Osteoporosis and genetic influence: a three-generation study.

We have studied 27 triads of mother, daughter and grandmother for possible genetic influence on distal and proximal forearm bone density, measured by single photon absorptiometry. We found a significant correlation of bone density at the proximal forearm between the mothers and grandmothers (r = 0.499, P < 0.01). There was also a weak correlation between proximal forearm bone densities of mothers and daughters (r = 0.327, P < 0.1). Significant correlations were found between the three generations for grip strength, pedometry, height and triceps skinfold thickness. There was also significant correlation between mother and grandmother for alcohol intake. There was no correlation for contraceptive pill use, smoking, dietary calcium intake, body weight or body mass index. The study concludes that, although there are similarities in bone mineral content between the three generations, genetic factors cannot be conclusively proven to be the major determinant of bone density. Lifestyle and environmental factors may have a bearing on achieving the peak bone mass and subsequent development of osteoporosis.

Climacteric symptoms in healthy middle-aged women.

The incidence of climacteric symptoms was determined in 247 healthy premenopausal women in a community setting. These volunteers had been recruited to a longitudinal study of bone density. Of these subjects, 46 ceased to menstruate during the study, and in this subgroup symptoms were compared before and after cessation of menstruation. Only hot flushes increased after cessation of menstruation in the longitudinal study and showed age correlation in the cross-sectional study. Hot flushes thus emerged as a true menopausal symptom. Although evidence for this is weaker, cold sweats and suffocation seem likely to be genuinely menopausal. Breast discomfort and the four mood symptoms of irritability, excitability, depression and poor concentration improved after cessation of menstruation, and this study gives no support for their being part of the menopausal syndrome; it suggests that these symptoms are more likely to be related to menstruation than to the menopause.

Determinants of forearm bone density in premenopausal women: a study in one general practice.

Predictors of distal and proximal forearm bone density, measured by photon absorbtiometry, were investigated in 248 premenopausal women aged 39-56 years. Only one strong predictor of lower bone density was found--history of previous fracture at any site (P less than 0.001). Two other factors showed a weaker association with density, but only at the distal site--history of diuretic use showed a positive association (P less than 0.02) whereas alkaline phosphatase level was inversely correlated with density (P less than 0.01). Other factors were not significant predictors: these included age, calcium intake, level of exercise, anthropometric measures of obesity, serum calcium level, parity, lactation history, a menopausal symptom history, use of the contraceptive pill, smoking and alcohol intake. These results contrast with the far stronger predictors found for postmenopausal women and suggest that genetic endowment rather than lifestyle may be the major determinant of bone density before the menopause.

Relationships between happiness, behavioural status and dependency on others in elderly patients.

Feelings of dependency on others were measured, by different scales, in two different samples of elderly people: 33 acute in-patients and 25 attenders at a geriatric day hospital. Findings were similar in each location. Dependent attitudes increased with the duration of patients' previous in-patient experience, and correlated negatively with subjective well-being but not at all with behavioural status. These results are consistent with theories which attribute low morale to feelings of dependence and this, in turn, to the experience of residential care. They are inconsistent with the view that dependence on others is a positive feature of old age. In addition, patients' subjective well-being was completely unrelated to nurse ratings of their behavioural status, and subjective ratings by nurses correlated somewhat with patients' behavioural status but not at all with their subjective well-being.

Quantification of dietary intake in long-stay geriatric patients: do we need seven days observation?

Nutrient intake was assessed for 15 long-stay elderly patients by 7-d weighed inventory. Analysis revealed neither significant day-to-day nor weekday/weekend variations for any studied nutrient except fibre. It would appear that acceptable indications of customary intake in this population can be achieved by measurement over a shorter period than 7 d, such as 3 or 4 consecutive weekdays.

The first year of a geriatric-orthopaedic liaison service: an alternative to 'orthogeriatric' units?

The use of orthopaedic beds by large numbers of elderly patients with multiple pathology will increase and already exceeds the provision of orthopaedic-geriatric rehabilitation units. A cross-specialty multidisciplinary ward round improved the quality of care of orthopaedic patients without requiring expenditure on equipment, facilities or staff, and abolished the need to transfer patients to geriatric beds for rehabilitation, this being achieved on the orthopaedic unit. The liaison service provided excellent medical training in acute and rehabilitative aspects of geriatric medicine, enhanced the role of other disciplines in the care of the elderly orthopaedic patient and facilitated communication between departments.

Anticonvulsant drugs and bone disease in the elderly.

Elderly psychiatric inpatients were studied to find the prevalence of osteomalacia in those taking anticonvulsant medication (n = 19) and a comparison group not taking these drugs (n = 37). Only one biopsy-proven case was discovered among the anticonvulsant group, and none in the comparison group. This was an unexpectedly low rate. The clinical and biochemical data (including alkaline and acid phosphatase isoenzymes) were further analysed to detect subclinical osteomalacia, but none was found. A difference between the two subgroups was found for total and liver alkaline phosphatase only. The possible explanations for these unexpected findings are discussed. The effect of anticonvulsants on vitamin D and bone metabolism is reviewed and the hypothesis that drug-induced changes in vitamin D metabolism are responsible for the bone changes described in earlier series is questioned.

Confirming long-stay status.

