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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.

Improving Detection Rates and Management of Dementia in Primary Care through Educational Interventions

Improving Detection Rates and Management of Dementia in Primary Care through Educational Interventions

Teaser: 


Kristin Casady, Editorial Director, Geriatrics & Aging.

A recent study examined the effectiveness of educational interventions in improving detection and management of dementia in the primary care setting (BMJ 2006;332:692-6). Achieving improved detection rates and advances in the provision of ongoing care for demented individuals is facilitated by the integration of decision support systems and practice-based workshops, the study’s authors concluded.

Introduction

Primary care practitioners play a role of fundamental importance in diagnosing dementia as they are the point of patients’ first medical contact. Practitioners must deliver prompt intervention and provide ongoing care for their patients receiving the diagnosis, yet inadequate detection and management have been widely documented. Further, it is observed that clinicians often face profound obstacles in executing this role. There may be difficulty in assessing the presence of dementia (for a recent discussion of the diagnosis and treatment of the older adult with cognitive complaints, see Myronuk L. Pitfalls in the diagnosis of dementia. Geriatrics Aging 2006;9:12-9). Challenges are reported to include such barriers as a lack of resources and insufficient cooperation among the general practitioner’s team, involved specialists, and community services.

Assessing Effective Diagnosis and Management: Study of U.K. Practices
Thirty-six general practices in the United Kingdom (central Scotland and London) were recruited as settings for an unblinded, cluster randomized, before-and-after controlled study organized around the provision of three educational interventions: one, a CD-ROM tutorial; two, decision-support software built into the practices’ electronic medical records; and three, practice-based workshops for the general practitioners (the curriculum used is available for download from the U.K.’s Alzheimer’s Society website, www.alzheimers.org.uk). Eight practices were randomly assigned to the electronic tutorial; eight to decision-support software; 10 to practice-based workshops; and 10 to control. Results were obtained from 450 valid and usable records. The design of the interventions was modeled to reflect different approaches to adult learning: the electronic tutorial for self-directed learning; decision-support software for real-time investigations of actual cases; and workshops to facilitate peer communication about the cases under consideration.

Based on searches of the record system for the terms dementia, confusion, memory loss, and cognitive impairment, all practices identified registered patients aged 75 and over who were diagnosed as having dementia or had been assessed as having probable dementia by a general practitioner or specialist.
Investigators audited detection rates prior to and approximately nine months after the intervention. Analysis was conducted of differences in baseline concordance scores with best-practice guidelines for the diagnosis and management of dementia, repeating the analysis for postintervention scores. The ten-item diagnosis concordance score gathered data on items that included whether clinicians took measures such as requesting blood tests at index consultation, took full histories, undertook cognitive testing, and completed scans, both at index consultation and then secondarily after index consultation (before diagnosis). Management concordance scores tracked items such as concerns of caregivers, behaviour problems, depression screening/treatment, referrals to social services, and initiation of pharmacological treatment regiments.

Outcome: Improved Rates of Detection

Regarding changes in rates of detection, diagnosis, and management, the study’s authors noted improved rates of detected dementia with decision-support software and practice-based workshops compared with control: individuals identified as having dementia after the interventions represented 31% of all cases diagnosed in the practice-based workshops arm, 20% in the electronic tutorial arm, 30% in the decision support software arm, and 11% in the control arm. Authors reported the positive effect of the decision-support software as particularly encouraging, with practitioners describing software as simple and practical to implement. However, no difference in concordance with guidelines regarding the management of dementia was noted. This outcome was ascribed to the modest number of cases identified after the intervention and the relatively few cases in the control arm. The result was also described as traceable to the investigators relying on the medical record for evidence of practice; they postulated that practitioners may have improved their practice but not noted it. The authors highlighted the value of focussed educational interventions directed at improving clinical record-keeping.

Conclusion
Successful management of dementing illnesses depends first on effective detection. This study affirms that interventions such as decision-support software and practice-based workshops can improve those rates. The authors highlight that future interventions aimed at improving concordance with recommended diagnosis or management may be furthered by the effect of combining locality initiatives with practice-based interventions, such as ones that incorporate local opinion leaders as well as encourage the direct involvement of patients and caregivers.

Pain and Depression in Aging Individuals

Pain and Depression in Aging Individuals

Teaser: 


Lucia Gagliese, PhD, CIHR New Investigator, School of Kinesiology and Health Science, York University; Department of Anesthesia, Behavioural Sciences & Health Research Division, University Health Network; Departments of Anesthesia and Psychiatry, University of Toronto, Toronto, ON.

Depression is highly prevalent among older adults with chronic pain living both in community and institutional settings. It is associated with decreased quality of life, including impairments in physical and social well-being. This article reviews the relationship between pain and depression. The potential mediating role of disability, life interference, and perceived control are described. Routine assessment of both pain and mood, using scales validated for this age group, is advocated. Finally, the importance of integrating pharmacological and psychological interventions for the management of pain and depression in the older adult is highlighted.
Key words: chronic pain, depression, mood disturbance, assessment, management.

