Age and Ageing Advance Access originally published online on May 3, 2006
Age and Ageing 2006 35(4):342-343; doi:10.1093/ageing/afl010
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News and Reviews |
News and Reviews
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The incidence of non-vertebral fractures and changes in bone mineral density (BMD) |
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The incidence of non-vertebral...
Leptin and adiponicten responses...Even if a drug changes the incidence of fractures in osteoporosis, it is often unclear how this has been achieved. This has been evaluated in a study of three recent trials of residronate, an anti-resorptive agent (J Bone Miner Dens 2005; 20: 2097–104). All were control trials that gave a total of 4,279 patients who were assessed initially and at the end of 3 years. In the treatment group, the incidence of non-vertebral fractures was 7.7% compared with 10.9% in the controls (P < 0.001), but there was no association between the incidence of these fractures and BMD. This implies that factors other than bone density were responsible for a change in the incidence of non-vertebral fractures. Candidates include trabecular geometry, the bone micro-structure and the material properties of the bone.
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Leptin and adiponicten responses to exercise in overweight elderly men |
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Proteins derived from adipose tissue, such as leptin and adiponectin can modify body mass by satiety control, increasing the basal metabolic rate (BMR) and regulating carbohydrate intake. In a control trial over 1 year, a group of overweight men aged 65–78 years were allocated to either no exercise, low-density exercise or high-density exercise (Clin End Metab 2005; 90: 590–7). After 1 year, both the levels of exercise were associated with an increased maximal exercise oxygen consumption and BMR. They were also associated with a reduction in skin-fold thickness and body mass index (BMI). For all these measures, there was a particularly strong association with high-density exercise. Both the levels of exercise were also associated with a reduction in leptin and adiponectin concentrations, and the largest changes in these were associated with maximal changes in BMI.
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Are old people getting healthier? |
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Given that there has been a dramatic increase in the life expectancy of inhabitants in the developed world, it might be expected that old people there would be healthier. In the United States, a comparison was made between elderly individuals assessed around 1991 and around 1999 in the National Health and Nutrition Survey (J Geront 2005; 600: 1409–13). Between the two periods, there was a 6% reduction in subjects with high cholesterol levels. Conversely, there was a 9% increase in those with systolic hypertension, a 10% increase in those with obesity and a 9% increase in those with raised C-reactive protein. It may be that we are witnessing a replacement of the diseases of poverty by those of affluence.
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Deep brain stimulation in Parkinson’s disease |
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With increased experience, surgeons have become more confident about subjecting selected patients with Parkinson’s disease to deep brain stimulation. Up-to-date evidence for the efficacy of such treatment has been provided by a meta-analysis of 45 clinical reviews (J Neurol 2005; 103: 756–67). Treatment achieved a 54% improvement in motor function and a 40% improvement in daily living activity. Though there were some minor differences in efficacy targeting between the globus pallidus and the subthalamic nucleus, the overall picture was that of a safe and effective technique.
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Inequalities in secondary prevention of coronary heart disease in older men |
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Medication is widely used in the secondary prevention of coronary heart disease, but are all age groups treated with the same vigour? A prospective study was conducted on the use of such medication in men with ischaemic heart disease (J Public Health 2005; 27: 378–87). Subjects aged 62–83 years were selected from general practice surgeries in the United Kingdom. With increased age, fewer patients received statins and, in individuals aged 75–84 years, the intake was only 60% of that in younger groups. There may be good reason for the reduction of statins in old age, but it is important that they be identified and remedied if necessary.
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Smoking and intermittent claudication |
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Fifty years ago, intermittent claudication was a male disease. Nowadays, things seem to be changing. This was established in a review of 19,745 individuals aged 40–69 years, who were given a short questionnaire (Vas Med 2005; 10: 257–63). It emerged that both men and women who smoked or were previous smokers were more likely to have peripheral vascular disease. Passive smoking had no effect on the condition. It is clear that the recent increase in women smokers is producing in them many of the diseases previously found in male smokers.
