Frailty and sarcopenia-from theory to practice.

Frailty and sarcopenia have emerged as important syndromes in geriatrics. Their impact is far reaching and are associated with many poor outcomes in older adults. Assessment of frailty and sarcopenia should form part of the assessment in older adults at all encounters between healthcare staff and older adults, coupled with comprehensive geriatric assessment. Early interventions are warranted based on existing consensus guideline recommendations. Recently, strict lockdown measures to protect at-risk groups during the coronavirus disease 2019 pandemic may have led to worsening of frailty and sarcopenia among older adults, owing to social isolation, reduced access to care, and physical inactivity. Assessment and prevention of frailty and sarcopenia are of particular importance during pandemics. Further study is warranted to find the best strategies for managing frailty and sarcopenia.

Practical guidelines for the acute emergency sedation of the severely agitated older patient.

The vulnerability of older people to serious underlying medical illness and adverse effects of psychotropics means that the safe and effective treatment of severe agitation can be lifesaving, the primary management goals being to create a safe environment for the patient and others, and to facilitate assessment and treatment. We review the literature on acute sedation and provide practical guidelines for the management of this problem addressing a range of issues, including aetiology, assessment, pharmacological and non-pharmacological strategies, restraint and consent. The assessment of the agitated older patient must include concurrent assessment of the likely aetiology of, the risks posed by, and the risks/benefits of management options for, the agitation. A range of environmental modifications and non-pharmacological strategies might be implemented to maximize the safety of the patient and others. Physical restraints should only be considered after appropriate assessment and trial of alternative management and if the risk of restraint is less than the risk of the behaviour. Limited evidence supports a range of pharmacological options from traditional antipsychotics to atypical antipsychotics and benzodiazepines. It is advised to start low and go slow, using small increments of dose increase. Medical staff are frequently called to sedate agitated older patients in hospital settings, often after hours, with limited access to relevant medical information and history. Safe and effective management necessitates adequate assessment of the aetiology of the agitation, exhausting all non-pharmacological strategies, and resorting to pharmacological and/or physical restraint only when necessary, judiciously and for a short-term period, with frequent review and the obtaining of consent as soon as possible.

Predictors for 5-year survival in a prospective cohort of elderly stroke patients.

OBJECTIVES: To examine predictors for 5-year survival in elderly stroke patients. MATERIALS AND METHODS: Prospective cohort study of 186 consecutive acute stroke patients aged ≥65 years admitted to Bankstown-Lidcombe Hospital, Australia 03/2002 to 03/2003. All subjects were followed up in 2007/8, at 5 years post-stroke, for outcome measures. Logistic regression analysis was performed to predict 5-year survival using covariables, including functional status, age, stroke type and severity and vascular risk factors. Patients lost to follow-up (n = 20) were excluded from the analyses. RESULTS: One hundred patients (60%) were dead at study end. Predictors for survival in final logistic regression model were as follows: Glasgow Coma Scale (GCS) on admission (OR 1.49, 95%CI 1.1-2.0, P = 0.01), preadmission functional independence measure (FIM) score (OR 1.04, 95%CI 1.0-1.1, P = 0.01), age (OR 0.93, 95%CI 0.87-0.98, P = 0.01) and atrial fibrillation (OR 0.43, 95% CI 0.19-0.95, P = 0.04). For 5-year survivors, mean Modified Rankin Scale was 3.1 ± 1.5, total FIM score 85 ± 32, mini-mental state examination (MMSE) 22 ± 8 and Hospital Anxiety and Depression (HAD) scores 5.4 ± 3.4 and 5.2 ± 3.9, respectively. FIM cognition score was significantly lower at 5 years when compared to baseline (24 ± 8 vs 29 ± 8, P < 0.05) (all scores expressed as mean ± SD). In contrast, MMSE, HAD and total FIM scores were not significantly different at 5 years when compared to baseline. CONCLUSIONS: The study identified lower GCS on admission, lower preadmission FIM score, age and atrial fibrillation as negative predictors for 5-year survival following stroke.

Meta-analysis of the cardiovascular benefits of intensive lipid lowering with statins.

