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Nutrition and Dementia among Older Adults

Nutrition and Dementia among Older Adults

Teaser: 

Click here to view the entire report from the 28th Annual Scientific Meeting of the Canadian Geriatrics Society

Nutrition and Dementia among Older Adults

Speaker: Carol Greenwood, PhD, Professor, Department of Nutritional Sciences, University of Toronto; Senior Scientist, Kunin-Lunenfeld Applied Research Unit, Baycrest Centre, Toronto, ON.

Dr. Carol Greenwood contextualized her discussion’s theme of nutrition and dementia as contributing to considerations of the environmental influences posing risk for cognitive decline and dementia. While dementia has important genetic roots, a large causative factor is environmental exposure. In cases of disease onset at >80 years of age, studies have suggested that ~60% relates to this factor.

Dietary Patterns that Increase Risk of Cognitive Decline

To understand the risk mediated by environmental exposure, she recommended that listeners focus on chronic diet rather than on instances of good or poor intake. The connection between nutrition and dementia relates to the underlying idea that neurons require nutritional support; altered nutrition equates to altered neuronal metabolism. Sound nutrition maintains brain insulin signaling, needed for learning and memory. Clinicians should aim to promote dietary habits that maintain brain neurotrophin levels, which support synaptic plasticity needed for memory consolidation; further, good diet and appropriate nutrient intake can reduce inflammation and oxidative damage, and maintain the cerebrovasculature’s capacity to supply essential nutrients to the brain.

Advances in this area of research could help to remediate an isolationist philosophy that can pervade viewpoints on chronic disease. The brain is highly sensitive to the health of the body, and through dietary modification it is possible to exert direct impact on diet-associated conditions such as cardiovascular disease (CVD), type 2 diabetes, and depression.

Many epidemiologic studies on diet are available, indicating that excess caloric intake leads to oxidative stress. Dr. Greenwood and colleagues have examined the role of fat intake. High fat intake, particularly of saturated and polyunsaturated fats, along with a dearth of Omega fats, are typical of the North American diet. Studies have shown that diets low in fruits, vegetables, whole cereal grains, and low in fish oils are associated with higher risk of dementia. This diet profile also associates with CVD, diabetes, depression, and other inflammatory and chronic disease states. The adverse effects on the brain are not simple, and multiple mechanisms are likely involved; separating the role of chronic disease from a direct impact on brain function would distort the effects.

Fish oils exemplify how individual nutrients can modulate multiple neuronal pathways. Studies involving fish oils and dementia risk have found the individual role hard to isolate because they, as all nutrients, have multiple effects in the body. As the Omega fats are incorporated into dietary recommendations the so-called physiologic role of the nutrient versus the pharmacologic role blurs. Incorporating the Omega fats on a wholistic nutritional basis is the sound approach, one that “nudges” the system. The other seeks to exert a large pharmacological impact with a “targeting and isolating” approach through supplements or food enrichment (e.g., eggs). Such an approach overlooks other aspects of fish protein that are valuable.

Similarly, investigations of health outcomes associated with altered antioxidant exposure have isolated micronutrients and supplied them in supplemental form, producing equivocal data. However, measuring the effects of this consumption should not be extrapolated to the effects of a dietary pattern that incorporates micronutrients on a grams per day nutritional intake. The targeted approach also overlooks that the full nutritional cocktail is more important (e.g., the synergistic aspect) than consuming any one individual compound. Food constituents work together.
These are pressing issues given the population-wide changes in health markers. Individuals with central adiposity (associated with development of the metabolic syndrome) are a “time bomb” of comorbidities, she stated. New study results suggest that central obesity in midlife increases dementia risk independent of diabetes and cardiovascular comorbidities; individuals with the greatest degree of central obesity bear a threefold increase of cognitive decline.1

The Mediterranean Diet
The needed clinical approach for such patients supports changing eating patterns, and the burden of evidence points toward the Mediterranean diet (Figure 1). The beneficial effects relate directly to increased fruit, vegetable and fish intake and reduced red meat consumption. Recent evidence for the approach was provided by a prospective study of 2,258 community-based nondemented individuals in New York; those with higher adherence to the Mediterranean diet had lower risk for Alzheimer’s disease (AD).2

The Role of Type 2 Diabetes and Glycemic Control
Increasing evidence suggests that diabetes per se appears to be a risk factor for cognitive decline, necessitating aggressive glycemic control in hyperglycemic patients.

