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Biomedical subjects

W H Hoefnagels

Publications and source records attributed to W H Hoefnagels.

At least 19 recordsLinked to original sources
PubMed2001

Measuring the opinions of memory clinic users: patients, relatives and general practitioners.

BACKGROUND: The opinions of memory clinic users are important to assess the value of memory clinics. OBJECTIVE: To measure the quality of care of an outpatient memory clinic for the elderly as perceived by patients, their relatives and general practitioners (GPs). METHODS: An observational study was conducted to measure the opinions of the users of a typical outpatient memory clinic. Opinions on five aspects were measured: (1) communication of the results, (2) provision of diagnostic information, (3) attitude of the clinicians, (4) usefulness of the medical assessment, and (5) information and advice to relatives. Patients and relatives were both interviewed with a dementia care satisfaction questionnaire. The GPs' opinions were derived with a self-constructed questionnaire. RESULTS: On 105 consecutive assessments, 101 opinions of GPs, 81 of caregivers and 31 of patients were recorded. Positive opinions were recorded on the way the results were communicated, the usefulness of the assessment and attitude of the clinicians. In contrast to GPs and relatives, patients were less positive about the clarity of the diagnostic information received. Both relatives and GPs were negative on information and advice to relatives. CONCLUSIONS: Patients, caregivers and GPs had positive opinions about the diagnostic value of the memory clinic. Quality improvement could focus on the clarity of the diagnostic information for patients and on better advice to relatives.

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PubMed2001

Toward individualized evidence-based medicine: five "N of 1" trials of methylphenidate in geriatric patients.

OBJECTIVES: To investigate the efficacy of methylphenidate in depressed or apathetic geriatric patients. DESIGN: Five "N of 1" trials (individual cross-over, double-blinded, randomized trials). SETTING: Department of Geriatrics, University Medical Center, Nijmegen, and two nursing homes in Nijmegen, the Netherlands. PARTICIPANTS: Patients suffered from depression due to a general medical condition (n = 2); depression resistant to antidepressive drugs (n = 1), chronic apathy due to mild and moderate severe dementia (n = 2). INTERVENTION: Methylphenidate (5 mg bid) and placebo (both for two subsequent days) in 5 weeks of randomized treatment blocks. MEASUREMENTS: Montgomery Asberg Depression Rating Scale (MADRS), Apathy Evaluation Scale (AES)-clinician, the AES-informant, Barthel index and a semiquantitative checklist of adverse effects. RESULTS: Among the three depressed patients, two showed significant improvement on the MADRS (P = .089 and P = .001; alpha = 0.10), one patient's apathy showed significant improvement on AES-clinician and -informant (P = .077 and P = .086). One apathetic patient's trial was stopped because AES could not be completed. None of the patients showed significant changes in the Barthel index. No side effects developed. CONCLUSION: "N of 1" trials are useful in evaluating efficacy of methylphenidate in depressed or apathetic geriatric patients. Single-patient trials can be a useful tool in pharmacotherapeutic decision-making in frail older subjects.

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PubMed2001

The influence of low-, normal-, and high-carbohydrate meals on blood pressure in elderly patients with postprandial hypotension.

BACKGROUND: Postprandial hypotension (PPH) is a common and serious disorder of blood pressure (BP) regulation in elderly people. It has been suggested that primarily the carbohydrate (CH) content of a meal induces the BP decrease. Therefore, we examined the relationship between the CH content of meals and postprandial BP responses in elderly patients diagnosed with PPH. METHODS: Twelve geriatric patients (aged 75 to 91 years; 6 men) who were previously diagnosed with PPH received standardized liquid meals with low- (25 g), normal- (65 g), and high- (125 g) CH content in random order on three separate days. Systolic BP (SBP), diastolic BP, and heart rate were measured every 5 minutes from 20 minutes before until 75 minutes after each meal. Postprandial symptoms were recorded every 15 minutes. RESULTS: The maximum decrease in SBP was significantly smaller after the low-CH meal (-28 +/- 5 mm Hg) than after the normal- (-39 +/- 7 mm Hg) and high-CH meals (-40 +/- 5 mm Hg) (p <.050 between groups). In addition, the duration of PPH was significantly shorter (p <.010), and postprandial symptoms were less frequent and less severe after the low-CH meal. CONCLUSIONS: Reducing the CH amount in meals induces significantly smaller decreases in SBP, shorter duration of PPH, and reduction of PPH-related symptoms. Therefore, limiting the CH content of an elderly patient's meal can be a clinically effective nonpharmacological treatment for PPH in elderly patients and can reduce the risk of developing symptomatic PPH.