OBJECTIVE: To evaluate the efficacy of intensive lipid lowering with higher-dose statins. METHODS: Meta-analysis of seven randomized controlled trials comprising 50,972 participants. RESULTS: Mean follow-up was 3.1 years with mean age 63 years. Final LDL-C levels in intensive lipid-lowering group were 1.42-2.07 mmol/l compared to 2.1-3.5 mmol/l in the less intensive or control group. The intensive arm had significantly lower risks for stroke OR 0.80 (95% CI 0.71-0.89); major coronary events OR 0.74 (95% CI 0.65-0.83); cardiovascular disease (CVD) or coronary heart disease (CHD) deaths OR 0.84 (95% CI 0.74-0.95). Significantly higher liver enzyme abnormalities occurred in intensive group* (OR 3.96; 95% CI 2.08-7.53), but it was not associated with drug discontinuations (OR 1.20; 95% CI 0.88-1.64). CONCLUSION: In those at high risk of cardiovascular events, intensive lipid lowering with statins to LDL-C level <2.1 mmol/l significantly reduces risk of stroke, major coronary events and CVD or CHD deaths compared to LDL-C level ≥ 2.1 mmol/l. [*Correction added on 11 January 2011 after first online publication on 27 October 2010. The phrase, "Significantly higher liver enzyme abnormalities occurred in less intensive group", was amended to "Significantly higher liver enzyme abnormalities occurred in intensive group".].

Anti-melanin antibodies are increased in sera in Parkinson's disease.

An increasing body of research suggests that a number of immune mechanisms play a role in degenerative pathways in Parkinson's disease (PD). In the current work we investigated a posited humoral immune response in this disorder. Sera from PD patients exhibited a significantly enhanced absorbance response on a novel ELISA for anti-melanin antibodies, compared to sera from age-matched control subjects. The enhanced ELISA absorbance response was specific for catecholamine-based melanins and was unrelated to antiparkinsonian dopaminergic medication. Further, the absorbance response was significantly and negatively correlated with disease duration. These data suggest that a specific humoral anti-melanin antibody response is present in PD and is more active in early disease. While the contribution of this novel immune response to the initiation and progression of this disorder is unclear, this finding supports the hypothesis that specific immune responses occurring in PD may respond to therapeutic interventions in this disorder.

Quality of life in a random sample of community dwelling older patients with essential tremor.

STUDY OBJECTIVE - Nested case-control study aimed to assess the quality of life of community dwelling participants aged 65 years or over with newly diagnosed Essential Tremor (ET). METHODS AND RESULTS - Thirty-two participants with newly diagnosed ET and 32 age and gender matched controls were administered the Rand-SF36 quality of life questionnaire. Medical co-morbidities were also assessed in the two groups. Results - Participants with ET had significantly lower scores in the physical function, role limitation because of physical function, role limitation as a result of emotional problem, pain, and energy/vitality subscales of the Rand-SF36 when compared with controls. CONCLUSIONS - Older patients with newly diagnosed ET have poorer quality of life than their community dwelling counterparts without ET.

Hindsight: a re-analysis of the severe acute respiratory syndrome outbreak in Beijing.

OBJECTIVE: To review the severe acute respiratory syndrome (SARS) epidemic in Beijing using basic epidemiological principles omitted from the original analysis. STUDY DESIGN: Analysis of Prospective surveillance data for Beijing collected during the outbreak. METHODS: Surveillance data were reclassified according to World Health Organization criteria. Cases previously excluded without date of onset of illness were included in the epidemic curve from estimates using the average time between date of onset and date of hospitalization for cases with both dates. Cases who failed to give a contact history were now included; 7% (n=5) of cases during the import phase and 61% (n=365) during the peak phase. Previously excluded cases were included for plotting on an epidemic curve, and basic spot mapping for distribution of cases was used from attack rates recalculated for age, gender, occupation, residential location, date of onset of illness and demographics. RESULTS: The spot map effectively illustrated clusters by residency, with the inner-city sustaining the highest attack rate (33.42 per 100,000), followed by an easterly distribution 5-30km away (21.62 per 10,000), and lowest in districts 60-160km away (9.21 per 100,000). The new epidemic curve shows the outbreak commencing 10 days earlier than initially reported, with a three-fold greater increase in cases during the escalation phase than previously estimated. CONCLUSION: In hindsight, the investigation of the Beijing SARS would have benefited from the use of spot maping as an essential outbreak tool for early identification of specific geographical area(s) for quarantining. If a spot map of incidence density rates was used during the early phase of the outbreak, the inner city might have been identified as a major risk factor requiring rapid quarantining. Contact history became uncommon as the outbreak progressed, suggesting that hospitals were over-burdened or pathogenesis and environment risk factors changed, strengthening the usefulness of early spot mapping and the need to modify risk factors included as contact history as the epidemic progresses.

