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.

Underutilization of antithrombotic therapy in atrial fibrillation.

Most patients with atrial fibrillation should be considered for antithrombotic therapy. In a retrospective survey we investigated practice in two hospitals. For patients at high risk, established guidelines recommend warfarin, or aspirin if anticoagulants are contraindicated; for those at medium risk, either may be used. Of 156 with atrial fibrillation (acute, chronic or paroxysmal), 119 were at high risk, mean age 79 years. According to the guidelines, 89 of these were suitable for anticoagulation but only 49 (55%) received warfarin; 27 received aspirin and 13 neither. Of 27 patients at medium risk (mean age 70 years), 6 were not prescribed any antithrombotic therapy. This survey indicates that guidelines on antithrombotic therapy are commonly disregarded and that, in particular, warfarin is underutilized in the group for whom it is most indicated.

Is isolated systolic hypertension in the elderly more associated with left ventricular hypertrophy and significant carotid artery stenosis than mixed hypertension and isolated diastolic hypertension?

The association of electrocardiographic left ventricular hypertrophy (ECG-LVH) (212 subjects) and haemodynamically significant internal carotid artery stenosis (ICAS) (27 subjects) with isolated systolic hypertension (ISH), mixed hypertension (MHT) and isolated diastolic hypertension (IDH) was studied in untreated elderly patients. Subjects were those aged 67-86 years, drawn from a community screening programme for hypertension in Wales. The prevalence of ECG-LVH with or without repolarisation abnormalities was higher in subjects with ISH (16.6%) than in subjects with mixed hypertension (11.6%, NS). Partial correlation of SBP, DBP, voltage of lead I and SV1+RV5 for each hypertensive subtype showed a consistent positive correlation of DBP with the voltage of lead I and SV1+RV5 in all the subtypes except with the voltage of lead I in IDH subjects. In MHT, the SBP was inversely related to both the voltage of R-wave in lead I and SV1+RV5 (P < 0.03). In IDH, the SBP was positively correlated with the voltage of R-wave in lead I and inversely with SV1+RV5. Atheromatous plaque was present in 40 of 54 (74.1%) internal carotid arteries investigated. The homogeneous type of plaque was predominant in ISH (67%). Heterogenous type of plaque was predominant in the MHT group (50%) and IDH group (43%). The normotensive group did not show any predilection to any morphological type. Plaque was invariably present in the case of ISH, chi 2 = 12.29, 0.1 > P > 0.05. There was more smooth plaque surface in normotensives (79%) and more rough or pitted plaque surface in hypertensives (all types), chi 2 = 6.51, 0.1 > P > 0.05. All normotensives and IDH subjects had non-haemodynamically significant stenosis. Haemodynamically significant stenosis was found in cases of ISH (25%) and MHT (7%); chi 2 = 7.66, 0.1 > P > 0.05. ECG-LVH and haemodynamically significant internal carotid artery stenosis were more commonly found in subjects with ISH than in subjects with MHT. Further studies with larger numbers of patient in each hypertensive subtype would be desirable to confirm these observations.

Prevalence of mixed hypertension, isolated systolic hypertension and isolated diastolic hypertension in the elderly population in the community.

The prevalence of mixed hypertension (MHT), isolated systolic hypertension (ISH) and isolated diastolic hypertension (IDH) was estimated in the elderly population in the register of a large general practice in Wrexam, North Wales. Of the 3289 elderly patients, born in 1927 or before, entered in the register of surgery, 1901 attended for the first screening. The mean SBP rose with age until the age of 80-84 years in males and 75-79 years in females and then gradually declined. The mean DBP showed an earlier decline in males than in females. The prevalence of hypertension at first screening was: mixed hypertension 9.8%, ISH 19.1% (DBP < 95 mmHg*, 23.1%*) and IDH 5.7% with a total prevalence of hypertension of 52.2%. The prevalence fell at each subsequent screening so that at the third screening MHT was 3.9%, ISH 4.2% (5.4%)* and IDH 1.0%, with a total prevalence of hypertension of 10.3%. The prevalence of ISH rose with age until 70-74 years of age and with the maximum prevalence in this age group and then gradually declined. There was a drastic drop in the prevalence of both mixed hypertension and IDH after the age of 70-74 years. This study provides data for this community and also supports earlier observations that hypertension is a common problem in the elderly and that ISH is the commonest form of hypertension in the elderly. It confirms the fall in mean DBP with age but reports a decline also in mean SBP after the age of 80-84 years in males and 75-79 years in females.(ABSTRACT TRUNCATED AT 250 WORDS)

A double-blind, placebo-controlled parallel trial of vitamin C treatment in elderly patients with hypertension.

