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Tricuspid Valve Disease in Older Adults: Diagnosis and Management

Tricuspid Valve Disease in Older Adults: Diagnosis and Management

Teaser: 

Mercè Roqué, MD, Cardiovascular Institute, Hospital Clínic de Barcelona, Spain.

Ernane D. Reis, MD, Department of Surgery, Mount Sinai School of Medicine, New York, U.S.A.

Introduction
Tricuspid valve disease is rarely an isolated condition. Most cases are associated with other valvular or myocardial disease, pulmonary hypertension or systemic disorders. The tricuspid valve is located in the outflow tract of the right ventricle, and is the largest heart valve with an area of approximately 11cm2. The valvular apparatus includes the fibrous annulus, the leaflets (anterior, septal and posterior), the tendinae chordae and the papillary muscles. Given that the tricuspid valve's main function is to regulate inflow to the right ventricle, conditions affecting the tricuspid valve generally have an impact on the right atrium and the venous circulation. Similarly, disorders affecting the left or right ventricle or the pulmonary arterial system can impair tricuspid valve function.

This review focuses on the most common causes of tricuspid stenosis (TS) and regurgitation (TR) in older adults. In these patients, functional tricuspid regurgitation is by far the most frequent tricuspid disorder. In the evaluation of tricuspid valve disorders, a thorough physical examination is essential to provide information for a correct diagnosis. An overview of the most useful ancillary tests and treatment options is also presented.

Management of Diabetic Foot Ulcers -- June 2002

Management of Diabetic Foot Ulcers -- June 2002

Teaser: 


Prevention is the Best Form of Care

Madhuri Reddy, MD, Dermatology Day Care (Wound Healing Clinic) Sunnybrook and Women's College Health Care Centre, Toronto, ON, Associate Editor, Geriatrics & Aging.

R. Gary Sibbald, BSc, MD, FRCPC (Med), FRCPC (Derm), MACP, DABD,
Associate Professor and Director of Continuing Education
Department of Medicine, University of Toronto, Toronto, ON.

Introduction
The most common reason for hospitalization of individuals with diabetes is a foot wound. Persons with diabetes are forty times more likely than are non-diabetics to have a non-traumatic amputation, and the most common precipitating events are infection in a non-healing ulcer and gangrene. Those who undergo a lower-extremity amputation have a 50% chance of amputation in the contralateral limb within five years.1

The systemic nature of diabetes requires a team approach, involving wound care specialists (e.g. physicians, nurses) and foot care specialists (e.g. chiropodists, podiatrists, occupational therapists, pedorthists). Prevention of ulcers is the best form of care for the diabetic foot. Teaching prevention should occur in the setting of comprehensive diabetic care.

Hallucinations in Patients with Parkinsonism: Clinical Features and Management

Hallucinations in Patients with Parkinsonism: Clinical Features and Management

Teaser: 

David J Burn, MD, MA, FRCP, Consultant & Senior Lecturer in Neurology, Regional Neurosciences Centre, Newcastle General Hospital, Westgate Road Newcastle upon Tyne, UK.

Ian G McKeith, MD, FRCPsych, Professor of Old Age Psychiatry, Department of Old Age Psychiatry, Institute for Ageing and Health Wolfson Research Centre, Newcastle General Hospital, Newcastle upon Tyne, UK.

Introduction
Parkinsonism is a common problem, particularly in the elderly. One percent of the population over the age of 65 has Parkinson's Disease (PD), rising to 2% over the age of 80. Parkinsonism is also a core feature of dementia with Lewy bodies (DLB), the second most common cause of neurodegenerative dementia, after Alzheimer disease (AD). To differentiate patients with PD who develop cognitive impairment from DLB, Consensus Criteria stipulate that parkinsonism must be present for 12 months or less for a patient with dementia to qualify for a diagnosis of DLB.1 If the extrapyramidal features are present for longer than this before the dementia develops, the diagnosis is referred to as PD with dementia.

Although parkinsonism occurs in numerous other neurodegenerative diseases, including multiple system atrophy, progressive supranuclear palsy and corticobasal degeneration, as well as AD, hallucinations are less common.

Ovarian Cancer in Older Women: Management and Treatment Options

Ovarian Cancer in Older Women: Management and Treatment Options

Teaser: 

Natalie S. Gould MD, Fellow and Clinical Instructor
D. Scott McMeekin MD, Assistant Professor Section of Gynecologic Oncology,
Department of Obstetrics and Gynecology
University of Oklahoma Medical Center, Oklahoma City, OK, USA.

