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| ABSTRACTS GERICON-2021 |
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| Year : 2021 | Volume
: 17
| Issue : 4 | Page : 120-125 |
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POSTER PRESENTATION
| Date of Web Publication | 21-Dec-2021 |
Correspondence Address:
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/0974-3405.332860
How to cite this article:
. POSTER PRESENTATION. J Indian Acad Geriatr 2021;17:120-5 |
| Comparision of Clinical Presentation Across Select age Groups, Elderly Compared with Young with Novel SARS Covid 19 Infection. A Retrospective Hospital Based Cohort Study from a Tertiary Care Hospital in Kerala | |  |
Niveda Srivatsa, Alex Baby Paul, Priya Vijayakumar, George Paul
Department of Geriatrics, Amrita Institute of Medical Science and Research, Kochi, Kerala, India
Background: Severe acute respiratory syndrome corona virus 2 (SARS-COV-2 ) Pandemic affected the entire world since 2019. India being one among the worst affected nation with the pandemic. Clinical presentation of covid 19 is multifaceted and variable. This study was done to identify the difference in clinical presetations in elderly compared with other age groups.
Objective: To study about differences in clinical presentation elderly patients and other age groups affected with COVID-19 infection.
Methods: Retrospective study was conducted. Data of 330 patients diagnosed and treated with COVID-19 infection were analyzed for a period of two months in the defined time period. Patients were grouped into two categories. Patients above the age of 65 diagnosed and treated for COVID 19 was included as Elderly group and the rest of the patients were in control group was considered as young. The co morbidities and clinical outcome among both groups were analyzed.
Results: Total 330 individuals were analysed 263 patients were below the age of 65 and 67 were older individuals. 30% of older individual presented with cough, 27% had breathing difficulty, 3% had bodyache. When compared to younger individual these symptoms were statistically significant with p <0.001. Severity of the infection was more in the elderly age group. In patients less than 65 years 88% were asymptomatic compared to elderly age group.
Conclusion: In the current study it was evident that elderly patients presented more with symptoms. Younger patients were predominantly asymptomatic. Duration of illness were longer in elderly. It is also evident that more severe infection presents in the elderly who already have underlying various co morbidities. Clinicians and Geriatricians should emphasize on meticulous care in elderly age group with SARS COVID 19 infection.
| Clinical Profile of Older Adults Admitted with Acute Pyelonephritis in a Tertiary Care Hospital | | |
Niger David, Benny Paul Wilson
Department of Geriatrics, Christian Medical College, Vellore, Tamil Nadu, India
Objective: To study the clinical profile of older adults admitted with acute pyelonephritis in a tertiary care hospital.
Methods: This is a retrospective study in which we enrolled elderly adults admitted with acute pyelonephritis from 1st November 2018 to 31st October 2019 using the tertiary hospital database. All patients admitted under Department of Geriatrics with a diagnosis of Acute pyelonephritis were enrolled and the clinical details were collected for analysis.
Results: There was a total of 1256 admissions under Department of Geriatrics, out of which 94 (7.5%) were admitted with Acute Pyelonephritis. The mean age was 75.4 and the average duration of hospital stay was 9.6 days. The most common presenting complaints were urinary symptoms (83%) followed by fever (73.4%) and delirium (41.4%). 6 (6.4%) patients presented with delirium but had neither fever nor urinary symptoms. The most common bacteria causing the infection was E. coli (64/94; 68.1%) followed by Klebsiella (12/94; 12.8%). Out of the positive urine cultures, 53 (56.4%) were ESBL resistant strains and 24 (25.5%) had bacteremia. The most common empirical antibiotic started was Meropenem (43/94; 45.7%) followed by Piperacillin-Tazobactam (40/94; 42.5%). The mortality rate in hospital was 12.7% (12/94).