We have investigated the effect on blood pressure of treatment with vitamin C (an antioxidant and free radical scavenger) in patients with both systolic and essential hypertension. Following a 2-week run-in phase, two age- and sex-matched groups of untreated hypertensive subjects were randomised in a double-blind study to receive 6 weeks' oral treatment with either vitamin C, 250 mg twice daily (n = 22; 8M/14F, mean age 73.7 +/- 4.9 years) or placebo, one capsule twice daily (n = 26; 10M/16F, mean age 73.8 +/- 5.3 years). Blood pressure was measured in the sitting position using a random zero sphygmomanometer on three occasions during the run-in phase, and again at 2, 4 and 6 weeks after commencing treatment. Venous blood samples for measurement of plasma ascorbic acid (AA) and lipid peroxides (LP) were measured in all subjects at baseline and at 4 and 6 weeks after the start of vitamin C or placebo treatment. During the study period, significant falls in both systolic (vitamin C group, mean change -10.3 (95% CI 0.7-20.0) mm Hg, p = 0.05) and diastolic (vitamin C group, mean change -5.9 (95% CI 0.2-11.5) mm Hg, p = 0.03; placebo group, mean change -4.7 (95% CI 0.3-9.1) mm Hg, p = 0.05) blood pressure occurred. However, no statistical difference between the effects of either treatment on blood pressure was observed. At baseline, AA concentrations were lower in the vitamin C-treated group compared with the placebo group (44.6 +/- 2.4 vs. 57.7 +/- 4.2 mumol/l, p < 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)

An audit of cardiac pacing in the elderly: effect of myocardial infarction on outcome.

OBJECTIVE: To audit the outcome of temporary endocardial pacing in an elderly population. DESIGN: Retrospective case-series analysis. SETTING: The Department of Medicine for the Elderly at the Wrexham Maelor Hospital, a District General Hospital with 612 beds serving a catchment population of 220,000. SUBJECTS: A sample of 50 consecutive elderly patients, with an age range of 65 to 99 years, undergoing transvenous cardiac pacing. MAIN OUTCOME MEASURES: Length of stay in hospital, complications of the pacing procedure, whether a permanent pacemaker was installed, and whether the patient died within 1 month of admission. RESULTS: There was no difference in length of stay between those with a myocardial infarction and those without. Minor complications occurred in three patients (one local infection and two "failures to pace"). Major complications occurred in two patients (septicemia and pneumonia). More patients without a myocardial infarction (86.9%) went on to implantation of a permanent pacemaker than those with an infarction (11.1%, P = 0.001), and fewer of them died (8.7% compared with 48.1%, P = 0.0025). In those patients with a myocardial infarction who died, there was no difference between the proportions who had inferior (7/18) and anterior (5/9) infarctions. CONCLUSION: Cardiac pacing seems to be a safe and reliable procedure in the elderly, although long term morbidity and mortality may be dependent on the presence or absence of myocardial ischaemic disease. Myocardial infarction in the elderly is an event of major significance, carrying with it a high mortality rate, particularly if accompanied by cardiogenic shock and the need for cardiac pacing.

Isolated systolic hypertension in the elderly: survey of practitioners' attitude and management.

A postal survey of 445 medical practitioners was carried out in the light of recent large studies supporting the treatment of isolated systolic hypertension (ISH) in the elderly. The response rate was 60.2%. 46% of the respondents would consider using drug therapy for ISH, and this was dependent on the patients age and the level of systolic blood pressure. Thiazide diuretic was the most popular first choice drug. The most recurring reason for not using drug therapy by 54% of medical practitioners was that treatment with drugs will reduce quality of life due to side effects of drugs. There was a large consensus on the use of non-pharmacological treatment of ISH in the elderly.

The effect of thyroxine on small intestinal motility in the elderly.

OBJECTIVE: To study the effects of thyroxine on orocaecal transit time in a group of elderly hypothyroid patients on long-term thyroxine replacement therapy. DESIGN: Measurement of the effect of withdrawal and subsequent replacement of thyroxine replacement therapy on orocaecal transit time. PATIENTS: Fifteen elderly, previously hypothyroid patients on full replacement therapy with oral thyroxine were studied. There were 11 females and four males, aged 60-94 years (median 78 years) receiving initially 50-200 micrograms of oral thyroxine daily (median 100 micrograms). MEASUREMENTS: Serum TSH and FT4 were measured by radioimmunoassay and orocaecal transit time assessed using a lactulose hydrogen breath test. These tests were repeated 7 days after withdrawal of thyroxine replacement and again 7 days after subsequent reinstatement of therapy. RESULTS: On withdrawal of therapy, the median transit time increased from 75.0 to 135 minutes (P less than 0.01), the median TSH increased from 1.8 to 2.3 mU/l (P = NS) and the median FT4 decreased from 13.7 to 10.6 pmol/l (P less than 0.01). On reinstatement of therapy, the median transit time decreased to 95 minutes (P = NS), the median TSH decreased to 1.1 mU/l (P = NS) and the median FT4 increased to 14.1 pmol/l (P less than 0.01). CONCLUSIONS: These findings demonstrate the sensitivity of the small bowel to changes in thyroid hormone status and suggest that constipation arising as a result of this hypomotility may well be an early physical manifestation of hypothyroidism.