Advertisement

Advertisement

management

Newer Therapies in the Management of Osteoporosis

Newer Therapies in the Management of Osteoporosis

Teaser: 

Jan Bruder, MD, Assistant Professor and Director of Osteoporosis Metabolic Bone Clinic, Division of Endocrinology, University of Texas Health Science Center, Department of Medicine, San Antonio, TX, USA.

Introduction
Osteoporosis is a disease characterized by low bone mass and bone strength, resulting in an increase in bone fragility and susceptibility to fractures.1 It is asymptomatic prior to fractures, which most commonly occur in the vertebral body, hip and forearm.

Dual energy x-ray absorptiometry is the technology used to measure bone mineral density at the sites of interest. This technology has revolutionized our approach to this disease. In 1994, the World Health Organization (WHO) published diagnostic guidelines for osteoporosis, which are based on an individual's bone mineral density (BMD) according to a T-score.2 The T-score is defined as the number of standard deviations (SD) above or below the mean BMD at peak bone mass at age 30 years. A T-score of -2.5 or lower defines osteoporosis. At risk individuals can now be diagnosed early, thereby allowing the use of highly effective interventional strategies which prevent further bone loss and potentially debilitating fractures. Unfortunately, currently once significant bone mass has been lost, there are no commercially available therapies that are proven to increase bone density. This will likely change in the next few years.

Pharmacologic Pain Management in the Elderly

Pharmacologic Pain Management in the Elderly

Teaser: 

Bill McCarberg, MD
Director of Pain Services, Board of Directors, American Pain Society
Department of Family Medicine, Kaiser Permanente Medical Center, San Diego, CA, USA.

 

As humans age, they invariably become more susceptible to disease, which can impair function and enjoyment of life and pose significant challenges to the health care system. Osteoarthritis, the most common joint disease, affects over 18% of adults in Ontario.1 Pain has also been associated with a three- to seven-fold increased prevalence of inability to perform daily tasks in the non-institutionalized elderly in Canada.2

More than half of elderly persons in the US are estimated to experience pain daily,3 and recent initiatives in the US have focused attention on the need to treat pain. The Joint Commission on Accreditation of Healthcare Organizations recently introduced new pain management standards to require better pain medicine in hospitals and other institutions as part of their accreditation process.

Non-pharmacologic Therapy
Although medications are commonly required to manage pain and maintain function in elderly patients, non-pharmacologic therapy remains a cornerstone of treatment. It should be started prior to the initiation of pharmacologic therapy, when possible, and be maintained throughout the pain management process.

Management of Headache in the Elderly Patient

Management of Headache in the Elderly Patient

Teaser: 

D'Arcy Little, MD, CCFP
Director of Medical Education, York Community Services, Toronto, ON,
and Academic Fellow, Department of Family and Community Medicine,
University of Toronto, Toronto, ON.

 

Introduction and Epidemiology
While symptom complaints tend to increase as the population ages due to age and comorbid conditions, the prevalence of headaches actually decreases in the elderly compared to their younger counterparts.1,2,3 However, headache is still very common in this age group and causes significant morbidity. It is the 10th most common reported symptom in women, and the 14th most common symptom in men over the age of 65 living in the community.1,2,3 A large cohort study found that 11% of women over the age of 65 years and 5% of men over this age reported frequent headaches.1

While most (two-thirds of) headaches in the elderly result from benign causes such as tension-type, migraines and cluster headaches, one-third of headaches in this age group arise secondary to systemic disease and primary intracranial lesions.2,4 This is significantly different from the situation in younger patients, where only 10% of headaches are caused by such significant conditions (Table 1).2,4 Another difference in headaches between the young and old is the fact that even benign dysfunctional headaches (e.g. migraine, tension-type, cluster) can have an atypical presentation in the elderly.

Management of Venous Ulcers in the Elderly

Management of Venous Ulcers in the Elderly

Teaser: 

Morris D. Kerstein, MD
Professor and Vice-Chairman,
Director of Research and Education,
Department of Surgery, Mount Sinai School of Medicine,
New York, NY, USA.

