Search

1. We have studied determinants of outcome of 7 day courses of treatment in 77 middle aged and elderly patients, in whom the general practitioner's diagnosis of urinary tract infections had been confirmed microbiologically. Bacteria were sensitive to cephalexin or trimethoprim. Where there was no preference, treatments were allocated randomly. Compliance was monitored using a pill box with a concealed electronic device which recorded openings of the box. 2. Prescribing trimethoprim, 200 mg twice daily, was more effective than cephalexin, 250 mg four times daily (cure rates 93 and 67%) (P less than 0.006). Those cured and not cured were not distinguished by age, gender, genitourinary history, or infecting organism. 3. Compliance as measured by box openings was worse for cephalexin than for trimethopim (P = 0.01). However, both totality and pattern of compliance were similar in patients cured and not cured by cephalexin. Thus rigid adherence to a conventional course did not promote cure: fewer doses could have been prescribed. 4. Estimating compliance is essential to clinical trials where medication is self-administered. Poor compliance may establish over exacting regimens. Counting box openings did overestimate compliance, but counting residual tablets overestimated it grossly: given the number of openings less than the ideal, there should have been 171 residual tablets, only 55 were found. [ABSTRACT FROM AUTHOR]

1. Insomnia is an even more frequent complaint in elderly patients with Parkinson's disease than might be expected from the effect of age alone on sleep. 2. A double-blind, placebo-controlled trial in eleven patients with Parkinson's disease of mean (s.d.) age 80(5) years, showed that nocturnal dosing with levodopa produced a clinically significant improvement in sleep both as assessed subjectively and by measurement of number of spontaneous moves in bed. 3. Despite the long interval between tablet administration and morning assessment, walking time was faster on mornings following active treatment. [ABSTRACT FROM AUTHOR]

A double-blind, placebo-controlled, cross-over trial of quinine in leg cramps occurring at rest was conducted in 22 elderly cramp sufferers. Despite demonstration of impaired quinine elimination in the elderly, prescription of the traditional dose of 300 mg quinine bisulphate at night failed to produce a significant (P = 0.1) reduction in the number or severity of cramps. There was a significant relationship between serum quinine concentration and attenuation of cramps. However, the simple expedient of increasing the nightly dose of quinine may carry the concomitant risk of cinchonism. [ABSTRACT FROM AUTHOR]

The accuracy of routine information on the response of a patient to rehabilitation was questioned. At the multidisciplinary ward round there may be on the one hand an inhibitory effect on the patient's performance due to the presence of a large team, but on the other reluctance of nurses and therapists to concede that all their efforts may only have maintained status quo. We present a randomised, controlled, crossover study of the effect of the ward round on a test of the ability to stand, walk a fixed distance, turn and sit down. Surprisingly, performance was not inhibited by the round: the 20 patients studied performed the test with equal skill, but greater speed, on the round than in a more private context. Cognitive function had a greater influence on the amount of help needed in standing and sitting safely, than on ability to walk and turn independently. [ABSTRACT FROM PUBLISHER]

Doreen Norton was a delightful, widely respected nurse who devoted her life to improving the care of elderly people. She researched the neglected problem of pressure sores, revolutionised their nursing care, and thus achieved international fame. Her Pressure Sore Scale was established as a management tool and is still used today. She was a key member of the design team that produced the 'King's Fund Bed', researched equipment required on geriatric wards, assessed all geriatric long stay units in Scotland and established research as a valuable nursing tool within her profession and health authorities. She lectured extensively and her publications attracted worldwide acclamation. After her retirement, she was subsequently appointed to the world's first Chair of Gerontological Nursing in Cleveland, Ohio., (© The Author(s) 2016.)

Dr Marjory Warren was a remarkable, formidable physician who reversed the neglect of chronic sick patients and brought their treatment into the modern era. She advocated the creation of the specialty of geriatric medicine with units based in district general hospitals, and that medical students and nurses should be taught about the diseases of old age. She treated the whole patient, applied advances in medicine and therapeutics, devised new techniques and equipment to assist disabled elderly stroke and amputee patients, and made great improvements in the ward environment. She emphasized the importance of the patient's social background, and electrified both staff and patients with her drive and enthusiasm. Many patients were treated successfully and discharged. Bed requirements were reduced and vacated wards allocated for other uses. She wrote extensively and lectured across the world to national and international approbation.

