News and Reviews
Age and testicular germ-cell tumoursA testicular germ-cell tumour characteristically is a disorder of young men. It is less common in older men but can be particularly virulent in them. Evidence of this was found in 93 patients over the age of 40 years (Urol Internat 2007; 79: 117–23). Only 15% over the age of 50 years had localised disease. They also had a reduced response to chemotherapy, an increased rate of tumour progression and an increased mortality.
Smoking, stopping and mortality in older people
A common response of an octogenarian rebuked for smoking is ‘Since I've smoked to this age it can't be doing much harm’. The rejoinder is that it is. Confirmation of this was found in Chinese subjects attending a health centre who were reviewed for over an average period of 4.1 years (Tobacco Control 2007; 16: 182–9). The relative risk (RR) of death between smokers and former smokers in men was 1.39 and that between smokers and non-smokers in men was 1.75. In women the figures for the same groups were 1.43 and 1.38. The lack of difference in women may have been due to there being fewer and lighter smokers. No matter how logical the arguments of old people for smoking, the statistics are against them.
Cardiac disease of hypertension and elective-hip arthroplasty
Orthopaedic surgeons are often faced with the dilemma of improving the mobility of an older patient with hip disease but dealing with an increased operative and post-operative risk because of concurrent disease. This has recently been evaluated by comparing mortality in patients receiving arthroplasty with or without cardiac disease or hypertension (J Royal College of Surgeons of Edinburgh 2007; 5: 260–5). Three months after surgery the mortality in patients with one of the two conditions was no greater than in the control group. The only difference between groups was that there was an increase in long-term mortality in patients with coronary artery disease but this is unlikely to have been associated with the operation. It may be that orthopaedic surgeons might be able to stretch their criteria for patients fit for arthroplasty. Clearly, however, they would want to keep their results under tight review.
Euthanasia in pre-industrial society, 1500–1800
Given the religious constraints of pre-industrial society it is surprising to read about the practice of euthanasia in this period (Social History of Medicine 2007; 20: 205–11). Some of the methods were bizarre and included simply removing a headrest or laying a terminally ill patient flat on a cold floor. There also were instances where the much more aggressive approach of suffocation was employed. It is suggested that one reason for euthanasia being practised was the strong belief in an afterlife so that ending a period of extreme suffering did not lead to oblivion. Given modern methods of palliative care it is to be hoped that no one would want to turn the clock back to these more primitive times.
Night-time sleep, afternoon naps and mortality in old age
Over many years there has been debate as to whether particular patterns of sleep lead to a decreased life expectancy. Recent evidence on this comes from a review of 3,079 inhabitants of Taiwan who were aged 64 years and over (Sleep 2007; 30: 1105). Men sleeping 10 h or more per night and women sleeping 8 h or more had an increased mortality. The duration of afternoon naps had no effect on the death rate. Which are cause and which are effect and the actual factors involved are unclear. For the time being there seems to be no good reason for annoying old people by wakening them early.
Prolonged hospitalisation and bed occupancy
Fifty years on there is continuing concern about the effects of prolonged hospitalisation on bed occupancy. Review of 117,178 admissions to a medical unit over five years established that only 0.6% of patients spent more than 100 days there (QJM 2007; 100: 539–45). Despite this they accounted for 11% of the total bed occupancy. It is suggested that more attention should be given to targeting this group. This might involve more active rehabilitation and more effective liaison with local authority and private services. I suspect, however, that the problem will never be completely eliminated and that experts will still be debating the issue in another 50 years.
Donepezil and agitation in Alzheimer's disease
One of the more contentious issues in Alzheimer's disease is the treatment of agitation with anti-cholinesterase inhibitors. A group of physicians in England have explored the issue by performing a 12-week controlled trial of donepezil in agitated patients with Alzheimer's disease (N Engl J Med 2007; 357: 1382–92). There were no differences between the effects of the drug and a placebo. This provides yet further evidence that anti-cholinesterase inhibitors are of little value in the treatment of agitation in dementia.
Quality of life in patients with peripheral vascular disease
It would not be surprising if peripheral vascular disease had an adverse effect on the quality of lives of sufferers. The association was investigated in 203 patients who were evaluated initially and one year later (J Vasc Dis 2007; 46: 507–12). Over the period there was an improvement in their health-related quality of life (HRQOL). Invasive treatment improved physical function and pain relief. Patients with a Type D personality (negative emotions and social inhibition) did less well. The message would appear to be that personality plays an important part in a patient's response to a serious physical illness.
Acute respiratory distress syndrome (Ards) in older patients
Increasing attention to the assessment of older patients admitted to a trauma unit has resulted in the more frequent identification of acute respiratory distress syndrome (ARDS) in this group. It might be expected that they would have a worse prognosis than younger patients but a recent review of 210 patients of 65 years and over has produced a more optimistic picture in that their mortality was 54.1% compared with 41.7% in younger individuals. There was a particularly high mortality in patients with a high acute physiology and chronic health evaluation (APACHE). It would appear that age itself is not a critical determinant of mortality and that the general health of patients of all ages is much more relevant.
Co-morbidity in osteoarthritis and disability in older patients
In patients with osteoarthritis co-morbidity can be as important a cause of disability as joint damage. The message was reinforced in a group of patients in general practice aged 50 years and over (J Rheum 2007; 34: 1899–1904). There were 1,026 with osteoarthritis and 8,160 without it. In the former where there was sufficient information 3.7% had no co-morbidity, 28.1% low co-morbidity, 25.3% moderate co-morbidity and 42.9% high co-morbidity. There was a strong correlation between the degree of co-morbidity and reduced physical function. The observation could be of critical importance in deciding on treatment and rehabilitation in patients with osteoarthritis.
Is an abnormal gait a feature of dementia?
A pioneer in the study of gait dysfunction was John Cleese who established the Ministry of Silly Walks. More recently it has emerged that an abnormal gait may be an early feature of dementia and of considerable diagnostic value. The phenomenon emerged in a study of 427 subjects of 70 years and over only 28 of whom were demented (J Neurol Neurosurg and Psych 2007; 78: 920–35). Over five years another 33 subjects developed dementia and there was a strong correlation between an abnormal gait on first evaluation and the development of this condition. The relevance of the association has yet to be established.
Efficacy and safety of statins in older patients
There is no doubt that statins have made an important contribution to the management of vascular disease in younger patients. What is the situation in older ones? A group tried to answer this by performing a meta-analysis of trials of statins in patients aged 60 years and over (J Gerontol—Med Sci 2007; 62A: 879–911). Evaluation of 51,351 subjects established that death from coronary artery disease was reduced by 26% and non-fatal stroke by 24%. The relative risk of patients on statins developing complications was 1.06 but the details of these were insufficiently standardised to provide a more detailed account. It would appear then that statins work in old people and that they seem to be relatively safe.
Notes
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Email: profmaclennan{at}sky.com
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