Contemporary Geriatric Medicine PDF
Preview Contemporary Geriatric Medicine
Contemporary Geriatric Medicine Volume 2 Contemporary Geriatric Medicine Editor-in-Chief: STEVEN R. GAMBERT • Valhalla, New York Editorial Board EDMUND H. DUTHIE, Jr. • Milwaukee, Wisconsin BRAD M. DWORKIN. Valhalla, New York STEVEN R. GAM BERT • Valhalla, New York STEPHEN C. JACOBS • Milwaukee, Wisconsin FRED G. KANTROWITZ. Boston, Massachusetts DONALD A. MAHLER. Hanover, New Hampshire GABE J . MALETTA • Minneapolis, Minnesota THOMAS W. SHEEHY. Birmingham, Alabama A Continuation Order Plan is available for this series. A continuation order will bring delivery of each new volume immediately upon publication. Volumes are billed only upon actual shipment. For further information please contact the publisher. Contemporary Geriatric Medicine Volume 2 Edited by Steven R. Gambert, M.D., F.A.C.P. Professor oj Medicine Director, Division oj Gerontology and Geriatric Medicine Department oj Medicine and Director, Center jor Aging and Adult Development New York Medical College Valhalla, New York Director oj Geriatrics Westchester County Medical Center and Chief oj Medical Services Ruth Taylor Geriatric and Rehabilitation Institute Valhalla, New York PLENUM MEDICAL BOOK COMPANY NEW YORK AND LONDON The Library of Congress has cataloged the first volume of this title as follows: Contemporary geriatric medicine. - Vol. 1- -New York: Plenum Medical Book Co., c1983- V.: ill.; 24 cm. Biennial. Editor: Steven R. Gambert. ISSN 0748-2760 = Contemporary geriatric medicine. 1. Geriatrics-Periodicals. I. Gambert, Steven R., 1949- [DNLM: 1. Geriatrics-periodicals. WI C0769MPJ] RC952.A1C66 618.97'005-dc19 84-643208 AACR2 MARC-S Library of Congress [8411] ISBN-13: 978-1-4684-5002-6 e-ISBN-13: 978-1-4684-5000-2 DOl: 10.1007 /978-1-4684-5000-2 © 1986 Plenum Publishing Corporation Softcover reprint of the hardcover 1st edition 1986 233 Spring Street, New York, N.Y. 10013 Plenum Medical Book Company is an imprint of Plenum Publishing Corporation All rights reserved No part of this book may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, microfilming, recording, or otherwise, without written permission from the Publisher Contributors DAVID AKMAN, M.D., F.A.C.C. • Assistant Professor of Medicine, Divi sion of Gerontology and Geriatric Medicine, Department of Medicine, New York Medical College; and Director of Cardiology, Ruth Taylor Geriatric and Rehabilitation Institute, Westchester County Medical Center, Valhalla, New York 10595 ZALMEN ARLIN, M.D. • Professor of Medicine, Chief, Division of Neo plastic Diseases, Department of Medicine, New York Medical College; and Westchester County Medical Center, Valhalla, New York 10595 PETER B. BARLOW, M.D. • Associate Professor of Clinical Medicine, Chief, Pulmonary Section, Dartmouth Medical School, Hanover, New Hampshire 03756 DALTON M. BENSON, M.D. • Assistant Professor, Divison of Gerontology and Geriatric Medicine, Department of Medicine, New York Medical Col lege, Valhalla, New York 10595; and Director of Geriatrics and Extended Care, Franklin D. Roosevelt Veterans Administration,Hospital, Montrose, New York 10548 MICHAEL BERGMAN, M.D., F.A.C.P. • Associate Professor of Medicine, Director, Rachmiel Levine Diabetes Center, Department of Medicine, New York Medical College; and Associate Professor of Medicine, Chief, Diabetes Clinic, Westchester County Medical Center, Valhalla, New York 10595 JAMES E. CAULEY, M. D. • Department of Urology, Medical College of Wisconsin, Milwaukee, Wisconsin 53226 EDMUND H. DUTHIE, JR., M.D. • Associate Professor of Medicine, Chief, Section of Geriatrics and Gerontology, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin 53226; and Chief, Nursing v vi CONTRIBUTORS Home Care Unit, Veterans Administration Medical Center, Milwaukee, Wisconsin 53193 BRAD M. DWORKIN, M.D. • Assistant Professor of Medicine, The Sarah C. Upham Section of Gastroenterology, Department of Medicine, N ew York Medical College, Valhalla, New York 10595 MICHAEL L. FRIEDLAND, M.D. • Associate Professor of Medicine, and Senior Associate Dean, Division of Neoplastic Diseases, Department of Medicine, New York Medical College; and Westchester County Medical Center, Valhalla, New York 10595 JAGADEESH C. GADDIPATI, M.D. • Fellow, Medical Oncology, Divi sion of Neoplastic Diseases, Department of Medicine, New York Medical College; and Westchester County Medical Center, Valhalla, New York 10595 STEVEN R. GAMBERT, M.D., F.A.C.P. • Professor of Medicine, Direc tor, Division of Gerontology and Geriatric Medicine, Department of Medi cine, and Director, Center for Aging and Adult Development, New York Medical College; and Director of Geriatrics, Westchester County Medical Center; and Chief of Medical Services, Ruth Taylor Geriatric and Rehabil itation Institute, Valhalla, New York 10595 PAUL A. L. HABER, M.D. • Regional Coordinator for Aging Veterans Ini tiatives, Western Region, Veterans Administration; and Clinical Professor, Department of Family, Community, and Preventive Medicine, Stanford University, Palo