Elderly Deaths Associated with Balneotherapy in Denizli,Turkey Province: Three Autopsy Cases

Introduction

S pa therapy consists of a complex curing program including methods such as balneotherapy, phytotherapy, climatotherapy, and hydrotherapy. Balneotherapy uses natural factors such as mineral and thermal waters, peloids, and gases in the form of bathing, drinking, and inhalation methods. ¹ Baths can be applied in swimming pools or bathtubs in private rooms.

Musculoskeletal diseases are one of the most common health problems among the elderly. Since thermomineral water baths are beneficial for pain management and regulation of the functions of muscles, joints, and extremities in the musculoskeletal system, they are preferred by elderly people. ² Nonetheless, a likelihood of the presence of multiple pathologies or limited cardiovascular functionality should be borne in mind while planning balneotherapy in elderly patients. ^1,3 However, in Turkey, balneotherapy still preserves its empirical and traditional content. In particular, pools and hot water baths are used on the suggestion of a friend without any medical counseling. No attention is paid to the duration of therapy, temperature, bathing frequency, and number of sessions per cure. Therefore, disregarding risk factors leads to serious outcomes, including mortality. ^4,5

Autopsy Studies

Discussion

Among elderly people, thermal waters can be used to apply physical rehabilitation for those suffering from various chronic diseases. In addition to musculoskeletal disorders, these waters have positive effects on cardiovascular and respiratory system diseases. Kurabayashi et al. reported that elderly patients with chronic obstructive pulmonary disease to whom thermomineral water bath is applied on conjunction with respiratory exercises had improvement in respiratory parameters. ⁶ Tei et al. reported that bathing has been found to be effective for patients with congestive heart failure, because of the hemodynamic improvement from thermal vasodilatation. ⁷ On the other hand, immersing the entire body in hot water in elderly patients with cardiovascular diseases can trigger ischemic changes. ^8,9

In thermal water baths, hemodynamics are affected by hydrostatic pressure and thermal influences of water. Hydrostatic pressure of water increases central venous pressure, which in turn leads to transient cardiac stress. Elevated cardiac capacity raises myocardial oxygen consumption; however, if coronary blood flow is inadequate, arrhythmia and ischemic changes may be triggered. ³ Tanabe and Goto monitored electrocardiogram data during the bathing and observed that physical stress arising from bathing caused coronary artery spasm and temporary ST-T changes. ¹⁰ Chiba et al. showed that a high level of double product (systolic blood pressure×heart rate) in the elderly suggests that more myocardial oxygen consumption is needed than for young adults, particularly in subjects with arrhythmia. ³ Hashiguchi et al. reported that double products for whole-body bathing were significantly larger than those for half-body bathing during bathing. ⁹ The sympathetic nervous system can be activated under the thermal influences of water. Thus, noradrenaline levels increase and lead to elevations in cardiac output and heart rate, whereas diastolic blood pressure and mean blood pressure are decreased. ¹¹ The 72-year-old case in this report with a history of chronic myocardial infarction along with cerebral and coronary atherosclerosis had signs of drowning. Inamura noted that fast and large decreases in blood pressure could lead to syncope, which would be the underlying cause of drowning. ¹² In their study, Aihara et al. found that 37 of their mortality cases who died in the bathroom were due to drowning associated with temporary ischemic attack. ¹³ Another case in the present study, a 67-year-old patient, had a history of hypertension. Hashiguchi et al. proposed that particularly among individuals with a history of hypertension, sudden blood pressure decreases during a bath might be a cardiac risk factor. ⁹

Conclusions

The probability of cardiovascular system limitations and rare deaths because of a hot water bath must be taken into account. ¹ Instead of empirical and general use of hot water baths in balneotherapy, guidance of a professional considering the individual's age and other limitations is more suitable.