Publication of THE LATEST IN ULCERATIVE COLITIS CARE supplement was made possible by an unrestricted educational grant from Aptalis Pharma

¹James Gregor, MD,²Co-authors: John Howard, MD, Nitin Khanna, MD, and Nilesh Chande, MD,

CLINICAL TOOLS

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• Key Points
• Clinical Pearls
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Résumé
L'un des atouts les plus importants dans la prise en charge des patients atteints de colite ulcéreuse consiste à avoir des patients bien informés. L'expérience clinique montre que la plupart des patients ont des questions similaires lors de leur diagnostic. En anticipant ces questions et en les adaptant à la gravité et l'étendue de la maladie d'un patient, il est possible non seulement de simplifier le suivi, mais également de réduire la confusion et d'augmenter les bienfaits apportés par la pléthore de renseignements disponibles au 21^e siècle. D'après notre expérience locale, nous avons défini les 10 questions les plus couramment posées par les patients et modifié les réponses, au besoin, pour qu'elles soient mieux adaptées aux patients atteints de rectite ou proctite ulcéreuse, de colite ulcéreuse gauche ou de pancolite.
Mos clés : colite ulcéreuse, patient, questions, classification, prise en charge.

I am someone who believes fervently in screening for colon cancer, and have had two colonoscopies (separated by 5 years). Even those at normal risk seem to benefit from some form of screening, and I have been particularly concerned because I have had close relatives afflicted by the disease. However, it is clear that many people who should know better refuse to be screened. Even simple screening tests such as fecal occult blood testing require people to endure relatively unpleasant activities, and colonoscopy prep is hardly fun.

Independent of my views, it is obvious that the rising prevalence of cancer of all types in Canada is a result of the aging of our population and the relative decline in cardiovascular mortality. Many of today’s cancer patients are relatively frail, or become so while getting treatment, and attention to geriatric medicine principles in these patients is important. Most oncology training programs in the United States incorporate a geriatric module to cover these issues. We are lagging a bit behind in Canada in this respect, but I am proud to say that one of the nation’s outstanding leaders in the field of geriatric oncology is our own senior editor, Dr. Shabbir Alibhai. The focus of this month’s edition is how cancer management is altered in older adults.

Our continuing education article, “Management of Primary Colon Cancer in Older Adults,” is by Dr. Robin McLeod, Selina Schmocker, and Dr. Erin Kennedy. Obviously, I hope never to have to worry about this because I have a commitment to screening! The very common ( and currently in the press) topic of “Multiple Myeloma in Older Adults: An Update” is written by Dr. Madappa N. Kundranda and Dr. Joseph Mikhael. The commonest cancer in older individuals is addressed in the article “Basal Cell Carcinoma” by Dr. Christian A. Murray and Dr. Erin Dahlke.

As well, we have our usual collection of articles on varied topics. Our Cardiovascular column is an “Update on the Management of Atrial Fibrillation in Older Adults” by Dr. Hatim Al Lawati, Dr. Fatemeh Akbarian, and Dr. Mohammad Ali Shafiee. Our Dementia article is on a common and difficult topic, “Withholding and Withdrawing Life-Sustaining Treatment in Advanced Dementia: How and When to Make These Difficult Decisions,” by Dr. Dylan Harris. In the area of nutrition, we have the article “Nutrition Guidelines for Cancer Prevention: More Than Just Food for Thought” by Kristen Currie, Sheri Stillman, Susan Haines, and Dr. John Trachtenberg. This is a natural extension from our focus this month. Our Community Care article is “Community-Based Health Care for Frail Seniors: Development and Evaluation of a Program” by Dr. Douglas C. Duke and Teresa Genge. Finally we feature one of Canada’s most prominent physicians in our “I Am a Geriatrician” column, namely Dr. Howard Bergman.

Enjoy this issue,
Barry Goldlist

Amitabh Gupta, MD, Clinical Fellow, Movement Disorders Centre, Toronto Western Hospital, University of Toronto, ON.
Susan Fox, MD, Assistant Professor, Movement Disorders Centre, Toronto Western Hospital, University of Toronto, ON.

