Ageing

Objective: To determine trends in use of Australian acute hospital inpatient services by older patients.Design and data sources: Secondary analysis of hospital data from the Australian Institute of Health and Welfare in the period 1993–94 to 2001–02, with population data for this period from the Australian Bureau of Statistics.Outcome measures: Population-based rates of hospital separations and bed utilisation.Results: The Australian aged population (65 years and older) increased by 18% compared with total population growth of 10%, yet the proportion of hospital beds occupied by older patients remained stable at 47%. The most substantial changes were observed in the population aged 75 years and older, with separations increasing by 89%, length of stay reducing by 35% and bed utilisation increasing by 23%. However, rates of bed utilisation (in relation to population) declined among older groups (10% decline in per capita use in population 75 years and older), but increased in the younger population (1% increase in per capita use in people younger than 65 years).Conclusion: Important trends in use of inpatient services were identified in this study. These trends are contrary to common perception. Ageing of the Australian population was not associated with an increase in the proportion of hospital beds used by older patients.

Len C Gray PhD, FRACP · Margaret A Yeo MPH, BSc(Hons) · Stephen J Duckett PhD, FCHSE

Should we do it, is it worthwhile, and who should decide? In the Western world, the number of people living beyond 80 years is increasing. In the United States, it is expected that 43% of the population will reach the age of 80.1 In Australia, men and women who reach 80 years may expect a further 7 and 10 years of life, respectively, the majority being disability free.2 Cardiac surgery in Australia has entered its fifth decade, and is now commonly performed (18 000 cases/year). The total cost (including salaries, equipment, building depreciation, etc) of having coronary artery bypass grafting (CABG) (which constitutes 75% of all cardiac surgery) at Western Australian teaching hospitals is about $12 000 per case (WA Department of Health, 1994, unpublished data). Over the past decade, the proportion of cardiac surgery patients aged 80 years or more has risen from negligible to 7% in selected centres.2-4 Surgical outcomes are encouraging: a 2002–03 report from six Victorian public hospitals revealed mortality rates of 2%–4% for elective CABG and 10%–12% for aortic valve replacement.4 However, follow-up assessment by direct patient contact has not been universal — commonly, outcome analyses rely solely on physicians’ perceptions.2 In a series of 64 octogenarians having cardiac surgery over a 5-year period at three Australian hospitals, our research group prospectively assessed outcomes and directly spoke to patients at several time intervals.2 The need for surgery was compelling — all had class III/IV symptoms of angina and/or dyspnoea. The total in-hospital mortality was 6.3% (nil in those having elective surgery and 10.5% in those requiring urgent surgery). The incidence of significant complications was low (perioperative myocardial infarction, 1.6%; stroke, 1.6%). At a mean follow-up time of 2.8 years, 44 patients were still alive, 42 (95%) were free of cardiovascular symptoms, and 42 remained independent, with a significantly improved quality of life. Kaplan–Meier actuarial survival for hospital survivors at 4 years was 74%. Interestingly, 8 patients (18%) had remarried and 8 had commenced on sildenafil. Not surprisingly, 43 (98%) of the patients said they would recommend cardiac surgery. Despite these favourable outcomes, one in five of the study participants had been originally advised by their general practitioner and/or physician not to proceed with surgery because of their age. Discrimination based on age alone is not uncommon.1,5 Performing surgery in these octogenarians was on a needs basis — other patients on waiting lists were not disadvantaged. If people over a certain age are to be barred access to healthcare, it is for society to debate and for governments to legislate. In Australia, Katrina Bramstedt (a bioethicist at the Department of Community Medicine and General Practice, Monash University) has cogently argued that age discrimination is common. Yet there is no ethical justification for denying cardiac surgery to octogenarians,5,6 particularly as empirical evidence validates the potential benefit of this treatment.5 It has been stated that “survival is not the most important outcome in the elderly”.7 Not so. Of the 102 patients on whom we have now operated, all wished to continue to live independently. So what have we learnt? Firstly, that surgery can be safely performed in octogenarians. The best people to make the decision whether to operate are the surgeon and the cardiologist, working in conjunction with one another. Secondly, that the success of surgery is critically dependent on the quality of anaesthesia and postoperative intensive care. There must be ongoing clinical governance so that expected outcomes match actual results.8 Not only are more and more octogenarians choosing to have cardiac surgery, but the chances of a good outcome are improving. Advances in surgical techniques in recent years mean that the risks of cardiac surgery, for all patients but especially those over 80 years, have been substantially reduced. The availability of “off-pump” technology (ie, doing coronary artery anastomoses without the use of cardiopulmonary bypass [CPB]), including mechanical aortocoronary anastomotic devices, allows CABG to be done not only without CPB, but also without manipulating the aorta, thus reducing atheroembolic risk.9 Furthermore, the duration of CPB and global myocardial ischaemia can be minimised by combining off-pump techniques with CPB (eg, valve replacement with CABG). Also, selective use of ventricular fibrillation (rather than cardioplegic arrest) when repairing a mitral valve avoids global myocardial ischaemia. Surgeons have several options for the technical performance of these operations. While there may be no surgical consensus on the optimal technique for a given patient, in my view a “one shoe fits all” surgical approach may prove hazardous. It is important to prepare the patient optimally before surgery. This includes universal carotid screening and judicious use of prophylactic carotid endarterectomy, together with preoperative optimisation of renal function and maintenance of perioperative enforced diuresis.10 Although none of these innovations has been tested in randomised controlled trials, myocardial, cerebrovascular and renal complication rates are now low. A critical factor determining surgical outcomes is whether the patient is in need of urgent surgery (ie, surgery required as a hospital inpatient because the patient cannot be satisfactorily stabilised with medical treatment).2-4 Delays in referring symptomatic patients are invariably associated with rapid clinical deterioration and poor results. The role of percutaneous coronary intervention (PCI) versus surgery for coronary artery disease requires comment. Neither surgery nor PCI is benign.11 For comparable patients of any age in experienced hands, the risks of inducing death, myocardial infarction, stroke or neurocognitive deficits are the same with either approach.12,13 With surgery, the failure rate is lower and there is less need for repeat interventions. However, surgery requires a sternotomy and graft harvest incisions on the leg. A number of clinical factors are associated with increased risk of PCI failure (eg, left main coronary artery or multivessel disease, diabetes).14 Before PCI is undertaken, it is essential that the cardiologist and the surgeon carefully assess which procedure is optimal for a particular patient. If PCI fails, performing emergency surgery (ie, within 24 hours of hospital admission) is associated with markedly increased risks, particularly in octogenarians. Which octogenarians should be offered cardiac surgery? Many, if not the majority, should be readily identifiable as unsuitable because of advanced comorbidities. However, the 20% of patients in our series who were advised not to proceed with surgery had no clear features distinguishing them from the 80% advised to proceed. It is impossible to provide unambiguous criteria for refusing surgery. Nor am I suggesting that all octogenarians be offered this treatment. What I am advocating is that age alone must not be a barrier to accessing cardiac surgery. We can be heartened that careful evaluation allows us to pick the right patients and that these patients are achieving acceptable outcomes. Patients should be offered a choice. Those who have had cardiac surgery believe it is worthwhile and are very grateful.2

John MP Alvarez FRACS

Objective: To assess the effect of home-based health assessments for older Australians on health-related quality of life, hospital and nursing home admissions, and death.Design: Randomised controlled trial of the effect of health assessments over 3 years.Participants and setting: 1569 community-living veterans and war widows receiving full benefits from the Department of Veterans’ Affairs and aged 70 years or over were randomly selected in 1997 from 10 regions of New South Wales and Queensland and randomly allocated to receive either usual care (n = 627) or health assessments (n = 942).Intervention: Annual or 6-monthly home-based health assessments by health professionals, with telephone follow-up, and written report to a nominated general practitioner.Main outcome measures: Differences in health-related quality of life, admission to hospital and nursing home, and death over 3 years of follow-up.Results: 3-year follow-up interviews were conducted for 1031 participants. Intervention-group participants who remained in the study reported higher quality of life than control-group participants (difference in Physical Component Summary score, 0.90; 95% CI, 0.05–1.76; difference in Mental Component Summary score, 1.36; 95% CI, 0.40–2.32). There was no significant difference in the probability of hospital admission or death between intervention and control groups over the study period. Significantly more participants in the intervention group were admitted to nursing homes compared with the control group (30 v 7; P < 0.01).Conclusions: Health assessments for older people may have small positive effects on quality of life for those who remain resident in the community, but do not prevent deaths. Assessments may increase the probability of nursing-home placement.

Julie E Byles PhD · Meredith Tavener BAppSci(Hons), MMedSci · Nick H Higginbotham PhD · Lyn Francis BN, MHM · John E Marley MD · Rachel L O’Connell BMath, MMedStat · Balakrishnan R Nair FRCP, FRACP · Brendan G Goodger PhD · Claire L Jackson MB BS, MPH · Mary E McKernon DipAppSci(Commun Nurs), GradDip(Nurs Admin) · Richard F Heller MD, FRACP · Jonathan Newbury MD

