Diagnosis and Management of Acute Coronary Syndromes

Nariman Malik, BSc, MD
Medical Writer,
Geriatrics & Aging

Coronary heart disease (CHD) is one of the leading causes of death in individuals over the age of 65¹ and, through a variety of syndromes, is responsible for symptomatic and asymptomatic functional abnormalities. The prevalence of cardiovascular disease increases with age and is a major cause of death and disability in the elderly population.² CHD is the most prevalent cardiac illness in this population: it accounts for 85% of all deaths due to heart disease in persons over the age of 65.³ By age 70, 15% of men and 9% of women have coronary artery disease (CAD) and are at an increased risk of suffering an acute coronary syndrome (ACS).⁴ By age 80, the severity of lesions becomes nearly equal for men and women.⁴ An estimated 40% of all individuals over the age of 80 have symptomatic cardiac disease.²

Despite advances in cardiology, CHD is still the leading cause of death in older individuals, especially those aged over 75.¹ Nevertheless, there is wide variation in the severity of coronary illness and in the functional status of elderly patients.

Lin Perry, MSc, RGN, RNT,
Faculty of Health & Social Care Sciences,
Kingston University and St. George's Hospital Medical School:
Sir Frank Lampl Building, Kingston University,
Kingston upon Thames, Surrey, UK.

Introduction
Stroke is a major cause of mortality and morbidity in all industrialized countries¹--incidence of a first-in-a-lifetime stroke in the UK is estimated at 2.4 per 1,000 population per year, with all strokes combined having an incidence 20-30% higher.²

Dysphagia is a frequent accompaniment to stroke.^3-5 Depending upon manner and timing of assessment, dysphagia is detected in 30-65% of acute stroke patients^6-10 with a small proportion experiencing clinically 'silent' aspiration of food/ fluids.^9,10 Dysphagia is associated with increased morbidity and mortality. Whilst this may partly be explained by its relationship with increased stroke severity, dysphagia also exerts an independent effect revealed by the tripling of mortality rates in alert dysphagic stroke patients compared to similar groups with intact swallow.⁸ It is associated with chest infection independent of aspiration⁷ which also risks chemical pneumonitis, infection and airway obstruction.^11,12 Although dysphagia frequently resolves rapidly, for a minority it produces enduring disability and handicap. Stroke-related impaired swallowing has been found in 5.

Serge Gauthier, MD, FRCPC
McGill Centre for Studies in Aging,
Montreal, Canada 

Alzheimer's disease (AD) is the most common cause of dementia, worldwide. It is well known that the incidence and prevalence of AD increase with age; therefore, because of the increasing longevity of our populations, and the large cohort of baby-boomers coming to maturity, more and more people will be affected by this condition. Fortunately, there are encouraging results from studies on symptomatic therapy and there is reason to hope that we may achieve long term stabilization and preventive treatment. This review will emphasize the important role of the primary care practitioner in the diagnosis and management of AD.

Clinical presentation of Alzheimer's disease
The Global Deterioration Scale describes the progression of AD as seven steps (Table 1), which is useful to describe the natural history of AD. This scale is familiar to most families who are caring for a patient with AD, and the primary care practitioner is often asked to describe the patient's current stage.

In 1869, french neurologist Jean-Martin Charcot first described a rapidly progressive, fatal neuromuscular disease. This disease, amyotrophic lateral sclerosis, or Lou-Gehrig's disease, is a neurodegenerative disorder that affects the patient's motor neurons; typically the patient is paralyzed or deceased within 2 to 5 years of the initial diagnosis. Currently, approximately 3000 Canadians suffer from this tragic disease.

Andrew Eisen MD, FRCPC
Professor and Head, Division of
Neurology, University of British Columbia,
Head of the Neuromuscular Diseases Unit,
Vancouver General Hospital

Amyotrophic lateral sclerosis (ALS) is a prototypic neurodegeneration of the aging nervous system. It has a worldwide incidence of about 2 per 100,000 members of the population and a prevalence of 4&endash;7 per 100,000. As is true of both Parkinson's and Alzheimer's disease, the incidence of ALS is increasing proportional to the increasing longevity of the population. Information regarding the specific incidence of ALS in the elderly (aged 75 years and older) is sparse. The apparent decrease in incidence of this disease in patients older than 70 years reflects mortality from competing diseases in later life.

The etiopathogenesis of ALS is complex and multi-factorial.

Neil Fam, BSc, MSc

Hepatitis refers to acute or chronic inflammation of the liver, with the majority of cases resulting from either viral infection or drugs. In Canada, hepatitis B and C infections are the most common cause of viral hepatitis, and may be associated with considerable morbidity and mortality. Globally, chronic viral hepatitis is the leading cause of chronic liver disease, cirrhosis, and hepatocellular carcinoma and is the most common indication for liver transplantation. This article provides an outline of the natural history of hepatitis B and C infections, and describes current approachs to diagnosis, treatment, and prevention. Unique aspects of hepatitis in the elderly are highlighted.

