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geriatrics

Rheumatoid Arthritis among Older Adults

Rheumatoid Arthritis among Older Adults

Teaser: 

Arthur Bookman, MD, FRCPC, Division of Rheumatology, Toronto Western Hospital/University Health Network, Toronto, ON.

Rheumatoid arthritis (RA) in older adults has a lower female-to-male ratio, and presents as either a rheumatoid factor positive typical case of RA, or an acute seronegative syndrome consisting of myalgia, fever, weight loss, and fatigue. Differentiating among systemic lupus erythematosus, polymyalgia rheumatica, and rheumatoid arthritis may initially be very difficult in older patients. Rheumatoid arthritis beginning in younger people can lead to earlier death, accelerated atherosclerosis, complicated polypharmaceutical management, debilitating deformity, osteoporosis, and more frequent infection as these patients enter their geriatric years.
Key words: rheumatoid arthritis, geriatrics, polypharmacy, chronic disease, inflammatory arthritis.

Insulin Therapy for Older Adults with Diabetes

Insulin Therapy for Older Adults with Diabetes

Teaser: 

Alissa R. Segal, PharmD, CDE, Associate Professor, Massachusetts College of Pharmacy and Health Sciences; Clinical pharmacist, Joslin Diabetes Center, Boston, Massachusetts, U.S.A.
Medha N. Munshi, MD, Assistant Professor, Harvard Medical School; Director of Joslin
Geriatric Diabetes Program, Joslin Diabetes Center; Division of Gerontology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, U.S.A.

The aging of the population and increasing prevalence of diabetes are worldwide phenomena that require a better focus on challenges of diabetes management in older adults. We now understand the benefits of tight glycemic control and have an armament of agents to achieve such a feat. However, in an aging population, balance must be sought between the goals of glycemic control and those of overall health status, including quality of life. Insulin therapy, in particular, requires significant self-care abilities. Insulin therapy can be used safely and effectively if diabetes management plans are formulated with consideration of the clinical, functional, and psychosocial contexts of an older adult.
Key words: diabetes, older adults, insulin therapy, geriatrics, glycemic control.

Incontinence among Older Adults

Incontinence among Older Adults

Teaser: 

David R. Staskin, MD, Department of Urology, New York Presbyterian Hospital, Weill-Cornell Medical College, New York, NY, USA.
Edward Zoltan, MD, Division of Urology, Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA.
Alan J. Wein, MD, Division of Urology, Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA.

Older adults have a high prevalence of urinary incontinence. Among the older adult population, many nonurinary pathological, anatomical, physiological, and pharmacological factors may serve as comorbidities in the development of incontinence. The treating physician must appreciate potentially reversible pathologies. Older adults frequently are prescribed several drugs; therefore, it is important to consider drug-drug metabolic interactions. Age-associated changes may affect pharmacological actions of the drug. Antimuscarinic therapy has been proven efficacious and represents the first line of pharmacologic therapy for overactive bladder (OAB). The selection of an antimuscarinic agent for the management of an older individual presenting with OAB is limited by the natural condition of the aging body and by the side effects associated with antimuscarinics as a class and the specific agents themselves.
Key words: urinary incontinence, antimuscarinics, older adult, frail older adult, geriatrics.

Cardiovascular Imaging and Noninvasive Diagnosis for Older Adults

Cardiovascular Imaging and Noninvasive Diagnosis for Older Adults

Teaser: 


Sherryn Rambihar, MD, Internal Medicine Resident, Schulich School of Medicine, University of Western Ontario, London, ON.
Beth Abramson, MD, MSc, FRCP(C), FACC, Assistant Professor of Medicine, University of Toronto; Director, Cardiac Prevention Centre and Women’s Cardiovascular Health, Department of Cardiology, St. Michael’s Hospital, Toronto, ON.

Coronary heart disease (CHD) is the leading cause of death among men and women at all ages, and older adults are at increased risk. In assessing an older adult at risk for CHD, Bayes’ theorem guides rational clinical decision-making. Physicians should consider a diagnosis of CHD for older adults, who have a high prevalence of disease but may present with atypical symptoms and multiple risk factors. In clinical presentation, older women may be more similar than dissimilar to men. Exercise treadmill testing is the recommended first-line noninvasive strategy in most symptomatic older adults. Risk factor optimization is imperative in all patients.
Key words: imaging, diagnostic, women, geriatrics, clinical practice patterns, delivery of health care.