Conclusion: This retrospective study showed that there was significant mortality associated with acute pyelonephritis in the older adults. The presentation of UTI in the older adults may not be typical and may present with just delirium. The emergence of drug resistant E. coli was evident in this study.
| Evaluation of Nutritional Status in Elderly Population | | |
Bhim Rao Bose, G. Usha, K. Uma Kalyani
Department of Geriatrics, Madras Medical College, Chennai, Tamil Nadu, India
Introduction: Malnutri+on is a frequent and serious problem in geriatric pa+ents. Malnutri+on in elderly is one of the most common overlooked problem in hospitals, nursing homes, and home care. Different studies have suggested that malnutri+on is an important predictor of morbidity and mortality in the elderly. The Mini-Nutri+onal Assessment (MNA) is a simple clinical scale for the screening of the nutri+onal status of elderly. By identifying older persons who are malnourished or at risk of malnutrition either in the hospital or community setting, the Mini-Nutri+onal Assessment allows clinicians to intervene earlier to provide adequate nutritional support, prevent further deterioration, and improve patient outcomes.
Aim: To estimate the prevalence of malnutrition in the elderly population aged 60 and above attending the out patient of geriatric medicine in Rajiv Gandhi Government general hospital.
Materials and Methods: A cross-sectional study was conducted and data collected from 100 elderly patients aged 60 and above by simple random sampling in the outpatient Department of Geriatrics at Rajiv Gandhi Government General Hospital ,Chennai using semi-structured questionnaire after obtaining their consent. Patients with cognitive impairment, aphasia and severe hearing loss were excluded from the study. Out of 100 participants 76 were male and 24 were female. The mean age group was 67.
The mini nutri+onal assessment test is composed of simple measurements and brief ques+ons that can be completed in less than 10 min Anthropometric measurements (weight, height, and weight loss).
- Global assessment (six ques+ons related to lifestyle, medica+on, and mobility)
- Dietary ques+onnaire (eight ques+ons, related to number of meals, food and fluid intake, and autonomy of feeding)
- Subjec+ve assessment (self-percep+on of health and nutri+on)
Malnutrition Indicator Score: 24 to 30 points - Normal nutritional status 17 to 23.5 points - At risk of malnutrition Less than 17 points – Malnourished.
Results: From the above study the 20% (n=20) of patients are found to be malnourished, 50% (n=50) are found to be at risk of malnutrition and 30% (n=30) are found to be of normal nutritional status.
Conclusion: Mini nutritional assessment allows physicians and health professionals to make rapid and reliable evaluation of the nutritional status of elderly, to recognise those with at risk of malnutrition and take appropriate steps to prevent development of malnutrition , which is associated with increased risk if morbidity.
| Clinical Profile of Urinary Retention among Admitted Older Persons - A Retrospective Observational Study Conducted in a Tertiary Care Hospital in South India | | |
R. Bharathi, Benny Paul Wilson
Department of Geriatrics, Christian Medical College, Vellore, Tamil Nadu, India
Introduction: Urinary retention can be defined as acute or chronic inability to voluntarily pass an adequate amount of urine on experiencing a sensation to micturate from the bladder. It is one of the most frequent problem encountered in our elderly population, more common in males. The etiology of urinary retention may be diverse and based on multiple factors.
Objectives: To study the clinical spectrum of acute and chronic urinary retention and their clinical outcome in geriatric population.
Methodology: Retrospective observational study of all the patients diagnosed with urinary retention of both acute and chronic from April 2018 to April 2020 at the time of admission and during hospital stay, using electronic medical records, from Christian Medical College and Hospital, Vellore.
Observation: There was a total of 2175 admissions under Department of Geriatrics, in which 50(2.2%) patients diagnosed with urinary retention. Out of 50 patients, 36(72%) were males and 14(28%) were females. The most common presenting complaints were inability to pass urine (75%), followed by delirium (55%) and urinary symptoms (30%). The most common risk factors associated with urinary retention are diabetes mellitus(62%), Benign prostatic hypertrophy(52%), constipation(44%) , anticholinergic drugs(26%), diabetic cystopathy (autonomic neuropathy)(22%) and neurodegenerative disorders(20%). 48% of them had associated urinary tract infection and 30% of them had renal disease (acute or chronic kidney disease) and hydroureteronephrosis was observed in 16% of the patients. 56% patients had painless urinary retention compared to painful retention(36%).All the patients were given a trial of voiding of which 25( 50%) patients failed and they were on Continuous Bladder Drainage (CBD).14( 28%) of them got readmitted, while 6(12%) died.
