Age and Ageing Advance Access originally published online on October 1, 2008
Age and Ageing 2008 37(6):616-617; doi:10.1093/ageing/afn202
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News and Reviews
Factors encouraging older people to seek tests of cognitive impairment
If there are benefits in the early detection of mental impairment what encourages older patients to attend a clinic for assessment of this? A review of such individuals suggested that the most important factor was anxiety about whether or not they had Alzheimer's disease (Alzheimer's Disease 2008; 22: 144–52). Those previously tested for cognitive function were also more likely to seek assessment.
Differences in the management and prognosis of myocardial infarction in older men and women
Data were analysed on the management and prognosis of 1,625 patients over the age of 65 years admitted to hospital with myocardial infarction (Am J Cardiol 2008; 101: 1531–6). The women were older, had a higher body mass ratio and were more likely to be suffering from diabetes, renal impairment or depression but were less likely to have had a previous myocardial infarction, chronic lung disease, cancer or to be smokers. Despite this, over an average follow-up period of 6.6 years, men aged 65–74 years were 40% more likely to die than women. In men of 75 years and over, there was an even greater difference from women in short- and long-term prognosis. The reasons for these paradoxical differences in outcome were not defined.
The influence of comorbid illness and functional status on benefit from treatment of type 2 diabetes with insulin
Treatment of type 2 diabetes with insulin makes life more difficult for patients so that it is important to define situations in which it is likely to be of benefit. In a group of patients aged 60–80 years on insulin for type 2 diabetes, those with tight control of Hb A1C were compared with those with less stringent management (Ann In Med 2008; 149: 11–9). Those on tight control achieved an increase between 51 and 116 quality-adjusted days. The benefit fell with the severity of premorbid illness and the initial level of functional impairment. The prognosis was also reduced in patients aged 60–65 years as opposed to older ones and in those with a longer duration of the condition. It remains unclear whether these differences in benefit would be sufficient to modify treatment.
Ascorbic acid and 
tocopherol in oxidative stress and DNA damage
Many of us continue to look for the elixir of youth. A recent approach has been to give ascorbic acid and tocopherol to older individuals (Ann Metab Nutr 2008; 52: 167–73). Sixty-six of them were divided into three groups. Group A received a placebo, Group B 500 mg of ascorbic acid and 400 IU of tocopherol and Group C 1000 mg of ascorbic acid and 400 IU of tocopherol. Changes at the end of 6 months were that the groups had increased superoxide dismutase and glutamine peroxidise levels, but that the change was not statistically different. There also were no statistically significant changes in Group C. There also were no differences in DNA migration between the three groups. We seem to be no further forward. Perhaps we should go back to trying to transmute base metals into gold.
Etanercept in giant cell arteritis
Corticosteroids are extremely effective in giant cell arteritis (GCA) but can have serious side-effects. Etanercept, a drug which suppresses tumour necrosis factor, has been investigated as a potential alternative (Ann Rheum Dis 2008; 67: 625–30). In a small trial, eight patients with GCA on etanercept and a corticosteroid were compared with nine on the steroid and placebo. After 12 months, those on etanercept had higher levels of glycaemia. GCA was under control in 50% of the treatment group compared to 22.2% on placebo. Those in the former group were on a lower dose of corticosteroids. Larger studies are required to compare the benefits of the drug against side-effects including those on glucose metabolism.
Aneurysms of the abdominal aorta in older men with an inguinal hernia
There is the suggestion that men with an inguinal hernia are more likely to have an aneurysm of the abdominal aorta. This was investigated by investigating 70 males aged 65–88 years with an inguinal hernia (Ann R Coll Surg Eng 2008; 90: 386–8). Ultrasound examination established that only 3% had an aneurysm. This useful negative result should eliminate the need for ultrasonography in patients with an inguinal hernia.
Cannabis and brain abnormalities
There is accumulating evidence that large doses of cannabis over a long period of time can cause brain damage. The hypothesis was explored in 15 individuals regularly smoking more than five joints per day (Arch Gen Psych 2008; 65: 694–701). Ultrasonography established that there was a reduction in the sizes of the amygdala and hippocampus and that there was a correlation between the dose of cannabis and the severity of psychiatric symptoms. Subjects also performed poorly on verbal learning. It may be that in future years the side-effects of cannabis may be a major cause for admission to psychogeriatric wards.
Rosiglitazone in diabetic retinopathy
Ophthalmologists have played a major part in improving the quality of life of older people. Another promising area of progress is the treatment of diabetic retinopathy (Arch Ophthal 2008; 126: 793–9). This was evaluated in a controlled trial of 124 patients with the condition treated with rosiglitazone, an antidiabetic drug compared with 158 on a placebo. After a mean time of 2.8 years, 19.2% of the treatment group had retinopathy compared with 47.4% of the controls. This is an extremely encouraging result.
There are exceptions to the poor prognosis associated with a head injury in old age. The outcome of 96 patients with a head injury over the age of 65 years has been reported ( J Neurol 2008; 8: 589–92). One-third received only palliative treatment, another third had supportive treatment without surgery and the remainder received surgery. There was an overall mortality of 70.8%. Predictors of mortality were an older age and brainstem damage. All those over the age of 85 years died. Nevertheless, it should be noted that a patient with an appalling prognosis occasionally does well, so that all older patients with a head injury deserve an accurate assessment and appropriate intervention.
Risk of fractures after discontinuation of corticosteroids
It has long been recognised that treatment with corticosteroids increases the risk of fractures. There is less information on which corticosteroids cause the greatest risk and the effect of discontinuation of therapy. These issues were evaluated in a study of 124,655 patients sustaining a fracture in 2000 and 375,962 controls not sustaining such an injury (Calc Tissue Int 2008; 82: 249–57). Oral prednisone/prednisolone was associated with an increased risk of fracture where the dose was >6.7 mg/day, while oral budesonide did not influence the risk of a fracture. Oral methyl prednisolone was also free of risk when given intermittently. In the case of oral prednisone/prednisolone, it took a year for the risk of fracture to return to normal after treatment was discontinued.
Risk factors and lifestyle in the secondary prevention of stroke
Can anything be done to improve the prognosis of a patient who has had a stroke? A research group in Sweden has investigated this in 394 stroke patients selected from a population cohort of 28,445 (Cardiovasc Dis 2008; 25: 526–32). 79.4% of stroke patients had hypertension, but only half were on appropriate therapy and only 11.9% had satisfactory control of their blood pressure. Few were on a lipid-lowering agent but 38% were on antithrombotic treatment. Many were overweight and one-third continued to smoke. It is clear that many of the sample had an increased risk of further episodes of cardiovascular disease. Much more could have been done to correct these if patient compliance had been appropriate.
Antibiotic treatment of Clostridium difficile-associated disease
One of the more virulent infections to attack older patients and elicit lurid press headlines is Clostridium difficile. The management of the condition in hospital was reviewed over 9 months (Clin Infect Dis 2008; 47: 56–65). Thirty-four out of fifty-two patients afflicted by it were oral metronidazole and the remainder given vancomycin. The latter was associated with more rapid elimination of the organism and resolution of diarrhoea within the first 5 days than those on metronidazole. In 10 patients a change from metronidazole to vancomycin achieved a more rapid resolution of the infection.
Notes
Contributions to this column should be sent to Professor W. J. MacLennan 21 Crawford Road Burnside, Glassow G73 4DL, UK
Email: profmaclennan{at}sky.com
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