Evidence for the interrelationship of glycemic control and dementing illness has been drawn from animal studies, and Dr. Greenwood and colleagues have investigated the effect of typical North American dietary patterns on cognitive performance in rats, specifically on learning and memory. Performance decrements were clearly associated with high saturated fat consumption; rats fed this diet were most likely to show random/chance performance in testing.

The task is to identify which qualities of the high saturated fat diet compromise cognitive function, and to disentangle these effects from diabetes’ effects. Dr. Greenwood cited studies with standard neuropsychiatric assessment results of hyperglycemic older adults, looking specifically at immediate and delayed recall (the latter calls on hippocampal function). Results show those more insensitive to insulin exhibit worse performance. With age, lost insulin sensitivity relates to impaired memory function.

Chronic Disease and Enhanced Dementia Risk

Current research further suggests that insulin resistance may outweigh the effects of fat consumption on cognitive decline. Recent studies using structural imaging have cast light on the relationship between diabetes and cognition. One study investigating loss of hippocampal function in older individuals not yet diagnostic of type 2 diabetes but with compromised glucose control found that worse control strongly associated with hippocampal atrophy. Such effects are evident among well-controlled diabetic individuals; as diabetes endures, and individuals lose metabolic control and develop hypercholesterolemia and hypertension, atrophy disperses throughout the brain, and the presence of white matter lesions becomes evident. These are the vascular components of diabetes appearing later in its course.

Insulin Signaling Is Needed for Memory Processing

Dr. Greenwood observed that while the brain is not often considered an insulin-sensitive organ, it has a high density of insulin receptors, and insulin signaling pathways play an integral role in memory consolidation. These insulin signaling pathways become disrupted in the setting of diabetes. These associations with the insulin pathway are important and may explain why the diabetic individual has poor memory performance relative to an age-matched nondiabetic, but it is not clear indication that diabetes contributes to dementia pathology.

It likely does both, Dr. Greenwood argued. The key enzyme involved in degradation of Ab protein promoting development of AD plaques is the insulin degrading enzyme, which is down-regulated in the brains of those with diabetes, slowing Ab degradation. In addition, the Ab export is impaired due to high levels of Ab in the periphery, leaving them at high risk of Ab accumulation. Diabetics also have higher levels of inflammatory cytokines, producing a disease state of Ab accumulation and corresponding inflammatory responses. The Ab inflammatory cycle facilitates plaque formation.

Studies featuring individuals with well-controlled diabetes but carrying a genetic polymorphism to tumour necrosis factor (TNF)a support this view. Such individuals are less able to manufacture TNFa and launch inflammatory responses. Those carrying the single nucleotide polymorphism (SNP) have performed better on testing and showed fewer decrements in performance. The role of inflammatory cytokines in the context of diabetes is likely integral to the maintenance of brain health, Dr. Greenwood stated.

Disturbances to the insulin signaling pathway may also contribute to the development of neurofibrillary tangles. Specifically, GSK-3, an enzyme dampened by the insulin signaling pathway, may be increased in those with diabetes. GSK-3 is important because it increases phosphorylation of the tau protein associated with development of neurofibrillary tangles, which appear in greater levels in the diabetic/obese state. The accumulation of tangles signals the move from normal loss of function into pathology. Correspondingly, some have argued that AD is the brain sequelae of diabetes, and while Dr. Greenwood expressed her disagreement, she thinks the disease occurs more rapidly in this setting.

Dietary Patterns that Promote Cognitive Well-Being
The focus of dietary recommendations for the diabetic patient should be on low-glycemic index food intake. Studies that have investigated postprandial cognitive performance found that after consuming simple carbohydrate foods, degraded processing and recall function results. It appears that insulin-induced cortisol secretion, and not changes in blood glucose, are key to this response. Increased cortisol exerts problematic effects in the hippocampus, some of which relate to oxidative stress. Further, diabetic individuals with sound antioxidant intake experience fewer decrements in cognition. The key is careful glycemic control to minimize the diabetic insult occurring repeatedly throughout the day.