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Aortic root dimensions (ARD) in patients aged 65 years and over at risk of cardiovascular disease |
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There already is a range of tests used to assess risk in patients with cardiovascular disease. A recent paper gives an account of ARD measured by ultrasonography as an additional technique for predicting the outcome in cardiovascular disease in old age (Am J Card 2006; 97: 270–5). In 3,933 subjects aged 65 years and over, there was a higher ARD in males and individuals with increasing age. Other features associated with an increased ARD were congestive cardiac failure, left ventricular hypertrophy, major electrocardiographic abnormalities and an increased left ventricular mass. Follow-up over 10 years showed that a high ARD was associated with an increased rate of congestive cardiac failure and stroke in men, and an increased cardiovascular mortality in men and women treated with hypotensive agents. Though the findings are of considerable epidemiological interest, it remains to be seen whether they will contribute to clinical management.
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Homocysteine-lowering vitamin treatment in elderly patients with vascular disease |
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Homocysteine increases the risk of cardiovascular disease by virtue of its effects on thrombosis, platelet activation and thrombo-embolism. A variety of vitamins inhibit its formation including folic acid, B12 and riboflavin. In a recent study, subjects of 65 years old or over were given nothing or folic acid and B12 or riboflavin (Am J Clin Nutr 2005; 32: 1320–6). Treatment with folic acid and B12 reduced homocysteine levels, but riboflavin had no effect. In patients with reduced homocysteine levels, there was no change in fibrinogen or von Willibrand’s factor levels or in performance on cognitive function tests. In Scottish legal parlance, the clinical value of vitamins in lowering homocysteine levels remains ‘not proven’.
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Heart disease and dementia |
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There is strong evidence that hypertension increases the risk of dementia. The relationship between ischaemic heart disease and dementia is less clear. In an effort to resolve any association, a record system in the Rochester Epidemiology Project was used to identify 916 patients with dementia and 916 controls (Am J Epidem 2006; 163: 135–41). The odds ratio of patients having a myocardial infarction before the onset of dementia was 0.46. After the onset of dementia, the risk of dying from cardiac disease was reduced by 18%. It is unclear what this means. What does seem clear is that myocardial infarction is not usually a cause of dementia.
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Changes in mortality in the second year after a stroke |
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Many professionals have the impression that once patients return home after rehabilitation, they maintain their initial level of function. There are reports, however, of a proportion deteriorating over a relatively short period of time. The issue was investigated in more detail by an initial assessment of patients followed up by a reassessment using a Richmond Mobility Index (RMI) in the second year after a stroke (Arch Phys Med Rehab 2006; 877: 45–50).
Though there was no change in the mean RMI over the period, 12% of patients experienced a decline in mobility. This was most common in those with depression, right-sided weakness, an ischaemic stroke, aphasia and cognitive impairment. It was also more likely in poor mobility linked to co-morbidity, poor mobility itself and poor social functioning. The only one among these factors to reach a level of statistical significance was depression. Overall, the paper suggests that the medium-term prospects for most stroke patients are relatively good.
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Osteoarthritis of the hands |
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Many old people have osteoarthritis of their fingers, but it is unclear whether this is local or part of a systemic disorder. The problem has been tackled by performing X-rays on the hands, hips and knees of 7,783 patients aged 55 years and over (Arth Rheum 2005; 52: 3523). In 19.7% of those with and 11.0% of those without arthritis of the hands, arthritis of the hips or knees was in evidence [OR 2.1 (95% 1.3–3.1)]. The former also had an increased risk of sustaining a hip fracture [OR 3.1 (95% 1.6–5.4)]. It seems clear then that osteoarthritis is part of a systemic disorder.
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Pharmacokinetics of fluoxetine in elderly men and women |
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Though pharmacokinetic studies on elderly patients provide invaluable information, there often are major practical and ethical issues that require resolution. It was encouraging therefore to see a report on a pharmacokinetic study of fluoxetine, a drug widely used in the treatment of depression in elderly patients (Gerontology 2006; 52: 45–50). In the study, 25 men and women between the ages of 65 and 83 years received 20 mg of fluoxetine for 1 week and 40 mg for 5 weeks. Plasma levels of fluoxetine were higher than those recorded in similar studies of younger patients, and women in the study had higher levels than men. The half-lives of the drug were longer in patients over the age of 75 years, and there was a slower rate of elimination of the drug in women. These observations should go some way to fine tuning the dose of the antidepressant appropriate for elderly patients.
DIOGENES
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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