IAGS-MARCH 1992-VOL. 40, NO. 3

quality of life of some patients, which is opposite to the main therapeutic goal in the elderly.' For these reasons, a low-sodium diet should be prescribed with caution in the elderly with CHF. In my experience, symptoms of chronic CHF in the elderly can be controlled in most cases by drug therapy associated with a mild restriction in sodium intake (1.6 to 4 g per day). With this scheme, larger doses of diuretics may be required to achieve relief of vascular congestion, and careful clinical and biological monitoring is needed. I recommend a low-sodium diet (0.8 to 1.6 g per day) in end-stage chronic CHF, or for only a few days in acute CHF to quickly control the symptoms. If a low-sodium diet is required in the elderly, careful attention should be paid to food intake and nutritional status of the patient. JOEL BELMIN, MD H6pital Girontologique Ren6 Muret-Bigottini Sevran, France

REFERENCES 1. Luchi RJ, Taffet GE, Teasdale TA. Congestive heart failure in the elderly. J Am Geriatr SOC1991;39:810-825. 2. Smith TW, Braunwald E. The management of congestive heart failure. In: Braunwald E, ed. Heart disease, 2nd Ed. Philadelphia: WB Saunders, 1984:503-559. 3. Rudman D, Feller AG. Protein-calorie undernutrition in the nursing home. J Am Geriatr Soc 1989;37:173-183.

Editor's note:-The above letter was referred to the authors of the original, article and Dr. Luchi's reply follows.

In reply:-We welcome the comments of Dr. Belmin. Restrictions of space rather than indifference to the importance of diet and nutrition in the elderly patient with congestive heart failure (CHF) prevented us from addressing this important subject in any detail.' The well-known alterations in gustatory sense, appetite, and thirst that occur in the elderly are compounded by additional factors such as hepatic congestion and the reported increase in tumor necrosis factor which occur in congestive heart failure.* Any therapy for CHF, including drugs and low-salt diets, which impairs the joy of eating and the nutritional status of the patient should be avoided if possible or balanced with an equivalent or greater gain in relief of CHF symptoms. We agree with Dr. Belmin that some elderly patients may not tolerate severe sodium restriction because of lack of food appeal or development of hypokalemia or hypotension. Rather than severe sodium restriction, we routinely propose moderate sodium restriction in the range of 4 g. of NaCl(l.6 g Na) per day. Prescribing a higher sodium intake while increasing the dose of diuretics is not benign and may increase the risk of adverse side effects of hypokalemia and dehydration. Perhaps a more attractive alternative involves consultation with an imaginative dietitian who can take the salt out the diet without compromising too severely the taste of the food. E. TAFFET, MD GEORGE THOMAS A. TEASDALE, MD ROBERTLUCHI,MD Baylor College of Medicine Houston, TX

LETTERS TO THE EDITOR

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REFERENCES 1. Luchi RJ, Taffet GE, Teasdale TA. Congestive heart failure in the elderly. J Am Geriatr SOC1991;39:810-825. 2. Levine B, Kalman J, Mayer L et al. Elevated circulating levels of tumor necrosis factor in severe chronic heart failure. N En@ J Med 1990;323:236.

Mental Retardation in the Elderly

To the Editor:-Estimates suggest 1%-3% of the population is mentally retarded/developmentally disabled (MR/DD),' with approximately 1 million over the age of fifty-five.' Clinicians caring for MR patients have selected 55 as the inception of aging since retarded individuals appear to age faster than the general population.' While there is certainly a paucity of geriatric literature applicable to MR/DD, it appears such individuals exhibit ailments similar to nonretarded aged, including hypertension, diabetes, and various age-associated maladies. They also experience psychiatric disorders similar to non-retarded individuals, although clinical presentation is often permuted; for example, depression is common and frequently missed. However, unlike nonretarded elderly, retarded persons are less likely to die from carcinoma or cardiac failure, but rather from respiratory disease secondary to seizure disorders, cerebral palsy, and weak cough and breathing mechanism^.^ Unfortunately, psychotropics, a misused annoyance of modern medicine, have a tenacious history of abuse among dependent people, but such practice appears to be abating. Moreover, psychotropic dosages in MR individuals are enigmatic and warrant further study but appear to be lower than in non-retarded elders, further negating clinical utility. While geriatric research has generally prospered undaunted, the development and compilation of an embryonic database of aging and mental retardation is lamentably inadequate. After reviewing available MR/DD literature, several questions arise which I believe merit further analysis: (1) What assessment instruments are available or useful in the older mentally retarded? (2) What research is ongoing and needed in mental retardation and aging? (3) Are pharmacodynamics and pharmacokinetics unique to this group of elders? and (4)What long-term care strategies are necessary for a small but unmistakable influx of MR/DD elderly? Exposing geriatric fellows and other trainees to the vagaries of mental retardation in the elderly could generate significant benefits for this unfortunate and deserving group. PAULROUSSEAU,MD VA Medical Center Phoenix, Arizona Arizona State University Tempe, AZ

REFERENCES 1. JanickiMP, Wisniewski HM. Aging and Developmental Disabilities, Issues and Approaches. Baltimore: Paul H. Brooks Publishing, 1985. 3. Howell MC. Old age in the retarded-a new program. J Am Geriatr SOC 2. 1986;34:71-72. Walz T, Harper D, Wilson J. The aging developmentally disabled person: A review. Gerontologist 1986;26:622-629.

Mental retardation in the elderly.

IAGS-MARCH 1992-VOL. 40, NO. 3 quality of life of some patients, which is opposite to the main therapeutic goal in the elderly.' For these reasons, a...
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