Patients' preferences and existential perspective: what to consider and how should patient's expectations be guided?

With an ageing population, surgical procedures in older patients are becoming increasingly more common. This can pose clinical and ethical dilemmas, during which clinicians need to make complex decisions. In this paper we discuss the importance of assessing mental capacity to assess if the older patient can make his or her own decisions relating to surgery. We also discuss the importance of understanding ethical principles, in order that clinicians can better guide patient's decision-making. In addition, we look at ageism, frailty, and co-morbidities, and their influence on clinician's decisions regarding surgery in older patients. Further to this, we look at the influence of evidence-based medicine on treatment options, and the under representation of older people in clinical trials and the importance of this. Finally, we consider the importance of considered decisions regarding resuscitation, when considering surgical intervention in older patients. We conclude that patient-centred individualised care, considering patients expectations, wishes, and priorities is vital, whilst aiming to improve or maintain quality of life, and minimise risks when able.

Determinants of burden in those who care for someone with dementia

OBJECTIVES

Caregiver burden is a key measure in caregiver research and is frequently used as a baseline measure in intervention studies. Previous research has found numerous factors associated with caregiver burden such as the relationship quality between carer and patient, the patient's cognitive ability, behavioural and psychological symptoms displayed by the patient, caregiver gender, adverse life events to name a few. Many studies have investigated these factors singularly however current thought suggests a multi-factorial role and inter-dependence of these factors. Based on this it was decided to investigate factors associated with caregiver burden using a multiple regression analysis in order to ascertain the predictive quality of these factors of caregiver burden.

METHOD

Cross-sectional study using validated measures of a patient's cognitive ability, ability to carry out day-to-day tasks and behavioural and psychological symptoms. Caregiver outcomes used are caregiver burden, relationship quality, caregiver confidence, experience of adverse life events, neuroticism, age and gender. Interviews and questionnaires were carried out on 74 patients diagnosed with dementia and their main caregivers from the Midlands of England.

RESULTS

Multiple regression analysis showed that caregiver overload, carer-patient relationship quality, the experience of adverse life events, caregiver gender, caregivers' level of neuroticism, caregiver role captivity and the level of caregiver confidence accounted for over 80% of the variance in caregiver burden.

CONCLUSION

These results confirm previous correlational research on caregiver burden. Furthermore, due to the use of multiple regression analysis the findings also show factors that are clear predictors of caregiver burden and we offer possible suggestions from these findings on future clinical practice interventions on caregiver burden.

Aspirin in Alzheimer's disease (AD2000): a randomised open-label trial

BACKGROUND

Cardiovascular risk factors and a history of vascular disease can increase the risk of Alzheimer's disease (AD). AD is less common in aspirin users than non-users, and there are plausible biological mechanisms whereby aspirin might slow the progression of either vascular or Alzheimer-type pathology. We assessed the benefits of aspirin in patients with AD.

METHODS

310 community-resident patients who had AD and who had no potential indication or definite contraindication for aspirin were randomly assigned to receive open-label aspirin (n=156; one 75-mg enteric-coated tablet per day, to continue indefinitely) or to avoid aspirin (n=154). Primary outcome measures were cognition (assessed with the mini-mental state examination [MMSE]) and functional ability (assessed with the Bristol activities of daily living scale [BADLS]). Secondary outcomes were time to formal domiciliary or institutional care, progress of disability, behavioural symptoms, caregiver wellbeing, and care time. Patients were assessed at 12-week intervals in the first year and once each year thereafter. Analysis of the primary outcome measures was by intention to treat. This study is registered as an International Standard Randomised Controlled Trial, number ISRCTN96337233.

FINDINGS

Patients had a median age of 75 years; 156 patients had mild AD, 154 had moderate AD, and 18 had concomitant vascular dementia. Over the 3 years after randomisation, in patients who took aspirin, mean MMSE score was 0.10 points higher (95% CI -0.37 to 0.57; p=0.7) and mean BADLS score was 0.62 points lower (-1.37 to 0.13; p=0.11) than in patients assigned to aspirin avoidance. There were no obvious differences between the groups in any other outcome measurements. 13 (8%) patients on aspirin and two (1%) patients in the control group had bleeds that led to admission to hospital (relative risk=4.4, 95% CI 1.5-12.8; p=0.007); three (2%) patients in the aspirin group had fatal cerebral bleeds.

INTERPRETATION

Although aspirin is commonly used in dementia, in patients with typical AD 2 years of treatment with low-dose aspirin has no worthwhile benefit and increases the risk of serious bleeds.

