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Africa, the poorest and youngest populated region in the world, is set to see a rapid increase in the number of older persons in the coming three decades. While the expected increase in the prevalence of non-communicable diseases is already evident, sparse data exist on the geriatric syndromes. Healthcare systems vary considerably between the countries, with universal healthcare available in only a handful. Public healthcare is generally underfunded, overburdened and unprepared for the care of older persons and private care unaffordable. Training in Geriatric Medicine is limited to a small number of facilities in a few countries. Despite the African Union Policy Framework and Plan of Action on Ageing, there has been very little progress on the implementation of age-sensitive policies. There is an urgent need to improve care of older persons in the region.

Introduction: HIV-infected adults aged over 50 years in South Africa are increasing. This study explored differences between baseline characteristics and 12-month outcomes of younger and older HIV-infected adults initiated on antiretroviral therapy (ART). Additionally, associations with outcomes within the older group were sought.Methods: We retrospectively reviewed treatment-naive HIV-infected adult patients at ART initiation. Patients aged 18.0–39.9 years were compared to patients aged over 50 years using log-binomial regression for baseline characteristics and 12-month outcomes. Within the older group, outcome associations were found using multivariate regression.Results: The older cohort (n = 1635) compared to the younger cohort (n = 10726) comprised more males (47.2% vs. 35.4%, PR 1.52, p < 0.05), smokers (12.9% vs. 9.7%, PR 1.32, p < 0.05) and overweight patients (26.0% vs. 20.0%, PR 1.32, p < 0.05). Fewer older patients had tuberculosis (10.2% vs. 15.3%, PR 0.67, p < 0.05), other opportunistic infections (16.9% vs. 23.3%, PR 0.70, p < 0.05), World Health Organization stage 3/4 disease (39.9% vs. 43.2%, PR 0.89, p < 0.05), anaemia (22.8% vs. 28.4%, PR 0.77, p < 0.05), liver dysfunction (17.1% vs. 21.3%, PR 0.83, p < 0.05) or low CD4+ count < 100 cells/mm3 (56.3% vs. 59.9%, PR 0.71, p < 0.05).Mortality was higher in the older cohort (11.3% vs. 7.5%, PR 1.48, p < 0.05). Virological suppression was greater in the older cohort (89.5% vs. 86.5%, PR 1.28, p < 0.05) but CD4+ restitution was lower (62.8% vs. 75.0%, PR 0.61, p < 0.05). There was no difference in treatment complications between the groups.Within the older cohort, associations with death were as follows: age > 55 years (PR 1.47, p < 0.05), an AIDS-defining condition (PR 2.28, p < 0.05), raised ALT (PR 1.53, p < 0.05) and CD4+ < 100 cells/mm3 (PR 2.15, p < 0.05). Associations with favourable treatment response at 12 months were unemployment (PR 1.18, p < 0.05) and raised ALT (PR 1.19, p < 0.05). Associations with a treatment complication at 12 months were unemployment (PR 1.12, p < 0.05), smoking (PR 1.20, p < 0.05) and nevirapine use (PR 1.36, p < 0.05) but secondary education was protective (PR 0.87, p < 0.05).Conclusion: HIV-infected South African adults aged over 50 years differ in characteristics and outcomes compared to their younger counterparts and justify specialised management within HIV treatment facilities.

BackgroundAge cohort differences in haemoglobin concentrations and associations with physical and cognitive performance among populations of lower income and middle-income countries have not previously been described. We examined the association between these factors among older men and women in rural South Africa.MethodsWe analysed cross-sectional data from a population-based study of rural South African men and women aged 40 and over (n=4499), with data drawn from questionnaire responses, a cognitive battery, objective physical function tests and blood tests. Anaemia was defined as a haemoglobin concentration ResultsIn total, 1042 (43.0%) women and 833 (40.1%) men were anaemic. Haemoglobin concentrations were inversely correlated with age for men but not for women; in adjusted analyses, haemoglobin was 0.3 g/dL lower per decade older for men (95% CI 0.2 to 0.4 g/dL). In adjusted analyses, haemoglobin concentration was independently associated with grip strength in women (B=0.391, 95% CI 0.177 to 0.605), but this did not reach significance in men (B=0.266, 95% CI −0.019 to 0.552); no associations were observed between haemoglobin levels and walk speed or cognitive score.ConclusionsAnaemia was prevalent in this study population of middle-aged and older, rural South African adults, but in contrast to high-income countries, it was not associated with poor physical or cognitive function. Our findings need to be replicated in other populations.