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PubMed2001

Effect of levodopa on orthostatic and postprandial hypotension in elderly Parkinsonian patients.

BACKGROUND: This study describes orthostatic and postprandial hypotension in elderly Parkinsonian patients and evaluates the effect of levodopa therapy on orthostatic and postprandial hypotension in these patients. METHODS: Seventeen elderly patients with a clinical diagnosis of Parkinson's disease or Parkinsonism based on the U.K. Parkinson's Disease Society Brain Bank criteria (age range, 66-84 years) participated in the study. Blood pressure was continuously monitored during standardized standing and meal tests, after starting 125-mg b.i.d. doses of levodopa/benserazide (Madopar) or placebo, in a double-blind, randomized, cross-over design. Seventeen age- and sex-matched healthy subjects served as controls. RESULTS: Orthostatic hypotension was infrequently found in Parkinsonian patients (13%) and healthy subjects (6%; p =.58, between groups), whereas postprandial hypotension was more frequent in Parkinsonian patients (82%) than in healthy subjects (41%; p <.05, between groups). Doses of levodopa/benserazide, administered 2 times per day, did not result in significantly larger blood pressure decreases after standing or eating, or in higher frequencies of orthostatic or postprandial hypotension in the Parkinsonian group. Postprandial hypotension was related to disease severity (r = -.56, p <.05). CONCLUSIONS: Postprandial hypotension, but not orthostatic hypotension, was more common in elderly Parkinsonian patients than in healthy subjects. Therapy with 125-mg b.i.d. doses of levodopa/benserazide did not significantly aggravate orthostatic or postprandial hypotension.

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PubMed2001

Cobalamin supplementation improves cognitive and cerebral function in older, cobalamin-deficient persons.

BACKGROUND: Mild cobalamin (Cbl) deficiency is frequently found in older persons and is associated with cognitive and cerebral abnormalities. The effects of Cbl supplementation on these abnormalities are largely unknown. METHODS: In a single-blind, placebo-controlled intervention study, 16 healthy community-dwelling elderly subjects with low plasma Cbl concentration and no cognitive impairments were studied. Subjects underwent 1 month of treatment with placebo, followed by 5 months of treatment with intramuscular injections of hydroxycobalamin. Before and after measurements of plasma cobalamin, total homocysteine (tHcy), methylmalonic acid (MMA), quantitative electroencephalograph (qEEG), and psychometric tests were taken. RESULTS: After Cbl supplementation, plasma Cbl concentrations increased, and plasma MMA and tHcy concentrations decreased. The performance on the Verbal Word Learning Test, Verbal Fluency and Similarities improved. qEEG showed more fast activity and less slow activity. Lower plasma tHcy concentrations were related to increased fast activity on qEEG on the one hand and improved performance on the Verbal Word Learning Test and Similarities on the other. Increased fast or decreased slow activity on qEEG was associated with improved performance on the Verbal Word Learning Test, Similarities and Verbal Fluency. CONCLUSIONS: Electrographic signs of improved cerebral function and improved cognitive function were found after Cbl supplementation in older subjects with low plasma Cbl concentrations who were free of significant cognitive impairment. These improvements were related to a reduction of plasma tHcy concentration.

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PubMed2001

A new course in age-based medicine at the University Medical Center of Nijmegen.

In 1995 the Medical Faculty of the University Medical Center of Nijmegen revised its curriculum to be more problem-oriented and student-centered. Each of the first four years now consists of ten four-week courses constructed around specific learning objectives. For the new curriculum the authors developed a fourth-year course on age-related health problems in which selected issues of pediatrics, general practice, and geriatrics are integrated. The primary objective of this course is to enable students to understand the differences and similarities in approaches to health problems in different age groups. Moreover, by the end of the course students should be able to analyze the physical, psychological, and social aspects of age-specific medical problems and understand their consequences for prevention and treatment. The course covers age-specific health concerns (e.g., neonatal jaundice, growth problems, sudden infant death syndrome, anorexia nervosa, dementia, multiple pathology, frailty) as well as important age-related differences in pathophysiology, etiology, diagnosis, and treatment (e.g., acute abdomen, constipation, maltreatment, urinary incontinence, pharmacokinetics). Based on assessments and evaluations after the first three implementations, the authors conclude that the enthusiastically received course is an effective introduction to age-specific health problems.

Age Factors↗
PubMed2000

Furosemide withdrawal in elderly heart failure patients with preserved left ventricular systolic function.