Conclusion
Dr. Greenwood observed that the risk of appearing to recommend weight loss to an older population is often raised as an objection to dietary modification. There are no clear guidelines as to when physicians should stop encouraging weight loss, which is correlated with frailty risk with advancing age. The best approach to minimizing frailty, she advised, is improved nutritional intake combined with increased exercise. A more aggressive approach to dietary patterns is required, given that the incidence of diabetes and the metabolic syndrome are changing, especially as baby boomers age. Dr. Greenwood advised listeners that the pressures driving dementia upward are vastly underestimated, and now is the time to implement lifestyle modifications.

References

  1. Whitmer RA, Gustafson DR, Barrett-Connor E, et al. Central obesity and increased risk of dementia three decades later. Neurology 2008;71:1057-64.
  2. Scarmeas N, Stern Y, Tang MX, et al. Mediterranean diet and risk for Alzheimer’s disease. Ann Neurol 2006;59:912-21.

Type 2 Diabetes among Older Adults

Type 2 Diabetes among Older Adults

Teaser: 

 


Click here to view the entire report from the 28th Annual Scientific Meeting of the Canadian Geriatrics Society

Type 2 Diabetes among Older Adults

Speaker: Graydon Meneilly, MD, Professor and Department Head, Medicine Department, Faculty of Medicine, University of British Columbia, Vancouver, BC.

Dr. Graydon Meneilly introduced his discussion of type 2 diabetes among older adults by emphasizing the condition’s underestimated prevalence. One in four older adults over age 60 has diabetes, yet ~50% are unaware they have the disease, underscoring the need for improved screening protocols.

Glycemic Control in Older Adults with Diabetes
The British Geriatrics Society, in conjunction with the European Association for the Study of Diabetes, established two sets of therapeutic goals for older people, the first of which applies to healthy, active older persons with diabetes. Their fasting glucose is targeted between 4-7 mM; the 2-hour postmeal sugar at 7-10 mM, and HbA1c at <7%. The forthcoming Canadian Diabetes Association (CDA) guidelines may offer a more aggressive HbA1c target; however, Dr. Meneilly does not recommend that HbA1c be targeted lower than 6.5% in older adults, as aggressive lowering has been associated with adverse events.

Evidence suggests that fasting glucose is a poor predictor of diabetes risk among older adults; postprandial glucose has better predictive value. The target should be <8 mmol/L; at this level, the risk of cardiovascular disease (CVD) and mortality are reduced when compared with postprandial glucose levels of >11, even among patients with good fasting glucose levels.

Glycemic Goals for Frail Patients
The second set of glycemic control goals apply to frail patients and target fasting glucose from 7-9 mM, the 2-hour postprandial sugar at 10-13 mM, and HbA1c at <8.5%. The renal threshold for glucose increases with age, so patients will not develop glucosuria at these glucose levels. It is not known whether this level of hyperglycemia could increase the risk of infection, worsen cognitive function, or adversely affect important health parameters for this patient segment. Some feel more stringent criteria should apply, but data are insufficient and cannot support a recommendation.

Controlling blood sugar appropriately in frail patients is key. Many doctors outside of geriatric medicine do not know how to modify the medical approach to diabetes that frailty requires.

Treatment of Other Risk Factors
Dr. Meneilly emphasized that treatment of hypertension in older adults with diabetes significantly modifies CVD and mortality risk.1

European guidelines recommend a target of less than 140/90 mm Hg. The benefits of reduced hypertension are clearly established but level off with increasingly aggressive treatment; benefits are less once BP targets are aimed <140. Comparably, with HbA1c, there is a great effect if patients drop from 9 to 8, but a reduced health yield with a reduction from 7 to 6. Treatment that achieves a systolic BP ≤140 is the best approach, Dr. Meneilly stated.
A second pillar of sound risk factor modification targets hypercholesterolemia with statins. Data from the Heart Protection Study show that persons over 65 with diabetes treated with statins experience a reduced risk of CV events by 20%; treatment of hyperlipidemia with statins in diabetics strongly benefits vascular outcomes.2

As for specific lipid targets, European guidelines aim for an LDL of ≤2.5; forthcoming CDA targets may be more aggressive. The benefit curve for LDL seems to flatten out below 3, he observed, adding among very old adults, the higher the patient’s cholesterol, the greater the longevity benefit. Dr. Meneilly does not test lipids in patients over age 85, or alter treatment if the patient has been stable on a statin for years.