Ernane D. Reis, MD
Assistant Professor
Department of Surgery,
Mount Sinai School of Medicine,
New York, NY, USA.

 

Venous leg ulcers influence the physical, financial and psychological well-being of patients, and result in an estimated two million workdays lost, annually. Despite a variety of therapeutic options, venous leg ulcers remain a substantial management challenge to the health-care professional. Some form of lower extremity venous disease is present in nearly 30% of the American adult population. Venous leg ulcers are often debilitating sequelae of venous insufficiency, and account for 80-90% of leg ulcers reported. A quality-of-life study reported that 65% of chronic-leg-ulcer patients had severe pain, 81% experienced reduced mobility, and nearly 100% reported a negative impact of their disease on work capacity.

Manifestations of venous insufficiency may include dilated superficial veins, with or without dilated tributaries of the deep vein system, swelling, leg pain, heaviness and changes in the skin (hyperpigmentation, venous dermatitis, eczema with dryness and itching). Ultimately, the adverse effects of venous disease appear as skin ulceration of lipodermatosclerosis.

Management of Complications of Hematologic Malignancies in the Elderly

Management of Complications of Hematologic Malignancies in the Elderly

Teaser: 

Jeffrey Zonder, MD
Ulka Vaishampayan, MD
Division of Hematology/Oncology,
Department of Medicine
Wayne State University School of Medicine/Barbara Ann Karmanos Cancer Institute
Detroit, MI, USA.

 

Introduction
The incidence of hematologic malignancies, especially lymphoma, is steadily rising in the elderly. These diseases and their complications pose specific problems for older patients. Factors that contribute to increased toxicity in the elderly include diminished marrow reserve, impaired renal and hepatic metabolism and, perhaps most importantly, poor performance status as a result of comorbidities.1 This article will focus on the management of common complications of hematologic malignancies, particularly as they pertain to older patients.

Febrile Neutropenia

Risk of Neutropenia in the Elderly
The incidence of life-threatening neutropenia (absolute neutrophil count, ANC, <0.5x 109/L) in elderly patients following chemotherapy for hematologic malignancies is 40% or higher.2 The risk of infection is affected by the duration and severity of neutropenia with a steep rise in infection incidence at a neutrophil count of less than 0.5x 109/L.

Diagnosis and Management of Acute Coronary Syndromes

Diagnosis and Management of Acute Coronary Syndromes

Teaser: 

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.

Management of Postoperative Pain in the Elderly Client

Management of Postoperative Pain in the Elderly Client

Teaser: 

 

Pamala D. Larsen, PhD, CRRN
Associate Dean for Academic Affairs,
College of Nursing and Health Professions,
The University of North Carolina at Charlotte, NC, USA.

 

Although the elderly compose a significant percentage of the surgical patient population, postoperative pain management for this population has received little attention.1 According to 1990 data, more than 4,000 documents are published annually about pain, but fewer than 1% focus on pain in the older adult.2 Lack of published information and research about geriatric pain results in most patients' pain being managed by trial and error.

Considerable evidence suggests that pain is undertreated in older patients. This may be due in part to the misconception that pain sensation diminishes with increasing age or that the elderly patient cannot tolerate narcotic analgesia.3 The perception that older adults have less pain sensitivity than do younger patients is influenced somewhat by the silent myocardial infarctions and emergent 'painless' intra-abdominal surgical events that frequently occur in older adults.4 The research involving pain perception in the elderly client provides mixed results. These conflicting results make it difficult to fully establish the relationship or connection between aging and the sensory pain component.

Perioperative Evaluation and Management in the Elderly

Perioperative Evaluation and Management in the Elderly

Teaser: 

 

Laurie G. Jacobs, MD
Head, Unified Division of Geriatrics,
Albert Einstein College of Medicine & Montefiore Medical Center,
Bronx, NY, USA.

