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Choosing a First-Line Drug for Older Adults with Hypertension: An Evidence-Based Approach

Choosing a First-Line Drug for Older Adults with Hypertension: An Evidence-Based Approach

Members of the College of Family Physicians of Canada may claim MAINPRO-M2 Credits for this unaccredited educational program.

www.cfpc.ca/Mainpro_M2
Teaser: 

James M. Wright, MD, PhD, CRCP(C), Professor, Departments of Anesthesiology, Pharmacology & Therapeutics and Medicine, University of BC, Coordinating Editor, Cochrane Hypertension Review Group, Vancouver, BC.

Abstract
Choosing the optimal first-line drug for patients with hypertension must address a hierarchy of treatment goals: reduction in mortality and morbidity, efficacy in lowering blood pressure, ensuring tolerability, and minimizing cost. This article examines the evidence for the different classes of first-line antihypertensive drugs in light of these four goals. The evidence indicates that first-line low-dose thiazides are better than or equivalent to other antihypertensive drug classes for each of the goals of therapy in both people with hypertension in general and in older adults ≥ 60 years of age.
Keywords: hypertension, thiazide, first-line, older adults, evidence-based.

Restorative Home Care Services

Restorative Home Care Services

Members of the College of Family Physicians of Canada may claim MAINPRO-M2 Credits for this unaccredited educational program.

www.cfpc.ca/Mainpro_M2
Teaser: 

Gill Lewin, BSc Hons Psych, MSc Clin Psych, MPH, PhD, FAAG, Professor, Centre for Research on Ageing, Curtin Health Innovation Research Institute, Curtin University of Technology; Research Director, Silver Chain, Perth, Western Australia.

Abstract
Restorative home care services are being developed around the world. While having somewhat different origins and structures, these services share a capacity building paradigm and are designed to assist older people to maximize their functioning and reduce their need for ongoing assistance to complete everyday tasks. The evidence for the effectiveness of these services is positive though limited. In comparison to usual home care, they have been shown to increase individuals' functional abilities, their self-rated health, and their confidence and well-being, and to decrease individuals' need for ongoing care. More research is needed to address a range of unanswered questions about these services.
Keywords: home care, restorative, older adults, functional improvement, service use.

Management of Primary Colon Cancer in Older Adults

Management of Primary Colon Cancer in Older Adults

Teaser: 

Robin McLeod, MD, Division of General Surgery, Mount Sinai Hospital, University of Toronto; Department of Health Policy, Management and Evaluation, University of Toronto; Zane Cohen Digestive Diseases Clinical Research Centre; Samuel Lunenfeld Research Institute, Mount Sinai Hospital, Toronto, ON.
Selina Schmocker, Zane Cohen Digestive Diseases Clinical Research Centre; Toronto General Research Institute, University Health Network, Toronto, ON.
Erin Kennedy, MD, PhD, Division of General Surgery, University Health Network, University of Toronto; Department of Health Policy, Management and Evaluation, University of Toronto; Zane Cohen Digestive Diseases Clinical Research Centre; Toronto General Research Institute, University Health Network, Toronto, ON.

Colorectal cancer is the third most common cancer worldwide, and more than half of those newly diagnosed with colon cancer are over the age of 70 years. Despite the large proportion of patients over the age of 70 diagnosed with colon cancer annually, this age group is significantly underrepresented in clinical trials and, therefore, there is little high-quality evidence on which to base treatment decisions or treatment guidelines. This article reviews the management of primary colon cancer in older adults, including screening, presentation and diagnosis, treatment, and follow-up in this population.
Key words: colon cancer, colorectal cancer, screening, tumour, older adults.

Dr. Anne Horgan and Dr. Shabbir Alibhai share their views on the current status of research in Colorectal Cancer

Dr. Anne Horgan and Dr. Shabbir Alibhai share their views on the current status of research in Colorectal Cancer

