News and Reviews
Tegaserod, Parkinson's disease and constipationIn Parkinson's disease, constipation is resistant to the more familiar forms of treatment such as bulking agents, stool softeners and laxatives. Recently, there has been a report on the use of tegaserod, a 5-hydroxyltryptamine type 1a agonist (Clin Neuropharm 2007; 30: 52–4). In five patients it was an effective laxative and improved bowel movements and stool consistency. The results are encouraging but larger numbers and controls are required to take this study further.
Exercise in older acute medical patients
Authors have tried to evaluate the efficacy of physical exercise in older patients admitted to acute medical units by reviewing 3,139 papers on the topic (Clin Rehab 2007; 21: 3–16). This yielded seven randomised controlled trials and two pseudo-randomised ones. Exercise combined with other forms of therapy increased the proportion of patients sent home (CI 1.03–1.14), and resulted in a small reduction in length of stay in hospital (CI –1.93 to –0.22) and a saving in hospital costs (CI –4.93 to –0.65). All these benefits with the effects of exercise were analysed separately from other measures. The results are pretty confusion but it would appear that exercise does not have much place for the patients in question. The other comment is that it seems a great waste of effort to perform over 3,000 studies that could not be used to answer the question under consideration.
Dental status in five cohorts of 70-year-old subjects
Sweden is widely acclaimed for the many cohort studies performed on old people. A recent study concentrated on five cohorts of patients aged 70 years whose dental health had been followed-up over 30 years (Community Dent Oral Epid 2006; 34: 446–54). Over the period, the proportion of dentate individuals increased from 49 to 93% with the mean number of teeth in individuals increasing from 14 to 21. The percentage of those with 20 or more teeth increased from 13 to 65%, and that of those paying annual visits to their dentist from 5 to 80%. Factors having an adverse effect on dental health were a poor education, smoking, being single, obesity and inactivity. Given problems in obtaining NHS dental care, a similar study in the United Kingdom might provide a salutary message.
The preferred treatment of European women for osteoporosis
The efficacy of long-term treatment of osteoporosis is dependent on compliance, hence the reason for asking women with osteoporosis to chose between the weekly and monthly administration of a bisphosphonate (Curr Med Ress Opin 2006; 22: 2375–81). Eighty-two per cent of the sample chose weekly treatment.
There can be no doubt that a regular heavy intake of alcohol can cause severe brain damage, but what about a low or moderate intake? A total of 1,341 subjects in east Finland have been under review for 21 years (Dementia and Cognitive Disorders 2007; 23: 140–9). Non-drinkers were more likely to have a poor episodic memory, low psychomotor speed and impaired executive function. I wish I had known this 20 years ago.
Staffing levels and nutrition in residential care
The paper is a timely reminder that poor nutrition is a major problem in residential care where there are inadequate numbers and training of care staff (Eur J Clin Nutr 2005; 59: 474–9). This review concerns 1,914 individuals in 14 residential homes in Hong Kong. Adequate information was collected from 1,699. Of these, 25% had a body mass index of less than 18.5 g/m2, the highest prevalence of low values being in homes run for profit. The number and training of staff was another important factor. Multifactorial analysis established that other correlates of poor nutrition were chronic obstructive airways disease, insufficient help with feeding, being female and being older.
Calcium supplements for bone loss in cardiac failure?
An unexpected observation was that over 50% of patients with congestive cardiac failure have a reduced bone density (Eur J End 2007; 156: 509–14). The message was reinforced in a study of 33 patients with cardiac failure where 15% had osteoporosis of the lumbar vertebrae, and 6% had the condition in the neck of the femur. Factors thought to be responsible for the association were that 70% of subjects had poor renal function, 42% had secondary hyperparathyroidism and 33% had hyogonadism. A controlled trial of 1000 g calcium daily for 1 year established that the treatment had no effect on bone density. Given the poor prognosis of many patients with congestive cardiac failure there must be doubt as to the relevance of diagnosing and treating this secondary disorder.
Oral B12 and cognitive function in older patients with low serum cyanocobalamin levels
There are some older patients who have low serum cyanocobalamin levels in whom the phenomenon has no apparent effect. One suggestion is that it could have an undetected effect on mental function. This was investigated by designing a double blind trial on 193 patients aged over 70 years to measure the effects of oral B12 on mental function (Evidence Based Medicine 2007; 12: 18). Three groups in the study received B12 alone, B12 and folic acid or no treatment for 24 weeks. There was no significant change in cognitive function in any of the groups. It would appear then that an isolated low serum cyanocobalamin is unlikely to have any effect on mental function in elderly patients.
Non-pharmacological treatment of heart failure in old people
A recent paper investigated the hypothesis that older patients on medication derive additional benefit from physical therapy designed to increase exercise capacity and promote relaxation (Gerontology 2007; 53: 74–91). This was investigated by selecting a group of patients with heart failure treated with drugs and placing them in three groups consisting of physical exercise (59), relaxation techniques (59) and no new treatment. Each of these approaches was continued for 24 weeks. The first two groups experienced better psychological and disease-specific outcomes than the third one. Relaxation techniques were more effective in improving psychological symptoms while the exercise programme was better at relieving fatigue.
Until recently, the view was that most old people died in hospital. Things seem to be changing in western Australia (Health and Place 2007; 13: 356–67). A review of 26,882 people dying over a period of 30 months in this state established that only half died in hospital. Most of the others died either at home or in residential home. A small group receiving specific palliative care were seven times more likely to die at home. A further move in this direction might reduce even further the proportion of old people dying in hospital.
Are there differences between young and old people with liver cancer?
The paper was designed to establish whether there are any differences in the aetiology of liver cancer in young and old people (Hepato-Gastroenterology 2006; 53: 013–8). In the series there were 73 patients under 50 years of age, and 941 of 50 years of age or over. The younger group had a higher ratio of males to females and a positive test for hepatitis B antigen. Those with an antibody to hepatitis C had higher alanine aminotransferase levels. Younger people also had a higher level of alcohol consumption. Though the findings are of interest they may be the result of a cohort effect and it is unclear how they will contribute to a more efficient diagnosis or treatment of liver cancer.
Though there have been many criticisms about the terminal care of patients there have been few examples of a more mismanaged death than that of King Charles II (Fraser A. King Charles II. London; Phoenix, pp 579–96). On 1 February 1685 he suffered what was almost certainly a stroke. A number of doctors were summoned. The first to intervene was Sir Edmond King who bled him. Thereafter a flock of other doctors each plied him with their favourite potions. They then shaved his head and applied a blistering agent followed by further bleeding. Despite this his condition improved.
Two days later he had a further seizure and twelve doctors swarmed around him applying ever more desperate measures. These included a sneezing powder, Burgundy pitch to his feet and another blistering agent to his head. He was also given salt and buckthorn enemas and emetics including white vitriol. Among the more bizarre oral remedies were the bezoar stone from a goat's stomach and a solution from a human skull. When these did not work his head and feet were cauterised and cupping glasses applied. By the following day he had made a slight improvement. Thereafter, he suffered convulsions and died. Even at this stage, none of the twelve physicians were able to put a label to his condition. It would have served the King much better if they had simply left him alone.
Notes
Contributions to this column should be sent to Professor W. J. MacLennan
Email: profmaclennan{at}aol.com
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