We describe a theoretical and computational model of the perception of plaid pattern motion which fully accounts for the majority of cases in which misperception of the direction of motion of Type II plaids has been observed [Yo, C., & Wilson, H. (1992). Perceived direction of moving two-dimensional patterns depends on duration, contrast, and eccentricity. Vision Research 32, 135-147]. The model consists of two stages: in the first stage local motion detectors signal both the one-dimensional (1-D) and two-dimensional (2-D) motion of the high luminance features (blobs) in the plaid pattern; in the second stage these local motion signals are combined using a recursive Bayesian least squares estimation process. We demonstrate both theoretically and using simulations of the computational model that the estimated direction of the plaid motion for Type II plaids is initially dominated by the 1-D motion of the longer edges of the elongated blobs, which is in a direction close to the vector sum direction of the component gratings. The recursive estimation process which combines the local motion signals in the second stage of the model results in a dynamic shift in the estimated plaid direction towards the direction of the 2-D motion of the blobs, which corresponds to the veridical plaid direction., (Copyright 2010 Elsevier Ltd. All rights reserved.)

Professor Norman Exton-Smith was a highly respected, distinguished postwar consultant geriatrician with a worldwide reputation. He devoted his life to improving the medical care of elderly people and researching age-related decline in physical function, particularly thermoregulation and postural balance. He established thriving clinical and research departments at St Pancras Hospital, London. Many of his junior medical staff became well-known geriatricians. He published and lectured extensively, organized many meetings and conferences, and was advisor to the Department of Health and Social Security for many years. He was a valued authority on geriatric medicine within the Royal College of Physicians of London and a major influence in the British Geriatrics Society (BGS) of which he was Secretary and later the President.

Lord Amulree was an outstanding advocate of geriatric medicine in the United Kingdom. His interest in the subject started while he was working for the Ministry of Health and blossomed with his clinical appointment to the new geriatric unit at St Pancras Hospital in London. Here he established a thriving department, expounded his general and specific philosophies on the subject in numerous publications, and trained many junior members of staff who, in their turn, became advocates of the speciality. He used his position in the House of Lords to promote the cause of older persons. He is best remembered for his maxim of Adding Life to Years not Years to Life.

Lord Amulree was unique amongst UK geriatricians in having a 'wide angled' view of the care of elderly people. This resulted from his work at the Ministry of Health, his clinical commitments and his position in the House of Lords, which enabled him to bring the problems of old age, elderly people and infirmity before a much wider audience. It can be argued that his joint Parliamentary Presentation in 1946 stimulated a surge in publications relating to the care of older people. He will be remembered for his maxim 'Adding Life to Years'

Experimental and theoretical results seem to demand that the study of neural representations in the brain considers both the subthreshold and suprathreshold dynamic activity of the neural membrane potential, rather than be solely focussed on stimulus representation in trains of action potentials. In a dynamical systems formulation, the membrane potential can be regarded as the "state" of the neuron, evolving continuously over time and space, within an infinite dimensional space, in response to ever changing inputs. Formally, the state of the neuron, together with future inputs, is sufficient to fully determine the future behaviour of the neuron. In this paper, the characterisation of membrane potential activity is approached from a control theoretic viewpoint as a "reachability" problem, in which the effect of particular stimulus-evoked synaptic inputs is seen as driving the cell from some initial state of the neuron to a particular terminal state on a given manifold. It is shown that a fluctuating subthreshold membrane potential induced by synaptic background activity, and the cooperative interaction of excitatory and inhibitory inputs, may be important factors in allowing the cell to "reach" a maximal subset of all possible membrane potential states, through the action of its synaptic inputs.

Sales of over-the-counter (OTC) medicines are rising, and will continue to rise as more products are reclassified from prescription-only status to OTC medicines (either pharmacy-only or general sales list). Patients and doctors often omit discussion of OTC medicines when giving or taking a medication history. This has serious potential for identifying adverse drug reactions and drug-drug interactions, which are more common in older people. Therefore, medication histories should include documentation of any OTC medicines taken.

