Editor's view |
Editor's view
Editor, Age and Ageing
The use of bedrails in the care of older people in hospitals and nursing homes has long been controversial and was the subject of a lively debate at a recent British Geriatrics Society meeting. On the one hand they are considered by many to be unethical as they constitute a form of restraint, whereas others justify their use in the prevention of falls from bed, which account for a quarter of all falls in a healthcare setting. A Systematic Review published in this issue has addressed not the ethics of using bedrails, but their effect on falls from bed and the resulting injuries (pp. 368–378). Although the studies included had methodological problems, the authors conclude that serious injury involving bedrails is usually related to outdated design and incorrect assembly, and suggest that appropriately designed bedrails do not increase the risk of falls or injury. The results are unlikely to satisfy either the protagonists or antagonists of the use of bedrails, but this review should at least stimulate further controversy and debate.
Over the last few decades, there has been a major interest in the potentially adverse effects of the hormonal changes associated with menopause on women's health. The decline in circulating testosterone concentrations with advancing age in men is less dramatic and its impact on men's health has, arguably, received less attention. A Research Letter reports the results of a ten-year prospective study in 187 older men from Finland, in whom baseline serum testosterone measurements were available (461–464). The authors show an inverse relationship between serum testosterone and mortality, which was independent of potential confounding factors. They speculate that high serum testosterone concentrations may protect against the development of vascular disease through a beneficial effect on lipoproteins, but acknowledge that testosterone also has important effects on the skeleton, muscles, mood and cognitive function. Unfortunately, the authors did not measure sex hormone-binding globulin (SHBG), which influences the concentration of the biologically active, unbound, free testosterone. The increase in SHBG with advancing age in men results in a greater age-related decline in free testosterone than total testosterone concentrations. Future studies should therefore include measurement of free testosterone, or calculation of free testosterone from the total testosterone and SHBG, which may provide greater insights into the effects of androgens.
An Editorial in this issue explores the relationship between androgens, ageing and vascular function in men (361–363). The authors highlight the decline in circulating testosterone concentration with advancing age in men and review the cardiovascular effects of androgens. Although hypogonadism is common in older men and may be a risk factor for cardiovascular disease, we should be circumspect about recommending widespread use of testosterone replacement, until we know more about the balance of risks and benefits. It was only when the results of the Women's Health Initiative Study of hormone replacement therapy (HRT) in post-menopausal women were published, that we realised that HRT increased rather than reduced the risk of cardiovascular disease.
Type II diabetes mellitus is associated with impaired cognitive function and an increased risk of dementia in older people. A study reported in this issue (pp. 458–461) examined the potential causes of impaired cognitive function in 77 consecutive patients aged between 65 and 85 years, referred to a single Diabetes Centre in Japan. The subjects underwent clinical assessment, a series of tests for cognitive function, measurement of haemoglobin A1c (HbA1c), fasting blood glucose, plasma insulin, lipids and MRI brain scan. Although it is difficult to draw firm conclusions from a small cross-sectional study at a single centre, impaired cognitive function was associated with higher HbA1c and insulin concentrations, and with MRI evidence of cerebral infarction. As the authors conclude in their discussion, a large, multi-centre interventional study would be required to establish if improved control of type II diabetes mellitus can prevent cognitive decline, but the logistical difficulties of conducting such a trial could be difficult to overcome.
Another study investigated the relationship between nutritional factors and cognitive function in 2,550 older adults taking part in the Singapore Longitudinal Ageing Study (pp. 423–429). After adjusting for age, gender and risks factors for vascular disease, low albumin, low haemoglobin and low body mass index (BMI) associated with chronic co-morbidity were all independently associated with cognitive impairment, as reflected by a mini mental state examination (MMSE) of 23 or less. Once again, prospective observational and interventional studies are required to clarify the relationship between these nutritional factors and cognitive decline, but in the meanwhile, the presence of low serum albumin, anaemia and low BMI associated with other co-morbid conditions should alert the clinician to the possibility of impaired cognitive function.
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