Boehlen, F.

Dechevrens, O.

Herrmann, F.

Michel, J.-P

Moerloose, P. de

Reber, G.

RERO DOC Digital Library

Age and Ageing 1997; 26: 319-321Letters to thePrevalence of anticardiolipin andantinuclear antibodies in an elderlyhospitalized population and mortalityafter a 6-year follow-upSIR—The prognosis linked to anticardiolipin (aCL)positivity in an elderly population is not known. Studiesof healthy elderly people give conflicting reports [1,2]but two recent studies did not find a significant age-related increase in aCL antibodies [3,4]. The discrepantresults observed in aCL prevalence are not only due todifferences in subject selection but also to the variousmethods used [5]. The situation is different in frailelderly subjects where a prevalence of 18.7% wasrecently found [4]. Here, we report a study in whichunselected elderly sick patients were included. Therelationship between aCL and clinical manifestationswas evaluated, a comparison with antinuclear anti-bodies (ANA) prevalence determined and an analysismade of whether the presence of aCL is associated withsurvival after 6 years.Screening for aCL and ANA was performed in 192consecutive patients (133 women and 59 men, aged70-99) admitted to a hospital geriatric unit betweenJuly 1989 and March 1990 for various diseases. Therewere no exclusion criteria. Diagnosis and ingestion ofdrugs at the time of admission as well as present or pasthistories of venous and thrombo-embolic diseases,cerebral or coronary ischaemic events, cardiac valvularabnormalities, infections, malignancies and thrombo-cytopenia were recorded. No patient had systemiclupus erythematosis or features of other connectivedisease. At 6-year follow-up, a survival analysis of theoutcomes of aCL-positive patients as compared with asex- and age-adjusted Geneva control population wasperformed (n = 8104).Blood samples were obtained on admission. aCL (IgGand IgM isotypes) was measured by ELISA. IgG andIgM aCL concentrations are expressed in GPL and MPLunits, respectively (where 1 unit represents the bindingactivity of 1 /*g/ml of affinity purified aCL antibody),and cut-offs for positivity for IgG and IgM isotypes wereset at 5 GPL and 3 MPL [6]. Depending on aCL levels,samples were classified as low (< 20 GPL, < 10 MPL),medium (20-50 GPL, 10-30 MPL) or high positive(> 50 GPL, > 30 MPL). It is important to report the titretogether with the isotype: IgG isotypes are more oftenassociated with clinical complications than IgM. ANAwere measured by immunofluorescence with Hep-2cell line cultures. A 1/160 titre was considered to bepositive.aCL was found in 21 patients (10.9%), 15 women(11.3%) and six men (10.2%). The sex distribution ofpositivity in this elderly population is different fromthat in a younger population, where female aCLpositivity is prominent. Sixteen (10 women and sixmen) had IgG, while six (all women) had IgM (onewoman having both isotypes). ANA were found in 61patients (31.8%), 48 women (36%) and 13 men (22%).In 35 patients the titre was 1/160, in 12 it was 1/320and in 14 it was higher. Only five patients were positivefor both aCL and ANA. Strokes and cardiac valvularabnormalities were more frequent in aCL-positivepatients. When three age-groups were considered(70-79, 80-89 and 90-99 years), the prevalence ofaCL decreased (17, 10 and 7% respectively) whereasthe prevalence of ANA increased (22, 32 and 42%).However, due to the relatively small number of patients,no statistical significant difference could be demon-strated (x2 for trend 2.3 for aCL and 3.42 for ANA,/)>0.05). For neither autoantibody was any significantassociation observed after splitting the data by sex.The most interesting (and unexpected) finding wasthat changes in aCL prevalence -with age showed theopposite pattern than that of ANA: although statisticallynot significant, the lowest prevalence (7-5%) wasobserved in the 90-99-year group. It was thereforetempting to postulate that aCL antibodies wereassociated with disorders that, because of their highmorbidity and lethality, would account for thedecreased prevalence in old age. However, during the6-year follow-up period there was no statisticallysignificant difference in survival between aCL-positivepatients and an age- and sex-adjusted Geneva popula-tion. At least two subsets of aCL exist, a pathogenic oneand a non-pathogenic one [7]. At the time of the studyno measurements of anti-/32 GP1 or other antiprotein-antiphospholipid antibodies were performed. It ispossible that the sum of two opposite trends (adecrease of pathogenic aCL and an increase of non-pathogenic aCL) could explain why, despite thetendency to decrease with ageing, the prevalence ofaCL remains higher than that observed in the youngpopulation.This study indicates that ANA and aCL are frequentfindings in sick patients admitted to a geriatric hospital.aCL per se did not seem to be linked with a decrease insurvival but a more precise characterization of thevarious types of aCL should be performed beforeinferring their prognostic significance.P. de Moerloose, F. Boehlen, G. ReberUnite d'Hemostase, Hopital Universitaire Geneve,1211 Geneva 14, Switzerland319Letters to the EditorO. Dechevrens, F. Herrmann, J.