To explore the possibilities of furosemide withdrawal in elderly heart failure (HF) patients with intact left ventricular (LV) systolic function and assess its effects on functional status and orthostatic blood pressure homeostasis, we performed a placebo-controlled pilot trial of furosemide withdrawal with 3 months of follow-up in 32 HF patients (aged 75.1 +/- 0.7 years [mean +/- SEM]) with a LV ejection fraction of 60 +/- 2% and without overt congestion. Investigations included repeated clinical assessment, spirometry, standardized 6-minute walking test, and chest x-rays. Measurements of blood pressure response on active standing and Doppler echocardiography were performed before and 3 months after furosemide withdrawal. Recurrent congestive HF occurred in 2 of 21 patients (10%) who discontinued furosemide use, and in 1 of 11 patients (9%) who continued furosemide (p = NS). Three patients restarted furosemide for ankle edema and 1 for blood pressure levels >180/100 mm Hg. After 3 months, there were no differences regarding HF symptom scores, blood pressure, heart rate, spirometric results, 6-minute walking distance, or quality of life scores between patients who discontinued use and patients who continued the therapy. In patients successfully withdrawn, Doppler E/A ratio increased from 0.68 +/- 0.05 to 0.79 +/- 0.06 after withdrawal (p <0.01), and maximum blood pressure decrease on active standing changed from -8 +/- 5 mm Hg to +5 +/- 3 mm Hg systolic (p <0.05). Thus, in this pilot investigation of furosemide withdrawal in elderly HF patients without overt congestion and with a normal LV systolic function, withdrawal was successful in almost all patients and was associated with improvement of LV diastolic filling and blood pressure homeostasis on active standing.

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PubMed2000

Clinical significance of low cobalamin levels in older hospital patients.

BACKGROUND: It is still a commonly held belief that many of the frequently found low cobalamin (Cbl, vitamin B12) levels in older people do not represent deficiency and are therefore without clinical significance and should not be treated. In this study this notion will be challenged. METHODS: In this prospective observational cohort design we studied 28 patients aged 65 years and older with low plasma Cbl (< or =150 pmol/l). A number of haematological (Hb, MCV, five- and six-lobed granulocytes), metabolic (plasma levels of methylmalonic acid and homocysteine), and gastrointestinal (plasma pepsinogen A and C and protein-bound and free Cbl absorption) parameters, and the response to Cbl treatment, were measured. Cbl deficiency was considered to be present when at least one of the following three criteria was fulfilled: (1) haematological or metabolic abnormalities compatible with Cbl deficiency; (2) Cbl malabsorption or atrophic gastritis; (3) a response to Cbl supplementation. RESULTS: Haematological or metabolic abnormalities were identified in 27 patients. Atrophic gastritis and Cbl malabsorption were identified in, respectively, 15 and 23 patients. Each treated patient showed a haematological or metabolic response to Cbl supplementation. All patients were considered Cbl deficient: 18 patients (64%) fulfilled three criteria of Cbl deficiency, eight (29%) fulfilled two criteria and two (7%) fulfilled one criterion. CONCLUSIONS: According to the generally accepted and a wide variety of criteria, we found that older patients with low Cbl levels were cobalamin deficient. Therefore, these patients should receive Cbl supplementation.

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PubMed2000

Cerebral oxygenation declines in healthy elderly subjects in response to assuming the upright position.

BACKGROUND AND PURPOSE: With increasing age, assuming the upright position is more often accompanied by symptoms such as dizziness and lightheadedness, possibly as a result of a diminished oxygen supply to the brain due to impaired cerebral autoregulation. We aimed to quantify postural changes in cerebral oxygenation and systemic hemodynamics in healthy elderly and young subjects. METHODS: In 18 healthy elderly subjects (aged 70 to 83 years) and 10 healthy young subjects (aged 22 to 45 years), frontal cortical oxygenation and hemodynamic responses were continuously monitored by near infrared spectroscopy and Finapres, respectively, before and during 10 minutes of active standing. RESULTS: -Cortical oxyhemoglobin concentration [O(2)Hb] decreased by -4.6+/-2.2 micromol/L (P<0.001) and cortical deoxyhemoglobin concentration increased by 1.5+/-2.4 micromol/L (P<0.05) in the elderly subjects after posture change, whereas these variables did not change significantly in the young subjects. The postural hemodynamic changes tended to be attenuated in the elderly subjects, except for the increases in systolic blood pressure (BP). Smaller postural increases in diastolic BP were related to larger [O(2)Hb] decreases (r=0.53, P<0.01, corrected for the age effect). CONCLUSIONS: Assuming the upright position evokes an asymptomatic decrease in frontal cortical oxygenation in healthy elderly subjects but not in healthy young subjects. Cortical [O(2)Hb] changes are affected by diastolic BP changes. These findings may indicate that regulation of cerebral oxygenation alters with increasing age.

