Intestinal permeability and orocaecal transit time in elderly patients with Parkinson's disease.

The aetiology of weight loss in patients with Parkinson's disease is likely to be multifactorial. We studied 15 patients with Parkinson's disease and 15 age- and sex-matched controls and looked for evidence of malabsorption due to small bowel bacterial overgrowth or alteration of intestinal permeability. There was a marked increase in orocaecal transit time in the patients with Parkinson's disease, although lactulose hydrogen breath testing did not show evidence of small bowel bacterial contamination. Intestinal permeability measured by the differential sugar absorption test was also deranged. There was reduced absorption of mannitol in patients with Parkinson's disease while lactulose absorption was similar in both groups, suggesting decreased non-mediated uptake across the enterocyte brush border membrane in patients with Parkinson's disease.

Atrial fibrillation in the elderly: physicians' attitudes to anticoagulation.

The use of warfarin and aspirin for the primary prevention of stroke in elderly patients with atrial fibrillation (AF) is controversial. To establish current practice we circulated a questionnaire to 300 geriatricians (G) and 300 cardiologists (C). The response rates were 47% G and 51% C. Most physicians prescribed warfarin in AF associated with mitral stenosis (G vs C, 86% vs 89%, NS). Cardiologists were more likely to prescribe warfarin in AF associated with dilated cardiomyopathy (G vs C, 52% vs 86%, P < 0.01). A minority would prescribe warfarin in aortic valve disease and AF (G vs C, 37% vs 24%, P < 0.05) and lone AF (G vs C, 10% vs 26%, P < 0.01). Aspirin was favoured in aortic valve disease and lone AF. The cardiologists were less reluctant to use warfarin in the young and more likely to electrically cardiovert the young with chronic AF.

Survey of cardiac arrests and cardiac arrest trolleys in a district general hospital.

In a 12-month period there were 137 cardiac arrests in a district general hospital. Cardiopulmonary resuscitation was instituted within 3 minutes in 82%. Delay in 18% was due to equipment failure. Survival at 6 months was 12%. Of the 18% of inappropriate arrests, 42% had 'do-not-resuscitate' orders in the casenotes. Survival did not depend on age, sex, location, presence of an anaesthetist, experience of house officer, time of day or admission diagnosis. Survival was more likely in the presence of ventricular fibrillation and absence of intubation. Of the 32 arrest trolleys, 66% were geographically acceptable to the area they served and 9% had significant deficiencies (these were situated in patient waiting areas and were infrequently checked).

Infective endocarditis and the dental practitioner.

This article reviews the relationship of dental treatment to infective endocarditis (IE). The current guidelines on the use of antibiotics in prophylaxis are also examined.

Do carotid bruits predict disease of the internal carotid arteries?

A carotid bruit is often thought of as a reliable sign of extracranial carotid artery disease. In addition finding a bruit may precipitate a referral to hospital. Carotid endarterectomy has now been shown to be beneficial in patients with symptomatic carotid territory ischaemia and 70-99% stenosis of the relevant carotid artery, therefore it is important that such patients are detected and referred. In this study of 331 consecutive patients referred to a specialist cerebrovascular clinic we examined the practical value of a carotid bruit mentioned by the referring practitioner. All patients underwent clinical assessment, evaluation of risk factors and Doppler duplex scanning of the carotid arteries. A bruit was stated in the referral letter of 110 (33%) patients. Moderate (30-69%) or severe (70-99%) stenosis was present in 37% of patients with, and 17% of those without a carotid bruit (P < 0.001). We found a carotid bruit was a poor predictor of such disease (positive predictive value, 37%). The false negative rate for severe disease was 43%. Normal carotid arteries were found in 32% of patients with a bruit. We therefore suggest that all patients with suspected carotid territory ischaemia should be referred for assessment whether there is a bruit present or not.

A study of the nutritional status of elderly patients with Parkinson's disease.

Patients with Parkinson's disease tend to lose weight although the reasons are uncertain. Fifteen patients with stable Parkinson's disease who had lost at least 5 kg in weight, and 15 age- and sex-matched control subjects were studied. All subjects underwent physical examination, anthropometric measurements, biochemical and haematological screening, measurement of tumour necrosis factor and full dietary assessment. The Parkinson's disease patients who had lost a mean of 6.2 kg had significantly less body fat and a lower total peripheral lymphocyte count than the control subjects. Dietary analysis showed a higher daily intake of calories in the patients which was derived from an increased carbohydrate intake. Tumour necrosis factor was not detected in either the patients or control subjects. Parkinson's disease patients lose weight in spite of an increased calorie intake. This may reflect an increased metabolic rate.

