Age and Ageing Advance Access originally published online on May 16, 2008
Age and Ageing 2008 37(4):366-367; doi:10.1093/ageing/afn113
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News and Reviews
Endarterectomy versus stenting in older patientsUntil recently the favoured treatment of carotid artery stenosis has been carotid endarterectomy (Surgeon 2008; 6: 14–18). More attention has now been given to arterial stenting. Review of five randomised controlled trials has indicated that the latter has no particular advantage over endarterectomy. It is of concern, however, that the follow-up period of these studies was short. Progress is underway on a large controlled study over a much longer period and the results are avidly awaited.
Laser vaporisation of hypertrophy of the prostate
There are considerable risks involved in treating massive hypertrophy of the prostate by open surgery or endoscopic resection (Urologia 2007; 79: 316–20). An alternative is to perform laser vaporisation. Review of this procedure in 100 patients established that 10 were left with urinary retention, 22 with dysuria, 5 with urinary infections and 16 with haematuria. Despite this, there was an improvement in symptom scores and a reduction in bladder residual volume. The technique may offer significant advantages in frail, older patients.
Maintenance of sinus rhythm in diabetic patients with diabetes mellitus after cardioversion
An increasing proportion of older patients with atrial fibrillation has been treated with cardioversion. Is this equally effective in those with diabetes mellitus? (Q J Med 2008; 101: 187–7). The effects of cardioversion were compared in 42 patients with diabetes and 247 without the condition. Follow-up over an average of 74 days established that overall only 63% were still in sinus rhythm, with a prevalence of 45% in those with diabetes mellitus and 67% without it. It was also confirmed that fewer of those with prolonged atrial fibrillation remained in sinus rhythm after cardioversion. Despite the less satisfactory results in diabetic patients, cardioversion should still be considered as an option in this group.
Personal and economic burdens in patients with late-stage rheumatoid arthritis
There has been a lot of publicity about patients being denied treatment with new drugs because of their high cost. More rational decisions could be taken if there was more accurate assessment of the social and economic costs of an illness, rather than the narrow clinical benefits of a particular drug (Rheumatology 2008; 47: 188–931). This was investigated in 505 patients with late-stage rheumatoid arthritis treated with adalimumab, a drug which inhibits the effect of tumour necrosis factor. There was an increase in physical function and maintenance of performance. Conversely, there was no change in the need for personal help or the provision of transport.
Urinary incontinence and the menopause
Data from 2,415 women has confirmed effects that the menopause can have on bladder function. During this period 15% of women with incontinence got worse, 34% improved and 53% remained unchanged (Obs Gyn 2008; 111: 667–77). Any deterioration was at its worst before the onset of the menopause. Another factor with an adverse effect on bladder function was obesity. Quite what these results mean in terms of advising individual women is unclear.
Surgery in patients with stable heart failure
Since there are many older patients undergoing treatment for stable heart failure a decision has to be made as to whether they are fit for surgery (Mayo Clin Proc 2008; 83: 280–9). This was investigated by comparing the surgical outcome in 557 patients with heart failure and 10,583 without it. The rate of complications one month after surgery was 1.3% in the group with heart failure compared with 0.4% in the one without it. When the two groups were matched for a range of relevant variables, however, the difference in side effects was eliminated. The only remaining differences were that patients with heart failure stayed longer in hospital and had a higher readmission rate. It would appear that surgery in patients with heart failure is a practical proposition.
Clinical response to paroxetine in older patients and serotonin transporter promoter polymorphism
Even in old age, genetic patterns may have an important effect on pharmacological activity. This was analysed in a group of 110 individuals with depression, who were genotyped and assessed by the Hamilton Rating Scale for Depression (HAMD) (J Psych Neurol 2008; 33: 123–30). It emerged that serotonin transporter promoter genotype influenced the circulating paroxetine concentration and the reponse to treatment for depression. Despite this encouraging result, the authors consider that the finding will only become clinically relevant if a wider range of alleles can be identified.
High-risk cancer operations in octogenarians
In treating patients with cancer it is important to strike a balance between undue pessimism and pushing ahead with aggressive treatment against all the odds. A recent review in the United States on patients over 80 investigated the outcome of surgery with cancer of the lung, the oesophagus or the pancreas and compared these with operations on similar conditions in a group aged 65–69 (J Am J Surg 2007; 205: 727–34). The operative mortalities for subjects over 80 and 65–69 were 20 and 9% for cancer of the oesophagus, 16 and 7% for cancer of the pancreas and 7 and 4% for lung cancer. Long-term survival for patients over 80 years surviving the operation was 11% for cancer of the pancreas, 78% for cancer of the oesophagus and 31% for cancer of the lung. The results place very old patients at increased risk from major surgery, but a surprisingly good prognosis for cancer if they survive the operation.
EEG abnormalities in lewy body dementia
Although Lewy body dementia has specific clinical features there often is difficulty in distinguishing it from Alzheimer's disease. A promising approach is that the condition has characteristic electroencephalogram (EEG) abnormalities. Their validity was tested by comparing EEG recordings in 18 patients with the condition with those of 34 with Alzheimer's disease and another 34 with a subjective memory disorder (SMD) (J Neur Pscychology 2007; 79: 377–80). The median General Total EEG (GTE) score was 11 in Lewy body disease, 5 in Alzheimer's disease, and 3 in SMD. Patients with Lewy body dementia could be distinguished from those with Alzheimer's disease with a sensitivity of 72% and specificity of 85%. Frontal delta activity was found in 33.3% of patients with Lewy body dementia and only 2.9% of those with Alzheimer's disease.
Does owning a home affect mortality?
Mortality between 1997 and 2003 was reviewed in 308,291 Finns between the ages of 40 and 80 years (J Epid Com Health 2008; 62: 293–7). The ratio of mortality between tenants and owners was 2.06 for men and 1.73 in women. The ratios were not influenced by alcohol intake, respiratory disease, lung cancer or endocrine, metabolic and nutritional disorders. Social factors of income, class and education also failed to influence the ratios between housing and mortality. Just why being a tenant should have an adverse effect on health remains to be defined.
Chromosomal abnormalities and joint replacement
One of the latest hypotheses is that treatment with a joint replacement may give rise to chromosomal abnormalities. This may be the result of prolonged use, producing an accumulation of metallic fragments within joint cavities (J Bone Joint Surg Am 2008; 90: 817–22). Three groups of patients studied for leukocyte chromosomal abnormalities were six without a joint implant, five with metal on metal surfaces and four with metal against polyethylene. Aneuploidy was three times more common in metal on metal implants, which also was associated with a 30-fold increase in chromosomal aberrations. The clinical manifestations of these chromosomal abnormalities remain to be seen. A consolation for older patients with joint replacements is that they are unlikely to live long enough for the clinical effects to manifest themselves.
Abdominal aortic calcification and the incidence of myocardial infarction and stroke
There has long been speculation as to whether there is a relationship between calcification of the abdominal aorta and cardiovascular disease. Researches fortuitously obtained access to lateral chest X-rays in a group of women and were able to compare radiological evidence of abdominal aortic calcification and subsequent myocardial infarction and stroke (J Bone Min Res 2008; 23: 409–16). Over the next 4 years it emerged that there was an increased incidence of myocardial infarction and stroke in the group. In view of this, should we be taking routine lateral chest X-rays on all middle-aged and elderly women, to screen for an increased risk of cardiovascular disease and would intervention reduce that risk?
Notes
Contributions to this column should be sent to Professor W. J. MacLennan, 21 Crawford Road Burnside, Glassow G73 4DL, UK
Email: profmaclennan{at}sky.com
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