Significant progress must be made in modifying diabetes and its associated risk factors, Dr. Meneilly urged. A recent study that examined the quality of diabetes control among older adults using NHANES data found that glycemic control targets are being met with limited success.3 When control of lipids or blood pressure are used as a measure, few patients had LDLs of less than 2.5; management of BP was even poorer. These are important factors to treat, Dr. Meneilly advised.

Current Treatments for Older Adults with Diabetes
Metformin

Metformin decreases hepatic glucose output and lowers fasting glycemia, and improves insulin sensitivity, making it a good choice for older adults. It is a useful drug to add as a second agent.

Some patients do not tolerate metformin well on initiation, making slow titration essential. Further, there are cases of delayed onset of weight loss as a side effect, sometimes occurring after years of treatment. The second problem affecting use of metformin is its contraindication in the setting of creatinine clearance <50, due to the risk of lactic acidosis, which occurs when patients with impaired renal function experience lactate-producing illness (e.g., acute heart failure, sepsis). Metformin should be discontinued during these illnesses.

Thiazolidinediones
Another class of agents used for this patient segment are the insulin sensitizers, the thiazolidinediones (TZs), whose glucose-lowering effects are mediated through improved insulin responsiveness in skeletal muscle, facilitating glucose uptake and utilization. Pioglitazone and rosiglitazone, used as monotherapy, are effective and can reduce HbA1c up to 1.5%. One of their chief benefits is that they allow the patient to be maintained on monotherapy for longer periods. The United Kingdom Prospective Diabetes Study (UKPDS) showed that HbA1c worsens over time, requiring institution of combination therapy.

Adverse effects associated with TZs in this patient segment include a two- to threefold increase in the risk of edema. Older patients with heart failure should not take them. Further, in women, rosiglitazone and pioglitazone decrease bone density and are associated with increased fracture risk. The final concern is their impact on CV events. Pioglitazone seems not to elevate the risk and offers less risk than rosiglitazone; Dr. Meneilly’s policy is to use pioglitazone alone, and only in men. Some patients prefer this agent as they wish to avoid insulin therapy.

Alpha-Glucosidase Inhibitors
Among this class, Dr. Meneilly specifically discussed the action and efficacy of acarbose, which acts by reducing absorption of glucose from the GI tract. It is effective as monotherapy among obese older adults with a contraindication to metformin, but does not offer optimal lowering of HbA1C. Roughly 1/3 cannot tolerate it for GI side effects; however, it does reduce postprandial blood sugars, suggesting good CV outcomes, but this requires further study.

Drugs Targeting Insulin Secretion: Sulfonylureas
Sulfonylureas lower glycemia by enhancing insulin secretion, and they lower HbA1c by ~1.5 %. Problems with this class of agents include a potential increase in CV risk, as with glyburide, which also increases the risk of severe hypoglycemia in older adults. There are sulfonylurea-like agents with better risk profiles that can be used, such as gliclazide, and glimepiride. The glinides repaglinide and nateglinide increase insulin secretion by a different mechanism than the original sulfonylureas. These are the closest oral agents available to rapid-acting insulin.
Regarding use of gliclazide in older patients, the cumulative frequency of hypoglycemia with glyburide is substantially greater than with gliclazide.4 Head-to-head studies suggest that long-acting gliclazide is associated with a lower frequency of hypoglycemia than glimepiride among older adults, which is in turn associated with a lower frequency of hypoglycemia than glyburide.5

Glinides
The glinides have a shorter circulating half-life than the sulfonylureas and must be administered more frequently. Glinides have been shown to reduce HbA1c by just under 1% in patients over 65.6 Dr. Meneilly described their advantage as the capacity to approximate a more physiological insulin profile, mimicking normal insulin secretion. Head-to-head studies of the glinides vs. glyburide showed that the latter did not result in insulin secretion earlier on but did result in substantial hyperinsulinemia a few hours after a meal. By comparison with glyburide, glinides reduce hypoglycemic events, and attenuate late postprandial drops in blood sugar. These agents are particularly effective in patients with erratic eating habits, in whom long-acting agents would be inappropriate.

Incretin Peptides
Dr. Meneilly has become interested in the mechanism of action and therapeutic potential of incretin peptides, especially in the pathophysiology and treatment of carbohydrate metabolism and diabetes in older adults. The effects of incretins are involved in the stronger insulin responses to oral over IV glucose.7 New research of interest to Dr. Meneilly involves the study of hormone activity in response to food intake, which could potentiate insulin secretion.
The two major incretins that do so are glucagon-like peptide–1 (GLP-1) and glucose-dependent insulinotropic peptide (GIP).