Progressive supranuclear palsy (PSP) is a rare, fatal neurodegenerative disease with limited treatment options that is characterized by gait and postural instability and a classical vertical supranuclear gaze palsy. Initially often misdiagnosed as idiopathic Parkinson’s disease (IPD), proper patient care in PSP may be delayed until late into the disease course, after dopaminergic medication fails to improve symptoms. Here, we review the diagnostic criteria that help to separate PSP from IPD and rarer forms of parkinsonian diseases to help clinicians with earlier recognition. We discuss current treatment concepts as well as ongoing experimental approaches that are derived from an emerging pathological understanding.
Key words: progressive supranuclear palsy, clinical diagnosis, imaging, differential diagnosis, management.

Keri-Leigh Cassidy, MD, Department of Psychiatry, Dalhousie University, Halifax, NS; Department of Psychiatry, University of Toronto, Toronto, ON.
Neil A. Rector, PhD, Department of Psychiatry, University of Toronto, Toronto, ON.

Late-life anxiety can often be “silent”--missed or difficult to diagnose as older adults tend to somatize psychiatric problems; have multiple psychiatric, medical, and medication issues; and present anxiety differently than do younger patients. Yet late-life anxiety disorders are a “geriatric giant,” being twice as prevalent as dementia among older adults, and four to eight times more prevalent than major depressive disorders, causing significant impact on the quality of life, morbidity, and mortality of older adults. Treatment of late-life anxiety is a challenge given concerns about medication side effects in older, frail, or medically ill patients. Antidepressants are recommended but not always tolerated, and benzodiazepines are generally to be avoided in this population. Effective psychotherapies such as cognitive behavioural therapy (CBT) are of particular interest for the older adult population, and the combination of CBT and medication is often needed to optimize treatment.
Key words: anxiety, late life, management, cognitive behavioural therapy.

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.

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.

Kristin Casady, Editorial Director, Geriatrics & Aging.

A recent study examined the effectiveness of educational interventions in improving detection and management of dementia in the primary care setting (BMJ 2006;332:692-6). Achieving improved detection rates and advances in the provision of ongoing care for demented individuals is facilitated by the integration of decision support systems and practice-based workshops, the study’s authors concluded.

Introduction
Primary care practitioners play a role of fundamental importance in diagnosing dementia as they are the point of patients’ first medical contact. Practitioners must deliver prompt intervention and provide ongoing care for their patients receiving the diagnosis, yet inadequate detection and management have been widely documented. Further, it is observed that clinicians often face profound obstacles in executing this role. There may be difficulty in assessing the presence of dementia (for a recent discussion of the diagnosis and treatment of the older adult with cognitive complaints, see Myronuk L. Pitfalls in the diagnosis of dementia. Geriatrics Aging 2006;9:12-9). Challenges are reported to include such barriers as a lack of resources and insufficient cooperation among the general practitioner’s team, involved specialists, and community services.

Assessing Effective Diagnosis and Management: Study of U.K. Practices
Thirty-six general practices in the United Kingdom (central Scotland and London) were recruited as settings for an unblinded, cluster randomized, before-and-after controlled study organized around the provision of three educational interventions: one, a CD-ROM tutorial; two, decision-support software built into the practices’ electronic medical records; and three, practice-based workshops for the general practitioners (the curriculum used is available for download from the U.K.’s Alzheimer’s Society website, www.alzheimers.org.uk). Eight practices were randomly assigned to the electronic tutorial; eight to decision-support software; 10 to practice-based workshops; and 10 to control. Results were obtained from 450 valid and usable records. The design of the interventions was modeled to reflect different approaches to adult learning: the electronic tutorial for self-directed learning; decision-support software for real-time investigations of actual cases; and workshops to facilitate peer communication about the cases under consideration.

Based on searches of the record system for the terms dementia, confusion, memory loss, and cognitive impairment, all practices identified registered patients aged 75 and over who were diagnosed as having dementia or had been assessed as having probable dementia by a general practitioner or specialist.
Investigators audited detection rates prior to and approximately nine months after the intervention. Analysis was conducted of differences in baseline concordance scores with best-practice guidelines for the diagnosis and management of dementia, repeating the analysis for postintervention scores. The ten-item diagnosis concordance score gathered data on items that included whether clinicians took measures such as requesting blood tests at index consultation, took full histories, undertook cognitive testing, and completed scans, both at index consultation and then secondarily after index consultation (before diagnosis). Management concordance scores tracked items such as concerns of caregivers, behaviour problems, depression screening/treatment, referrals to social services, and initiation of pharmacological treatment regiments.

