Dr J. Holroyd-Leduc, MD, FRCPC
Dr. M. Reddy, MD, FRCPC
Associate Editor,
Geriatrics & Aging.
Osteoporosis and the Frail Elderly
- According to prevalence data from 1993, based on bone mineral density assessments 1.4 million Canadian women had osteoporosis and over 60,000 women were estimated to have osteoporosis-related fractures that year.
- In those over 65, the projected number of hip fractures in Canadians over 65 will increase from 12% in 1993 to 25% in 2041.
- The mean one-year cost of a hip fracture is $26,527 (CAN) based on an observational study conducted by Wiktorowicz, et al. (Osteo Int;2001:12(4)).
- Bisphosphonates are the only agents documented to reduce hip fracture risk in calcium and vitamin D replete adults with osteoporosis.
- Non-pharmacological strategies shown to be effective include correcting calcium and vitamin D deficiency in the very elderly, use of hip protectors in fall-prone individuals, and fall-prevention programs in nursing homes.
Prevention in Geriatric Care
- Exercise programs reduce falls and fall-related injury by 35% and are most effective in those 80 years and older.
- Some preventative targets in the elderly, other than disease-specific issues, include disability, frailty, inappropriate LTC admission and hospitalization, "nosicomal" delirium and deconditioning, and inappropriate drug use.
Influenza and Superbugs in the Nursing Home
- 80-90% of influenza-related morbidity and mortality occurs in older adults.
- Vaccination is only 50-60% effective for preventing illness in older people, however it is 80-90% effective at preventing serious complications.
- Influenza in the elderly can present atypically, lower respiratory tract involvement is common, and constitutional symptoms can be prolonged resulting in disability.
- Superbugs, which includes MRSA and VRE, can be controlled effectively with appropriate universal hand- washing (patients, staff, visitors, and volunteers) and without requiring isolation.
Osteoarthritis
- Risk factors for developing osteoarthritis include advancing age, female sex, bent knee activities, heavy lifting, muscle weakness, absence of osteoporosis, genetic predisposition, obesity and possibly recreational sports.
- Nonpharmacological management therapies of variable effectiveness include weight loss, exercise, orthoses, education, Glucosamine, vitamin C, vitamin D and transcutaneous electrical nerve stimulation (TENS).
- Pharmacological treatment in the elderly should include consideration of a trial with regular dosing of acetaminophen. The main issues of concern with acetaminophen use includes compliance, variable effectiveness, and potential for liver toxicity.
- Cox-2 inhibitors are another option in the elderly. They appear to demonstrate less gastrointestinal toxicity than do traditional NSAIDS; however they still have the potential for renal toxicity, hypertension and peripheral edema. Coxibs should be used with caution in individuals with a history of gastrointestinal ulcers; concomitant use of NSAIDs, anticoagulants or steroids; age over 60; and/or a history of heart disease.
Non-Alzheimer Dementia: Frontal Temporal
- Diagnosis can be divided into Frontotemporal dementia (socially inappropriate behaviour, perseveration, and stereotypic behaviour); Primary progressive aphasia; Corticobasal degeneration (atypical extrapyramidal-apraxic syndrome); Semantic dementia (loss of meaning of things, loss of comprehension and naming). However, different subtypes can co-occur in the same individual.
- There is evidence of serotonin deficiency in Frontal Temporal dementias.
- The frontal system is responsible for executive control, and executive dysfunction leads to problem behaviour.
- One form of bedside testing includes the CLOX test, where an individual is asked to draw an unprompted clock, copy a clock and draw intersecting pentagons. An individual with executive dysfunction can copy but will have impairment in unprompted clock drawing, compared to an individual with Alzheimer disease who will demonstrate difficulties in both copying and unprompted clock drawing.
- There are few studies that examine clinical management of Frontal Temporal dementia, and the available studies are open-label and case series
see Table 1.
Diabetes Mellitus
- Incidence is 20% in persons 75 years and older.
- Mortality in elderly diabetics is not dramatically higher compared to age-matched non-diabetics. However there are morbidity benefits from glycemic control. There is an association between elevated Hgb A1C and retinopathy, and elevated Hgb A1C and coronary artery disease.
