News and Reviews
Mortality in acute coronary syndrome (ACS) and intravenous morphineIntravenous morphine is often used in ACS to relieve pain and distress. It was disturbing to note that in a review of 17,000 patients with ACS given this treatment and 40,046 not given it that the odds ratio for mortality in the former was 1.5 (Am Heart J 2005; 149: 1043). This was not a controlled trial and confounding variables such as those receiving morphine having more pain may have influenced the results. Nonetheless, the benefits and costs of this time-honoured treatment need further evaluation.
Hostility, age and mortality in patients with cardiac disease
Viewers of Victor Meldrew (‘One Foot in the Grave’) would not be surprised that hostility contributes to mortality in grumpy old men. A more clinical approach to the problem was to investigate the relationship of responses to a hostility questionnaire in 1,325 patients with cardiovascular disease (Am J Cardiol 2005; 96: 64–6). The only group in which there was a positive relationship between hostility and mortality was in patients under the age of 62.5 years. One hypothesis yet to be established is that many old people relish aggression and channel it into a prolonged life expectancy.
Anthropometry and metabolic abnormalities in elderly men
Researchers have asked whether there are any anthropometric variables that predict metabolic variables in elderly men (Am J Clin Nutr 2005; 81: 1313–21). A review of 2,924 men aged from 60 to 69 years indicated that a high body mass index and waist circumference were associated with hypertension, a high triglyceride level, a high blood glucose and insulin resistance (Am J Clin Nutr 2005; 81: 1313–21). The observation is of some limited interest. In clinical practice, however, it might be more practical to perform direct measurements of the metabolic variables of concern.
Non-steroidal anti-inflammatory (NSAI) drugs and breast cancer
NSAI drugs have so many negative side-effects that it is nice to learn of a positive one. Review of 7,000 patients with breast cancer against 3,906 controls established that the odds ratio for those on NSAI drugs having breast cancer was 0.78 (Am J Epidemiol 2005; 162: 165–70). The ratio fell the longer a patient had been on the medication. These results are sufficiently encouraging to merit further investigation but further work is required before NSAI drugs can be recommended for preventative treatment.
Does viagra liberate old men or put them at risk? In a recent review, there is a reminder that viagra taken with nitrates can cause hypotensive syncope (Am J Med 2005; 118: 569–70). Administration along with hypotensive agents may cause the same problem. There has also been concern about it causing cardiac failure but this seems to be ill-founded. A more ironic consequence is that by providing sexual liberation, viagra doubles the incidence of sexually transmitted disease in old men and may also increase their risk of infection from HIV. It might be safer sticking to dominoes or watching Coronation Street.
It was interesting to note that one of the most common causes of suicide in elderly Americans was dropping from a great height (Am J Public Health 2005; 95: 1000–2). Records for New York from 1990 to 1998 revealed a suicide rate of 12.2 per 100,000 in individuals aged 75 years and older. The proportion of these choosing dropping from a height as the method varied between 28 and 33%. There is concern that the choice may be due to easy access to high-risk buildings.
Weighing a very fat patient can be distressing for hospital staff and embarrassing for the individual. One unit faced with the problem considered using scales in a loading bay or using two clinical scales at the same time (Am Emerg Med 2005; 46: 98–9). Another approach is to place weight pads under all four legs of a bed. In Edinburgh, an initiative not yet utilised would be to make use of scales in the local world class zoo.
Clinical diagnosis of deep leg vein thrombosis (DLVT)
The clinical diagnosis of DLVT is notoriously difficult, particularly in elderly patients. In a recent meta-analysis, features associated with the condition were a previous DVLT, recent immobilisation, ankle swelling and a difference in calf diameters (Ann Intern Med 2005; 145: 140–5). The condition was unlikely in patients with no ankle swelling and no difference in calf diameters. DVLT was also usefully predicted by using the Wells score, a system computing a single score from a number of clinical scores. This proved accurate in predicting patients in low-, medium- and high-risk groups. Despite this, clinical evaluation cannot be said to provide an accurate diagnosis. Contrast radiography is essential for this.
Survival in elderly patients with bullous pemphigoid
Bullous pemphigoid is a skin condition with a substantial mortality. In a recent study of 171 patients with a median age of 83 years, it was found that factors associated with a reduced lifespan were an increased age, female gender, an associated medical condition and a low Keminofsky score (general assessment of medical status) (Arch Dermatol 2005; 141: 691–8). Neither hypertension nor the number of cutaneous lesions was associated with an increased mortality. Multivariate analysis reduced the independent risk factors to an increased age and a low Keminofsky score. In practical terms, this meant that the 1-year survival in patients under the age of 83 years with a Keminofsky score of >40 was 90%, whereas in those aged 83 years or over with a score of £40 the survival was 38%.
Elderly people are more likely to sustain eye injuries in car crashes. A computerised model was used to relate the risk of injury to foam particles, the steering wheel and an air bag (Arch Ophthalmol 2005; 123: 789–94). Compared with younger casualties, such factors placed increased strain on the rear section of the ciliary body and the lens, which had much less flexibility. Recommendations were that old people should wear goggles. It also was suggested that car manufacturers should do research on reducing the risk of an air bag coming into contact with the driver’s eye.
Prostate tissue ablation by ultrasound
In elderly patients, it is important that elective surgery should be performed with a minimum of trauma. One area in which this might be achieved would be to ablate prostatic tissue with a high-intensity focused ultrasound (Br J Urol Int 2005; 98: 71–8). The technique was recently evaluated in eight patients, where it was effective in destroying the relevant tissue and had few side-effects. This provides sufficient evidence for more formal clinical trials.
Cohort, socioeconomic position (SEM) and hysterectomy
There has been discussion as to whether the rate of hysterectomy is related to a poor SEM. This has been evaluated in three cohorts born between 1919 and 1940 (Br J Obstet Gynaecol 2005; 112: 1126–33). In the earliest cohort, a high rate of hysterectomy was associated with a poor SEM in childhood, but there was little association between a low SEM and hysterectomy in adult life. The reason for these surprising results may be that patients with a poor SEM were less likely to present with their problem but that the situation improved in subsequent cohorts.
Life expectancy in the middle ages
While, as is my wont, I helped to dig up skeletons from a medieval cemetery, I was struck by the large number of infant and childhood burials and the absence of elderly individuals. This impression was confirmed by the excavation of skeletons from a medieval cemetery at Whithorn. The number of children was so high that there was a separate burial area for them (Hill P. Whithorn and St Ninian 1997; Sutton Publishing: Stroud, 552–9).
DIOGENES
Contributions to this column should be sent to Professor W. J. MacLennan, 26 Caiystane Avenue, Edinburgh EH10 6SG, UK Email: Profmaclennan{at}aol.com
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