Epidemiology and Risk Factors
Hepatitis B virus (HBV) is a DNA virus that infects over 350 million people worldwide. Although HBV infection is extremely common in parts of Asia and Africa, Canada has a relatively low level of endemicity. In North America, HBV infection occurs mainly in sexually active young adults. Important risk factors for HBV include sexual activity, IV drug use, occupational exposure, travel or residence in an endemic area and previous blood transfusion. The route of transmission may be sexual, parenteral, or vertical, with an incubation period of 6 weeks to 6 months.

Nariman Malik, BSc

Introduction
Mitral regurgitation is a common valvular heart disease, especially in the elderly.¹ It is defined as a condition in which there is an abnormal flow of blood from the left ventricle to the left atrium across an incompetent mitral valve during ventricular systole.² The mitral valve consists of four main components: the annulus, anterior and posterior leaflets, the chordae tendinae and the papillary muscles. Mitral regurgitation has a number of underlying etiologies that can be broadly classed into two groups: mitral regurgitation due to organic disease (e.g. rheumatic disease or infective endocarditis) or mitral regurgitation due to functional causes (regurgitation results from myocardial dysfunction as opposed to valvular problems). In developed countries, the etiologic profile of mitral regurgitation has changed over recent years due to the decreased incidence of rheumatic heart disease.³ Mitral regurgitation is most frequently due to degenerative and ischemic causes in the western world.⁴ See table 1

D'Arcy Little, MD, CCFP
York Community Services, Toronto and
Department of Family Medicine, Sunnybrook Campus of Sunnybrook and Women's College Health Sciences Centre, Toronto, Ontario

Epidemiology
Diabetes mellitus, a metabolic disease characterized by hyperglycemia secondary to defective insulin secretion and/or action, is an extremely common, chronic illness with a high burden of potentially preventable complications. It is a leading cause of coronary artery disease, peripheral vascular disease, kidney failure, peripheral neuropathy and new-onset blindness. A full five percent of Canadians have been diagnosed with the disease, and this percentage is predicted to translate into 2.2 million cases by the year 2000. However, statistics from the United States suggest that for every person diagnosed with diabetes, another has the disease and remains undiagnosed. Appropriate screening for diabetes provides the means to identify those undiagnosed individuals who may benefit from earlier intervention.

Neil Fam, BSc, MSc

Pneumonia is a common and serious condition that claims over 6,000 lives in Canada annually. The elderly are particularly at risk, with individuals over 65 accounting for 50% of all pneumonia cases and 90% of deaths due to lower respiratory tract infection.¹ Indeed, elderly patients with pneumonia have a mortality rate 3-5 times that of young adults. A combination of factors contribute to the increased incidence of pneumonia in the elderly, including the presence of comorbid illness and the effects of aging on the lungs and immune system (see Age-related Changes to the Respiratory System Will Not Affect Healthy Elderly). Recent advances in our understanding of pneumonia have led to a re-evaluation of traditional approaches to the disease. This review outlines disease presentation, common pathogens and current diagnostic, treatment and preventive options in the care of elderly patients with pneumonia.

Warren T Blume, MD, FRCP(C)
Professor, Department of Clinical Neurological Sciences, Director, EEG Laboratory,
London Health Sciences Centre, London, Ontario

Presented with an elderly patient exhibiting apparent cognitive decline, the physician must address three questions: (1) Does the decrease in apparent intellectual performance represent true dementia or pseudo-dementia? (2) Is there a treatable etiology? and (3) What is the prognosis? Of the diagnostic tests that society can afford, a well performed EEG can answer these questions as well as any test--after a thorough functional enquiry and physical examination.

Diffuse, persistent, excess delta (1-3 Hz) activity in this awake 75 year old man with cognitive decline.

Alzheimer's disease, a principal cause of dementia in the elderly, can produce several EEG abnormalities: a slowing of background rhythms, the appearance of diffuse slow-waves, triphasic waves, and a lack of clear EEG distinction between wakefulness, drowsiness, and light sleep. Rae-Grant et al. found a true dementing illness in 38 of 39 elderly subjects when such features appeared persistently in the recording and in 31 of 39 in whom they appeared intermittently.

Lilia Malkin, BSc

Breast cancer has the dubious distinction of being the most frequently diagnosed neoplasm and the second leading cause of cancer deaths in Canadian women today. Since the incidence of breast cancer increases with age, its appropriate diagnosis, management, and prevention are highly important in the geriatric population.

Epidemiology
A widely quoted statistic is that one in nine Canadian women will develop breast cancer in her lifetime, while one in twenty-five will die from it. The National Cancer Institute of Canada (NCIC) estimates that 18,700 Canadian women will be diagnosed with breast cancer and that 5,400 will succumb to it in 1999. In Ontario alone, more than 7,000 new cases are reported and approximately 2,000 women die each year. Although breast cancer affects men as well as women, male patients make up less than one percent of all cases. In 1994, when nearly 16,000 Canadians were diagnosed with breast cancer, only 97 of them were male.

Breast cancer remains a significant contributor to morbidity and mortality in the female geriatric population. More than 50% of breast cancer patients are older than 65 at diagnosis. According to NCIC's 1999 estimates, 6,000 of the new breast cancer cases will occur in Canadian women aged 70 and over.