Conclusion: Urinary retention is more common in elderly, especially in males. Identification of risk factors associated with urinary retention at the earliest is important in order to avoid urinary tract infection and renal failure.
| A Case of Drug Induced SIADH | | |
O. A. Nabil Fayas, G. Usha, Uma Kalyani
Department of Geriatric Medicine, MMC and RGGGH, Chennai, Tamil Nadu, India
Introduction: Severe Hyponatremia is one of the rare side effect of NSAIDs. Nausea and Generalised Malaise may be the initial symptoms in patients with Mild hyponatremia. However, serious CNS symptoms like Headache, Lethargy, Altered sensorium, seizures and coma can occur if the Sr. Na falls below 115 mEq/L. The above mentioned complications due to hyponatremia can be induced by NSAIDs like Indomethacin, Diclofenac, Ibuprofen, Meloxicam etc.
Case Report: A 60 years old Male, known Diabetic and Hypertensive presented to Geriatric Medicine OPD with complaints of Giddiness, Hiccups, Altered sensorium and vomiting for 3 days duration. No H/O Fever, cough, Expectoration, Chest / Abdominal Pain, Vomiting, Loose stools. Patient had h/o frequent use of over the counter analgesic medication – Ibuprofen 400 mg 3-4 days / week for 4 Years duration for Malaise and chronic back ache. (Daily dosing for past 5 months due to increased pain intensity). Not a known Smoker or Alcoholic. On initial Examination, Patient Conscious, confused, Afebrile, Not Dyspneic, No Pallor, No Pedal Edema, Euvolemic, Hydration – Fair. Vitals – stable, System examination – CVS – S1 S2 +, RS – NVBS +, P/A – Soft, No Organomegaly, CNS – B/L PERL +, EOM – Full, Cranial Nerves – NAD, Tandem walking impaired, Romberg's sign – Positive. Investigation revealed severe hyponatremia, hence work up initiated for the same & found to have Euvolemic Hyponatremia. Further analgesic intake was withheld, treated with Free water Restriction, 3% Hypertonic Saline, OHAs, Antihypertensives, Antiemetics & Ulcer protectives. Pt's clinical condition and Sr. Sodium levels improved day by day & the patient became symptomatically better in 5 days. Patient was discharged in hemodynamically stable condition, advised Fluid Restriction, to avoid over the counter Analgesics and to continue OHAs & Antihypertensives. Follow up done after 2 weeks during which Patient was clinically better along with normal Sr.Na levels.
Investigations: Urea – 19, Creatinine – 0.5, Sr.Na – 106 (Repeat sample sent for reverification – 102), Sr.K – 3.4, Uric Acid – 1.2, Calcium – 8.9, Urine Routine –Normal, Urine PCR – 0.12, Urine Na – 64, Urine Osmolality – 290 mOsm/kg, Urine Culture – No growth, Blood Culture – No growth, Viral Markers (HIV, HbSAg, HCV) – Negative, RBS – 220, FBS – 186, PPBS – 279 (Repeat FBS – 84, PPBS – 162) ,CBC, RFT, LFT, ABG, Lipid Profile, TFT & Sr. Cortisol – WNL. Normal ECG & Echocardiography, USG abdomen and pelvis – Normal Study. CXR & CT Chest – Normal study. CT brain showed Age related cortical changes & Encephalomalacic changes (softening) in Right Temporal lobe.
Conclusion: A diagnosis of NSAID induced SIADH is made after the criteria for SIADH is met & other causes of SIADH & Euvolemic Hyponatremia are ruled out. Even though, limited literatures are availabe for NSAID induced Hyponatremia, this diagnosis should also be kept in mind in patients presenting with Euvolemic Hyponatremia with history of chronic NSAIDs use. Since NSAIDs are frequently used by older population, a proper medication review is essential during hospital admission, because discontinuing the medication is the first step in management of Drug induced Hyponatremia.
| Spontaneous Muscle Hematoma Complicating Dengue Hemorrhagic Fever | | |
M. S. Jegan, Subramaniyan
Government Villupuram Medical College Hospital, Madurai, Tamil Nadu, India
Introduction: Dengue fever is a common infection with increasing numbers of patients affected. Its clinical manifestations are wide spectrum, may present as mild fever to shock. Muscle hematomas are a rare complication of dengue fever.
