Andrew Elder

Epilepsy in later life

Epilepsy is most likely to develop in later life. The burden of this disorder on health-care resources will rise further as the worlds population continues to age. Making a secure diagnosis can be challenging because the clinical manifestations of seizures and the differential diagnoses and causes of epilepsy can be different in older individuals compared with younger individuals. Obtaining a reliable account of the events for accurate assessment is particularly important in guiding the appropriate choice and interpretation of investigations to arrive at the correct diagnosis. In older age, unique pharmacokinetic and pharmacodynamic changes occur. The use and selection of antiepileptic drugs is often further complicated by the presence of comorbidities, polypharmacy, and concomitant functional impairment, but there is a paucity of high-level clinical evidence on the effects of these factors as well as on the choice of treatment in the elderly. A comprehensive model of care should combine expertise in the diagnosis and treatment of epilepsy with effective assessment and management of the psychosocial effects to improve the prognosis in this vulnerable and poorly studied group of patients.

Long term outcome of percutaneous mitral balloon valvotomy in patients aged 70 and over

OBJECTIVE To assess the immediate haemodynamic improvement and long term symptomatic benefit of percutaneous mitral balloon valvotomy in patients aged over 70 years. DESIGN Pre- and postprocedure haemodynamic data and follow up for 1 to 10 years by clinic visit or telephone contact. SETTING Tertiary referral centre in Scotland. SUBJECTS 80 patients age 70 and over who had mitral balloon dilatation: 55 were considered unsuitable for surgical treatment because of frailty or associated disease. In an additional four patients mitral dilatation was not achieved. MAIN OUTCOME MEASURES Increase in valve area after balloon dilatation and survival, freedom from valve replacement, and symptom class at follow up. RESULTS Mean (SD) valve area increased by 89% from 0.84 (0.28) to 1.59 (0.67) cm2. There was a low rate of serious complications, with only two patients having long term major sequelae. Of 55 patients unsuitable for surgical treatment, 28 (51%) were alive without valve replacement and with improvement by at least one symptom class at one year, and 14 (25%) at five years. In the 25 patients considered suitable for surgical treatment, 16 (64%) achieved this outcome at one year and nine (36%) at five years. CONCLUSIONS Percutaneous mitral balloon valvotomy is a safe and useful palliative procedure in elderly patients who are unsuitable for surgery. Balloon dilatation should also be used for elderly patients whose valve appears suitable for improvement by commissurotomy, but echo score is an imperfect predictor of haemodynamic improvement.

Does ageism affect the management of ischaemic heart disease

OBJECTIVES To analyse access by age to exercise testing, coronary angiography, revascularisation (percutaneous transluminal coronary angioplasty/stent insertion and coronary artery bypass graft surgery) and receipt of thrombolysis, where indicated, for hospital patients with diagnosed cardiovascular disease. METHOD Retrospective case note analysis, tracking each case backwards and forwards by 12 months from the patients date of entry to the study. The setting was a district hospital in the eastern part of outer London. The case notes eligible for inclusion were those of elective and emergency in-patients with an in-patient ICD-10 code of ischaemic heart disease, angina pectoris or acute myocardial infarction and a consecutive 20% sample of new cardiac outpatients with these diagnoses. RESULTS Analysis of 712 case notes showed that older hospital patients with ischaemic heart disease, and with indications for further investigation, were less likely than younger people to be referred for exercise tolerance tests and cardiac catheterisation and angiography. This was independent of both gender and severity of condition. Older patients did not appear to be discriminated against in relation to receipt of indicated treatments (revascularisation or thrombolysis), although, in the case of revascularisation, older patients were more likely to have been filtered out at the investigation stage (catheterisation and angiography), so selection bias partly explains this finding. CONCLUSIONS The current findings from a single hospital are comparable with the results from a broader study of equity of access by age to cardiological interventions in another district hospital in the same region. Although only two hospitals were analysed, the similarity of findings enhances the generalisability of the results presented here. It appears that age per se causes older cardiac hospital patients to be treated differently.

