An automatic device to measure time spent upright

Objective measurements of time spent standing or walking would be of benefit in assessing response to therapy. We have tested a device consisting of a mercury tilt switch attached to an electronic counter to measure time spent upright. Eleven subjects, six male and five female age 67-88 years (mean 76 years) undergoing rehabilitation were studied. Diagnoses included: Parkinson's disease, dementia, stroke and femoral fracture. The device was fitted with the tilt switch on the lateral aspect of thigh. Measurements compared stopwatch readings made by an observer and the device. Study periods were of one to three hours. There was excellent correlation between stopwatch and device measurements of time spent standing (t = 0.994; p < 0.001). The device functioned well during physiotherapy and ward activities although measurements were inaccurate when subjects used an exercise bicycle or climbed steps greater than 20 cm in height. The device should prove useful for monitoring activity and response to mobilization therapy.

Combined orthogeriatric care in the management of hip fractures: a prospective study

AIMS

To evaluate the efficacy of combined care between orthopaedic surgeons and geriatricians in the management of patients with fractured necks of femur.

PATIENTS AND METHODS

A prospective study of the admissions to a district general hospital with hip fractures was carried out over a 5-year period. In the years 1992-1994, medical problems in this patient group were managed by a consultation-only service. At the end of 1994, a consultant geriatrician was appointed to manage these patients jointly with the orthopaedic surgeons, and the study was then carried through until the end of 1996. Information about the patients from admission to discharge or death was gathered prospectively using a proforma for the 3 years prior to orthogeriatric care, and the 2 years after. Main outcome measures were mortality, length of stay and discharge destination. These were compared for the two periods--pre- and post-orthogeriatric care.

RESULTS

No significant differences were noted in mortality, length of stay or discharge destination.

CONCLUSIONS

Combined orthogeriatric care according to our model did not have an impact on our chosen outcome measures.

Comparison of elderly people's technique in using two dry powder inhalers to deliver zanamivir: randomised controlled trial

OBJECTIVE

To determine whether elderly people can learn to use the inhaler used to deliver zanamivir (Relenza Diskhaler) as effectively as the Turbohaler and to identify which aspects of inhaler technique are most problematic.

DESIGN

Randomised, controlled, intervention study.

SETTING

Wards for acute elderly care in a large district general hospital.

PARTICIPANTS

73 patients who were unfamiliar with the use of an inhaler, aged 71 to 99 (mean 83) years.

MAIN OUTCOME MEASURES

Initial scores and changes in scores 24 hours later using a 10 point scoring system of five aspects of inhaler technique.

RESULTS

38 patients were allocated the Relenza Diskhaler and 35 the Turbohaler. The mean total score was significantly greater in the Turbohaler than Diskhaler groups both initially (8.74 v 7.05) and after 24 hours (8.28 v 5.43). The major difference between inhalers was in loading and priming. After tuition 50% (19 of 38) of patients allocated the Diskhaler were unable to load and prime the device and 65% (24 of 37) were unable to do so 24 hours later. Of those allocated the Turbohaler, two patients were unable to load and prime the device after initial review and one after 24 hours.

CONCLUSION

Most elderly people cannot use the inhaler device used to deliver the anti-influenza drug zanamivir. Treatment with this drug is unlikely to be effective in elderly people unless the delivery system is improved.

A comparison of large volume spacer, breath-activated and dry powder inhalers in older people

AIMS

To see if elderly people can use the breath-activated (Easi-breathe) and dry powder (Turbohaler) inhalers as effectively as the metered-dose inhaler and Volumatic system.

METHODS

102 inhaler-naive patients (aged 75-101, mean 84 years), without cognitive impairment, were randomly allocated one of Easi-breathe, Turbohaler or metered-dose inhaler and Volumatic placebo inhalers. Standardized tuition was done on enrolment and at 6 h review. Inhaler technique was assessed immediately after enrolment tuition and at 6 and 24 h. Assessment was by scoring (0 = poor, 1 = moderate, 2 = perfect) five aspects of technique.

RESULTS

Mean total scores were significantly (P < 0.005) higher for Turbohaler and Easi-breathe than metered-dose inhaler and Volumatic on enrolment and 6 h and at 24 h (P < 0.045). Fewer patients achieved excellent scores of 9 or 10 when using metered-dose inhaler and Volumatic. The main difficulties were in assembling the metered-dose inhaler and Volumatic and detecting when the metered-dose inhaler and Volumatic or Easi-breathe was empty.

