Editor's view |
Editor's view
Editor, Age and Ageing
Delirium is relatively common in older people admitted acutely to hospital, particularly in those with severe illness, cognitive impairment or disability. The authors of a research paper in this issue (pp. 326–332) have previously reported that C-reactive protein levels measured shortly after admission predict the development of and recovery from delirium in older people. They have now examined the relationship between a number of cytokines, insulin-like growth factor-I (IGF-I) and APOE genotype on the development of delirium and its severity in a prospective study in 67 older people admitted to hospital. Cognitive function was assessed by the Mini-Mental State Examination (MMSE), while the Confusion Assessment Method (CAM) was used to detect delirium and the Delirium Rating Scale (DRS) to assess the severity of delirium. These clinical assessments and laboratory investigations were performed shortly after admission and repeated twice weekly. Of the patients studied, 37.3% had delirium on initial assessment and 4.5% developed it during their admission. The authors report that low levels of IGF-I and interleukin 1 receptor antagonist (IL-1RA), which are both neuroprotective factors, was associated with delirium, whereas high interferon gamma (IFN-
) and low IGF-I concentrations had a significant effect on the severity of delirium. In contrast, there was no relationship between the pro-inflammatory cytokines studied, APOE genotype or illness severity and delirium or its severity. As the authors correctly acknowledge, one cannot infer cause and effect from an observational longitudinal study. Nevertheless, if these findings are confirmed in much larger studies, it raises the intriguing possibility that there may ultimately be a role for IGF-I and/or IL-1RA in the treatment of delirium.
Iron deficiency anaemia and aortic stenosis are both common in older people, so their coexistence may be disregarded as coincidence, rather than reflecting a possible association. A paper in this issue reviews the pathogenesis, diagnosis and treatment of Heyde syndrome (pp. 267–270), which comprises aortic stenosis, acquired coagulopathy and anaemia, due to bleeding from intestinal angiodysplasia or from other sites. The review highlights that the evidence that aortic stenosis is the cause of the coagulopathy is stronger than that for a casual association with angiodysplasia. Patients with Heyde syndrome who are treated by intestinal resection generally continue to bleed from other sites, whereas aortic valve replacement usually corrects the coagulopathy and anaemia. The important clinical message therefore is that recognition of the condition may alter the management of patients with aortic stenosis and iron deficiency anaemia. In particular, older patients presenting with gastrointestinal bleeding should be examined carefully for aortic stenosis and there should be a low threshold for performing echocardiography.
Urinary incontinence is common in older people, where it has a major impact on quality of life. A research paper has investigated changes in continence status among a large cohort of older women, taking part in the Australian Longitudinal Study of Women's Health (pp. 333–338). This recruited 12,432 women aged 70–75 years in 1996, 7,158 of whom completed four health surveys over the subsequent decade, the last of which was completed in 2005. A quarter of the women studied in 2005 reported urinary incontinence, which was twice as high as the prevalence when they were surveyed 6 years earlier. Longitudinal models demonstrated a significant association between incontinence and dementia, dissatisfaction with physical ability, falls, obesity, constipation, urinary tract infection and history of prolapse and prolapse repair. The authors conclude that the association with obesity, urinary tract infection and constipation provides opportunities for the prevention of urinary incontinence among older women.
The number of people with dementia is predicted to rise dramatically in the next 30 years, as life expectancy continues to increase. A research paper in this issue has estimated the size of the disabled population in England and Wales over the next two decades and examined the potential number of older people with cognitive impairment and disability (pp. 319–325). The authors predict that population ageing will result in 39% more older people between 2006 and 2026. The number of older people with disability will rise by over 80%, whereas the proportion with cognitive impairment will increase by 48%. This clearly has profound implications for the provision of both heath and social care, which needs to be addressed as a matter of urgency.
Pyogenic liver abscess is a serious condition, with a considerable mortality. A research paper from Taiwan has compared the clinical features, pathogenesis and outcome of pyogenic liver abscess in 118 patients aged 65 years and above and 221 younger patients (pp. 271–276). The older patients were more likely to have severe illness, as defined by a high Acute Physiology and Chronic Health Evaluation II (APACHE II) score on admission than younger patients. They were also more likely to have underlying gallstones or malignancy and less likely to have alcoholism. Older patients had a higher prevalence of infection with multiple organisms and anaerobic and antibiotic-resistant bacteria. Reassuringly, although the hospital stay was longer in the older patients, their mortality (13.6%) was not significantly higher than the younger patients (8.6%).
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