Teaser: 
The incidence of colorectal cancer increases with age, with approximately 60% of patients in the US (and similar numbers in Canada) older than 65 years at diagnosis and 40% over the age of 75. As highlighted by McLeod et al in this issue, the management of older patients with colorectal cancer is challenging. The prevailing difficulty is the lack of randomized trial data to support and guide treatment decisions. Pivotal trials establishing the standard of care for this disease have tended to enroll younger patients. For example, the median age of patients enrolled in phase III studies of systemic chemotherapy for metastatic colorectal cancer is commonly 60-64 years,1,2 with fewer than 20% of patients being 70 years and older. In the large colorectal screening studies, older patients are again under-represented, with only 15-17% of randomized patients being 70 years or older.3, 4 Similarly, elderly patients are less likely to be enrolled in surgical trials than younger patients.5 With this absence of prospective data, evidence regarding safety and efficacy of interventions in older patients with colorectal cancer has come mainly from subgroup analyses or meta-analyses of large randomized clinical trials, both in the adjuvant and metastatic disease settings. These analyses suggest that older patients gain similar benefit from chemotherapy as do younger patients, with little difference in the rates of severe toxicity.6 This should be reassuring to clinicians.  The relation between age and outcomes from colorectal cancer surgery is more complex, however. Poorer outcomes in terms of postoperative morbidity and mortality are reported with increasing age, but these are confounded by presentation with more advanced disease stage, a greater frequency of emergency surgery and fewer curative surgeries compared to younger patients.7 All of these analyses suffer from selection bias with patients in these studies generally being fit and of good performance status. Data from randomized studies will ultimately help optimize management of older patients with colorectal cancer. However, careful consideration should be given to the design of these studies.  A growing appreciation of the heterogeneity of this patient population has led to a better understanding and use of geriatric specific assessments. These assessments which evaluate functional status, comorbid medical conditions, cognitive function, psychological state, and social supports may have value in predicting postoperative complications following surgery and may help better predict tolerance to systemic therapies. Incorporation of these assessments into both the clinical trial setting and daily clinical practice is encouraged but challenging due to time constraints in busy practices. Identifying elder-specific clinical predictors of tolerability to various interventions will ultimately lead to a more tailored approach for these patients. The essential principles of managing colon cancer in the elderly are the same as in younger patients, however, as the authors state, an individualized approach is necessary. Frameworks for determining a patient’s remaining life-expectancy, risks of toxicities and operative complications, and quality of life issues must be developed and should ultimately underlie these individualized decisions. No competing financial interests declared. References: 1.    Goldberg RM, Sargent DJ, Morton RF et al. A randomized controlled trial of fluorouracil plus leucovorin, irinotecan, and oxaliplatin combinations in patients with previously untreated metastatic colorectal cancer. J Clin Oncol 2004; 22: 23-30. 2.    Seymour MT, Maughan TS, Ledermann JA et al. Different strategies of sequential and combination chemotherapy for patients with poor prognosis advanced colorectal cancer (MRC FOCUS): a randomised controlled trial. Lancet 2007; 370: 143-152. 3.    Hardcastle JD, Chamberlain JO, Robinson MH et al. Randomised controlled trial of faecal-occult-blood screening for colorectal cancer. Lancet 1996; 348: 1472-1477. 4.    Mandel JS, Bond JH, Church TR et al. Reducing mortality from colorectal cancer by screening for fecal occult blood. Minnesota Colon Cancer Control Study. N Engl J Med 1993; 328: 1365-1371. 5.    Stewart JH, Bertoni AG, Staten JL et al. Participation in surgical oncology clinical trials: gender-, race/ethnicity-, and age-based disparities. Ann Surg Oncol 2007; 14: 3328-3334. 6.    Kumar A, Soares HP, Balducci L, Djulbegovic B. Treatment tolerance and efficacy in geriatric oncology: a systematic review of phase III randomized trials conducted by five National Cancer Institute-sponsored cooperative groups. J Clin Oncol 2007; 25: 1272-1276. 7.    Surgery for colorectal cancer in elderly patients: a systematic review. Colorectal Cancer Collaborative Group. Lancet 2000; 356: 968-974.

Psychoactive Medications and Falls

Psychoactive Medications and Falls

Teaser: 

James W. Cooper, RPh, PhD, BCPS, CGP, FASCP, FASHP, Emeritus Professor and Consultant Pharmacist, College of Pharmacy, University of Georgia, Athens, and Assistant Clinical Professor of Family Medicine, Medical College of Georgia, Augusta, GA, USA.
Allison H. Burfield, RN, PhD, Assistant Professor, School of Nursing, College of Health and Human Services, University of North Carolina-Charlotte, Charlotte, NC, USA.

The high incidence of falls among older adults leads to increased health care costs and decrements in functional status. Psychoactive medications consumed by older adults are often implicated in falls. This article briefly reviews the associations between falls and psychoactive medications, with a focus on the long-term care setting, and offers an assessment method and strategies to reduce the risk of certain classes of medications known to contribute to fall risk.
Key words: falls, medications, psychoactive load, interventions, older adults.