Even for nonagenarians, anniversaries are an opportunity for looking forward as well as looking back. Wondering what sort of articles the MJA might be publishing in the near future, and what might be the areas of focus and challenge for the medical profession, we asked over 40 of Australian medicine’s current opinion leaders: “. . . what area in your discipline is not currently researched or not resourced [by conventional conservative funding bodies], but ought to be developed as it will yield dividends.” In true editorial spirit, each contributor was asked to answer the question in less than 100 words, and to “think outside the square”. The replies came in thick and fast and we can’t publish them in full in print. However, a number of themes emerged, within which we have grouped excerpts from contributors’ responses. (The full text from the contributors is available here) Promising technologiesFor complex reasons, medicine lags behind the rest of the world in its use of information technology, but several contributors say it’s time we caught up! Information technology allows the “bedside" to be anywhere a mobile phone data signal can be received (photo courtesy m. Net Corporation). Cameron (emergency medicine) believes that patient-held electronic health records would save lives. An unconscious patient is brought “lights and sirens” to the emergency department. “The ED team work feverishly to save the person’s life, knowing nothing of the past medical history, medications, allergies or advance directives”. Why aren’t we already using these “health cards”? “The technology exists but the political will and the resources do not.” Discussing anaesthetics, Kerridge was on the same wavelength. The current speed and complexity of inpatient care have increased the need for “rapid access to comprehensive patient and other information, and decision making in the face of uncertainty”. To ensure that care remains “safe and high-quality”, we need to develop both clinical information and decision-support systems. Roberton (paediatrics) would like to see information technology used for research and policy development to ensure the wellbeing of children. The “singularly important need”, he believes, is “development and linkage of databases relevant to child health”. Databases to be linked might include those relating to perinatal statistics, mortality/morbidity data, immunisation records, health service utilisation and prescribing data, cancer databases, educational outcome assessments, and Australian Bureau of Statistics and Social Health Atlas information. While Roberton referred to his proposal as a “policy and funding challenge”, Scott, Braund and Ng (internal medicine) were bolder, entitling their contribution, “Stop funding laboratory benches. Start funding decision support and communication!”. As patients present with more and more comorbidities, we need mobile computers to provide real-world decision support at the bedside. Research findings should appear as “critically appraised evidence summaries and guidelines, accessible via desktop icons”. The justification for shifting our efforts to decision support? — “remembering to apply what’s known saves more lives than new knowledge”. Computer-assisted knee-joint replacement surgery. A camera detects markers on the patient and the instruments, and transmits information to a computer monitor. Size, position and alignment can be computer modelled before surgical bone cuts, or selection of a definitive implant (photo courtesy Professor Peter Choong). Contributors saw the computer age as a boon for the surgical specialties. According to Choong (orthopaedics), “the power of the computer will revolutionise, innovate, and enhance our understanding of what we do as surgeons”. Computer-assisted surgery in orthopaedics can improve surgical precision and accuracy. “While prosthetic implantation is a major beneficiary of computer-assisted surgery, so too is minimally invasive surgery, which will change not only how surgery is performed, but also the type of surgery possible, implant design, and patient outcomes.” O’Leary (ear, nose and throat surgery) finds the idea of virtual-reality surgical training exciting. “Immersed in a 3-D environment . . . trainee surgeons may one day be able to ‘see’ and ‘feel’ their virtual patient as they acquire skills in ear and nose surgery.” Improvements in safety, standardisation, access and quality control are reasons to develop this technology “now”. Some contributors whose specialties use evolving technologies nominated areas of promise in their disciplines. Peters (radiation oncology) believes more research is needed on a new technique which uses “the single greatest attribute of radiation as a therapeutic tool — the accuracy and certainty with which a specified dose can be delivered to any site in the body.” The technique involves using targeted beams of radiation to activate toxic pro-drugs within tumour-bearing tissues. Meanwhile, Rowe (nuclear medicine) predicts an expanding role for positron emission tomography. “Over the next decade, PET will become routine, not only for cancer staging, but also for tailoring treatment. It will be used to assess early response, plan radiotherapy and, through the use of more specific tracers, will permit better treatment selection.” Virtual ear surgery trainer developed by the University of Melbourne and the CSIRO (photo courtesy Associate Professor Stephen O'Leary, University of Melbourne, and CSIRO). Two contributors commented on the way we use existing technology. Cicuttini (rheumatology) believes an area that has received little attention is the most cost-effective way to investigate common painful conditions. “As in many other areas of medicine, there has been a history of adding new investigations to the old ones, rather than substituting new for old.” She suggests the need for research on the rational use of investigations. For instance, does a patient with back pain still need a plain radiograph of the spine? Also ripe for research, says Cordner (forensic pathology), is the use of new imaging techniques at autopsy. He believes that this will lead to “improved characterisation of pathology, and, in some cases, improved decision making about the value of autopsy”. Bringing into focusA group of contributors suggested a new angle or a new focus for research in their specialties. In the first two of these, the results of the research may also benefit other disciplines. Those dealing with inflammatory or immunological disease processes may well be interested in Marks’ (dermatology) suggestion that, instead of continuing to investigate what turns on the inflammatory/immunological response in atopic disease, we should be focusing on what turns off the response. O’Hehir (allergy and immunology), surprised by the escalating use of alternative therapies, wants not only clinical and laboratory research on alternative therapies, but also “well-conducted qualitative studies to determine motivations for their uptake”. These data might be useful in other disciplines. Baby with atopic eczema. What turns off the inflammatory response? (photo courtesy Professor Robin Marks). Chronic venous disease is the forgotten child of vascular surgery, says Myers, and the costs of treating varicose veins and their complications are enormous. We must understand the pathogenesis. “Do abnormal haemodynamics distend normal veins or do normal pressures distend abnormal veins? Intensive biochemical and cellular research is needed to devise biological mechanisms to retard varicose disease.” In gastroenterology, there is a new subspecialty — neurogastroenterology. The gut is unique for the complexity of its intrinsic nervous system, says Hebbard. In 30%–50% of patients with disordered gastrointestinal function, no organic causes can be found. Research in neurogastroenterology is classifying the disorders; subclassifying patients by epidemiological, psychological and symptom analysis; measuring function by motor and sensory testing; and expanding understanding of the neurophysiology of the enteric system. The deplorable state of the health of Aboriginal and Torres Strait Islander peoples troubled several contributors. After decades of research in the epidemiology of Indigenous health, says Anderson (Aboriginal health), the “research agenda needs to be refocused on the development and evaluation of interventions in clinical care and population health, and an investigation of systemic barriers to providing accessible and effective healthcare”. Marks (respiratory medicine) hypothesises that suppurative airway disease in Indigenous Australian children and adults, and obstructive lung disease in Indigenous adults, may have a common pathological pathway. He calls for research focusing on “understanding the respective roles of a pathogenic environment and compromised airway and mucosal defences”. There may be ancillary benefits for control of respiratory infectious diseases in the wider community. House dust mite – a common cause of asthma and hayfever. What motivates people to seek out alternative remedies? In renal medicine, research efforts and resources have concentrated on end-stage kidney disease, but Walker (renal medicine) says the focus has shifted to earlier kidney disease (proteinuria and/or impaired glomerular filtration rate), “which has assumed epidemic proportions, is a major cause of morbidity and mortality, and an independent and highly significant risk factor for a dramatically increased, all-causes cardiovascular disease mortality.” Funding is required for large-scale, intervention randomised-controlled trials. Out of the vacuumMany contributors expressed a desire to reconnect medicine with the person; a replacement of the reductionist approach by a more holistic view. Kerridge (anaesthesia) called for a shift from “small studies using surrogate endpoints, such as physiological or biochemical changes”, to “large, multicentre trials which examine common ‘simple’ interventions in ‘normal’ patient care”, measuring “ ‘real’ outcomes such as mortality, morbidity, or length of stay.” Cameron (rehabilitation medicine) was similarly minded, citing a need for research to “. . . understand better what will improve life for people with disability in the long term through careful epidemiological studies and clinical trials, looking particularly at appropriate environmental and personal factors”. At the same time he saw a need to reorient healthcare services to provide “rehabilitation with a community focus”. Mendelson (radiology) says imaging specialists have been slow to take up the challenge of measuring the effects of their craft on patient outcomes and quality of life. For instance, “Does the detection of ‘incidentalomas’ benefit the patient or just cause anxiety, expense and morbidity? Does recurrent imaging of patients receiving palliative therapy for malignancy confer any benefit?” These are questions which need to be considered in this era of expensive and limited technology. Connecting with the communitySeveral contributors saw the need to begin taking patient and community preferences into account. Scott, Braund and Ng (internal medicine) applied this to research: “Meta-analyses of effectiveness address the physician’s perspective. Patients need meta-analyses of the downside (risk) as well.” Others, such as Maddern (surgery), see it as imperative that we live up to community expectations to be “competent, up-to-date and able to achieve world-class results”. In doing this, he says, surgical research will need to be able to demonstrate not only that procedures are effective in the short term, but to show “long-term results in terms of cure or function within communities”. The establishment of optimal training environments (so surgeons and their teams can master the necessary skills before treating patients), ongoing national audit of surgeons, hospitals and operative approaches, and corrective systems are important if we are to achieve these results. Then there is a need for greater understanding of community values and societal pressures. Harris (general practice) points out that, while GPs can offer patients more options than ever before, “our patients are increasingly sceptical and misinformed (especially by the media and Internet)”. He believes we need more research on “how much Australian GPs and their patients agree on management or what factors or supports can make agreement easier or harder to achieve”. Wodak sees community values as creating tension in the area of drugs and alcohol as “the irresistible obstacle of community abhorrence of illicit drugs opposes the irresistible force of demand for these drugs”. The future should see us looking for compromises. Similar to the current acceptability of methadone, he suggests we need to develop “some form of regulated supply of orally well-absorbed, dilute and mild opiates, stimulants and hallucinogens” which are “reasonably acceptable to both the drug-abhorring majority and the drug-seeking minority”. Compassion and a need to research and resource ways to improve quality of life were also emphasised by some. Cordner (forensic medicine) sees a need to provide resources to “consult families about autopsy (eg, tissue retention for transplantation, research or diagnosis) and provide them with its results”. Meanwhile, in developing countries, the lack of appropriate expertise in detecting human rights abuses has led to “community mistrust of the criminal justice system, and therefore continuing instability and poverty”. These countries require aid to train forensic physicians and pathologists. In palliative care, Currow believes we should provide care for the caregivers through “. . . information, emotional support and respite that is responsive and funded”. Furthermore, palliative-care services should be judged on the carers’ outcomes, including “the ability to have health, create a life without the person for whom they have cared, and achieve a level of function with which they are satisfied”. Even our opinion leader in the world of health informatics regarded the human and systemic factors as being as important as the IT infrastructure. Coiera describes the computer as “the sacred ground in health informatics research”. This includes multiple information systems, such as the electronic health record, the Internet and mobile computing. However, he adds that “the profane ground, largely ignored, is the broader human system that is needed to make anything actually work. Technological systems repeatedly fail for cultural and organisational reasons”. The focus now needs to be on fusing the human and technical elements into effective systems. The da Vinci robot for radical prostatectomy. Brilliant advance or expensive toy? (© 2004 Intuitive Surgical, Inc). Hirst (urology) takes a broader cultural and societal view, saying that “the last 30 years has seen a significant shift in medicine from a moral economy to an increasingly market-based economy”. Several forces, such as pharmaceutical, instrument and device manufacturers and competitive behaviour within the profession, contribute to this. The shift has had most impact on procedural specialties like urology, and we need to take steps to ensure that its impact on quality, cost and training is positive. Age shall not weary usNot surprisingly, several contributions acknowledged the implications for future clinical practice of the “greying” of the Australian population. Flicker (geriatric medicine) is concerned about the dire lack of evidence to guide the management of people in advanced old age, and wants to see “evaluation of multicomponent interventions for the many coexisting diseases in old people with reduced physiological reserves”. Dobb (intensive care) was similarly concerned: as the cohort of elderly people is growing, so is our ability to ensure survival after severe illness. “We need to target intensive care to the patients who will truly benefit”, which requires understanding more about “the effects of age, comorbidities and functional status on recovery from severe illness”. Women ageing well (photo courtesy Dr Kay Cox). The dilemma of the upper-age entry limit (70 years) for clinical trials in cancer therapy — and that half the patients with cancer are now aged over 70 at diagnosis — was raised by Fox (medical oncology). “There is insufficient evidence-based data to guide management of ageing patients. We need to recognise that cancer will be predominantly a disease of the aged, and investigate it and manage it as such.” Constable (ophthalmology) reminds us about the epidemic of age-related macular degeneration. While Australian research has contributed to the epidemiology of macular degeneration, we know little about genetic predisposition and biological determinants. “Cellular biology, genetic manipulation, transplantation and induction of animal models will accelerate our understanding, create intellectual property and result in an early interventional approach.” Tonkin (cardiology) takes the bull by the horns and suggests “a public-interest trial: aspirin for primary cardiovascular prevention in the elderly.” The rationale? Previous trials mostly involved middle-aged males, and the risk of bleeding increases with age. At present, only a third of Australians 70 years and over, including those with overt disease, take aspirin routinely. “Aspirin is cheap and equitable; it may be extraordinarily cost-effective; and it may also prevent cognitive decline, depression and cancer.” There is a drawback — “with few gains for industry, this trial appears unfundable — 20 500 subjects, 5 years’ follow-up, $35 million!” How about it, Bill and Melinda? A panacea for the elderly? A bottle of aspirin powder, first marketed in 1899. Finally, Flicker points out that we still need to establish “which mix of lifestyle, health and social activities would maximise our chances of ageing well, an outcome which is not simply the absence of disease”. Connections between silosOne of the biggest changes in medicine since the MJA was born 90 years ago is ever-increasing subspecialisation. Some contributors saw a need to broaden the knowledge base of their disciplines. Sawyer, Sanci and Patton (adolescent health) say young people’s health problems are complex, but that the responses to problems such as depression, chronic physical illness, eating disorders and obesity often draw on “too narrow a skill-set from single-discipline practitioners who claim clinical expertise and responsibility”. More effective clinical, research and training responses will require “broader engagement of the health system and other sectors”. Wesselingh also sees a need for “adequately resourced, multidisciplinary responses” in the field of infectious diseases. Despite the extraordinary success and high profile of Australian infectious diseases research, he identifies three significant failures that warrant a multidisciplinary approach. “Firstly, our Aboriginal communities still suffer from excessive infection-related morbidity; secondly, our hospitals remain environments with a significant risk of acquiring infection with a multiresistant organism; and, thirdly, the Asia-Pacific region is following Africa towards an HIV/AIDS- and TB-led catastrophe.” In considering burns care, Wood (plastic surgery) believes we need a multidisciplinary scientific approach “to ensure the quality of the scar is worth the pain of survival”. This approach has potential for dealing with the three management steps: assessment (using multimodality imaging, including confocal microscopy and synchrotron technology); debridement (combining autolytic and image-guided physical debridement techniques); and reconstruction (using nanotechnology to provide the framework for appropriate tissue regeneration). The new geneticsAs genetics is a newer “basic science” discipline, contributors called for more integration with clinical research and practice. Waring (molecular genetics) notes that the availability of genetic tests for many diseases, such as inherited neurological and cardiovascular conditions and cancer, has created strong clinical demand. There is now “an urgent need to build integrated clinical and laboratory genetic infrastructure and to train scientists, pathologists and clinicians in molecular genetics”. Also required are a national strategy and a funding model for molecular genetics. Understanding how the brain works. MRI, showing brain fibre tracks in an infant with brain injury (photo courtesy Professor Terrie Inder). Williamson (genetics) says that “the Human Genome Project has given lots of data on genes of known function, and we know about single-gene diseases caused by their mutations. However, two-thirds of our genes are still a mystery”. Where are these genes? Mostly in the brain, he says, where genetic and environmental factors interact to produce “brain function, intelligence, consciousness, values and culture”. Williamson’s wish is for a project which integrates the Human Genome Project, neurogenetics, psychology, MRI fetal imaging and artificial intelligence “so we can really understand how the brain works”. Wiley (haematology) believes we now have “a major opportunity to explore genetic risk factors for pathogens which, in some people, survive and flourish in our intracellular environment”. Pathogens such as mycobacteria, chlamydia, toxoplasma and leishmania are killed by macrophages of the innate immune system, following similar pathways, but we are not sure which genetic factors in the host predispose to these diseases. “Studies which bridge haematology, immunology and infectious diseases are much needed to define genetic defects in innate immunity.” Just do it!A sense of urgency pervaded several of the contributions. “The world desperately needs an HIV vaccine”, says Kent (HIV medicine). “How can this slippery virus be checkmated? Where is its Achilles heel? What cells can be manipulated to exploit any weaknesses? What is the innate immune system doing? Can we generate an immune barrier to resistant strains? History will judge our dedication to this task.” Driscoll (occupational health) sees an urgent imperative for research into “establishing links between occupational exposure and disease, preferably at a stage early enough to modify the disease process”. We also need “better understanding of health risks (and benefits) associated with the large-scale transfer of jobs from heavy industry to information and service industries”. Mindel (sexual health) says there is an urgent need to control the commonest bacterial sexually transmitted infection in Australia. “Chlamydia is a leading cause of infertility and a significant drain on the public purse.” A national strategy is needed to encourage yearly screening of sexually active adults under 25 years (with a suitable urine chlamydia test), with treatment of those infected and their contacts, supplemented by promotion of consistent condom use, and testing and treatment for other STIs. For Mitchell (psychiatry) it is time to “grasp the nettle”. We now have new investigatory tools (genetic markers, structural and functional brain imaging), and have “rediscovered” gene–environment interactions (gene variants that increase the risk of mental illness, but only in conjunction with environmental factors). Thus, “the time is ripe for funding of large-scale, longitudinal studies to examine the roles and contributions of these factors combined (and in isolation) in determining the development and timing of onset of the major mental illnesses — schizophrenia, bipolar disorder and depression. Potential benefits in understanding aetiology, and thereby designing ‘tailored’ therapies, are enormous.” Leeder (public health) also takes a “just do it” attitude. He quotes Jeffrey Sachs, Director of the Earth Institute at Columbia University (New York), who says public health is “whatever it takes to improve the public’s health”. And what are the imperatives in public health? “Developing a robust ethic for public health; inviting private enterprise, unions, insurers and the public to the public health table; and learning the skills to speak eloquently with these people. Whatever it takes!” A doubling in prevalence of type 2 diabetes in Australia since 1980 means we simply can’t wait 10–15 years to do conventional research studies, says Chisholm (endocrinology). Intensive interventions (modified diet plus physical activity) can dramatically reduce diabetes incidence in predisposed people, but are prohibitively costly for whole communities. “To combat diabetes, obesity and cardiovascular disease, Australia should immediately implement ‘best-guess’ measures with progressive research analysis and modification (as was done to reduce cigarette smoking).” In short, let’s just do it! The future belongs to those who dare! Contributors: A/Prof Ian P Anderson, Dr Wilton Braund, Prof Ian D Cameron, Prof Peter A Cameron, Prof Donald J Chisholm, Prof Peter F M Choong, A/Prof Flavia M Cicuttini, Prof Enrico W Coiera, Prof Ian J Constable, Prof Stephen M Cordner, Prof David C Currow, Dr Geoffrey J Dobb, Dr Tim Driscoll, Prof Leon A Flicker, Prof Richard M Fox, Prof Mark F Harris, Dr Geoffrey S Hebbard, Dr Geoffrey H L Hirst, A/Prof Stephen J Kent, Dr Ross K Kerridge, Prof Stephen R Leeder, Prof Guy J Maddern, Dr Guy B Marks, Prof Robin Marks, A/Prof Richard M Mendelson, Prof Adrian Mindel, Prof Philip B Mitchell, Prof Kenneth A Myers, Dr Kenneth Ng, Prof Robyn E O’Hehir, A/Prof Stephen J O'Leary, Prof George Patton, Prof Lester J Peters, Prof Donal M Roberton, Dr Christopher C Rowe, Dr Lena A Sanci, Prof Susan Sawyer, A/Prof Ian A Scott, Prof Andrew M Tonkin, A/Prof Rowan G Walker, A/Prof Peter Waring, Prof Steve L Wesselingh, Prof James S Wiley, Prof Robert Williamson, Dr Alex D Wodak, Prof Fiona M Wood.

