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Octogenarians can benefit from spinal surgery
PATIENTS aged 80 years and older with lumbar stenosis, with or without degenerative spondylolisthesis, had substantial improvements in all patient-reported health measures after undergoing spinal surgery compared to those who had non-operative treatment, according to research published in the Journal of Bone and Joint Surgery. The research was based on 105 patients aged at least 80 years and 1130 patients younger than 80 who had neurogenic claudication or radicular leg pain with associated neurological signs, spinal stenosis on imaging, pain that persisted for at least 12 weeks and physician confirmation that they were a surgical candidate. In the 80 years and older group 58 patients (55.2%) underwent surgery, which included decompression alone in 68% of patients, non-instrumented arthrodesis in 14% and instrumented arthrodesis in 18%. Primary and secondary outcomes were measured over 4 years. Improvements in all primary outcome measures from baseline were significantly greater in the older patient operative group, particularly in bodily pain score, physical function and disability, than in the older non-operative group. However, the treatment effect was significantly smaller in the older group than in the younger patients. The researchers wrote that within-group comparisons of preoperative and postoperative data in patients aged at least 80 years showed that the operative treatment of lumbar stenosis with or without degenerative spondylolisthesis offered patients “a substantial benefit over nonoperative treatment”. Further studies were needed to determine if such procedures were also “truly cost-effective in this elderly and retired population”.
“Alarming” increase in symptoms at end-of-life
US research published in Annals of Internal Medicine shows that despite national efforts to improve end-of-life care, proxy reports of pain and other alarming symptoms in the last year of life increased between 1998 and 2010. The researchers used data from 7204 community-dwelling adults aged 51 years and older who died while enrolled in a nationally representative longitudinal survey to analyse trends in pain intensity and symptom prevalence. After each participant’s death, a proxy informant (typically a family member) was interviewed about symptoms in the participant’s last year of life. Mean age at death was 79.1 years and 54% were women. Cancer was reported in 22% of participants, 33% had chronic heart failure or chronic lung disease, 16% were frail and 16% died suddenly, while 14% reported none of these categories. About 50% were reported to have had moderate or severe pain, depression, periodic confusion, dyspnoea, or incontinence; about 60% were reported to have had any pain, severe fatigue, or anorexia; and about 12% were reported to have had frequent vomiting. Over the study period, proxy reports of many symptoms increased in prevalence by 11.9%, including for pain, depression and periodic confusion. However, there were no significant changes in individual symptoms prevalence in cancer patients. “Proxy reports of worsening symptom prevalence raise concerns about shortcomings in end-of-life care despite increasing national attention and resources devoted to it”, they wrote. The researchers speculated that increased attention to end-of-life care in general and symptoms specifically could have resulted in the increase in proxy reporting. “Given our knowledge of best practices and continued gaps in applying them, there is an urgent need to benchmark current practice against current knowledge”, they wrote.
Death risk higher in women than men with type 1 diabetes
INTERNATIONAL researchers, including from Australia, have found that women with type 1 diabetes have a 37% greater excess risk of all-cause mortality, and twice the excess risk of fatal and non-fatal vascular events, compared with men with the disease. The systematic review and meta-analysis of 26 studies including 214 114 individuals and 15 273 deaths, published in The Lancet Diabetes & Endocrinology, found the pooled women-to-men ratio of the standardised mortality ratio (rSMR) for all-cause mortality and incident stroke was 1.37, for fatal renal disease was 1.44, and for fatal cardiovascular diseases was 1.86. The authors wrote that for incident coronary heart disease the sex difference was more extreme; with an rSMR of 2.54. The authors wrote that the results showed “a significant and clinically meaningful sex difference exists” in the excess risk of mortality, particularly vascular mortality for type 1 diabetes “to the detriment of women”. They said the findings added to accumulating evidence that suggested a greater adverse effect of hyperglycaemia and diabetes on vascular risk in women than in men. They speculated that the excess vascular mortality could be due to women having an overall greater cumulative lifetime exposure to hyperglycaemia because of poorer glycaemic control compared with men, as previous studies had shown notable sex differences in diabetes control. “Ultimately, an increased understanding and appreciation of sex differences in the effect of type 1 diabetes on vascular-related disease is likely to have profound clinical implications for how women with type 1 diabetes are treated and managed throughout their life course”, the researchers concluded. An accompanying commentary called for additional expenditure for patients with type 1 diabetes, saying “additional investment in the services and equipment to improve glycaemic control must start now”.
