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diagnosis

Heart Failure: Old Disease, Older Adults, Fresh Perspective

Heart Failure: Old Disease, Older Adults, Fresh Perspective

Teaser: 


George A. Heckman, MD, MSc, FRCPC, McMaster University, Hamilton General Hospital, Hamilton, ON.
Catherine Demers, MD, MSc, FRCPC, McMaster University, Hamilton, ON.
David B. Hogan, MD, FCRPC, University of Calgary, Calgary, AB.
Robert S. McKelvie, MD, PhD, FRCPC, McMaster University, Hamilton, ON.

The burden of heart failure is rapidly rising. Heart failure is associated with substantial mortality, morbidity, and economic cost, which disproportionately affect older adults. Heart failure among older individuals is frequently complicated by geriatric syndromes, including frailty, functional decline, cognitive impairment, and atypical clinical presentations. Understanding the nature of these geriatric syndromes and their impact on the assessment and management of heart failure is a critical component to diagnosing and delivering appropriate care to these patients. In this article we review the geriatric aspects of heart failure.
Key words: geriatric syndrome, heart failure, older adults, diagnosis, frailty.

Dehydration in Geriatrics

Dehydration in Geriatrics

Teaser: 

MC Faes, MD, MSc, Department of Geriatric Medicine, University Medical Centre Nijmegen, The Netherlands.
MG Spigt, PhD, Department of General Practice/Research Institute CAPHRI, University of Maastricht, The Netherlands.
MGM Olde Rikkert MD, PhD, Department of Geriatric Medicine, University Medical Centre Nijmegen, The Netherlands.

Homeostasis of fluid balance is an important prerequisite for healthy aging. The high prevalence of disturbances of fluid balance among older adult patients has triggered clinical research on age- and disease-related changes in water homeostasis. Empirical findings on risk factors of dehydration and on diagnostic and therapeutic strategies are reviewed in this paper. No single measure has proved to be the gold standard in the diagnosis of dehydration. Diagnosing dehydration and monitoring fluid balance requires repeated measurements of weight, creatinine, and physical signs such as tongue hydration. Rehydration and prevention requires fluid on prescription (> 1.5 litre/day), and the route of fluid administration depends on the acuteness and severity of clinical signs.
Keywords: older adults, dehydration, fluid therapy, risk factors, diagnosis.

Post-Stroke Depression -- July/August 2007

Post-Stroke Depression -- July/August 2007

Teaser: 

Lana S. Rothenburg, BSc(Hons), Neuropsychopharmacology Research Program, Department of Pharmaceutical Sciences, University of Toronto, Toronto, ON.
Nathan Herrmann, MD FRCP(C), Neuropsychopharmacology Research Program; Department of Psychiatry, Sunnybrook Health Sciences Centre; Department of Psychiatry, University of Toronto, Toronto, ON.
Krista L. Lanctôt, PhD, Neuropsychopharmacology Research Program; Department of Psychiatry, Sunnybrook Health Sciences Centre; Departments of Psychiatry and Pharmacology, University of Toronto, Toronto, ON.

Depression is a common sequela of stroke, occurring in approximately 33% of all patients. Post-stroke depression (PSD) is associated with greater cognitive and functional impairments, excess mortality, and increased health care costs, although symptoms are often mild. Diagnosis of PSD can be made using standard clinical criteria, despite the potential overlap with the somatic and vegetative symptoms of stroke. Post-stroke depression responds to standard antidepressant pharmacotherapies, but use of tricyclic antidepressants may result in increased cardiac adverse events. Given the high prevalence and major negative impact of PSD, active screening of all stroke patients for depression and aggressive treatment is recommended.
Key words: stroke, depression, diagnosis, risk factors, treatment.

Chronic Obstructive Pulmonary Disease in the Older Adult: New Approaches to an Old Disease

Chronic Obstructive Pulmonary Disease in the Older Adult: New Approaches to an Old Disease

Teaser: 

The accredited CME learning activity based on this article is offered under the auspices of the CE department of the University of Toronto. Participating physicians are entitled to one (1) MAINPRO-M1 credit by completing this program, found online at www.geriatricsandaging.ca/cme

Andrew McIvor MD, MSc, FRCP, Professor of Medicine, McMaster University; Firestone Institute for Respiratory Health, St Joseph’s Healthcare, Hamilton, ON.

