Increasing incidence of chronic subdural haematoma in the elderly.

BACKGROUND: Chronic subdural haematoma (CSDH) is a condition predominantly affecting the elderly. We reported an incidence of 8.2 per 100 000 per year in people above the age of 65 in 2002. AIM: Since recent studies have demonstrated a higher incidence, we repeated our study to estimate the current incidence of CSDH amongst people above the age of 65 in North Wales. DESIGN: We used radiological reports to identify patients with CSDH over a 1-year period. METHODS: We collected data on demographics, clinical presentations, indications for brain imaging, drug history and 30-day outcome from the case notes and electronic records. RESULTS: The population of North Wales was 687 937 of which 138 325 (20%) were above 65. There were 66 cases of CSDH giving an incidence of 48 per 100 000 per year. Mean age was 81 and there were 32 males and 34 females. Falls and confusion were the commonest indications to request a CT scan (90%). Other indications were drowsiness (9%) and focal neurological deficit (4%). 17 were on antiplatelets and 20 were on warfarin. Ten underwent surgical intervention. At 30 days 28 were discharged, 22 were still in hospital and 16 died. CONCLUSION: The incidence of CSDH is much higher than previously reported. Reasons include a low threshold for imaging patients with recurrent falls and confusion, increasing use of anti-thrombotics and ageing population. In many older patients CSDH is a marker of underlying co-morbidities rather than a primary event.

Autopsy in older medical patients: concordance in ante- and post-mortem findings and changing trends.

Despite modern diagnostics, the discordance between ante- and post-mortem diagnoses is still around 25%, reiterating the need for high post-mortem rates. In our study, 3.5% had class I errors that, had they been detected during life, would or might have affected short-term outcome. Another 14% had major errors, conditions recorded as primary cause of death that were clinically missed or unrecorded but would not have affected the outcome. There has been an unexplained decline in hospital post mortems and more than a third of UK autopsies are now performed under the instruction of the relevant Coroner's office. The UK Coroners' system is currently under judicial and administrative review to improve the speed of and reduce the need for post-mortem analysis.

Chronic subdural haematoma in the elderly.

Chronic subdural haematoma is predominantly a disease of the elderly. It usually follows a minor trauma. A history of direct trauma to the head is absent in up to half the cases. The common manifestations are altered mental state and focal neurological deficit. Neurological state at the time of diagnosis is the most important prognostic factor. Morbidity and mortality is higher in the elderly but outcome is good in patients who undergo neurosurgical intervention.

Nephrotoxicity in the elderly due to co-prescription of angiotensin converting enzyme inhibitors and nonsteroidal anti-inflammatory drugs.

Both angiotensin converting enzyme inhibitors and nonsteroidal anti-inflammatory drugs can lead to functional renal insufficiency. In an observational study we assessed the frequency of this adverse effect in patients aged over 75 years receiving these drugs in combination. In one year, out of 1500 patients whose records were screened, 12 were prescribed this combination. 2 developed acute renal failure, of whom one died and the other recovered after discontinuation of both drugs. 4 patients showed deterioration in renal function, which returned to normal after one of the drugs was stopped. Renal function remained stable in 6 patients: patients with deterioration in renal function were older and more likely to be on diuretics. This drug combination is commonly nephrotoxic in the elderly and should be avoided, especially in those taking diuretics.

Diagnoses in discharge communications: how far are they reliable?

To discover whether general practitioners are correctly notified of a patient's final diagnosis following hospital discharge, an observational study was undertaken in a district general hospital. The final diagnosis was compared with the diagnosis documented in the discharge summary and the take-home prescription. Two hundred discharges were studied. Only 163 (81%) discharge summaries and 138 (69%) take-home prescriptions had the correct diagnosis; 24 (12%) take-home prescriptions did not have any diagnosis at all. In some cases the diagnosis differed between the discharge summaries and the take-home prescriptions. Only in 122 (61%) cases was the final diagnosis correctly documented in both instances. Communication regarding diagnosis in discharge letters is less than adequate. Every effort should be made to improve this.