Recent experimental observations have disclosed the existence of a septal-hippocampal feedback circuit, composed of medial septum diagonal band of Broca (ms-dbB) GABAergic projections to the inhibitory interneurons of the hippocampus, and hippocampal GABAergic projections to the ms-dbB, the major targets of which are the GABAergic septo-hippocampal projection cells. We propose that this feedback circuit provides the mechanism for the rhythmic suppression of interneuronal activity in the hippocampus, which is observed as low-level GABAergic-mediated theta activity. We also propose that this circuit may be the mechanism by which ascending brain stem pathways to the ms-dbB, in particular from the reticular formation, can influence hippocampal information processing in response to particular behavioral states, by exercising control over the level and frequency of theta activity in the hippocampus. In support of these proposals, we describe a minimal computational model of the feedback circuit which uses a set of four coupled differential equations describing the average dynamic activity of the populations of excitatory and inhibitory cells involved in the circuit. We demonstrate through simulations the inherently robust 4-6-Hz oscillatory dynamics of the circuit, and show that manipulation of internal connection strengths and external modulatory influences on this circuit changes the dynamics in a way which closely mimics corresponding manipulations in recent neurophysiological experiments investigating theta activity.

Older people in the UK receive a disproportionate amount of medication. They comprise 18% of the population but receive 45% of all prescription items. Not surprisingly they experience drug-related illnesses - in 1980, 1 in 10 admissions to acute geriatric units were wholly or partly due to adverse drug reactions. Drugs which should be used with particular care or even avoided in older people include benzodiazepines, warfarin, digoxin, aminoglycosides, tricylic antidepressants, antipsychotics and long-acting oral hypoglycaemic agents. Pharmacists can promote safer prescribing practices by advising both patients and doctors. The community pharmacist can assist in drug compliance by providing patients with additional information about individual drugs, identifying potential adverse drug reactions and interactions, supplying appropriate drug containers or compliance aids, and even arranging home visits for patients unable to visit the pharmacist. Some community pharmacists provide pharmaceutical advice and services to residential and nursing homes. Pharmacists' advice to doctors can include one to one discussions in either primary or secondary care, assisting in medication review, providing information to prescribing committees, compiling drug formularies, assisting in auditing of prescribing practices and organising disposal of unwanted medicines and poisons campaigns.

The elderly have benefitted considerably from the vast increase in the range of drugs available for prescription. However it is now well recognized that the incidence in adverse drug reactions increases with age. This is mainly due to altered pharmacodynamics and pharmacokinetics as well as multiple prescribing and the effect of illness rather than the effect of age per se. Since adverse drug reactions are such a potent cause of illness, it is sensible for doctors to follow simple rules when prescribing for the elderly.

A major role of therapeutic drug monitoring services is to advise on the dose of a drug which would be required to bring the concentration in the blood to within specific 'therapeutic' limits. Monitoring digoxin usage constitutes a substantial part of the work load. We have examined the potential variability in recommendations for digoxin dosages based on a series of serum digoxin measurements in each of 80 out-patients. In over a third of cases a dose, which seemed to be optimal on the basis of the first assay result, would have produced concentrations outside the conventional therapeutic range when the measurement was repeated. This was despite careful supervision of medication and the timing of the blood sample in relation to its administration. In routine practice the apparent variability in dose requirements would be far greater. Objectives of therapeutic drug monitoring services remain the same, the way forward would seem to lie in their taking on a heavy commitment to counsel and supervise patients before repeated blood sampling. However, effort and resources might be better channelled into producing simple prescribing aids relating the risk of cardiotoxicity directly to the size of the maintenance dose and the individual's renal function.

Hyperthyroidism developed in three patients during the administration of potassium iodide given for the purpose of blocking the thyroid uptake of radioactive iodine liberated in the course of the 125I-fibrinogen test. In a consecutive series of 31 geriatric patients, who received potassium iodide for the same reason, biochemical hyperthyroidism developed in three instances and significant depression of thyroid function was observed in 10. The performance and the interpretation of the 125I-fibrinogen test are unaffected if iodide is not administered to the patient. The possible hazards to some patients of either induced hyperthyroidism or faulty assessment of thyroid function may be greater than the risk of thyroid irradiation. It is suggested that for the performance of the 125I-fibrinogen test potassium iodide need not be given to the elderly and should be given in a dose of 30 mg daily for two weeks to younger patients. Under certain circumstances potassium perchlorate may be a preferable drug for preventing the accumulation of radioactive iodine by the thyroid.

