John E. Clague

Predictors of outcome following hip fracture. Admission time predicts length of stay and in-hospital mortality

Many factors may contribute to the mortality and morbidity following hip fracture, including the provision of care. We wished to examine the contribution of potential factors to in-hospital mortality, length of hospital stay and 90-day mortality by statistical analyses of an audit database of all hip fractures admitted to a teaching hospital following the introduction of a fast track admission system. In-hospital mortality was predicted by ASA grade, the presence of any complications, cardiovascular complications, grade of surgeon, operation type and shorter admission time, a measure of time taken to admit a patient to a hospital bed (P<0.001). Length of hospital stay was predicted by increased age, presence of chronic cognitive impairment/dementia, presence of an implant complication, operation type, fracture type and longer admission time, r=0.455, P<0.001. Ninety-day mortality was predicted by the presence of chronic cognitive impairment/dementia, cardiovascular complications, pulmonary complications, ASA grade, grade of surgeon and admission day, P<0.001. Rapid admission following a hip fracture may not be the ideal management approach for all patient groups. Further study is required to identify factors in the process of care which are associated with better outcomes.

Opinions of Elderly People on Treatment for End-Stage Renal Disease

Background: As more people survive into old age, a greater number are becoming eligible for dialysis treatment for end-stage renal failure. In the UK the elderly have previously been excluded from treatment programmes, and continuing financial constraints are unlikely to improve this situation. There are few data on the views of elderly subjects on renal replacement treatment. We have, therefore, explored the views of elderly subjects in this study. Methods: 50 subjects were selected from hospital geriatric wards and nursing homes. A short clinical vignette about a 75-year-old patient with renal failure was presented, and the subjects were asked to give their opinion on choices made by the patient to different treatment options. The subjects were then asked what choice they would make if in the same situation. They were asked what level of symptoms they would tolerate and for their views on cost and treatment allocation. Important contributors to quality of life were also determined for each subject using visual analogue scales. Results: 84% of the subjects would choose dialysis treatment, and 78% of all elderly would attend hospital as necessary, if their symptoms could be relieved. 54% of the in-patient elderly and 83.3% of nursing home elderly even when physically disabled and living in a nursing home would want dialysis for end-stage renal failure. 74% of all elderly preferred to have home dialysis treatment. Only 36% of the subjects thought cost was important when allocating dialysis to the elderly. Being independent and free from major symptoms was regarded as important for a good quality of life. Conclusions: In this survey, elderly subjects wanted dialysis treatment. Neither age nor cost were considered important determinants for resource allocation. Symptom relief and maintaining independence were considered the main goals of treatment.

Effects of death within 11 years on cognitive performance in old age

Six different cognitive tests and the Heck Depression Inventory (BDI) were given to 3,572 active community residents aged 49 to 93 years. Causes of death were ascertained for 443 who died between 36 and 3,903 days later. Subsequent survival predicted test scores during the 3,903 days and independently during Days 36 to 1,826 and Days 1,827 to 3,903. Scores on the BDI and cumulative verbal learning and vocabulary tests predicted mortality after demographics and performance on other cognitive tests had been considered. Predictors were similar for deaths from heart disease, malignancies, and other causes. A new finding that cognitive tests did not predict survival duration within the sample of deceased explains previous findings of greater terminal decline in performance for young than for elderly adults.

Injury in the aging: recovery and rehabilitation

Interest in how victims of traumatic injuries recover is increasing and a number of observational studies have now been done. There are very few intervention studies aimed at enhancing recovery, but there will be more as our knowledge base grows. Older recipients of traumatic injuries differ from the young in the types of injuries they sustain, in the way they respond to their injuries and in the consequences of even relatively minor injuries on their future independence. In this paper, we summarise our understanding of recovery after injury and consider this in more depth for older people with specific injuries.

The effect of aging on the metabolic clearance rate and distribution of cortisol in man.

Previous studies of cortisol kinetics in old people have been flawed. All but one used a large dose of unlabelled cortisol, which will itself alter the kinetic parameters, and in none was metabolic clearance rate (MCR) calculated. We have, therefore, injected [(3)H]cortisol into men aged 20-38 and healthy (screened) men and women aged 63-83 years and followed its disappearance from the circulation for 3 h. In all three groups the disappearance curves corresponded closely to a double exponential, with half-lives of around 5 and 65 min. A two-pool model was assumed, one being purely a side-pool. The initial and total volumes of distribution and the MCR, but not the clearance rate for exchange between the two pools, tended to be lower in the elderly men than in the young; only the difference in total volume was significant. All these parameters were lower in the elderly women than in the elderly men. We conclude that any decline in cortisol MCR and related kinetic parameters with aging in men is small compared with variation from other sources. These parameters are lower in elderly women than men, in line with a reported sex difference in MCR in young subjects.