Outcome: Improved Rates of Detection
Regarding changes in rates of detection, diagnosis, and management, the study’s authors noted improved rates of detected dementia with decision-support software and practice-based workshops compared with control: individuals identified as having dementia after the interventions represented 31% of all cases diagnosed in the practice-based workshops arm, 20% in the electronic tutorial arm, 30% in the decision support software arm, and 11% in the control arm. Authors reported the positive effect of the decision-support software as particularly encouraging, with practitioners describing software as simple and practical to implement. However, no difference in concordance with guidelines regarding the management of dementia was noted. This outcome was ascribed to the modest number of cases identified after the intervention and the relatively few cases in the control arm. The result was also described as traceable to the investigators relying on the medical record for evidence of practice; they postulated that practitioners may have improved their practice but not noted it. The authors highlighted the value of focussed educational interventions directed at improving clinical record-keeping.

Conclusion
Successful management of dementing illnesses depends first on effective detection. This study affirms that interventions such as decision-support software and practice-based workshops can improve those rates. The authors highlight that future interventions aimed at improving concordance with recommended diagnosis or management may be furthered by the effect of combining locality initiatives with practice-based interventions, such as ones that incorporate local opinion leaders as well as encourage the direct involvement of patients and caregivers.

Lucia Gagliese, PhD, CIHR New Investigator, School of Kinesiology and Health Science, York University; Department of Anesthesia, Behavioural Sciences & Health Research Division, University Health Network; Departments of Anesthesia and Psychiatry, University of Toronto, Toronto, ON.

Depression is highly prevalent among older adults with chronic pain living both in community and institutional settings. It is associated with decreased quality of life, including impairments in physical and social well-being. This article reviews the relationship between pain and depression. The potential mediating role of disability, life interference, and perceived control are described. Routine assessment of both pain and mood, using scales validated for this age group, is advocated. Finally, the importance of integrating pharmacological and psychological interventions for the management of pain and depression in the older adult is highlighted.
Key words: chronic pain, depression, mood disturbance, assessment, management.

The week before writing this article, I received an urgent call from a patient’s daughter. I had seen the patient in the past to provide advice on the control of her hypertension. The daughter told me that her mother was in agony with a pounding headache, which the daughter assumed meant that her blood pressure was dangerously elevated. I quickly went to see her, and of course the problem was not related to her blood pressure. In fact, this woman had had a lifelong history of severe headaches, generally self-managed with large doses of acetaminophen with codeine. She had never really received a systematic assessment for her severe pain, and this led me to consider how many older patients have poorly managed pain. Certainly the scientific literature suggests that it is all too common. There are numerous reasons for this. We often assume that with all their medical conditions older adults should be in pain, and there is often a nihilistic attitude towards management. Often the management is focussed exclusively on analgesics, an approach that is too limited for chronic pain conditions. As well, the multiplicity of diseases that some older adults present with makes diagnosis and specific management quite difficult. I am pleased, therefore, that the theme of this issue is on Pain Management in the Older Adult.

The CME article this month is by Dr. Marek Gawel, a neurologist who is also an international authority on headache. His article is entitled “Headaches in the Older Adult.” After my recent experience, it seems rather important for me to complete the CME course! Then, Dr. Deborah Dillon McDonald discusses “Post-Operative Pain Management for the Aging Patient.” In order to understand the intensity of treatment required for a painful condition, the physician must be able to assess the severity of the patient’s pain. This topic is beautifully addressed in the article “Assessing Pain Intensity in Older Adults” by Drs. Sophie Pautex and Gabriel Gold. Finally, Dr. Lucia Gagliese explores the association between physical pain and mood in her review of “Pain and Depression in Aging Individuals.”

As usual, we also have several articles on other topics. In our cardiovascular column, Drs. Rachel L. McIntosh and Tien Y. Wong consider the importance of “Hypertensive Retinopathy as a Risk Marker of Cardiovascular Disease.” As a geriatrician, I believe that poor dental health in demented patients can trigger an inexorable downward spiral as nutrition is impaired. I am pleased that Dr. Michael J. Sigal is addressing this problematic area in his article “Dental Considerations for Persons with Dementia.” For those of us who like to eat (I am one of those!), the importance of healthy teeth and a healthy oral cavity cannot be over emphasized. Drs. Richard J. Payne, Jamil Asaria, and Jeremy L. Freeman review the important topic of “Oral Cavity Cancer in the Older Population.” Finally, our caregiving article by Dr. Rory Fisher addresses a very timely ethical issue, “Euthanasia and Physician-Assisted Suicide: Are They Next?”

Enjoy this issue,
Barry Goldlist