At present, some 750,000 Canadians are known to have chronic obstructive pulmonary disease (COPD). This number is believed to represent the tip of the iceberg, as COPD is often only diagnosed in the advanced stage. Respiratory symptoms or a previous smoking history are common among older adults yet they seldom trigger further assessment for COPD. Objective demonstration of airflow obstruction by spirometry is a simple procedure, even in older adults, and is the gold standard for diagnosis of COPD. Early intervention with routine nonpharmacological management includes partnering with the patient and family, providing education, smoking cessation, vaccination, collaborative self-management, and advice on exercise and pulmonary rehabilitation. Anticholinergic inhalers remain the gold standard for optimal bronchodilation and dyspnea relief in COPD, and new long-acting agents have underpinned new treatment algorithms, improving quality of life and exercise capacity as well as reducing exacerbations. For those with advanced disease, recent trials have reported further benefits with the addition of combination inhalers (inhaled corticosteroid and long-acting B2-agonist) to core anticholinergic treatment. Physicians and patients can expect a promising future for COPD treatment as significant advances in management and improved outcomes in COPD are now being made.
Key words: chronic obstructive pulmonary disease, older adults, spirometry, diagnosis, management.

An Approach to the Diagnosis of Unintentional Weight Loss in Older Adults, Part One: Prevalence Rates and Screening

An Approach to the Diagnosis of Unintentional Weight Loss in Older Adults, Part One: Prevalence Rates and Screening

Teaser: 


Karen L. Smith, MSc, Kunin Lunenfeld Applied Research Unit, Baycrest and Department of Nutritional Sciences, University of Toronto, Toronto, ON.
Carol Greenwood, PhD, Kunin Lunenfeld Applied Research Unit, Baycrest and Department of Nutritional Sciences, University of Toronto, Toronto, ON.
Helene Payette, PhD, Research Center on Aging, Health & Social Services Center - University Institute of Geriatrics of Sherbrooke, Faculty of Medicine and Health Sciences, University of Sherbrooke, Sherbrooke, QC.
Shabbir M.H. Alibhai, MD, MSc, Division of General Internal Medicine & Clinical Epidemiology, University Health Network; Geriatric Program, Toronto Rehabilitation Institute; Departments of Medicine and Health Policy, Management and Evaluation, University of Toronto, Toronto, ON.

Unintentional weight loss is a common problem among community-dwelling older adults. Although a slight decline in body weight is considered a normal part of the aging process, clinically significant weight loss (>5% of usual body weight) has harmful consequences on functional status and quality of life, and is associated with excess mortality over a three- to twelve-month period. A variety of physical and psychological conditions, along with age-related changes, can lead to weight loss. In up to one-quarter of patients, there is no identifiable cause. A rational approach to clinical investigation of these patients can facilitate arriving at a diagnosis and minimize unnecessary diagnostic procedures.
Key words: weight loss, older adults, mortality, epidemiology, diagnosis.

West Nile Virus: A Pathogen of Concern for Older Adults

West Nile Virus: A Pathogen of Concern for Older Adults

Teaser: 


Michael A. Drebot, PhD, Chief, Viral Zoonoses, Zoonotic Diseases and Special Pathogens, National Microbiology Laboratory, Public Health Agency of Canada, Winnipeg, Manitoba, Canada.
Harvey Artsob, PhD, Director, Zoonotic Diseases and Special Pathogens, National Microbiology Laboratory, Public Health Agency of Canada, Winnipeg, Manitoba, Canada.

Since its introduction into North America in 1999, West Nile virus (WNV) has rapidly expanded its range across the continent. There is evidence that it has moved into the Caribbean and South and Central America. The virus has significantly affected public health, causing more than 20,000 cases of associated illness and resulting in the largest WNV epidemic ever recorded. Although neuroinvasive disease occurs in less than 1% of infections, the risk for encephalitis and other neurological illnesses increases with age. Currently there is no specific therapy for the treatment of WNV-associated disease and a vaccine is not yet available. Decreasing the risk of virus exposure requires seasonal preventative and control measures.
Key Words: West Nile virus, epidemiology, diagnosis, neurological illness, disease prevention.

Multiple System Atrophy: An Update

Multiple System Atrophy: An Update

Teaser: 

Felix Geser, MD, PhD, Clinical Department of Neurology, Innsbruck Medical University, Innsbruck, Austria.
Gregor K. Wenning, MD, PhD, Clinical Department of Neurology, Innsbruck Medical University, Innsbruck, Austria.

Multiple system atrophy (MSA) is a sporadic neurodegenerative disorder characterized clinically by various combinations of parkinsonian, autonomic, cerebellar, or pyramidal signs and pathologically by cell loss, gliosis, and a-synuclein-positive glial cytoplasmic inclusions in several brain and spinal cord structures. The clinical recognition of MSA has improved, and the recent consensus diagnostic criteria have been widely established in the research community as well as in movement disorders clinics. Although the diagnosis of this condition is largely based on clinical expertise, several investigations have been proposed in the last decade to assist in early differential diagnosis. Symptomatic therapeutic strategies are still limited.
Key words: multiple system atrophy, clinical presentation, diagnosis, treatment.

