Erythrocyte sedimentation rate and disease in the elderly.

The erythrocyte sedimentation rate (ESR) is not always elevated in relation to disease. Of 188 elderly autopsy patients studied, 125 had nonmalignant disease and 63 had malignant disease. Of the patients with malignant disease, 13 percent had a clinical ESR of less than 10 mm/hr and 26 percent a rate of less than 20 mm/hr, the upper level of normal for the elderly. Of the patients with nonmalignant disease, 9.6 percent had an ESR of less than 10 mm/hr and 25.6 percent a rate of less than 20 mm/hr. Thus, in about a quarter of the patients, the ESR was below the top normal level for the elderly. Moreover, the ESR may be as high as 35--40 mm/hr in healthy aged persons. Therefore, the ESR is unreliable as a test for the presence of disease (malignant or nonmalignant) in the elderly.

The corneal reflex in elderly patients.

The corneal reflex was absent in 23.5 percent of 115 elderly patients, particularly in those with cerebrovascular disease. However, it was also absent in many of the patients without neurologic disease. Therefore, physicians should not attach too much importance to lack of the corneal reflex in elderly persons.

The "elephant man" of Cambridge. a case report of neurofibromatosis.

The case is presented of a 65-year-old man with neurofibromatosis manifesting facial and skeletal features resembling those of the "elephant man" described by Sir Frederick Treves. Autopsy revealed not only a pheochromocytoma (a common accompaniment of neurofibromatosis), but an enlarged infarcted spleen and a subphrenic abscess. These findings have not been described previously in a patient with neurofibromatosis.

Nephrotic syndrome in the elderly.

Study of hospital activity analysis data over a ten-year period in a district general hospital show that nephrotic syndrome is uncommon in the elderly. The spectrum of histology, however, is no different from the younger adults. The other interesting findings were: diabetic elderly with nephrotic syndrome may have minimal change, therefore should have renal biopsy; and occurrence of sero-negative lupus nephritis in a 90-year-old male and a focal glomerulo-nephritis in a 75-year-old female.

Isotopic scanning of bone in the diagnosis of osteomalacia.

Results of a study performed over 18 months in 21 elderly patients showed that isotopic bone scanning is a sensitive technique for the detection of osteomalacia. It can be used not only to indicate the presence of the disease but the response to treatment.

Copper and zinc levels in "healthy" and "sick" elderly.

Healthy elderly as a group have a wider range for serum copper, ceruloplasmin, and serum zinc than the adjusted ranges for the laboratory. In disease serum copper and/or ceruloplasmin act as acute-phase reactants in vascular disease, inflammation, and malignancy. Serum zinc values likewise are affected by the presence of inflammation and malignancy. The reported low level of copper in patients with osteoporosis was not confirmed by the present study. Neither was there any evidence found for zinc deficiency in patients with dementia.

A double-blind, placebo controlled study of Ginkgo biloba extract ('tanakan') in elderly outpatients with mild to moderate memory impairment.

Thirty-one patients over the age of 50 years and showing a mild to moderate degree of memory impairment entered a 6-month double-blind, placebo controlled, parallel group design study to assess the effects of a standardized Ginkgo biloba extract (containing 24% flavonoid glycosides and 6% terpenes) on cognitive function. Patients were allocated at random to receive oral doses of 40 mg Ginkgo biloba extract or identical placebo 3-times daily. Assessments were made at baseline and after 12 and 24 weeks of treatment using a range of psychometric tests. Efficacy data were available for 27 patients (15 in the placebo group and 12 in the active treatment group). Statistical analysis of the data as compared to baseline suggests that Ginkgo biloba extract had a beneficial effect on cognitive function in this group of patients. Performance on the Digit Copying sub-test of the Kendrick battery was significantly improved at both 12 and 24 weeks, while the median speed of response on a computerized version of a classification task also showed a significant superiority over placebo at 24 weeks.

Adverse effect of splenectomy in renal transplantation.

Between January 1968 and June 1974 at Newcastle upon Tyne, 63 patients underwent splenectomy in association with transplantation; 45 of these had splenectomy with bilateral nephrectomy before (20) or at the time of (25) transplantation; 18 had post-transplant splenectomy for leucopenia. Mortality was significantly higher in splenectomized patients than in 136 non-splenectomized controls. Of the 63 splenectomized patients, 25 died within 1 year of transplantation, 12 of severe infection associated with leucopenia. Although splenectomy produced a temporary rise in white cell count, leucopenia during the first year of immunosuppressive therapy was not significantly less frequent in splenectomized patients than in controls. There was no significant difference in graft loss between the splenectomy and control groups. It is concluded that splenectomy is contra-indicated in patients who are to undergo renal transplantation and confers no benefit when carried out because of leucopenia developing after renal transplantation.

The effect of recurrent early homograft rejection on subsequent patient and renal graft survival.

