Rapid Responses to:
|
|
Rapid Responses: Rapid Responses published:
-
![[Read Rapid Response]](/icons/misc/sectionDOWN.gif)
Disability in the elderly: the protective effect of osteoarthritis
- David J Robinson, Diarmuid O'Shea, Consultant Physician, St Vincent's Hospital, Dublin 4 (23 July 2009)
-
Leukoaraiosis and Cognitive Fundtion
- Rizaldy Pinzon (3 August 2009)
|
|
|||
|
David J Robinson, Specialist Registrar in Geriatric Medicine Royal Hospital, Donnybrook, Dublin 4, Diarmuid O'Shea, Consultant Physician, St Vincent's Hospital, Dublin 4
Send response to journal:
|
We read with some interest Inzitari et al’s description of the association between white matter changes in older patients and subsequent functional decline (1). This research suggests that there may exist novel occult markers of disease, and reinforces some of our intuition as clinicians dealing daily with the sort of patients described in the study. The patient group described is heterogenous and complex, and the study raises some other interesting questions. Firstly, while we note the protective effect of education on subsequent decline, it is interesting that the presence of osteoarthritis confers a stronger protection than a year of education, even when adjusted for other risk factors. The authors do not postulate a mechanism for this in the text. It is possible that the anti-inflammatory effect from the concomitant use of non- steroidal anti-inflammatory drugs (NSAIDs) conferred some benefit. COX-2 inhibitors are well-known to increase cardiovascular risk (2), while the evidence of harm from non-selective NSAIDs is limited (3). Indeed, some beneficial effects of non-selective NSAIDs on cognitive decline, albeit contended, have been noted (4). Was medication use included in the data collected, and if so, were there associations between NSAID use or NSAID-class and progression to death or disability? It is possible that issues of statistical power preclude a definitive answer to this question. Secondly, if white matter changes contribute independently to morbidity, as this study suggests, it would be interesting to know if burden of white matter disease correlated with incident delirium in the study population. Such a finding would go some way towards explaining relatively high rates of delirium in older patients who were previously considered to be cognitively intact (5). Finally, the composite rate of transition to disability or death of 15.8 per 100 person years serves to remind us that patients in the older age group who seek medical attention – despite presenting as non-disabled – carry a high - risk of progression to unfavourable outcome. This should inform the practice of those of us – geriatricians and general physicians alike – who deal with older people in an increasingly rationed environment. David Robinson (i), Diarmuid O’Shea (ii) (i) Specialist Registrar in Geriatric Medicine, Royal Hospital, Donnybrook, Dublin 4 (ii) Consultant physician in Geriatric Medicine, St Vincent’s University Hospital, Dublin 4 1. Inzitari D, Pracucci G, Poggesi A, Carlucci G, Barkhof F, Chabriat H, et al. Changes in white matter as determinant of global functional decline in older independent outpatients: three year follow-up of LADIS (leukoaraiosis and disability) study cohort. Bmj 2009;339:b2477. 2. Fosbol EL, Gislason GH, Jacobsen S, Folke F, Hansen ML, Schramm TK, et al. Risk of myocardial infarction and death associated with the use of nonsteroidal anti-inflammatory drugs (NSAIDs) among healthy individuals: a nationwide cohort study. Clin Pharmacol Ther 2009;85(2):190-7. 3. Roumie CL, Mitchel EF, Jr., Kaltenbach L, Arbogast PG, Gideon P, Griffin MR. Nonaspirin NSAIDs, cyclooxygenase 2 inhibitors, and the risk for stroke. Stroke 2008;39(7):2037-45. 4. Rogers J, Sabbagh MN. Interactions of stroke, nonsteroidal anti- inflammatory drugs, and APOE status in dementia risk. Neurology 2008;70(1):5-6. 5. Siddiqi N, House AO, Holmes JD. Occurrence and outcome of delirium in medical in-patients: a systematic literature review. Age Ageing 2006;35(4):350-64. Competing interests: None declared |
|||
|
|
|||
|
Rizaldy Pinzon, Neurologist Bethesda hospital Yogyakarta Indonesia 55224
Send response to journal:
|
The study from Inzitar, et.al (2009) showed that leukoaraiosis is an independent risk factor for functional disability. Previous reports showed that leukoaraiosis progresses over time. Progression of leukoaraiosis relates to cognitive decline, but this association is complex and modulated by other morphological factors like brain atrophy. Leukoaraiosis has been inconsistently associated with cognitive impairment, assorted motor dysfunctions, and gait disturbances. This new evidence has suggested that leukoaraiosis may be clinically important. Patients with leukoaraiosis have a poor prognosis in terms of death, stroke, and myocardial infarction. Leukoaraiosis may be an independent and strong predictor of dementia in stroke patients. The presence of leukoaraiosis also increases the risk of intracranial bleeding in patients with cerebrovascular diseases treated with anticoagulants. All of the above-mentioned results will require clinicians to examine in greater detail the status of the brain before deciding optimal preventive measures. Competing interests: None declared |
|||