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older adults

Skin Ulcers in Older Patients

Skin Ulcers in Older Patients

Teaser: 

Christopher Frank, MD, CCFP, Department of Medicine, Division of Geriatrics, Queen’s University, Kingston, ON.

Skin ulcers are common among older adults, especially those in hospital or in long-term care facilities. Prevention of ulcers is important in all clinical settings. Clarifying the cause(s) and exacerbating factors is the first step in management. Pressure and venous insufficiency are the most common causes among older adults. Poor nutrition, edema, arterial insufficiency, and anemia may impair wound healing. Adequate debridement and cleaning is important to decrease infection risk and to promote healing. The choice of dressings depends on the needs of the individual wound but should emphasize the provision of a moist wound environment. Options for dressings are summarized.
Key words: skin ulcers, treatment, wound healing, older adults, pressure ulcers.

Postural and Postprandial Hypotension: Approach to Management

Postural and Postprandial Hypotension: Approach to Management

Teaser: 


Kannayiram Alagiakrishnan, MD, MPH, FRCPC, ABIM, Associate Professor, Division of Geriatric Medicine, Department of Medicine, University of Alberta, Edmonton, AB.

Postural and postprandial hypotension are common conditions among older adults. They are causes of dizziness, syncope, and falls in older people. These conditions may result in significant morbidity, a decrease in function, and mortality. Dysregulation of blood pressure in older adults can result in postural and postprandial hypotension. Routine screening for these conditions is easy to perform and helps to diagnose and manage them appropriately. Management includes a combination of nonpharmacological and pharmacological interventions.
Key words: postural hypotension, postprandial hypotension, management, blood pressure, older adults.

Assessing Cancer-Related Fatigue: Conceptualization Challenges and Implications for Research and Clinical Services

Assessing Cancer-Related Fatigue: Conceptualization Challenges and Implications for Research and Clinical Services

Teaser: 


Pascal Jean-Pierre, PhD, Department of Radiation Oncology, Department of Family Medicine, University of Rochester Medical Center, Rochester, New York, USA.
Gary Morrow, PhD, MS, Department of Radiation Oncology, Department of Psychiatry, University of Rochester Medical Center, Rochester, New York, USA.

Fatigue due to cancer and its treatments is a highly prevalent and debilitating symptom experienced by many patients. This symptom is often present prior to a pathologically confirmed diagnosis of cancer and can be experienced both during and for considerable periods after treatment. Oncology professionals are becoming more cognizant of the impact of cancer-related fatigue on key aspects of patients’ psychosocial performance, cognitive functioning, and overall quality of life. This paper discusses the importance of cancer-related fatigue, the challenges involved in assessing this debilitating symptom among cancer patients, and the influence of researchers’ conceptualization of this symptom on the characteristics of the measures developed to assess it. Strategies to facilitate differential diagnosis of cancer-related fatigue are also presented and discussed.
Key words: cancer-related fatigue, assessment, measurement dimension, older adults, quality of life.

Fever in Older Cancer Patients: A Medical Emergency

Fever in Older Cancer Patients: A Medical Emergency

Teaser: 


Deepali Kumar MD, MSc, FRCP(C), Consultant, Infectious Diseases, Immunocompromised Host Service, University Health Network; Assistant Professor, University of Toronto, Toronto, ON.

The incidence of cancer continues to increase, and many persons receiving treatment for cancer are older adults. Fever in older adults with cancer can be an emergency. Any patient with fever and neutropenia should be given antibiotics as soon as possible. In addition to the immune senescence associated with aging, individuals with cancer have immunodeficiencies specific to their underlying malignancy, and these predispose them to specific infections. Older adults are also at higher risk of the complications of chemotherapy, including infections. Prompt evaluation and judicious management of the febrile cancer patient can reduce morbidity and mortality. The following review considers an approach to the etiologies and evaluation of fever in cancer including the infectious and noninfectious causes.
Key words: fever, cancer, older adults, antibiotics, neutropenia.

Incontinence among Older Adults

Incontinence among Older Adults

Teaser: 

David R. Staskin, MD, Department of Urology, New York Presbyterian Hospital, Weill-Cornell Medical College, New York, NY, USA.
Edward Zoltan, MD, Division of Urology, Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA.
Alan J. Wein, MD, Division of Urology, Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA.

