Ž. Background: The prevalence of chronic heart failure CHF rises with increasing age, from -1% in those below 65 years of age to ) 5% in those over 65 years of age and is a major cause of morbidity and mortality in older people. Recent European guidelines point to a major deficiency in our knowledge of how to treat diastolic chronic heart failure, and a lack of information on treatment for heart failure in the elderly in general. Aims: The aims of this trial are to assess the potential benefits of the ACE inhibitor perindopril to treat chronic heart failure in elderly people, in the absence of any major left ventricular systolic dysfunction. Subjects: One thousand people over the age of 70 years will be recruited into this study. Evidence of chronic heart failure will be confirmed by clinical criteria and echocardiography. Methods: Once a diagnosis of chronic heart failure has been confirmed, the patient will receive either perindopril or placebo in addition to their usual treatment. Death, and unplanned heart failure related hospitalisations, are the primary outcomes. Quality of life, as measured by the Guyatt questionnaire will be assessed at the beginning of the study and at 1 year. Sub-studies of this trial include a Ž . 6-min walking test and more detailed evaluation of ventricular function as assessed by echocardiography . Both parameters will be measured at 8 weeks and 1 year, and analysed against baseline data. Cognitive function in this group of patients will also be evaluated at baseline and 1 year.

Objective-To examine the reproducibility and responsiveness to change of a six minute walk test and a quality of life measure in elderly patients with heart failure. Design-Longitudinal within patient study. Subjects-60 patients with heart failure (mean age 82 years) attending a geriatric outpatient clinic, 45 of whom underwent a repeat assessment three to eight weeks later. Main outcome measures-Subjects underwent a standardised six minute walk test and completed the chronic heart failure questionnaire (CHQ), a heart failure specific quality of life questionnaire. Intraclass correlation coeYcients (ICC) were calculated using a random eVects one way analysis of variance as a measure of reproducibility. Guyatt's responsiveness coeYcient and eVect sizes were calculated as measures of responsiveness to change. Results-24 patients reported no major change in cardiac status, while seven had deteriorated and 14 had improved between the two clinic visits. Reproducibility was satisfactory (ICC > 0.75) for the six minute walk test, for the total CHQ score, and for the dyspnoea, fatigue, and emotion domains of the CHQ. EVect sizes for all measures were large (> 0.8), and responsiveness coeYcients were very satisfactory (> 0.7). EVect sizes for detecting deterioration were greater than those for detecting improvement. Conclusions-Quality of life assessment and a six minute walk test are reproducible and responsive measures of cardiac status in frail, very elderly patients with heart failure.

The prevalence of visual impairment among elderly patients admitted to hospital is unknown. This group of patients may be particularly at risk from poor vision which could jeopardise their independence. A prospective study of visual impairment and its aetiology in acute geriatric admissions assessed after the acute illness had settled was performed. Subjects were all patients aged 65 years or over, excluding those chronically confused, admitted to the Department of Geriatric Medicine at the Royal Liverpool University Hospital with an acute medical illness. After the acute illness had settled visual impairment, as defined by the American criteria (best acuity 6/18), was assessed on the ward with a Snellen chart read at 6 m using binocular vision and current glasses. Those patients identified with impaired vision on initial screening were formally assessed in the ophthalmology department to identify the cause. 200 patients were examined. 101 patients (50.5%) had impaired vision. In these patients, correctable refractive errors were present in 40%, cataract in 37% and senile macular degeneration in 14%. Of the 101 patients with impaired vision 79% had a reversible cause. Comparing these results with a recent study in the community showed a much higher incidence for patients admitted to hospital. There was a particularly high prevalence in those elderly patients who were admitted with falls (76%, p = 0.0003). In conclusion, elderly patients, especially those presenting with falls, admitted to hospital have a high prevalence of visual impairment. Visual impairment may be compounding or causing falls. Hence, screening the elderly ‘faller’ admitted to hospital for visual impairment may be beneficial to the patient and cost-effective as many of the causes are simply reversible.