CONCLUSIONS

Breath-activated and dry powder inhalers were more likely to be used correctly than metered-dose inhalers with large volume spacers.

Randomised, controlled trial of spirometric changes in elderly people receiving timolol or betaxolol as initial treatment for glaucoma

AIM

To investigate respiratory and cardiovascular side effects in elderly people in the first 12 months after commencing topical beta antagonists.

METHODS

40 patients (mean age 74 years) were recruited to a randomised, masked study. Spirometry, pulse, and blood pressure were recorded before, 1 month, and 12 months after starting topical therapy with either timolol 0.5% twice daily or betaxolol 0.5% twice daily.

RESULTS

After 1 month five of 20 patients allocated timolol and three of 20 given betaxolol had discontinued it for respiratory reasons, not always accompanied by symptoms. There were no significant differences in changes in mean values of spirometry, pulse, or blood pressure between groups. No further changes were made in therapy for respiratory reasons in the following year. One patient suffered a hypotensive stroke within 2 days of starting timolol.

CONCLUSIONS

By performing spirometry before starting topical beta antagonist therapy and repeating it after 1 month most patients at risk of respiratory impairment can be identified.

Glaucoma therapy may take your breath away

Chronic simple glaucoma is a common disease in old age and lowering intraocular pressure is the treatment strategy. Although this can be achieved surgically, medical treatment with eye drops is more often prescribed. Beta-antagonists are the class of drug most often chosen, although other medical therapies are available. Systemic absorption of beta-antagonist eye drops can cause unsuspected respiratory impairment. Physicians should be alert to the possibility of respiratory side-effects of topical therapy with beta-antagonists and whenever such side-effects occur should use alternative treatments.

Topical beta-blockade with intrinsic sympathomimetic activity offers no advantage for the respiratory and cardiovascular function of elderly people

Topical therapy with beta-antagonists, such as timolol, may cause unrecognized impairment of respiratory and cardiovascular function in elderly people. Beta-antagonists with intrinsic sympathomimetic or cardioselective properties, such as carteolol or betaxolol, may cause less impairment. In a randomized, double-masked study of glaucoma patients, over 60 years of age, without history of bronchospasm and who were using timolol (0.5%), 60 patients were allocated to betaxolol (0.5%) or carteolol (2%) or continued timolol (0.5%) treatment. Spirometry, pulse and blood pressure were measured on enrollment and after 4 weeks. In the timolol and carteolol groups there were no significant changes in mean spirometric values. Changing to betaxolol improved mean peak flow (PF) by 9.1%, from 310 to 3411/min (p < 0.05) and forced expiratory volume in 1 second (FEV1) by 9.4%, from 1.74 to 1.861 (p < 0.05). Differences in the changes in PF and FEV1 between betaxolol and timolol as well as betaxolol and carteolol groups were statistically significant (p < 0.05). Twenty-one per cent of those allocated to betaxolol showed clinically significant improvement in FEV1. There was no change in pulse or blood pressure when carteolol was substituted for timolol but an increase of 10 beats per minute (p < 0.05) in mean resting pulse in the betaxolol group. Therapy with cardioselective beta-blockade may offer significant advantages in respiratory function for elderly people with glaucoma over non-selective drugs, even if they have sympathomimetic activity.

Avoiding unsuspected respiratory side-effects of topical timolol with cardioselective or sympathomimetic agents

Topical timolol given for the treatment or chronic simple glaucoma may cause unrecognised bronchospasm among elderly people. We recruited 80 patients aged over 60 years, who were without a history of airways disease and already used timolol, into a randomised crossover study comparing the effects on spirometry and exercise tolerance of changing to betaxolol or dipivefrine therapy. Results showed an increase of 13% and 8% in mean peak flow rate and forced expiratory volume in 1 s (FEV1), respectively, when using betaxolol; and of 14% and 11% when using dipivefrine. There was also improved exercise tolerance with both agents. More than a quarter of the patients showed at least a 15% improvement in FEV1 when changed from timolol. Analysis of enrolment symptoms and response to nebulised salbutamol failed to produce a method of identifying these patients. Timolol may impair respiratory function and exercise tolerance of elderly patients even if they have no history of reversible airways disease.

