The effect of birth weight on clottable and intact fibrinogen levels: a twin study.

Several studies in singletons have found an association between low birth weight and increased plasma concentrations of clotting factors in adult life. Twins provide an opportunity to assess the possible contribution of genetic factors to this association. Forty-four monozygotic and 60 dizygotic same-sex twin pairs aged 19-50 years and 78 singleton controls matched for age, gestational age, gender, maternal age and parity were recruited from an obstetric database. Associations between both adult clottable fibrinogen (measured by the Clauss method) and intact fibrinogen (measured by the immunoprecipitation test), and birth weight were assessed by linear regression with adjustment for current age, gender, smoking and body mass index. Twins were significantly lighter at birth than singleton controls, but did not differ significantly in adult height, weight or fibrinogen levels from the singleton controls. There was a significant inverse association between birth weight and clottable fibrinogen levels among singleton controls [-0.22 g L(-1) kg(-1) (95% CI: -0.41,-0.03), P = 0.03], but not in unpaired twins. For intact fibrinogen there was no significant association with birth weight in either singleton controls or twins. In the within-pair analysis in twins there was a significant inverse association between differences in birth weight and clottable fibrinogen levels in dizygotic twin pairs [-0.34 g L(-1) kg(-1) (95% CI: -0.65,-0.02), P = 0.04], but not in monozygotic twin pairs [-0.12 g L(-1) kg(-1) (95% CI: -0.53, 0.28), P = 0.54]. These results support the possibility that genetic factors may contribute to the association between low birth weight and clottable fibrinogen levels.

Clinical features predicting dementia in idiopathic Parkinson's disease: a follow-up study.

We followed up, after 3 1/2 years, a whole population cohort of 249 patients with Parkinson's disease (PD) 1st examined in 1983 to 1984. Of the survivors, 23.6% qualified for a DSM III-R diagnosis of dementia. In univariate tests, age, certain items of the Webster scale, the Hoehn and Yahr scale, a 10-question mental status questionnaire, and a history of smoking were associated with a diagnosis of dementia 3 1/2 years later. Logistic regression with DSM III-R diagnosis (demented versus nondemented) as the dependent variable, and age and symptom scales for PD as predictor variables, revealed that PD symptoms predicted dementia even after controlling for age. We conclude that dementia is probably more common in PD patients than would be expected in the general population and is associated with the severity of PD symptoms and signs independently of age.

The clinical application of a urine albumin:creatinine ratio point-of-care device.

INTRODUCTION: Microalbuminuria is an accepted predictive marker for the early detection of renal disease and the identification of patients at high risk of developing complications of diabetes and hypertension. The Bayer Clinitek 50 is a urine chemistry point-of-care analyser for the semi-quantitative measurement of albumin and creatinine and calculation of albumin:creatinine ratio (ACR). METHOD: Urine samples were obtained from 252 consecutive patients attending a city center diabetic clinic, and from 40 patients on admission to the ICU. Albumin and creatinine measurements were carried out using the Clinitek 50 and by the central laboratory. RESULTS: The Clinitek 50 results agreed with the central laboratory results in 89% of the diabetic patient samples and 80% of the ICU patient samples. Excluding samples defined as normal by the Clinitek 50 (ACR<3.4 mg/mmol) would have resulted in an 80% reduction in samples sent to the lab for further quantification. The average length of stay in the group of ICU patients with normal ACR was significantly less than for those patients with an abnormal ACR (p<0.005). CONCLUSIONS: The Clinitek 50 provides useful, immediate clinical information regarding the microalbuminuria status for use in the diabetic clinic setting or as a potential immediate risk management tool in intensive care.

Coping in family supporters of elderly people with dementia.

Research into supporters of elderly people with dementia has a brief but significant history. Initially, research sought to establish the nature and extent of the distress that supporters endured in the fulfilment of their caring role. More recently, researchers have turned their attention towards the identification of coping techniques used by supporters in the community. The Dundee Study of Supporters and Dementia is concerned with factors associated with the maintenance and care of the demented elderly in the community, and with the impact of dementia on family supporters. A total of 228 family supporters of community-resident elderly (50 per cent of elders with dementia, 50 per cent without) were interviewed. Part of the interview focused on self-reported coping, and identified coping strategies using open-ended questions and a revised, 31-items Ways of Coping checklist. Findings indicated that the majority of supporters of community-resident elderly relatives reported coping well. Supporters predominantly used emotion-focused coping strategies as their main way of coping. However, those supporters who reported using a problem-focused strategy were found to score better on measures of coping than those supporters using an emotion-focused strategy. The supporters' main coping strategy was not associated with characteristics of the elder-supporter dyad. Factors derived from the Ways of Coping checklist produced a pattern of associations with characteristics of the elder-supporter dyad, but the same factors were largely not associated with other measures of coping. The implications of the findings are discussed with regard to coping research, and for interventions to improve the well-being of supporters of an elderly relative with dementia in the community.

Community care for demented and non-demented elderly people: a comparison study of financial burden, service use, and unmet needs in family supporters.