The sensitivity of human blood platelets to the aggregating agent ADP during different dietary sodium intakes in healthy men

SummaryWe have investigated the effect of varying sodium intake on the renin-angiotensin system, ADP-induced patelet aggregationin vitro, and blood 5-HT concentrations in 9 male volunteers.Systolic blood pressure was slightly reduced during a low sodium diet, whereas the diastolic pressure remained unchanged. Plasma renin activity and aldosterone concentration both fell significantly when sodium intake was increased; plasma angiotensin lI concentraion also fell, but not significantly.There was a significant fall in haematocrit after an increased sodium intake, but there was no change in the whole-blood platelet count after correcting for this. There were no significant changes in either total (i. e. PRP) or platelet 5-HT concentrations.The extent of platelet aggregation induced by 5 and 20 μmol · 1−1 of ADP increased significantly when dietary sodium intake was increased. When compared with low or normal sodium intakes, lower concentrations of ADP were required to produce 50% of maximum aggregation after a high sodium intake. The 5-HT2, receptor antagonist ketanserin (1 μmol · 1−1in vitro) reduced the extent of aggregation induced by 5 μmol · 1−1 ADP after the volunteers had taken a high sodium diet, whereas the angiotensin 11 receptor anatgonist saralasin (1 nmol-1−1) increased the rate of aggregation after the low sodium diet.Thus, during a high sodium intake, human platelets become more sensitive to the aggregating agent ADP It is possible that this effect is mediatedvia platelet 5-HT2 receptors, since ketanserin abolished the increase in salt-induced aggregation seen with 5 μmol · 1−1 ADP.

Percutaneous balloon dilatation of the mitral valve in patients who were unsuitable for surgical treatment.

OBJECTIVE--To assess the effects on haemodynamic function and symptoms of percutaneous balloon dilatation of mitral stenosis in patients unable to undergo surgical treatment because of associated medical/cardiac problems. DESIGN--A review of clinical outcome in 28 patients (of 108 undergoing balloon dilatation of the mitral valve) who were unsuitable for surgery. SETTING--A tertiary cardiac referral centre: some patients referred were from other cardiac centres in Scotland. PATIENTS--28 patients judged by cardiac surgeons to be unsuitable for valve replacement or valvotomy because of respiratory disease (15 patients), nonmitral cardiac disease (6), multi-organ impairment (5), psychiatric problems (1) or dense intrathoracic adhesions (1). INTERVENTIONS--Percutaneous anterograde balloon dilatation of the mitral valve with polyethylene/polyvinyl balloons in 20 patients and the Inoue balloon in eight patients. MAIN OUTCOME MEASURES--Haemodynamic variables were measured before and immediately after mitral valve dilatation. Patient survival and symptom class (New York Heart Association) were followed for a year after the procedure. RESULTS--Dilatation at the mitral orifice was achieved in all cases. The mean (SD) pressure drop across the valve fell from 13.9 (5.3) to 5.6 (2.5) mm Hg, cardiac output rose from 3.18 (1.02) to 3.96 (2.5) l/min, and valve area increased from 0.78 (0.32) to 1.58 (0.56) cm2. The procedure was well tolerated by most patients, even those with metabolic/electrolyte disturbance, severe obstructive airways disease, myocardial impairment, and coronary disease. In three patients a small shunt developed at the atrial level: none developed severe mitral reflux. The two patients who required assisted ventilation died soon after the procedure and in one patient with severe coronary artery disease myocardial infarction developed and she died in cardiogenic shock. Early symptomatic improvement was reported by 23 of the 25 survivors, though the increase in exercise capacity was often limited by their non-mitral disease. At one year follow up a further 6 patients had died because of their additional disease: 15 continued to show symptomatic improvement. CONCLUSIONS--Percutaneous balloon dilatation of the mitral valve is a useful new option in patients who are too ill to undergo cardiac surgery; but longer term benefit can be limited by the associated disease.

Mitral Balloon Valvotomy for the Treatment of Mitral Stenosis in Octogenarians

OBJECTIVES: To study the safety and benefit of mitral balloon valvotomy (MBV) in patients aged ≥ 80 years.

Age and sex do not bias the use of angiotensin-converting enzyme inhibitors in acute myocardial infarction and congestive heart failure

JAGS 51:572–583, 2003