Ruth M Armstrong BMed · Helen M Randall BSc, DipOT · Martin B Van Der Weyden MD, FRACP, FRCPA

Objective: To examine trends in hospital admission for hip fracture in New South Wales between July 1990 and June 2000.Design: Analysis of routinely collected hospital separation data.Setting: Public and private acute-care hospitals in NSW.Participants: Admissions of patients aged 50 years and over with a primary diagnosis of fracture of the neck of femur (International classification of diseases, 9th revision [ICD-9] code 820 or ICD-10 codes S72.0–S72.2).Main outcome measures: Number and rates of hospital admission for fracture of the neck of femur per 1000 population; inpatient mortality rates per 1000 admissions.Results: Between July 1990 and June 2000, the number of admissions to NSW acute-care hospitals for hip fracture increased by 41.9% in men (from 1059 to 1503 per year) and by 31.2% in women (from 3160 to 4145 per year). However, age-specific and age-adjusted rates remained practically unchanged. The average length of stay for admissions for hip fracture decreased significantly from 19.2 days (95% CI, 18.5–19.8 days) in 1990–1991 to 14.2 days (95% CI, 13.8–14.6 days) in 1999–2000. No significant change was observed in the overall inpatient death rates per 1000 admissions.Conclusions: The findings support recent reports that the increase in hip fracture rates during most of the past century may have ended. However, the number of admissions for hip fracture is still rising. Preventive measures to reduce the burden of this condition on the healthcare system and community need to be pursued and strengthened.

Soufiane Boufous BH(Hons), MPH(Hons) · Caroline F Finch BSc(Hons), MSc, PhD · Stephen R Lord BSc, MA, PhD