Dementia: Making the Right Diagnosis

Dementia: Making the Right Diagnosis

Teaser: 

Those of you who are regular readers of this journal, and my column, know that I am especially interested in the cognitive changes that occur with aging, particularly the various neurodegenerative disorders. While cardiovascular disorders and cancer are the top two killers in old age, neither robs its victims so completely of their identity. To see loved ones die with Alzheimer’s disease or another dementing disorder is like seeing them die twice; once when their personality and memory are so impaired that they are but a shadow of their former selves, and a second time when their heart stops beating. Sometimes only after the physical death has occurred can the relatives and friends allow themselves to remember their loved ones as they were, rather than what they became.

We have just entered the era when medical care for patients with dementia can make a difference. This means that accurate diagnosis of dementia, including the type of dementia, will become ever more important in clinical practice. Gone are the days when we could simply call the patient “senile.” Unfortunately, the diagnosis is not always easy to make, and Dr. Lonn Myronuk addresses this problem in his article “Pitfalls in the Diagnosis of Dementia.” As well, Dr. Ging-Yuek Robin Hsiung reviews the “Current Pharmacological Management of Alzheimer’s Disease and Vascular Dementia.” Dr. Ron Keren, the chair of the 3rd Canadian Colloquium on Dementia (CCD), keeps us up to date with the newest information on dementia by reviewing the highlights from the Colloquium, which was held in October 2005 in Ottawa. This conference, held every other year, has become the leading conference on dementia for Canadian clinicians and clinician researchers, and has a global impact. The 4th CCD, scheduled for the fall of 2007, will be held in Vancouver. The innovative format of the meeting ensures that everybody can benefit, whether specialist, researcher, or primary care physician.

Many of our regular columns this month also touch on the topic of dementia. Dr. John Wherrett’s Biology of Aging column, “Morphological and Cellular Aspects of the Aging Brain,” provides important baseline information for those of us who try to understand the clinical pathological changes of the various dementias. Keeping with the theme, our Caregiving column this month is on “Reporting on Quality of Long-Term Care Homes in Ontario” by Jennifer Gold, Tamara Shulman, and Dr. Paula Rochon. The topic of our Dementia column this month is “Nonpharmaceutical Management of Hypokinetic Dysarthria in Parkinson’s Disease” by Drs A. M. Johnson and S.G. Adams. Even our book review this month touches on dementia. Hazel Sebastian, a renowned geriatric social worker, reviews the book “Parenting Your Parents, 2nd Edition” by Bart Mindszenthy and Dr. Michael Gordon.

This month’s Cardiovascular Disease column is on that most common of arrhythmias in the elderly: atrial fibrillation. Finally, Drs. Rajneesh Calton, Vijay Chauhan, and Kumaraswamy Nanthakumar review a critical controversy in the management of atrial fibrillation in their discussion of “Rate vs. Rhythm Control and Anticoagulation.”

Enjoy this issue,
Barry Goldlist

Osteoporosis Screening and Diagnosis

Osteoporosis Screening and Diagnosis

Teaser: 


Rowena Ridout, MD, FRCPC, Toronto Western Hospital, Toronto, ON.

Osteoporosis is a significant cause of morbidity and mortality in the older population. Bone density testing is recommended for all men and women 65 or older. In postmenopausal women, and in men over the age of 50, testing is recommended for those at high risk for osteoporosis. Effective therapy is available for those at risk for fracture. Bone density testing combined with clinical risk factors, including age and fracture history, can be used to assess fracture risk and identify those individuals most likely to benefit from drug therapy.
Key words: osteoporosis, bone density, fracture, diagnosis.

Diagnosis and Management of Mild Cognitive Impairment

Diagnosis and Management of Mild Cognitive Impairment

Teaser: 

Raj C. Shah, MD, Rush Alzheimer’s Disease Center; Department of Family Medicine, Rush University Medical Center, Chicago, IL, USA.
David A. Bennett, MD, Rush Alzheimer’s Disease Center; Department of Neurological Sciences, Rush University Medical Center, Chicago, IL, USA.

Mild cognitive impairment (MCI), the presence of cognitive difficulties without having dementia, is viewed as a preclinical state for Alzheimer’s disease (AD) or another dementing illness. With the burden of AD expected to increase, research efforts have focused on interventions to delay the progression of MCI to AD. In this review, we first discuss the current conceptual understanding of MCI. Then, we outline a simplified approach to help clinicians diagnose MCI. Finally, we provide an overview of how to address the clinical needs of individuals with MCI.
Key words: mild cognitive impairment, Alzheimer’s disease, diagnosis, prognosis, treatment.