Ovarian cancer is a disease of older women, with 48% over the age of 65 at diagnosis.1 It is also the most deadly of gynecologic malignancies, accounting for more deaths than cervical and endometrial carcinoma combined in the US. An estimated 23,400 new cases of ovarian cancer will be diagnosed in 2001 with 13,900 deaths in the US.2 As our population ages, the number of women affected by ovarian cancer will increase. Cancer limited to an ovary is typically silent and discovered incidentally on exam or at surgical exploration for other reasons. Patients with disease that has spread beyond the ovaries may present with vague gastrointestinal symptoms, bloating, diarrhea, pain and changes in bowel or bladder habits. On physical exam, patients will have a pelvic mass and often ascites. Due to the absence of symptoms until the malignancy has spread beyond the ovaries, and the lack of good screening tests, approximately 70% of patients present with advanced disease and overall survival is poor.3 (Table 1).

Initial management involves cytoreductive surgery aimed at removal of the greatest volume of tumour (Table 2).

Non-Pharmacological Management of Pain

Non-Pharmacological Management of Pain

Teaser: 

Jane Oshinowo, RNEC, Primary health care Nurse Practitioner,
York Community Services, Toronto, ON.

Introduction
Pain is more than the perception of a nociceptive stimulus in the peripheral or central nervous system. It is "what the person says it is."1 Ferrell1 developed a conceptual model that identifies four dimensions of pain and their impact on a person's quality of life (Figure 1). This model can be used to enhance the caregiver's understanding of the patient's experience of pain. Pain can be acute, chronic or chronic malignant in nature. In the elderly, illness tends to be chronic and the pain is often related to a degenerative condition. However, the elderly do experience acute pain. Whether acute or chronic, pain is more difficult to assess in the cognitively impaired elder. Despite our recognition of the global impact of pain on the individual, and the morbidity and mortality associated with inadequately managed pain, 25-50% of community dwelling elders are living in pain.2

Chronic pain management today is multidimensional. Analgesics tend to be the mainstay of therapy. However, non-pharmacological therapies are currently under investigation and in practice as complementary or alternative therapies to medications. This field is very large and continues to expand. For the purposes of this article, only the more commonly used and better-researched therapies will be discussed.

Management of Dysarthria in Amyotrophic Lateral Sclerosis

Management of Dysarthria in Amyotrophic Lateral Sclerosis

Teaser: 

Kathryn M. Yorkston, Ph.D., BC-NCD, Department of Rehabilitation Medicine, University of Washington, Seattle, WA.
David Beukelman, Ph.D., Department of Special Education and Communication Disorders, University of Nebraska, Lincoln, Munroe-Meyer Institute for Genetics and Rehabilitation, University of Nebraska, Omaha, NE.
Laura Ball, Ph.D., Munroe-Meyer Institute for Genetics and Rehabilitation, University of Nebraska, Omaha, NE.

Summary
This article describes intervention for dysarthria associated with amyotrophic lateral sclerosis (ALS). Five critical periods are presented including a stage with normal speech, detectable speech disturbance, behavioural intervention, use of augmentative communication, and loss of useful speech. Intervention strategies at each of these stages are outlined with the goal of maintaining functional communication regardless of the severity of dysarthria.

ALS is a rapidly progressive degenerative disease of unknown etiology involving the motor neurons of both the brain and spinal cord.1 The symptoms characteristic of ALS are generally classified by site of involvement (that is, upper motor neuron versus lower motor neuron) and by whether spinal nerves (those innervating the arms and legs) or bulbar nerves (those innervating the muscles of speech and swallowing) are involved.

Newer Therapies in the Management of Osteoporosis

Newer Therapies in the Management of Osteoporosis

Teaser: 

Jan Bruder, MD, Assistant Professor and Director of Osteoporosis Metabolic Bone Clinic, Division of Endocrinology, University of Texas Health Science Center, Department of Medicine, San Antonio, TX, USA.

Introduction
Osteoporosis is a disease characterized by low bone mass and bone strength, resulting in an increase in bone fragility and susceptibility to fractures.1 It is asymptomatic prior to fractures, which most commonly occur in the vertebral body, hip and forearm.

