Clinical review

Geriatric medicine

Sharon E Straus, geriatrician. 

Mount Sinai Hospital, Toronto, Ontario, Canada M5G 1X5

sstraus{at}mtsinai.on.ca

The number of people older than 65 years is increasing, and the proportion of people older than 85 is increasing exponentially. ^{1 2} In response to this challenge, clinicians need to assess and optimise health care for this group.

	Methods

Top Methods Cardiovascular risk Heart failure Stroke Dementia Osteoporosis Falls Conclusions References

I reviewed the contents of ACP Journal Club and Evidence Based Medicine from 1998 to 2000 and, after discussion with colleagues, selected articles that I believed to be relevant to the care of geriatric patients. It is not possible to give a comprehensive review of all recent advances here, but additional articles are listed on the BMJ 's website.

	Cardiovascular risk

Top Methods Cardiovascular risk Heart failure Stroke Dementia Osteoporosis Falls Conclusions References

Several studies have shown the benefits of angiotensin converting enzyme inhibitors in patients with left ventricular dysfunction, but the findings of the heart outcomes prevention evaluation study provide evidence for the use of ramipril in patients at high risk of cardiac events who do not have left ventricular dysfunction. Treatment with ramipril decreased the risk of death (number needed to treat 56, 95% confidence interval 32 to 195), myocardial infarction (42, 27 to 89), and stroke (67, 43 to 145) compared with placebo.³

Cholesterol
A subgroup analysis of data on patients older than 65 from the cholesterol and recurrent events trial has been published recently.⁴ The study was a randomised, double blind, placebo controlled trial in which patients with a recent history of myocardial infarction and average cholesterol concentrations were allocated to either pravastatin 40 mg/day or placebo and subsequently followed for the development of major coronary events. Among the 1283 patients aged between 65 and 75 years, those randomised to pravastatin had reduced risks of major coronary events (number needed to treat 11, 95% confidence interval 8 to 24) and stroke (34, 22 to 333) at a median follow up of five years compared with patients who received placebo.⁴ This study provides an example of how a constant reduction in relative risk of morbidity or mortality across different age groups will result in a greater absolute risk reduction (and a smaller number needed to treat) in elderly people because they have a higher baseline risk of the outcome event.

Hypertension
Clinical practice guidelines for the management of hypertension prepared by various organisations suggest use of diuretics or  blockers as first line treatment for patients with hypertension unless they have coexistent illnesses or other contraindications. ^{7 8} However, as with lipid lowering drugs, diuretics are underused despite evidence that they reduce the risk of stroke and cardiovascular mortality.⁹ A recent systematic review of randomised trials evaluating diuretics and  blockers as first line drugs in patients aged 60 years or older found that diuretics reduced the risk of stroke, coronary heart disease, and all cause mortality whereas  blockers reduced only the risk of stroke.¹⁰ Thiazides were also found to be the most effective first line drugs for hypertension in a systematic review that looked at randomised trials of diuretics,  blockers, calcium channel blockers, and angiotensin converting enzyme inhibitors.¹¹

	Heart failure

Top Methods Cardiovascular risk Heart failure Stroke Dementia Osteoporosis Falls Conclusions References

Congestive heart failure is a common cause of morbidity and mortality in elderly people. Two systematic reviews of 18 randomised trials that evaluated  blockers in patients with congestive heart failure who were already receiving diuretics and angiotensin converting enzyme inhibitors showed a decrease in mortality and hospital admission (table). ^{12 13} In a recently published randomised trial of extended release metoprolol versus placebo in patients with symptomatic chronic heart failure and stabilised with standard treatment (ejection fraction of  40%), metoprolol was found to decrease the risk of death and of the combined end point of total mortality and all cause hospital admissions. ^{14 15} In a predefined subgroup analysis, no significant increase in total mortality was observed in patients older than 70 years, although the confidence intervals for this estimate were wide. This evidence supports the use of  blockers in patients with heart failure who are receiving diuretics and angiotensin converting enzyme inhibitors.

Spironolactone has also been shown to reduce mortality in patients with congestive heart failure.¹⁶ A trial was conducted in 1663 patients with severe heart failure and an ejection fraction less than 35% and who were receiving angiotensin converting enzyme inhibitors and loop diuretics (if tolerated). Spironolactone reduced all cause mortality (number needed to treat 9, 7 to 16) and hospital admissions for cardiac causes (13, 8 to 27).¹⁶ Clinicians and patients need to consider the severity of heart failure, the risks and benefits of treatments, and the patient's values when making decisions about the use of spironolactone and  blockers in the management of heart failure.

	Stroke

Top Methods Cardiovascular risk Heart failure Stroke Dementia Osteoporosis Falls Conclusions References

A systematic review published in 1997 showed that specialised stroke units decrease the risk of death, dependency, and the need for long term institutional care compared with care on a general medical ward.¹⁷ One of the studies included in this review has recently published the long term effects of admission to a stroke unit. Two hundred and twenty patients with acute stroke were randomised to care in a specialised stroke unit or to usual care on a general medical ward.¹⁸ Stroke unit care improved long term survival and quality of life and increased the number of patients living at home (number needed to treat 6, 4 to 21) at five years. Stroke units also improved survival and increased the proportion of patients able to live at home 10 years after their stroke.¹⁹

	Dementia

Top Methods Cardiovascular risk Heart failure Stroke Dementia Osteoporosis Falls Conclusions References

The association between apoliprotein E and Alzheimer's disease is well established. A blinded comparison of the diagnostic accuracy of Apo E genotypes and clinical findings with pathological findings at necropsy found that although Apo E testing increased the specificity of the clinical diagnosis it decreased the sensitivity.²⁰ Given the current state of the evidence, genotype testing cannot be recommended for routine clinical use.

