Ethics of Preanesthesia Mandatory Laboratory Testing.

Some practices require mandatory preoperative laboratory testing for select patients presenting for anesthesia and surgery. Such mandatory preanesthesia laboratory testing has significant ethical implications related to informed consent and patient autonomy. Assumptions that a patient provides "presumed consent" by merely presenting for a test are flawed because such consents are often not informed and do not acknowledge patient autonomy.

The Evolution of the Ethical Guidelines of the American Society of Anesthesiologists.

In 1992, the American Society of Anesthesiologists Committee on Ethics was formed primarily to address the rights of patients with existing Do-Not-Resuscitate orders presenting for anesthesia. Guidelines written for the ethical management of these patients stated that such orders should be reconsidered-not rescinded-thus respecting patient self-determination. The Committee also rewrote the reigning Guidelines for the Ethical Practice of Anesthesiology by expanding its ethical foundations to reflect the evolving climate of ethical opinions.

Cost-Effectiveness of Antihypertensive Therapy in Patients Older Than 80 Years: Cohort Study and Markov Model.

Background: Blood pressure and antihypertensive treatment (AHT) generally increase with age, but there is uncertainty concerning the value of treatment at very advanced ages.

Objectives: To estimate the cost-effectiveness of AHT in people aged 80 years and older.

Methods: A Markov model compared AHT with no blood pressure treatment for prevention of cardiovascular disease.

Trajectory of Total Cholesterol in the Last Years of Life Over Age 80 Years: Cohort Study of 99,758 Participants.

Background: Epidemiological studies suggest that lower total cholesterol (TC) may be associated with higher mortality. This study aimed to evaluate whether a decline in TC before death might account for the association of TC with mortality over age 80 years.

Methods: Cohort study using primary care electronic health records of 99,758 participants aged 80-105 years from the UK Clinical Practice Research Datalink.

Longitudinal Trends in Hypertension Management and Mortality Among Octogenarians: Prospective Cohort Study.

The role of hypertension management among octogenarians is controversial. In this long-term follow-up (>10 years) study, we estimated trends in hypertension prevalence, awareness, treatment, and control among octogenarians, and evaluated the relationship of systolic blood pressure (SBP) ranges with mortality. Data were based on the English Longitudinal Study of Ageing (ELSA).

Kicking Back Cognitive Ageing: Leg Power Predicts Cognitive Ageing after Ten Years in Older Female Twins.

Background: Many observational studies have shown a protective effect of physical activity on cognitive ageing, but interventional studies have been less convincing. This may be due to short time scales of interventions, suboptimal interventional regimes or lack of lasting effect. Confounding through common genetic and developmental causes is also possible.

Drug therapies in older adults (part 2).

In this, the second of two articles, we continue our evaluation of drug therapies in older adults. Having previously described the pharmacokinetic and pharmacodynamic consequences of physiological ageing, along with the challenge of appropriate prescribing, we proposed four key questions which should be considered when prescribing for this cohort of the population. Does this agent reflect the priorities of the patient? Are there alternatives - with greater efficacy, effectiveness or tolerability - that might be considered? Are the dose, frequency and formulation appropriate? How does this prescription relate to concurrent medication? We also highlighted the reliance on subgroup analysis to demonstrate the efficacy of drug therapies for older adults in osteoporosis and the underutilisation of appropriate treatments for patients with Alzheimer's disease as a result of flawed guidelines.

Drug therapies in older adults (part 1).

Prescribing for older adults represents a significant challenge as the UK population ages. Physiological decline and the rising prevalence of frailty increase the likelihood of altered pharmacodynamics and pharmacokinetics, suboptimal prescribing and adverse effects among this growing cohort of the population. In the first of two articles, we begin by considering these issues and posit four key questions which should be considered when prescribing for older adults.

Intentional non-adherence to medications by older adults.

'The extent to which an individual's medication-taking behaviour and/or execution of lifestyle changes, corresponds with agreed recommendations from a healthcare provider', is a highly complex behaviour, defined as adherence. However, intentional non-adherence is regularly observed and results in negative outcomes for patients along with increased healthcare provision costs. Whilst this is a consistent issue amongst adults of all ages, the burden of chronic disease is greatest amongst older adults.

Development and validation of a fall-related impulsive behaviour scale for residential care.

Introduction: impulsivity in older people with cognitive impairment has yet to be examined rigorously as a risk factor for falls. The objective of this study was to evaluate the psychometric properties of a new fall-related impulsive behaviour scale (FIBS) for a cognitively impaired population living in residential care.

Methods: one hundred and nine care home residents (84.

Therapeutic benefit of the anesthesiologist-patient relationship.

