How should we investigate CUO (C-Reactive Protein elevation of unknown origin)? A case-based discussion of infective endocarditis in an octogenarian.

Infective endocarditis and other chronic infections may cause diagnostic difficulties, regardless of age. The likelihood of an atypical presentation of chronic infection probably increases with age. Serum CRP may be a useful guide to the presence of underlying infection and its resolution in older people. The term CUO (CRP elevation of unknown origin) may have a place in triggering further investigation for the presence of infection or other pathology.

Cognitive dysfunction after surgery and anaesthesia: what can we tell the grandparents?

'Grandpa was never the same after his operation!'. This statement describes a myriad of possible clinical difficulties that can afflict older people after hospitalisation for major surgery. We summarise the evidence pertaining to the phenomenon of Postoperative Cognitive Dysfunction, a condition defined as an abnormality on neuropsychological testing, which is said to afflict up to 14% of over 70 years olds undergoing elective surgery. So far none of the expected surgical, anaesthetic and environmental risk factors have been convincingly demonstrated to be responsible for this observed deterioration. While recognising the high incidence of the condition as an neuropsychological entity we accept that it is difficult to translate this into a reliable estimate of clinical risk for the individual patient.

Effect of multivitamin and multimineral supplementation on cognitive function in men and women aged 65 years and over: a randomised controlled trial.

BACKGROUND: Observational studies have frequently reported an association between cognitive function and nutrition in later life but randomised trials of B vitamins and antioxidant supplements have mostly found no beneficial effect. We examined the effect of daily supplementation with 11 vitamins and 5 minerals on cognitive function in older adults to assess the possibility that this could help to prevent cognitive decline. METHODS: The study was carried out as part of a randomised double blind placebo controlled trial of micronutrient supplementation based in six primary care health centres in North East Scotland. 910 men and women aged 65 years and over living in the community were recruited and randomised: 456 to active treatment and 454 to placebo. The active treatment consisted of a single tablet containing eleven vitamins and five minerals in amounts ranging from 50-210 % of the UK Reference Nutrient Intake or matching placebo tablet taken daily for 12 months. Digit span forward and verbal fluency tests, which assess immediate memory and executive functioning respectively, were conducted at the start and end of the intervention period. Risk of micronutrient deficiency at baseline was assessed by a simple risk questionnaire. RESULTS: For digit span forward there was no evidence of an effect of supplements in all participants or in sub-groups defined by age or risk of deficiency. For verbal fluency there was no evidence of a beneficial effect in the whole study population but there was weak evidence for a beneficial effect of supplementation in the two pre-specified subgroups: in those aged 75 years and over (n 290; mean difference between supplemented and placebo groups 2.8 (95% CI -0.6, 6.2) units) and in those at increased risk of micronutrient deficiency assessed by the risk questionnaire (n 260; mean difference between supplemented and placebo groups 2.5 (95% CI -1.0, 6.1) units). CONCLUSION: The results provide no evidence for a beneficial effect of daily multivitamin and multimineral supplements on these domains of cognitive function in community-living people over 65 years. However, the possibility of beneficial effects in older people and those at greater risk of nutritional deficiency deserves further attention.

Medical student attitudes toward older people and willingness to consider a career in geriatric medicine.

OBJECTIVES: To evaluate the attitudes of first- and fourth-year medical students toward older people and the relationship between these attitudes and possible career choice. To examine the effects of an intensive geriatric medicine (GM) teaching program on these attitudes and career aspirations. DESIGN: Observational study. SETTING: University of Aberdeen. PARTICIPANTS: Medical students. MEASUREMENTS: In September 2005, first-year students (n=163) at the start of their undergraduate training completed a questionnaire based on the University of California at Los Angeles Geriatrics Attitudes Scale. Students were asked how likely they were to consider a career in GM in the future on a 5-point Likert scale. From the beginning of the academic year 2005/06, fourth-year students completed the same questionnaire before and after an intensive 8-day GM teaching program. RESULTS: First-year medical students had a mean attitude score+/-standard deviation of 3.69+/-0.39. A more-positive attitude increased the likelihood of considering a career in GM (P<.001). Fourth-year students had better attitude scores than first-year students (3.86+/-0.36, P=.002). The GM teaching program did not significantly affect attitude scores but significantly increased the willingness to consider a career in GM by a mean 0.52 points (95% confidence interval=0.35-0.70, P<.001). CONCLUSION: Attitudes toward older people were better in fourth-year than first-year medical students. A more-positive attitude toward older people increased the likelihood of considering a career in GM. An intensive 8-day course in GM had no significant effect on attitudes but increased the likelihood of fourth-year students considering a career in GM.

