Letters to the Editor / JAMDA 19 (2018) 89e9392 Discussion Our study in a group of Chinese nonagenarians in Singapore who already has “success” in longevity allowed important insights into factors that promote aging success- fully. Using the Katz approach of viewing successful aging from the perspective of multidimensional measurements, our study affirmed the utility of a multidimensional approach beyond the biomedical model.3 Of note, the most striking difference between successful agers and nonagenarians with disability was in terms of psychological factors such as opti- mism, resilience, conscientiousness, low neuroticism, and fewer depressive symptoms; lifestyle factors such as low nutritional risk and engagement in activity; and social factors such as a good marital relationship. With the exception of stroke, disease factors appeared to be less salient in this long- lived group. Ironically, in our study, SA nonagenarians had a higher prevalence of hypertension, hyperlipidemia, and dia- betes mellitus. Our results are consistent with the recom- mendations of the World Health and Aging Report of the World Health Organization, which emphasizes that “healthy aging is more than just the absence of disease” and highlights the importance of raising the intrinsic capacity throughout the life course.10 Taken together, this highlights the importance of using age-sensitive multidimensional definitions of successful aging in the oldest-old that encompass psychosocial domains.3 Our findings also suggest the potential of a life-course approach of culturally appropriate and evidence-based in- terventions that target lifestyle, environmental, and psycho- social dimensions to promote aging successfully that will support aging-in-place.11 This is supported by recent work published showing interactions between familial longevity and environmental factors that affect health in old age in China.12 In summary, using an enriched sample of successfully aged versus disabled nonagenarians, we demonstrated the salience of psychological, lifestyle, and social dimensions above and beyond the biomedical model. Because of the cross-sectional design, we cannot exclude reverse causality and, hence, the reported associa- tions should preferably be replicated in longitudinal studies. To complement our findings that examines successful aging using the Rowe and Kahn paradigm, we also propose studies that examine successful aging using the complementary Havighurst approach of understanding successful aging from the perspectives of older persons themselves.3 References 1. Rowe JW, Kahn RL. Human aging: Usual and successful. Science 1987;237: 143e149. 2. Nosraty L, Sarkeala T, Hervonen A, Jylhä M. Is there successful aging for no- nagenarians? The vitality 90þ study. J Aging Res 2012;2012:9. 3. Michel JP, Sadana R. “Healthy aging” concepts and measures. J Am Med Dir Assoc 2017;18:460e464. 4. Young Y, Frick KD, Phelan EA. Can successful aging and chronic illness coexist in the same individual? A multidimensional concept of successful aging. J Am Med Dir Assoc 2009;10:87e92. 5. Sahadevan S, Lim PP, Tan NJ, Chan SP. Diagnostic performance of two mental status tests in the older Chinese: Influence of education and age on cut-off values. Int J Geriatr Psychiatry 2000;15:234e241. 6. Neelakantan N, Whitton C, Seah S, et al. Development of a semi-quantitative food frequency questionnaire to assess the dietary intake of a multi-ethnic urban Asian population. Nutrients 2016;8:528. 7. Scheier MF, Carver CS, Bridges MW. Distinguishing optimism from neuroticism (and trait anxiety, self-mastery, and self-esteem): A re-evaluation of the Life Orientation Test. J Pers Soc Psychol 1994;67:1063e1078. 8. Connor KM, Davidson JR. Development of a new resilience scale: The Connor- Davidson Resilience Scale (CD-RISC). Depress Anxiety 2003;18:76e82. 9. Friedman HS, Martin LR. The Longevity Project: Surprising Discoveries for Health and Long Life From the Landmark Eight-Decade Study. New York: Hudson Street Press; 2011. 