Dual energy x-ray absorptiometry is the technology used to measure bone mineral density at the sites of interest. This technology has revolutionized our approach to this disease. In 1994, the World Health Organization (WHO) published diagnostic guidelines for osteoporosis, which are based on an individual's bone mineral density (BMD) according to a T-score.2 The T-score is defined as the number of standard deviations (SD) above or below the mean BMD at peak bone mass at age 30 years. A T-score of -2.5 or lower defines osteoporosis. At risk individuals can now be diagnosed early, thereby allowing the use of highly effective interventional strategies which prevent further bone loss and potentially debilitating fractures. Unfortunately, currently once significant bone mass has been lost, there are no commercially available therapies that are proven to increase bone density. This will likely change in the next few years.

Pharmacologic Pain Management in the Elderly

Pharmacologic Pain Management in the Elderly

Teaser: 

Bill McCarberg, MD
Director of Pain Services, Board of Directors, American Pain Society
Department of Family Medicine, Kaiser Permanente Medical Center, San Diego, CA, USA.

 

As humans age, they invariably become more susceptible to disease, which can impair function and enjoyment of life and pose significant challenges to the health care system. Osteoarthritis, the most common joint disease, affects over 18% of adults in Ontario.1 Pain has also been associated with a three- to seven-fold increased prevalence of inability to perform daily tasks in the non-institutionalized elderly in Canada.2

More than half of elderly persons in the US are estimated to experience pain daily,3 and recent initiatives in the US have focused attention on the need to treat pain. The Joint Commission on Accreditation of Healthcare Organizations recently introduced new pain management standards to require better pain medicine in hospitals and other institutions as part of their accreditation process.

Non-pharmacologic Therapy
Although medications are commonly required to manage pain and maintain function in elderly patients, non-pharmacologic therapy remains a cornerstone of treatment. It should be started prior to the initiation of pharmacologic therapy, when possible, and be maintained throughout the pain management process.

Management of Headache in the Elderly Patient

Management of Headache in the Elderly Patient

Teaser: 

D'Arcy Little, MD, CCFP
Director of Medical Education, York Community Services, Toronto, ON,
and Academic Fellow, Department of Family and Community Medicine,
University of Toronto, Toronto, ON.

 

Introduction and Epidemiology
While symptom complaints tend to increase as the population ages due to age and comorbid conditions, the prevalence of headaches actually decreases in the elderly compared to their younger counterparts.1,2,3 However, headache is still very common in this age group and causes significant morbidity. It is the 10th most common reported symptom in women, and the 14th most common symptom in men over the age of 65 living in the community.1,2,3 A large cohort study found that 11% of women over the age of 65 years and 5% of men over this age reported frequent headaches.1

While most (two-thirds of) headaches in the elderly result from benign causes such as tension-type, migraines and cluster headaches, one-third of headaches in this age group arise secondary to systemic disease and primary intracranial lesions.2,4 This is significantly different from the situation in younger patients, where only 10% of headaches are caused by such significant conditions (Table 1).2,4 Another difference in headaches between the young and old is the fact that even benign dysfunctional headaches (e.g. migraine, tension-type, cluster) can have an atypical presentation in the elderly.

Management of Venous Ulcers in the Elderly

Management of Venous Ulcers in the Elderly

Teaser: 

Morris D. Kerstein, MD
Professor and Vice-Chairman,
Director of Research and Education,
Department of Surgery, Mount Sinai School of Medicine,
New York, NY, USA.

Ernane D. Reis, MD
Assistant Professor
Department of Surgery,
Mount Sinai School of Medicine,
New York, NY, USA.

 

Venous leg ulcers influence the physical, financial and psychological well-being of patients, and result in an estimated two million workdays lost, annually. Despite a variety of therapeutic options, venous leg ulcers remain a substantial management challenge to the health-care professional. Some form of lower extremity venous disease is present in nearly 30% of the American adult population. Venous leg ulcers are often debilitating sequelae of venous insufficiency, and account for 80-90% of leg ulcers reported. A quality-of-life study reported that 65% of chronic-leg-ulcer patients had severe pain, 81% experienced reduced mobility, and nearly 100% reported a negative impact of their disease on work capacity.

Manifestations of venous insufficiency may include dilated superficial veins, with or without dilated tributaries of the deep vein system, swelling, leg pain, heaviness and changes in the skin (hyperpigmentation, venous dermatitis, eczema with dryness and itching). Ultimately, the adverse effects of venous disease appear as skin ulceration of lipodermatosclerosis.