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Objectives: To study whether geriatric patients with mild-to-moderate hyponatremia (≤131 mmol/l) reveal different outcomes in structured tests for functional and cognitive impairments, depression and malnutrition compared to normonatremic patients., Design: Single-center, retrospective case control study., Setting: The study was conducted in a Geriatric Evaluation and Management Unit of a Department for Geriatrics and Internal Medicine., Methods and Participants: We included 2,880 elderly patients (75.6% female, mean age 78.6 ± 6.98 years), consecutively admitted to the GEMU primarily or from another hospital or emergency department. Results were compared between a group of 129 patients with mild-to-moderate hyponatremia (118-131 mmol/l) and an age- and sex-matched control group of 129 patients with normal serum sodium values (>135 mmol/l). To assess functional and cognitive status, depression and malnutrition we used standardized tests of a geriatric assessment., Results: 16.7% (n = 477) of the total 2,880 patients were hyponatremic (≤135 mmol/l), 4.5% (n = 129) revealed moderate hyponatremia. Compared to the control group, these patients had significantly worse results in all tests of the Geriatric Assessment, including Activities of Daily Living, Mini Mental State Examination, Clock Completion Test, Geriatric Depression Score, Tinetti Mobility Test and the Timed Up&Go Test and the Mini Nutritional Assessment. Comorbidities were assessed by the Charlson Comorbidity Index and the Cumulative Illness Rating Scale with no significant difference between the two groups. The hyponatremic patients received significantly more medications than the normonatremic control group, but we could not find a significant difference with respect to the use of a distinct single drug therapy., Conclusion: We were able to demonstrate that geriatric patients with mild-to-moderate hyponatremia revealed a significantly worse outcome in all standardized tests of the geriatric assessment compared to a normonatremic control group. Serum sodium levels should therefore be considered when interpreting common tests of geriatric assessment., (Copyright © 2012 S. Karger AG, Basel.)

Background: We studied the characteristics and resource utilization of patients with syncope in a German emergency department (ED)., Methods: We carried out a single-center retrospective analysis of patients with syncope who presented to the ED of the Klinikum Nürnberg (a municipal hospital in Nuremberg, Germany)., Results: Among the 28 477 patients who presented to the ED from 15 May 2009 to 30 September 2009, 440 (1.5%) presented with syncope. Their mean age was 62 years (standard deviation, 20 years); 50.4% were women, 43.4% were over age 70, 11.8% had cardiogenic and 4.8% neurological syncope, and 18.2% had more than two comorbid conditions. 20.7% were discharged after evaluation in the ED, 14.1% were brielfly hospitalized in the ED's clinical observation unit, and 56.6% were admitted to one of the hospital's specialty wards. 8.6% left the ED against medical advice. All of the syncope patients were evaluated by history-taking, physical examination, and 12-lead electrocardiogragraphy (ECG); ECG revealed abnormal findings in 36.4% of patients. Nearly all patients also underwent laboratory testing, which revealed hyponatremia (a serum sodium concentration under 130 mmol/L) in 5.9% and a serum creatinine level above 2 mg/dL in 5.3%. Many underwent technology-intensive tests such as cranial computed tomography (129 patients), but these tests only rarely yielded abnormal findings (3.1%). 27% of the syncope patients underwent Doppler ultrasonography of the vessels supplying the brain, with abnormal findings in 6.7% of cases. (Orthostatic testing was performed in 14.5% of the patients and was positive in 26.6%.), Conclusion: Many patients presenting with syncope to a German ED are elderly, and multiple comorbidities are common. Technology-intensive testing in patients with syncope has a low diagnostic yield and consumes resources. The introduction of standards for the evaluation of syncope in the ED would be helpful.

Evaluating patients with acute chest pain presenting to the emergency department remains an ongoing challenge. The spectrum of etiologies in acute chest pain ranges from minor disease entities to life-threatening diseases, such as pulmonary embolism, acute aortic dissection or acute myocardial infarction (MI). The diagnosis of acute MI is usually made integrating the triad of patient history and clinical presentation, readings of 12-lead ECG and measurement of cardiac troponins (cTn). Introduction of high-sensitivity cTn assays substantially increases sensitivity to identify patients with acute MI even at the time of presentation to the emergency department at the cost of specificity. However, the proportion of patients presenting with cTn positive, non-vascular cardiac chest pain triples with the implementation of new sensitive cTn assays increasing the difficulty for the emergency physician to identify those patients who are at need for invasive diagnostics. The main objectives of this mini-review are 1) to discuss elements of disposition decision made by the emergency physician for the evaluation of chest pain patients, 2) to summarize recent advances in assay technology and relate these findings into the clinical context, and 3) to discuss possible consequences for the clinical work and suggest an algorithm for the clinical evaluation of chest pain patients in the emergency department.