We report our efforts to make a rehabilitation hospital work. The simple intervention of introducing a patient record system, in which problems, management, achievements and discharge plans were clearly documented, doubled the number of patients who returned home over an eight-month period. This resulted in greater availability of acute geriatric beds at the District General Hospital (DGH), where two thirds of the elderly medical inpatients occupy beds on other units, and in an improvement in morale of patients and staff. Greater co-operation between geriatric and medical teams in selecting those patients who would benefit from continuing rehabilitation is required. The advantages of accommodating such patients separately from patients with a poor prognosis and those requiring long-term care are discussed.

Capillary fragility has been examined in 110 elderly patients, excluding those patients who might have been expected to have abnormal fragility. Nonetheless, fragility appeared to be greater in elderly patients than in younger subjects. It was much increased in the non-paralysed arm of hemiplegic patients but not in the paralysed arm--perhaps because petechiae were obscured by trophic changes. Capillary fragility was significantly correlated with systolic blood pressure but not with age. This suggests that higher values in elderly patients may be related to the high prevalence of arteriosclerosis rather than to age itself.

A study of the well elderly living at home has demonstrated that the ranges for serum thyroxine (T4), triiodothyronine (T3) uptake and free-thyroxine index (FTI) are much narrower than those for the sick elderly in-patient. The prevalence of thyroid disease appears similar in both types of elderly population.

We have introduced enalapril, in doses equal to or less than the 2.5 mg currently recommended, as an adjuvant to digoxin and diuretics in 17 patients of mean (SD) age 83 (5) years with severe heart failure. Only eleven patients tolerated its introduction. Unlike those reported in younger patients, all but one of the adverse drug reactions occurred 8 h or more after the first dose. Aged patients started on ACE inhibitors should be observed in hospital until stabilized on a maintenance dose. Three patients had an adverse reaction which differed in nature from those previously reported: acute confusional state, ataxia and mesenteric ischaemia. Ten patients were discharged on 5 mg or 10 mg maintenance doses of enalapril. In nine of them improvement on triple therapy was sustained for a minimum of three months. ACE inhibition was lost in the other patient when her compliance with enalapril therapy fell to around 75%: monitoring compliance is essential when ACE inhibitors are used in low dosages. Enalapril was withdrawn during follow up in three patients because of symptoms of mesenteric ischaemia and in four because of dramatic deterioration of renal function. One of the latter was found subsequently to have severe bilateral atheromatous renal artery stenosis. When isosorbide dinitrate was substituted for enalapril, symptoms of mesenteric ischaemia resolved and renal function returned to baseline. Continuing surveillance for adverse effects is essential in patients of this age group with severe heart failure, and the risk of occult renal artery stenosis requires regular biochemical screening during follow up.(ABSTRACT TRUNCATED AT 250 WORDS)

A retrospective survey of elderly patients admitted with perforation of a duodenal ulcer showed that some presented with typical symptoms and signs of a perforation, while others presented as a gastro-intestinal bleed or with confusion or malaise. Diagnosis tended to be delayed in the latter group and mortality was higher. Earlier diagnosis may be helped by taking a chest radiograph or lateral decubitus films of the abdomen with a repeat film in a few hours if the diagnosis is still being considered.

The plasma concentration of beta-thromboglobulin was estimated in elderly in-patients using a radio-immuno-assay technique. There were highly significance differences between the mean values of patients with arterial or venous thrombosis, as compared with controls. The ability of the test to detect thrombosis above the inguinal ligament means that it is a useful addition to the existing battery of tests for detecting thrombosis.

It has previously been shown that the incidence of pressure sores is related inversely to the amount of movement made during the night. The present study of 30 in-patients of geriatric units suggests that the measurement of mean lateral displacement of the centre of gravity may better characterize those at risk than the total amount of movement. The mean displacement was reduced in Parkinson's disease and in dementia. The prevalence of pressure sores was markedly increased where Parkinson's disease and dementia coexisted.