Effect of multivitamin and multimineral supplements on morbidity from infections in older people (MAVIS trial): pragmatic, randomised, double blind, placebo controlled trial.

OBJECTIVE: To examine whether supplementation with multivitamins and multiminerals influences self reported days of infection, use of health services, and quality of life in people aged 65 or over. DESIGN: Randomised, placebo controlled trial, with blinding of participants, outcome assessors, and investigators. SETTING: Communities associated with six general practices in Grampian, Scotland. PARTICIPANTS: 910 men and women aged 65 or over who did not take vitamins or minerals. INTERVENTIONS: Daily multivitamin and multimineral supplementation or placebo for one year. MAIN OUTCOME MEASURES: Primary outcomes were contacts with primary care for infections, self reported days of infection, and quality of life. Secondary outcomes included antibiotic prescriptions, hospital admissions, adverse events, and compliance. RESULTS: Supplementation did not significantly affect contacts with primary care and days of infection per person (incidence rate ratio 0.96, 95% confidence interval 0.78 to 1.19 and 1.07, 0.90 to 1.27). Quality of life was not affected by supplementation. No statistically significant findings were found for secondary outcomes or subgroups. CONCLUSION: Routine multivitamin and multimineral supplementation of older people living at home does not affect self reported infection related morbidity. TRIAL REGISTRATION: ISRCTN: 66376460.

A multi-centre European study of factors affecting the discharge destination of older people admitted to hospital: analysis of in-hospital data from the ACMEplus project.

OBJECTIVES: to examine the relationship between seven predictor variables (recorded on Day 3 of hospital admission) and discharge destination in non-elective medical patients aged 65+ years. DESIGN: prospective cohort. SETTING: eight centres in six European countries. PREDICTOR VARIABLES: age, gender, living alone, physical function (three categories based on Barthel Index), cognition (Katzman's orientation-memory-concentration test), main body system affected (based on International Classification of Diseases), number of geriatric giants (GGs) involved in the referral (a GG being a problem with falling, mobility, continence or cognition). MAIN OUTCOME MEASURES: discharge destination (by Day 90) in three categories: 'HOMESAME' (return to previous residence), 'INSTIN90' (discharge to alternative residence or still in hospital at 90 days), 'DEADINHO' (death in hospital), RESULTS: in 1,626 patients, discharge destination was HOMESAME in 84.7%, DEADINHO in 8.9% and INSTIN90 in 6.4%. Mean duration of stay was 17.7 days, median 12. Univariate analyses showed a statistically significant relationship between all seven predictor variables and discharge destination. Physical function was the best single predictor with a seven-fold difference in adverse outcome rates between the best and worst categories. On multiple logistic regression, significant predictor variables were as follows. (i) For DEADINHO: physical function, cognition, gender; (ii) for INSTIN90: physical function, living alone, GGs, age, gender. Multiple linear regression identified physical function, GGs and living alone as predictors of loge length of stay. CONCLUSION: case-mix systems to compare risk-adjusted hospital outcome in older medical patients need to incorporate information about physical function, cognition and presenting problems in addition to diagnosis.

A systematic literature review of factors affecting outcome in older medical patients admitted to hospital.

INTRODUCTION: The ACMEplus project aims to devise a standardised system for measuring case-mix and outcome in older patients admitted to hospitals in different parts of Europe for primarily 'medical' (i.e. not surgical or psychiatric) reasons. As a first step in this project, a systematic review was carried out to identify factors which had a significant influence on outcome in such patients. METHODS: The systematic search used Medline 1966-2000, Cinahl 1982-2000, Web of Science 1981-2000, reference lists of relevant papers and a hand search of Age and Ageing 1974-2000. A six-category grading system was devised to classify the 313 identified papers with regard to their relevance to the ACMEplus project, study design and power. The analysis of the 14 'category 1' papers is presented. RESULTS: The main areas of assessment of case-mix were function, cognition, depression, illness severity, nutrition, social elements, aspects of diagnosis and demographic details. Statistically significant predictors, for the four outcome measures, listed below were: For length of stay: functional status score, illness severity, cognitive score, poor nutrition, comorbidity score, diagnosis or presenting illness, polypharmacy, age and gender. For mortality: functional status score, illness severity, cognitive score, comorbidity score, diagnosis or presenting illness, polypharmacy, age and gender. For discharge destination: functional status score, cognitive score, diagnosis or presenting illness and age. For readmission rate: functional status score, illness severity, co-morbidity, polypharmacy, diagnosis or presenting illness and age. CONCLUSIONS: Factors affecting outcome in older medical patients are complex. When looking at outcomes of hospital admission in older people it is important not just to look at routinely available statistics such as age, gender and diagnosis but also to take into account multifaceted aspects such as functional status and cognitive function.