Clinical recordsOutbreak 1In January 2002, an outbreak of influenza A occurred at a Melbourne aged-care facility (ACF) housing 42 residents (median age, 86 years; range, 64–98 years). There were 29 staff working at the facility (median age, 46 years; range, 29–64 years) (Box 1). The index case (Visitor A) was an 86-year-old woman who regularly visited her husband (Resident A) at the ACF. Visitor A developed respiratory symptoms on 26 Dec 2001 (Day 0), was hospitalised with fever and respiratory symptoms on Day 2, and died of pneumonia on Day 17. Visitor A had a history of emphysema and had received the influenza vaccine in March 2001. On Day 5, Resident A developed respiratory symptoms, and between Days 8 and 13, 15 more residents developed respiratory illness, of whom nine were hospitalised. The hospitalisation of four residents on a single day (Day 13) with suspected pneumonia led to the emergency department manager notifying the Victorian Department of Human Services (DHS) of the outbreak. On Day 14, DHS staff visited the ACF and collected nose and throat swabs from symptomatic individuals whose onset of respiratory symptoms had occurred less than 5 days earlier (ideally, specimens should be collected within 72 hours of onset). Where possible, acute and convalescent sera were collected. The Victorian Infectious Diseases Reference Laboratory tested combined nose and throat swabs for influenza virus RNA using a respiratory multiplex polymerase chain reaction (PCR) assay, designed to detect RNA from respiratory syncytial virus; parainfluenza virus types 1, 2, and 3; influenza A virus (subtypes H3N2, H1N1); influenza B virus; and picornaviruses (rhinoviruses, enteroviruses). The reference laboratory also tested acute and convalescent sera for antibodies to influenza A virus, influenza B virus, Mycoplasma pneumoniae, Legionella spp., and Chlamydia pneumoniae antibodies. On Day 14, the DHS recommended that the ACF implement infection control measures (Box 2). The DHS also gave notification of the outbreak to attending general practitioners and infection control staff at hospitals where patients had previously been admitted. Thirty-eight of 42 residents, but only two of 29 staff, had received the 2001 influenza vaccine in either February or March 2001. As an outbreak control measure, 22 of 23 unvaccinated staff who were unaffected by illness were vaccinated (the four unvaccinated residents had already developed respiratory symptoms). On Day 15, 24 hours after collection, PCR test results showed that the samples were positive for influenza A (H3N2). The DHS then recommended antiviral therapy for all residents and all unvaccinated staff: amantadine for prophylaxis and zanamivir for therapy or prophylaxis. Oseltamivir was not recommended at the time, as it was not licensed for prophylaxis. Because of the perceived difficulties in administration and possible gastrointestinal and neurological side effects in elderly and chronically ill people, the facility elected not to use amantadine, and decided on zanamivir for treatment and prophylaxis. However, as the ACF was unable to obtain sufficient stock of zanamivir for these purposes, two residents and four staff members received zanamivir for treatment and 21 unaffected residents received prophylactic oseltamivir (despite its use being outside the licensed indications for the drug at the time). None of the residents who were given prophylactic oseltamivir developed influenza. The latest date of onset of respiratory illness occurred on Day 18 (13 January 2002). The World Health Organization (WHO) Collaborating Centre for Reference and Research on Influenza (Melbourne) identified the outbreak strain as influenza A/H3N2/Moscow-like and concluded that the H3N2-like strain in the 2001 vaccine protected against infection with this virus. Outbreak 2In March 2002, an outbreak of influenza A occurred at a Melbourne ACF housing 32 elderly residents (median age, 84 years; range, 55–91 years). There were 31 staff working at the facility (median age, 42 years; range, 20–55 years) (Box 1). The first two cases in the outbreak were residents who developed respiratory symptoms on 3 March 2002 (Day 0). Their infection could not be linked with a source case. Between Day 1 and Day 3, 22 more people associated with the ACF developed respiratory symptoms. The DHS was notified of the outbreak on Day 5 by an attending GP. On Day 5, the DHS recommended infection control measures (as with outbreak 1), and nose and throat swabs and acute and convalescent sera were collected. Infection with influenza A (H3N2) was confirmed on Day 8, but, by that stage, most affected individuals had recovered and antiviral therapy was not recommended. Although 30 out of 32 residents had received the 2001 influenza vaccine, only three of the 31 staff members had been vaccinated in 2001. Because the outbreak occurred in March, all staff and residents received the influenza vaccine as part of the 2002 influenza vaccination program. The WHO laboratory determined that the outbreak strain was influenza A/H3N2/Moscow-like and concluded that the H3N2-like strain in the 2001 vaccine protected against infection with this virus. However, the infecting viruses in outbreaks 1 and 2 were genetically different, suggesting they were not directly linked. Preventing and controlling influenza outbreaks in ACFsVaccinationIn Australia, influenza vaccination is recommended and funded annually for people aged 65 years and over and recommended, but not publicly funded, for healthcare workers in ACFs.1 Elderly residents may have an impaired response to the vaccine because of age or comorbidities.2,3 Outbreaks have been reported in ACFs, despite high vaccination coverage rates (> 85%) in residents using a vaccine that matches the circulating strain.4,5 This was the case in the outbreaks described here, in which at least 90% of residents had received the influenza vaccine. In view of this, the priority for preventing influenza outbreaks in ACFs should be to prevent individuals introducing the virus into the facility. The key way to do this is to ensure that ACF healthcare workers (including attending GPs) are vaccinated. Educating visitors about vaccination and instructing them to stay away from the ACF when unwell is less likely to be successful. In both outbreaks, there was low staff vaccination coverage, and in outbreak 2, staff appeared to contribute to ongoing transmission. Diagnosis and infection controlThe current non-systematic method of notification of influenza outbreaks in Melbourne ACFs is inadequate. Facilities should be encouraged to establish a sentinel surveillance system to recognise, notify and diagnose early cases of respiratory illness to allow timely outbreak control measures to be implemented.2,6 The response to influenza outbreaks in ACFs should be a collaborative effort between the ACF, the attending GPs and the DHS. The DHS is currently developing guidelines to manage outbreaks of respiratory virus infection in ACFs and will be piloting a system of ACF respiratory diseases surveillance for the 2004 respiratory virus season. Antiviral therapyAntiviral agents available in Australia include amantadine, zanamivir and oseltamivir. Amantadine has been shown to be 70%–90% effective in preventing illness caused by naturally occurring strains of influenza A virus7 and has been successful in controlling 60%–80% of influenza A outbreaks.8 In Australia, amantadine is approved for prophylaxis of influenza A virus but not treatment. Amantadine has several disadvantages, including lack of activity against influenza B, the potential for the occurrence of adverse side effects (despite individualised dosing based on renal function), and the rapid emergence of resistance to the drug.9 Spread of amantadine-resistant viral strains has been associated with simultaneous prophylaxis and treatment in the same facility.8 Zanamivir and oseltamivir are a newer class of antiviral agents (neuraminidase inhibitors) that are effective against both influenza A and B and have less serious side effects. Initial reports indicate that the frequency of emerging resistance to these agents is low during clinical use.9 In Australia, both agents have been recently licensed for prophylaxis. Neuraminidase inhibitors are 74% effective (95% CI, 50%–87%) in preventing illness caused by naturally occurring strains of influenza viruses in healthy adults.10 From the few available published reports of the use of these antiviral agents for chemoprophylaxis in outbreaks, both appear to be effective in stopping outbreaks in ACFs.9,11 When ACF staff and attending GPs are making decisions about antiviral treatment and prophylaxis in outbreak situations, they should take into account the influenza strain, the health status of the residents, the dosage schedules required, the potential side effects of the drug and the cost (antiviral drugs are not covered by the Pharmaceutical Benefits Scheme). The following recommendations for the use of antiviral agents to control influenza outbreaks will be detailed in guidelines being developed by the DHS: To be effective, treatment with zanamivir or oseltamivir must be started within 48 hours of symptom onset and continued for 5 days; Antiviral prophylaxis should be offered to all residents (whether vaccinated or unvaccinated) and to all unvaccinated staff members and should continue for 10 days or until the outbreak is declared over; If the outbreak is caused by a strain of influenza not covered by the vaccine, prophylaxis should be considered for all staff members, regardless of their vaccination status; To limit the potential transmission of drug-resistant virus during outbreaks, measures should be taken to reduce contact as much as possible between people taking antiviral drugs for treatment and those taking them for prophylaxis; and ACF staff should make arrangements with attending GPs to ensure residents can be prescribed antiviral treatment and prophylaxis rapidly and efficiently. Lessons from practice Even when vaccination coverage is high among residents, influenza outbreaks (with a strain covered by the vaccine) can still occur in aged-care facilities (ACFs), including during the summer months. Because of the poor health status of many residents, influenza outbreaks in ACFs can cause significant morbidity and mortality. When influenza vaccine coverage among residents is high, coverage in ACF healthcare workers is a priority for preventing outbreaks. If an influenza outbreak is suspected, this should be confirmed using nasopharyngeal aspirates or nose and throat swabs tested by a polymerase chain reaction assay. Serological testing may also be useful when symptoms have been established for longer than 72 hours. When influenza outbreaks occur in ACFs, antiviral therapy should be considered as an outbreak control measure. 1: Timeline for influenza A outbreaks in two aged-care facilities (confirmed and probable cases) Outbreak 1 Day Number of people with onset of respiratory symptoms and major events (action taken/findings) 0 1 visitor 5 1 resident 8 1 resident 10 1 resident 11 4 residents 12 5 residents 13 4 residents DHS notified of outbreak 14 1 resident, 4 ACF staff members Laboratory specimens collected. ACF advised to implement infection control measures 15 1 resident, 1 ACF staff member Specimens confirmed positive for influenza A (H3N2) by PCR assay. Antiviral therapy recommended 16 1 DHS staff member 17 2 residents Antiviral therapy implemented 18 1 ACF staff member Summary.* Residents (n = 42): 20 Inf (19 C, 1 P); 10 H; ACF staff (n = 29): 6 Inf (4 C, 2 P); Visitors: 1 Inf (1 C); 1 H; 1 D; DHS staff: 1 Inf (1 C). Outbreak 2 Day Number of people with onset of respiratory symptoms and major events (action taken/findings) 0 2 residents 1 5 residents 1 ACF staff member 2 2 residents 5 ACF staff members 2 visitors 3 3 residents 4 ACF staff members 4 2 residents 1 visitor 5 1 ACF staff member DHS notified of outbreak. Laboratory specimens collected. ACF advised to implement infection control measures 6 1 ACF staff member 8 1 ACF staff member Specimens confirmed positive for influenza A (H3N2) by PCR assay 9 2 residents Summary.* Residents (n = 32): 16 Inf (15 C, 1 P); 8 H; 1 D; ACF staff (n = 31): 13 Inf (3 C, 10 P); 3 H; Visitors: 3 Inf (3 P). ACF = aged-care facility. DHS = Victorian Department of Human Services. PCR = polymerase chain reaction. * Inf = developed influenza A (C = confirmed; P = probable); H = hospitalised; D = died. 2: Infection control measures for influenza A outbreaks in aged-care facilities (ACFs)* Restrict visitors from entering the ACF. Isolate sick residents in their rooms until 5 days after the onset of illness or until symptoms have completely resolved. Exclude sick staff from work for 5 days from the onset of symptoms of a respiratory illness or until symptoms have resolved. Restrict all admissions of new residents during the outbreak; Cancel daily activities programs. Instruct staff to increase hand washing, wear masks while providing care to symptomatic residents and enhance environmental cleaning. * Recommended by the Victorian Department of Human Services to control the outbreaks described here.

Rebecca J Guy MAppSc, MAppEpid · Richard Di Natale MB BS · Sean Tobin MB BS, MPH, FAFPHM · Priscilla M Robinson PhD, MPH, MHlthSc · Graham Tallis MB BS, FAFPHM · Heath A Kelly MB BS, MPH, FAFPHM · Stephen B Lambert MB BS, MAppEpid, FAFPHM · Alan W Hampson BSc, MSc

There have been dire predictions that population ageing will result in skyrocketing health costs. However, numerous studies have shown that the effect of population ageing on health expenditure is likely to be small and manageable. Pessimism about population ageing is popular in policy debates because it fits with ideological positions that favour growth in the private sector and seek to contain health expenditure in the public sector. It might also distract attention from the need to evaluate the appropriateness and effectiveness of current patterns of care. Pessimistic scenarios have stifled debate and limited the number of policy options considered. Policy making in Australia would be improved if we took a more realistic view of the effect of population ageing on health expenditure.