Establishment of a stroke unit in a district hospital: review of experience.

BACKGROUND: The experience and outcomes of co-locating acute stroke and stroke rehabilitation care in a district hospital were reviewed. METHOD: Information for patients admitted to Blacktown and Mt Druitt Hospitals before and after setting up an acute stroke unit (SU) (12 months data for each period), including mortality and length of stay (LOS) at the hospital were obtained from various sources, including the diagnosis-related group and subacute and non-acute casemix databases. RESULTS: There was a significant reduction of mortality (18 vs 10%; P = 0.01) and reduced total LOS (46 vs 39 days; P = 0.01) with similar functional outcomes in the post-SU period. Fifty per cent of patients were unable to access the acute SU. Patients admitted into the SU had lower mortality (5 vs 14%; P = 0.01) and were also discharged from hospital earlier (35 vs 54 days; P = 0.01) than patients admitted into general wards during the post-SU period. Thirty-four per cent of patients received rehabilitation within the rehabilitation facility in the post-SU period compared with 19% in the pre-SU period. CONCLUSION: The Blacktown experience showed the feasibility of establishing a co-located SU within rehabilitation facility with good outcomes as illustrated by the significant reduction in the stroke mortality, a reduction in the total LOS and an increase in the number of patients receiving rehabilitation post-stroke.

Stroke risk factor, pattern and outcome in patients with cancer.

OBJECTIVE: To investigate risk factors, stroke pattern and outcome in stroke patients with cancer. METHODS: A retrospective review of all stroke patients with cancer (n = 69) admitted to Bankstown-Lidcombe Hospital, Sydney, Australia, between January 1999 and December 2004 was conducted, and comparison made to age- and gender-matched non-cancer stroke patients admitted to the same hospital during the same period. RESULTS: Vascular risk factors did not significantly differ between cancer and non-cancer groups. There was a trend towards greater risk of intracerebral haemorrhage in the cancer group vs the non-cancer group. Previous deep vein thrombosis was more common, and prothrombin time and activated partial thromboplastin time were prolonged in the cancer group vs the non-cancer group. More patients died in hospital in the cancer group vs the non-cancer group. CONCLUSIONS: Coagulation disorders are more likely to be seen in stroke patients with cancer, and patients with cancer have a higher in-hospital post-stroke mortality.

Identifying the determinants of 1-year post-stroke outcomes in elderly patients.

OBJECTIVES: To examine 12-month outcomes and develop predictive models for outcomes in elderly stroke patients. METHODS: Prospective study of 186 consecutive acute stroke patients aged > or = 65 years admitted to a local hospital between March 2002 and March 2003. Outcome measurements included mortality, functional independence measure (FIM) score and nursing home placement. Two predictive models, using multiple logistic regression analysis, were developed to identify the factors associated with (i) mortality, and (ii) being alive and independent (defined as mean FIM score > or = 90) at 12 months. RESULTS: One hundred and seventy two (92%) patients were followed up at 12 months post-stroke. Mortality rate was 31%, and was significantly higher in nursing home vs non-nursing home origin patients (68% [15/22] vs 25% [38/150]). Nursing home placement for non-nursing home origin survivors was 28% (31/112). Age > or = 85 years was associated with higher mortality (odds ratio = 5.3, 95% confidence interval = 1.8-15, P < 0.01) and lower FIM for patients living at home pre-stroke. Predictive models showed that age, not living at home pre-stroke, pre-stroke FIM < 108, inability to walk on admission, dysphasia, visual field loss and haemorrhagic stroke were associated with worse outcome. CONCLUSIONS: Predictive models--by developing new strategies to improve outcomes through identifying treatable predictive factors--may be clinically useful in elderly stroke patients.