Some physicians regard patients of Geriatric Units as a homogeneous population with respect to digoxin dosage requirements. Others advocate the use of pharmacokinetic models in prescribing digoxin for the elderly. Sixty in-patients of Geriatric Units were studied and the results compared with those previously obtained from 129 patients of other adult Units; all were receiving maintenance digoxin. For each patient the dose required to achieve a mean steady-state serum digoxin concentration of 1.6 nmol X l-1, the standardized dose, was calculated, assuming proportionality between the dose given and the concentration achieved. A mean of four estimates of standardized dose for each individual was used in the analysis. Threefold ranges of standardized dose covered the requirements of approximately 85% of patients both of Geriatric Units (62.5 to 187.5 micrograms per day) and of other adult Units (125 to 375 micrograms per day). The variables, serum creatinine concentration, sex, age, and body weight were of relatively little value in predicting the standardized dose for the patients in Geriatric Units. There was a sub-group of these in-patients for whom the standardized dose was extremely large.

A quarter of the thyroid gland obtained at post-mortem examination from a group of elderly inpatients were nodular. There was a significant preponderance of women with goitre, but no relationship to age. The incidence of hyperthyroidism was increased in patients with nodular glands. There was no correlation between the weight of the thyroid gland, the age of the patient and the free-thyroxine index. Histological examination of macroscopically normal glands showed tiny follicles, microscopic colloid nodules and fibrosis. Nodular glands had the features of long-standing colloid nodular goitre. Focal lymphocytic thyroiditis was observed in a fifth of the glands. Microscopic evidence of altered function was common but could not always be correlated with the results of the thyroid function studies.

The side-effects of drugs increase steadily in accordance with the age of the patient. This can be the result of incorrect clinical assessment, multiple prescribing, poor drug compliance, inadequate supervision of long-term medication, altered drug handling and increased organ sensitivity with age. Consequently, great care should be taken when prescribing for the elderly. Rules for prescribing are listed.

A study of clubbing, assessed by spherometer measurements of fingernail-skinfold angle, was made in recent and long-established hemiplegic elderly patients. This showed that clubbing developed in all digits studied and that it increased with the duration of the stroke. Clubbing did not correlate with the grip strength of the weakened hand.

Forty-nine of 498 (10%) blood cultures taken in a 14-month period in a geriatric department were positive. These cultures were taken from 295 patients. Respiratory infections, recent onset of confusion, non-specific malaise and suspected sub-acute bacterial endocarditis were the most common clinical indications for the test. Twenty-seven of the 49 positive cultures were considered significant, the remainder being regarded as due to skin contaminants. This yield was found to be of clinical value, particularly in chest infection when the responsible organism often could not be cultured from the sputum.

Systolic murmurs present in 129 geriatric patients followed to post-mortem were assessed as mitral or aortic in origin by simple clinical assessment alone. Post-mortem examination contradicted clinical findings in only 2% of cases. Mitral valve pathology, mostly post-inflammatory scarring or mucoid degeneration, was present in 50% of the cases with murmurs. There was a significant correlation between the presence of murmurs, particularly mitral murmurs, and congestive cardiac failure, and there was also a significant correlation with age. A tendency for aortic systolic murmurs to be associated with a higher mean systolic blood pressure was not significant and there was no significant association between systolic murmurs and ischaemic heart disease.

A retrospective study of elderly patients admitted with subdural haematoma showed a greater incidence in men. Although a history of falls or head injury was obtained in about two thirds of the patients, the initial diagnosis of subdural haematoma was only made in about one fifth of the cases. In most patients the symptoms were attributed to a cerebrovascular accident or cerebral metastases. However, in those patients where the diagnosis was established at post mortem, it was not the principal cause of death. Only half the patients treated by surgery were well enough to return home, although less severely ill patients treated by medical methods or conservatively were all able to return home.

The glomerular filtration rate was measured in the sick elderly patients using the single shot 51Cr EDTA method. As would be expected, such patients have worse renal function than the fit elderly. The filtration rate can be usefully predicted from either blood urea or serum creatinine, but a superior prediction is obtained when these factors are combined using a formula derived from multiple regression analysis.

A case of vertebral osteomyelitis due to Pseudomonas aeruginosa is described and the problems of diagnosis and treatment discussed.