- Suggested goals of therapy in healthy elderly are FBS <7 and Hgb A1C < 15% above upper limit of normal; the goals in the frail elderly are FBS <10 and Hgb A1C < 40% above the upper limit of normal.
- The DECODE study found that postprandial glucose is an independent risk factor for mortality and cardiovascular disease in type 2 diabetics and in non-diabetics. It also found that most of the excess mortality and cardiovascular risk associated with high fasting glucose depends on simultaneous high 2-hr postprandial glucose.
Congestive Heart Failure
- A model of chronic disease management in the community has been developed in Vancouver, BC, Canada that encompasses an integrated algorithmic approach to the management of heart failure.
The Masks of Depression in the Elderly
- Depression, apathy, delirium, dementia and grief are all separate clinical entities but can co-occur.
- Apathy, depression and delirium can all be manifestations of frontal lobe dysfunction.
- Depression is the most common psychiatric disorder in the elderly, and depression can develop at any point in the lifespan.
- Depression often coexists with medical conditions (stroke 30%; MI 18%; Hip fracture 50%; pain 50%) and it can interfere with the treatment of other medical conditions.
- Depression is not uncommon in patients with Alzheimer dementia and will respond to treatment.
- In early stages of Alzheimer disease the individual complains of a sad mood and feelings of worthlessness, and will appear sad and/or irritable.
- In late stages of Alzheimer disease the individual will appear sad and will have vocalizations of discomfort.
Disturbing Behaviour in Dementia
- in managing aggression and psychosis in a demented individual one needs to first assess safety concerns, then rule out delirium (including contributing medical disorders and medication effects), and pre-existing psychiatric illness. The agitation should then be described and the target behaviour identified. Appropriate treatment can be aimed at addressing the target behaviour.
- some behaviours that are relatively resistant to antipsychotic medication includes wandering, pacing, exit-seeking, and repetitive screaming and calling out
- nonpharmacological interventions can include following care schedules, avoiding stress, using simple verbal and non-verbal cueing, providing good personal care, good sleep hygiene, music therapy, appropriate lighting levels, appropriate environmental changes, and exit control
- it is important to nuture the personhood of the individual with dementia
Alzheimer Disease and Vascular Dementia
- 1/3-1/2 of autopsy proven Alzheimer's disease also has evidence of cerebrovascular disease
- a potential common risk factor is Apo E e4
- Apo E is involved in lipid transport and in the CNS is involved in mobilising lipids for growth and repair
- Apo Ee4 is associated with elevated plasma cholesterol, LDL, and atherosclerosis, and is also associated with late-onset Familial Alzheimer's disease and an increased risk of sporadic Alzheimer's disease
- Alzheimer's disease and cerebrovascular disease are both common and share risk factors
- Controlling hypertension in the Sys Euro trial (Lancet 1998) demonstrated a 50% reduction in the incidence of dementia
- There was a 60-73% reduction in dementia prevalence in individuals with hypercholesterolemia who were treated with a HMG-CoA reductase inhibitor (Arch Neurol 2000)
- there appears to be similar cholinergic deficits in Alzheimer's disease and Vascular dementia
- in preclinical models, rivastigmine has been shown to prevent a decrease in cholinergic indices in ischemic conditions and to prevent of post-ischemic neuronal death in the hippocampus
- The treatment effect of rivastigmine was higher in Alzheimer patients with vascular risk factors (ADAS cog Study 352)
- galantamine improved the ADAS cog scores by 2-3 points compared to placebo when given to individuals with probable Vascular dementia, intermediate Vascular dementia, or mixed Vascular dementia and Alzheimer's disease (Neurology 2001;s38:340)
Parkinson's disease and the Frail Elderly
- levodopa is still the gold standard for relief of Parkinson's disease symptoms
- the new dopamine agonists are devoid of the rare ergot-related toxicity but are equivalent in terms of other toxicity, including nausea, postural hypotension, and psychosis
For reviews of disturbing behaviour in dementia, Alzheimer Disease, Vascular Dementia and Parkinson's disease in the elderly, see our website at www.geriatricsandaging.ca.