10. Beard JR, Officer A, de Carvalho IA, et al. The World Report on ageing and health: A policy framework for healthy ageing. Lancet 2016;387: 2145e2154. 11. Morley JE. Aging successfully: The key to aging in place. J Am Med Dir Assoc 2015;16:1005e1007. 12. Shi WH, Zhang HY, Zhang J, et al. The status and associated factors of successful aging among older adults residing in longevity areas in China. Biomed Environ Sci 2016;29:347e355. Mei Sian Chong, MBBS, FRCP, FAMS Department of Geriatric Medicine Tan Tock Seng Hospital Singapore Geriatric Education and Research Institute, Ministry of Health Singapore Cai Ning Tan, BSc Institute of Geriatrics and Active Ageing Tan Tock Seng Hospital Singapore Suzanne Yew, BSN Institute of Geriatrics and Active Ageing Tan Tock Seng Hospital Singapore Jun Pei Lim, MBBS, MRCP Department of Geriatric Medicine Tan Tock Seng Hospital Singapore Wee Shiong Lim, MBBS, MMed, MRCP, MHPE, FAMS Department of Geriatric Medicine Tan Tock Seng Hospital Singapore Institute of Geriatrics and Active Ageing Tan Tock Seng Hospital Singapore Ping Kong Lieu, MBBS, MMed, FAMS Institute of Geriatrics and Active Ageing Tan Tock Seng Hospital Singapore Department of Community and Continuing Care Tan Tock Seng Hospital Singapore http://dx.doi.org/10.1016/j.jamda.2017.10.015 Platypnea-Orthodeoxia Syndrome Masked by Delirium in an 85-Year-Old Woman To the Editor: On February 3, 2016, an 85-year-old woman was brought to the emergency department (ED) because of mental confusion and intolerance of the sitting position, which had begun suddenly 2 days before. She had been wheelchair-bound for the past 9 years after a stroke that had left her with mild left-sided hemiparesis but http://refhub.elsevier.com/S1525-8610(17)30604-7/sref1 http://refhub.elsevier.com/S1525-8610(17)30604-7/sref1 http://refhub.elsevier.com/S1525-8610(17)30604-7/sref1 http://refhub.elsevier.com/S1525-8610(17)30604-7/sref2 http://refhub.elsevier.com/S1525-8610(17)30604-7/sref2 http://refhub.elsevier.com/S1525-8610(17)30604-7/sref2 http://refhub.elsevier.com/S1525-8610(17)30604-7/sref3 http://refhub.elsevier.com/S1525-8610(17)30604-7/sref3 http://refhub.elsevier.com/S1525-8610(17)30604-7/sref3 http://refhub.elsevier.com/S1525-8610(17)30604-7/sref4 http://refhub.elsevier.com/S1525-8610(17)30604-7/sref4 http://refhub.elsevier.com/S1525-8610(17)30604-7/sref4 http://refhub.elsevier.com/S1525-8610(17)30604-7/sref4 http://refhub.elsevier.com/S1525-8610(17)30604-7/sref5 http://refhub.elsevier.com/S1525-8610(17)30604-7/sref5 http://refhub.elsevier.com/S1525-8610(17)30604-7/sref5 http://refhub.elsevier.com/S1525-8610(17)30604-7/sref5 http://refhub.elsevier.com/S1525-8610(17)30604-7/sref6 http://refhub.elsevier.com/S1525-8610(17)30604-7/sref6 http://refhub.elsevier.com/S1525-8610(17)30604-7/sref6 http://refhub.elsevier.com/S1525-8610(17)30604-7/sref7 http://refhub.elsevier.com/S1525-8610(17)30604-7/sref7 http://refhub.elsevier.com/S1525-8610(17)30604-7/sref7 http://refhub.elsevier.com/S1525-8610(17)30604-7/sref7 http://refhub.elsevier.com/S1525-8610(17)30604-7/sref8 http://refhub.elsevier.com/S1525-8610(17)30604-7/sref8 http://refhub.elsevier.com/S1525-8610(17)30604-7/sref8 http://refhub.elsevier.com/S1525-8610(17)30604-7/sref9 http://refhub.elsevier.com/S1525-8610(17)30604-7/sref9 http://refhub.elsevier.com/S1525-8610(17)30604-7/sref9 http://refhub.elsevier.com/S1525-8610(17)30604-7/sref10 http://refhub.elsevier.com/S1525-8610(17)30604-7/sref10 http://refhub.elsevier.com/S1525-8610(17)30604-7/sref10 http://refhub.elsevier.com/S1525-8610(17)30604-7/sref10 http://refhub.elsevier.com/S1525-8610(17)30604-7/sref11 http://refhub.elsevier.com/S1525-8610(17)30604-7/sref11 http://refhub.elsevier.com/S1525-8610(17)30604-7/sref11 http://refhub.elsevier.com/S1525-8610(17)30604-7/sref12 http://refhub.elsevier.com/S1525-8610(17)30604-7/sref12 http://refhub.elsevier.com/S1525-8610(17)30604-7/sref12 http://refhub.elsevier.com/S1525-8610(17)30604-7/sref12 http://dx.doi.org/10.1016/j.jamda.2017.10.015 