Among the new incretin therapies on the market and/or being tested for treating diabetes in older adults are GLP-1 and its mimetics, the GLP-1 analogues, and the incretin enhancers (inhibitors of dipeptidyl peptidase 4 [DPP-4]), which inhibit breakdown of endogenous GLP. Exenatide, a GLP-1 mimetic administered by subcutaneous injection twice daily, results in significant weight loss; a once-weekly form of administration is in development.

The DPP-4 inhibitors are a class of oral hypoglycemics whose advantages include efficacy, ease of use, and lack of hypoglycemia or weight gain; in older patients they may result in weight loss.8 By preventing the degradation of the incretin hormones, predominantly GLP-1, DPP-4 inhibitors prolong GLP-1 action, resulting in stimulation of insulin and inhibition of glucagon secretion, in a glucose-dependent manner (Figure 1). They may also promote expansion of B-cell mass via stimulation of cell proliferation and inhibition of apoptosis.

DPP-4 levels are reduced in older adults and as a consequence Dr. Meneilly had originally questioned whether the inhibitory action would work in older adults, but study data are positive.9 Preliminary study results suggest substantial increments in glucose-induced insulin secretion in older adults with diabetes treated with sitagliptin, a DPP-4 inhibitor, in conjunction with oral glucose, but more clinical trial data is needed, Dr. Meneilly stated. Sitagliptin is used either alone or in combination with other oral antihyperglycemic agents (sitagliptin is approved in Canada as combination therapy with metformin); sitagliptin and the other DPP-4 appear to be equally effective in older and younger patients.10 Adverse effects include a slightly elevated risk of upper respiratory infection, which needs to be carefully monitored in older patients.

Insulin Therapy among Older Adults
Study data suggest that rapid-acting insulin formulations offer little benefit for older patients with diabetes, likely due to changes in insulin clearance with age.

Among the insulin formulations of clinical value in this patient segment, Dr. Meneilly included insulin glargine, a long-acting basal insulin analogue. A study of once-daily insulin glargine plus metformin versus premixed insulin found greater reductions in HbA1c than premixed insulin; risk of hypoglycemia was significantly lower.11 Dr. Meneilly finds insulin glargine very useful in those patients who require insulin therapy to maintain normal or near-normal glucose levels and benefit from a once-daily formulation (e.g., in those who do not self-administer their medication).

Similarly, insulin detemir, a long-acting human insulin analogue, offers benefits in reduced HbA1C levels compared with NPH, but without the same risk of hypoglycemia and with lower weight gain. Dr. Meneilly advised clinicians to be aware of unit differences (by comparison with other insulin analogues, more detemir is generally needed for the same effect).12

Conclusion
Dr. Meneilly concluded by stressing the importance of lifestyle modification in the prevention of diabetes. Improvements in diet appear to be as or more effective than physical activity.13 Pharmacological adjuncts can support the effects of lifestyle interventions; however, some agents fail to offer a sufficiently safe side effect profile. Future avenues of research in pharmacological therapies, such as the role of incretin peptides in delaying progression to diabetes, suggest promising avenues for modifying the incidence and severity of diabetes in older adults.