Substance misuse in the older population

Substance misuse among the older population is largely overlooked and underreported. Many factors contribute to this, not least the fact that presentation may be atypical and hence easily missed by the medical practitioner. There may be many clues to its existence, provided the physician remains alert to these. Despite this it is quite comforting to know that once identified, the evidence to date suggests that older people may respond at least as well as younger people to treatment.

Long-term donepezil treatment in 565 patients with Alzheimer's disease (AD2000): randomised double-blind trial

BACKGROUND

Cholinesterase inhibitors produce small improvements in cognitive and global assessments in Alzheimer's disease. We aimed to determine whether donepezil produces worthwhile improvements in disability, dependency, behavioural and psychological symptoms, carers' psychological wellbeing, or delay in institutionalisation. If so, which patients benefit, from what dose, and for how long?

METHODS

565 community-resident patients with mild to moderate Alzheimer's disease entered a 12-week run-in period in which they were randomly allocated donepezil (5 mg/day) or placebo. 486 who completed this period were rerandomised to either donepezil (5 or 10 mg/day) or placebo, with double-blind treatment continuing as long as judged appropriate. Primary endpoints were entry to institutional care and progression of disability, defined by loss of either two of four basic, or six of 11 instrumental, activities on the Bristol activities of daily living scale (BADLS). Outcome assessments were sought for all patients and analysed by logrank and multilevel models.

FINDINGS

Cognition averaged 0.8 MMSE (mini-mental state examination) points better (95% CI 0.5-1.2; p<0.0001) and functionality 1.0 BADLS points better (0.5-1.6; p<0.0001) with donepezil over the first 2 years. No significant benefits were seen with donepezil compared with placebo in institutionalisation (42% vs 44% at 3 years; p=0.4) or progression of disability (58% vs 59% at 3 years; p=0.4). The relative risk of entering institutional care in the donepezil group compared with placebo was 0.97 (95% CI 0.72-1.30; p=0.8); the relative risk of progression of disability or entering institutional care was 0.96 (95% CI 0.74-1.24; p=0.7). Similarly, no significant differences were seen between donepezil and placebo in behavioural and psychological symptoms, carer psychopathology, formal care costs, unpaid caregiver time, adverse events or deaths, or between 5 mg and 10 mg donepezil.

INTERPRETATION

Donepezil is not cost effective, with benefits below minimally relevant thresholds. More effective treatments than cholinesterase inhibitors are needed for Alzheimer's disease.

Drug absorption may be delayed after stroke: results of the paracetamol absorption test

BACKGROUND

Autonomic changes are frequent after stroke but it is not known whether gastric emptying is altered. We have investigated this using the paracetamol absorption test.

METHODS

12 acute stroke patients and 13 healthy controls of similar age received 1 g oral paracetamol tablets. We studied all patients within 24 h of the stroke and 5 days later. Standard pharmacokinetic measurements were derived from the plasma paracetamol-time curve.

RESULTS

In acute stroke patients, mean plasma T(max) was delayed compared with that in controls (96.3 vs 46.2 min, P=0.015). The C(max) of paracetamol was also lower (16.1 vs 23.9 mg l(-1), P=0.028). The area under the curve of paracetamol did not differ significantly in acute stroke patients and controls.

CONCLUSIONS

Gastric emptying appears to be delayed in acute stroke patients, and this may result in delayed pharmacological action of orally administered drugs.

Effect of hemiparetic stroke on pulse oximetry readings on the affected side

BACKGROUND AND PURPOSE

Hypoxia is common after stroke, and monitoring by pulse oximetry is suggested in the acute phase. Physical changes on the affected side or intravenous infusions may affect oximeter readings. This study was designed to test whether pulse oximetry recordings are the same on the affected and nonaffected sides in stroke patients.

METHODS

Oxygen saturation (SpO(2)) and heart rate (HR) were assessed simultaneously in the left and right hands in patients with hemiparetic stroke over a 3-hour period with 2 Minolta Pulsox-3i oximeters attached to the index fingers.

RESULTS

Fifteen patients (53% men; 67% left hemiparesis; mean age, 73 years [SD, 7.5 years]) were recruited. HR and SpO(2) (12 measurements per minute) were monitored. The maximum difference between simultaneous left and right arm readings was 2% SpO(2). HR fluctuated more, but no affected/nonaffected side pattern was seen. Means for each patient of HR and SpO(2) for the affected and nonaffected sides were compared by t tests. Mean SpO(2) was 96% (SD, 1%) on both sides. Mean HR was 81 bpm (SD, 11 bpm) on the affected side and 80 bpm (SD, 10 bpm) on the nonaffected side. There was no significant difference between the 2 sides for either parameter (n=15; P=0.86 for SpO(2) and P=0.91 for HR).

