Social care data in England: what they tell us and what they do not tell us.

A large volume of statistics is published nationally on adult social care in England. The data are used locally to manage and improve delivery of care. Social care data have the potential to give invaluable information on the prevalence of dementia and other chronic conditions, and on end-of-life care. However, examination of these statistics reveals that there are problems with their accuracy and detail which limit their usefulness for describing geographical differences and differences over time. Comparison is made with the national statistics available on health service activity. Linkage of health and social care data would provide a great deal of useful information. It is suggested that the key to improving quality and detail of national social service data is to make greater use of them.

Criteria for use in the evaluation of health impact assessments.

This paper reports the conclusions of a recent workshop that was established to discuss how health impact assessments (HIAs) might be evaluated. The main purposes of HIA are: (a) to predict the consequences of different decisions; (b) to make the decision-making process more open by involving stakeholders; and (c) to inform the decision makers. 'Prediction', 'participation' and 'informing decision makers' are thus the three domains in which HIA should be evaluated. In the 'prediction' domain, process criteria scrutinize the methods used to see if it is likely that they would produce reliable predictions. Outcome criteria involve verifying the predictions, but this is frequently impractical and predictions for the counter factual (the option not chosen) can never be verified. In the 'participation' domain, process criteria examine the ways in which stakeholders were involved, while outcome criteria explore the degree to which the stakeholders felt included. In the 'informing decision makers' domain, process criteria are concerned with the communication between decision makers and those doing the HIA, and should reflect upon the relevance of the HIA content to the decision makers' agenda. Outcome criteria explore the degree to which the decision makers considered that they had been informed by the HIA. This paper concludes with suggestions for the types of information that should be included in HIA reports in order to permit the readers to make an assessment of the 'quality' of the HIA using the three domain criteria outlined above.

A birth cohort analysis of smoking by adults in Great Britain 1974-1998.

BACKGROUND: The aim of the study was to determine for Great Britain the percentage of current smokers and ever smokers by age in successive birth cohorts and the percentage of ever smokers who continue, by analysis of data from serial cross-sectional surveys of smoking status (General Household Survey). METHOD: A series of 5 year birth cohorts were followed through data from the 13 national surveys conducted at biennial intervals between 1974 and 1998. RESULTS AND CONCLUSION: In all birth cohorts, male and female, after age 25 years the percentage of current smokers falls with age. In the earliest birth cohort for males (1897-1901) about 85 per cent were ever smokers (i.e. had smoked at some time). After the 1922-1926 cohort this started to fall, to reach the level of about 50 per cent in the 1962-1966 cohort. In females only 25 per cent of the earliest cohort ever smoked but this rose, reaching about 65 per cent in the 1922-1926 cohort before falling back to about 50 per cent in the 1962-1966 cohort. The age at which smokers quit appears to be falling in successive cohorts. Once they have started quitting the rate at which smokers do so is very similar in all cohorts, with about 1 per cent of ever smokers quitting each year. If these trends are continued the UK smoking prevalence targets will not be met.

Can health impact assessment fulfil the expectations it raises?

The United Kingdom and other European Governments are increasingly calling for Health Impact Assessment (HIA) of policies in order to predict how they will affect the health of populations. Approaches to HIA can be characterised as broad focus (holistic, sociological, qualitative) or tight focus (limited, epidemiological, quantitative). HIA must add value to decision making and lead to better decisions than would have otherwise been made. The quality of HIA will be judged on its utility, its predictive accuracy and its process. HIA must be closely integrated with the decision making process. HIA may be undertaken in combination with Environmental Impact Assessment (EIA) or separately. HIA does not mean that health should take primacy over other policy goals but does ensure that health is considered.

Single-blind randomized controlled trial of an educational booklet for patients with chronic arthritis.

Consecutive new attendees at a rheumatology clinic were randomly allocated to one of three groups. All groups received routine care, but one received no other intervention, one an educational booklet on arthritis and one the booklet plus instruction from a health professional. Prior to intervention, all groups had similar knowledge. Nottingham Health Profile (NHP) and Health Assessment Questionnaire (HAQ) score. After 6 weeks, the knowledge score was significantly increased in both groups given the booklet, but not in the control group. The group instructed by a health professional showed no greater increase than the group given the booklet alone. Increased knowledge was not associated with improved clinical status and no group showed a significant change in NHP or HAQ scores. Nearly all patients said they found the booklet useful.