http://crossmark.crossref.org/dialog/?doi=10.1016/j.jamda.2017.10.022&domain=pdf Letters to the Editor / JAMDA 19 (2018) 89e93 93 without cognitive impairment. According to her medical records at the ED, she was initially found hypoxemic (SO2 ¼ 75% in room air) and disoriented. She was diagnosed with pneumonia, and because there was major improvement regarding her oxygenation after hydration (SO2 ¼ 94% in room air), she was discharged homewith a prescription of oral amoxicillin-clavulanate. Six weeks later, during an ambulatory consultation her family reported that she had remained confused and agitated especially during the night and that the patient became distressed every time they attempted to sit her up. They had to offer her food while she was lying down on her bed because she would not tolerate the upright position at all. During consultation, she had an oxygen saturation of 86% in room air while recumbent and was referred for hospital admission on the same day for the assessment of her hypoxemia and other possible organic causes of her mental status change. Platypnea-orthodeoxia syndrome (POS) was determined the cause of her orthostatic intolerance as even on oxygen therapy her oxygen saturation fell from 95% to 84% when changing from decubitus to the upright position. Transcranial Doppler scan with microbubbles contrast showed microbubbles within the middle cerebral artery 5 car- diac cycles after infusion, which is characteristic of extracardiac right-to-left shunt.1 Transesophageal echocardiography with microbubbles contrast ruled out the presence of any interatrial communication and disclosed severe pulmonary hypertension (systolic pulmonary arterial pressure of 81mmHg). Chest angiotomography revealed lingular pulmonary infarction and multiple foci of chronic pulmonary embolism involving the medium lobe, the right superior lobe, and subsegmental branches of the lower left lobe. Laboratory tests did not disclose hepatic dysfunction. The patient was anticoagulated and discharged home on oxygen therapy after 3 weeks of hospitalization. Her cognitive status improved; she experienced only mild improvement regarding her orthostatic intolerance. POS is a rare syndrome represented by dyspnea and hypoxia induced by orthostasis and relieved by decubitus. The proposed pathophysiology of POS involves 3mechanisms: intracardiac shunt, ventilation/perfusion mismatch, and pulmonary arteriovenous shunt.2 Intracardiac right-to-left shunts represent the most common causes of POS and are usually associated with patent foramen ovale or interatrial septal defects in the presence of other anatomic or functional disorders.1 The requirement for another functional or anatomic disorder in the presence of interatrial malformations is the reason why POS occurs most frequently in older adults. It is believed that anatomic alterations such as kyphosis and aortic dilation lead to changes in the shape of the right atrium, which would align the inferior vena cava outflow with a patent foramen ovale or interatrial defect, hence, leading to the passage of deoxy- genated blood from the right atrium directly to the left atrium.2 Pulmonary hypertension represents the most common functional disorder associated with POS in the presence of interatrial septum malformations. It is assumed that interatrial communications become stretched when patients are upright, therefore, increasing the magnitude of right-to-left shunt in that position. Hepatopulmonary syndrome and vascular malformations are examples of arteriovenous shunts. In hepatopulmonary syndrome, the endogenous production of nitric oxide is increased, leading to precapillary and capillary vasodilation predominantly in the basal lung segments.1 During orthostasis, when blood flow to the basal segments is increased, such capillary dilation would allow the direct passage of deoxygenated blood into the pulmonary veins. The same mechanismwould occur in arteriovenous malformations or fistulae of basal location. Ventilation/perfusion mismatch represents the least reported