References

  1. Tuomilehto J, Rastenyte D, Birkenhäger WH, et al. Effects of calcium-channel blockade in older patients with diabetes and systolic hypertension. Systolic Hypertension in Europe Trial Investigators. New Engl J Med 1999;340:677-84.
  2. Collins R, Armitage J, Parish S, et al., for the Heart Protection Study Collaborative Group. Lancet 2003;361:2005-16.
  3. Suh DC, Kim CM, Choi IS, et al. Comorbid conditions and glycemic control in elderly patients with type 2 diabetes mellitus, 1988 to 1994 to 1999 to 2004. J Am Geriatr Soc 2008;56:484-92.
  4. Tessier D, Dawson K, Tétrault JP, et al. Glibenclamide vs gliclazide in type 2 diabetes of the elderly. Diabetic Medicine 1994;11:974-80.
  5. Schernthaner G, Grimaldi A, Di Mario U, et al. GUIDE study: double-blind comparison of once-daily gliclazide MR and glimepiride in type 2 diabetic patients. Eur J Clin Invest 2004;34:535-42.
  6. Del Prato S, Heine RJ, Keilson L, et al. Treatment of patients over 64 years of age with type 2 diabetes: experience from nateglinide pooled database retrospective analysis. Diabetes Care 2003;26:2075-80.
  7. Nauck MA, Homberger E, Siegel EG, et al. Incretin effects of increasing glucose loads in man calculated from venous insulin and C-peptide responses. J Clin Endocrinol Metab 1986;63:492-8.
  8. Ahren B. Inhibition of dipeptidyl peptidase-4 (DPP-4) - a novel approach to treat type 2 diabetes. Curr Enzyme Inhib 2005;1:65-73.
  9. Meneilly GS, Demuth HU, McIntosh CH, et al. Effect of ageing and diabetes on glucose-dependent insulinotropic polypeptide and dipeptidyl peptidase IV responses to oral glucose. Diabet Med 2000;17:346-50.
  10. Williams-Herman D. Abstract P875. International Diabetes Federation 19th World Diabetes Congress, Cape Town, South Africa, 3-7 December 2006.
  11. Janka HU, Plewe G, Busch K. Combination of oral antidiabetic agents with basal insulin versus premixed insulin alone in randomized elderly patients with type 2 diabetes mellitus. J Am Geriatr Soc 2007;55:182-8.
  12. Garber AJ, Clauson P, Pedersen CB, et al. Lower risk of hypoglycemia with insulin detemir than with neutral protamine hagedorn insulin in older persons with type 2 diabetes: a pooled analysis of phase III trials. J Am Geriatr Soc 2007;55:1735-40.
  13. Diabetes Prevention Program Research Group, Crandall J, Schade D, Ma Y, et al. The influence of age on the effects of lifestyle modification and metformin in prevention of diabetes. J Gerontol A Biol Sci Med Sci 2006;61:1075-81.

Simulation Technology in Geriatric Education

Simulation Technology in Geriatric Education

Teaser: 


Anita S. Bagri, MD, Geriatric Research, Education, and Clinical Center (GRECC), VA Healthcare System, Miami, FL, USA.
Bernard A. Roos, MD, GRECC, VA Healthcare System, Miami; Stein Gerontological Institute, Miami, FL, USA.
Jorge G. Ruiz, MD, GRECC, VA Healthcare System, Miami; University of Miami Miller School of Medicine, Miami; Stein Gerontological Institute, Miami, FL, USA.

Geriatrics education is severely limited by the paucity of trained educators and models of care for implementing the standardized and competency-building learning experiences that have been recognized during the past decade. Simulation can increase the reach, effectiveness, adoption, implementation, and maintenance of geriatrics education. Through simulation, educators can repeatedly present, with reduced faculty presence, standardized clinical scenarios to multiple learners with no threats to patient autonomy and safety. The knowledge-skill-attitudes elements addressed through simulation can include not only the historically well-tested technical and action skills but also individual cognitive and critical thought processes, team performance, and communication.
Key words: training, competency-based education, older adults, computer simulation, professional competence.

Urinary Tract Infections in Older Adults: Current Issues and New Therapeutic Options

Urinary Tract Infections in Older Adults: Current Issues and New Therapeutic Options

Teaser: 

Sophie Robichaud, MD, FRCP(C), Medical Microbiology and Pediatric Infectious Diseases, Royal University Hospital and Saskatoon Health Region, and Departments of Microbiology and Immunology and Pathology, University of Saskatchewan, Saskatoon, SK.
Joseph M. Blondeau, MSc, PhD, RSM(CCM), SM(AAM), SM(ASCP), FCCP, Head of Clinical Microbiology, Royal University Hospital and Saskatoon Health Region, and Adjunct Professor of Microbiology and Immunology, Clinical Assistant Professor of Pathology, Departments of Microbiology and Immunology and Pathology, University of Saskatchewan, Saskatoon, SK.

