing schedules and INR testing without physician intervention. Ou r analysis indicates the patient s have a low incidenc e of major AE with this protocol. Clinical Implications: Monitoring of anticoagulated geriatric pati ent s can be safely performed by geriatric nurs es follOwing a defined protocol with supe rvision of a physician.

PULMONARY EMBOLISM IN THE ELDERLY: EPIDEMIOL· OGY, CLINICAL PRESENTATION, AND OUTCOME Manana Sisoshvilli, MD , Lishko, MD, A Raykher , MD , EJ Lazar, MD .-The Brooklyn Hospi tal Cen ter, New York University School of Medicin e, NY, USA

°

Purpose: Pulmonary e mbolism (PE) is a pote ntially devastating problem in older patient s (pts), however few studies have focused on PE in the elde rly. We att empted to det ermin e the risk factors, clinical featu res and outcome in patient s more than 70 dxed with PE. CHEST / 112 / 3 / SEPTEM BER, 1997 SUPPLEMENT

955

Tuesday, October 28, 1997 Geriatrics

Health-Care Delivery

Methods : We reviewed the inpatient record s of all pts more than 70 with a dx of PE admitted from Jan 1995-D ec 1996. 31 pts had intermediate or high pro bability \'/Q scans and were included in the study popul ation. Pts with low probabili ty scans or intermediate scans and matched defects on CXR were not includ ed. Data extracted included co-mor bid conditio ns, meds, risk factors, h/o previous DVT. IIPI , PEx and diagnostic studies were also recorded . Results: Th e most common present ing complaint was dyspnea, seen in 61.3%. Chest pain was present in 48.4%. 54.8% had sinus tachycardia, 19.4% had a tachyarrhythmia and 6.5% had a normal EKG. Risk factor analysis revealed that 45.2% had immobilization as a risk factor, 29% may have been related to surge ry/trauma and 29% had more than one risk factor. 19.4% had no obvious risk factors. Overall mortality was 32.3%. Conclusions : Im mobilization was an important risk factor , notab ly related in several cases to long travel periods . This may be fostered by decreased mobility seen in older pts. Clinical presentation was similar to tha t in younger age groups, althou gh chest pain see med to occur less frequ ent ly. Mortality and complications were higher in the elderly than in younger pop ulations as one might expect. Clin ical Implications: Pulmona ry embolism in the elderly is a serious and potentially lethal problem . Clinicians should maintain a high index of suspicion as the pre sentation may be more varied. Older pts should be advised to move about as often as possible whe n traveling.

RE FERRAL PATTER NS FOR CARDIAC CAT HETERIZATION AND CORONARY RE VASC ULARIZATION I N I\IULTIETHNIC MALES AND FEMALES R Al-Bezem , S Fahm y, A. Safi, R Williams, LT Clark- SUNY Health Science Center at Brooklyn, NY

Presenti ng Co mplaints Dyspnea Chest Pain Cough F UO, Palpit, Asymp tomatic Hemoptysis, Confusion

19 (61.3%) 15 (48.4%) 4 (12.9%) 2 (6.5% ) 1 (3.2%)

DOES PATI E NT AGE I NFLUE NC E TH E D ECI SIO N TO PLA CE A PULMO NARY ART ERY CAT HETER? Jay S Steingru b, MD , William T McGee, MD .-Critical Care Division, Baystate Medical Center, Springfie ld, MA, and Tuft s University School of Medicin e, Boston, MA; and Peter Callas, PhD .-Biometry, University of Vermont, Burlington , VT Purpose : To describe the effect of age on pulmonary artery catheter (PC) use in patients admitt ed to a multidisciplinary ICU , for severe sepsis, after adjusting for disease severity. Method s: Data was derived from a retro spective analysis of severe sepsis patient s admitted to a multidisciplinary ICU of a 850 bed community teaching hospital du ring 1983-85 and 1989-90. Identification of severe sepsis patient s was similar to the ACCP/SCCM consensus conference definition. Patient s were strati fied by severity of illness using the Mort ality Probab ility Model (MPM) and presence or absence of a pulmonary artery cathete r (PC) within the first 48 hours after lC U admission. A logistic regression techniqu e defined the relationship of PC use, age and illness severity . A p value :5.05 was conside red Significant. Resul ts: In 1989-90, of 132 patient s thcre was no significant difference in the mean age of patients who did or did not receive a PC (6.1 .8 yrs for PC = yes and 63.9 yrs for PC =no), adjusting for severity of illness (p = .213). l n 1989-90, for patients < 40 years old, 6.3.6% received a PC, for ages 40-64, '34.0% received a PC, and for age ;;:65 64.8% received a PC. Adjusting for illness severity, the re was no significant difference in PC use among these age categories (p = 1.0). For 1983-83 (245 patient s), results similarly did not show an association between age and PC use adjusting for severity of illness (p =. 316). PC use in severe sepsis patient s over the age of 65 did not change over the time period examined. 53.7% in 1983-85 and 64.8% in 1989-90 (p = 0.15). Con clusions: (I ) Patient age does not appear to influence the decision to place a pulm onary artery cathe ter in severe sepsis patient s. (2) No change in the frequ ency of PA cath eterization for olde r patient s was observed over time.