CONCLUSIONS

Oximeters can be attached to either the affected or nonaffected side in hemiparetic stroke.

Domiciliary visits to the old and the mentally ill: how valuable?

In the early days of the British National Health Service, domiciliary visits were a continuation of the tradition whereby general practitioners (GPs) met consultants in the patient's home. The nature of domiciliary visits, which still attract a special fee, has since changed. We analysed the effectiveness of all domiciliary visits undertaken in a NHS trust providing primary care, mental health and elderly care services to a population of 470,000. Data were obtained from domiciliary visit claim forms and from questionnaires completed by the consultant, the referring GP and consultant peer reviewers. The largest number of visits (total 234) was in geriatric medicine 48.9%, followed by old-age psychiatry 44.9%. Geriatric medicine was more likely than psychiatry to admit patients to hospital (19%) after a visit. All domiciliary visits in old-age psychiatry were done during the day (9 am to 5 pm). Only 2% of GPs stated that they attended any of the domiciliary visits; almost all thought that the outcome of domiciliary visits was of value. Old-age-psychiatry peer reviewers believed that all visits in that specialty were appropriate; in geriatric medicine this figure was 77% and in other psychiatric specialties 65%. The findings indicate that domiciliary visits were not being used routinely as a pathway to hospital admission, though they were often used to expedite admission or gain a quick consultant opinion; the visits were valued by GPs. The practice of domiciliary visits differs greatly from the definition in NHS terms and conditions of service. One or other should be altered.

Orthostatic haemodynamic responses in acute stroke

Little is known about orthostatic blood pressure regulation in acute stroke. We determined postural haemodynamic responses in 40 patients with acute stroke (mild or moderate severity) and 40 non-stroke control in-patients, at two days ('Day 1') and one week ('Week 1') post-admission. Following a 10-minute supine rest and baseline readings, subjects sat up and blood pressure and heart rate were taken for 5 minutes. The procedure was repeated with subjects moving from supine to the standing posture. Haemodynamic changes from supine data were analysed. On standing up, the control group had a transient significant fall in mean arterial blood pressure on Day 1 but not Week 1. No significant changes were seen on either day when sitting up. In contrast to controls, the stroke group showed increases in mean arterial blood pressure on moving from supine to the sitting and standing positions on both days. Persistent postural hypotension defined as > or = 20 mmHg systolic fall occurred in < 10% of either of the study groups on both days. Sitting and standing heart rates in both groups were significantly faster than supine heart rate on both days. The orthostatic blood pressure elevation is consistent with sympathetic nervous system overactivity which has been reported in acute stroke. Upright positioning as part of early rehabilitation and mobilisation following mild-to-moderate stroke would, therefore, not predispose to detrimental postural reductions in blood pressure.

Blood pressure measurement and antihypertensive therapy in acute stroke

Inappropriate management of high blood pressure in acute stroke can adversely affect outcome. We examined blood pressure evaluation and antihypertensive therapy during the first week post-stroke in 40 patients at a district general hospital with no stroke unit. In the first 24 hours, median frequency of blood pressure recording was 3 (range 1-12). After day 1, 11 (28%) had no blood pressure readings for one or two consecutive days. The side of measurement was not recorded in any patient. None of the 22 hypertensives (55%) had a bilateral measurement to exclude interarm inequality, and only 3 (7%) of all patients had postural readings to exclude orthostatic hypotension. Fourteen (35%) received antihypertensive therapy without meeting recommended indications; some even had low blood pressure. As most stroke patients are managed in general medical wards rather than stroke units, a greater awareness of these important aspects of blood pressure evaluation and therapy are needed among medical and nursing staff.

Clinical pharmacokinetic considerations in the elderly. An update

There are a number of areas in which advances have been made over the last few years in the area of pharmacokinetics in the elderly. There is increasing understanding of the diversity of cytochrome P450s (CYP) and the variability of the age-related decline in CYP activity. This has helped to explain some of the interindividual variability in drug metabolism with age. The importance of ethnic differences has emerged, but specific work is needed in this area in the elderly. Differences in the handling of chiral compounds has been reported but as yet no clinically important findings that may lead to a change in clinical practice have emerged. The emerging importance of extrahepatic drug metabolism, especially in the intestine, has added a new complexity to our understanding of pharmacokinetics. The issue of frailty is also discussed in this article. Whether it will be of value at the bedside has yet to emerge. Nonetheless, as a concept, recent data has supported its potential use to define those more at risk of clinically meaningful pharmacokinetic alterations. Other advances have included the appreciation that selectivity in induction and inhibition in the elderly are due to the existence of multiple CYP forms. Similarly, the role of these various enzymes in disease is also improving our clinical understanding, as exemplified in Parkinson's disease.