This paper discusses an assessment procedure for the formal identification of patients requiring long-stay geriatric care. It was introduced immediately prior to the reorganization of geriatric in-patient care at St Pancras Hospital which saw the abolition of mixed wards of acute, rehabilitation, and long-stay patients and their replacement by six specialized wards, three of which are long-stay wards accommodating 51 patients. The formal assessment and referral for long-stay care is itself one outcome of deliberations made by a multidisciplinary panel formed a few months before the hospital reorganization to examine the kind of care and environment that might best enable the long-stay elderly to enjoy, within the limits of their disabilities, as dignified and worthwhile lives as possible. The paper begins by outlining the reasons why an assessment procedure came to be seen as a necessary and important element in the new system of continuing care of geriatric patients. This is followed by a brief consideration of how the procedure operates. An example of the assessment form is included.

Real-time measurement of serum C-reactive protein in the management of infection in the elderly.

The serum concentration of C-reactive protein (CRP), a nonspecific acute phase reactant which responds sensitively to bacterial infection, was measured by homogeneous enzyme immunoassay in all patients admitted to a general hospital geriatric unit. It was then monitored frequently in those in whom infection was suspected. Results were reported rapidly to the clinical team and particularly in the context of a patient population with complex multisystem pathology, often without pyrexia, leucocytosis or other classical signs of infection, they made a significant contribution to patient management. Very high CRP levels were most commonly due to infection (75% of those over 50 mg/l and 94% of those over 100 mg/l) and the pattern of the CRP response during antimicrobial therapy provided a sensitive, objective index of its efficacy. Failure of CRP levels to fall promptly stimulated additional diagnostic investigations, revealing resistant infection, localized pus or serious noninfective pathology, particularly malignancy, and led to appropriate management. Furthermore the CRP results on admission were of considerable prognostic significance, being significantly higher (median 70 mg/l) in those patients who did not survive than in those who did (18 mg/l).

Autonomic neuropathy and hypertrophic osteoarthropathy in association with malignancy.

A case of autonomic neuropathy and hypertrophic osteoarthropathy in association with metastatic giant cell carcinoma of the lung and leiomyosarcoma of the stomach is reported. The link between these conditions is discussed and the role of pancreatic polypeptide as a possible marker for hypertrophic osteoarthropathy reported.

Late infection of joint prostheses.

Late infection of an orthopaedic prosthesis can cause serious illness in elderly patients. Four cases are described to show the importance of recognizing this condition.

A comparison of the erythrocyte sedimentation rate and serum C-reactive protein concentration in elderly patients.

Fifty-five consecutive admissions to an acute geriatric unit were studied prospectively. Individuals were classified according to the obvious presence or absence of an active disease process on admission and their serum C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) were measured then and five days later. There was no significant difference between the ESR values in the two groups either on admission or at day 5, nor was there any significant change between admission and day 5. In contrast, CRP values were very significantly higher in the active than in the non-active group and there were marked changes over the 5-day period corresponding to changes in clinical condition. These results indicate that the serum CRP concentration is superior to the ESR as an objective, non-specific marker for disease activity in the elderly.

Abnormalities of liver function and the predictive value of liver function tests in infection and outcome of acutely ill elderly patients.

In a prospective study of 79 acute admissions of elderly patients to a Geriatric Unit, elevated alkaline phosphatase levels were commonly associated with the presence of extrahepatic bacterial infections. The changes were attributed to alkaline phosphatase liver isoenzymes. There was no significant change in aspartate transaminase levels or in bilirubin levels in infection. Such frequent abnormalities of alkaline phosphatase disproportionate to bilirubin and aspartate transaminase are not described in younger patients with infection. These findings may reflect age-related changes in liver function. In the same series, both bilirubin and albumin were predictors of outcome.

Acute phase protein response to infection in elderly patients.

The presence of infection is often difficult to diagnose in elderly patients. In view of this, laboratory markers of infection are of great clinical importance. The pattern of change in acute phase proteins has not hitherto been studied in elderly patients. In a prospective series of 114 acute elderly admissions to a Geriatric Unit there was a significant change with infection in all proteins studied, but C-reactive protein was the most sensitive marker of the presence and severity of infection and the response to antimicrobial therapy. The best pair of acute phase proteins in the prediction of infection were alpha 1-acid glycoprotein and C-reactive protein whilst albumin and alpha 1-acid glycoprotein together contributed significantly to the prediction of outcome.

Value of admission profile tests for prognosis in elderly patients.

In a series of 934 elderly patients admitted to the geriatric department of a general hospital, several admission laboratory tests were found to provide prognostic information. When tests were combined as a discriminant function, the matter of death or survival at six weeks after admission was predicted with 84 percent accuracy in women and 77 percent in men. Values for serum sodium, blood urea, triiodothyronine uptake, and hemoglobin contributed significantly to the prediction in both sexes, whereas the values for serum albumin and blood glucose contributed only in women.

Paraplegia and quadriplegia in the elderly due to spinal cord lesions: association with malignancy.

A retrospective study showed that paraplegia and quadriplegia due to spinal cord lesions occurred with a frequency of 1 in 500 admissions to a geriatric department. These cases predominantly were caused by malignant disease, particularly of the bronchus. However, elderly patients presenting to other hospital departments included a far higher proportion of cases with benign causes, particularly cervical spondylosis which affects patients of lower average age. Male patients predominated in both malignant and benign categories.