Impaired transcriptional upregulation of Parkin promoter variant under oxidative stress and proteasomal inhibition: clinical association.

We provided data to show that the transcriptional activity of wildtype -258T in the parkin promoter region was significantly higher than the -258G variant in human cell lines. The transcriptional activity of wildtype -258T was significantly increased under oxidative stress by hydrogen peroxide, but this was not observed for the -258G variant. The transcriptional upregulation was significantly higher for wildtype -258T compared to -258G variant at 0.1, 0.2 and 0.4 mM of hydrogen peroxide. Similar results were obtained when the cells were treated with a proteasome inhibitor, MG132.Furthermore, in a case control study involving 753 subjects, we demonstrated that the parkin promoter -258G variant was associated with an increased risk of sporadic Parkinson's disease (PD) in the elderly ethnic Chinese population. Our clinical and laboratory data provide corroborative evidence that some older individuals who have the -258G variant may have a higher risk of developing PD.

Prevalence of Parkinson's disease in Sydney.

OBJECTIVE: To examine the prevalence of Parkinson's disease (PD) in Bankstown, Sydney, using the same methodology as a previous study in Randwick, Sydney, Australia (1998-1999). PARTICIPANTS AND METHODS: Twenty census districts (CDs) for the Bankstown local government area were randomly selected. Research personnel door-knocked every household within the CDs to locate people aged > or =55 years. A structured questionnaire (containing four screening questions for PD) was administered to those agreeing to participate. Screened positive participants were invited to come for a clinical examination. This is a continuation of the previous study and data have been combined. RESULTS: Combining data for Bankstown and Randwick gave 1028 participants; crude prevalence, 780 per 100,000 (CI: 546-1077). In Bankstown, there were 501 participants aged > or =55 years (response rate 70%); 135 were screened positive with 101 (74.8%) agreeing to a clinical examination. The prevalence of PD in the Bankstown community was 3.4% (17 of 501) (95% CI: 1.98-5.43) for those aged > or =55 years; crude prevalence 776 per 100,000 (CI: 452-1241). CONCLUSION: The combined results of two Sydney studies appear to indicate that Sydney has one of the highest prevalence estimates of PD in developed countries.

Prevalence of Parkinson's disease in a Chinese population.

BACKGROUND: Ethnic differences in the prevalence of Parkinson's disease have been observed, but may be due to differences in screening instruments and diagnostic criteria. AIMS: To compare the prevalence of Parkinson's disease in Hong Kong Chinese and Australians in Sydney. METHODS: A door-to-door community survey in the Hong Kong Chinese population was carried out using a two-staged procedure (screening questionnaire followed by physical examination), which had been validated for use in the community in a survey among Australians, to determine the prevalence in Chinese and to compare with that in Australians. RESULTS: A total of 1080 households were contacted, the non-response rate was 27%. The prevalence among those aged 55 years in the community and above was 0.5%, and 0.186% for the overall population assuming no subjects were below 55 years. These figures are lower than the 3.6% for Australians, aged >55 years. CONCLUSION: There appears to be a difference in prevalence of Parkinson's disease between Hong Kong Chinese and Australians in Sydney. Such differences may be due to documented differences in prevalence of genetic polymorphisms associated with Parkinson's disease between Chinese and Australians, or to differences in environmental factors.

Treatment of recurrent aspiration pneumonia in end-stage dementia: preferences and choices of a group of elderly nursing home residents.

