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Treatment of Chronic Obstructive Pulmonary Disease in Older Adults

Treatment of Chronic Obstructive Pulmonary Disease in Older Adults

Teaser: 

George P. Chandy, MD, MSc, Department of Medicine, University of Ottawa, Ottawa, ON.
Shawn D. Aaron, MD, MSc, Department of Medicine and the Ottawa Health ResearchInstitute, University of Ottawa, Ottawa, ON.

Chronic Obstructive Pulmonary Disease (COPD) has been increasing in prevalence over the past several decades. The impact of COPD on the health status of Canadians will continue to be a major issue, despite declining rates of smoking, as physiologic manifestations of COPD may only be evident decades after the initiation of smoking. Given the delay between the initiation of smoking and the development of significant disease, COPD is primarily a disease of the older population. While a cure for COPD is not available, a number of medications have been noted to have a significant impact on symptoms, exercise tolerance, and quality of life.

Key words:
COPD, treatment, management, older adults.

Cutaneous Adverse Drug Reactions in Older Adults Part II: Management

Cutaneous Adverse Drug Reactions in Older Adults Part II: Management

Teaser: 

G.A.E. Wong, MBChB, MRCP(UK), and N.H. Shear, MD, FRCP(C), Divisions of Dermatology and Clinical Pharmacology, Sunnybrook & Women’s College Health Sciences Centre, University of Toronto, Toronto, ON.

Cutaneous adverse drug reactions are a common problem affecting ambulatory and hospitalized patients. Older patients may be predisposed to adverse drug reactions due to inappropriate medication prescription, age-associated changes in pharmacokinetics and pharmacodynamics, altered homeostatic mechanisms, multiple medical pathologies, and use of drugs with a narrow therapeutic margin. In this second of two articles, the management of cutaneous adverse drug reactions
is reviewed.

Key words: adverse drug reaction, skin, cutaneous, rash, drug eruption, treatment, management.

Pharmacological Management of Alzheimer Disease: An Update

Pharmacological Management of Alzheimer Disease: An Update

Teaser: 

Ging-Yuek Robin Hsiung, MD, MHSc, FRCPC and Howard Feldman, MD, FRCPC, Division of Neurology, Department of Medicine, University of British Columbia, Vancouver, BC.

In the past decade, there have been numerous advances in our understanding of the molecular biology and pathogenesis of Alzheimer disease (AD). Although to date no pharmacological treatments have been shown to alter the pathology of AD, several medications have been proven to offer symptomatic improvement and to delay the progression of cognitive, behavioural and functional deficits. This article reviews the currently available medications for management of cognitive symptoms in AD, as well as other promising drugs that are under investigation.

Key words: Alzheimer disease, management, cholinesterase inhibitors, donepezil, memantine.

Introduction
An estimated 8% of the Canadian population over age 65 suffers from dementia, of which 60–70% is caused by Alzheimer disease (AD). The incidence of dementia doubles for every five years of increased age between 65 and 85 years.1 The management of dementia is a significant burden to our health care system, with an estimated annual cost of $3.9 billion in 1991.2 Epidemiologic studies suggest that if the symptoms of dementia can be delayed by just two years, prevalence will decrease by 25%, with significant savings to the long-term care of these individuals.

Screening and Management of Diabetic Microvascular Complications in Older Adults

Screening and Management of Diabetic Microvascular Complications in Older Adults

Teaser: 

Amish Parikh, MD and I. George Fantus, MD, FRCPC, Division of Endocrinology and Metabolism, Department of Medicine, University of Toronto, Toronto, ON.

Microvascular complications of both Type 1 and Type 2 diabetes mellitus (DM) can be classified into three major categories: retinopathy, nephropathy and neuropathy. Numerous studies have consistently shown that the development of complications in both Type 1 and Type 2 diabetes is related to several factors. The most important ones, however, include glycemic control (as measured by hemoglobin A1c) and the duration of diabetes. This article reviews the details of screening and management of diabetic microvascular complications in older adults. It incorporates guidelines from both the Canadian and American Diabetes Associations, as well as reviews of recently published literature.
Key words: diabetes mellitus, retinopathy, nephropathy, neuropathy, screening, management.

Recognition Most Crucial Issue in Delirium Management

Recognition Most Crucial Issue in Delirium Management

Teaser: 

I am writing this editorial shortly after returning from the 2nd Canadian Colloquium on Dementia (CCD2), held from October 16-18 in Montreal. This was one of the finest meetings I have ever attended, and if you are interested in cognitive disorders you should reserve time to attend the next meeting, planned for 2005 in Ottawa.

Several of the topics in this issue of Geriatrics & Aging also were addressed at the Colloquium. The crucial issue of recognizing delirium (and dementia and depression) is addressed here by Rola Moghabghab and her colleagues, as they describe the process of implementing nursing best practice guidelines for the recognition of these disorders.