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PubMed2000

Diuretic therapy in elderly heart failure patients with and without left ventricular systolic dysfunction.

Long term prescription of diuretics for heart failure is very prevalent among elderly patients, although the rationale for such a treatment strategy is often unclear, as diuretics are not indicated if volume overload is absent. The concept of diastolic heart failure in the elderly might particularly change the role of diuretic therapy, since diuretics may have additional adverse effects in these patients. This paper reviews the effects of diuretic therapy in elderly patients with heart failure, emphasising the differences between patients with normal and decreased left ventricular systolic function. Studies on diuretic withdrawal in elderly patients with heart failure are discussed, with emphasis on issues involved in decision making such as diuretic dose reduction and withdrawal in elderly patients and factors that have been established to predict successful withdrawal. Existing guidelines on the prescription of diuretics in elderly patients with heart failure with normal and decreased left ventricular systolic function and in those with diastolic heart failure are also discussed. By reducing intravascular volume, diuretics may further impair ventricular diastolic filling in patients with diastolic heart failure and thus reduce stroke volume. Indeed, preliminary studies demonstrate that diuretics may provoke or aggravate hypotension on standing and after meals in these patients. Therefore, it is suggested that elderly patients with heart failure with intact left ventricular systolic function should not receive long term diuretic therapy, unless proven necessary to treat or prevent congestive heart failure. This implies that physicians should carefully evaluate the opportunities for diuretic dose tapering or withdrawal in all of these patients, and that a cautiously guided intermittent diuretic treatment modality may be critical in the care for older patients with heart failure with intact left ventricular systolic function.

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PubMed1999

Furosemide withdrawal improves postprandial hypotension in elderly patients with heart failure and preserved left ventricular systolic function.

OBJECTIVE: To assess the effects of furosemide withdrawal on postprandial blood pressure (BP) in elderly patients with heart failure and preserved left ventricular systolic function. METHODS: Noninvasive measurement of blood pressure (BP) and heart rate, computation of stroke volume and cardiac output (after a 1247-kJ (297-kcal) meal, and Doppler echocardiography before and 3 months after placebo-controlled withdrawal of furosemide therapy. RESULTS: Of 20 patients with heart failure (mean+/-SEM age, 75+/-1 years; left ventricular ejection fraction, 61%+/-3%), 13 were successfully able to discontinue furosemide therapy. At baseline, 11 (55%) of the 20 patients (had maximum postprandial systolic BP declines of 20 mm Hg or more. In the withdrawal group, the maximum systolic BP decline lessened from -25+/-4 to -11+/-2 mm Hg (P<.001) and the maximum diastolic BP from -18+/-3 to -9+/-1 mm Hg (P= .01), compared with no changes in the continuation group. In the withdrawal group, maximum postprandial declines in stroke volume and cardiac output decreased from -9+/-1 to -4+/-2 mL (P =.01) and from -0.6+/-0.2 to -0.2+/-0.1 L/min) (P = .04), respectively. The baseline maximum postprandial systolic BP decrease was correlated with the ratio of early to late flow (n = 20; Spearman rank correlation coefficient, 0.58; P = .007). For patients in the withdrawal group, the changes in postprandial systolic BP response were independently related to changes in peak velocity of early flow (n = 13; r2= 0.61; P = .003). CONCLUSIONS: Postprandial hypotension is common in elderly patients with heart failure and preserved left ventricular systolic function. The withdrawal of furosemide therapy ameliorates postprandial BP homeostasis in these patients, possibly by improving left ventricular diastolic filling.

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PubMed1999

Monitoring hypovolemia in healthy elderly subjects by measuring blood pressure response to Valsalva's maneuver.

Quantification of hypovolemia by physical examination has limited validity. We explored the use of non-invasive measurement of blood pressure (BP) response to Valsalva's maneuver in monitoring hypovolemia in nine healthy elderly volunteers, recruited from participants of the Nijmegen Annual Four-Days Marches. Heart rate (HR), systolic and diastolic BP, and mean arterial pressure (MAP) response (Finapres) to a Valsalva's maneuver as well as clinical and laboratory assessment of fluid balance were determined 5 minutes before, and 3, 5, and 48 hours after administration of 40 mg furosemide orally. Subjects' (4 males aged 74.2 +/- 3.0 years) weight was 66.1 +/- 9.7 kg, mean BP was 139 +/- 21 over 76 +/- 12 mm Hg. A maximum weight loss of -2.8 +/- 0.9% occurred 5 hours after furosemide administration. Systolic and diastolic BP, HR, clinical assessment scores, and serum creatinine and urea nitrogen did not change during the total study period. Significant changes occurred in Valsalva phase I to phase II systolic BP response (difference +14.2 +/- 11.3 mm Hg, ratio difference -0.09 +/- 0.07 after 5 hours, P < 0.01). Changes after 48 hours did not differ from baseline values. Finapres measurement of Valsalva BP response may be useful in monitoring hypovolemia in the elderly.

