News and Reviews
Peri-operative evidence based pathway and morbidity after hip fracture surgeryElderly patients treated for a fractured hip have high mortality and morbidity. A useful approach might be to apply a peri-operative evidence-based pathway (EBP) of management. The approach was tested on 663 patients subjected to EBP against 678 controls given standard management (Quality and Safety in Health Care 2006; 15: 375–79). The two groups had no differences in in-hospital mortality or overall length of stay, but subjects allocated to EBP had a lower post-operative morbidity and a reduced necessary period of rehabilitation. It would appear that EBP was a useful approach but so many variables were involved that further evaluation seems necessary.
Repeated pulmonary rehabilitation: in chronic obstructive airways disease (COAD)
Many elderly people suffer from chronic obstructive airways disease COAD and might benefit from more frequent courses of pulmonary rehabilitation (PR). This was evaluated by assigning a group of such patients of all ages to receive courses of PR initially, at 6 months and at 1 year. A control group received treatment initially and 1 year later (Respiration 2006; 73: 763–66). Extra treatment produced a decline in peak effort dyspnoea and leg fatigue and an improvement in health related quality of life. Such patients also received less frequent hospital admissions and spent fewer days in hospital. Given the frailty of some elderly patients, treatment with PR may be more problematic but it certainly appears to be an approach worth trying.
Depression in patients with rheumatoid arthritis
Given chronic unrelenting pain, severe disability and insomnia, it is not surprising that some patients with rheumatoid arthritis become depressed. What is surprising is that its prevalence is only between 1 in 10 and 1 in 5 of patients (Rheumatology 2006; 45: 1325–27). It is more likely to occur in younger patients, in those with low self-esteem in those with feelings of helplessness. The conviction and charisma of the clinicians may also be important. At a biological level it would appear that depression is more likely if there is a high level of C reactive protein or of tumour necrosis factor. Cytokine levels may also be important.
On a more reassuring note, the depression of most rheumatoid patients responds well to treatment. This will not happen, however, if the clinician is not sufficiently perceptive in diagnosing the condition.
Insomnia affects individuals of all ages but, anecdotally at least, there are different features in young and old subjects. This was studied systematically in 8,500 individuals aged 16–74 years (Sleep 2006; 29: 1391–97). The condition presented problems in 37% but was more common in older people with a poor physical health quality of life. It was this group also who were more likely to be taking benzodiazepines. This does not tell us much that we did not already suspect but perhaps it is time we got down to finding a solution rather than merely writing about the problem.
Ultrasound, carotid plaques and cardiovascular disease
The authors of this paper proposed that detection of an asymptomatic carotid plaque by ultrasound identifies individuals at increased risk from cardiovascular disease (Vascular Medicine 2006; 11: 123–30). Review of the medical literature identified a number of studies with over 300 subjects, nine of which provided criteria for sound meta-analysis and seven provided sufficient data for comparison of ultrasound diagnosis of a carotid plaque with the incidence of cardiovascular disease. All studies established a good correlation between the presence of carotid plaque and the onset of cardiovascular disease.
With the amount of diagnostic equipment now available, the question may be how many tests should we use for screening purposes. A patient with enough money could have a different test each week but what would this cost him and what effect would it have on his life expectancy?
Dealing with falls in old age costs a great deal of money. A review of this in individuals over the age of 65 years has been conducted in the United States (Injury Prevention 2006; 12: 290–95). In the year 2000 there were 16,300 fatal and 2.6 million medically treated non-fatal falls. Managing fatal falls cost $0.2 billion and treating non-fatal ones $19 billion. In non-fatal falls the costs broke down to $12 billion for hospitalisation, $4 billion for emergency treatment and $3 billion for other treatment. Expenditure for women was two to three times that of men. Clearly there are financial as well as humanitarian reasons for investigating all aspects of falls in old people.
Eating disorders in the elderly
On the odd occasion that I have glanced at a woman's magazine in a dental waiting room, I have got the impression that to be a celebrity you must be young, fashionable and anorexic. It helps even more if you talk about the latter. Focussing on the medical literature it would appear that anorexia is not confined to the young. The issue was explored by sending an appropriate questionnaire to 1,000 women between the ages of 60 and 70 years (International Journal of Eating Disorders 2006; 38: 576–82). Forty eight per cent returned sufficient data for useful analysis. They had a mean body mass index (BMI) of 25.1. Despite this ideal, the average they would have preferred was 23.3. Whatever their BMI, 60% were unhappy with their body shape. Of much greater concern was that 3.8% met the clinical criteria for either bulimia or anorexia. Clinicians should take such disorders in old people more seriously. They will only find them if they look for them.
General practitioner led screening for depression in a nursing home
It is likely that depression often goes undetected in old people in nursing homes. An Australian team has devised a scheme for getting to grips with the problem (In J Psychogeriatric Med 2006; 21: 1026–30). Their approach was to provide general practitioners with a single education session on late life depression and train them in using the Cornwall Scale for Depression. Following this, ten general practitioners and 38 patients completed all aspects of the programme. This yielded 24% of patients who probably had depression and another 32% who had some symptoms of depression. Following these observations a further 29 patients were treated with antidepressants. A message from this is that it is all too easy to label a frail elderly patient with a treatable disorder as ‘just another old crumble’.
While being encouraged to learn something new every day, my problem is retrieving things from the back of my dusty mental filing cabinet. One such condition is reflex sympathetic dystrophy. It does not figure large in most modern books on stroke but is a cause of much pain and disability (Int J Rehab Res 2006; 275–301). It is related to stroke and features include a painful shoulder, a swollen and painful hand, vasomotor instability, joint contractures and limited hand movement. Review of 95 patients with stroke defined 29 with the condition. Factors linked with it were limb flaccidity and glenohumoral subluxation. Subsequent review established that the condition had an adverse effect on rehabilitation.
Fracture of the shaft of the humerus
Until I read this paper, the only fractures of the shaft of the humerus I had come across were natural breaks in skeletons exhumed from a medieval graveyard. (Historic Scotland gave us permission to do this.) The authors of the current paper established that the incidence of the condition in the living over the age of 16 years was 14.5 per 100,000 (J Bone Joint Surg 2006; 888: 1469–73). From this level, the incidence increased to 60 per 100,000 in the ninth decade. Clearly this must be another osteoporosis-related fracture. The reason that it does not feature more commonly in our consciousness is that it is a relatively uncommon injury.
Treatment of older women with androgen
One of the consequences of ageing is muscle wasting and weakness. In an attempt to slow the process down, a group of elderly women were given androgens (J Clin End Metab 2006; 91: 3844–49). The approach was to give five women with a mean age of 65 years a 7.5 mg oral dose of a recently developed agent, oxarbin, twice a day. The effects were controlled with those in a group of ten men given the drug in a dose of 10 mg twice daily. Over 2 weeks, the women developed an increase in skeletal muscle mass and an increase in fractional systematic rate. The male controls experienced an even greater increase in muscle mass. Whereas males also experienced an increase in androgen receptor expression, there was no such change in women. The treatment may suggest an approach to the elixir of use, but I would take the more conservative approach of encouraging more women to attend appropriate exercise classes.
Notes
Contributions to this column should be sent to Professor W. J. MacLennan Email:
Profmaclennan{at}aol.com
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