Clinics in geriatric medicine
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Depression, anxiety and delirium are relatively common during the final stages of terminal disease, and each can profoundly impact the quality of those last days for both patient and involved family. In this article the authors review the assessment and treatment of each syndrome in the context of palliative care for older adults. ⋯ Finally, caregivers of dying patients are vulnerable to stress, depression, grief, and complicated bereavement. Interventions for caregivers who are debilitated by these states are briefly summarized.
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Tamoxifen is useful for adjuvant treatment of breast cancer and in some women for the prevention of breast cancer. The risk-benefit ratio in regard to the skeleton and perhaps other organ systems may very well be different for postmenopausal versus premenopausal women. In postmenopausal women, tamoxifen (20 mg/d) increased BMD in the spine and perhaps the hip; however, the effect on fracture risk is unclear. ⋯ Therefore, women who take raloxifene can expect a reduction in the likelihood of having a vertebral fracture, and possibly breast cancer. The lack of definitive efficacy against hip fracture is not a major deterrent to use of this agent in this age group because hip fracture risk is very low. Raloxifene might not be the treatment of choice for elderly women who are at particularly high risk of hip fracture.
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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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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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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.