Normal Aging of Teeth

Normal Aging of Teeth

Teaser: 

Gregory An, DDS, MPH, Director, Geriatric Dentistry Fellowship Program, Harvard School of Dental Medicine, Harvard University, Cambridge, MA, USA.

The rate of edentulism (being toothless) is declining in older adults. Thanks to more effective community-based prevention programs , reliable treatment methods, and improved dental technology, people are retaining more of their natural teeth. Since it has been only recently that people have lived as long and retained so much of their teeth, research done in the area of normal and abnormal aging of the teeth is limited. This article reviews some of the current knowledge regarding normal aging of the different structures of teeth and clinical manifestations of advancing age. More specifically, age-related changes in tooth enamel, dentin, pulp, and cementum are reviewed.
Key words: aging, dental, teeth, older, adults.

Treating Infectious Disease in the Older Adult

Treating Infectious Disease in the Older Adult

Teaser: 

Sir William Osler referred to pneumonia as “the old man’s friend,” correctly realizing that infection is a common cause of death in old age. Some hundred years later, even in this age of potent antimicrobial agents, Osler’s assessment still holds true. Disease frequently presents in an atypical manner in old age, and often fever in bacterial infections is a late manifestation, following delirium, falls, or “taking to bed.” Delay in treatment may result in poor outcomes but, on the other hand, overtreatment may be likely to harm an older person. One of the most difficult environments in which to accurately diagnose infection is the long-term care (LTC) facility. The residents tend to be more frail and more likely to be cognitively impaired than community-dwelling patients coming to their family doctor’s office; therefore, the utility of the history is much decreased. As well, the vast array of diagnostic tools available in the acute hospital is relatively inaccessible in LTC, and the transfer to acute care from LTC often results in deleterious consequences to the patient.

Our focus in this issue is infectious disease in the older adult, and our CME article addresses a major public health concern: “Long-term Care for Older Adults: Reservoirs of Methicillin-Resistant Staphylococcus Aureus and Vancomyin-Resistant Enterococci” by Drs. D.F. Gilpin, M.M. Tunney, N. Baldwin, and C.M. Hughes. We all know that we should not treat asymptomatic bacteriuria, but most of us are unsure whether our patients are truly asymptomatic or not. The article “Asymptomatic Bacteriuria: To Treat or Not to Treat” by Dr. Dimitri M. Drekonja will address this clinical conundrum. I still remember treating my first case of severe antibiotic-induced colitis as an intern. It was in the wife of my physician-in-chief and occurred two months before clindamycin-associated pseudomembranous colitis was first described in a classic article in the Annals of Internal Medicine. Since then, C. difficile infection has become a major problem in older patients, particularly for those in acute hospital or LTC. This important topic is addressed in the article “Treatment and Prevention of Clostridium difficile Infection in the Long-Term Care Setting” by Dr. Natasha Bagdasarian and Dr. Preeti N. Malani.

Further, we offer our usual collection of important and informative articles on medical care of older people. In geriatric medicine, it has been frequently noted that the risk factors for each of the “geriatric giants” overlap to a great degree. In our Cardiovascular column, our frequent and much valued contributor, Dr. Wilbert S. Aronow, asks the question “Bone Mineral Density: What Is Its Relationship to Heart Disease?” Our Dementia column reviews the difficult area of screening in the article “Screening for Dementia: First Signs and Symptoms Reported by Family Caregivers” by Dr. Mary Corcoran. There is more evidence arriving on a regular basis to show how important our teeth are for both quality of life and for good health, so it is very appropriate that our Biology of Aging column by Dr. Gregory An discusses “Normal Aging of Teeth.” Our Falls and Fitness column, “Psychoactive Medications and Falls” is written by Dr. James Cooper and Dr. Allison Burfield. Our featured geriatrician this month is Dr. Angela Juby, the president of the Canadian Geriatrics Society.

Enjoy this issue,
Barry Goldlist

Approach to Thrombocytopenia in Older Adults

Approach to Thrombocytopenia in Older Adults

Teaser: 

Mohammed E. Hussain, Department of Medicine, Mount Sinai Hospital, Toronto, ON.
Dominick Amato, Department of Medicine, Mount Sinai Hospital; Department of Medicine, University of Toronto, Toronto, ON.