Alto, California 94304 STEPHEN C. JACOBS, M.D. • Associate Professor of Urology, Depart ment of Urology, Medical College of Wisconsin, Milwaukee, Wisconsin 53226 LEONARD B. KAMEN, D.O. • Resident, Department of Physical Medicine and Rehabilitation, Temple University Health Sciences Center, Philadel phia, Pennsylvania 19040 SAUL KAMEN, D.D.S., F.A.C.D., F.G.S.A. • Chief of Dental Service, Jewish Institute for Geriatric Care, New Hyde Park, New York 11040; and Professor of Dental Health, School of Dental Medicine, State University of New York at Stony Brook, Stony Brook, New York 11794-8700 FRED G. KANTROWITZ, M.D. • Assistant Professor of Medicine, Harvard Medical School; and Chief, Department of Rheumatology, Beth Israel Hos pital, Boston, Massachusetts 02215 MICHAEL H. KEELAN, JR., M.D. • Professor of Medicine, Section of Car diology, Department of Medicine, Medical College of Wisconsin; and Mil waukee County Medical Center, Milwaukee, Wisconsin 53226 NOEL D. LIST, M.D., M.P.H. • Clinical Associate Professor, Department of Medicine and Preventive Medicine, University of Maryland School of Medicine; and Senior Medical Consultant, Head of the Ethics Committee, State of Maryland Office on Aging, Baltimore, Maryland 21201 CONTRIBUTORS vii DONALD A. MAHLER, M.D. • Associate Professor of Medicine, Director, Pulmonary Function Laboratory, Dartmouth Medical School, Hanover, New Hampshire 03756 GABE J. MALETTA, M.D. • Program Director, Geriatric Research, Edu cation and Clinical Center, Minneapolis Veterans Administration Medical Center; and Departments of Psychiatry and Neurology, University of Min nesota School of Medicine, Minneapolis, Minnesota 55417 GEORGE MUNOZ, M.D. • Clinical and Research Fellow in Medicine, Harvard Medical School; and Department of Rheumatology, Beth Israel Hospital, Boston, Massachusetts 02215 H. WORTH PARKER, M.D. • Assistant Professor of Clinical Medicine, Director, Respirator Therapy, Dartmouth Medical School, Hanover, New Hampshire 03756 WENDEL S. PRICE, M.D. • Fellow, Endocrinology and Metabolism, Department of Medicine, New York Medical College, Valhalla, N ew York 10595 NEAL ROBERTS, M.D. • Clinical and Research Fellow in Medicine, Har vard Medical School; and Department of Rheumatology, Beth Israel Hos pital, Boston, Massachusetts 02215 SAM SCHATTEN, M.D. • Clinical and Research Fellow in Medicine, Har vard Medical School; and Department of Rheumatology, Beth Israel Hos pital, Boston, Massachusetts 02215 TIMOTHY B. SEATON, M.D. • Assistant Professor of Medicine, Associate Director, Rachmiel Levine Diabetes Center, Department of Medicine, New York Medical College; and Assistant Attending Physician, Westchester County Medical Center, Valhalla, New York 10595 THOMAS W. SHEEHY, M.D. • Chief of Medicine, Birmingham Veterans Administration Medical Center; and Professor of Medicine, University of Alabama in Birmingham, School of Medicine, Birmingham, Alabama 35233 STEVE STERN, M.D. • Clinical and Research Fellow in Medicine, Har vard Medical School; and Department of Rheumatology, Beth Israel Hos pital, Boston, Massachusetts 02215 REIN TIDEIKSAAR, P.A., Ph.D. • Co-Director, Falls and Immobility Pro gram, Department of Geriatrics and Adult Development, Mount Sinai Med ical Center, New York, New York 10029 PANAYIOTIS D. TSITOURAS, M.D. • Director of Medicine and Geron tology, Coler Memorial Hospital, Roosevelt Island, New York, New York 10044; and Associate Professor of Medicine, Assistant Director, Center for Aging and Adult Development, N ew York Medical College, Valhalla, New York 10595 Preface In the last two years, a wealth of new information has accumulated regarding both clinical and research aspects of health care for the elderly. Although many controversial issues have been resolved, many still remain. Volume 2 of Contemporary Geriatric Medicine is once again dedicated to the clinician who cares for the elderly on a continuing basis. Although, for the most part, general topics first introduced in Volume 1 have been retained, all infor mation in this volume is new and represents the current state of the art. In addi tion, several new topics-including falls, interpretation of laboratory data, and oral health care-have been introduced to enhance this volume's usefulness to the busy clinician. Through these easy-to-read essays, we attempt once again to keep the non geriatrician abreast of the current state of the art regarding the special needs and problems of the elderly. Each chapter is not meant to be an exhaustive review of all topics in the field, but rather to focus on issues receiving a great deal of atten tion. Our goal is to create an exciting approach to contemporary issues in gerIatric medicine. The editors are once again appreciative of the opportunity given to develop the Contemporary Geriatric Medicine series. Appreciation is also given to our secretaries, our professional colleagues, and our families, who have supported our efforts and helped bear the burden of this time-consuming venture. Most of all, we thank our elderly patients for providing the inspiration and impetus to improve our understanding and knowledge of the health care needs of the elderly. Steven R. Gambert Valhalla, New York ix Contents Chapter 1 Geriatric Cardiology and Blood Pressure Edmund H. Duthie, Jr., and Michael H. Keelan, Jr. 1.1. Cardiovascular Morbidity-Mortality. . . . . . . . . . . . . . . . . . . . . . . . 