Various drugs have been evaluated for treating this disorder, but most of the evidence is on the use of cholinesterase inhibitors. Tacrine was the first of these drugs to be assessed, but many patients cannot tolerate it because of severe adverse effects.²¹ Several studies have looked at other cholinesterase inhibitors including donepezil,²² metrifonate,²³ and rivastigmine.²⁴ All these drugs produce similar, small improvements in cognition and behaviour. Further research is needed to look at longer follow up periods and at how patients should be selected for these treatments. If patients with mild to moderate Alzheimer's disease are interested in treatment with a cholinesterase inhibitor, clinicians should discuss the potential risks and benefits of treatment with them and explore the patients' values and the outcomes that are important to them before starting treatment.

	Osteoporosis

Top Methods Cardiovascular risk Heart failure Stroke Dementia Osteoporosis Falls Conclusions References

Osteoporosis is an important public health concern in older women. Several advances have been made in the prevention and treatment of this condition over the past few years. A randomised, double blind, placebo controlled study of 445 people older than 65 living in the community evaluated the effectiveness of calcium and vitamin D supplementation in reducing non-vertebral fractures.²⁵ Participants were randomised to either elemental calcium 500 mg/day and vitamin D 700 IU/day or to placebo and were followed up for three years. The risk of non-vertebral fractures was decreased in people who received calcium and vitamin D compared with patients who received placebo (number needed to treat 15, 8 to 12).

Fractured brittle and spongy bone from patient with osteoporosis

The fracture intervention trial assessed 2027 postmenopausal women with osteoporosis who were randomised to alendronate or placebo.²⁶ All women who had a daily calcium intake of less than 1000 mg/day were also given calcium and vitamin D supplementation. The study showed that alendronate decreased the risk of fracture (vertebral and hip) compared with placebo. A subgroup analysis reported that alendronate was effective across all age groups (see BMJ 's website for further details).²⁷ Alendronate can cause gastrointestinal side effects, and patients are therefore advised not to lie down for 30 minutes after taking the drug. This may make it difficult for some people to adhere to treatment.

The multiple outcomes of the raloxifene evaluation study recently showed that raloxifene, a selective oestrogen receptor modulator, can decrease the risk of fracture in postmenopausal women with osteoporosis (number needed to treat 29, 20 to 52).²⁸ Raloxifene was shown to decrease the risk of vertebral fractures but not non-vertebral fractures. The investigators also found that raloxifene decreased the risk of breast cancer (123, 74 to 253).²⁹ However, the drug increased the risk of venous thromboembolism (number needed to harm 155, 101 to 363), which makes it an unsuitable alternative to alendronate for the treatment of osteoporosis alone. Additionally, women who want the vasomotor and urogenital effects of oestrogen may not wish to take raloxifene.

Elderly people benefit from exercise

	Falls

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Falls are the leading cause of accidental death among people aged 75 years or older and are also responsible for appreciable morbidity including fracture, impaired mobility, fear of falling, and admission to long term care facilities.^30-32 The morbidity and mortality associated with falls result in large costs for the healthcare system, and they are a major public health concern.³³ A recent systematic review suggested that compared with usual care, complex interventions that targeted modification of multiple risk factors on the basis of individual health assessments decreased the number of people who fell.³⁴ However, the limited number and size of the studies makes it difficult to determine which components are the most effective in decreasing the risk of falls. Indeed, a systematic review recently identified over 400 variables that have been investigated as potential risk factors including sensory impairment, dizziness, mobility impairment, and cognitive impairment.³⁵ Further evidence is also needed to determine which interventions can decrease the risk of injury (including fractures) from falls. Parker and colleagues have suggested that external hip protectors may decrease hip fractures among elderly people in nursing homes.³⁶ However, compliance with these cumbersome devices is low.

	Conclusions

Top Methods Cardiovascular risk Heart failure Stroke Dementia Osteoporosis Falls Conclusions References

Although we have evidence about the effectiveness of some interventions in elderly people, and many advances have been made in the care of elderly people, many gaps in our knowledge remain. We need to encourage research in elderly people and encourage our elderly patients to participate in this research. In particular, we need to encourage the inclusion of frail elderly people (those with complex medical and psychosocial problems) in studies assessing interventions, prognosis, and quality of life.

	Acknowledgments

I thank Ken Locke for his comments on earlier drafts of the manuscript and Aleksandra Lalovic for secretarial help. SES is funded by a career scientist award from the Ontario Ministry of Health and Long Term Care.

	Footnotes

Competing interests: None declared.

Further references and data on osteoporosis are available on the BMJ's website

	References

Top Methods Cardiovascular risk Heart failure Stroke Dementia Osteoporosis Falls Conclusions References

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