The psychologic effect of the preoperative visit by an anesthetist has been compared with the effect of pentobarbital for preanesthetic medication. Patients receiving pentobarbital 1 hour before an operation became drowsy but it could not be shown that they became calm. Patients who had received a visit by an anesthetist before operation (informing them about the events which were to occur on the day of operation and about the anesthetic to be administered) were not drowsy but were more likely to be calm on the day of operation.

Cognitive change in older women using a computerised battery: a longitudinal quantitative genetic twin study.

Cognitive performance is known to change over age 45, especially processing speed. Studies to date indicate that change in performance with ageing is largely environmentally mediated, with little contribution from genetics. We estimated the heritability of a longitudinal battery of computerised cognitive tests including speed measures, using a classical twin design.

Under-representation of older adults in pharmacokinetic and pharmacodynamic studies: a solvable problem?

The impact of advancing age, with or without the presence of structural and/or functional organ impairment, on the disposition and effects of drugs, demands adequate representation of older adults in pharmacokinetic and pharmacodynamic studies. Currently, however, this group remains poorly represented both in pre- and post-marketing studies. This review discusses recent data on the participation of older adults in pharmacokinetic/pharmacodynamic studies using established databases, the potential barriers to study recruitment and retention and possible strategies to enhance participation in this group.

United States anesthesiologists over 50: retirement decision making and workforce implications.

Background: Anesthesiology is among the medical specialties expected to have physician shortage. With little known about older anesthesiologists' work effort and retirement decision making, the American Society of Anesthesiologists participated in a 2006 national survey of physicians aged 50-79 yr.

Methods: Samples of anesthesiologists and other specialists completed a survey of work activities, professional satisfaction, self-defined health and financial status, retirement plans and perspectives, and demographics.

The Hypertension in the Very Elderly Trial - latest data.

Early trials in the field of hypertension focused on adults in their fifties and sixties. However, with the passage of time, a progressive effort has been made to expand the evidence base for treatment in older adults. 2008 saw publication of data from the Hypertension in the Very Elderly Trial which demonstrated significant mortality and morbidity benefits from antihypertensive therapy in octogenarians.

Ageing, genes, environment and epigenetics: what twin studies tell us now, and in the future.

Compared with younger people, older people are much more variable in their organ function, and these large individual differences contribute to the complexity of geriatric medicine. What determines this variability? Is it due to the accumulation of different life experiences, or because of the variation in the genes we are born with, or an interaction of both? This paper reviews key findings from ageing twin cohorts probing these questions. Twin studies are the perfect natural experiment to dissect out genes and life experiences.

Risk: benefit of treating high blood pressure in older adults.

Older people (those aged 65 years or over) comprise over 15% of the UK's population and this cohort is growing. Whilst at greatest risk from systemic arterial hypertension (hypertension), its resultant end organ damage and clinically significant cardiovascular disease, this group was initially neglected in clinical trials and thereby denied treatment, with the lack of evidence cited as justification. However since the 1960s, when the first landmark trials in severe diastolic hypertension were published, there has been a progressive attempt to understand the pathophysiology of hypertension and to expand the evidence base for treatment in older adults.

Identification of high risk fallers among older people living in residential care facilities: a simple screen based on easily collectable measures.

Purpose: To develop a simple screen based on easily collectable measures to identify older people living in residential care facilities at high risk of falls.

Methods: This prospective study was conducted in seven residential care facilities in the U.K.

Off-label prescribing in older patients.

The practice of off-label prescribing, i.e. prescribing drugs either for unregistered/unapproved therapeutic indications and age groups or using unregistered/unapproved doses or methods of administration, is common in older patients.

Understanding risk of falls in people with cognitive impairment living in residential care.

Objectives: To better understand fall risk factors in older adults with cognitive impairment living in residential care.

Design: A prospective observational cohort study.

Setting: Residential care homes in South London, UK.

Determinants of a positive response to carotid sinus massage and head-up tilt testing.

Background: Orthostatic hypotension (OH) and carotid sinus hypersensitivity (CSH) are common causes of syncope in older people. The aim of this study was to determine if patient's age, sex and presenting symptoms influence the result of carotid sinus massage and head-up tilt testing.

Methods: Retrospective analysis of the database and reports was carried out between 1995 and 2006 at a tertiary referral centre.

Glucose intolerance and diabetes as risk factors for cognitive impairment in people at high cardiovascular risk: results from the ONTARGET/TRANSCEND research programme.

Aims: To assess the cross-sectional associations of the measures of glycemia and cognitive function in subjects at high cardiovascular risk.

Setting And Patients: The ONgoing Telmisartan Alone and in combination with Ramipril Global Endpoint Trial (ONTARGET) and concurrent Telmisartan Randomized Assessment Study in ACE intolerant Subjects with Cardiovascular Disease (TRANSCEND) are multi-center, randomized, controlled investigations of different approaches to angiotensin receptor blockade in over 30,000 high CV risk subjects. Baseline data in both trials was used to analyze relationships between measures of glycemic control and cognition.