Hip fractures are the most serious complication of osteoporosis and are associated with high morbidity and mortality. Generally, patients who sustain osteoporotic hip fractures are older adults who have a number of comorbid diseases which predispose them to perioperative complications, disability and death. Furthermore, patients who survive a hip fracture are at higher risk of a subsequent fracture. The morbidity and mortality of hip fractures can be substantially reduced by a structured multidisciplinary approach to pre- and postoperative management. This review will focus on the epidemiology of hip fractures, predictors of mortality and the acute and long-term management of hip fractures.

A 73-year-old female patient with osteoporosis, who had been taking alendronate for over 15 years, sustained bilateral, atypical femoral fractures two years apart. There was evidence of a stress fracture preceding the current fracture, as seen in the X-rays performed two years prior. Subsequently, she was found to have primary hyperparathyroidism.

Cognitive impairment in people with type 2 diabetes is a barrier to successful disease management. We sought to determine whether impaired executive function as detected by a battery of simple bedside cognitive tests of executive function was associated with inadequate glycaemic control.People with type 2 diabetes attending a tertiary referral diabetic clinic who consented to participate in the study underwent a brief battery of cognitive testing (the Bedside Executive Screening Test) designed to detect executive function impairment. Glycaemic control was determined using blood glycated haemoglobin levels (HBA(1c)). Inadequate glycaemic control was defined as HBA(1c)or =7%.Executive function impairment was detected in 51 (52%) of the 98 study participants. The presence of executive function impairment was significantly associated with poor glycaemic control (HBA(1c)or =7%) (odds ratio 4.9, 95% confidence interval 1.3 - 18.8, p=0.019). There were no significant differences between patients with and without executive function impairment with regard to age, target organ damage, patient reported adherence, and hypoglycaemic therapy. Patients with a lower level of education were more likely to demonstrate executive impairment when glycaemic control was poor (p=0.013).Executive function impairment is common in a population of people with difficult-to-manage type 2 diabetes. The presence of executive impairment is significantly associated with poor glycaemic control.

Objective: To report the nature of stroke in patients infected with human immunodeficiency virus (HIV) in a region with high HIV seroprevalence and describe HIV associated vasculopathy. Methods: Patients with first ever stroke, infected with HIV and prospectively included in the stroke register of the Groote Schuur Hospital/University of Cape Town stroke unit were identified and reviewed. Results: Between 2000 and 2006, 67 of the 1087 (6,1%) stroke patients were HIV infected. Of these, 91% (n = 61) were younger than 46 years. Cerebral infarction occurred in 96% (n = 64) of the HIV positive patients and intracerebral haemorrhage in 4% (n = 3). HIV infected young stroke patients did not demonstrate hypertension, diabetes, hyperlipidaemia or smoking as significant risk factors for ischaemic stroke. Infection as a risk factor for stroke was significantly more common in HIV positive patients (p = 0.018, OR 6.4, CI 3.1 to 13.2). In 52 (81%) patients with ischaemic stroke, an aetiology was determined. Primary aetiologies comprised infectious meningitides/vasculitides in 18 (28%) patients, coagulopathy in 12 (19%) patients and cardioembolism in nine (14%) patients. Multiple aetiologies were present in seven (11%) patients with ischaemic stroke. HIV associated vasculopathy was identified in 13 (20%) patients. The HIV associated vasculopathy manifested either extracranially (seven patients) as total or significant carotid occlusion or intracranially (six patients) as medium vessel occlusion, with or without fusiform aneurysmal dilation, stenosis and vessel calibre variation. Conclusion: Investigation of HIV infected patients presenting with stroke will determine an aetiology in the majority of patients. In our cohort, 20% of patients demonstrated evidence of an HIV associated vasculopathy.

To determine the burden and risk factors for adverse drug events (ADEs) in older patients. Design. A prospective cross-sectional study.Patients (65 years and older) presenting to the tertiary Emergency Unit of Groote Schuur Hospital, Cape Town, between February and May 2005, were assessed for well established ADEs, as defined by the South African Medicines Formulary. Logistic regression models were fitted to determine drugs and other factors associated with the likelihood of developing ADEs.ADEs were identified in 104 of the 517 (20%) presentations. The most frequently involved drug classes were cardiovascular (34%), anticoagulant (27%), analgesic (19%) and antidiabetic (9%). Patients who developed ADEs were more likely to have five or more prescription drugs (p0.0001), more than three clinical problems (p = 0.001), require admission (p = 0.04), and report compliance with medication (p = 0.02) than those who did not. Drugs shown to independently confer increased risk of ADEs were angiotensin-converting enzyme inhibitors (RR = 2.6, 95% CI: 1.3 - 5.2, p = 0.009), non-steroidal anti-inflammatory drugs (RR = 4.1, 95% CI: 2.1 - 8.0, p0.0001) and warfarin (RR = 3.1, 95% CI: 1.6 - 6.3, p = 0.0014).ADEs contribute significantly to the burden of elderly care in the Emergency Unit. In a setting such as ours, increased pill burden and certain drug classes are likely to result in increased risk of ADEs in the older population group.