 

Introduction
Increasingly, older adults are undergoing invasive procedures and surgery. Surgery in the elderly has been associated with a greater morbidity and mortality than in younger patients due to the physiologic changes of aging, concurrent medical conditions and an increased rate of emergency procedures. Age alone is often a determining factor in whether a procedure or surgery should even be undertaken. Preoperative evaluation and perioperative care of the elderly patient requires evaluating the risk of complications, maximizing functional and physiologic parameters, instituting preventative measures, and focused management to assess potential risk and benefit for an individual patient.

Surgical Stress and Operative Risk
Noncardiac surgery in adults is associated with an incidence of postoperative myocardial infarction of 1-2%. Those with known heart disease, advanced age and serious comorbid conditions have a significantly greater risk for MI and other serious complications. Cardiovascular complications represent 50% of the causes of postoperative morbidity and mortality. In older adults, pulmonary, renal, infectious and cognitive adverse events are also extremely common.

Diagnosis and Management of Dysphagia After Stroke

Diagnosis and Management of Dysphagia After Stroke

Teaser: 

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 patients6-10 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.

Managing Behavioural Disorders in Dementia

Managing Behavioural Disorders in Dementia

Teaser: 

A. Mark Clarfield

The fact that dementia is finally beginning to receive the attention that it deserves is evidenced by the editors of Geriatrics & Aging wisely deciding to devote most of this issue to the subject. Dementia is primarily associated with memory loss; this means, unfortunately, that professionals often pay far less attention to the other symptoms that can accompany the syndrome. In fact, caregivers tell us that their loved one's problem with memory is usually far less burdensome than are the behavioural symptoms. Two of these symptoms are featured in this issue: agitation, by Dr. Elizabeth Sloan (a resident in Psychiatry at the U of T); and wandering, written by Dr. Bob Chaudhari, of the same department.

Dr. Sloan reminds us that agitation--sometimes accompanied by other symptoms such as screaming and aggression--is not a diagnosis per se but rather consists of a "constellation of symptoms." In geriatric care we are not afraid of such terminology, even if the terms are not always easily found in the index of Harrison's Textbook of Medicine. The same, of course, would hold for falls or incontinence.

As is the case with many of the non-specific ("atypical") presentations of disease in the elderly, Sloan points out, an underlying medical illness must never be overlooked as a possible causal factor. As I like to teach my medical students, "Take a history before prescribing haldol." (Unfortunately, now that the older anti-psychotic medications are increasingly being replaced by less toxic molecules, I'll have to figure out a new alliteration to go with, for example, risperidone--now what starts with an "r"? "rectum", no; "respiratory system"--doesn't ring true.) But I digress.

Dr. Sloan goes on to offer a great deal of good advice and the interested reader is advised to consult the references in her comprehensive bibliography.

Dr. Chaudhuri tackles the related problem of wandering, where he offers an interesting tri-partite classification which I admit that I have not seen before: volitional (depressive), motivational (anxious) and repetitive behavioural (irritable) wandering. Perhaps as a geriatrician, I am used to a more "medical" classification; but the author, not surprisingly as he is a psychiatrist, offers a more psychodynamic approach.

Like Sloan, Dr. Chaudhuri points out that management must take into account the patient's environment. Appropriately, he does not spend much time on a pharmacological approach, which is not usually an effective method unless, of course, your aim is to drug the patient into a stupor.

My own experience is that the wandering (pacing) patient with dementia must be allowed his/her own space. Obviously, as is also the case at the other end of the age spectrum with the toddler, wanderers must be protected against the obvious dangers involved. However, when all is said and done, the milieu extérieur seems to me to be of more importance than the milieu intérieur.

Dr. Clarfield is the Chief of Academic Affairs at the Herzog Hospital in Jerusalem, Director of Geriatrics in the Ministry of Health, and on staff in the Division of Geriatric Medicine, Sir Mortimer B. Davis-Jewish General Hospital, McGill University, Montreal.