Editor's view |
Editor's view
Editor, Age and Ageing
Clinicians are often reluctant to start warfarin in older people with atrial fibrillation (AF) who are at high risk of falls, have cognitive impairment or are poorly compliant with medication, because of concerns about haemorrhage. A prospective study reported in this issue (pp. 156–162) examined the impact of frailty on the use of warfarin and on outcome in 220 older in-patients with AF, two thirds of whom were identified as frail using the Edmonton Frail Scale. Frail patients were less likely to receive warfarin than those without frailty, and during their hospital admission the proportion of frail patients prescribed warfarin decreased, whereas the use of anticoagulant treatment increased in non-frail subjects. During the 6-month follow-up period, 20.8% of patients experienced major or severe haemorrhage, most of whom were taking warfarin ot other antithrombotic treatment, whereas 9.7% developed embolic stroke, the majority of whom were not rceiving warfarin. Frail patients were more likely to experience embolic stroke and had greater mortality than those without frailty. An accompanying editorial (pp. 140–142) highlights that although aspirin is often considered a safe alternative to warfarin treatment in frail older people with AF, there may be a similar risk of haemorrhage and haemorrhagic stroke, without necessarily conferring the same benefits in stroke prevention. Coincidentally, another editorial emphasises that antiplatelet therapy is the mainstay of acute treatment and long-term prevention for ischaemic stroke (pp. 142–144), but highlights that to avoid the gastrointestinal complications, we need to understand more about the acute pathophysiological changes occurring in the gastrointestinal tract following stroke and the influence of other potential risk factors for gastroduodenal ulceration and bleeding.
The regular consumption of modest amounts of alcohol appears to protect against the development of coronary heart disease and ischaemic stroke, but heavier episodic drinking is associated with an increased risk of cardiovascular disease. A study in this issue (pp. 206–212) examined the effect of alcohol consumption on cardiovascular morbidity and mortality at different ages. A representative sample of 1,257 men and women, equally distributed across three age groups (18–34, 35–49, and 50–64 years) were recruited from Winnipeg, Manitoba in 1990–91. They underwent baseline assessment of the quantity and frequency of alcohol consumption and were then followed up for 10 years, when data on cardiovascular mortality and morbidity were collected from provincial health service utilisation records. Older men aged 50–64 years at baseline in the highest tertile for regular alcohol consumption (>18.1 g/day) had a lower risk of cardiovascular disease, whereas heavy episodic drinking (>104 g in one session) was associated with an increased risk in middle aged men and greater risk of hypertension in older men. Although this may be the first study to examine the effect of episodic drinking in different age groups, the authors acknowledge that it is limited by the relatively small number of participants in each age and gender group. Pending the results of larger studies, it would be prudent to advise people of all ages to avoid heavy episodic ‘binge’ drinking!
The risk of falls increases with advancing age and is higher in older people with cognitive impairment and those living in residential and nursing homes than in community dwelling people of the same age. Previous studies of falls prevention in nursing home residents have generally excluded patients with dementia. A research paper reporting a cluster randomised trial of multifactorial falls prevention in nursing home patients (pp. 194–199) with dementia is therefore particularly welcome. The study recruited 518 patients from psychogeriatric wards in 12 nursing homes in The Netherlands, who were randomised by nursing home to serve in the control group or to the intervention, which comprised medical assessment and multidisciplinary falls prevention measures directed at the ward environment and at individual participants. There was a significantly lower incidence of falls in the intervention group at 2.09 falls/ patient/year compared with 2.54 falls/patient/year in the control group. Although the authors recognise the limitations of the study, their results suggest that falls prevention measures are feasible and successful in nursing home patients with dementia.
Osteoarthritis of the knees is a risk factor for falls, but the effect of total knee replacement on the incidence of falls has not been investigated previously. A prospective study examined falls before and for 12 months after joint replacement surgery in 99 consecutive patients (pp. 175–181). A quarter of the patients reported falls in the three months before surgery, which decreased to just under 12% in the year after joint replacement. Higher scores on the Geriatric Depression Scale and previous falls before surgery were significant independent predictors of falling after total knee replacement. The authors suggest that patients being considered for total knee replacement should be asked about falls history and undergo falls risk assessment and intervention. Could this be yet another role for doctors and nurses involved in orthogeriatrics?
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