Clinics in geriatric medicine
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Thyroid nodules in the elderly are more frequent and more frequently malignant. Fine needle aspiration is the first step to diagnose these type of nodules, and thyroid scans and ultrasounds may be obtained in special cases. Thyroid suppression is frequently not effective in decreasing the size of the nodule and may cause subclinical or clinical thyrotoxicosis. It is not uncommon to discover that what initially was thought to be a solitary nodule is only the dominant nodule of a multinodular goiter.
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Clin. Geriatr. Med. · Aug 1994
ReviewSurrogate decision making. Who will make decisions for me when I can't?
The necessity of surrogate decision making arises for geriatric patients who can no longer make decisions for themselves. Almost every clinical situation involves some assessment of a patient's decisional capacity. Because decisional capacity is decision specific and entails the ability to manipulate information, it is best to conduct functional evaluations and use psychiatric measurements for dementia cautiously in determining decisional capacity. ⋯ These theoretical grounds are supplemented by emerging empirical evidence that elderly patients themselves almost always prefer that family members serve in the role of surrogate decision makers. Dealing with family surrogates obliges the geriatrician to ensure that failures in communication do not arise and that conflicts of interest are avoided in protecting the best interests of the patient. Although recent legal climate has shown a preference for a substituted judgment standard in surrogate decision making, medical concern for the best interests of the patient, together with empirical evidence that the elderly are most interested in decisions that arise out of trusted interdependencies, suggests that rules and laws are no substitute for the good faith human actions of trusted surrogates.
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One important device that has evolved within the legal system for dealing with the problem of cognitively incapacitated individuals and the concomitant need for some form of surrogate decision making on their behalf is guardianship. This article outlines the most salient ethical challenges related to guardianship for clinicians who interact professionally with older persons of diminished capacity and their families. Special attention is devoted to the clinician's role in initiating guardianships, questioning the guardian, in the guardianship proceeding, and evaluating the therapeutic impact of guardianship.
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Clin. Geriatr. Med. · Feb 1994
ReviewApproach to ischemic heart disease, coronary care, and severe heart failure (including cardiogenic shock).
Elderly patients with cardiovascular disease require slightly different management strategies compared with younger patients. Diagnosis is more difficult. ⋯ Decisions regarding these therapies are based on an incomplete data base and an understanding of the patients' needs. A review of the available data on cardiac surgery, angioplasty, myocardial infarction, and heart failure in the elderly is presented.
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Clin. Geriatr. Med. · Feb 1994
Review Comparative StudyNutritional support of the elderly patient in an intensive care unit.
Critically ill elderly patients are at high risk to develop protein-energy malnutrition as well as micronutrient deficiencies. They have characteristic metabolic alterations which must be understood in order to provide nutritional support. Current nutritional status can be assessed by clinical and laboratory parameters. The enteral and parenteral routes of administering nutrition and their advantages, disadvantages, complications, and monitoring are discussed.