Are elderly Asians in Britain at a high risk of vitamin D deficiency and osteomalacia?

Many studies have shown the indigenous elderly population and Asian immigrants to be groups at particular risk of vitamin D deficiency and osteomalacia, but there are no data on the risks in elderly Asians. In this community-based study a group of elderly Asians was compared with control groups of elderly and young whites and young Asians. Levels of 25-hydroxyvitamin D3 (25-OHD3) were significantly lower (p < 0.0001) in elderly Asians (21/37) and young Asians (7/17) compared with white controls. The difference in parathyroid hormone (PTH) between Asians and whites was also significant (p < 0.0007) as was that between young and old (p < 0.0002). Abnormal PTH and 25-OHD3 (high PTH and low 25-OHD3), indicative of a high risk of osteomalacia, occurred in 22% of elderly Asians compared with 6% of elderly whites. The calcium, phosphate and alkaline phosphatase were normal in all individuals. Among the Asians, vegetarianism was not related to lower 25-OHD3 levels. Symptoms suggestive of osteomalacia were more common (p < 0.05) in elderly Asians than in their white counterparts. This first study of 25-OHD3 levels in community-resident elderly Asians suggests that more than half were low, placing them at a significantly higher risk of osteomalacia.

The excretion of large vitamin C loads in young and elderly subjects: an ascorbic acid tolerance test.

An ascorbic acid tolerance test is described for assessing vitamin C status. The test is simple to administer and suitable for elderly patients. It involves giving an oral load of 1 g ascorbic acid in water and then measuring urinary excretion of vitamin C over the next 6 h. The excretion pattern at dosing has been studied in ten young subjects. The result of the ascorbic acid tolerance test in these young subjects was significantly different after supplementation with 1 g ascorbic acid daily for 1 month. Two series of elderly patients were also studied with the ascorbic acid tolerance test. They had low initial plasma ascorbic acid levels and much less vitamin C was excreted in the urine after dosing. Seven of these elderly patients were then supplemented with 1 g ascorbic acid for 1 month. After supplementation the initial plasma levels and their response to the ascorbic acid tolerance test became similar to that seen in younger subjects.

Eating patterns in childhood and adult health.

This paper first reviews the evidence that the pathogenesis of many diseases which present in adult life begin in childhood, and that intervention in childhood may delay their onset. The diseases discussed include ischaemic heart disease, malignancy, cerebrovascular accidents, hypertension and obesity. The factors determining food habits are described and the possibilities of influencing food preferences and eating patterns in childhood are explored.

Timing of screening for osteomalacia in the acutely ill elderly.

Hypocalcaemia and hypophosphataemia either on admission or before discharge from hospital are poor discriminators for the presence of subclinical osteomalacia in the elderly. Reliance has to be placed on the measurement of alkaline phosphatase even though false positive tests are common. Use of paired admission and predischarge data reduces the false positive rate by approximately 50% thereby reducing the requirement for histological confirmation of the diagnosis of osteomalacia. Since the prevalence of osteomalacia is low in this type of hospital population, any measure which reduces the requirement for bone biopsy is of considerable practical value.

Safety of treatment for subclinical osteomalacia in the elderly.

Forty one elderly patients admitted to hospital for acute illnesses were also found to have subclinical osteomalacia. Immediately before discharge, therefore, all were randomised to receive either vitamin D2 25 micrograms daily, alfacalcidol 0.5 micrograms daily, or placebo. Treatment was given for at least three months, those allocated to placebo then being switched to an active drug. Within the first three months of treatment with either of the active drugs most patients had exhibited a fall to normal in osteoid values. In only four treatment periods was there a mild increase in serum calcium concentration, and in no patient was this accompanied by deterioration in renal function. Any increase in serum creatinine concentration was invariably attributable to the underlying disease for which the patient had been admitted in the first place. Subclinical osteomalacia in the elderly may be corrected by relatively low doses of alfacalcidol (0.5 micrograms daily) or vitamin D2 (25 micrograms daily) given for three months. Such treatment is safe and not accompanied by a serious risk of hypercalcaemia or renal impairment.

How common is osteomalacia in the elderly?