Older adults have a high prevalence of urinary incontinence. Among the older adult population, many nonurinary pathological, anatomical, physiological, and pharmacological factors may serve as comorbidities in the development of incontinence. The treating physician must appreciate potentially reversible pathologies. Older adults frequently are prescribed several drugs; therefore, it is important to consider drug-drug metabolic interactions. Age-associated changes may affect pharmacological actions of the drug. Antimuscarinic therapy has been proven efficacious and represents the first line of pharmacologic therapy for overactive bladder (OAB). The selection of an antimuscarinic agent for the management of an older individual presenting with OAB is limited by the natural condition of the aging body and by the side effects associated with antimuscarinics as a class and the specific agents themselves.
Key words: urinary incontinence, antimuscarinics, older adult, frail older adult, geriatrics.

Managing Psychotic Symptoms in the Older Patient

Managing Psychotic Symptoms in the Older Patient

Teaser: 


Abi Rayner, MD, MPH, Buller Medical Service, Westport, New Zealand.

Hallucinations and delusions increase the risk of developing dementia, delirium, functional impairment, and of death. The differential diagnosis includes isolated hallucinations, delirium, depression with psychotic symptoms, late-onset schizophrenia, and unrecognized dementing disorder, including Lewy Body disease and frontotemporal dementia. Optimum management requires diagnosis, assessment of the goals of treatment, and understanding the risks and benefits associated with psychoactive medications. Atypical neuroleptics are appropriate first-line agents for most patients with dementia and psychotic symptoms. Response to medications is modest and a second agent (including acetylcholinesterase inhibitors, antidepressants, and anticonvulsants) may be necessary to reduce behaviour to acceptable levels. In addition, decline in cognitive status and increased risk of cerebrovascular events and death are associated with the use of antipsychotic medications. Change in functional status and time alter the impact of behavioural symptoms. Periodic reassessment and reduction of medication dosage over time appears safe, usually without re-emergence of symptoms.
Key words: psychotic symptoms, older adult, dementia, antipsychotics, behavioural disturbance.


Chronic Obstructive Pulmonary Disease in the Older Adult: New Approaches to an Old Disease

Chronic Obstructive Pulmonary Disease in the Older Adult: New Approaches to an Old Disease

Teaser: 

The accredited CME learning activity based on this article is offered under the auspices of the CE department of the University of Toronto. Participating physicians are entitled to one (1) MAINPRO-M1 credit by completing this program, found online at www.geriatricsandaging.ca/cme

Andrew McIvor MD, MSc, FRCP, Professor of Medicine, McMaster University; Firestone Institute for Respiratory Health, St Joseph’s Healthcare, Hamilton, ON.

At present, some 750,000 Canadians are known to have chronic obstructive pulmonary disease (COPD). This number is believed to represent the tip of the iceberg, as COPD is often only diagnosed in the advanced stage. Respiratory symptoms or a previous smoking history are common among older adults yet they seldom trigger further assessment for COPD. Objective demonstration of airflow obstruction by spirometry is a simple procedure, even in older adults, and is the gold standard for diagnosis of COPD. Early intervention with routine nonpharmacological management includes partnering with the patient and family, providing education, smoking cessation, vaccination, collaborative self-management, and advice on exercise and pulmonary rehabilitation. Anticholinergic inhalers remain the gold standard for optimal bronchodilation and dyspnea relief in COPD, and new long-acting agents have underpinned new treatment algorithms, improving quality of life and exercise capacity as well as reducing exacerbations. For those with advanced disease, recent trials have reported further benefits with the addition of combination inhalers (inhaled corticosteroid and long-acting B2-agonist) to core anticholinergic treatment. Physicians and patients can expect a promising future for COPD treatment as significant advances in management and improved outcomes in COPD are now being made.
Key words: chronic obstructive pulmonary disease, older adults, spirometry, diagnosis, management.