Background: Expenditure on health-care is increasing over the last years and the demographic shift leads to more elderly patients in the health-care system. Debates about the financial situation and solution about this topic are common. Direct, as well as hidden, rationing is verified by experts. This article discusses the concept of age-dependent prioritization and rationing of health-care expenditures in a cross-national setting., Methods: With a standardised questionnaire geriatric physicians in Germany and Austria were asked about their attitude and experience with health-care expenditures in elderly patients. Dimension of medical staff, organising institution and financial resources were also evaluated. The sample was tested with t-test, Mann-Whitney-U-test and explorative factor analysis. All the data were calculated with PASW 17 Statistics(®)., Results: From 419 standardised questionnaires 288 forms (60%, Germany: 123, Austria: 165) were evaluated. Differences were shown in patient-age (Germany: 80.4 y, Austria: 71.8 y), carrying capacity (Germany: 74.8, Austria: 110.8) and in medical staff as physicians (Germany: 6.8, Austria: 12.7) and nursing (Germany: 32.2, Austria: 84.3). In infrastructural basic services and normative focusing there was only marginal discrepancy, the public/ecclesiastical organising institution was 71% in both countries. Related to the different financial systems, there was less cost pressure in taking care of elderly patients in Austria., Conclusion: Age-dependent rationing was approved, but there was also a clear endorsement for making resources available for elderly patients in future. The discussion about rationing of health-care expenditures will still go on and therefore the impact of ageism has to be evaluated in further studies.

Community-acquired pneumonia (CAP) is a common infectious disease that still causes substantial morbidity and mortality. Elderly people are frequently affected, and several issues related to care of this condition in the elderly have to be considered. This article reviews current recommendations of guidelines with a special focus on aspects of the care of elderly patients with CAP. The most common pathogen in CAP is still Streptococcus pneumoniae, followed by other pathogens such as Haemophilus influenzae, Mycoplasma pneumoniae, Chlamydophila pneumoniae and Legionella species. Antimicrobial resistance is an increasing problem, especially with regard to macrolide-resistant S. pneumoniae and fluoroquinolone-resistant strains. With regard to β-lactam antibacterials, resistance by H. influenzae and Moraxella catarrhalis is important, as is the emergence of multidrug-resistant Staphylococcus aureus. The main management decisions should be guided by the severity of disease, which can be assessed by validated clinical risk scores such as CURB-65, a tool for measuring the severity of pneumonia based on assessment of confusion, serum urea, respiratory rate and blood pressure in patients aged ≥65 years. For the treatment of low-risk pneumonia, an aminopenicillin such as amoxicillin with or without a β-lactamase inhibitor is frequently recommended. Monotherapy with macrolides is also possible, although macrolide resistance is of concern. When predisposing factors for special pathogens are present, a β-lactam antibacterial combined with a β-lactamase inhibitor, or the combination of a β-lactam antibacterial, a β-lactamase inhibitor and a macrolide, may be warranted. If possible, patients who have undergone previous antibacterial therapy should receive drug classes not previously used. For hospitalized patients with non-severe pneumonia, a common recommendation is empirical antibacterial therapy with an aminopenicillin in combination with a β-lactamase inhibitor, or with fluoroquinolone monotherapy. With proven Legionella pneumonia, a combination of β-lactams with a fluoroquinolone or a macrolide is beneficial. In severe pneumonia, ureidopenicillins with β-lactamase inhibitors, broad-spectrum cephalosporins, macrolides and fluoroquinolones are used. A combination of a broad-spectrum β-lactam antibacterial (e.g. cefotaxime or ceftriaxone), piperacillin/tazobactam and a macrolide is mostly recommended. In patients with a predisposition for Pseudomonas aeruginosa, a combination of piperacillin/tazobactam, cefepime, imipenem or meropenem and levofloxacin or ciprofloxacin is frequently used. Treatment duration of more than 7 days is not generally recommended, except for proven infections with P. aeruginosa, for which 15 days of treatment appears to be appropriate. Further care issues in all hospitalized patients are timely administration of antibacterials, oxygen supply in case of hypoxaemia, and fluid management and dose adjustments according to kidney function. The management of elderly patients with CAP is a challenge. Shifts in antimicrobial resistance and the availability of new antibacterials will change future clinical practice. Studies investigating new methods to detect pathogens, determine the optimal antimicrobial regimen and clarify the duration of treatment may assist in further optimizing the management of elderly patients with CAP.