Thrombocytopenia, whether symptomatic or not, is a relatively common finding in clinical medicine. The causes of thrombocytopenia are many, and all of these may be found at all ages. However, just as the frequencies of these causes vary between pediatric and adult age-groups, so too is there variation between younger adults and older individuals. Also, the pathophysiological approach to thrombocytopenia (decreased production, increased destruction, sequestration, dilution) remains just as valid to the seasoned hematologist as to the neophyte. In this article, we provide a suggested approach to the patient with thrombocytopenia, with emphasis on the more common causes in older adults.
Key words: thrombocytopenia, platelets, bleeding disorders, primary hemostasis, older adults.

Managing Cancer in Older Adults

Managing Cancer in Older Adults

Teaser: 

I am someone who believes fervently in screening for colon cancer, and have had two colonoscopies (separated by 5 years). Even those at normal risk seem to benefit from some form of screening, and I have been particularly concerned because I have had close relatives afflicted by the disease. However, it is clear that many people who should know better refuse to be screened. Even simple screening tests such as fecal occult blood testing require people to endure relatively unpleasant activities, and colonoscopy prep is hardly fun.

Independent of my views, it is obvious that the rising prevalence of cancer of all types in Canada is a result of the aging of our population and the relative decline in cardiovascular mortality. Many of today’s cancer patients are relatively frail, or become so while getting treatment, and attention to geriatric medicine principles in these patients is important. Most oncology training programs in the United States incorporate a geriatric module to cover these issues. We are lagging a bit behind in Canada in this respect, but I am proud to say that one of the nation’s outstanding leaders in the field of geriatric oncology is our own senior editor, Dr. Shabbir Alibhai. The focus of this month’s edition is how cancer management is altered in older adults.

Our continuing education article, “Management of Primary Colon Cancer in Older Adults,” is by Dr. Robin McLeod, Selina Schmocker, and Dr. Erin Kennedy. Obviously, I hope never to have to worry about this because I have a commitment to screening! The very common ( and currently in the press) topic of “Multiple Myeloma in Older Adults: An Update” is written by Dr. Madappa N. Kundranda and Dr. Joseph Mikhael. The commonest cancer in older individuals is addressed in the article “Basal Cell Carcinoma” by Dr. Christian A. Murray and Dr. Erin Dahlke.

As well, we have our usual collection of articles on varied topics. Our Cardiovascular column is an “Update on the Management of Atrial Fibrillation in Older Adults” by Dr. Hatim Al Lawati, Dr. Fatemeh Akbarian, and Dr. Mohammad Ali Shafiee. Our Dementia article is on a common and difficult topic, “Withholding and Withdrawing Life-Sustaining Treatment in Advanced Dementia: How and When to Make These Difficult Decisions,” by Dr. Dylan Harris. In the area of nutrition, we have the article “Nutrition Guidelines for Cancer Prevention: More Than Just Food for Thought” by Kristen Currie, Sheri Stillman, Susan Haines, and Dr. John Trachtenberg. This is a natural extension from our focus this month. Our Community Care article is “Community-Based Health Care for Frail Seniors: Development and Evaluation of a Program” by Dr. Douglas C. Duke and Teresa Genge. Finally we feature one of Canada’s most prominent physicians in our “I Am a Geriatrician” column, namely Dr. Howard Bergman.

Enjoy this issue,
Barry Goldlist

Update on the Management of Atrial Fibrillation in Older Adults

Update on the Management of Atrial Fibrillation in Older Adults

Teaser: 

Hatim Al Lawati, MD, FRCPC, Cardiology Resident, Division of Cardiology, Faculty of Medicine, University of Toronto, Toronto, ON.
Fatemeh Akbarian, MD, Dermatologist, Research Fellow, University of Toronto, Toronto, ON.
Mohammad Ali Shafiee, MD, FRCPC, General Internist, Nephrologist, Department of Medicine, Toronto General Hospital, University Health Network; Clinician Teacher, University of Toronto, Toronto, ON.

Atrial fibrillation (AF) is by the far the most common cardiac rhythm disturbance encountered in clinical practice. It is associated with significant morbidity and mortality and has potentially lifelong implications in terms of therapy and complications. This disease is more commonly seen now given the increased life expectancy and the remarkable advances made in health care. The already at-risk older adult population is particularly vulnerable to complications from AF, especially embolic cerebrovascular events. This article reviews the evidence-based management of AF with a particular focus on the older adult population.
Key words: atrial fibrillation, older adults, stroke, rate control, rhythm control, stroke prophylaxis, anticoagulation.