Complications of cerebral angiography in patients with symptomatic carotid territory ischaemia screened by carotid ultrasound.

After nearly 40 years, carotid endarterectomy has been shown to be of benefit to patients with symptomatic carotid territory ischaemia and greater than 70% stenosis of the relevant internal carotid artery. Cerebral angiography is performed before surgery and is not without risk. These risks must be added to those of surgery before recommending the procedure to patients. The study evaluated the local, systemic and neurological complications following digital subtraction angiography with selective catheterisation of the carotid arteries in 200 patients presenting to a cerebrovascular clinic for assessment of cerebral ischaemia. All patients had carotid ultrasound screening before angiography to screen out those with normal arteries or mild disease (less than 30% stenosis of symptomatic internal carotid artery). Complications occurred in 28 patients. There were six (3%) local, two (1%) systemic and 20 (10%) neurological complications. Seventeen neurological complications occurred within 24 hours and there were three late complications (24-72 hours). Neurological complications occurred more frequently when angiography was performed by a trainee rather than a consultant neuroradiologist (p < 0.01). The neurological complications were transient (resolved within 24 hours) in 10/200 (5%), reversible (resolved within seven days) in two (1%) and permanent in 8/200 (4%). Two patients died after a stroke and two other patients suffered a disabling stroke. At 24 hours post angiography the permanent (persisting beyond seven days) neurological complication rate was 2.5%. The incidence of total neurological complications and post angiographic strokes was higher in patients with greater than 90% stenosis of the symptomatic internal carotid artery (p < 0.001). The increased use of non-invasive Doppler duplex screening will reduced the absolute number of patients put at risk of angiography, yet the rate of post angiographic complications is likely to increase as patients with severe stenosis of the symptomatic internal carotid artery are probably most at risk of complications and have most to gain from carotid endarterectomy.

Professional attitudes to cardiopulmonary resuscitation in departments of geriatric and general medicine.

Cardiopulmonary resuscitation for the elderly has long been a contentious issue. We have established by means of a postal survey the attitudes of 300 consultant geriatricians, 300 consultant physicians and 249 registered nurses to cardiopulmonary resuscitation. We also audited 400 case notes to document current practice in departments of general medicine and medicine for the elderly. No formal resuscitation policies were in operation. Geriatricians were more likely than physicians to make a positive resuscitation decision (p < 0.001), and involve nursing staff in the decision-making (p < 0.001). All professional groups felt age was unimportant in deciding on resuscitation, while the patients' prognoses and their wishes were most important. Case note audit revealed that geriatricians were better at documenting resuscitation decisions. Inappropriate resuscitation of patients is unacceptable. Each department or hospital ought to have agreed guidelines for cardiopulmonary resuscitation.

Too many rectal examinations? A survey of nursing management of constipation in elderly patients.

A survey of nursing practices for the diagnosis and management of constipation in elderly patients in a Department of Medicine for the Elderly showed that up to 100 patients each week were subjected to unsupervised digital rectal examination. This procedure may be distressing to the patients and is probably unnecessary. We question whether this is acceptable or desirable practice.

The effect of ageing on the pharmacokinetics of dihydrocodeine.

Although poor renal function reduces clearance of dihydrocodeine in man, and renal impairment occurs with ageing, no significant differences occurred in the handling of single doses of dihydrocodeine between elderly patients and young, normal subjects. After multiple dosing, the maximum concentration was significantly different between the groups, being higher in the elderly. The increase in the area under the curve in the elderly was 25% greater than in the young on chronic therapy. This difference was not statistically significant, but was likely to be of clinical significance. The elderly patients' mean creatinine clearance (61.8 ml per min) was significantly lower than that in the young (137 ml per min), and there was a significant correlation between the half-life at single dosing and the blood urea concentration. Variability in all measurements was marked in both groups, and hence no clear guidelines can be given on therapeutic dosing. The small initial dose with alterations thereafter depending on clinical effect is the best advice.