Search

There is little information dealing specifically with motor neuron disease (MND) in the elderly. Given current epidemiological trends, geriatricians will be increasingly called upon to diagnose and manage this condition. We report four patients who presented within a six month period to a geriatric medical unit, and place this experience in the perspective of 229 patients from a population-based study of adult-onset MND in Scotland in 1989 and 1990. In 1990 Scotland had a crude annual incidence of MND of 2.25/100,000; the figure for those over 65 is four times greater. MND is more common in men, but the sex ratio was nearly equal over the age of 65. The risk of presenting with bulbar palsy was greater in women, and even higher in elderly women. This, together with increasing age, is the most important negative prognostic factor in MND. Problems with the diagnosis and management of MND in the elderly are highlighted.

A retrospective study was carried out of the outcome of surgical decompression of cervical spondylotic myelopathy in 21 elderly patients. The presenting symptoms and signs were similar to those in younger patients. The indication for surgery was recent progressive neurological deficit. Assessment of pre-operative state was based on information from hospital records. Post-operative evaluation was made from a home visit in 17 cases (mean age 71) after a mean post-operative period of 19 months (3 patients had died in the interim and one had emigrated). Objective functional improvement was found in the upper limb in 58% and in the lower limb in 71%; the remainder were unchanged. Surgical decompression in cervical spondylotic myelopathy is a safe procedure, which benefits appropriately selected elderly.

The operation over ten years of a simple and practical method of collaboration between general surgeons and geriatricians is described. This was designed, by means of a weekly ward round by geriatricians and consultant surgeons on general surgical wards (120 beds), to give geriatric medical advice and, when appropriate, to arrange transfer for geriatric assessment, medical treatment and rehabilitation, long-term care, or terminal care. Some 240 such transfers are described, comprising approximately 2% of all patients over the age of 65 admitted to the surgical units. The commonest single surgical diagnosis was of malignant disease. A total of 43% had had no operation and 18% had no medical diagnosis. 64% of those transferred for assessment etc. went home, half of them within two weeks, but nearly a third of them after more than four weeks. The system was effective, and benefited both surgeons and geriatricians, at no cost to the former and little to the latter in terms of time or increase in work load.

Two hundred and eighty elderly patients who were referred because of a principal problem of confusion were investigated by computerized tomography; 94% were suffering from a 'dementia syndrome' and unrecognized receptive dysphasia was the commonest problem in the remainder. One hundred and twenty-four patients were suffering from senile dementia of the Alzheimer type, and 79 from multi-infarct dementia. Space-occupying lesions (tumour, subdural haematoma or hygroma) were found in 32 (11%). Of the 25 with other intracranial and extracranial causes, 64% had potentially treatable lesions (PTL). In only four cases was no diagnosis made. PTL were found in 31% of 170 patients with a duration of confusion of less than a year compared with 1% of 110 patients with a longer duration. In 48 of the former group, confusion was an isolated phenomenon; 12 of these (25%) had a PTL, as had 27 of 88 with confusion and a focal neurological deficit (31%). All five patients with recognized seizures, and six of 15 of those with reduced alertness had PTL. Twenty of 37 patients with neurosurgical lesions underwent surgery.

Eight hundred and eight subjects participated in three surveys of random samples of people aged 65 years or more living in their own homes. Neurological history and examination showed the prevalence of completed stroke to be 73 per 1000. Eighty-seven subjects per 1000 gave a history of transient cerebral ischaemic attacks. These prevalence rates were unaffected by age or sex. Senile dementia was diagnosed in 24 subjects per 1000 under 75 years and 109 per 1000 over that age. The prevalence of dementia of all types was 43 per 1000 under, and 140 per 1000, over 75 years of age. Parkinsonism was diagnosed in 16 subjects per 1000, and essential tremor in 17 per 1000. The prevalence of epilepsy was four subject per 1000. Other neurological disorders were diagnosed in 36 subjects, and a similar number had neurological abnormalities to which a definite diagnosis could not be given.