Case Presentation: We report a case of 37-year-old male with dengue hemorrhagic fever who developed right sided iliacus muscle hematoma. He presented with fever, progressive thrombocytopenia. He was treated with intravenous fluid and supportive measures. He gradually improved. During the recovery phase, he developed severe pain in right hip on movement. Diagnosis was confirmed by pelvic computed-tomography scan. He was managed conservatively.
Conclusions: Dengue fever is a common tropical infection. Recognizing serious complications such as iliacus haematoma presenting as simple complaints such as hip pain and inguinal pain are important to prevent mortality.
| Gemcitabine Induced Hemolytic Uremic Syndrome in Lung Cancer | | |
Prashant Ahlawat, Monica Gupta, Prateek Upadhyay1
Department of General Medicine, Government Medical College and Hospital, Chandigarh, India, 1Department of Anesthesia and Intensive Care
Objective: A case of Gemcitabine induced hemolytic uremic syndrome (HUS) in lung cancer patient.
Materials and Methods: A 65-year-old male, known case of lung carcinoma who was being managed on gemcitabine and carboplatin noticed pedal oedema which was gradually progressive and associated decreased urine output after completion of 5th cycle of chemotherapy. He presented with shortness of breath. Blood investigations revealed thrombocytopenia with peripheral blood smear showing schistocytes and fragmented red blood cells. He was investigated further to rule out other causes of HUS. A thorough review of literature on gemcitabine induced HUS reviewed which made the possibility of HUS induced by gemcitabine unveil to us. Hence, the patient was managed with plasmapheresis and haemodialysis.
Results: On plasmapheresis his urine output and renal functions showed improving trend.
Conclusion: The outcome of gemcitabine induced HUS is poor and has high mortality rate. This case describes the HUS caused by gemcitabine in lung carcinoma patient undergoing chemotherapy and the due unheeded attention it deserved to be given.
| A Case of Primary Adrenal Insufficiency in Elderly | | |
P. Dinesh Kumar, Thangam, G. S. Shanthi
Department of Geriatric Medicine, MMC and RGGGH, Chennai, Tamil Nadu, India
Introduction: Adrenal insufficiency is an acute life-threatening emergency in any age group, more so in elderly contributing to the excess mortality. The incidence of adrenal crisis is 6.3 per 100 patient-years, with reports of increased risk of adrenal crisis in elderly with no difference between males and females.
Case Report: A 78 year old male a K/C/O T2DM, systemic hypertension developed left hemi paresis 1 week after covid vaccination. He was admitted in a private hospital and treated for left capsuloganglionic infarct. Patient developed cough and dyspnea 3 weeks later and found to be covid RTPCR positive. He was referred in to RGGGH for admission considering age and co morbidities. His CT severity score as 11/25, he was treated with Oxygen, steroids, anticoagulants, Remdesvir. After 21 days of admission repeat covid swab was negative, Since patient had recurrent hyponatremia, hypotension, anorexia and diarrhea patient was transferred to Geriatric ward.
O/E patient was in Delirium with CAM score of 4/4, dehydrated, febrile (Temp-99F), tachycardic, hypotensive (BP 80/50 mmHg), hypoglycemic (47 mg/dL).He had urinary catheter insitu which was draining cloudy urine. Initial diagnosis of Urosepsis, Septic shock (qSOFA score > 2) was made. Investigation showed leukocytosis (TC-16 x 10^3/uL) Mild anemia (Hb-9.8g/dL), Urine culture - E coli 10^5 Blood culture- No growth were confirming diagnosis of Urosepis with LFT, RFT reports normal.
Patient started on Intravenous Fluids, Empirical higher antibiotics, antipyretics and symptoms improved gradually. Since the patient continued to have hypotension, recurrent hypoglycemic episodes, adrenal insufficiency were considered and serum cortisol test was done. The early morning Serum Cortisol was less than 3ug/dL (range between6.02-18.4ug/dL) confirming the clinical suspicion He was supported with steriods and he rapidly improved and discharged.