cause of POS. Recently, a case of POS was reported in a patient with bilateral basal pulmonary fibrosis.3 In that case, the authors argued that the upright position caused relative hypoperfusion of healthy pulmonary apex regions and greater perfusion of the diseased basal segments, hence, maximizing the existing ventilation/perfusion mismatch. We hypothesize that our patient’s platypnea resulted from a combination of ventilation/perfusion mismatch and pulmonary arteriovenous shunt. We believe she suffered an acute pulmonary embolism, which was initially misdiagnosed as community-ac- quired pneumonia and evolved into chronic pulmonary embolism with severe pulmonary hypertension. The presence of pulmonary emboli affecting the lower lobes could have caused the ventilation- perfusion mismatch that worsened oxygenation in the upright position. Extracardiac right-to-left shunt, demonstrated by the transcranial Doppler scan with microbubbles contrast, could have resulted from the opening or recruitment of intrapulmonary arte- riovenous anastomoses because of increased pulmonary micro- vasculature pressure and chronic hypoxemia.4,5 Because of delirium, she was unable to report breathlessness while upright and her recorded SO2 improvement at the ED could have resulted frommeasurement in decubitus and/or from increased perfusion of upper lung regions because of improved preload after hydration. It is possible that other cases of POS in older patients with cognitive impairment and chronic oxygen dependence also go undiagnosed because POS is rarely suspected. POS should be entertained as a diagnostic possibility in cases of agitation triggered by the upright position in older adults with delirium or dementia. We are grateful to Jader Cabral for his assistance in reviewing the medical recordsof thepatient and toLeonardoZornoff fordiscussing differential diagnoses regarding the patient’s condition with us. References 1. De Vecchis R, Baldi C, Ariano C. Platypnea-orthodeoxia syndrome: Multiple pathophysiological interpretations of a clinical picture primarily consisting of orthostatic dyspnea. J Clin Med 2016;5:E85. 2. Rodrigues P, Palma P, Sousa-Pereira L. Platypnea-orthodeoxia syndrome in re- view: Defining a new disease? Cardiology 2012;123:15e23. 3. Takhar R, Biswas R, Arora A, Jain V. Platypnoea-orthodeoxia syndrome: novel cause for a known condition. BMJ Case Rep 2014;2014:bcr2013201284. http://dx. doi.org/10.1136/bcr-2013-201284. 4. Lovering AT, Goodman RD. Detection of Intracardiac and Intrapulmonary Shunts at Rest and During Exercise Using Saline Contrast Echocardiography. In: Ainslie P, editor. Applied Aspects of Ultrasonography in Humans. Rijeka: InTech; 2012. p. 159e174. 5. Vodoz JF, Cottin V, Glerant JC, et al. Right-to-left shunt with hypoxemia in pul- monary hypertension. BMC Cardiovasc Disord 2009;9:15. Leonardo A.R. Brito Fernanda B. Fukushima, MD, PhD Rodrigo Bazan, MD, PhD Danieliso R. Fusco, MD, PhD Edison I.O. Vidal, MD, MPH, PhD Botucatu Medical School Univ Estadual Paulista (UNESP) Botucatu, SP, Brazil http://dx.doi.org/10.1016/j.jamda.2017.10.022 http://refhub.elsevier.com/S1525-8610(17)30604-7/sref1 http://refhub.elsevier.com/S1525-8610(17)30604-7/sref1 http://refhub.elsevier.com/S1525-8610(17)30604-7/sref1 http://refhub.elsevier.com/S1525-8610(17)30604-7/sref2 http://refhub.elsevier.com/S1525-8610(17)30604-7/sref2 http://refhub.elsevier.com/S1525-8610(17)30604-7/sref2 http://dx.doi.org/10.1136/bcr-2013-201284 http://dx.doi.org/10.1136/bcr-2013-201284 http://refhub.elsevier.com/S1525-8610(17)30604-7/sref4 http://refhub.elsevier.com/S1525-8610(17)30604-7/sref4 http://refhub.elsevier.com/S1525-8610(17)30604-7/sref4 http://refhub.elsevier.com/S1525-8610(17)30604-7/sref4 http://refhub.elsevier.com/S1525-8610(17)30604-7/sref4 http://refhub.elsevier.com/S1525-8610(17)30604-7/sref5 http://refhub.elsevier.com/S1525-8610(17)30604-7/sref5 http://dx.doi.org/10.1016/j.jamda.2017.10.022 Platypnea-Orthodeoxia Syndrome Masked by Delirium in an 85-Year-Old Woman References