A series of 111 intracranial tumours in elderly patients, investigated by modern methods, is reviewed. The clinical picture of progressive neurological deficit, and/or intellectual impairment, did not differ greatly from that of younger patients, but the manifestations of raised intracranial pressure (headache and papilloedema) were much less common in the elderly. Intermittency of symptoms appeared to be a relatively common phenomenon with meningiomas, occurring in four of 12 symptomatic cases. Operative treatment, for removal of meningiomas or relief of obstructive hydrocephalus, produced improvement in almost all cases, with a low morbidity and mortality. High-dose steroid therapy produced substantial, if temporary, benefit in 51% of hemisphere tumours.

Digoxin elimination phase kinetics have been studied in 24 hospital in-patients (mean age 79 years), six of whom showed no evidence of digoxin toxicity. The others, with suspected toxicity, have been grouped according to the nature of the drug effects observed. Renal function, digoxin elimination half-life, apparent volume of digoxin distribution, and notional body content of digoxin have been compared between the groups. Apart from two hyperthyroid patients, the volumes of distribution averaged 6.1 1/kg. Toxic patients tended to have lower creatinine clearances, longer digoxin half-lives, and higher body contents of digoxin than the nontoxic, but the highest body contents were found in those with systemic toxicity. Thyrotoxicosis increases the apparent volume of digoxin distribution in the elderly.

Twenty elderly patients with intracranial tumour were treated with high-dose steroids (beta- or dexamethasone 12--16 mg per day). Six of eight patients with primary intracranial malignancies and four of six with metastatic tumours showed a definite response of conscious level and/or neurological deficit. One of two patients with lymphoma responded but neither of two with meningioma. Six patients were able to return home. Two patients suffered serious, and three minor, side-effects attributable to steroid therapy, but this treatment has a definite place in the management of intracranial tumour in old age.

Two indices of the possibility of malnutrition were constructed from the number of nutrients (up to 10) taken in amounts below recommended levels (index A) or below specified lower levels (index B). Values for these indices were determined from nutritional data for 264 old people living at home. High values for both indices were significantly related to the amount spent on food per week, the taken ing of 7 or fewer hot meals per week, and the presence of physical disability, but not to social class, living alone, or presence of a psychiatric diagnosis. The amount spent on food per week, taking 7 or fewer hot meals per week, and physical disability, are thus possible pointers to malnutrition in the elderly at home and may be useful for screening purposes.

A study is reported of the religious beliefs, attitudes, and practice of old people in the West of Scotland, based on a questionnaire given to 501 people aged 65 years and over randomly selected from those living at home. Almost all had had a full range of religious instruction, and regarded their parents as religious. Weekly church attendance was commoner among Catholics (70%) than Protestants (40%), among women than men, among those whose beliefs were those of organized religion, and among those with unrestricted mobility. The pattern of participation in church organizations and social activities was similar. A firm belief in an after-life was expressed by 80% of Catholics and 60% of Protestants, and higher proportions derived comfort from religion, especially in bereavement. Over 70% expressed no fear of their own death. In this elderly population, religious beliefs and attitudes remain important considerations, which should therefore be of concern to all those involved in the care of the elderly.

The skinfold thickness on the dorsum of the right hand over the second metacarpal was measured with Harpenden calipers in 276 women and 152 men aged 65 and over living at home. Mean values were higher in men than women and declined with age in both sexes. Skinfold thickness was related to body size, as estimated from lean body mass, but was unrelated to the presence of osteoporosis as assessed from bone mass of the second metacarpal or the presence of vertebral fractures. The skinfold thickness was low in those subjects who had senile purpura and also in a small group of subjects on long-term steroid therapy.

Three principal diagnostic problems were encountered in a group of 81 elderly patients with epileptic seizures: Post-ictal paresis (Todd's palsy) occurred in 13 patients (16%), of whom seven had evidence of past or present cerebral infarction, and six no such evidence. The paresis lasted up to 4 days, and could be confused with recurrent infarction or a transient ischaemic episode. Ictal and post-ictal confusional states of 24 h or more duration (up to 7-8 days) were noted in 11 patients (14%). They occurred in association with normal intellectual function as well as with pre-existing dementia, and required to be distinguished from other causes of delirium. Two patients presented paroxysmal sensory phenomena of ictal type. The differential diagnosis of episodic pain in hemiplegic limbs is discussed.