He got readmitted with complaints of diarrhea and fatigue after 1 week. He was in altered sensorium, hypotension with hyponatremia and had hypoglycemic episode. Serum cortisol was repeated it was found to 20ug/dL. Relative adrenal insufficiency was considered and patient was started on intravenous steroids and symptoms improved drastically. Patient was discharged on oral steroids which was tapered and stopped over a period of 1 month. He was reviewed after 1 month with Cosyntropin(250mcg) stimulation test shows low levels of (Fasting, 30 mins, 60 mins) serum cortisol and with elevated ACTH level considered as adrenal insufficiency.
Diagnosis: Primary Adrenal insufficiency probably due to Covid Infection.
Discussion: Patient developed recurrent epdisodes of hypoglycemia, hypotension, hyponatremia, altered level of conscious, fatigue and subsequent investigations confirmed diagnosis of primary adrenal insufficiency. Few mechanisms are suggested and reported even in a case of mild covid infection.
Conclusion: It is important to consider Covid 19 as one of the cause of primary adrenal insufficiency and in elderly high clinical suspicion is essential.
| Factors Associated with Insulin Resistance in Patients with Type 2 Diabetes | | |
Greeshma Grace Thomas, Samuel George Hansdak, Herb Giebel
Christian Medical College, Vellore, Tamil Nadu, India
Objectives: To study the various lifestyle, laboratory and disease related factors associated with insulin resistance in Type 2 Diabetic patients.
Materials and Methods: A retrospective chart review of adult patient who attended the Medicine IV- Wellness clinic and who had answered the lifestyle questionnaire and required parameters checked was done. Insulin resistance was calculated using the HOMA 2-IR calculator and association with various factors was analysed.
Results:
Conclusion: Factors like glycemic control and duration of diabetes did not seem to have any correlation with insulin resistance. However, obesity and other lifestyle factors such as decreased activity, inadequate sun exposure and sleep appears to be associated with higher insulin resistance. Various laboratory parameters including lipid levels, hsCRP, Vitamin B12 and Vitamin D levels also couldnot be elicited to have an association with insulin resistance.
| Isoniazid Associated Delirium in an Elderly Female with Spinal Tuberculosis | | |
Rohit Singh, Sankha Shubhra Chakrabarti, Upinder Kaur
Department of Geriatrics Medicine, Institute of Medical Sciences, BHU, Varanasi, Uttar Pradesh, India
Aims and Objectives: To describe a case of isoniazid associated delirium in an elderly female with spinal tuberculosis.
Materials and Methods: A 64-year-old lady was referred to our centre with a complaint of low backache of 2 months duration. A magnetic resonance imaging (MRI) of the dorsal-lumbar spine performed at the referring center had revealed tubercular spondylitis at L2-L3 level, with wedge compression of L1 vertebra and bilateral psoas abscess. There, she was started on antitubercular therapy comprising of isoniazid (H), rifampicin (R), pyrazinamide (Z) and ethambutol (E). However, within days, she developed severe gastrointestinal intolerance and altered sensorium. The HRZE regimen was stopped, and a modified regimen comprising of levofloxacin, ethambutol and injectable streptomycin was started. Detailed medical records of previous admission were not available. At the time of her presentation to us, her vitals were stable with E4V5M6. Considering the importance of both isoniazid and rifampicin, patient was shifted back to the initial HRZE regimen with careful monitoring. However, she developed altered sensorium, in the form of poor speech, reduced attention, and decreased responsiveness to external stimuli. Serum sodium levels were mildly decreased (128 mEq/L). Due to tubercular involvement of the L2-L3 vertebra, cerebrospinal fluid analysis could not be performed. MRI of brain was non-contributory. Simultaneously, the patient developed thrombocytopenia (platelet count (PC) < 100,000/μL,). Since PC was normal at the time of admission, rifampicin was considered the probable culprit and was replaced by levofloxacin. Improvement in PC was observed over the subsequent 2-3 days. To manage the persisting delirium, a trial of intravenous dexamethasone and mannitol was given, and hyponatremia was corrected but with no improvement. In view of rare neuropsychiatric adverse effects of isoniazid, the drug was withdrawn. Remarkable improvement in sensorium was observed over the next 48 hours. Isoniazid and rifampicin being major components of ATT, rifampicin was reintroduced, after informing the caregivers of possible benefits and risks. PC again reduced to 79,000/μL but then remained stable over the next week. The lady was discharged in improved condition on the ATT regimen of rifampicin, pyrazinamide, levofloxacin, and ethambutol, with an advice of serial monitoring of electrolytes and liver function.