Urinary tract infections (UTIs) are the most common infectious problem among older adults both in the community and institutional settings. With the expected increase in this population, UTI-related costs--both human and financial--will rise in a parallel fashion. The diagnosis of symptomatic UTI among older adults is complicated by the high prevalence of asymptomatic bacteriuria, which does not require any treatment, and the difficulty in interpreting the signs and symptoms of UTI in a population in which significant comorbidities can undermine the communication between the patient and the medical team. Another important issue is the constant increase in antimicrobial resistance, especially in long-term care facilities, where antimicrobial use is greater than in the community. Newer agents are now available for the treatment of UTI among older adults, targeting both the usual and the multiresistant uropathogens. Rational use of antimicrobials in the treatment of UTI in the older adult is important to both provide appropriate care and control the spread of resistant organisms in this population.
Key words: urinary tract infection, older adults, UTI management, antimicrobials.

Blood Pressure and Cardiovascular Disease Risk among Older Adults

Blood Pressure and Cardiovascular Disease Risk among Older Adults

Teaser: 


M. Bachir Tazkarji, MD, CCFP, CAQ Geriatric Medicine, Lecturer, Family Medicine Department, University of Toronto, Toronto, ON; Toronto Rehabilitation Institute, Toronto; Family Physician, Summerville Family Health Team, Mississauga, ON.

Arterial hypertension is one of the most important and preventable causes of death worldwide; therefore, adequate treatment of high blood pressure should be mandatory for patients with hypertension. Hypertension is defined on the basis of systolic and diastolic blood pressure levels and classified into stages on the basis of the degree of elevation. Normal blood pressure is widely considered as being less than 120/80 mm Hg. The presence of risk factors such as elevated blood cholesterol, smoking, diabetes, and obesity greatly increases the risk for hypertension-related morbid events.
Cardiovascular disease and stroke disproportionately affect older adults. Blood pressure is a potent modifiable target for reducing the risk for stroke and cardiovascular morbidity and mortality in older adults. In clinical trials, the number needed to treat to prevent one cardiovascular death was 79, one fatal or nonfatal stroke was 48, and one fatal or nonfatal coronary event was 64.
Key words: blood pressure, myocardial infarction, CVA, cardiovascular risk, older adults.

Diagnostic Tools for Osteoporosis in Older Adults

Diagnostic Tools for Osteoporosis in Older Adults

Teaser: 


Angela G. Juby, MD, Associate Professor, Department of Medicine, Division of Geriatrics, University of Alberta, Edmonton, AB.
David A. Hanley, MD, Professor, Department of Medicine, Division of Endocrinology and Metabolism, University of Calgary, Calgary, AB.

Low bone density is major risk for osteoporotic fracture. In older adults special precautions apply in interpreting bone mineral density measurements (either by central dual energy X-ray absorptiometry [DXA] or peripherally with calcaneal ultrasonography). Clinical assessment for vertebral fractures is an important part of the management. Therapeutic regimes for osteoporosis treatment are complicated and require repeated reinforcement to ensure long term compliance. Adequate compliance (80%) is required for optimal therapeutic benefit.
Key words: calcaneal ultrasonography, central dual energy x-ray absorptiometry (DXA), bone mineral density (BMD), older adult, special precautions.

Urinary Incontinence among Aging Men

Urinary Incontinence among Aging Men

Teaser: 

Ehab A. Elzayat, MD, Urology Fellow, Dalhousie University, Halifax, NS.
Ali Alzahrani, MD, Urology Fellow, Dalhousie University, Halifax, NS.
Jerzy B. Gajewski, MD, FRCSC, Professor of Urology and Pharmacology, Department of Urology, Dalhousie University, Halifax, NS.

Urinary incontinence is a common symptom among older adults that is often marginalized and not properly addressed. It is, however, often associated with potentially treatable conditions. Concurrent chronic medical problems add more challenges in this patient population. Comprehensive assessments and evaluations are necessary because of the multifactorial underlying pathology. The selection of the best treatment option is challenging. This article reviews the effect of age on lower urinary tract symptoms, mainly incontinence, and describes the evaluation and management of urinary incontinence in older men.
Key words: urinary incontinence, aging male, older adults, men’s health.

Diabetes and Cardiovascular Disease among Older Adults: An Update on the Evidence

Diabetes and Cardiovascular Disease among Older Adults: An Update on the Evidence

Teaser: 


Pamela Katz, MD, Department of Endocrinology and Metabolism, University of Toronto, Toronto, ON.
Jeremy Gilbert, MD, FRCPC, Staff Endocrinologist, Toronto General Hospital, University Health Network, Toronto, ON.