Measurement of serum-phenytoin concentrations in 17 elderly patients showed that levels of 40 mumol/l or more were not produced by daily doses of less than 300 mg/day, but that doses of 350 mg/day or more produced higher and potentially toxic levels. Determination of mean values for Vmax and Km for phenytoin gave values little different from those for younger patients. The implications of these findings for anticonvulsant therapy in the elderly are discussed.

The vitamin intakes of 77 men and 187 women aged 65 and over living at home were studied using seven-day dietary records. Intakes of ascorbic acid were below 10 mg/day in 5 per cent 25 per cent of men and 33 per cent of women took less than 50 i.u./day of vitamin D. Intakes of other vitamins (vitamin A, thiamine, riboflavin, nicotinic acid, pyridoxine, and folate) were, in general, adequate, except for small numbers of subjects. The findings are compared with those of the Panel on Nutrition of the Elderly (1972).

A study has been made of chronic respiratory disease among 83 men and 217 women aged 65 and over, randomly chosen from those living in their own homes. Twenty-six per cent of the men and 13% of the women had chronic bronchitis. The prevalence of chronic bronchitis was related to current cigarette smoking in both sexes, and to socio-economic status in men. Chronic bronchitis was a contributory cause of disabling dyspnoea and recurrent chest illness in half of the subjects with these symptoms. Significant radiological evidence of tuberculosis was found in 9% of men and in 4% of women, asthma in 2% of women, industrial lung disease in 4% of men, and bronchogenic carcinoma in three subjects.

Eleven patients with Parkinson's disease were tested for prosodic abnormality, on three tests of speech production (of angry, questioning, and neutral statement forms), and four tests of appreciation of the prosodic features of speech and facial expression. The tests were repeated after a control period of two weeks without speech therapy and were not substantially different. After two weeks of intensive domiciliary prosodic therapy, the prosodic abnormality score was improved, as were three of the four tests of recognition of the prosodic features of speech and facial expression, and two of the three tests of production (of angry and questioning forms). The apparent receptive disorder of speech in Parkinson's disease can thus respond to therapy. Possible mechanisms of improvement are briefly discussed.

Sixty-six elderly subjects (mean age 77 years) whose mental state was assessed clinically and by simple psychometric tests have been studied by computerised tomography. The mean maximum ventricular area in the 17 mentally normal subjects was above the upper limit of normal for younger subjects, and there was a broad relationship between increasing ventricular dilatation and increasing intellectual impairment. No such clear relationship was demonstrable for measures of cortical atrophy.

Intakes of calcium, iron, potassium, and magnesium are reported for 77 men and 187 women aged 65 and over and living at home in N. Glasgow. Calcium intakes were below the national average. The importance of milk as a source of calcium and the relevance of calcium intake to bone disease in old age are discussed. Iron intakes were probably adequate, but those of potassium and magnesium may well be below optimum levels.

Twenty-six patients with the speech disorder of Parkinson's disease received daily speech therapy (prosodic exercises) at home for 2 to 3 weeks. There were significant improvements in speech as assessed by scores for prosodic abnormality and intelligibility' and these were maintained in part for up to 3 months. The degree of improvement was clinically and psychologically important, and relatives commented on the social benefits. The use of a visual reinforcement device produced limited benefit over and above that from prosodic exercises alone, except to patients with severe speech disorder.

The haemodynamic response to postural stress (60 degrees foot-down tilt) was measured by impedance cardiography in six elderly cardiovascular-normal patients and 39 with symptomatic postural hypotension (systolic blood pressure drop greater than or equal to 20 mmHg or more). In the normal elderly the mean increase in heart rate, fall in blood pressure and cardiac output, and rise in peripheral resistance was less than that described in younger subjects. The changes were at their maximum in 1 min, and there was little further change over the next 5 min. In those with postural hypotension, orthostatic reduction (or failure to rise) of the peripheral resistance was the mechanism in 83% of cases, whatever the cause, and the time course of the haemodynamic changes was the same in the majority as in the normals. Serial tests in patients whose postural hypotension was controlled (by cessation of causal drugs, often multiple, by fludrocortisone, or by dihydroergotamine) showed return to normal.