Health status and disability among elderly people in three UK districts

AIM

To obtain population data on health status and disability of elderly people which may help in planning and maintaining services and be used as comparators for research.

METHOD

Random samples of people aged 70 and over were interviewed in their own homes in West Glamorgan, Dudley and North Staffordshire. The interviews included standardized assessments of health status (SF-36), disability (Barthel index) and cognitive function (Abbreviated Mental Test).

RESULTS

1608 interviews were completed. Response rates varied between 66 and 84%. Age and sex adjusted scores for five of the eight parameters of the SF-36 and the Barthel score differed significantly between districts.

CONCLUSIONS

Local studies are required to provide appropriate normative data for each area. In the absence of such studies, the data in this paper are the best currently available.

Multiple dose netivudine, a potent anti-varicella zoster virus agent, in healthy elderly volunteers and patients with shingles

Netivudine is a nucleoside analogue with potent anti-varicella zoster virus activity. We now report two open studies of the pharmacokinetics and tolerability of netivudine in doses of 50, 100 and 200 mg twice daily. In one study, healthy volunteers received an initial, single dose followed, a week later, by repeat dosing for 9 1/2 days; in the other, patients with shingles were treated for 8 days and data were also recorded for rash resolution and pain duration and intensity. Netivudine was well tolerated in both studies. Plasma concentrations were similar in patients and healthy volunteers and increased in proportion to dose. Steady state concentrations were 15-25% lower than expected from single dose data, probably because of slightly decreased netivudine absorption after food. Elimination half-life was l4-20 h. Plasma concentrations of 5-propynyluracil (5-PU), the main metabolite of netivudine, did not increase in proportion to the netivudine dose and tended to be higher in patients than volunteers. 5-PU concentrations remained elevated for up to 72 h after the last netivudine dose, suggesting continued but slow release from unabsorbed netivudine in the gut lumen. New lesion formation ceased and vesicles crusted most quickly in the 200 mg group; zoster-associated pain intensity, was reduced in a dose-related manner.

Inhibition of dihydropyrimidine dehydrogenase by 5-propynyluracil, a metabolite of the anti-varicella zoster virus agent netivudine

OBJECTIVE

To study the effects of the anti-herpetic drug netivudine on dihydropyrimidine dehydrogenase activity in elderly volunteers and to relate them to concentrations of netivudine and its metabolite 5-propynyluracil.

METHODS

Three groups of eight elderly volunteers received 400 or 800 mg netivudine or placebo once daily for 8 days. Plasma netivudine, 5-propynyluracil, and uracil, an indirect measure of dihydropyrimidine dehydrogenase activity, were assayed before the first dose and on days 2, 3, 5, 7 and 8. Full plasma profiles of netivudine and 5-propynyluracil were determined after the last dose.

RESULTS

Plasma uracil was unquantifiable in all subjects before the first dose and at all time points in the placebo group. In recipients of netivudine it reached a plateau between days 3 and 5, with mean values of 23.2 and 23.5 mumol/L on day 8 in the subjects who received 400 and 800 mg. Plasma netivudine concentrations were approximately dose proportional, but 5-propynyluracil concentrations were similar in both groups. The half-maximal rise in plasma uracil occurred after a cumulative 5-propynyluracil exposure of 120 mumol/L.hr; such exposures will be achieved even after doses as low as 50 to 100 mg daily.

CONCLUSIONS

Netivudine dosing produces complete inhibition of plasma dihydropyrimidine dehydrogenase. Coadministration with the antimetabolite 5-fluorouracil will require a substantial reduction in 5-fluorouracil dose to avoid toxicity but may also improve the therapeutic index of 5-fluorouracil.