-R MichelInstitutions Universitaires de Geriatrie,Hopital Cantonal Universitaire, 1226 Thonex,Geneva, SwitzerlandFax: (+41) 22 37 29 777References1. Fields RA, Toubbeh H, Searles RP, Bankhurst AD. Theprevalence of anticardiolipin antibodies in a healthy elderlypopulation and its association with antinuclear antibodies.J Rheumatol 1989; 16: 623-5.2. Manoussakis MN, Tziofas AG, Silis MP, Pange PJE,Goudevenos J, Moutsopoulos HM. High prevalence of anti-cardiolipin and other auto-antibodies in a healthy elderlypopulation. Clin Exp Immunol 1987; 69: 557-65.3. Chakravarty KK, Gray RES, Webley M, Byron MA, WozniakJ. Prevalence of anticardiolipin antibodies in the elderlyBritish population. Postgrad J Med 1991; 67: 358-61.4. Juby A, Davis P, Genge T, McElhaney J. Anticardiolipinantibodies in two elderly subpopulations. Lupus 1995; 4:482-5.5. Reber G, Arvieux J, Comby E, Degenne D, de Moerloose P,Sanmarco Metal Multicenter evaluation of nine commercialkits for the quantitation of anticardiolipin antibodies. ThrombHaemost 1995; 73: 444-52.6. Reber G, Tremblet C, Bernard C, Mermillod B, deMoerloose P. Anticardiolipin and thrombosis: buffers'influence on the detection and quantitation of anti-cardiolipin antibody measured by ELISA. Thromb Res1990; 57: 215-26.7. Triplett D. Antiphospholipid-protein antibodies: labora-tory detection and clinical relevance. Thromb Res 1995; 78:1-31.Inappropriate acute admissions fromnursing and residential homesSIR—This •winter period we have seen an increasednumber of acute admissions to this district generalhospital, and this seems to have been the casethroughout many units in the UK. A proportion ofreferrals coming from nursing homes and, to a lesserextent, residential homes in the area seem to beinappropriate. We have recently completed the firststage of an audit looking at admissions from nursingand residential homes to the acute medical unit in Mayand June 1996.A similar project has been performed in Falkirk andDistrict Royal Infirmary (Age Ageing 1995; 25 (suppl.1): 12). Of the 42 admissions to that hospital over6 months from nursing homes, 13 were deemedinappropriate: six patients requiring nursing careonly and five patients who died very soon afteradmission. They have now introduced admissionsguidelines, with some benefit.The data for our audit were taken from the case mixsystem. Of 2698 acute admissions to the medical unit,there were 297 admissions from nursing and residen-tial homes (11% of the total). We were able to retrieve170 patients' case notes and from these reduced thefigure for admissions from nursing and residentialhomes to 111 (by excluding patients who wereadmitted as day cases or outpatients, those who wereadmitted to and discharged from the medical assess-ment unit on the same day, those who were admitted tonon-medical specialties and those admitted outside theallotted dates).Of the 111 admissions, 33 came from residentialhomes. Fifty-six nursing homes and 18 residentialhomes were represented. The highest number ofadmissions from a single residential home was eightand the highest number from a single nursing homewas six. Seventy-four general practitioners hadrequested these 111 admissions, the most from asingle general practitioner being six. The length of stayvaried from 1 day to over 20 days. Twenty patients hada stay of 24 h or less: five of these were transferred to acommunity hospital, five died and 10 returned to thenursing home. There were seven patients with a lengthof stay of 2 days: one of these went to a communityhospital and two died. Of the seven who stayed 3 days,four died.Those who died within the first 3 days usually diedfrom a terminal event on a background of chronicneurological disease—for example, bronchopneumoniain patients with multiple strokes, dementia or Parkin-son's disease. Twenty-two patients were dischargedback to the nursing home within 3 days. These hadfairly trivial or self-limiting conditions—for example,drowsiness related to excess neuroleptic drugs, milddehydration, self-limiting angina, seizures in patientsknown to have epilepsy, constipation causing abdom-inal pain, back pain and mild chest infections. Thosepatients who transferred to the community hospitals(seven in the first 4 days) usually had problems whichwarranted further medical input.Therefore, the King's Mill Centre had more admis-sions to acute medical wards from nursing andresidential homes than did the Falkirk and DistrictRoyal Infirmary.Admissions from residential homes were probablymore appropriate as nursing care is not available there.We feel that some of the admissions from nursinghomes were inappropriate. These include most ofthose of patients who died within 3 days, of patientswith self-limiting conditions and of patients for whosecare a community hospital bed would have been moreappropriate.We have discussed with officers of the hospital trusthow we might take this initial phase further. Weconsidered repeating the study prospectively, drawingup some guidelines for admissions to medical wards orcreating an out-reach team involving a geriatrician and320

Letters to the Editor: Prevalence of anticardiolipin and antinuclear antibodies in an elderly hospitalized population and mortality after a 6-year follow-up

Letters to the Editor: Prevalence of anticardiolipin and antinuclear antibodies in an elderly hospitalized population and mortality after a 6-year follow-up

Abstract

Similar works

Full text

Available Versions

RERO DOC Digital Library