Results and Conclusions: Isoniazid is recommended as a first line agent along with rifampicin, pyrazinamide, and ethambutol, in pulmonary and extra-pulmonary tuberculosis. Among neurological adverse effects, isoniazid has been associated with peripheral neuropathy and rarely with acute psychosis in the form of paranoid delusions, mood alterations and hallucinations.1,2 Other rare adverse effects of the drug include metabolic acidosis and renal dysfunction.3 The association of isoniazid with pure delirium is rare and so far has been reported only in the settings of uraemia and liver failure.4,5 In our patient, pure delirium developed with INH within days of INH administration and in the absence of organ dysfunction and confounding drugs. The rapid and fluctuating course of symptoms and marked improvement within days of drug withdrawal supported the DSM-V criteria of delirium. The exact mechanism of isoniazid associated delirium needs to be investigated. Being a non-selective monoamine oxidase (MAO) inhibitor, the drug enhances the catecholamine levels in brain. It interferes with pyridoxine dependant GABA synthesis but can elevate the GABA levels in brain by inhibiting GABA-transaminase (GAT).6 Enhanced GABA can suppress the cholinergic pathway producing delirium like features.
Thrombocytopenia can occur with rifampicin after a brief period of interruption, as was seen in the present case and confirmed by positive dechallenge and rechallenge with rifampicin.7 Occurrence of thrombocytopenia posed difficulties in designing an optimal ATT regimen for the lady. Considering the importance of rifampicin in the antitubercular regimen and failure to give isoniazid in the patient, the drug was reintroduced. Tolerance develops sometimes to rifampicin associated thrombocytopenia when the drug is given on a daily basis, as was observed in the patient.7
Neurological disturbances in the form of pure delirium without psychosis can occur with isoniazid. The drug should be suspected as one of the causative factors if any elderly patient on ATT develops new onset delirium.
| Coma Vigilante-A Case Report | | |
V. Manoj Reddy, Betsy Mathew
PES Institute of Medical Sciences and Research, Kuppam, Andhra Pradesh, India
Introduction: Locked-in syndrome (LIS) is a devastating rare neurological condition in which there is complete paralysis of all voluntary muscles except for the ones that control vertical movements of the eyes. Patients are conscious and cognition is unaffected. It is also referred to as “deafferented state”, “pseudocoma” and “coma vigilante”. Here we report one such case.
Case Report: A 64 year old man, with no known comorbidities and a significant history of smoking and alcoholism was brought to ER with history of giddiness and vomiting the day prior and sudden loss of consciousness on the day he presented to ER. He was intubated in view of low GCS (4/15) and impending respiratory failure. Blood pressure was 230/120 mm of Hg on arrival and labetolol injection was given. All the 4 limbs were flaccid and plantars were mute. Hypertensive emergency with intracerebral bleed was suspected but CT brain was normal and subsequent blood pressure readings were normal without anti-hypertensives. After about 36 hours, he regained consciousness and was opening his eyes spontaneously. He was quadriplegic, had no facial movements and only vertical eye movements and blinking were present. MRI brain showed infarcts in mid brain, pons, bilateral cerebellar hemispheres and left thalamus. Diagnosis of acute locked-in syndrome was made. As his family wished to take him home he was discharged against medical advice.
Discussion: Our patient had initial loss of consciousness but once he regained consciousness he was aware of his surroundings but he was unable to move his limbs or facial muscles and only vertical eye movements were preserved. LIS should be differentiated from persistent vegetative state wherein patient may be awake without awareness. It is due to bilateral ventral pontine lesions of which most common is basilar artery thrombosis. It is a clinical diagnosis. MRI brain (with diffusion weighted imaging) will show acute infarcts. EEG cannot definitely identify awareness but normal EEG in an unresponsive patient will help differentiate LIS from persistent vegetative state.
Conclusion: Geriatricians should be familiar with LIS because of the high incidence of stroke and increasing post-stroke survival in elderly. Currently there is no medical cure treatment is as for any stroke. Eye-coded communication should be established with the patient and early multidisciplinary rehabilitation is helpful.
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