The global prevalence of diabetes has increased substantially in recent years, attributable to an increase in new cases and declining mortality. Aging is associated with changes in beta cell function and insulin resistance that predispose to diabetes. Cardiovascular disease is the leading cause of death among older adults with diabetes. In order to reduce the excessive risk of cardiovascular disease, all coronary risk factors must be addressed and treated aggressively. This article will focus on the importance of blood pressure and glycemic control and lipid lowering with statin therapy. Specific considerations in this patient population include high rates of comorbid disease, shorter life expectancy, polypharmacy and falls risk. These factors may alter the therapeutic goals. Treatment should therefore be individualized with consideration given to patient preference and quality of life.
Key words: diabetes, cardiovascular disease, older adults, metabolic syndrome.

Supporting and Treating the Older Adult with Cancer: It Starts in Primary Care

Supporting and Treating the Older Adult with Cancer: It Starts in Primary Care

Teaser: 

As I rapidly advance towards the geriatric age group, fears of cancer, in my case colon cancer because of a positive family history, start to increase. As a result, the unpleasantness of a recent colonoscopy was greatly alleviated later on by learning that I had no polyps or tumours. I am not alone in my concern about cancer, and the increasing prevalence of cancer as our population ages (and as age-corrected cardiovascular mortality declines) make these concerns quite legitimate. This high prevalence of cancer means that nearly all physicians--specialists as well as family physicians--who cares for adult patients will be caring for individuals with cancer in their practice. This issue’s focus on cancer in older adults allows us to address some of the learning needs of physicians caring for older adults with cancer.

Before her untimely death from breast cancer, a colleague of mine at the University Health Network wrote poignantly about the fatigue she experienced with her cancer. This taught me that as important as relieving pain is in cancer, many other symptoms are equally distressing for the patient. Our continuing education article this month is on some of these symptoms, and is titled “Fatigue, Pain, and Depression among Older Adults with Cancer: Still Underrecognized and Undertreated” by Dr. Manmeet Aluwhalia. An overview for supportive care of patients with cancer is addressed in the article ”Psychosocial Oncology for Older Adults in the Primary Care Physician’s Office” by Dr. Bejoy Thomas and Dr. Barry Bultz. Finally, in the same vein, is the article “Palliative Care in the Primary Care Setting” by Dr. Sandy Buchman, Dr. Anthony Hung, and Dr. Hershl Berman.

Our Cardiovascular Disease column this month is on “Diabetes and Cardiovascular Disease among Older Adults: An Update on the Evidence” by Dr. Pamela Katz and Dr. Jeremy Gilbert. Our Dementia column is on “Managing Non-Alzheimer’s Dementia with Drugs” by Dr. Kannayiram Alagiakrishnan and Dr. Cheryl Sadowski. One of the most important problems facing older adults, “Age-Related Hearing Loss,” is addressed by Dr. Christopher Hilton and Dr. Tina Huang. Urinary incontinence is usually considered a concern for older women; however, men are not exempt. Our Men’s Health column this month is on “Urinary Incontinence among Aging Men,” and is written by Dr. Ehab A. Elzayat, Dr. Ali Alzahran, and Dr. Jerzy Gajewski, who is a member of our partner association, the Canadian Society for the Study of the Aging Male. Dr. Gayatri Gupta and one of our international advisers, Dr. Wilbert S. Aronow, contribute an important article on "Prevalence of the Use of Advance Directives among Residents of a Long-term Care Facility" this month. Finally, it is imperative that physicians acknowledge the increasing prevalence of herbal medication use, which can lead to adverse drug interactions among their older patients. Dr. Edzard Ernst reviews this this topic in "What Physicians Should Know about Herbal Medicines.

Enjoy this issue.
Barry Goldlist

Update on Prostate Cancer among Older Men

Update on Prostate Cancer among Older Men

Teaser: 

Michel Carmel, MD, FRCSC, Professor, Sherbrooke University; Chair, Division of Urology, CHUS, Sherbrooke, QC.

Prostate cancer is the highest in incidence in Canada, ahead of lung and colon cancers. This is largely due to prostate-specific antigen (PSA) screening. Choosing among management options, including watchful waiting, active surveillance, and surgery, seems more difficult than ever for the patient and his physician as new treatments are emerging, often presented as accepted alternatives, while long-term efficacy and toxicity results are not yet available.
Key words: cancer, prostate, older adults, prostate-specific antigen, screening.