Michael D Coory MB BS, PhD, FAFPHM

Leon A Flicker,* Samuel D Vasikaran,† Jenny Thomas,‡ John G Acres,§ Paul E Norman,¶ Konrad Jamrozik,** Nicola T Lautenschlager,†† Peter J Leedman,‡‡ Osvaldo P Almeida§§ * Professor of Geriatric Medicine, ‡ Research Nurse, School of Medicine and Pharmacology, § Research Fellow, School of Medicine and Pharmacology and School of Psychiatry and Clinical Neurosciences, ¶ Associate Professor of Surgery, †† Senior Lecturer in Psychiatry of Old Age, ‡‡ Professor of Medicine, §§ Professor of Psychiatry of Old Age; University of Western Australia, Royal Perth Hospital, Box X2213, Perth, WA 6000. † Head, Department of Core Clinical Pathology and Biochemistry, Royal Perth Hospital, Perth, WA. ** Professor of Primary Care Epidemiology, Imperial College London, London, UK. leonflicATcyllene.uwa.edu.au To the Editor: Elevated levels of homocysteine (Hcy) have recently been associated with increased risk of vascular events1 and dementia.2 The clearance of Hcy is dependent on three vitamins — folate, B6, and B12. Vitamin B12 deficiency has been described in older people for over 40 years,3 and may have wide-ranging effects through this vitamin’s influence on Hcy. The aims of this study were to examine serum B12 and folate status, and their relationships with plasma Hcy concentrations, in community-dwelling healthy older people living in Perth. Older men and women were recruited from two different sources: 299 men aged 75 years and over were recruited from a large population-based study of screening for abdominal aortic aneurysm,4 where 70% of those invited joined the project; and we recruited 273 community-dwelling women aged 70 years and over through advertisements. Exclusion criteria for both groups included significant cognitive impairment, severe physical illness and current use of B-group vitamin supplements. The Human Research Ethics Committee at the University of Western Australia approved the study, and all participants provided informed consent. Fasting total plasma Hcy, serum B12 and folate concentrations were measured in all participants, and serum creatinine concentration was measured in the men only to calculate glomerular filtration rate (cGFR). For analyses, the variable plasma Hcy was heavily skewed to the right and natural logarithmic transformation was used. Pearson’s product moment correlations were calculated for univariate analyses of continuous variables. Descriptive statistics are presented in Box 1. Fourteen per cent and 1% of the men, and 6% and 1% of the women, were deficient in B12 and folate, respectively. Hcy concentrations above upper reference limits (15 μmol/L for men and 13 μmol/L for women) were found in 24% of both men and women. There were significant (P < 0.001) positive correlations between age and log Hcy concentration for men (r = 0.23; 95% CI, 0.12–0.33) and women (r = 0.25; 95% CI, 0.13–0.36), inverse correlations between B12 and log Hcy concentrations for men (r = – 0.25; 95% CI, – 0.14 to – 0.35) and women (r = – 0.30; 95% CI, – 0.19 to – 0.41), and inverse correlations between folate and Hcy concentrations for men (r = – 0.43; 95% CI, – 0.33 to – 0.52) and women (r = – 0.28; 95% CI, – 0.16 to – 0.39). Plots of log Hcy against B12 and folate concentrations for all participants are presented in Box 2. Under multiple regression, the association of B12 and folate concentrations with log Hcy concentration remained after adjustment for age and cGFR in men only; beta values (SE) were: – 0.00060 (0.00011) for B12 concentration; – 0.0155 (0.0017) for folate concentration; – 0.0029 (0.0008) for cGFR; and 0.012 (0.005) for age. In this sample there were high prevalences of B12 deficiency and hyperhomocysteinaemia. Although the prevalence of folate deficiency was substantially lower, there were still moderate inverse associations between serum folate and Hcy concentrations. Unfortunately, vitamin B12 deficiency of this kind may not be universally corrected with small doses of oral supplements,5 and this has intensified concerns about precipitating neurological complications by population-based folate supplementation.6 There is a need for intervention studies of B-group supplements to evaluate whether the risks associated with hyperhomocysteinaemia can be ameliorated. 1: Demographic characteristics, serum B12 and folate, and plasma homocysteine in 299 older men and 273 older women Men Women Mean (SD) Range Mean (SD) Range Age (years) 78.9 (2.8) 68–86 74.8 (4.4) 70–92 Weight (kg) 78.4 (1.2) 50.6–119.5 69.3 (1.3) 39.0–120.0 Height (cm) 171 (6.5) 150–197 159 (6.7) 132–176 Body mass index (kg/m2) 26.6 (3.5) 16–37 27.4 (5.3) 17–52 Ever smoked 66% 41% Ever drank alcohol 95% 66% Serum folate (nmol/L) 24.3 (7.6) 5.5–45.3 (RI, 7–34) 25.3 (7.6) 3.9–45.2 (RI, 7–34) Serum B12 (pmol/L) 254.5 (116.7) 57–890 (RI, 140–646) 313.5 (158.7) 59–1270 (RI, 140–646) Plasma Hcy (μmol/L) 13.50 (5.3) 6.7–70.5 (RI, 6.0–15.0) 11.46 (6.8) 3.8–96 (RI, 5.0–13.0) Glomerular filtration rate (mL/min) 78.3 (16.3) 35.8–142.4 SD = standard deviation. Hcy = homocysteine. RI = reference interval. 2: Plot of serum B12 and folate concentration against log homocysteine concentration (with regression line for B12) in 299 older men and 273 older women

Leon A Flicker · Samuel D Vasikaran · Jenny Thomas · John G Acres · Paul E Norman · Konrad Jamrozik · Nicola T Lautenschlager · Peter J Leedman · Osvaldo P Almeida

Dealing with dementia. A guide to Alzheimer’s disease and other dementias. Brian Draper. Sydney: Allen and Unwin, 2004 (xvi + 255 pp). ISBN 1 86508 853 6. Dementia is a condition that is common and costly. It affects not only those with the disease, but also their carers and families. Public awareness of dementia has increased in recent times, but many aspects are still misunderstood. Dealing with dementia is a comprehensive, easy-to-read book that covers “all you need to know” about dementia and is primarily written for those living with the condition. The strength of the book is that Draper covers all aspects of dementia care, ranging from the purely medical to alternative therapies. He addresses often-asked questions such as those about nutrition and occupational exposures. Non-pharmacological approaches to management, such as reality and validation therapy, music therapy, and a myriad of others, are described and supported by research outcomes, if these are available. Ethical and legal issues associated with the care of a person with dementia are clearly explained. A glimpse into possible future treatments gives hope to readers. This book is primarily for Australian readers. It contains a comprehensive description of community care services and residential care processes available in this country, and this is particularly useful for stressed families trying to sort through the maze of available services. Even though specifically Australian-based, the information presented in the book is easily adapted for an international audience. A useful summary of national and international websites is included for further exploration. Draper is a respected researcher and clinician in the field of dementia, including the needs of carers, who writes with a personal and often humorous style. The book is reasonably priced and health professionals can recommend it as a useful reference for patients and carers. Dina C LoGiudiceGeriatrician, Extended Care and Rehabilitation Centre, Melbourne, VIC

Dina C LoGiudice

Pituitary adenomas are found in 10%–25% of unselected autopsy series and are evident in about 10% of asymptomatic individuals by magnetic resonance imaging. Diagnosis of pituitary disorders is often delayed by lack of awareness and the subtlety of symptoms and signs. Hypopituitarism is suspected when peripheral hormone concentrations are low without an elevation in the corresponding pituitary tropic hormone(s). Severe adult-onset growth-hormone deficiency results in reduced muscle mass, increased fat mass and diminished quality of life, which are reversed by growth hormone replacement therapy. While trans-sphenoidal surgery remains first-line treatment for acromegaly, drug treatment has an important role in controlling residual growth-hormone excess and, in some circumstances, as first-line treatment. Dopamine-agonist therapy (cabergoline or bromocriptine) is the treatment of choice for micro- and macroprolactinomas. In patients with suggestive clinical features, elevated 24-hour urine free cortisol level is usually sufficient to diagnose endogenous Cushing’s syndrome; careful additional investigation is needed to determine whether the cause is Cushing’s disease (pituitary adenoma secreting adrenocorticotropic hormone [ACTH]), ectopic ACTH secretion or adrenal disease.

David M Hurley PhD, FRACP · Ken K Y Ho MD, FRACP

Adequate staffing and devices to impIement active strategies are the key Pressure ulcers significantly reduce the quality of life of patients and increase the costs of patient care, as well as length of hospital stay. The most notable feature of pressure ulcers is that most are preventable. Prevalence studies in Australian acute-care hospitals have found their prevalence to range from 4.5% to 27%.1 . . . The most notable feature of pressure ulcers is that most are preventable. Guidelines for preventing and treating pressure ulcers have been developed in many countries, beginning with the Netherlands2 and the United States.3 Guidelines specifically tailored to Australian healthcare were released in 2001 by the Australian Wound Management Association.4 A major limitation of all these guidelines is the level of evidence on which they are based. Using the evidence-grading system of the National Health and Medical Research Council,5 only one recommendation in the Australian guidelines achieved level 1 (evidence obtained from a systematic review of all relevant randomised controlled trials) — the recommendation that pressure-reducing or pressure-relieving mattresses or beds be used in place of standard hospital mattresses in high-risk patients. As is common with many guidelines for preventing pressure ulcers, much recommended practice is based only on consensus statements from experts in the field. In this issue of the Journal, Jolley and colleagues (page 324) report a randomised controlled trial of a newly developed pressure-reducing surface, the Australian Medical Sheepskin, compared with standard care in the prevention of pressure ulcers.6 The trial was in 441 hospital patients considered at low to moderate risk of developing pressure ulcers. Patients using the sheepskin developed new pressure ulcers at a rate half that of patients receiving standard care. Clearly, in this group of patients, the Australian Medical Sheepskin is better than standard care. However, it must be appreciated that standard care in this study was itself suboptimal. It consisted of “any other pressure-relieving device or prevention strategy deemed appropriate by ward nursing staff, comprising standard hospital mattress and sheet, with or without other low-technology constant pressure-relieving devices and repositioning as determined by nursing staff”. Standard care resulted in 16.6% of patients developing a pressure ulcer. The answer to reducing the prevalence of pressure ulcers lies not in implementing any one strategy, but in providing an institution-wide prevention program. Common to guidelines for preventing pressure ulcers is identification of patients at risk. It is imperative that some form of structured method to identify those at risk is applied to all hospital inpatients. Assessments need to be repeated regularly throughout a patient’s hospital stay and when there is a significant change in health status. A number of risk-assessment tools can be used, the most common being the Norton Risk Assessment Score,7 the Braden Scale8 and the Waterlow Risk Assessment card.9 The major risk factors for developing pressure ulcers are immobility, sensory loss, impaired cognitive state, urinary and faecal incontinence, age over 65 years, male sex, European background, chronic illness, poor nutritional status, impaired oxygen delivery to tissues, raised skin temperature, skin dryness and the presence of pressure, shear or friction forces. After establishing a patient’s risk of developing a pressure ulcer, the next step is to implement preventive strategies to reduce that risk. This requires the support of hospital administrations in providing both the necessary trained staff and pressure-reducing or pressure-relieving devices. It is also imperative that staffing levels are adequate to ensure that nurses have sufficient time to provide the “hands-on” care necessary for these high-risk patients. For patients at low to moderate risk of developing pressure ulcers, the ideal preventive strategy may include any one of a wide range of pressure-reducing or pressure-relieving surfaces, including the Australian Medical Sheepskin, combined with a repositioning strategy. The Australian Medical Sheepskin has yet to be compared with other surfaces and devices in this group of patients. A major challenge in many areas of medical practice is to successfully implement guidelines for clinical practice. A recent review of effective strategies for implementing pressure-ulcer guidelines concluded that active strategies were more successful in reducing ulcer prevalence.10 The most effective strategies used targeted educational sessions and, in particular, multiple approaches. Such a strategy was recently shown to reduce pressure-ulcer prevalence in a multicentre Australian study.11 This indicates that developing guidelines alone is not sufficient to influence outcomes, but that they need to be linked to educational strategies to ensure their successful implementation and subsequent influence on clinical outcomes.