Background Intracranial aneurysms related to human immunodeficiency virus (HIV) infection have been well described in pediatric patients but not in adults. Objective To describe a case of intracranial large-vessel aneurysmal vasculopathy causing stroke in a 27-year-old HIV-infected woman. Design Comparison of clinical and histological data with previously published cases. Setting A referral hospital stroke unit. Patient A 27-year-old HIV-infected woman presenting with stroke; neuroimaging demonstrated fusiform aneurysmal dilation of the left internal carotid and the left middle cerebral artery and its branches. Results Autopsy showed degeneration of the elastic lamina, myxoid degeneration, and medial atrophy, causing consequent ectasia of the involved intracranial vessels. Conclusion Aneurysmal dilation of the intracranial arteries occurs in HIV-infected adults, but the pathogenic role of HIV remains unknown.

Pneumonia is common in the elderly and clinical manifestations are frequently atypical. Pneumonia should be considered in any older person presenting with falls, confusion, incontinence, worsening comorbidities or a deterioration in functional status. The respiratory rate is the most reliable sign to alert the health carer to the presence of pneumonia. Therapy should follow the recommendations of the South African Pneumonia Guidelines. Prevention strategies include the prevention and management of aspiration, reduction in the use of neuroleptic medication, influenza vaccination, maintenance of oral hygiene, smoking cessation and possibly the use of the newer antiviral preparations.

Postoperative delirium is an acute brain failure syndrome. It is a manifestation of complex interactions between the patient’s intrinsic neural reserve/compensation, disease processes (systemic versus localised), medical/surgical therapies, and the health care environment. Older age, comorbid neurodegenerative disease and the use of anticholinergic drugs predispose to more severe and prolonged delirium, with neurodegeneration as a consequence. There is an associated 30-40% one-year mortality following an episode of delirium in the older person.

Background. Stroke is a leading cause of death and disability in South Africa. An increase in the burden of stroke is predicted as the population is undergoing a rapid epidemiological transition with increased exposure to, and development of, stroke risk factors, together with aging of the population. Objective. The objective was to update the guideline published in 2000, to place the recommendations within the current South African context, and to grade evidence according to the level of scientific rigour. Recommendations. Ideally, all patients with acute stroke should be managed in a dedicated stroke unit. There is ample evidence that protocol-driven multidisciplinary stroke unit care within a hospital improves recovery from stroke. Treatment in a stroke unit has been shown to reduce mortality as well as reduce the likelihood of dependency after stroke. An effective stroke service requires the establishment of a seamless network consisting of acute stroke units, post-acute care and rehabilitation, and further care in the community. Primary preventive measures reduce stroke incidence and should be universally available and actively promoted at all levels of health care in South Africa. Successful care of a stroke patient begins with recognition by the public and health professionals that stroke should be considered an emergency. Avoiding delay should be the major aim of the prehospital phase of acute stroke care. Acute stroke or transient ischaemic attack (TIA) should be treated as a medical emergency and evaluated with minimum delay. General supportive treatment is emphasised and is directed at maintaining homeostasis and the treatment of complications. Intravenous thrombolytic therapy with recombinant tissue plasminogen activator (tPA) is an accepted therapy for acute ischaemic stroke within 4.5 hours of onset of symptoms, but can only be administered at centres with specific resources. Awareness and treatment of the neurological and systemic complications of acute stroke are an integral part of management. Patients with suspected TIA and minor stroke with early spontaneous recovery should be evaluated as soon as possible after an event. Brain imaging is recommended, and non-invasive imaging of the cervicocephalic vessels should be performed urgently and routinely as part of the evaluation. Carotid endarterectomy (CEA) is recommended for patients with severe (70 - 99%) ipsilateral stenosis, and the procedure should be performed as soon as possible after the last ischaemic event – ideally within 2 weeks – in centres with a peri-operative complication rate (all strokes and death) of less than 6%. Survivors of a TIA or stroke have an increased risk of another stroke, which is a major source of increased mortality and morbidity. Secondary prevention strategies are aimed at reducing this risk. Stroke rehabilitation is a goal-orientated process that attempts to obtain maximum function in patients who have had strokes and who suffer from a combination of physical, cognitive and language disabilities.