Getting into Telemedicine: Information for Physicians

Getting into Telemedicine: Information for Physicians

Teaser: 

Peter N. McCracken, MD, FRCPC, Professor of Medicine, Division of Geriatric Medicine, University of Alberta, Edmonton, AB.
Darryl Rolfson, MD, FRCPC, Assistant Professor of Medicine, Division of Geriatric
Medicine, University of Alberta, Edmonton, AB.

Even within the Canadian health care system, one which strives to be comprehensive, universal, and accessible, disparities exist for Canadians who are unable to access timely clinical and educational support due to distance. Telemedicine, which bridges distances to allow clinical, educational, and administrative interactions, fits this need like a glove. In 2005, the acceptability of the technology now leaves clinicians, health educators, and health care administrators in a position to assist almost without excuse. To be successful, telehealth requires willing participants, sensible application technology, and a dense network of broadband linkages. Although qualitative research is plentiful, high quality quantitative research into telehealth is still only emerging, as evidenced by the example of telehealth applications in educational and clinical geriatrics.

Key words: telemedicine, telehealth, geriatrics, medical education, research.

Reperfusion Therapy for Acute Myocardial Infarction in the Elderly

Reperfusion Therapy for Acute Myocardial Infarction in the Elderly

Teaser: 

A Review of the Literature

Alan K. Berger, MD, Sections of Cardiology and Epidemiology, University of Minnesota, Minneapolis, MN, USA.

While elderly patients (aged = 75 years) represent a small segment of the general population, they account for disproportionate morbidity and mortality associated with acute myocardial infarction. Consequently, the efficacy and utilization of reperfusion therapy--thrombolysis and primary coronary angioplasty/stenting--remain highly relevant. A randomized clinical trial of thrombolysis in the elderly has never been performed, although subgroup analyses have suggested a benefit. The effectiveness of thrombolysis in the elderly has been challenged by observational studies documenting unexpectedly high mortality. The efficacy of primary coronary angioplasty/stenting is now well established and growing evidence suggests this approach is superior to thrombolysis in the elderly.
Key words: geriatrics, thrombolysis, primary coronary angioplasty, acute myocardial infarction, guidelines.

A One Minute Survey of Learning Needs for Regional Geriatric Program Central Personnel

A One Minute Survey of Learning Needs for Regional Geriatric Program Central Personnel

Teaser: 

David Jewell, MSW, MHSc, Irene Turpie, MB, ChB, MSc, FRCP(C),
Christopher Patterson, MD, FRCP(C), David Lewis, PhD, Julia Baxter, BScHK,

affiliated with the Regional Geriatric Program Central Ontario.

Objective: To determine the top learning needs of local specialized geriatrics services staff.
Participants: Health care professionals within the Regional Geriatric Program central area.
Methodology: A snowball sample (n=67) ranked five of 20 possible learning needs (derived from a literature review) by priority.
Analysis: Responses were sorted by those listing a particular subject in any priority, those making it the top priority, and Q-sort.
Results: The top three learning needs--scoring highest on all techniques--were management of dementia, risk and discharge from hospital to community.
Conclusion: This appears to be a viable method of appraising needs for education planning.
Key words: geriatrics, continuing education, survey, needs assessment, Q-sort

History of Geriatrics

History of Geriatrics

Teaser: 

Dr. Clarfield, MD, FRCSC, is the Chief of Academic Affairs at the Herzog Hospital in Jerusalem, Director of Geriatrics in the Ministry of Health, and on staff in the Division of Geriatric Medicine, Sir Mortimer B. Davis-Jewish General Hospital, McGill University, Montreal, PQ.

Geriatrics, the medical specialty which deals with the old, is still relatively young. Although not all Canadian medical schools offer a comprehensive approach to teaching this subject, progress has been made especially in the last two decades. There are now more clinical units, more research is being carried out, and certainly more attention is being paid to the subject of the elderly than ever before.