Discussion of the prevalence of osteomalacia in the elderly is complicated by the different definitions used and the fact that diagnostic criteria are rarely stated. In this study osteomalacia was defined as more than 25% of trabecular bone surface in an iliac crest biopsy sample covered with osteoid and a mean osteoid seam thickness of greater than 11 micron. All patients admitted to a geriatric unit over one year were screened and biopsy samples obtained from a high proportion. The estimated prevalence in this population was 3.7%; the prevalence was higher in women than in men and in those over 80 years than in those under 80.

Osteoid in bones of elderly patients without bone disease.

Bone samples were taken at post-mortem examination by Jamshidi needles from 88 elderly patients who were known to have normal bone biochemistry in life. The extent of osteoid in these samples is quantitatively described. In patients with normal creatinines the relative osteoid area ranges from 0 to 3.7% and trabecular osteoid surface percentage ranges from 0 to 23%, but higher values were seen in those with raised creatinines. Osteoid extent did not vary with age, sex or time of year. Descriptions of other series of control bone biopsies in the literature are reviewed and it is suggested that relative osteoid area greater than 3.5% or osteoid surfaces greater than 25% should be considered excess osteoid.

The distribution of supposed indicators of nutritional status in elderly patients.

The results of a survey of indicators of nutritional status in patients on admission to wards in the Department of Health Care of the Elderly in Nottingham are reported. Results outside conventional limits of normality are common. Little or none of the observed variance in the biochemical indicators in this population is explained by age or sex. Weight, mid-arm circumference, triceps skinfold thickness, albumin, retinol binding protein and retinol tend to be lower in patients who subsequently die, in patients who are clinically classified as thin or wasted, in patients with poor appetites and in patients with a diagnosis of malignancy. Plasma vitamin C, erythrocyte glutathione reductase activation coefficient and erythrocyte transketolase activation coefficient do not show these trends and are likely to be determined by different factors.

Screening for subclinical osteomalacia in the elderly: normal ranges or pragmatism?

Although osteomalacia is known to be common in some sections of the elderly population, the disease is often subclinical and there is uncertainty about the point at which treatment is necessary. Identification and treatment of osteomalacia are inseparably bound; the response of varying degrees of subclinical disease to treatment with vitamin D or alfacalcidol is described here. The response is assessed in relation to a simply derived reference range based on standard biochemical measurements together with a Jamshidi needle biopsy of the iliac crest. Although this technique does not define a truly normal range it identifies a treatable abnormality which could form the basis of further study of the problem of subclinical osteomalacia in the elderly.

Effect of age, sex and illness on salt taste detection thresholds.

Salt taste detection thresholds have been measured by a forced-choice, up-down sip method in 146 healthy subjects aged 10-95 years, and in 43 ill elderly patients. Thresholds are shown to increase log linearly with age after the age of 20 years. Thresholds are higher in smokers than non-smokers and the lower thresholds of women are accounted for by their lower prevalence of smoking. Ill patients have higher thresholds than healthy subjects of the same age and this is not specifically associated with any diagnosis. The methodology of taste threshold measurement and earlier studies of taste thresholds are reviewed.

Age-independent anthropometry: an examination of data from rural Khartoum, Sudan.

The data collected in a mixed cross-sectional longitudinal survey of children in a village in rural Khartoum, Sudan, were analysed in order to identify age-independent anthropometric indices. The mean values of weight/height, weight/height, mid arm circumference, mid arm fat area and triceps skinfold thickness all change little with age over certain parts of the age range. 15% of the boys and 22% of the girls had weights less than 75% of standard weight for age. The ability of age-independent indices to identify these low-weight individuals was investigated in terms of their sensitivity and specificity. Weight/height discriminated best, correctly classifying 85% of the low weight boys and 78% of the normal weight boys in the under-five age group. Weight/height and mid arm circumference were also useful, but triceps skinfold thickness and mid arm fat area did not discriminate usefully. All tests performed better in the under-five age group than in the older age bands.

Growth velocity in children in rural Khartoum, Sudan.

The results of a mixed cross-sectional and longitudinal anthropometric survey of Sudanese children up to the age of sixteen years are reported. Weight velocity, height velocity, mid arm circumference velocity, and mid arm muscle circumference velocity, and the age at which 50% of females have reached menarche have been calculated. Growth velocities are lower than for English children and the puberty growth spurts occurs about one year later in Sudanese than in English children