OBJECTIVE: To measure and compare perceived financial burden, use of services, and perceived unmet service needs of supporters of demented and non-demented elderly people. DESIGN: Comparison study of age and sex matched demented and non-demented elderly people and their supporters. SETTING: 25 primary health care teams in Dundee. SUBJECTS: 114 community resident elderly (age over 65) people with dementia, 114 age and sex matched comparators, and the main informal supporter of each elderly person. MAIN OUTCOME MEASURES: Carers' perceptions of financial impact of looking after an old person, service use (from a list of locally available services), unmet service needs, and needs for three types of generic service (help with supervision, housework, or personal care). RESULTS: Financial impact was low, except for extra household expense in the dementia group. There was significantly greater use of mainstream domiciliary and day care services in the dementia group. Dementia was nevertheless associated with a high level of unmet need, mainly for more mainstream support and help with supervision of the elderly person. CONCLUSION: Supervisory care for demented elderly people should be further developed within an expanded domiciliary service to meet supporters needs.

Time trends and geographical variation in Parkinson's disease in Scotland.

Parkinson's disease is a common and disabling condition which principally affects the elderly. The time and space distribution of Parkinson's disease has been examined to determine if it provides clues as to aetiology and factors affecting its distribution. Previous studies have used mortality data, data from epidemiological studies, and prescribing information particularly with regard to the use of levodopa. These studies have looked within countries and between countries.

The treatment of Parkinson's disease in older people.

Parkinson's disease is characterised by a variable combination of tremor, rigidity, bradykinesia and impaired righting reflexes. The cumulative life-time risk is one in 40. Levodopa remains the single most effective treatment in older patients, and the minimum dose to achieve maximum functional benefit should be employed. When fluctuations occur, controlled release preparations and selegiline can improve function. Oral dopamine agonists have a role but the combined side effect profile with levodopa should be monitored. COMT inhibitors have recently become available. Subcutaneous apomorphine can be helpful when "on-off" phenomena are marked. The concept of neuroprotection continues to be debated. Surgery is an option for fitter older people but neurotransplantation remains essentially a research tool.

Mortality and causes of death in idiopathic Parkinson's disease: results from the Aberdeen whole population study.

Two hundred and forty-nine patients with Parkinson's disease previously examined by Mutch et al 1,2 were followed up three and a half years after the original study. Cognitive impairment, age, some postural signs and symptoms of Parkinson's disease and high scores on the Hoehn and Yahr scale predicted premature death. Patients were more likely to die from respiratory infections than controls. Respiratory diseases as cause of death recorded on the death certificate were not related to kyphosis, posture scores or Hoehn and Yahr scores before death. The hypothesis is advanced that death of respiratory causes might be associated with signs of general autonomic dysregulation.

Specialist clinics: a better way to care?

A questionnaire on the development of specialist clinics was distributed to the members of the Association of British Neurologists and completed by 104 members (85 consultants). Half of the respondents already ran a specialist clinic. The same proportion felt that a Parkinsonism clinic would be useful despite the fact that only 20% stated that they would run one. It is argued that specialist clinics facilitate the effective management of conditions such as Parkinson's disease, especially if supported by a specialist nurse or other appropriate staff.

Finger tremor in Parkinson's disease.

Finger tremor was investigated in 20 patients (age range 54-88 yr) diagnosed as suffering from idiopathic Parkinson's disease and six controls of a similar age and no known neurological abnormality. In nine of the patients tremor was not clinically obvious. When the tremor of these patients was recorded immediately after voluntary movement and subjected to instrumental analysis there were consistently observable differences from the controls. Such analysis may have diagnostic potential when there is clinical uncertainty. Surface EMG recordings were obtained from four patients. One patient had a large resting tremor with obvious reciprocating activity in flexors and extensors; in the others who had no symptomatic tremor there was reciprocating activity only after movement, and this died away in a few seconds as the induced tremor disappeared.

Is it a hypo? Knowledge of the symptoms of hypoglycaemia in elderly diabetic patients.

Knowledge of the symptoms of hypoglycaemia was assessed in 161 elderly diabetic patients using insulin or a sulphonylurea. Nine percent knew no symptoms. Patients on insulin and those with poorer control had significantly greater knowledge (p less than 0.01). Those reporting episodes of hypoglycaemia had significantly greater knowledge of some symptoms. Knowledge decreased with age, but was not related to sex, duration of diabetes or living alone. Patients and relatives had similar knowledge and education of both needs to be improved.

Reversible mild diabetes in children after treatment with chlorpropamide.

In 9 patients with juvenile-onset chemical diabetes treated with oral chlorpropamide, oral or intravenous assessments of carbohydrate tolerance were made regularly three weeks after withdrawal of therapy. 6 patients with sequential intravenous tests achieved statistically significant reversal of their carbohydrate intolerance and have remained normal for an average of 5.6 years (range 1-11 years). 2 patients who subsequently required insulin therapy were maintained in remission for 3.5 years and 5 years, respectively. There appears to be a group of young patients with chemical diabetes who achieve significant remission with sulphonylurea therapy.

