Age and Ageing Advance Access originally published online on March 6, 2006
Age and Ageing 2006 35(3):218-219; doi:10.1093/ageing/afj064
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News and Reviews
Cortisol production and bone lossDespite evidence that treatment with cortisol enhances bone loss, there is less information on the effects of the natural synthesis of the hormone on skeletal status. A minor advance has been the evaluation of the effects of hypothalamic–pituitary–adrenal axis on 151 men and 96 women aged 61–73 years (Calcif Tissue Int 2005; 77: 134–8). The main criterion of bone status was bone mineral density (BMD) initially and 4 years later.
In men, a high-peak plasma cortisol level was associated with an increase in BMD of the lumbar vertebral bodies, whereas in women, the same change in cortisol accentuated a reduction in BMD of the neck of femur. Explanations for these changes and their therapeutic implications have yet to be defined.
Hyperbaric oxygen in cerebral ischaemia
Research into the therapeutic possibilities of hyperbaric oxygen (HBO) over the last 50 years has continued to emphasise its use in underwater emergencies. A comprehensive review of relevant projects from 1966 to 2005 has reconsidered its role in cerebral ischaemia (Cerebrovasc Dis 2005; 20: 417–26). Animal studies suggest that HBO may reduce the size of an infarction and may improve neurological recovery. The results in humans have been less satisfactory, but this could be due to the small number involved in each trial. There is also the fact that it is possible to start treatment more rapidly in an animal where a stroke is planned than in a patient where this occurs spontaneously.
Cat scratch disease in older people
Most of us have encountered psittacosis in elderly bird lovers, but it was a surprise to learn that keeping company with a cat can also be hazardous (Clin Infect Dis 2005; 41: 969–74). Review of 846 patients with cat scratch fever recorded between 1991 and 2002 in 52 patients aged 60 years or over revealed that the subjects were less likely to have lymphadenopathy but complained more often of a general malaise. Atypical complications were endocarditis, encephalitis and pyrexia of unknown origin. In view of this worrying information, we should perhaps encourage older people to keep goldfish.
Blood pressure and Alzheimer’s disease
At one time, life was simple, with most cases of dementia being due to Alzheimer’s disease or multiple cerebral infarcts. There is now increasing evidence that hypertension may be a factor in the pathogenesis of Alzheimer’s disease. An important contribution to the debate was a survey of 159 patients in the Netherlands suffering from Alzheimer’s disease (Dementia 2005; 20: 331–7). This established that a high blood pressure and systolic pressure were associated with an increased rate of temporal lobe atrophy. It remains to be seen whether treatment for hypertension would slow the exacerbation of signs of dementia.
Binge drinking and the risk of dementia
There is a great deal in the press about the effects of binge drinking on individuals and their local community. Some studies have started to look ahead to see whether the habit has any long-term effects (Epidemiology 2005; 16: 766–71). One of these reviewed 556 middle-aged individuals who had provided data on their alcohol intake, and it emerged that those with a history of binge drinking in 1975 had a 3.2 times relative risk of having signs of dementia when reassessed between 1999 and 2001. It would be interesting to see whether such bouts have any effect on the mental competence of ‘ladettes’, one of the more fashionable groups of young ladies.
Much ink has been spilt on the dangers of drug interactions in old people suffering from multiple pathology. The problem received further attention in a group of patients before and after hospital discharge (Eur J Clin Pharmacol 2005; 601: 475–81). These consisted of 83 surgical patients and 117 medical ones, with a mean age of 75 years ranging from 25 to 99 years. When patients were visited less than a week after discharge, it was found that they were taking a total of 1,622 drugs either daily or on demand. Each was taking between 1 and 24 drugs daily. From all drugs taken by patients, there were 476 potential interactions. None of these had caused adverse effects. Although there is no room for complacency, it may be that the theoretical risk of side-effects is greater than the reality of the problem.