Non-drug interventions reduce delirium and falls
MULTICOMPONENT non-drug interventions for delirium are effective in reducing delirium incidence and preventing falls in older hospitalised patients, according to research published in JAMA Internal Medicine. The meta-analysis pooled the outcomes of delirium incidence, falls, length of stay and institutionalisation from 14 interventional studies involving 4267 patients (average age 79.7 years) in acute medical and surgical wards, and involved 12 unique interventions. The authors said the interventions to target delirium risk factors included reorientation, early mobilisation, therapeutic activities, hydration, nutrition, strategies to improve sleep, and vision and hearing aids. The authors found that, overall, 11 studies showed significant reductions in the incidence of delirium, decreasing by 44% in four randomised or matched clinical trials. The rate of falls decreased among patients in four studies, and in two randomised or matched trials reduced by 64%. The authors wrote that the effect on fall prevention was “a novel and important finding”. “Because delirium is the leading contributor to hospital falls, prevention of falls with these interventions is a consistent and compelling result”, they wrote. Length of hospital stay and institutionalisation was also decreased in intervention groups, but the difference was not statistically significant. The authors wrote that the results demonstrated these interventions “decrease the substantial health care and societal burden of delirium incidence and falls, improving quality of life for these patients and their families”. However, an accompanying commentary said changing practice in the acute care setting was a difficult process, and the key to the effectiveness of these interventions was convincing hospitals and health care professionals to apply them consistently.
Nutrition supplement improves pressure ulcer healing
AN oral supplement containing arginine, zinc and antioxidants improves the healing of mild to severe pressure ulcers (PU) in malnourished adult patients in long-term residential or home care, according to a study published in the Annals of Internal Medicine. Researchers conducted a randomised, controlled trial of the 200 patients with mild to severe PU to assess the effectiveness of the experimental oral supplement. Patients were randomly allocated to receive either the energy-dense, protein-rich oral formula or an equal volume of control formula for 8 weeks. All received wound care according to evidence-based guidelines. The authors found that at 8 weeks, the mean reduction in PU size in the experimental formula group was 60.9% compared with 45.2% in the control group. A total of 69.9% of patients in the experimental formula group had a 40% or greater reduction in PU healing compared with the control group, the authors wrote. “Our findings apply to long-term care residents and patients receiving home care services, and given the aging of populations, may have a large public health effect.” The authors said that the issue of cost-effectiveness needed to be addressed to support the use of the oral supplement. “Nutritional intervention should be considered an integral part of PU care”, the authors wrote.
Adolescent inequality on the rise
SOCIOECONOMIC inequality has increased across many domains of adolescent health, coinciding with the unequal distribution of wealth between rich and poor people, a study published in The Lancet has found. Researchers analysed the data of 492 788 adolescents, aged 11‒15 years, from 34 countries in North America and Europe who participated in the WHO Health Behaviour in School-aged Children study. The authors measured socioeconomic-related inequalities across five areas of adolescent health — physical activity, body mass index, psychological symptoms (irritability, feeling low, feeling nervous, and difficulty sleeping), physical symptoms (headache, stomach ache, backache, and feeling dizzy, and life satisfaction). From 2002 to 2010, average levels of physical activity, body mass index Z score (zBMI) and life satisfaction rose slightly. However, the researchers found that inequalities between socioeconomic groups increased overall in physical activity, zBMI, psychological symptoms and physical symptoms. Only in life satisfaction did health inequality fall during the study period. Adolescents living in countries with greater income inequality were less physically active, had higher BMI scores and lower life satisfaction, and reported more psychological and physical symptoms, the authors wrote. They said the widening socioeconomic inequalities in adolescent health contrasted with the improvements seen for children, where there had been reductions in child poverty and inequalities in child health. “Research and policy attention is needed to continue monitoring of these trends and to develop and assess policy approaches to promotion of health and health equity in adolescents”, the authors wrote.