The effect of recurrent early homograft rejection on subsequent patient and renal graft survival. Two hundred renal transplants performed in Newcastle between 1968 and 1974 and followed up for at least 6 months are reviewed. There was a significant fall ingraft survival at 1 year in those patients who suffered a rejection episode during the first two months post-transplant and this fall became greater with each successive rejection episode. The rise in patient mortality with increasing numbers of rejections showed a similar trend but was less (40-50% at 1 year in those suffering 3 or 4 rejection episodes) and did not reach statistical significance beyond the first episode. We, therefore, conclude that in patients not suitable for home dialysis and in whom, because of uncommon tissue type, a second transplant is not likely to be offered under prevailing conditions of kidney donor shortage, it is justifiable to treat third and fourth rejections occurring during the first two months.

Clinical evaluation of computer processing of liver gamma camera scans.

A prospective study to assess the clinical usefulness of computer processing of liver scans has been carried out on 203 patients. All patients have had six months follow up to confirm the diagnostic accuracy of the scan results. Four presentations have been studied using ROC analysis: (i) original gamma-camera pictures; (ii) processed images obtained using a non-stationary filter; (iii) images processed using nine-point smoothing; (iv) images obtained by linear interpolation at 25 isocount levels of display. It is concluded that pictures obtained by use of a non-stationary filter at 25 isocount levels are superior to a conventional gamma-camera pictures and displays obtained by linear interpolation only. All three are considerably superior to the images obtained by nine-point smoothing in detection of focal space-occupying lesions. Based on the results obtained, a strategy for the rational use of computer processing of gamma-camera liver scans is proposed.

Use of COOP charts in the day hospital.

The day hospital is an essential component of health service provision for the elderly. Demonstrating out-come improvement has not been uniformly successful. COOP charts have been validated in general practice as a tool to demonstrate improvement in functional activity. Therefore the aim of this study was to examine the usefulness of the COOP system in measuring change to a rehabilitation program in an elderly care day hospital. Thirty elderly patients (F/M: 24/6 with age range 75-91 years) attending the day hospital for rehabilitation for musculoskeletal (25) or neurological (5) problems were asked to complete COOP charts during the first or second attendance and after treatment had been completed. A fall in COOP score indicates improvement. The total COOP score improved from 27.9+/-4.3 to 22.5+/-4.0 (C.I.=3.8-6.9; t value=7.2; P<0.0001). Significant improvement was documented in 7 out of 9 individual areas of function/aspects of daily living. The results show that COOP charts, which are easy to administer, may be useful in monitoring change in elderly patients attending day hospital for rehabilitation.

Urinary incontinence handicap inventory.

Urinary incontinence is a common symptom encountered in the elderly. To measure the handicaps associated with urinary incontinence due to detrusor instability an instrument consisting of 17 questions (Urinary Incontinence Handicap Inventory (UIHI)) was developed and validated in thirty elderly women. The results show that the instrument has a high Cronbach alpha coefficient (0.87) and high test-to-retest reliability (0.99, P < 0.0001). The total score on the UIHI correlates significantly with the results on the visual analogue scales representing perception of distress felt by the individual (r = 0.91, P < 0.0001) and the severity of the symptom r = 0.78, P < 0.0001).

New handicap scale for elderly in hospital.

The new handicap scale, consisting of 12 questions based on ICD classification of handicap, was developed as an outcome measure and assessed in 29 in-patients and 27 day hospital attenders. Results show that the handicap score obtained using this new instrument correlates significantly with the score obtained using the London handicap scale. In addition the score correlated with the Nottingham extended activities of daily living, the functional autonomy measurement system, two of the commonly used measures of outcome, and some of the parameters of SF-36. In the 29 inpatients the results show improvement in handicap with treatment including rehabilitation. For assessment of reproducibility and stability over time the handicap scale was administered twice to 10-day-hospital attenders over a three days period end the results revealed a high coefficient (0.98) and kappa (0.92) values. Thus the results obtained from this small study suggest that the questionnaire is a useful tool for assessment of handicap in elderly patients receiving treatment in hospital.

The Functional Autonomy Measurement System (SMAF): a measure of functional change with rehabilitation.

The Functional Autonomy Measurement System (SMAF) is an instrument developed for the measurement of needs of the elderly and the handicapped. As this study shows, it can be used to demonstrate progress during rehabilitation. Of the 94 patients admitted and discharged from a 22 bed acute/rehabilitation ward for the elderly, 78 were discharged home or to their original accommodation, 7 died in hospital and 9 were transferred to a continuing care ward or a nursing home. The mean total score (admission vs. discharge: 18.06 vs. 9.18, P < 0.0001) as well as the score for subsections of Activities of Daily Living (ADL) (admission vs. discharge: 15.69 vs. 8.15, P < 0.0001), Communication (admission vs. discharge: 1.01 vs. 0.5, P < 0.0001) and Mental Function (admission vs. discharge: 1.29 vs. 0.64, P < 0.0001) showed significant improvement in the 78 patients who were discharged back to their original accommodation. Patients who died or required placement into a continuing care bed or nursing home showed no change in mean scores with treatment. The inter-observer agreement between two nurses and a doctor showed that the minor modifications to SMAF did not significantly affect the instrument.

