Two older patients with atrial fibrillation, receiving warfarin for thromboembolic prophylaxis, with a target range of 2.0-3.0, were significantly over anticoagulated prior to elective intervention, in spite of having adhered to the standard protocol of 5 days of warfarin interruption. Neither patient had any abnormality of liver function nor was taking any interacting drug known to inhibit warfarin metabolism or affect sensitivity to warfarin. Both had variant cytochrome P2C9 (CYP2C9) alleles which reduce the metabolic capacity of the CYP2C9 enzyme responsible for the metabolism of the S-warfarin enantiomer. Need for preoperative administration of vitamin K or postponement of an operation because of an INR >1.5 could be explained by variant alleles for CYP2C9 and age.

Providing symptomatic palliation in terminal malignant disease is integral to high-quality elderly-care medicine. Effective pharmacological treatment, especially pain relief, is the mainstay of palliative care, but physical intervention is sometimes required to relieve mechanical problems. Interventional radiology is rapidly evolving and there are many clinical situations in which it is indicated. It is as effective as open surgery, but without the risk of general anaesthesia and surgical morbidity. Most interventional radiology procedures can be performed with a much shorter hospital stay than the alternative surgical procedure, and often as a day case admission. Reducing hospital stay and recovery time is of great importance to the older patient who may have a short life expectancy because of the cancer and co-morbidities.