Michael C Stacey DS, FRACS

Objective: To estimate the effectiveness of a new high-performance Australian medical sheepskin (meeting Australian Standard 4480.1-1998) in preventing pressure ulcers in a general hospital population at low to moderate risk of these ulcers.Design: Open-label randomised controlled clinical trial.Setting: A large metropolitan teaching hospital in Melbourne, Victoria, in 2000.Participants: 441 patients aged over 18 years admitted between 12 June and 30 November 2000, with expected length of stay over 2 days and assessed as at low to moderate risk of developing pressure ulcers.Intervention: Patients were randomly allocated to receive a sheepskin mattress overlay for the duration of their hospital stay (218 patients) or usual treatment, as determined by ward staff (referent group, 223 patients).Main outcome measures: Incidence rate and cumulative incidence of pressure ulcers, assessed daily throughout hospital stay.Results: 58 patients developed pressure ulcers (sheepskin group, 21; referent group, 37). Cumulative incidence risk was 9.6% in the sheepskin group (95% CI, 6.1%–14.3%) versus 16.6% in the referent group (95% CI, 12.0%–22.1%). Patients in the sheepskin group developed new pressure ulcers at a rate less than half that of referent patients (rate ratio, 0.42; 95% CI, 0.26–0.67).Conclusions: The Australian Medical Sheepskin is effective in reducing the incidence of pressure ulcers in general hospital inpatients at low to moderate risk of these ulcers.

Damien J Jolley MSc(Epi), MSc · Robyn Wright RN, GradDipAppSci(SM) · Sunita McGowan RN, MAppSci · Mark B Hickey BAppSci(Hons) · Kenneth C Montgomery BSc, PhD · Don A Campbell MD, MMedSci(ClinEpi) · Rodney D Sinclair FACD

All women and men with a history of fragility fractures should be considered for treatment of osteoporosis to reduce their risk of future fracture. There is high-level evidence for the anti-fracture efficacy of treatment in women with osteoporosis, particularly if there is prevalent fracture; the evidence is less compelling for women with osteopenia, with or without a fracture, and for men. The rigorously investigated drugs reported to reduce vertebral fractures are the bisphosphonates alendronate and risedronate, the selective oestrogen-receptor modulator raloxifene, the anabolic agent parathyroid hormone and, most recently, strontium ranelate. Only the two bisphosphonates and hormone replacement therapy (HRT) have been reported to reduce hip fractures in community-dwelling women, and calcium plus vitamin D and hip protectors have been reported to reduce these fractures in elderly people in institutions. HRT is not recommended in women for fracture risk reduction alone. Evidence for the anti-fracture efficacy of calcitonin, fluoride, anabolic steroids and active vitamin D metabolites is insufficient to justify their use; lifestyle changes, while not shown to reduce fracture risk, may have a role in maintaining bone strength throughout life.

Ego Seeman BSc, FRACP, MD · John A Eisman FRACP, PhD

Keri Lockwood,* Ian D Cameron,† Susan E Kurrle‡ * Coordinator, Hip Protector Studies Unit; ‡ Director, Rehabilitation and Aged Care Service, Hornsby Ku-ring-gai Hospital, Hornsby, NSW; † Head, Rehabilitation Studies Unit, University of Sydney, PO Box 6, Ryde, NSW 1680. iancATmail.usyd.edu.au To the Editor: Hip protectors may be an effective means of preventing hip fracture in residents of aged-care facilities, if there is adequate compliance with their use.1 Research studies conducted in the Northern Sydney and Illawarra health regions2,3 have found that, if a hip protector is worn at the time of a fall, the chance of hip fracture is reduced by about 80%. We wished to determine the extent to which hip protector use had become a routine part of healthcare in residential aged-care facilities generally, and whether there was a greater uptake of their use in areas where the research had been conducted. A brief questionnaire about hip protector use was sent to all residential aged-care facilities in the Northern and South Eastern Sydney health regions, and the region covered by the New South Wales Southern Area Health Service. The response rate was 60% in each region, and responses are summarised in the Box. Only 30 residential aged-care facilities participated in the previous study, and the results indicate that use is now much more widespread. Another contrast is that, in the research study, hip protectors were provided free of charge, whereas most current users pay for hip protectors. Overall, the survey indicates that 61% of aged-care facilities across three regions of NSW are either using hip protectors or have used them in the past. Hip protector use was similar in Northern Sydney and Southern NSW; however, comparing Northern Sydney (where previous research had been conducted) with the other two regions combined showed a greater prevalence related to conducting previous research. Issues such as cost, laundering of the hip protectors, and comfort are seen as major barriers to their use, but many aged-care facilities continue to use them for selected residents at high risk of hip fracture. It is our impression that the more residents within a facility who wear hip protectors, the better the adherence to hip protector use and the management of these issues. It is also evident that hip protector research encourages use of hip protectors. We are unsure of the mechanism involved, but believe that knowledge and enthusiasm for use of hip protectors is spread by word of mouth between health professionals, staff working in nursing homes and hostels and, in some cases, through relatives of the residents of residential aged-care facilities. Hip protector use in residential aged-care facilities in three health service regions of New South Wales Region (no. of residential aged-care facilities) Any hip protector use* Northern Sydney (99) 74% South Eastern Sydney (104) 43% Southern NSW (35) 75% * χ2 = 7.5, df = 1, P = 0.006 for comparison of frequency of use in Northern Sydney with use in the other two area health services combined.

Keri Lockwood · Ian D Cameron · Susan E Kurrle

Osteoporosis is:

Tuan V Nguyen PhD · Jacqueline R Center PhD · John A Eisman MB BS, PhD

Clinical records Case 1: An 89-year-old woman was admitted to hospital from a nursing home with a 12-hour history of drowsiness, progressing to an unrousable state and inability to eat or drink. A low dose of long-acting morphine had been commenced 2 days earlier for painful arthritis. A capillary blood glucose (glucometer) reading taken in the nursing home on the morning of hospitalisation was 4.1 mmol/L. Past history included well controlled type 2 diabetes mellitus associated with corticosteroid use, for which she had been prescribed glimepiride 0.5 mg daily 2 months previously. The last dose was given on the morning of hospital admission. She was taking multiple other medications for comorbid conditions. The ambulance officers transporting her to hospital had recorded a “Lo” glucometer reading and administered 25 mL of 50% glucose. Within 5 minutes, a repeat glucometer reading was 14.7 mmol/L. On arrival at hospital the woman was opening her eyes and responding appropriately to pain, but not verbalising. Her Glasgow Coma Score was 9/15. In emergency triage, a glucometer reading showed 4.8 mmol/L, but shortly afterwards her venous serum glucose concentration was 1.3 mmol/L and serum creatinine level was 0.19 mmol/L (normal range, 0.05–0.09 mmol/L). Results of a cerebral computed tomography scan were unremarkable. Over the next 15 hours, there were six more glucometer readings with levels < 3.5 mmol/L, including readings of 0.6 mmol/L and 1.8 mmol/L (18 and 27 hours after the last dose of glimepiride, respectively). Despite a total of 250 mL of 50% glucose in eight bolus doses and a 5% glucose infusion commenced at admission and continued throughout hospitalisation, her level of consciousness deteriorated. She died 18 hours after presentation. Case 2: A 79-year-old woman living in a nursing home had been discharged from hospital several days earlier after internal fixation of a fracture of the femoral neck. She was readmitted after a sudden deterioration, characterised by drowsiness, decreased response to questions and dyspnoea. Her past history included type 2 diabetes mellitus for 4 years, for which she was taking glibenclamide 2.5 mg twice daily, a dose which had not been changed for 3 years. Glucometer readings had ranged between 7 mmol/L and 9 mmol/L during her recent hospitalisation. Other major comorbidities included a dominant middle cerebral artery stroke resulting in persisting hemiplegia and dysphasia, atrial fibrillation, hypertension and congestive cardiac failure. Because of her multiple comorbidities she was taking numerous medications. A glucometer reading was not performed before transfer to hospital. In the emergency department, the woman was initially treated for pulmonary oedema and pneumonia, which were evident clinically and radiologically. Her venous serum glucose concentration was 0.6 mmol/L and her serum creatinine level was 0.04 mmol/L (normal range, 0.05–0.09 mmol/L). Over the ensuing 27 hours, five more glucometer readings were < 3.5 mmol/L, including one of 0.7 mmol/L, and another of 2.3 mmol/L (24 and 36 hours after the last dose of glibenclamide, respectively). In total, she required 300 mL of 50% glucose in six bolus doses and a 5% glucose infusion for 48 hours. Over the ensuing days, her condition improved and she was able to take a purée and thickened fluid diet. One week after presentation, she appeared to vomit and aspirate while eating, and suffered an asystolic cardiac arrest from which she could not be resuscitated. Sulfonylureas act by stimulating insulin secretion from the pancreas and augmenting glucose-stimulated insulin secretion. Some, such as glibenclamide and glimepiride, are long acting and have metabolites that are excreted renally. Others, such as gliclazide and glipizide, are shorter acting and do not have active metabolites.1 Hypoglycaemia is the major risk associated with the use of sulfonylureas, particularly in elderly people. Serious hypoglycaemia is usually defined as that causing death, or requiring hospitalisation or emergency department admission. The rate is probably between 1% and 2% per year.2 Previous reports suggest, and the cases described here demonstrate, that this may occur even with very low doses of a sulfonylurea. The resultant hypoglycaemia can be prolonged and recur for a period of more than 24 hours despite treatment. Case fatality rates of 4%–10% are reported and 5% of survivors may have permanent neurological impairment.3 In elderly people, the classical autonomic adrenergic symptoms and signs of hypoglycaemia may not be present (or evident), and neuroglycopenic features, such as drowsiness or confusion, may dominate the picture (as in the cases described), so the diagnosis can be easily missed.4 Elderly patients with these symptoms who are taking medication for hypoglycaemia need immediate (and repeat) measurement of blood sugar level (BSL). If the BSL is low and the patient is alert and able to swallow, oral carbohydrate loading is the preferred management regimen — otherwise an ambulance should be called and the patient transported to hospital as a matter of urgency. While 10–25 g of carbohydrate delivered in 50% glucose is essential to restore the patient to euglycaemia in the short term, in the presence of sulfonylurea it stimulates more insulin secretion by the pancreas, and therefore can contribute to recurrent hypoglycaemia. The 50% glucose bolus should be followed immediately by an infusion of 5% or 10% glucose, usually at a rate of 100–200 g of carbohydrate daily, and BSL should be monitored for at least 24 hours. Subcutaneous synthetic somatostatin analogues may be used to reduce the likelihood of rebound hypoglycaemia and reduce glucose requirements, but there is no role for glucagon in the management of sulfonylurea-induced hypoglycaemia.5 Numerous studies show that longer-acting sulfonylureas are associated with a higher risk of hypoglycaemia, including serious hypoglycaemia. Gliclazide and glipizide have been shown to cause less hypoglycaemia than glibenclamide, and one study also suggested that glimepiride was safer than glibenclamide.6-9 There are no published reports comparing glimepiride directly with gliclazide or glipizide for hypoglycaemia. Other risk factors for hypoglycaemia, evident in the cases described here, include advanced age, recent hospitalisation, multiple medications, and drug accumulation caused by renal or hepatic impairment (keeping in mind that renal function usually declines linearly with age). Medication changes, including an increase in hypoglycaemics while a patient is unwell in hospital, may not be adequately communicated to the patient’s general practitioner, and recent hospitalisation is perhaps the major risk factor for sulfonylurea-induced hypoglycaemia. The presence of any of these risk factors should affect the choice and dose of medication and increase vigilance in monitoring BSL and renal function. In conclusion, the above cases serve to remind us of the dangers of long-acting sulfonylureas, which should perhaps be avoided in elderly people. Shorter-acting sulfonylureas such as gliclazide and glipizide are safer options. Elderly patients with altered mentation taking sulfonylureas require an urgent BSL measurement and, if they are unable to take food or fluids orally, they should be referred to hospital promptly. Lessons from practice Long-acting sulfonylureas, such as glibenclamide (and perhaps glimepiride) should be used with extreme caution in frail elderly people. Recent hospitalisation is a major risk factor for sulfonylurea-induced hypoglycaemia and necessitates increased vigilance in monitoring the patient’s condition and blood sugar levels. The classical adrenergic features of hypoglycaemia may be absent (or not evident) in frail elderly people. Drowsy or confused elderly patients taking sulfonylureas should have their blood sugar level measured urgently. Once sulfonylurea-induced hypoglycaemia is confirmed, oral carbohydrate loading is the preferred management regimen in alert patients, but those unable to take oral food or fluids should be transferred to hospital as a matter of urgency. Even with low-dose sulfonylurea therapy, hypoglycaemia can be severe, prolonged and recurrent over at least 24 hours.