Quality of life cards - a novel way to measure quality of life in the elderly.

Taking into account the multiple factors/dimensions that contribute to the concept of quality of life (QoL), a pack of cards (80 cards) was developed and validated in 30 elderly patients, fifteen from the continuing care setting and fifteen from the day hospital. Twenty of the 80 cards contained words or statements indicating positive or negative affect, 20 cards were based on positive or negative life experience and 40 cards dealt with satisfaction or happiness or dissatisfaction or unhappiness relating to areas of personal or family life. The score obtained using the QoL cards correlated significantly (r = -0.96, P < 0.0001) with the score obtained on the delighted-terrible scale and with a result obtained using an analogue scale (r = 0.93, P < 0.0001). Test to retest reliability in 11 patients revealed an 'r' value of 0.99 (P < 0.0001). In addition, high correlations were noted between the total score obtained using the 80 QoL cards and the subscale scores for 'affect', 'life experience' and 'satisfaction/happiness' in the 30 patients studied initially and in the 20 patients studied subsequently.

Study to assess quality of life (morale and happiness) in two continuing care facilities - a comparative study in the UK and The Netherlands.

The elderly in a nursing home in Nijmegen are less disabled and have higher morale and happiness scores than the elderly in a continuing care facility in London. These scores, however, do not correlate with physical or mental disabilities within each group. In Nijmegen, religion (practising and importance of) is associated with high happiness scores in the elderly, whereas use of sedatives lead to reduced happiness or low morale in both groups of elderly.

[Digoxin poisoning in patients of 2 geriatric departments in London: prevalence and mortality]. / Digoxine-intoxicatie bij patiënten van twee Londense geriatrische afdelingen: prevalentie en mortalitiet.

Digoxin is a toxic drug with a narrow therapeutic index that is mostly used by the elderly. Although it is accepted that toxicity of digoxin occurs more frequently in elderly than in younger patients, there is dispute about its prevalence and associated mortality. A study was therefore set up to, on the one hand, find the prevalence and associated mortality of digoxin toxicity in patients admitted onto two geriatric wards in London and, on the other hand, to study the relationship between serum digoxin level and age, serum urea, serum potassium and serum calcium in geriatric patients with digoxin toxicity. Over a period of three years 1438 patients (age 75-93) were admitted of whom 452 (31%) were on digoxin. Thirty-five patients (7.7%) were diagnosed as having digoxin toxicity. Eight patients (22.9%) with digoxin toxicity died during admission. Mortality was higher although not statistically significant for the patients with toxicity than for the patients who were on digoxin without toxicity. The fatal outcome was not predicted by age, serum urea, serum potassium or serum calcium. The serum digoxin level of the eight patients who died was lower than the level of those (n = 23) who survived. Four patients (11%) had a normal serum digoxin level and clinical features of digoxin toxicity that disappeared on stopping digoxin. A hypothesis is put foreward to explain the weak association between serum digoxin level and digoxin toxicity in geriatric patients.

Terodiline with bladder retraining for treating detrusor instability in elderly people.

OBJECTIVE: To compare terodiline with bladder retraining against placebo with bladder retraining in the treatment of detrusor instability in frail elderly patients. DESIGN: Randomised, double blind, parallel group study. Treatment lasted for six weeks. Frequency of micturition and episodes of incontinence recorded on diary chart by patients. SETTING: Incontinence clinic and a geriatric day hospital at two teaching hospitals. PATIENTS: 37 frail but ambulant patients, mean (range) age 80.4 (70-89) years with urinary frequency and urge incontinence, due to detrusor instability. Two patients withdrew before the first assessment (one in each group) and one could not complete the diary chart (placebo group). INTERVENTIONS: 19 patients received bladder retraining and terodiline 25 mg daily and 18 bladder retraining and placebo. MAIN OUTCOME MEASURES: Change in urinary frequency and number of episodes of incontinence after six weeks' treatment. Patient's subjective evaluation of symptoms. RESULTS: Little difference was found in the results of treatment with terodiline and placebo. The change in episodes of incontinence per 24 hours was no different in the two groups (95% confidence interval -0.6 to 1.2; p = 0.75) and the difference between treatments in the change in frequency of micturition per 24 hours (-0.2) was not significant (-1.1 to 1.2; p = 0.76). Ten patients taking terodiline thought they had improved compared with seven receiving placebo; this difference was not significant. CONCLUSION: Although the number of patients in each group was small and may have been insufficient to detect a drug effect, the possible benefit of terodiline is likely to be small.