1 1.2. Cardiovascular Anatomy and Physiology. . . . . . . . . . . . . . . . . . . . . 2 1.2.1. Anatomic Changes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 1.2.2. Intrinsic Cardiac Function. . . . . . . . . . . . . . . . . . . . . . . . . 2 1.2.3. Autonomic Reflexes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 1.2.4. Pulse Wave Characteristics . . . . . . . . . . . . . . . . . . . . . . . . 3 1.3. Clinical Evaluation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 1.4. Laboratory Investigations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 1.4.1. Electrocardiogram. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 1.4.2. Exercise Electrocardiography. . . . . . . . . . . . . . . . . . . . . . . 6 1.4.3. Nuclear Cardiology .............................. 6 1.4.4. Echocardiography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 1.4.5. Ambulatory Electrocardiography. . . . . . . . . . . . . . . . . . . . 8 1.4.6. Computerized Tomography. . . . . . . . . . . . . . . . . . . . . . . . 8 1.4.7. Invasive Procedures .............................. 8 1.4.7.1. Catheterization and Angiography. . . . . . . . . . . . 8 1.4.7.2. Electrophysiology........................ 9 1.5. Coronary Artery Disease ................................. 9 1.5.1. Presentation and Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . 9 1.5.2. Therapy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 1.5.2.1. Nitrates................................ 10 xi xii CONTENTS 1.5.2.2. Beta-Blockers........................... 10 1.5.2.3. Calcium Channel Blockers. . . . . . . . . . . . . . . . . 11 1.5.2.4. Antiplatelet Agents. . . . . . . . . . . . . . . . . . . . . . . 12 1.5.3. Unstable Angina. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 1.5.4. Myocardial Infarction. . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 1.5.5. Angioplasty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 1.5.6. Coronary Artery Surgery. . . . . . . . . . . . . . . . . . . . . . . . . . 14 1.6. Congestive Heart Failure. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 1.6.1. Amyloidosis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 1.6.2. Hypertrophic Cardiomyopathy ..... . . . . . . . . . . . . . . . . 15 1.6.3. Thyroid Disease. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 1. 7. Dissection of the Aorta . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 1. 7.1. Diagnosis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 1.7 .2. Therapy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 1.8. Valvular Heart Disease .................................. 17 1.8.1. Aortic Valve Disease ............................. 17 1.8.2. Mitral Valve Disease. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 1.8.3. Endocarditis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20 1.8.4. Valve Surgery. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20 1.9. Atrial Septal Defect. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21 1.10. Syncope............................................... 21 1.10.1. Heart Block .............................. 21 1.10.2. Sick Sinus Syndrome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22 1.10.3. Ventricular Arrhythmias. . . . . . . . . . . . . . . . . . . . . . . . . . 22 1.10.4. Diagnosis and Treatment of Problem Cases . . . . . . . . . . . 22 1.11. Cardiovascular Pharmacology. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 1.11.1. Digoxin........................................ 23 1.11.2. Antiarrhythmics................................. 24 1.11.3. Vasodilators.................................... 24 1.12. Preoperative Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 1.13. Blood Pressure and Aging. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 1.13.1. Blood Pressure: Determinants and Effects of Age. . . . . . . 27 1.13.1.1. Cardiac Influences ...................... 27 1.13.1.2. Neurohumoral Influences. . . . . . . . . . . . . . . . . 28 1.13.2. Population Studies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29 1.13.3. Hypertension: Definition . . . . . . . . . . . . . . . . . . . . . . . . . . 29 1.13.4. Approach to the Patient. . . . . . . . . . . . . . . . . . . . . . . . . . . 30 1.13.4.1. History............................... 30 1.13.4.2. Physical Examination. . . . . . . . . . . . . . . . . . . . 30 1.13.4.3. Laboratory Evaluation . . . . . . . . . . . . . . . . . . . 31 1.13.5. Essential Hypertension in the Aged. . . . . . . . . . . . . . . . . . 33 1.13.6. Therapeutic Decision Making. . . . . . . . . . . . . . . . . . . . . . 34 1.13.6.1. Systolic Hypertension. . . . . . . . . . . . . . . . . . . . 34 1.13.6.2. Combined Systolic Diastolic Hypertension ... 35
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