Peter C Veitch MB BS, FRACP · Rory J Clifton-Bligh MB BS, PhD

A palliative care approach has much to offer people in the advanced stages of neurodegenerative diseases, as well as elderly people dying from diseases other than cancer. Palliative care can be part of the treatment repertoire of any health worker, supported by intermittent consultation or referral to specialist palliative care services (eg, for management of neuropathic pain). A palliative care approach encourages a focus on pain and symptom management, and prompts more open communication about end-of-life issues. This approach recruits as necessary the expertise of specialists and multidisciplinary teams to encourage a flexible, responsive service. Home carers and healthcare providers require education to ensure a palliative approach that meets the physical, psychological, spiritual and social challenges facing patients and their families, and enhances dignity and quality of life.

Linda J Kristjanson PhD · Christine Toye PhD · Sky Dawson MSc

The majority of older people remain in good health until a relatively short period before their death. Most of those who acquire chronic illness tend to have only mild to moderate disability and are not dependent on others for life’s basic tasks. Common chronic diseases associated with mild disability include arthritis, hypertension, ischaemic heart disease and diabetes mellitus. However, the minority of older people who have chronic illness associated with severe disability have a large impact on our healthcare and welfare systems. Depression, Alzheimer’s disease and other dementias, stroke with residual disability, and various progressive neurological disorders contribute greatly to the overall burden of disability experienced by our society. Although circulatory, neoplastic and respiratory diseases are the most common causes of death, nervous-system disorders contribute the greatest proportion of years of life lost to disability in the older population.1 Disability-adjusted life-years (DALYs), which combine the effects of shortened life expectancy and years lost to disability, enable an assessment of the overall burden of illness. In terms of DALYs, ischaemic heart disease and stroke rank first and second, respectively, in both sexes, followed by lung cancer in men and dementia in women.1 While the experience of chronic illness is different for each individual, its impact may be experienced in two broad dimensions, depending on the nature of the illness and the type of disability it produces. The patient may experience predominantly somatic symptoms, such as dyspnoea, pain, weakness, lethargy or nausea. The resulting discomfort interferes with enjoyment of life. Many people with conditions such as cardiac, respiratory and neoplastic disorders may remain relatively independent, at least in the confines of their own home, until late in the progression of the illness. However, they live with the constant threat of exacerbation and associated visits to hospital, and uncertainty about their life expectancy. Our challenge with these patients is to ameliorate distressing symptoms, halt progression of the disease, and prevent complications and unnecessary hospital admissions. On the other hand, the patient experience may be dominated by disability and handicap. Patients in this situation become distressed by their lack of independence in various life skills, which ultimately reduces their ability to survive in their “usual” living environment. Chronic conditions such as stroke and degenerative neurological disorders cause profound disturbances of personal functioning that increase as the illness progresses, such that dependence on others becomes continuous. Basic tasks such as walking, bathing, dressing and feeding become impaired. The situation is exacerbated by the presence of cognitive dysfunction. Ultimately, survival at home is dependent on the support of family members, often with the assistance of community services. It is these illnesses that drive the demand for nursing home places. Some 70% of residents of nursing homes have moderate to severe cognitive impairment. These clinical scenarios highlight the predicament that faces all societies as the proportion of older people increases. With smaller families, and greater numbers of people entering old age either divorced or never married, there is a considerable challenge to provide the care that is so vitally needed. The paucity of family-member carers will be accompanied by declining numbers of people in the workforce. Similarly, the number of taxpayers who provide funds for care will decline in relation to those requiring it.2 Ultimately, the challenge will be to minimise the period of discomfort and dependence on others towards the end of life. This will require advances in prevention, management of disability and technology to reduce the reliance on others. It will also require robust social service support networks and public utility infrastructure that are sensitive to the needs of elderly people and provide adequate high-quality residential care for people who can no longer live independently.

Leonard C Gray PhD FRACP · Ian A Scott FRACP MHA MEd

Clinical records Patient 1 An 88-year-old man gave a 12-month history of seeing insects attacking his legs and crawling along the floor of his house. He described these insects as 4 cm long, black and white bugs with beaks, which pecked at his legs, causing wounds. He often felt a sharp stinging sensation heralding their presence. He also had burning pain in both legs below the knees. He had had his house fumigated twice in the previous year and put various chemicals across his doorways and bed to ward off the bugs. He described no other hallucinations or delusions. He was not using any regular medications and had never been a consumer of alcohol. He lived alone and managed all activities of daily living independently. His home was clean, and he had no pets. Score on Folstein Mini Mental State Examination was 28/30. Neurological examination revealed signs of peripheral neuropathy of the lower limbs. His visual acuity was poor. During the examination, he pointed to several “bugs” on his legs, which were actually pieces of skin peeling from superficial ulcers. Nerve conduction studies confirmed peripheral neuropathy. Computed tomography and magnetic resonance imaging of the brain showed ischaemic changes. Magnetic resonance angiography showed severe stenosis of the left internal carotid artery. Septic screen and serological tests for syphilis gave negative results. The patient’s symptoms were thought to be due to neuropathic pain. He was prescribed carbamazepine (100 mg twice daily) to alleviate the sensory stimuli, and risperidone (0.5 mg in the morning, 1 mg at night). After 2 weeks, the pain and delusions had decreased substantially. Diagnosis: Delusional parasitosis associated with medical conditions — neuropathy and poor visual acuity. Patient 2 A 72-year-old woman had a 20-year history of the delusion of worms crawling throughout her body, especially around a scar on her hip. She was convinced that the scar should be surgically explored. Past medical history included type 2 diabetes mellitus, normal pressure hydrocephalus with shunt insertion, ischaemic heart disease and fractured right neck of femur. She lived in a hostel. Her cognition was normal, and clinical examination found no abnormalities. She was treated briefly with thioridazine (40 mg daily), which provided some benefit but caused drowsiness. She was then treated with pimozide (2 mg twice daily), which was changed to olanzapine (2.5 mg in the morning, 5 mg at night) because of continuing agitation, paranoid ideation about her neighbours and “intruders”, and aggression to neighbours and hostel staff. Her symptoms decreased but did not resolve, and compliance was poor. Diagnosis: Paranoid schizophrenia with major psychotic symptom related to infestation. Patient 3 An 81-year-old woman was referred with a persistent belief that she had scabies and lice infestation of her eyes, nose, arms and anus. This resulted in her persistently washing her clothes and herself and reporting the retirement village where she lived to the Health Department. She had received anti-scabies treatment empirically. She had a long history of severe depression after the death of her husband, for which she took doxepin. She had paranoid ideation about her neighbours and saw things crawling down the walls, and had moved residences several times to avoid these problems. Other medical problems included treated hyperthyroidism, oesophageal stricture and partial pneumonectomy. She did not drink alcohol. Score on Folstein Mini Mental State Examination was 28/30. She was prescribed haloperidol (0.5 mg twice daily) and continued taking doxepin. The delusions of scabies subsided. Four years later, she developed new thoughts that dirt was being deposited in her unit by builders working nearby. She had stopped taking haloperidol in the interim. She became agitated, covering her furniture and closing all gaps around doors and windows. She was prescribed olanzapine (2.5 mg at night). Diagnosis: Delusional parasitosis in conjunction with depressive illness. Patient 4 A 74-year-old woman was referred for assessment of tactile hallucinations. She had a 2-month history of presumed worm infestation and persistent complaints of anal and vaginal pruritus despite multiple courses of an anthelminthic. She had complained previously of feeling head and body lice. Her past medical history included chronic airways limitation, trigeminal neuralgia, which was treated with sodium valproate, and temporal arteritis, which had responded previously to corticosteroid therapy. She lived alone and was previously active, but had became depressed and isolated because of these delusions. No abnormalities were found on physical examination. Examination of a skin specimen, which the patient thought contained worms, showed cotton threads. Full blood count was normal, with no eosinophilia and normal erythrocyte sedimentation rate. Sigmoidoscopy found no abnormalities, while computed tomography of the head showed a previous left parietal infarct. She was prescribed pimozide (2 mg daily), with complete resolution of the worm sensation. Diagnosis: Isolated delusional parasitosis. An older person requesting treatment for an infestation may not seem unusual. However, when the complaint persists despite repeated treatments for lice, scabies and other parasites, and examination shows no evidence of an infestation, the differential diagnosis includes delusional parasitosis. Management of this condition is challenging but rewarding, as it may cause severe emotional, social and physical disability in both the afflicted individuals and those around them. We describe four patients with delusional parasitosis who were managed in our department of geriatric medicine (see Clinical records). Delusional parasitosis, named in 1946,1 is a chronic psychiatric disorder in which patients have a false and fixed belief that they are infested by parasites. It is not a phobia.2 The core of the disease is the delusion of infestation and, although it is a psychiatric disorder, patients usually seek help from dermatologists. Its onset is insidious, and the delusion is typically preceded by a primary tactile experience, such as pruritus or paraesthesia, or tactile hallucination, which precipitates the secondary delusion of infestation. The condition may occur as an isolated thought disorder in a person whose psyche is otherwise intact, as illustrated by Patient 4. This has also been termed monosymptomatic hypochondriacal psychosis3 and “primary” delusional parasitosis.4 When associated with a psychiatric condition, such as schizophrenia (Patient 2) or depression (Patient 3), delusional parasitosis has been termed “secondary functional”, and, when caused by a medical illness (eg, diabetes, malignancy or nutritional deficiency), medication or substance misuse, it has been termed “secondary organic”5 (Patient 1). In the classification system of the Diagnostic and statistical manual of mental disorders (DSM-IV), primary delusional parasitosis corresponds to “delusional disorder, somatic type”, while the secondary organic type corresponds to “psychotic disorder due to general medical condition”.6 The prevalence of delusional parasitosis is unknown, but our literature review identified several hundred cases reported by dermatologists and entomologists.2,3,5,7,8 It can occur at any age, the average being in the fifth decade. In the older age group, women are more often affected than men.2,7 Mean duration of symptoms before attending tertiary care was 1.3 years in one study.8 Patients with no precipitating medical problems or psychiatric illness often have a personality disorder and isolate themselves, but function well in other aspects of their day-to-day living.3 Patients provide incredibly detailed descriptions of the “bugs” and explanations about why they are not visible on examination. They often bring in “specimens” in a small container, which are actually pieces of skin, lint or hair (“the matchbox sign”), or may identify “bugs” during examination by probing into skin until they are able to pick up a small piece of tissue. This may produce traumatic ulcers of varying size, typically on areas the patient can reach, in an asymmetrical distribution corresponding to the dominant hand. Secondary dermatitis may develop as a result of repeated washing and application of chemical preparations.2 Management involves first excluding a real infestation and any underlying condition, including psychiatric disorders, medical conditions with altered sensation, use of drugs (prescribed and illicit) or withdrawal from alcohol or cocaine. Mental state, including cognition, needs to be assessed. Other investigations may include examination of skin scrapings and skin biopsies. In therapy, the most important step is to establish a trusting doctor–patient relationship. An empathic approach is required, acknowledging the reality of patients’ symptoms without challenging or confirming their views about the cause. Samples of any alleged parasites presented must be examined. Ideally, patients should be referred to a psychiatrist, but many resist this. Consequently, medication with an antipsychotic should be initiated by the doctor who makes the diagnosis. Treatments include pimozide2,3,5,7 and the newer atypical antipsychotics, such as risperidone.9 Medication compliance can be a problem. There have been some reports that tricyclic antidepressants and anxiolytic agents alleviate the reactive component of the condition without much effect on the delusions.2,7 Doxepin has strong antihistamine and anxiolytic effects, in addition to its antidepressant effect, and, based on its effectiveness in chronic neurotic excoriation,10 may be useful in patients who frequently experience intense pruritus, anxiety and agitation as well as depressive symptoms. Corticosteroid creams and lotions may be helpful adjuncts to alleviate skin symptoms. Lessons from practice Delusions of parasitosis may occur alone or in association with medical or psychiatric illness. Antipsychotic agents are the mainstay of medical management. Empathy and a good doctor–patient relationship are required to optimise outcome.