Pain Management in the Older Adult

Pain Management in the Older Adult

Teaser: 



The week before writing this article, I received an urgent call from a patient’s daughter. I had seen the patient in the past to provide advice on the control of her hypertension. The daughter told me that her mother was in agony with a pounding headache, which the daughter assumed meant that her blood pressure was dangerously elevated. I quickly went to see her, and of course the problem was not related to her blood pressure. In fact, this woman had had a lifelong history of severe headaches, generally self-managed with large doses of acetaminophen with codeine. She had never really received a systematic assessment for her severe pain, and this led me to consider how many older patients have poorly managed pain. Certainly the scientific literature suggests that it is all too common. There are numerous reasons for this. We often assume that with all their medical conditions older adults should be in pain, and there is often a nihilistic attitude towards management. Often the management is focussed exclusively on analgesics, an approach that is too limited for chronic pain conditions. As well, the multiplicity of diseases that some older adults present with makes diagnosis and specific management quite difficult. I am pleased, therefore, that the theme of this issue is on Pain Management in the Older Adult.

The CME article this month is by Dr. Marek Gawel, a neurologist who is also an international authority on headache. His article is entitled “Headaches in the Older Adult.” After my recent experience, it seems rather important for me to complete the CME course! Then, Dr. Deborah Dillon McDonald discusses “Post-Operative Pain Management for the Aging Patient.” In order to understand the intensity of treatment required for a painful condition, the physician must be able to assess the severity of the patient’s pain. This topic is beautifully addressed in the article “Assessing Pain Intensity in Older Adults” by Drs. Sophie Pautex and Gabriel Gold. Finally, Dr. Lucia Gagliese explores the association between physical pain and mood in her review of “Pain and Depression in Aging Individuals.”

As usual, we also have several articles on other topics. In our cardiovascular column, Drs. Rachel L. McIntosh and Tien Y. Wong consider the importance of “Hypertensive Retinopathy as a Risk Marker of Cardiovascular Disease.” As a geriatrician, I believe that poor dental health in demented patients can trigger an inexorable downward spiral as nutrition is impaired. I am pleased that Dr. Michael J. Sigal is addressing this problematic area in his article “Dental Considerations for Persons with Dementia.” For those of us who like to eat (I am one of those!), the importance of healthy teeth and a healthy oral cavity cannot be over emphasized. Drs. Richard J. Payne, Jamil Asaria, and Jeremy L. Freeman review the important topic of “Oral Cavity Cancer in the Older Population.” Finally, our caregiving article by Dr. Rory Fisher addresses a very timely ethical issue, “Euthanasia and Physician-Assisted Suicide: Are They Next?”

Enjoy this issue,
Barry Goldlist

Rosacea: Relieving a Chronic Inflammatory Facial Disorder

Rosacea: Relieving a Chronic Inflammatory Facial Disorder

Teaser: 


Maeve A. Mc Aleer, MRCP(UK), Regional Centre of Dermatology, Mater Misericordiae University Hospital, Dublin, Ireland.
Frank C. Powell, MD, FRCPI, Regional Centre of Dermatology, Mater Misericordiae University Hospital, Dublin, Ireland.

Rosacea is a common, but frequently misunderstood, skin condition. As it affects the face and is unsightly, rosacea can cause considerable social distress, especially because of the historical belief that alcohol is involved in its causation. This article outlines the clinical features of rosacea and the standard subtype classification of the condition. The theories of pathogenesis are outlined and the management approaches are discussed.
Key words: rosacea, classification, rhinophyma, ocular disease, management.

Beyond Sad Mood: Alternate Presentations of Major Depression in Late Life

Beyond Sad Mood: Alternate Presentations of Major Depression in Late Life

Teaser: 



Tony Lo, MD, Resident, Department of Psychiatry, University of Calgary, Calgary, AB.
Nadeem H. Bhanji, BSc(Pharm), MD, FRCP(C), Assistant Professor, University of Calgary; Staff Psychiatrist, Carewest Glenmore Rehabilitation Hospital; Elderly Psychiatrist, Department of Psychiatry, Peter Lougheed Centre; Assistant Professor, University of Calgary, Calgary, AB.