Twenty four young (mean age 29-2 years, range [25][26][27][28][29][30][31][32][33][34][35] and 21 elderly (mean age 66-5, range 60-80) healthy subjects collected their urine in timed aliquots over 24 hours. The elderly subjects had been selected for their fitness by clinical and laboratory examinations and all lived independently at home. Sodium and potassium excretions were reduced in the elderly subjects compared with the young subjects, potassium excretion considerably so. This was despite similar 24 hour urine volumes and total solute excretion by both groups.The ratios of rates of excretion of water, electrolytes, and solutes during the night to the rates of excretion during the day were found to be higher in the elderly than the young subjects.Reduced day to night ratios of urinary excretion may be partly responsible for complaints of nocturia and sleep disturbance in elderly people. Introduction For many years it has been known that urine flow is lower at night than during the day in healthy subjects.' There is also an accompanying nocturnal reduction in electrolyte excretion.2 It has been speculated that reduction in urine flow at night in mammals may have evolved to permit undisturbed sleep.3Several studies of excretory rhythms in old patients have been reported.4-9 The first study was of patients in psychiatric hospitals4 5; the second of elderly patients in hospitals long term6; the third of nine patients in hospital, only two of whom were

Ageing is associated with reduction of grey matter volume and it is reported that the frontal lobes are preferentially affected. We have applied quantitative magnetic resonance spectroscopy (MRS), incorporating measurement of brain tissue water content and metabolite T(2) relaxation times, to determine absolute concentrations of the putative neuronal marker N-acetylaspartate (NAA), creatine (Cr) and choline (Cho) compounds in the frontal lobe of 50 male subjects aged between 20 and 70 years (10 per decade). The fractional brain water content (beta(MR)) did not change significantly as a function of age (r = 0.07, P = 0.65) and had a mean value of 81% (CV = 2%). The concentration (in millimoles per litre brain tissue) of NAA decreased significantly with age (r = -0.42, P = 0.003), with an overall decrease of 12% between the third and seventh decades. The concentrations of Cr and Cho did not change significantly with age. The interpretation of the age-dependent decrease in NAA concentration as reflecting either a reduction in neuronal volume, number or function is discussed.

Gait disturbance is common in patients with Alzheimer's disease (AD). The aim of this study was to analyse the clinical gait syndromes of patients with AD using Nutt's classification. Fifty-five patients who satisfied the NINCDS-ADRDA criteria for probable AD and 55 controls were recruited from a geriatric and a psychogeriatric unit. Patients with classical musculoskeletal or neurological syndromes causing gait disturbance were excluded. A standardized neurological examination was carried out in all subjects. Twenty-two (40%) patients and ten (18%) controls had a higher level gait disorder (p < 0.01). The pattern of gait disturbance in AD patients varied according to the stage of the disease. Cautious gait was the commonest gait disorder in AD patients with mild dementia, while frontal gait disorder was the commonest disturbance in patients with severe dementia. The prevalence of frontal release signs (gegenhalten or any primitive reflex) was highest among patients with frontal gait disorder.

Objective: To evaluate insulin resistance and systemic inflammation in older patients with systolic (SHF) or diastolic heart failure (DHF). Patients: 52 non-diabetic patients (. 70 and , 90 years old) with chronic heart failure (CHF) and hospitalised within the previous six months for heart failure were studied, together with a control group of older healthy volunteers (n = 26). On the basis of Doppler echocardiographic criteria patients were classed as having SHF (n = 27) or DHF (n = 25). Main outcome measures: Fasting glucose, insulin, C reactive protein, interleukin 6, and tumour necrosis factor a soluble receptor II (TNF-aSRII) concentrations were determined. Insulin resistance was estimated by the homeostasis model assessment (HOMA). Results: HOMA index (median, interquartile range) was higher in patients with DHF (1.77, 1.06-2.26) than in patients with SHF (0.97, 0.81-1.85) or healthy volunteers (1.04, 0.76-1.44; p = 0.01). After adjustment for body mass index, age, and use of angiotensin converting enzyme inhibitors, both groups of patients with CHF were more insulin resistant than were healthy volunteers (p = 0.02). C reactive protein, interleukin 6, and TNF-aSRII were all significantly (p , 0.001) higher in patients with DHF and SHF than in healthy volunteers. All markers of systemic inflammation were independently associated with the presence of clinical CHF. Conclusion: Insulin resistance and inflammatory activation are present in older patients with SHF and DHF.

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