The walking speed of older people varies from the individual who makes snail-like progress with a Zimmer to the enthusiast who might well be a competitor for the next Olympic walking race. A review of factors influencing walking speed amongst community-dwelling older people has illustrated just how complicated the topic is (Gerontology 2005; 51: 390–5). In a group of 668 individuals aged 75–98 years, factors influencing speed included lower limb strength, postural sway, leaning balance, reaction time, body pain, edge control sensitivity, vitality score and age. The most important of these factors was lower limb strength. It is hoped that the data should be useful in making therapeutic plans and determining prognosis.
There is firm evidence that diet can have an effect on the incidence of colorectal cancer. The information is only relevant if individuals can be persuaded to modify their diets accordingly. This was tested by offering appropriate dietary leaflets to patients attending a colorectal outpatient clinic. (Health Educ J 2005; 64: 247–55). The extent to which individuals remembered details from this was validated by administering a questionnaire to them on their return to the clinic. This established that the approach improved motivation to adhere to the diet for at least a month. The results are encouraging, but will patients adhere to recommendations in the long term and will this reduce the incidence of cancer?
Anticoagulants are increasingly used in hip fractures to prevent deep leg vein thrombosis. The approach is not without its risks, and detailed attention was recently given to 33 hip fracture patients on the anticoagulant at the time of their admission to hospital (Injury 2005; 36: 1311–5). In terms of anticoagulant activity, the average international normalised ratio (INR) on admission was 3.2, and a week later, this had fallen to 2.2. Despite the change, both values were well within the normal therapeutic range.
In 64% of patients, however, it was decided to delay surgery until the INR had reached optimal levels. In 33% of the subgroup, it was decided to let the INR reach this naturally, and this took up to 72 h before this was achieved and surgery undertaken. In the remainder of the subgroup, the change in the INR was accelerated by giving fresh plasma or vitamin K intravenously.
The final outcome was that one patient died from haematemesis and another two died from causes unrelated to the use of an anticoagulant. Given the small sample size, the message would appear to be that if a hip fracture patient has an INR imbalance, this should be treated aggressively rather than waiting to see what happens.
Stroke and the circadian rhythm
There is an increasing stack of papers that suggest that the circadian rhythm has an effect on the time of onset of a stroke. Observers reviewed this by collecting information from 117 patients with a recent stroke (Int J Clin Pract 2005; 59: 1272–5). They found that the peak incidence of the condition was between 6 a.m. and 12 midday and that it often was associated with hypertension or myocardial ischaemia. Having established the factors linking strokes to diurnal variation, it may be possible to sort out the underlying mechanisms behind this.
A multi-variant score of health assessment and depression in older patients
One of the larger medical industries is devising health scores for patients in just about every situation. The one in question describes the construction of a score in which all factors relating to mortality were grouped together (J Clin Epidemiol 2005; 53: 1134–41). Items included in the score were risk factors, disabilities, medical conditions and physiological phenomena.
While developing the score, the group discovered that patients with depression scored worse on all items. At a more focused level, patients with depression were more likely to have a history of inflammation. This reiterates the message that there is a link between depression and poor physical health. The 64,000-dollar (or should it now be 1 million) question seems to be which comes first.
Predicting poor mobility and physical incapacity in type 2 diabetes
The wide range of complications of type 2 diabetes mellitus has a serious effect on mobility and physical function in general. In Australia, a series of patients with this condition were reviewed to establish which of these complications were most likely to cause incapacity (Diabetes Care 2005; 28: 2441–7). Deterioration in mobility was increased by 6% in older patients, by 40% in those with a peripheral neuropathy and by 82% in those with both albuminaemia and arthritis. Mobility was improved by 39% in those taking regular exercise and by 32% in those who were married. Physical incapacity was increased by 22% in those with mobility problems, by 92% in those with a stroke and 42% in those with depression. Although all these data are very interesting, it is more difficult to decide how to make practical use of it. In relation to the protective effect of marital status, should we be encouraging patients to join a dating agency?
Contributions to this column should be sent to Professor Bill MacLennan, 26 Caiystane Avenue, Edinburgh EH10 6SG, UK Email: profmaclennan{at}aol.com
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