Linda Le BM BS, DCH · Peter N Gonski BMedSc, FRACP

Objectives: To provide detailed projections for the prevalence of disability and associated common health conditions for older Australians for the period 2006–2031.Design: Secondary analyses of datasets (national 1998 Survey of Disability, Ageing and Carers; and projections of Australia’s population from 2006–2031) collected by the Australian Bureau of Statistics.Outcome measures: (i) The projected number of people with differing levels of disability (core activity restrictions in self-care, mobility or communication) up to 2031; (ii) The projected number of people with the main health conditions associated with disability in 2006 and 2031.Results: Projections indicate a 70% increase in the number of older people with profound disability over the next 30 years. The main conditions associated with profound or severe core activity restriction in older Australians are musculoskeletal, nervous system, circulatory and respiratory conditions and stroke.Conclusions: In the future, there will be many more older Australians requiring assistance because of disability. This will present a challenge to families, friends, volunteers and paid service providers. The Australian planning ratio for residential aged-care services and community aged care services should be changed to take account of the shift to an older population with greater need of support.

Lynne C Giles MPH, AStat · Maria Crotty PhD, FAFRM (RACP) · Ian D Cameron PhD, FAFRM (RACP)

Objectives: To assess the use of evidence-based investigations and treatments in patients with acute stroke in selected Australian hospitals and to compare management and outcomes between stroke and other types of hospital specialty unit.Design: Retrospective, multicentre audit of hospital case files.Setting: Eight metropolitan tertiary-care hospitals from five Australian States.Subjects: 300 consecutive patients from each hospital admitted between 17 September 1999 and 23 May 2001 and having a discharge diagnosis of stroke or transient ischaemic attack.Main outcome measures: Use of investigations and treatments supported by best available evidence; comparison of management and outcomes between stroke, neurology, general medical and geriatric units.Results: 2383 patients were audited (median age, 72.7 years; 52% men); 72% had ischaemic events, and 28% haemorrhagic events. Use of investigations and treatments varied between hospitals and types of unit. Stroke units or teams cared directly for 23% of patients (range across hospitals, 0–100%). Although 47% of patients with ischaemic events presented within 3 hours of symptom onset (when thrombolysis might provide benefit), only nine (2%) received thrombolysis. Angiotensin-converting enzyme (ACE) inhibitors were given to 28% of survivors at discharge (range, 14%–38%). Stroke units were more likely to use diagnostic tests, while neurology units were more likely to prescribe heparin acutely for patients with ischaemic stroke (not recommended for patients in general), and geriatric units were less likely to discharge patients with atrial fibrillation on anticoagulation therapy. Outcomes also varied significantly between types of unit. In-hospital survival rates were 90% (stroke units), 91% (neurological units), 82% (general medical units) and 79% (geriatric units) (P < 0.001). Stroke units and neurological units sent more patients home than the other units. Stroke units also sent fewer patients to rehabilitation and had longer mean length of stay.Conclusions: Acute stroke care varies between Australian tertiary-care hospitals and types of specialty unit, with suboptimal use of many evidence-based interventions.

Brendan K Duffy MD · Paddy A Phillips DPhil, FRACP, FACP · Stephen M Davis MD, FRACP · Geoffrey A Donnan MD, FRACP · Miriam E Vedadhaghi BSc, PGDipNutrDiet

Objective: To evaluate the benefits of coordinating community services through the Post-Acute Care (PAC) program in older patients after discharge from hospital.Design: Prospective multicentre, randomised controlled trial with six months of follow-up with blinded outcome measurement.Setting: Four university-affiliated metropolitan general hospitals in Victoria.Participants: All patients aged 65 years and over who were discharged between August 1998 and October 1999 and required community services after discharge.Interventions: Participants were randomly allocated to receive services of a Post-Acute Care (PAC) coordinator (intervention) versus usual discharge planning (control).Main outcome measures: Comparison of quality of life and carer stress at one-month post-discharge, mortality, hospital readmissions, use of community services and community and hospital costs over the six months post-discharge.Results: 654 patients were randomised, and 598 were included in the analysis (311 in the PAC group and 287 in the control group). There was no difference in mortality between the groups (both 6%), but significantly greater overall quality-of-life scores at one-month follow-up in the PAC group. There was no difference in unplanned readmissions, but PAC patients used significantly fewer hospital bed-days in the six months after discharge (mean, 3.0 days; 95% CI, 2.1–3.9) than control patients (5.2 days; 95% CI, 3.8–6.7). Total costs (including hospitalisation, community services and the intervention) were lower in the PAC than the control group (mean difference, $1545; 95% CI, $11–$3078).Conclusions: The PAC program is beneficial in the transition from hospital to the community in older patients.

Wen K Lim FRACP · Sue F Lambert PhD, BEcons · Len C Gray PhD, FRACP

Objectives: To evaluate a Framingham risk function for coronary heart disease in an elderly Australian cohort and to derive a risk function for cardiovascular disease (CVD) in elderly Australians.Design and setting: Analysis of data from a prospective cohort study (the Dubbo Study) in a semi-urban town (population, 34 000).Participants: 2805 men and women 60 years and older living in the community, first assessed in 1988, and a subcohort of 2102 free of CVD at study entry.Main outcome measures: Incidence of CVD (myocardial infarction, coronary death or stroke) over 5 and 10 years.Results: A Framingham risk function assessing "hard" coronary heart disease (ie, myocardial infarction or coronary death) accurately predicted 10-year incidence in men and women aged 60–79 years who were free of prevalent CVD or diabetes at study entry. In a multiple logistic model, CVD incidence was significantly predicted by age, sex, taking antihypertensive medication, blood pressure, smoking, total cholesterol level and diabetes. For a given age and cholesterol level, CVD risk over 5 years was doubled in the presence of antihypertensive medication or diabetes, increased by 50% with cigarette smoking, and halved in women compared with men.Conclusions: We have derived a simple CVD risk function specifically for elderly Australians that employs risk factors readily accessible to all medical practitioners.

Leon A Simons MD, FRACP · Judith Simons MACS · Latha Palaniappan MD, FACP · Yechiel Friedlander PhD · John McCallum DPhil

Counseling the Alzheimer's caregiver: a resource for health care professionals. Mary S Mittelman, Cynthia Epstein and Alicia Pierzchala. Chicago: AMA Press, 2002 (vii + 346pp). ISBN 1579472621. This is an excellent book for staff, researchers or policy makers whose business it is to assist people with dementia and their families. The book amply lives up to its subtitle — it is the best practical guide I have seen for workers in the field, who often struggle to support dementia caregivers through the myriad problems they have to face. Theoretical topics are vividly brought to life with clinical vignettes, and the book is well written and easy to navigate, with a short index that I could not fault. There is plenty of advice about most problems likely to be encountered during the long ‘career’ of someone with dementia — from early diagnosis to death. There is a guide for staff to assess caregiver needs, covering topics such as changes in relationship roles, unsafe driving, problem behaviours and the need for services such as nursing home care. Other family members are included in the approach advocated by the authors, and there is an emphasis on empowering caregivers and their families to solve future problems, with support from the professional counsellor when necessary. The breadth of approach is illustrated by interesting topics such as “the caregiver’s role in hospital”. Here, caregivers are advised how to deal with hospital staff in a tactful manner while negotiating the hazards of a hospital stay. These authors, from the United States, advocate a thorough approach to caregiver support that surely is rarely achieved in Australia or, for that matter, in most of the world. They prescribe a number of education and counselling sessions with the caregiver alone, then with the caregiver and other family members. Caregivers can access a counsellor at any time to deal with new problems. In a landmark clinical trial, this expensive-sounding program led to improved caregiver wellbeing and impressive delays in subsequent admissions to nursing homes. Although economic studies have not yet appeared, this program may well be cost-effective. It is somewhat sobering to ponder on the enormous gap between what is possible to help dementia sufferers and their families and what actually occurs in Australia, where dementia care remains fragmented and crisis driven. Nevertheless, the book provides adequate detail to assist policy makers, and the practical guidance should prove invaluable to all involved in dementia care. I strongly recommend it. David G BruceProfessor Department of Community and Geriatric Medicine Fremantle Hospital, Fremantle, WA

David G Bruce

Practical guide to geriatric medicine. Ranjit N Ratnaike (editor). Sydney: McGraw-Hill, 2002 ($109.95, xxv + 958 pp). ISBN 074710338. The elderly consume an increasing amount of the health care dollar, hospitals are under pressure to discharge patients early and, increasingly, care is provided in the community. For these reasons Practical guide to geriatric medicine is a useful addition to the reference library of any general practitioner, general physician or geriatrician. The book comprehensively covers a wide range of topics relevant to the clinical care of the elderly. It has a lot of practical tips on the management of common problems such as psychiatric illness, neurological disorders and dementia, and includes lots of relevant validated screening tools. Whole-body systems are well covered, with an emphasis on screening and prevention. The chapter authors are experts from various international backgrounds and almost half are Australian. This balance is a bonus, as it ensures that the information is relevant to clinical practice in Australia. For example, there is a chapter on the functional assessment of the over-75-year-old as part of the enhanced primary care package. For the academically minded reader it would have been helpful to cross-reference the text with the bibliography and further reading references that appear at the end of each chapter. This book is well written and easy to read, with a wealth of useful information. The presentation is excellent, with paragraph headings and useful tables, as well as figures highlighting the important points. It is excellent value for money and highly recommended for the busy clinician. George SzonyiGeriatricianBalmain Hospital, NSW Order this book

George Szonyi