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Treatment-Resistant Hypertension among Older Adults

Treatment-Resistant Hypertension among Older Adults

Teaser: 


Fatemeh Akbarian, MD, Dermatologist, Clinical Research Fellow, University of Toronto, Toronto, ON.
Vahid Ghafarian, MD, MPH, BSc.PT, Physiotherapist, Northpark Physiotherapy and Annex Retirement Residence, 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.

Treatment-resistant hypertension (TRHTN) is a common challenge in geriatric practice and a significant cause of mortality and morbidity among older adults. In this overview, we will use a case-based approach to define the magnitude of the problem, identify characteristics of individuals with TRHTN, and explore the causes of uncontrolled hypertension including technical issues, patient-related and physician-related factors, and secondary causes of hypertension. We will then provide a simple approach to the problem, illustrating straightforward diagnostic workup and therapeutic options. In our approach most of the emphasis has been given to detailed history-taking and a targeted physical examination.
Key words: resistant hypertension, hyperaldosteronism, obstructive sleep apnea, older adults.

A Rational Approach to Constipation

A Rational Approach to Constipation

Teaser: 

Hershl Berman, MD, FRCPC, Assistant Professor, University of Toronto Faculty of Medicine, Department of Medicine, University Health Network, Toronto, ON.
Laura Brooks, RegN, MscN, APN, Advanced Practice Nurse in Palliative Care, Department of Psychosocial Oncology and Palliative Care, University Health Network, Toronto, ON.
Shawna Silver, MD, PEng, Hospital for Sick Children; University of Toronto, Toronto, ON.

Constipation is a common complaint, especially in older adults. It results in millions of physician visits per year, with hundreds of millions of dollars spent on laxatives. Untreated it can lead to serious morbidity and can be a contributing factor in mortality. A rational approach to the patient presenting with constipation includes a detailed history, general and focused physical examination, specific investigations, and appropriate therapy. Treatment should aim to address the underlying cause, as should the choice of laxative. In general, it is best to clear out hard stool in the distal bowel before using an aggressive oral regimen.
Key words: constipation, laxatives, older adults, opioids.

Distress—the Sixth Vital Sign in Cancer Care: Implications for Treating Older Adults Undergoing Chemotherapy

Distress—the Sixth Vital Sign in Cancer Care: Implications for Treating Older Adults Undergoing Chemotherapy

Teaser: 

Barry D. Bultz, PhD, Director, Department of Psychosocial Resources, Tom Baker Cancer Centre, Alberta Cancer Board; Department of Oncology, University of Calgary, Calgary, AB.
Bejoy C. Thomas, PhD, Department of Psychosocial Resources, Tom Baker Cancer Centre, Alberta Cancer Board, Calgary, AB.
Douglas A. Stewart, MD, FRCPC, Divisions of Medical Oncology and Hematology, Departments of Oncology and Medicine, Tom Baker Cancer Centre and University of Calgary, Calgary, AB.
Linda E. Carlson, PhD, Department of Psychosocial Resources, Tom Baker Cancer Centre, Alberta Cancer Board; Department of Oncology, University of Calgary, Calgary, Alberta, Canada

Cancer is perceived as an illness that most frequently affects the older adult population, yet there is a dearth of research on the psychosocial aspects of cancer affecting this cohort. The effect of chemotherapy on the psychosocial sequelae in this group is moderately researched. This article discusses emotional distress across the trajectory of cancer care in the older adult population. It also identifies key milestones, times when distress is likely to peak, and the psychological, physiological, and social symptoms of distress. The benefits of psychosocial interventions are also discussed.
Key words: older adult, cancer, chemotherapy, emotional distress, 6th vital sign.

Warfarin-Drug Interactions among Older Adults

Warfarin-Drug Interactions among Older Adults

Teaser: 

Andrew Liu, BSc Hon, BScPhm, RPh, Clinical Pharmacist, Thrombosis Service, Toronto East General Hospital, Toronto, ON.
Carmine Stumpo, BScPhm, PharmD, RPh, Director, Pharmacy and Emergency Services, Toronto East General Hospital, Toronto, ON.

Warfarin-drug interactions are often encountered in the care of older adults. Interactions may be classified as pharmacokinetic, resulting in changes in serum warfarin concentrations, or pharmacodynamic, resulting in changes in hemostasis or platelet function. Knowledge of these mechanisms of warfarin-drug interactions may help identify warfarin interactions, facilitate prescribing decisions, and assist with appropriate monitoring.
Key words: warfarin, drug interactions, anticoagulants, cytochrome P-450 enzyme system, older adults.

Disorders of Potassium Homeostasis

Disorders of Potassium Homeostasis

Teaser: 

Madhav V. Rao, MD1, Department of Medicine, Section of Nephrology, University of Chicago, Chicago, IL, USA.
Vijaykumar M. Rao, MD, FACP, FASN, President, Associates in Nephrology, Chicago, IL, USA.

Alterations in potassium balance occur frequently in all patient populations, but in particular, among older adults. Physicians commonly encounter such disorders when taking care of patients in the clinic or in the hospital. Most often the etiology of such disturbances is due to prescribed medications, but a number of clinical conditions exist which predispose people to both hyperkalemia and hypokalemia. These conditions can have grave consequences if not addressed quickly. Furthermore, the approach to definitive treatment depends on the underlying physiology that often occurs at the tubular level within the kidney.
Key words: potassium balance, hyperkalemia, hypokalemia, older adults.