From 2008 to the end of 2009 the Joint Poison Information Center (PIC) in Erfurt observed 7 incidents involving 17 persons (1 fatality) with signs of carbon monoxide poisoning from indoor barbecues (COFIB). To find out whether COFIB is a regional or a general phenomenon in Germany, Austria and Switzerland, all information about COFIBs recorded by the 11 German-speaking Poison Information Centers and the BfR Berlin were retrospectively analyzed for the period 2000 to 2009. In all, 60 COFIBs (accidental: 90.0 %, suicidal: 8.3%, reason unknown: 1.7%) involving 146 individuals were reported. The number of incidents increased from one case with 2 persons in 2000 to 18 cases involving 34 persons in 2009. The 146 victims (female 26.7%, male 27.4%, gender unknown 45.9%; adults 58.2%, children 24.7%, age unknown 17.1%) lived in 15 of the 16 federal states of Germany and in Switzerland. The highest number of victims was found in Bavaria (23), Brandenburg (18), and Baden-Wuerttemberg (18). The symptoms according to the Poisoning Severity Score were none to mild in 60.3%, moderate in 13.7%, severe in 11.6%, fatal in 6.9% and unratable in 7.5%. No clear correlation was found between the carboxyhemoglobin concentration and the severity of the symptoms. As a rising number of COFIBs often involving several individuals was observed from 2000 to 2009, the general public was informed about the risks of indoor barbecues.

Frailty, as a geriatric syndrome, is characterised by the increased vulnerability of the elderly person to internal and especially external stressors. The aim of laboratory diagnostics in the context of the concept of frailty is to record the conditions which encourage the development of frailty, in order to improve these conditions through individual measures or to avoid them for the purpose of preventing frailty. After a presentation of the features of laboratory diagnostics in old age, this article examines haematological aspects, the importance of an adequate vitamin supply, particularly of vitamin D and the adequate description of endocrine functions.

Background: increasingly, markers of systemic inflammation like C-reactive protein (CRP) levels and white blood count (WBC) are being used for assessing the prognosis of patients with community-acquired pneumonia (CAP). However, their predictive value has not been validated in populations of elderly patients., Objective: to evaluate the prognostic value of CRP and WBC in comparison with the CURB score and the pneumonia severity index (PSI) in elderly, hospitalised patients with CAP., Methods: the charts of all patients, aged 65 years and older, who were consecutively admitted to the Department of Geriatrics, Marienhospital Herne, Germany, for treatment of CAP between January 2001 and September 2005, were reviewed. CRP, WBC, CURB and PSI were analysed in relation to 30-day mortality., Results: in a total of 391 patients, median age 80 years, no association was found between CRP or WBC and mortality. In contrast, the CURB score and PSI were significantly associated with mortality and treatment in the intensive care unit (ICU)., Conclusion: in elderly, hospitalised patients with CAP, admission CRP and WBC are not predictors of the prognosis.

The presence of chronic obstructive pulmonary disease (COPD) is an important risk factor for cardiovascular comorbidity. Of note, cardiovascular diseases such as myocardial infarction or heart failure are - aside pulmonary cancer - the main reasons for the high morbidity and mortality in COPD patients. Heart failure is present in 20 - 30 % of COPD patients, but remains often under- or misdiagnosed. Subsequently, recommended treatment of heart failure in affected COPD patients could be improved. The difficulty in the diagnosis of heart failure related dyspnea in patients with known pulmonary disease is due to the lacking specificity of signs and symptoms for the diagnosis of cardiac or non-cardiac dyspnea. Thus, it is very important to consider a cardiovascular comorbidity in all COPD patients. Measurement of natriuretic peptides are extremely helpful to support the differentialdiagnosis of acute dyspnea in COPD patients in the emergency department. Using cut-off values of 100 pg/mL B-type natriuretic peptide (BNP) or 300 pg/mL N-terminal-proBNP have a high negative predictive value to exclude the presence of heart failure in COPD patients with acute dyspnea. Interpretation of plasma natriuretic peptide levels alone is not sufficient to "rule in" the diagnosis of left ventricular dysfunction in COPD patients. "Rule in" of the diagnosis of heart failure should therefore include the interpretation of patient history, physical and technical examinations such as echocardiography. In summary, measurement of natriuretic peptide levels in dyspneic patients with known pulmonary disease are helpful to exclude or support the diagnosis of heart failure related dyspnea.

Frailty associated functional changes in the elderly lead to different problems treating geriatric patients in an intensive care unit. Patients suffering from frailty have less physiological reserves in acute illness, complications are more frequent and recovery is clearly delayed. Frailty is also an established and independent predictor for mortality. Therefore understanding of physiological ageing and knowledge of geriatric syndromes must be part of modern intensive care medicine. The importance of Frailty for intensive care is shown by means of selected clinical pattern.

Frailty is a complex term and has a broad influence on the elderly patients. For evaluating the monetary impact of frailty it is necessary to approach in a differentiated way. It is of great interest to discover the relevance of multidisciplinary assessment and accordant preventive actions. In this article the costs of osteoporosis and (hip) fractures are briefly presented.