A screening and alerting questionnaire for parkinsonism.

A self-administered eight-symptom questionnaire on parkinsonism was completed by 35 patients known to have parkinsonism and 88 controls independently selected by a local general practice. The presence of shaking and difficulty opening things/doing small buttons were the commonest positive responses among the cases (27/35). While a shuffling walk and difficulty turning in bed were the least frequent positive responses among the cases, they were also the two questions least likely to be positive in the control group. The question on shaking was the most discriminating between cases and controls. When the question on a shuffling walk was added, a positive answer to questions correctly identified 91% of cases and 92% of controls. These questions can form the basis of an alerting/screening questionnaire for parkinsonism and could be useful in screening smaller targeted populations such as a general practice list.

Parkinson's disease: disability, review, and management.

Data from a descriptive study of idiopathic Parkinson's disease were analysed aimed at getting a clearer picture of the impact of the disease on the community and the help available to patients and carers. Altogether 267 patients aged 40-92 were identified, and the median duration of disease in those in whom this could be assessed was 7.2 years. Of the 267 patients, 204 (76.4%) were living in the community, 51 alone. A total of 201 patients were taking levodopa, 29 out of 102 had retired early, and 60 out of 84 (71.4%) had given up driving. Most patients had symptoms at the time of study, and signs such as bradykinesia, rigidity, impaired speech, and abnormal gait were often moderate or severe. Of 214 patients whose disease was assessed using the scoring system of Hoehn and Yahr, 78 (36.4%) had grade 4 and 23 (10.7%) grade 5 disability. Despite this, however, 105 of 265 patients (39.6%) were not subject to regular medical review and only 57 of 227 patients (25.1%) had been seen by an occupational therapist, 16 (7.0%) by a physiotherapist, and 10 (4.4%) by a speech therapist. Patients with Parkinson's disease may benefit from regular medical review and being seen by therapists.

The relationship between Parkinson's disease and dementia. A study using proton NMR imaging parameters.

The value of the spin lattice relaxation time (T1) obtained during nuclear magnetic resonance imaging of the brain was studied in patients with idiopathic Parkinson's disease, with and without dementia. T1 increases significantly in the basal ganglia and cerebral white matter of the demented and non-demented groups. T1 of the cerebral white matter correlates with the severity of dementia.

A study of the early signs of drug induced parkinsonism.

Postural tremor was recorded from psychiatric patients who had been treated with phenothiazine or butyrophenone neuroleptic drugs. None of the patients had previously been diagnosed as having extrapyramidal dysfunction. A significant number of these patients had abnormally low tremor frequencies. Low frequency tremors are often associated with Parkinson's disease (PD) so that some of these patients may have early signs of drug induced Parkinsonism (DIP). The results indicate that DIP is not necessarily characterised by a bilateral slow frequency tremor, but may initially be similar to idiopathic PD, even though its cause and prognosis are different.

Identifying older people with dementia: the effectiveness of a multiservice census.

A census of all relevant services in an area can be used to identify people with mental impairment suggestive of dementia. Two censuses in Tayside, Scotland, were used to test the effectiveness of this method. False positives accounted for 12% of returns. After excluding false positives, by comparison with expected dementia prevalence based on EURODEM, 66% of all sufferers and 50% of those living in the community were identified by the censuses. By pro-rating for non-response, the proportion of sufferers known to services was estimated as 72%. The characteristics of those not known to services are unclear and further research is needed on this. The cost of a census in an area of 250,000 population is under pounds 3000. A multiservice census offers a simple, inexpensive, practicable method of constructing a sample frame for population needs assessment.

A population needs assessment profile for dementia.

The Tayside Profile for Dementia Planning is an instrument designed to obtain data for population needs assessment and planning. It provides a brief tool to collect a minimum dataset by non-specialists. Third-party informants-informal carers or involved professionals-are used as data sources. The key concept is the use of a descriptive profile rather than a summative score or categorization. The profile consists of a set of needs indicators, information on current service response and demographic and background data. Key levels of dependency are measured by time interval dependency. Validity, reliability, acceptability and usability are satisfactory, with the crucial exception that informal carers and professionals appear to perceive needs differently. Further research is needed to assess which type of informant provides the more useful data.

Parkinson's disease in Aberdeen: survival after 3.5 years.

The increasing age of the general population and of patients suffering from Parkinson's disease suggests that a reappraisal of mortality rates and factors related to increased mortality should be carried out. A 3.5 year follow-up of a whole population sample of 267 patients and 233 controls matched by age, sex and general practitioner, yielded a relative mortality rate of 2.35 (99%-confidence interval: 1.60-3.43). Factors predicting death within the follow-up period were: cognitive impairment, old age, late age of onset, long history of smoking, lower blood pressure, and a variety of signs, symptoms and sequelae of Parkinson's disease associated with decreased mobility. However, age less than 70 years, age of onset before 66 years, absence of kyphosis or normal Webster posture score, mild impairment on the Hoehn & Yahr scale (1-2), or no impairment in a 10-question mental status questionnaire (9-10), were not associated with an increased risk of death.