Pharmacokinetics and tolerability of single oral doses of 882C87, a potent, new anti-varicella-zoster virus agent, in healthy volunteers

882C87 is a nucleoside analog with potent, specific activity against varicella-zoster virus. It is approximately seven times as potent as acyclovir with an in vitro 50% inhibitory concentration of 1 to 2 microM. The tolerability and pharmacokinetics of single doses of 882C87 have been investigated in a series of studies with healthy young and elderly adult volunteers. The young received 50 to 1,600 mg, and the elderly received 50 and 100 mg. Concentrations of 882C87 and its main metabolite, the pyrimidine base 5-(1-propynyl)uracil (5PU), in plasma and urine were assayed by an automated sequential trace enrichment of dialysate-high-performance liquid chromatography procedure, and noncompartmental pharmacokinetic parameters were derived from the data. Concentrations of 882C87 in plasma increased proportionally for doses of up to 400 mg, but after higher doses the increase was less than dose proportional. In young adults, after 200, 400, and 1,600 mg, the maximum concentrations of the drug in plasma were 9.0, 16.3, and 34.7 microM, respectively, and the areas under the concentration-time curve (AUC) from 0 h to infinity were 166.6, 333.7, and 822.9 microM.h, respectively. Elimination half-life was 11.3 to 13.0 h after 50 to 400 mg, increasing to 15.3 h after 1,600 mg, associated with a small decrease in renal clearance. In healthy elderly volunteers concentrations of 882C87 in plasma after 50 and 100 mg were similar to those in young adults after twice the dose; apparent clearance and renal clearance were significantly reduced, and half-life was significantly longer at 15 h. Administration of 882C87 with food produced a small, nonsignificant reduction in mean AUC from 0 h to infinity, but in subjects with a low fasting AUC there was an increase after food and in subjects with a high fasting AUC there was a decrease. Concentrations of 5PU in plasma were one-third to one-half those of 882C87 and, in most subjects, were not dose proportional. There was a lag of at least 5 h after dosing with 882C87 before 5PU was detectable in plasma.

Evaluation of a clinical score for prognostic stratification of elderly stroke patients

Orpington Prognostic Score (OPS) is a clinically derived score which incorporates measures of motor deficit, proprioception, balance and cognition. OPS and urinary continence were measured prospectively in 217 stroke survivors over 75 years of age at 1, 2 and 4 weeks after stroke and were correlated with dependence at discharge. Three levels of dependence were defined based on personal self-care abilities. OPS ranged from 2.0 to 3.2 (median 2.8) at 2 weeks after stroke in patients independent at discharge (n = 54). Their initial median Barthel index of 4 improved by a median of 12. Urinary continence was achieved in 95% of these patients by 2 weeks. All patients were discharged home, 39 (72%) within 4 weeks. Patients with limited dependence at discharge (n = 129) had OPS of 3.2-4.8 (median 4.0) at 2 weeks. Two-thirds were continent at 2 weeks. Their initial median Barthel index was 2 and changed by a median of 12. Seventy-one (55%) of these patients went home. OPS ranged from 5.2 to 6.8 (median 6.0) at 2 weeks in patients dependent at discharge (n = 34). About 20% of these patients were continent. Their initial median Barthel index of 2 improved by a median of 6 at discharge. Only five (15%) patients in this group went home. OPS was comparable with urinary incontinence for sensitivity (96% vs. 90%), specificity (36% vs. 39%) and accuracy (75% vs. 66%) in identifying stroke patients achieving independent living. OPS had a greater predictive value than urinary incontinence in identifying patients requiring institutional care (82% vs. 57%). OPS is a simple objective predictor of outcome in elderly stroke patients, suitable for everyday clinical use. It also can facilitate stroke research by identifying a 'middle group' of patients who would be most sensitive to changes in therapy or organization of stroke services.

Indomethacin and cognitive function in healthy elderly volunteers

1. Cognitive function was studied after single and multiple doses of indomethacin (I) and matched placebo (P) in 20 healthy elderly volunteers using a double-blind crossover design. 2. Arousal, attention, integration, coordination, memory and mood were investigated using a battery of psychomotor tests and the Hospital Anxiety and Depression Scale. Assessments were performed before and after the first and last doses of a 7 day course of medication. 3. Critical flicker fusion threshold fell by a mean of 1.96% on indomethacin compared with a 1.13% rise on placebo 5 h after the first dose (P = 0.029). A beneficial effect on choice reaction time latency (P = 0.012) was seen both after acute and continuing administration of indomethacin. Performance at the most discriminating level (level 3) of the paired word association test was significantly better following 8 days of treatment with indomethacin in the younger (55-65 year-old) age group (P = 0.001). 4. There was no significant difference in performance on the symbol-digit substitution test and the continuous attention task. No change was seen in hospital anxiety and depression scale scores. 5. These results suggest that performance on tests of sensorimotor coordination and short term memory may improve in healthy volunteers following indomethacin administration, whereas tests of attention and psychomotor speed remain unaffected. However, further controlled studies in rheumatic patients are needed to evaluate fully the psychomotor effects of indomethacin and other NSAIDs in clinical practice.