Although there are proven strategies for handling these concerns, recognition is crucial in order for these to be implemented. Several of the speakers at the CCD2 also commented on the issue of what happens after delirium. Dr. Jane McCusker addresses this topic more systematically in her article on the long-term prognosis of delirium.

The theme of under-recognition of delirium and its consequences is addressed more comprehensively by Drs. James L. Rudolph and Edward R. Marcantonio, followed by articles that examine delirium in more specific settings. Dr. Yoanna Skrobik discusses the recognition and management of delirium in the critical care setting, while Dr. Lars S. Rasmussen reviews the detection and prevention of postoperative cognitive dysfunction in older adults. Although the incidence of postoperative delirium is quite variable, it can reach as high as 50% in certain circumstances (older patients with hip fractures), and is a considerable concern whenever it does occur. In fact, I am writing this editorial immediately after seeing a patient in clinic who says, with confirmation from her daughter, that her memory has never returned to normal since her coronary artery bypass surgery six years ago.

We also have our usual varied collection of columns in this issue. Dr. Joseph H. Friedman reviews the incredibly common issue of drug-induced parkinsonism in older adults, while Dr. Osman O. Al-Radi discusses the pathophysiology of mitral regurgitation and its implications for surgical management. Our senior editor, Dr. Shabbir Alibhai, and his colleagues Drs. Foster and Oughton have reviewed the literature on the role of calcium and vitamin D3 supplementation for the primary prevention of fractures.

Enjoy this issue, and I hope to see you in Ottawa for the 3rd Canadian Colloquium on Dementia.

Falls: A Perfect Paradigm for Multifaceted Management

Falls: A Perfect Paradigm for Multifaceted Management

Teaser: 

When medical residents rotate through our geriatric service at the University Health Network, we provide a group of seminars on the "Geriatric Giants": confusion, instability and falls, incontinence, geriatric pharmacology and failure to thrive. I have to admit that my personal favourite among the geriatric giants is the topic of falls. I find it to be a perfect paradigm for the clinical practice of geriatric medicine, and thus an excellent tool for teaching the general principles of geriatric care.

What are those principles? I think the first is that any number of problems can result in falls, and that the overwhelming majority of falls in the elderly are not caused by a single factor but by the combination of a multitude of problems. This allows me to demonstrate to the students the various factors that can predispose to falls. These can be intrinsic to the patient (age-related changes or diseases), or external to the patient (environmental factors). The key for the doctor is to determine what factors are operant in a particular patient, and of these, which are modifiable. The next step is to determine which factors can be improved rapidly (e.g., stopping certain medications) and which require long-term strategies (e.g., proximal muscle strengthening). I also emphasize to the residents that there is no such thing as a trivial fall, although some falls only result in trivial injuries. That person's next fall might result in a devastating injury.

The nature of the scientific study of falls in the elderly took an exciting and dramatic turn in the early 1990s, with the article by Mary Tinetti in the New England Journal of Medicine.1 Her study demonstrated that proper attention to falls risk factors in a primary care setting could actually reduce the number of falls these people would have (absolute risk reduction of 12%, number needed to treat to prevent one fall is 8). This demonstrated clearly that with a comprehensive interdisciplinary approach, complex functional issues in the elderly could be systematically approached and improved.

The new issue in falls prevention is how to reach all those at potential risk. With our rapidly aging population, the individual doctor-patient interaction, while very important, is not enough. The next step in falls prevention is the implementation of community-based programs (e.g., exercise programs) that can have a broader impact. These programs have shown clear efficacy in high quality clinical trials, and we now need to determine if they will be effective when introduced into the community at large.

This issue of Geriatrics & Aging has been designed to provide the tools for primary care physicians to assess the risk factors for falls in their elderly patients, and to allow them to prevent some of these devastating occurrences. Gabriele Meyer, Andrea Warnke and Ingrid Mühlhauser tackle the general topic of fall and fracture prevention in the elderly, and Dr. Fiona E. Shaw addresses the thorny problem of falls in those with dementia. Drs. Nadine Gagnon and Alastair Flint review one of the crippling consequences of falls, namely fear of falling, which dramatically reduces function and quality of life. Dr. Boyd Swinburn and Richard Sager give some practical advice in their article on the promotion of exercise prescriptions for elderly populations. Dr. Margaret Grant provides treatment strategies for one of the most potent risk factors for falls, orthostatic hypotension, while Dr. Karim Khan, et al. present strategies for the optimal delivery of falls prevention programs to the elderly in the community.

Enjoy this issue.

Reference

  1. Tinetti ME, Baker DI, McAvay G, et al. A multifactorial intervention to reduce the risk of falling among elderly people living in the community. N Engl J Med 1994;331:821-7.