Major depression and subsyndromal depression are common in older persons. Unrecognized depression results in increased morbidity and mortality. Recognition of depression is challenging due to patient- and clinician-related factors. Diagnosis in the older person is confounded by medical comorbidities as well as normal changes. Depression in older adults manifests differently: somatic complaints, nonspecific symptoms, and cognitive difficulties are common, as are behavioural changes, including apathy and irritability. Anhedonia better reflects depression, since depressed mood is often denied by the older person. Depression is likely to be missed if only typical symptoms are sought. Appropriate recognition can lead to improved treatment and outcomes.
Key words: depression, older adult, diagnosis, recognition, management
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Incontinence in Long-Term Care Residents with Dementia

Incontinence in Long-Term Care Residents with Dementia

Teaser: 

Jayna M. Holroyd-Leduc, MD, FRCPC, Assistant Professor, Department of Medicine, University of Toronto; Clinician-Investigator, University Health Network, Toronto, ON.
Cara Tannenbaum, MD, FRCPC, MSc, Assistant Professor, Department of Medicine, University of Montreal; Director, Geriatric Incontinence Clinic, McGill University Health Centre; Director, Institut Universitaire de Geriatrie de Montreal, Montreal, QC.

Urinary incontinence is a prevalent condition among long-term care residents, particularly those with dementia. The costs and morbidity associated with urinary incontinence are significant. Urinary incontinence can be easily assessed within the long-term care setting. Several modifiable risk factors should be identified and addressed. Effective behavioural treatment options for incontinence exist and several treatment strategies can be used successfully for patients with dementia.

Key words: urinary incontinence, dementia, long-term care, diagnosis, management.

Hemoptysis in Older Adults: Etiology, Diagnosis, and Management

Hemoptysis in Older Adults: Etiology, Diagnosis, and Management

Teaser: 

Samir Gupta, MD, FRCPC, Division of Respirology, Department of Medicine, St. Michael’s Hospital, University of Toronto, Toronto, ON.

Robert Hyland, MD, FRCPC, Division of Respirology, Department of Medicine, St. Michael’s Hospital, University of Toronto, Toronto, ON.

Hemoptysis is an important clinical problem that is especially ominous when seen in older patients. The main causes of hemoptysis in first world nations are bronchogenic carcinoma, bronchitis, and bronchiectasis. In older patients cancer remains the main concern, especially if there is a smoking history. The diagnostic approach to nonmassive hemoptysis starts with a chest x-ray, followed by a CT scan and then fibre optic bronchoscopy, which is well tolerated by older adults. In massive hemoptysis, chest x-ray is usually followed immediately by fibre optic or rigid bronchoscopy. Older patients require closer monitoring due to poor cardiopulmonary reserve; management options include endoscopic interventions, bronchial artery embolization,
surgery, and radiation.

Key words:
hemoptysis, etiology, management, older adults, bronchiectasis.

Management of Community-Acquired Pneumonia in Older Adults

Management of Community-Acquired Pneumonia in Older Adults

Teaser: 

Ashraf Alzaabi, MD, FRCPC, Respirology Fellow, University of Toronto, Toronto, ON.

Theodore K. Marras, MD, FRCPC, Respirologist, Toronto Western Hospital, University Health Network; Assistant Professor of Medicine, University of Toronto, Toronto, ON.

Community-acquired pneumonia (CAP) in the older adult is a common disease with significant mortality. This review focuses on the management of CAP, with specific reference to the older adult. Common etiologic organisms and organism-specific risk factors that tend to be associated with increasing age are presented. A systematic approach is described to help physicians decide on the best treatment site (ambulatory, long-term care facility, or acute care hospital). The rationale behind initial empiric antibiotic therapy and drug resistance are discussed. Recent guidelines for the selection of empiric antibiotic therapy are compared and a synthesis of guidelines for antibiotic selection and recommendations regarding parenteral to oral switch-therapy are presented. Guidelines are suggested to help the physician safely discharge the patient home.

Key words:
pneumonia, management, older adults, guidelines, resistance.

CME: Diagnosis and Treatment of Chronic Obstructive Pulmonary Disease in Older Adults

CME: Diagnosis and Treatment of Chronic Obstructive Pulmonary Disease in Older Adults

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.htm

Jean Bourbeau MD, MSc, FRCPC, Montreal Chest Institute of the Royal Victoria Hospital, McGill University Health Centre; Respiratory Epidemiology and Clinical Research Unit, Department of Epidemiology and Biostatistics, McGill University, Montreal, QC.

With the population progressively aging, the geriatric aspects of COPD deserve special consideration. Older adults with respiratory symptoms and a current or previous history of smoking should be considered for a diagnosis of COPD. Objective demonstration of airflow obstruction is mandatory for the diagnosis of COPD. The majority of older people can adequately perform spirometry for an objective demonstration of airflow obstruction. Nonpharmacological treatment includes smoking cessation, vaccination, self-management education and communication with a case manager, and pulmonary rehabilitation. Bronchodilators are the most important agents in the pharmacotherapy of COPD. Inhaled corticosteroids are indicated for patients with recurrent exacerbations who are already on optimal bronchodilator therapy.

Key words:
chronic obstructive pulmonary disease, older adults, diagnosis, spirometry, management.