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PubMed1998

[Medical-scientific research in the elderly in The Netherlands; historic milestones and methodological problems].

OBJECTIVE: To describe the methodological development of medical research regarding elderly subjects in the Netherlands. DESIGN: Descriptive. SETTING: Nijmegen University, the Netherlands. METHOD: All research on aging published in the Netherlands Tijdschrift voor Geneeskunde (Dutch Journal of Medicine) starting from its first volume in 1857 up to 1983 was studied. Selected were those articles in which new research methods were introduced. Next, six pioneering researchers in geriatrics were interviewed on the methodological development of geriatric research and on the problems they encountered in their own research. RESULTS: Research started with studies on age-associated diseases such as prostatism, presbyacusis and senile dementia. It was only after a considerable delay that new diagnostic instruments such as electrocardiography and new research designs such as randomized trials found their way into research on elderly patients. The development of a questionnaire on the health of the elderly, the introduction of the concept of activities of daily living and of diagnostic instruments in the field of psychogeriatrics were important steps that made possible current geriatric research. From the outset, researchers encountered methodological problems still relevant in current research and caused by characteristics of geriatric patients: frailty, high prevalence of comorbidity, coexistence of physical, psychological and social problems, and large interindividual differences.

Activities of Daily Living↗
PubMed1998

Loop diuretics in patients aged 75 years or older: general practitioners' assessment of indications and possibilities for withdrawal.

OBJECTIVE: To examine the indications for prescription and possibilities for withdrawal of loop diuretics in community-dwelling patients aged 75 years or older, as reported by their general practitioners (GPs). METHODS: Analysis of dispensary data to identify patients aged 75 years or older using loop diuretics on 1 February 1996. Questionnaires were sent to the GPs of these patients to inquire about the indications for loop diuretic prescription and the necessity for continuation. We subsequently determined loop diuretic prescription rates in the survey population over the next 9 months. SETTING: A panel of nine Dutch community pharmacies. RESULTS: Questionnaires were returned for 338 out of 667 patients (50.7%) using loop diuretics on 1 February 1996. Reported indications for loop diuretic use were heart failure in 223 patients (66.0%), hypertension in 35 patients (10.4%), and a combination of both in 23 patients (6.8%). Loop diuretics were used for ankle edema in 27 patients (8.0%) and for unknown reasons in another 27 patients (8.0%). Continuation of treatment was considered unnecessary by GPs in 66 out of 338 patients (19.5%). However, prescription rates for these 66 patients in the following months were no different from rates for the remaining 272 patients. Loop diuretics were still prescribed to 47 of 66 patients (71.2%) after 12 weeks, and to 26 patients (39.4%) after 36 weeks. CONCLUSIONS: GPs reported substantial opportunities for withdrawal of loop diuretics in patients over 75 years of age, but this did not influence actual prescription rates in these patients. Future studies should explore means of facilitating withdrawal of these medications in this population.

Age Factors↗
PubMed1998

Use of diuretics and opportunities for withdrawal in a Dutch nursing home population.

BACKGROUND: Diuretics are frequently used by elderly patients and overprescription has been suggested. However, the present withdrawal patterns of these medications in clinical practice elderly patients are unclear. METHODS: Retrospective medical record analysis of all 584 patients aged 75 years or older admitted to a 240-bed nursing home facility in the years 1990-1994. One-year follow-up by record review and collection of updated information from nursing home physicians. RESULTS: Two hundred and twenty patients (37.7%) used diuretics, and use increased with age (p < 0.05). Reported indications for prescription were heart failure (n = 77), hypertension (n = 38), ankle edema without heart failure (n = 21), or not reported (n = 84). Diuretics were withdrawn in 82 of 220 patients (37.3%), but a doubtful actual indication for diuretic use was found in 72 of the remaining 138 patients (52.2%). After withdrawal, the probability of remaining free from diuretics for at least one year was 0.47. There were no reports of life-threatening or fatal incidents after withdrawal. Mortality rates for the patients whose diuretics were withdrawn did not differ from patients continuing on diuretics. CONCLUSIONS: Withdrawal of diuretics was frequently performed and often successful. In addition, doubtful indications for diuretics were found in half of the patients continuing on these medications, suggesting additional opportunities for diuretic withdrawal.

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