96S

Back ground: Previous studies have suggested that women presentin g to hospitals with acute chest pain were less frequently refer red for cardiac catheterization than their male counterpa rts. Method : In this study, we analyzed the impact of gender on rates of referral for cardiac catheterization and coronary revascularization in 3089 consecutive patient s hospitalized because of acute coronary syndromes. Re sults: Fifty-five percen t (1693) of patients were female and 45% (1396) male; 80% were African-American, 10.6% Hispanic, 5.7% white , and 3.6% other. Only 12.2% of patient s were ultimately referre d for cath . Patient s referred for cath were younger (57.6 vs, 61.3 yrs; P< .05), but there were no differences in referr al rates by gender [males (12.5%) and fem ales (11.9%)]. Cathet erization diagnoses of coronary artery disease (CAD) were made in 68% of males and 57% of fema les. Similar rates of single and multivessel discase were observed . Seventy percent of men with CAD and 63% of women with CAD were re ferred for angioplasty or bypass surgery. P value was not statistically significant for the differential referral rate by sex. Conclusion: In our inner city population, despite an overa ll low refer ral rate, there were no race or gender differences in referral rate for cardiac cathete rization and coronary revascularization.

ATR IAL F IBRILLATI ON AFTER BYPASS SURGERY: DOES THE ARRHYTH MIA OR TilE CHARACTERISTICS OF THE PATIE NT S PROLONG HOSPI TAL STAY? Steven Borzak, FCCP , JE Tisdale, NB Amin, AD Goldber g, CR Webb, FC CP, 10 Pahd i, OM Frank, G Jacobsen , G Paone, RSD Higgins, N Silvennan.- Henry Ford Heart and Vascular Institute , Detroit, MI, USA Purpose: Atrial fibrillation follmving CABG surgery (AF) has been associated with prolonged hospital stay. However, AF is more common in elde rly patient s, who may already have a longer stay due to comorbid diseases and slower rehabilitation. We sought to determin e the relative contributions of the arrhythmia and patient characteristics to long hospitalization . Method s: We prospectively studied 436 consecutive patients undergoing isolated CABG at one institution . Re sults: AF developed in 101 (23%). Logistie regression showed that more advanced age was associated with AF developm ent (66:!:9 yrs for AF, 61:!:1O no AF, p
SE DATI ON GUIDELINES F OR VENTILATED PATI E NT S I N ME DICAL I NTE NSI VE CARE: PHYSI CIANS AND NURSES UTILI ZATI O N AND PER CEPTIONS Lori Hoffman-Hogg, MS; L Mion, PhD ; MB Bobek, Phan nD ; A Arroliga MD; J Slomka, PhD; N Bair, MSN; MAtkins, MPA; H Palmer , MD.-The Cleveland Clinic Foundation, Cleveland, OH Purpose: Little is known regardin g physicians' and nur ses' views of clinical guidelines of sedation, analgesia and/o r neuromuscular blocking agent s for ven tilated patient s in MICU. Th is study described and compared MDs' and RNs' rationale, compliance, and perception of guideline effectiveness four month s post implement ation. Abstracts of Original Investigati ons, CHEST 1997-Poster Presentatio ns