Age and Ageing Advance Access originally published online on January 25, 2007
Age and Ageing 2007 36(2):128-129; doi:10.1093/ageing/afl182
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News and Reviews
Cancer of the prostate; prognosisThough it is debatable whether all patients with cancer of the prostate would want to be told their prognosis, information on this would be useful in determining the appropriate treatment. A team recently studied the relationship between prostate specific antigen (PSA) and C reactive protein (CRP) levels and the prognosis for metastatic cancer of the prostate (Urologia 2006; 77:127–9). Both PSA and CRP levels were independent predictors of survival so that they would be useful measures in the management of this condition.
Surgery for gastric cancer in old age
Given the poor prognosis for stomach cancer it might be concluded that surgery in old age is rarely appropriate. The picture is not as bleak as this. Operations for the condition were reviewed in patients in Germany aged <60 years, 60–75 years and over 75 years (World J Surgery 2006; 30: 1468–74). There was increased co-morbidity in old age and the 30-day post-operative mortality was zero in patients aged under 60 years and increased to 8% in those over 75 years. In contrast, there was little change in the rate of recurrence and in the mortality from cancer over 5 years (61%, 59% and 61%). Such being the case age should not be a barrier to the treatment of this condition.
Violent patients in care of the elderly units
Violence is not confined to busy accident and emergency departments. Staff can also come to grief in a unit for the care of the elderly. Interviews of 848 members of staff elicited that 97 had been assaulted (Caring Sciences 2004; 18: 410–6). More than one-third sustained a bruise or wound. Their response to the attack included feelings of aggression or astonishment and antipathy towards the patient. They also often had a feeling of powerlessness, of being insulted and of fear. Far from the attack being due to confusion most staff felt that it had been intentional. This situation clearly places staff at physical and psychological risk and could even rebound on patients if not remedied.
Sleep disruption in Alzheimer's disease
A recent survey of 426 patients with Alzheimer's disease in Northern Ireland elicited the fact that 46% had sleep disturbances (Sleep 2006; 29: 1083–7). This was even more common where MAO-A VTNR promoter polymorphism was identified. Whether the identification of the genetic feature will improve treatment of patients remains to be seen.
Renal function prior to transplantation
Data from records in the United States were used to establish serum creatinine levels in patients about to receive a renal transplant (QJM 2006; 99: 595–90). Concentrations of creatinine in mg per dl were 10.7 for those aged 20–44 years, 8.56 for those aged 45–64 years, 7.39 for those aged 65–74 years and 6.88 for those aged 75 and over. The suggestion is that using the serum creatinine as an index of renal function underestimates the severity of renal failure in old age and dangerously postpones transplantation. There is of course the ethical issue of whether, given a shortage of donor organs age should play a part in the selection of recipients.
Exercising mental function in Alzheimer's disease
It is the view of many lay people that to maintain the function of their brain it is important that they use it. Evidence is accumulating that they are right about this. A group of 46 patients with mild Alzheimer's disease and on a cholinesterase inhibitor were included in a trial of cognitive exercises (J Neur Neurosurg Psych 2006; 77: 1116–21). The exercises were an interactive multimedia internet system (IMIS) and an integrated psychostimulation programme (IPP). Patients were divided into a group receiving IMIS and IPP, another receiving IPP and a third merely on an anticholonesterase inhibitor.
Over 12 weeks patients on both IMIS and IPP and IPP alone exhibited improved cognitive function. The improvement monitored over a total of 24 weeks continued and was substantially greater than in those merely on an anticholinesterase inhibitor. It was also noted that patients on both cognitive exercise programmes had a more sustained effect.
Aneurism of the abdominal aorta: endovascular repair (EVAR)
Clinicians are constantly seeking out non-invasive procedures for the treatment of frail elderly patients. One such approach is to perform EVAR on an abdominal aorta. Data collated from five trials were used to study the efficacy of the procedure on patients over the age of 60 who had cardiac, pulmonary or renal co-morbidity. There were 565 patients classified in this way who received EVAR and 61 who received standard surgical treatment. The early mortality of EVAR patients was 3.9% compared with 5.1% for those receiving standard treatment. At 1 year the death rate was 56% in the EVAR group compared with 66% in the controls. Further follow-up at 4 years established that the rate of non-rupture was 99.5 in the EVAR group and 97.2% in the controls. It is clear that EVAR is effective and has few major complications in frail elderly patients.
Local factors influencing hip fractures
A great deal of attention has been given to hip fractures and bone density but there is accumulating evidence that other local factors may be important. Laboratory studies in the United States have used dual energy X-ray densitomety to simulate effects of a fall on stress patterns in the greater trochanter (J Bone Min Res 2006; 21: 1425–32). In women over 50 years stress over the inferior medial neck were similar to that in younger women. Over the superior lateral neck, however, the stress in older women was 13% greater than in the younger group. A factor protecting old people against these stress patterns is that there is an expansion of the head of femur. Such results are a long way from the orthopaedic or geriatric unit but they provide evidence that more sophisticated methods for assessing the risk of bone fractures are on the way.
Vitamin D not only increases the risk of a fall causing a fracture. It may actually cause the fall. The hypothesis has been strengthened by a review of 1,231 men and women over the age of 65 (J Clin End Metab 2006; 91: 2990–5). In this group individuals who fell three or more times over a year were more likely to have a 25-hydroxyvitamin D (25-OHD) level less than 10 ng/ml compared to those who fell twice or less in the year. The relationship was absent in individuals over the age of 75. It may be that in this group many other factors disguise the separate effect of the vitamin.
Treatment of Alzheimer's Disease; a novel approach
Conditions in which current approaches to treatment have limited success often attract unusual remedies. An example of this is the treatment of Alzheimer's disease with vagal stimulation (J Clin Psych 2006; 67: 1171–8). Seventeen patients were treated by electrical stimulation of the vagal nerve for 1 year. At the end of the period 7 out of 17 had improved cognitive function and another five did not deteriorate. Trials with larger numbers and controls will be required to establish whether this is really a treatment of the future.
Depression and mortality in elderly inpatients
Does depression influence mortality in elderly patients? This was investigated in 500 patients over the age of 60 in two Montreal hospitals. None has more than a mild degree of dementia (J Geront 2006; 61A: 976–81). A total of 23.3% had a history of depression but their mortality was no different from that of the rest of the sample. The only ones to differ from controls were in a subgroup with current major depression that had a lower mortality. It would be good to hear from someone who has an answer to this conundrum. Unfortunately there are no funds for a prize.
Hypotensive agents and the alleviation of bone loss
This entry is yet another example of unusual treatment for common diseases of old age. It relates to a metanalysis that has established that both thiazide and beta-blockers reduce the incidence of fractures (J Int Med 2006; 260: 350–62). The effect of these agents on bone metabolism are well recognised but this is one of the few studies to show that these can be put to practical value. The authors advise that there should be further investigations to confirm their efficacy.
Notes
Contributions to this column should be sent to Professor W. J. MacLennan Email:
26 Caiystane Avenue, Edinburgh EH10 6SG, UK
Profmaclennan{at}aol.com
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