Screening for and Staging Chronic Kidney Disease

Screening for and Staging Chronic Kidney Disease

Teaser: 

Gemini Tanna, MD, FRCPC, Division of Nephrology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
Sarbjit Vanita Jassal, MB, BCh, MD, Division of Nephrology, University Health Network, University of Toronto, Toronto, Ontario, Canada


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Chronic kidney disease (CKD) is increasingly common among older adults. In the older individual, the presence of CKD is predictive of cardiovascular death, increased all- cause mortality, and progression to end-stage renal disease and the need for dialysis. Early identification of these high-risk individuals may prevent or delay such adverse outcomes. The Canadian Society of Nephrology (CSN) released a position statement in September 2006 suggesting that screening be limited to those at high risk. We recommend that clinicians follow the CSN algorithm for screening for CKD among older adults.
Key words: chronic kidney disease, estimated glomerular filtration rate, older adults, renal function, screening.

Dehydration in Geriatrics

Dehydration in Geriatrics

Teaser: 

MC Faes, MD, MSc, Department of Geriatric Medicine, University Medical Centre Nijmegen, The Netherlands.
MG Spigt, PhD, Department of General Practice/Research Institute CAPHRI, University of Maastricht, The Netherlands.
MGM Olde Rikkert MD, PhD, Department of Geriatric Medicine, University Medical Centre Nijmegen, The Netherlands.

Homeostasis of fluid balance is an important prerequisite for healthy aging. The high prevalence of disturbances of fluid balance among older adult patients has triggered clinical research on age- and disease-related changes in water homeostasis. Empirical findings on risk factors of dehydration and on diagnostic and therapeutic strategies are reviewed in this paper. No single measure has proved to be the gold standard in the diagnosis of dehydration. Diagnosing dehydration and monitoring fluid balance requires repeated measurements of weight, creatinine, and physical signs such as tongue hydration. Rehydration and prevention requires fluid on prescription (> 1.5 litre/day), and the route of fluid administration depends on the acuteness and severity of clinical signs.
Keywords: older adults, dehydration, fluid therapy, risk factors, diagnosis.

Use of Atypical Antipsychotic Medications in Later Life

Use of Atypical Antipsychotic Medications in Later Life

Teaser: 


Tarek Rajji, MD, Geriatric Mental Health Program, Centre for Addiction and Mental Health; Department of Psychiatry, University of Toronto, Toronto, ON.
Benoit H. Mulsant, MD, MSc, FRCPC, Western Psychiatric Institute and Clinic and Department of Psychiatry, University of Pittsburgh, Pittsburgh, USA; Geriatric Mental Health Program, Centre for Addiction and Mental Health; Department of Psychiatry, University of Toronto, Toronto, ON.
Hiroyuki Uchida, MD, PhD, PET Centre, Centre for Addiction and Mental Health, Toronto, ON.
David Mamo, MD, MSc, FRCPC, PET Centre and Geriatric Mental Health Program, Centre for Addiction and Mental Health; Department of Psychiatry, University of Toronto; Centre for Addiction and Mental Health, Toronto, ON.

Antipsychotics are increasingly being prescribed to older patients for the management of a variety of neuropsychiatric conditions. Available evidence supports the use of second-generation antipsychotics (SGAs) when treating these conditions. However, given their modest clinical effect for certain conditions (e.g., behavioural and psychological symptoms of dementia), their adverse effects, and their safety profile, a careful analysis of their risks and benefits is needed before initiating treatment with an SGA for an older patient. Among SGAs, choice of medication should be guided by their respective clinical indications and adverse effect profile, with use of lower initial and target doses (compared to younger adults) and periodic reviews of whether or not their continued use is warranted.
Key words: antipsychotics, older adults, dementia, delirium, schizophrenia.

Blood Pressure and Survival in the Very Old

Blood Pressure and Survival in the Very Old

Teaser: 


Kati Juva, MD, PhD, Department of Psychiatry, Helsinki University Central Hospital, Helsinki, Finland.
Sari Rastas, MD, PhD, Department of Neuroscience and Neurology, University of Kuopio, Kuopio, Finland; Kauniala Disabled War Veterans’ Hospital, Espoo, Finland.
Tuula Pirttilä, PhD, Professor, Department of Neuroscience and Neurology, University of Kuopio and Kuopio University Hospital, Kuopio, Finland.

The harmful effects of high blood pressure on cardiovascular morbidity and mortality are well established. However, hypertension in the very old is an extremely complex issue. Current epidemiological data suggest that high blood pressure may be a marker of survival in the very old, and lowering blood pressure may lead to an increase in total mortality. In this review we will summarize the evidence on the association between blood pressure and mortality and discuss the implications of the data.
Key words: older adults, hypertension, survival, very old, blood pressure.

Pharmacological Treatments for Diabetes among Older Adults: An Update

Pharmacological Treatments for Diabetes among Older Adults: An Update

Teaser: 

Jeremy Gilbert, MD, FRCPC, Staff Endocrinologist, Toronto General Hospital, Toronto, ON.

Diabetes is a very common condition, especially among older adults. There are numerous benefits associated with improved glycemic control. However, achieving glycemic targets can be challenging, particularly for older adults with comorbidities. In recent years more oral antihyperglycemic agents have become available to better manage diabetes, and there are many pharmacological therapies currently in development. In order to select the most appropriate agent to use as monotherapy or in combination for an individual patient, it is important to be familiar with the mechanism, efficacy, safety, and cost of the various antihyperglycemic agents.
Key words: diabetes, older adults, oral antihyperglycemic agents, monotherapy, combination therapy.