Unsuspected bronchospasm in association with topical timolol--a common problem in elderly people: can we easily identify those affected and do cardioselective agents lead to improvement?

The extent of impairment of respiratory function in a group of 52 elderly, glaucomatous patients receiving topical timolol therapy was investigated. To predict those patients who were likely to benefit from changing therapy, symptoms were elicited by direct questioning, and lung spirometry was measured before and after inhalation of salbutamol. Changing from timolol to either pilocarpine or the cardioselective betaxolol produced improvement in lung function tests. Mean peak flow increased from 278 l/min to 328 l/min (p < 0.001), forced expiratory volume in 1s (FEV1) from 1.66 l to 1.85 l (p < 0.001) and forced vital capacity (FVC) from 2.41 to 2.64 l (p < 0.001). Spirometry in a control group of 20 subjects was unchanged. Nineteen of 47 patients demonstrated a clinically significant (defined as 15% or more) increase in all values of lung function tests. Change to pilocarpine or betaxolol was equally effective in producing improvement but betaxolol had fewer side-effects. The presence of exertional dyspnoea, cough with sputum, raised dyspnoea score and improved lung function tests after salbutamol identified those patients experiencing clinically significant bronchospasm with an 89% specificity and 74% sensitivity.

Improved lung function tests on changing from topical timolol: non-selective beta-blockade impairs lung function tests in elderly patients

Fifty-two elderly glaucomatous patients, without a history of asthma or obstructive airways disease, who were using topical timolol for control of intraocular pressure were recruited. Their topical therapy was changed to either betaxolol or pilocarpine. The change was associated with improvement in mean peak flow from 278 l/min to 328 l/min (t = 5.73, p < 0.001), mean FEV1 from 1.66 l to 1.85 l (t = 7.09, p < 0.001) and mean FVC from 2.40 l to 2.64 l (t = 5.07, p < 0.001). Change to either betaxolol or pilocarpine was associated with improved lung function tests. Lung function tests in a control group of 20 showed no significant changes. Both drugs maintained control of intraocular pressure but betaxolol had fewer ocular side effects.

Effectiveness of inhaled bronchodilator delivery systems for elderly patients

A prospective study of inhaler technique using aerosol metered dose inhalers (MDIs), Rotahalers and a breath-activated device (Aerolin Autohaler) was undertaken to assess how effectively elderly patients use their inhalers. Fifty-one patients aged 67-89 years (mean 77.4 years) were enrolled. Peak flow, FEV1 and FVC were recorded, before and after inhalation of 2.5 mg of salbutamol via a nebulizer, to assess the extent of reversible airways obstruction. Inhaler technique was assessed using a scoring system, based on performance in five aspects of inhaler use. Those with poor technique were randomly allocated to an alternative inhaler and reassessed. Twenty-nine of 51 patients demonstrated reversibility in their airways disease. Twenty-one of 47 had poor technique using an MDI and were given Rotahaler or Aerolin devices to use. Ten of 11 given Aerolin Autohalers improved but seven of ten using Rotahaler showed no improvement (p = 0.006). Subsequently, five of these seven were able to improve their technique with the breath-activated autohaler. The breath-activated Aerolin Autohaler is a better delivery system than Rotahalers for inhaled bronchodilators for elderly patients.

Role of the Venereal Disease Research Laboratory test in the detection of syphilis

Of 9733 consecutive serological samples received by Portsmouth and Southampton Public Health Laboratories (PHL) and tested for syphilis, 190 (140 from men and 50 from women) gave positive results. Thirty new cases of syphilis were identified. Most sera were tested initially by both a specific antibody test (the Treponema pallidum haemaglutination (TPHA) test) and a cardiolipin test (the Venereal Disease Research Laboratory (VDRL) test). Among the 14 patients whose sera gave VDRL-positive but TPHA-negative results, 12 sera gave false-positive results. The sera of 90 patients gave TPHA-positive but VDRL-negative results; sera from only seven of these patients gave false-positive results. The VDRL test is very unlikely to identify a new case of syphilis where a TPHA test has failed to do so. The results of the survey suggest that the VDRL test should be withdrawn from initial testing for syphilis except where early primary disease is suspected.