Nausea and Vomiting: An Overview of Mechanisms and Treatment in Older Patients

Nausea and Vomiting: An Overview of Mechanisms and Treatment in Older Patients

Teaser: 

Esmé Finlay, MD, Fellow, Division of Hematology/Oncology, Hospital of the University of Pennsylvania, Philadelphia, PA, USA.
Joseph B. Straton, MD, MSCE, Chief Medical Director, Wissahickon Hospice; Assistant Professor, Family Medicine and Community Health; Assistant Professor, Anesthesiology and Critical Care, Hospital of the University of Pennsylvania, Philadelphia, PA, USA.
Jonathan R. Gavrin, MD, Director, Symptom Management and Palliative Care; Clinical Associate Professor, Anesthesiology and Critical Care; Clinical Associate Professor, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA, USA.

Nausea and emesis are distressing symptoms that can contribute to malnutrition, dehydration, and decreased quality of life in older patients. Dopaminergic, cholinergic, histaminergic, serotonergic, and neurokinin receptor mechanisms play roles in the causation of nausea. Pharmacologic therapy targeted at these and other mechanisms is necessary to effectively treat the symptoms of nausea and vomiting. Multidrug regimens that target multiple mechanisms are often needed to control persistent symptoms. However, caution is advised when prescribing these medications in older patients, as many of the effective medications can cause sedation, confusion, or delirium. This article describes the mechanisms of nausea and vomiting and reviews effective treatment regimens.
Key words: nausea, vomiting, emesis, antiemetics, older adults.

An Approach to the Nonpharmacologic and Pharmacologic Management of Unintentional Weight Loss Among Older Adults

An Approach to the Nonpharmacologic and Pharmacologic Management of Unintentional Weight Loss Among Older Adults

Teaser: 

Karen L. Smith, MSc, Kunin Lunenfeld Applied Research Unit, Baycrest and Department of Nutritional Sciences, University of Toronto, Toronto, ON.
Carol Greenwood, PhD, Kunin Lunenfeld Applied Research Unit, Baycrest and Department of Nutritional Sciences, University of Toronto, Toronto, ON.
Helene Payette, PhD, Director, Research Center on Aging, Health & Social Services Centre - University Institute of Geriatrics of Sherbrooke, Faculty of Medicine and Health Sciences, University of Sherbrooke, Sherbrooke, QC.
Shabbir M.H. Alibhai, MD, MSc, Division of General Internal Medicine & Clinical Epidemiology, University Health Network; Geriatric Program, Toronto Rehabilitation Institute; Departments of Medicine and Health Policy, Management and Evaluation, University of Toronto, Toronto, ON.

Unintentional weight loss is common among older adults and is associated with significant adverse health outcomes, increased mortality, and progressive disability. The diagnosis is often associated with an underlying illness; however, in as many as one in four older adults with unintentional weight loss, no obvious medical cause can be identified. A variety of nonpharmacologic interventions may improve energy intake and lead to weight gain. The most common approach to the treatment of weight loss among older adults is consumption of high-energy/protein oral supplements between meals as a means of increasing daily energy intake. Involving other health professionals, including a dietitian, may be helpful in the assessment and management plan. In addition, a number of pharmacologic treatments have been investigated, but the potential benefit of these treatments remains unclear.
Key words: weight loss, older adults, malnutrition, oral nutritional supplementation, megestrol.

Irritable Bowel Syndrome with Constipation among Older Adults

Irritable Bowel Syndrome with Constipation among Older Adults

Teaser: 

Richard Saad, MD, Lecturer, Division of Gastroenterology, Department of Medicine, University of Michigan Medical Center, Ann Arbor, MI, USA.
William D. Chey, MD, AGAF, FACG, FACP, Associate Professor of Internal Medicine; Director, GI Physiology Laboratory, University of Michigan Medical Center, Ann Arbor, MI, USA.

Irritable bowel syndrome (IBS) is traditionally considered a disorder of young adulthood; however, it affects adults of all ages, including older adults. As the older population increases so will the impact of IBS in this age group. Irritable bowel syndrome with constipation (IBS-C) is believed to be particularly significant given the prevalence of constipation among the aged. At present, the evaluation and management of this disorder has been largely driven by data obtained from younger adults. However, there are numerous aspects of the underlying pathophysiology, evaluation, and treatment of IBS-C that remain unique to older adults, of which the clinician should be cognizant.
Key words: irritable bowel syndrome, constipation, older adults, functional bowel disorder.