BACKGROUND: Clinicians are often faced with the dilemma of how best to manage patients with advanced dementia who present to the hospital with repeated episodes of aspiration pneumonia. Rarely, if at all, are the opinions of the group that is most likely to be directly affected, that is the older nursing home resident, sought. This study seeks to fill that gap. AIMS: To study the choices and preferences of a group of elderly nursing home residents in the treatment of recurrent aspiration pneumonia on a background of severe disability from end-stage dementia. METHODS: A descriptive cross-sectional interview study using a hypothetical scenario carried out in six nursing homes within eastern Sydney, from June to August 2000. Views and attitudes towards hospitalization, antibiotic use, tube feeding and other treatment measures, given a situation of recurrent aspiration pneumonia and end-stage dementia, were obtained. RESULTS: Fifty-two elderly nursing home residents who were cognitively intact and not depressed were interviewed. Most of the subjects would prefer further hospital admissions (61.5%, P<0.1) and would choose to have antibiotic treatment (73.1%, P<0.001). Slightly more than half would not agree to artificial ventilation. Sixty-nine percent of the respondents would not agree to feeding via a nasogastric tube (P<0.05) and 71% would not agree to a feeding gastrostomy (P<0.001). Most would agree to a modified diet (75%, P<0.0001) and to continue oral feeding despite the attendant risk of re-aspiration (59.6%, P<0.01). CONCLUSIONS: The participants generally preferred to be treated in a hospital setting given the scenario. Most disagreed with the use of artificial feeding.

Genetic and environmental risk factors and their interactions for Parkinson's disease in a Chinese population.

The interaction between genetic and environmental factors for PD was examined in a Chinese population. It was found that although the intron 2 MAOB (GT)(n) repeat polymorphism was not associated with PD in the population, a relationship might have been masked by the "protective effect" of tea drinking. In individuals who did not drink tea (<1 cup/day), the possession of short length < or = 178 bp (GT)(n) alleles conferred a borderline significant increased risk for PD (adjusted OR=1.47; C.I.=1.03-2.1). As the extent of tea consumption increased, the association between the < or = 178 bp allele and PD disappeared. This result suggests that the MAOB gene may be associated with PD in Chinese if the putative protective effect of tea drinking is taken into account. The significance of this finding is unclear as the study may be limited because of its marginal significance and limited numbers. However, it does demonstrate the importance of considering putative positive and negative environmental risk factors in any examination of genetic risk factors for PD.

Strong association between N-acetyltransferase 2 genotype and PD in Hong Kong Chinese.

BACKGROUND: The slow acetylator genotype for N-acetyltransferase 2 (NAT2 genotype) may be associated with PD in white subjects and the genotype is common in both white and Chinese populations. Whether there is a relationship between NAT2 genotype and PD in Chinese subjects is not known. OBJECTIVE: To investigate the association between the slow acetylator genotype for N-acetyltransferase 2 and PD in a Chinese population. METHODS: The authors obtained DNA samples and documented sex, age, and smoking history in 99 Chinese patients with PD and in 126 control subjects from two major Hong Kong hospitals. PCR-restriction fragment length polymorphism was used to identify M1, M2, and M3 mutant polymorphisms of the slow acetylator genotype for N-acetyltransferase 2. Logistic regression analyses were carried out to investigate the relationships between the different variables and PD. RESULTS: The frequency of the slow acetylator genotype for N-acetyltransferase 2 in the PD group was significantly higher than that of the control group (68.7% vs 28.6%) with an OR of 5.53 (95% CI 3.08 to 9.92) after adjusting for age, sex, and smoking history. In a subgroup analysis smoking had no modifying effect on the association between genotype and PD. CONCLUSIONS: There is a significant association between PD and the slow acetylator genotype for N-acetyltransferase 2 in Hong Kong Chinese. The OR found is among the highest reported so far in all susceptibility gene studies for PD in both Chinese and white subjects and provides evidence for a possible functional relationship between NAT2 slow acetylator genotype and PD in both racial groups.

Lack of association between CYP1A1 polymorphism and Parkinson's disease in a Chinese population.

Apart from very few families who have a direct cause from genetic mutation, causes of most Parkinson's disease (PD) remain unclear. Many allelic association studies on polymorphism of different candidate genes have been studied. Although these association studies do not imply a causal relationship, it does warrant further studies to elucidate the pathophysiologic significance. CYP1A1 polymorphisms have been reported to be associated with PD in a Japanese population sample. Since CYP1A1 transforms aromatic hydrocarbons into products that may be neurotoxic and perhaps lead to PD, we therefore undertook a study to look at the possible association of CYP1A1 polymorphism and PD in a Chinese population. Contrary to the Japanese result, we did not find any statistically significant difference between the PD group and the control group in our study with a bigger sample size.