Eighty-one elderly patients with epileptic seizures are described, of whom 60 were investigated by computed tomography. The cause was cerebrovascular disease in 44%, tumour in 12%, extracerebral in 11%, and unknown in 16%. Partial seizures were commoner in patients with tumour than with other causes. The findings are discussed in relation to other studies and to the investigation of elderly patients presenting with seizures.

The cardiac output has been measured in 40 elderly patients by impedance cardiography and an isotopic indicator-dilution method. There was no significant systemic difference between the results obtained by the two methods. The mean difference between paired values was 0.76 1/min (approximately 16%). The value and limitations of impedance cardiography in the study of the circulation in the elderly are discussed.

Twenty eight patients with Parkinson's disease (average age 63 years, average duration of disease 8 years) and 28 normal elderly controls (average age 70 years) were tested for their ability to appreciate the prosodic aspects of their own and others' speech and facial expression. Compared with the controls the Parkinsonian subjects performed worse at these tests, though both groups could easily identify neutral statements. The Parkinsonian subjects were unable to produce statements in an angry or questioning form. These seemed to be features of early Parkinson's disease.

Nine normal elderly subjects and 81 patients with dementia have been studied by computerised tomography (CT) and electroencephalography (EEG). There was a broad relationship between slowing of the basic frequency of the EEG and the severity of mental impairment. Localised slow-wave activity was found in 19% of those with non-vascular dementia and 72% of those with dementia of vascular origin. The mean size of the ventricles, as determined from CT scans, was larger in the vascular than in the non-vascular group. Within the vascular group it was larger in those without than in those with visible infarcts. There was no relationship in either group between ventricular size and dominant EEG frequency.

The cardiac output has been determined by radionuclide angiocardiography and by impedance cardiography in 93 elderly patients. The agreement between the two methods was excellent in patients in sinus rhythm, without regurgitant valvular lesions, and without severe airways obstruction or right bundle branch block. In atrial fibrillation the lack of correlation may be due to differences in heart rate during the two measurements, in regurgitant valvular lesions to the fact that impedance cardiography measures stroke output, whether forward or backward, in airways obstruction to high values for the basal thoracic impedance, and in right bundle branch block perhaps to the abnormal impedance wave-form often present.

Studies were made for evidence of heart disease on 501 people aged 65 and more living at home; 22-4 per cent had clinical and/or electrocardiographic evidence of ischaemic heart disease. The prevalence of ischaemic heart disease increased with age, and was slightly greater in men than women. The frequency of ischaemic heart disease increased with increasing current cigarette consumption and with total cigarette consumption. There was no increase in relation to any of the following possible risk factors: systolic and diastolic blood pressure, blood glucose, serum cholesterol, skinfold thickness, percentage of ideal body weight. The survival over a 5-year period of all subjects with ischaemic heart disease did not differ significantly from that of all subjects together, but the mortality of subjects with ischaemic heart disease and an abnormal electrocardiogram was 1-5 to 2 times that of subjects in whom ischaemic heart disease was diagnosed on the basis of angina pectoris or past cardiac infarction, the electrocardiogram being normal.

The possibility that pregnancy may play a part in the development of diabetes was investigated. A study was made of the records of 543 diabetic women and 413 diabetic men aged 40-79 years. The individuals came from a defined population of the City of Oxford and surrounding districts and attended a diabetic clinic with newly-discovered diabetes in the years 1954-1965. Among the women the risk of diabetes increased with increasing parity. Comparison with other studies shows that between the ages of 50 and 80 years the excess risk above that of a nullipara is 20% for 1 child 45% for 2 100% for 3 200% for 4 or 5 and 400% for 6 or more children. Parous women were heavier than nulliparous but there was no increase in weight with increasing parity. The frequency of family histories of diabetes was unrelated to parity. Among the men the risk of diabetes was unrelated to civil state or to the number of children. Men have a risk almost 50% in excess of that for nulliparae a figure virtually the same as that for women with 2 children. It is suggested that perhaps the environmental influence is added to the genetic to give the increased risk of diabetes.

A simple and objective method of estimating the longterm control of diabetes and derived from urine terms tests at routine clinic attendances has been investigated. The per cent of such urine tests showing 2 per cent glycosuria (glycosuria percentage) is shown to be significantly related to the mean of blood sugars determined at the same attendances. This relationship is unaffected by the number of clinic attendances, if these number five or more.