Considerations in the Management of Epilepsy in the Elderly

Considerations in the Management of Epilepsy in the Elderly

Teaser: 

Warren T. Blume, MD, FRCPC, London Health Sciences Centre, University Campus, Epilepsy Unit; Professor, University of Western Ontario, London, ON.
David J. Harris, LRCP(Lond), MRCS(Eng), FRCPC, MRCPsych, London Health Sciences Centre, South Street Campus, Geriatric Mental Health Program; Associate Professor, University of Western Ontario, London, ON.

Management of epilepsy in an elderly person requires accurate classification of seizures, a sufficient neurologic assessment to define etiology, and awareness of the patient's health and social situation. Treatment with an antiepileptic drug requires an understanding of the general health of the patient and the nature of all medications being given to the patient by other physicians. Effective communication with the patient, spouse, any adult children or other caregivers aims to ensure that all understand the goals of treatment, medication side effects and monitoring methods. Concomitant illness such as neurological, psychiatric, metabolic or cardiac disorders will require individualization of treatment plans.
Key words: epilepsy, elderly, differential diagnosis, management.

Recent Developments in the Assessment and Management of Hypertension: CHEP, ALLHAT and LIFE

Recent Developments in the Assessment and Management of Hypertension: CHEP, ALLHAT and LIFE

Teaser: 

Kelly B. Zarnke, MD, MSc, Departments of Medicine, Epidemiology & Biostatistics, University of Western Ontario, London, ON, and on behalf of the Canadian Hypertension Education Program (CHEP).

Poor blood pressure control, particularly among the older Canadian population, remains an important cause of preventable cardiovascular morbidity and mortality. It behooves Canadian health care workers to identify, treat and control hypertension. Recent trials, including ALLHAT and LIFE, add to the information clinicians need to achieve these targets. ALLHAT establishes the central role of thiazide-like diuretics for many hypertensive patients. ALLHAT demonstrates that good blood pressure control can be achieved in the majority of hypertensive patients if a systematic effort is maintained. LIFE adds important information regarding angiotensin receptor blockers as an effective alternative to the other commonly used classes of antihypertensive drugs, particularly among patients with diabetes or isolated systolic hypertension. Finally, the Canadian Hypertension Education Program will continue to produce and disseminate annually updated systematic reviews and recommendations related to the assessment and management of hypertension.
Key words: hypertension, recent clinical trials, clinical practice guidelines.

Management of Premalignant Gastrointestinal Lesions

Management of Premalignant Gastrointestinal Lesions

Teaser: 

Clarence K.W. Wong, MD, FRCPC, Gastroenterologist and Clinical Lecturer, Division of Gastroenterology, University of Alberta; Consultant, Cross Cancer Institute, Alberta Cancer Board, Edmonton, AB.

Introduction
Gastrointestinal malignancies collectively account for the greatest number of cancer deaths in Canada.1 This is particularly evident in the elderly population in which 90% of all new cancers are diagnosed in individuals over the age of 45.2 Of these new cancers, one in five are gastrointestinal cancers. As these malignancies are often lethal, improved survival depends on preventive strategies to effectively detect and manage the associated precursor conditions. This paper will review the premalignant conditions associated with three common gastrointestinal cancers. Effective management of conditions leading to esophageal, gastric and colon cancers can greatly reduce the burden of disease among the geriatric population.

Esophageal Cancer
Cancers of the esophagus are lethal, with a death to case ratio of 1.11.1 Although this estimate is high due to incomplete registration of new cases, it underscores the lack of effective treatment for this disease. Until recently, squamous cell carcinomas were the most common type of esophageal cancer. However, in the last few decades the incidence of esophageal adenocarcinomas has increased exponentially. It is likely that this increase is linked to a rise in incidence of its only known risk factor, Barrett's esophagus.

Evaluation and Treatment of Constipation

Evaluation and Treatment of Constipation

Teaser: 

Marisa Battistella, BScPhm, Pharm D, Education Coordinator & Hemodialysis Pharmacist, Pharmacy Department, University Health Network, Toronto, ON.
Shabbir M.H. Alibhai, MD, MSc, FRCP(C), Staff Physician, University Health Network, Toronto, ON.

Constipation is a common symptom in patients of all ages, but its occurrence is highest among persons 65 years of age or older.1,2 Constipation has been shown to diminish both quality of life and feeling of well-being.3-5 Although constipation can have many causes, it is most often functional or idiopathic.5,6 Furthermore, constipation can lead to serious complications such as malnutrition, fecal impaction, fecal incontinence, colonic dilation and even perforation of the colon.7

Definition
Constipation has different meanings to patients and physicians. A patient's perception of constipation may include not only the objective observation of infrequent bowel movements but also subjective complaints of straining with defecation, incomplete evacuation, abdominal bloating or pain, hard or small stools or a need for digital manipulation to enable defecation. Because the definition of constipation can be subjective, an international committee has recommended an operational definition of chronic functional constipation in adults.