The roots of geriatrics can be traced back to the beginning of this century, and two of its pioneers hail from opposite sides of the Atlantic: Dr. Ignatz Nascher, an American whose medical career began at the end of the 19th century;1 and an English physician, Dr. Marjory Warren, who reached the zenith of her influence in the 1940s.2

Dr. Nascher was born in Vienna in 1863 and was brought up in New York. In 1882, aged 19, he graduated in pharmacy and several years later completed his MD and began private practice. Little is known about his early years, but Dr. Nascher's first paper on geriatrics ("Longevity & Rejuvenesence," New York Medical Journal, 1909) was to have a profound influence on the discipline simply by giving us its name.

Genetics and Geriatrics

Genetics and Geriatrics

Teaser: 


A Promise of Breakthroughs in Geriatric Medicine with the Imminent Completion of the Human Genome Project

Barry Goldlist, MD, FRCPC, FACP
Editor in Chief,
Geriatrics & Aging

When I started practicing geriatric medicine in 1979, I felt that I had left genetic diseases behind. Little did I know how much medicine would change with the advent of molecular genetics. One of the crucial changes in geriatrics is, of course, the elucidation of the genetic nature of Alzheimer's disease. Although currently only symptomatic treatments for the disease are available, an understanding of the genetics of the disease is helping us understand where we should target therapeutic strategies. There is great hope that modulating the metabo- lism of the amyloid precursor protein will allow us to influence the course of Alzheimer's disease. Understanding molecular genetics has been crucial in the development of a mouse model for Alzheimer's disease, which will likely speed the pace of discoveries in the future. Families of patients with Alzheimer's disease are aware of these genetic links, and they require an explanation of the risks that they personally face.

In fact, chronic diseases that have strong genetic contributions dominate geriatric medicine. Examples include diabetes mellitus and coronary artery disease. The genetics are often not simple, and currently modification of risk factors is the only therapeutic strategy that is commonly used. However, it is not inconceivable that this will change in the future and we will be better able to predict who is at risk, and perhaps even use specific therapies that directly modulate the genetic risk. Our experience with most modern medical therapies indicates that the elderly benefit at least as much as younger people. It will be interesting to see if this holds true for more specific interventions directed at the proteins for which specific genes code.

One of the greatest issues in geriatric medicine is that of 'polypharmacy'. Clearly the elderly have more diseases, and are more likely to require medications than younger patients. However, they are more prone to side effects as well. Our ability to tailor medications is very limited because we are often unable to accurately predict the likelihood of side effects. It is possible that a greater understanding of the genetic variability of drug metabolism will allow us to predict more accurately who will benefit from certain drugs and who will not.

These breakthroughs will all be brought about through the growth in knowledge of the human genome. Clearly the field of molecular genetics will dominate medical progress for years to come. This journal has an article on the human genome project. One of the major controversial issues currently is who 'owns' the rights to the human genome. I am one of those who firmly believes it should be in the public domain. I think there is an analogy here from the era of colonial exploitation. When European explorers 'discovered' new areas (ones that were already inhabited!) their actions resulted in untold human misery. Millions perished, some after enduring unimaginable agony. In fact, the explorers had not really discovered anything. North America and Africa had always been there, and had been inhabited by sophisticated societies. Similarly, the human genetic code has 'always' been there. If private concerns 'own' rights to the genome I feel we open up the process to great abuse, and might actually increase human misery.

I don't have the same concerns when it comes to new drugs or therapies, based on an understanding of genetics, being developed. Profit from such endeavors is a spur to innovation and improvements in health care and patent protection is clearly appropriate. However, no one created the human genetic code, and I feel no one should have exclusive rights to any part of it.

Enough moralizing! We have some very interesting interviews for you this month. To complement our article on the Human Genome Project, we have questioned Dr. Jamie Cuticchia, Head of the Bioinformatics Group at the Hospital for Sick Children, on the Genome Project and how having the entire human sequence may one day alter the field of medicine. We also have a fascinating interview with Dr. Tomas Prolla, an Assistant Professor in the Department of Genetics and Medical Genetics at the University of Wisconsin, who discusses recent evidence that the biology of aging is actually controlled by a very small set of genes. Finally, an interview with Dr. John Phillips from the University of Guelph, a specialist in 'oxygen toxicity', reveals that data from his research into fruit fly genetics led to important discoveries about how antioxidants may prevent some of the ravages of old age.

I hope you enjoy this issue, and its emphasis on genetics. I also hope you appreciate the irony for those specializing in geriatrics once again being overwhelmed by trying to understand genetics.