Screening for alcohol misuse in older people.

OBJECTIVES: To evaluate whether the CAGE, MAST-G or an abnormally high MCV are effective screening instruments for alcohol misuse and if not to devise a new instrument. DESIGN: Questionnaire survey of randomly selected patients. SETTING: Acute admission wards of two district general hospitals. PERIOD: 9 months. SUBJECTS: Randomly selected patients, aged 65 and over, admitted as emergencies. MAIN OUTCOME MEASURES: Excessive alcohol intake, alcohol dependence. RESULTS: The sensitivities of the CAGE, MAST-G and an abnormally high MCV for excess alcohol intake and alcohol abuse are low, ranging from 0.13 to 0.54. CONCLUSION: The results confirm previous UK studies which indicate that the CAGE and an abnormally high MCV are poor screening instruments for alcohol misuse in older patients and also indicate that the MAST-G is an insensitive screening instrument. A new two-step instrument with five questions in total was generated. This requires further validation.

A study of plasma sodium levels in elderly people taking amiloride or triamterene in combination with hydrochlorothiazide.

This study was performed to compare the effect of one month's treatment with hydrochlorothiazide (25 mg) in combination with either amiloride (2.5 mg) or triamterene (50 mg) on plasma sodium levels in elderly people in institutional care. Fifty residents of NHS nursing or social service residential care established on diuretics for congestive cardiac failure and aged 64 years or over were recruited. Forty-one patients were included in the final data analysis. Patients on hydrochlorothiazide/amiloride had a significantly lower plasma sodium (137 vs 139 mmol/l, 95% confidence interval for difference between medians 0-2 mmol/l) than those on hydrochlorthiazide/triamterene (P = 0.01). In equivalent potassium-retaining doses, amiloride is associated with significantly lower plasma sodium levels than triamterene, when given in combination with hydrochlorothiazide in elderly patients with congestive cardiac failure. This finding adds weight to uncontrolled observations implicating thiazide/amiloride diuretic combinations in causing serious hyponatraemia. This danger, although uncommon, should perhaps influence prescribing habits in an at-risk population.

Spinal infection by Mycobacterium xenopi in a non-immunosuppressed patient.

A previously fit 77-year-old woman was found to have a paravertebral abscess. This was aspirated, yielding Mycobacterium xenopi, but no other pathogens. Antituberculosis chemotherapy with four first-line agents was commenced, with some response but continuing pain. Reports of extrapulmonary M. xenopi infections are rare. Most previous cases have involved immunosuppressed patients. This is the first reported case of spinal M. xenopi infection in a non-immunosuppressed patient, but radiological evidence suggests that previous tuberculous infection may have damaged the lumbar vertebrae, rendering them susceptible to infection by M. xenopi.

The pharmacokinetics of cefuroxime axetil in the sick elderly patient.

The pharmacokinetics of cefuroxime axetil (RS3 formulation) were studied in 20 elderly patients following admission for lower respiratory or urinary tract infection. The mean age was 83.9 years. A 12-hourly dose of 250 mg was given for five days. The mean time to attain maximum serum concentration was 3.2 h with a mean peak concentration of 8.5 mg/l. The mean serum elimination half-life was 3.5 h and the AUC0-infinity 60.4 mg/h.l. There was no accumulation of the drug in the patients studied after five days treatment. The data suggest that the standard dosage regimen is adequate in the sick elderly patient.

Evaluation of imipenem/cilastatin for treatment of infection in an elderly population.

Eighty-seven episodes of infection occurring in 83 patients were treated with imipenem as the sole antibiotic (1.5-4 g daily). All patients were aged 65 years or over, many with other non-infective diseases. A favourable clinical outcome (infection cured or improved) was obtained in 88% of cases. Of the 37 patients who were microbiologically evaluable, a favourable clinical outcome occurred in 92% and a favourable bacteriological outcome (pathogen eradicated or suppressed) occurred in 86% of cases. There were 13 deaths amongst the study group, which might be expected in an ill elderly population. None of the deaths was thought attributable to imipenem. Minor clinical side effects occurred in 10.6%, and one patient sustained a cerebral ischaemic episode and fits, possibly related to imipenem. No serious changes were detected in laboratory parameters.

The beneficial effects of joint orthopaedic-geriatric rehabilitation.

A London inner city Health District has had joint orthopaedic geriatric beds (RU) for rehabilitation of elderly orthopaedic patients since 1981. The effect of this on the orthopaedic department was studied by means of Hospital Activity Analysis data for 1980-85. The results showed that in patients greater than or equal to 60 years this approach leads to a significant reduction in length of stay for those with and without the diagnosis of fractured neck of femur and in the numbers staying 60+ days and 90+ days. The combined approach produced a saving of 46% in bed-days for fractured neck of femur alone. The relatively long duration of stay in the acute orthopaedic unit prior to admission to the RU suggests that intervention by the joint approach from the date of admission is required to maximize efficiency.

A prospective study of early onset rheumatoid arthritis over fifteen years: prognostic features and outcome.

A total of 218 patients with early onset rheumatoid arthritis were entered into a prospective study over fifteen years. Of these, 151 remained in the study at three years (of whom 14 died), and a further 39 (23 deaths) defaulted after this time. The severity of disease was assessed by four different methods. Although persistently active joint disease was recorded in 26% of patients, only 13% had severe functional impairment, and only 14% developed severe erosions. An episode of RA lasting two to three years followed by complete remission with none or minimal sequelae ("non recurrent" RA) was present in 34%. Using discriminant analysis, which selected rheumatoid factor, haemoglobin level and platelet count from a number of clinical and laboratory variables measured at onset, it was possible to predict three mutually exclusive outcome categories correctly in 50-60% of patients depending on the method of assessment of outcome.

Mini-mental state examination in neurological patients.

The Mini-Mental State examination has been found to be a quick and valuable test for simple bedside screening, and for serial assessment of cognitive function in a population of 126 neurological patients. Amongst those with cognitive impairment, there was a close relation between the Mini-Mental State examination and the conventional Weschler Adult Intelligence Scale (WAIS). However, the Mini-Mental test was not a sensitive indicator of focal versus diffuse hemisphere disease. Further refinement in the areas of language and visuo-spatial function may improve its value.