News and reviews
Identifying ‘normal’ peopleOne of the most difficult problems in studying dementia in extreme old age is the identification of suitable controls. A recent paper recounts a method for defining such individuals older than 85 years (Alzheimer's disease and Associated Disorders 2006; 20: 101–4). Letters were sent to such individuals listed in a register, totalling 24,366. These elicited around 3,000 replies, of which 500 scored three or more criteria for dementia. Of the remainder, 128 were subjected to a telephonic interview of cognitive status (TICS) and clinical dementia rating scale (CDRS). Clinicians unaware of these results reviewed the subjects and found that 120 had normal mental function and 8 were demented. It would appear that the system is a useful method of defining very old people with normal mental function.
Fruit and vegetable intake and bone mineral status
It is possible that vitamin D is not the only vitamin that has an effect on bone density. A recent review compared the fruit and vegetable intake of individuals with their bone density (Clin Nutr 2006; 83: 1420–8). In groups of males and females from adolescence to old age, the only group in which there was an association were boys between 16 and 18 years, in whom there was a link between the intake of fruits and vitamin C and bone mineral density. Since so many subgroups were investigated, there must be some doubts regarding the relevance of this subgroup. Despite this doubt, the attractiveness of the hypothesis is such that further investigation may be warranted.
Subclinical hypothyroidism and heart disease
It is common for old people to have undiagnosed hypothyroidism. Is this associated with heart disease? Meta-analysis of 14 studies established that there was an odds ratio (OR) of 1.65 (Am J Med 2006; 119: 541–51) for heart disease in patients with this condition. In studies in which adjustments were made for cardiovascular risk factors, the OR increased to 2.38. It seems clear that a more diligent search should be made for subclincal hypothyroidism in an attempt to further reduce the incidence of heart disease.
Most studies on falls in old age relate to falls indoors. There has recently been a case control review of individuals older than 45 years who sustained falls outdoors (Am J Publ Health 2006; 96: 1192–1200). The incidence of falls increased in patients indulging in increased physical activity associated with leisure and also in those with poor health. Most falls were associated with uneven surfaces, obstacles on the ground, walking off a pavement or kerb or crossing a road; 47% of individuals were walking when they fell. Whether realistic measures can be taken to reduce these risk factors remains to be seen.
A particularly disabling condition in old age is a venous ulcer. This has recently been treated by Pyrogel, an agent that works by reducing the surrounding oedema. A controlled trial compared oral treatment with the local application of a Pyrogel powder along with compression with a bandage (Angiology 2006; 56: 699–705). Local treatment was more effective than the systemic one. If the drug is to be used at all, it should be used locally. Of course, a confounding factor is that it may have been local pressure that was the most important factor.
Senile macular degeneration and stroke
Does senile macular degeneration increase the risk of stroke? This hypothesis was tested by reviewing 10,405 individuals between the ages of 49 and 73 years in the United States (Ann In Med 2006; 145: 98–106). The review identified 498 subjects with early stage macular degeneration and 10 subjects with late degeneration. After adjustment was made for several confounding variables, it was found that those with macular degeneration had a 4.05% incidence of stroke compared with 2.14% in controls.
There was considerable variation in the difference between treatment and control groups in the different states and also between Whites and African Americans, but this may have been due to the small number of subjects in the subgroups. Overall, however, there does seem to be a link between macular degeneration and stroke, which requires further investigation.
The significance of biochemical markers for osteoarthritis
Contrary to earlier views, it seems likely that osteoarthritis is a metabolic disorder. This was demonstrated in 42 patients with osteoarthritis of the knee (Ann Rheum Dis 2006; 65: 1050–4). Detailed information on the shape of the joint was obtained by whole organ magnetometer resonance imaging (WORMS). A wide range of metabolic indices was also measured.
Baseline measurements failed to establish any link between the joint image and biochemical markers. However, an increase in the tetrapeptide of type II collagen was associated with thinning of the medial and lateral tables of cartilage. Multiple regression analysis predicted that high levels of hyaluronic also predicted deterioration in osteoarthritis. It would appear that this might be useful for predicting the prognosis of patients with arthritis and could have an important impact on management.
Physical function in elderly women after a fracture
There is a paper that investigated the relationship between physical function and performance in elderly women who had sustained a fracture (Arch Phys Med 2006; 87: 914–7). It emerged that those who sustained a fracture had a lower Romberg's balance test. They were also more likely to have a reduced gait speed and an increased tendency to falls. A limitation of this investigation is that it was difficult to establish whether the abnormalities preceded or followed the fractures.
Treatment of advanced cancer of the prostate
Controversy continues over the most appropriate treatment of advanced local cancer of the prostate. There has recently been a review of aggressive treatment in this condition (BJU 2006; 98: 335–40). Recourse to a register of the condition indicated that between 1995 and 2001 the proportion of men who received aggressive treatment had risen by 11%. This comprised a 20% increase in the use of radiotherapy and a reduction in radical prostatectomy by half. Radiotherapy was more likely to be an option in younger men, while African Americans were less likely to have any form of aggressive therapy. What remains to be established is whether these changes will result in an improvement in the prognosis of advanced cancer.
Laparoscopic or open surgery for colorectal cancer?
Laparoscopic surgery for colorectal cancer in elderly patients was the subject of a meta-analyis consisting of 12 trials that compared it with open surgery (Br J Surg 2006; 93: 921–8). The former was associated with less blood loss and pain, an earlier resumption of bowel function and/or shorter hospital stay. Conversely, it did not result in fewer complications or a lower post-operative mortality, cancer-related mortality or overall mortality. It also took longer to perform. Given such equivocal results, there seems to be little reason to opt for laparoscopy as the treatment of choice at present.
Blood lipid levels and types of brain infarction
A seemingly abstruse question is whether particular blood lipid abnormalities are associated with specific types of brain infarction (Cerebrovasc Dis 2006; 22: 101–8). This was investigated by matching 492 patients with brain infarcts (BI) with the same number of controls. High levels of blood total cholesterol, high-density lipoprotein cholesterol, low-density lipoprotein cholesterol and apolipoproteins A1 and B were linked to a greater risk of BI. An OR for a low blood level of low-density lipoprotein cholesterol and atheromatous strokes was 1.74, and that for the same in lacunar strokes was 2.71. Thus the evidence is that high blood levels of most lipids increase the risk of BI but that specific patterns of blood lipid abnormalities do not differentiate between different types of BI.
Secular changes in the incidence of atrial fibrillation
It might be a reasonable assumption that an increase in the number of patients presenting de novo with atrial fibrillation is due to the increasing age of the population. This has been confounded in the United States by a 20-year review of 4,418 patients developing the condition de novo (Circulation 2006; 114: 119–25). Adjustment for age and sex left a strong temporal increase in the incidence of the condition over a period of 20 years. Evidence from other studies indicates that a possible culprit for the pattern might be an increase in the prevalence of obesity over the same period.
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