James L. Rudolph, MD, SM, Division of Aging, Brigham and Women's Hospital and the Boston VA Geriatric Research, Education, and Clinical Center, Boston, MA.

Edward R. Marcantonio, MD, SM, Hebrew Rehabilitation Center for Aged and Beth Israel Deaconess Medical Center, Boston, MA.

Delirium is a common syndrome in hospitalized older patients that is frequently undiagnosed by health care professionals. This is particularly troubling because delirium is associated with poor outcomes such as increased nursing home placement, nosocomial infections and increased mortality. Criteria for the diagnosis of delirium are validated, reliable and can readily be applied to patients by health care professionals. Solid evidence exists that delirium can be prevented with educated prescribing of medications, practical in-hospital interventions and geriatric consultation.
Key words: delirium, differential diagnosis, prevention, Confusion Assessment Method.

Gabriele Meyer, Research Fellow, Andrea Warnke, Research Fellow and
Ingrid Mühlhauser, Professor; Unit of Health Sciences and Education,
University of Hamburg, Hamburg, Germany.

Prevention of falls in the elderly is a high priority in many countries. Single component and multifaceted interventions have been extensively studied. However, only two interventions have been shown to reduce injuries or fractures. Hip protectors effectively reduce hip fractures. Home-based exercise programs administered by qualified professionals may reduce falls and fall-related injuries. Most interventions are intensive and require substantial resources. Before considering implementation of a fall prevention program, its practicability, acceptance and cost-effectiveness should be explored.
Key words: accidental falls, prevention, hip fractures, hip protector, protective devices.

G. Daniel Schachter, MD, FRCPC, DABD, Consultant Dermatologist, Sunnybrook & Women's College Health Sciences Centre and St. John's Rehabilitation Hospital; Lecturer, University of Toronto, Toronto, ON.

During the past century, the amount of time spent at leisure and exposed to the sun has increased, yet we have also become increasingly aware of the detrimental effects of the sun. The skin ages slowly (intrinsic, chronologic aging), but this process is enhanced or accelerated by sun exposure (extrinsic aging, photoaging). The features of photoaging will be presented, followed by the importance of the prevention of sun damage by sun avoidance and use of sunscreens. Methods of treating or reversing photodamage will be reviewed, including topical agents, chemical peels and use of lasers and other light sources.
Key words: photoaging, ultraviolet radiation, prevention, sunscreen, skin rejuvenation.

Ron Keren, MD, FRCPC, Clinical Director, University Health Network and Whitby Mental Health Centre Memory Clinics; Assistant Professor, University of Toronto, Toronto, ON.

In recent years, a number of observational studies have shown that when consumed in moderation, alcohol may contribute to healthy living, reducing the risks of both coronary artery disease and dementia. While the ill effects of excessive drinking on cognition have been extensively described, there are no clinical or pathological consensus criteria defining alcohol-induced dementia. In fact, its existence as a distinct entity is controversial. More research on the effects of alcohol on the brain is needed in order to advise patients on the potential risks and benefits of alcohol consumption.
Key words: alcohol consumption, dementia, prevention, cognition, Wernicke-Korsakoff.

While investigating the benefits of statin therapy in the seldom studied elderly, the PROSPER study found that pravastatin reduced the risk of coronary disease as it has in studies of middle-aged people, yet unlike previous studies, did not have a clear effect on risk of stroke.

The benefits of statins have been demonstrated for the primary and secondary prevention of both coronary and cerebrovascular events, but most of this evidence has involved middle-aged people. The rationale for such treatment in those older than 70 years is less clear, since the association between cholesterol levels and risk of coronary artery disease diminishes with increasing age, and the frequency of stroke is associated with hypertension rather than with cholesterol. However, there has been enough conflicting evidence to challenge these concepts such that investigators launched the Prospective Study of Pravastatin in the Elderly at Risk (PROSPER) to look more closely at the efficacy of statin therapy in older people. The researchers set out to determine whether pravastatin reduces the risk of cardiac events, stroke, cognitive decline and disability in those with existing (secondary prevention) and those at high risk of developing (primary prevention) vascular disease.

A total of 5,804 men and women 70-82 years old were recruited if they had pre-existing vascular disease or a high risk of developing vascular disease due to smoking, hypertension or diabetes. Of these, 2,891 were randomized to treatment with pravastatin 40mg per day and 2,913 to placebo. Plasma total cholesterol levels had to be 4.0-9.0mmol/L and their triglyceride concentration less than 6.0mmol/L. Every three months, lipoprotein profiles were measured, and every year an electrocardiogram was recorded and cognitive function tests and disability assessments were performed. Follow-up was 3.2 years on average and the primary outcome was the combined endpoint of definite or suspect death from coronary heart disease, non-fatal myocardial infarction and fatal or non-fatal stroke. Secondary outcome was a separate examination of coronary and cerebrovascular components, while tertiary outcomes included disability and cognitive function.

Pravastatin was found to reduce the risk of the primary endpoint by 15% (relative reduction; p=0.014), yet this risk reduction was largely attributable to a reduction in risk of coronary events only. Upon separation, investigators noted a 19% reduction in coronary events (p=0.006) but no discernable effect on cerebrovascular events (p=0.81). Reductions, although non-significant, were found in transient ischemic attacks and the frequency of revascularization procedures among participants taking pravastatin. There were no observed differences between treatment and placebo groups in all-cause mortality or rates of hospital admissions for heart failure. Furthermore, serious adverse events were reported with similar frequency in both groups, and cognitive function declined at the same rate.

The overall reduction in the primary endpoint in pravastatin-treated subjects was less than predicted because of the lack of effect on rates of stroke. This finding was not, however, due to pravastatin's inability to lower low-density lipoprotein (LDL) cholesterol; at three months LDL cholesterol was 34% lower in treated subjects and after two years remained 33% lower than levels measured in placebo subjects. Researchers propose that the lack of effect on stroke might be due to a lack of statistical power, or may be a consequence of the short duration of the trial since other research suggests that stroke benefit from statin therapy does not begin to appear until after three years (whereas coronary risk reduction is an early event).

Extrapolating results from the PROSPER study to clinical practice is difficult. Although it provides clear evidence that statin therapy in elderly individuals reduces the risk of coronary disease, as it does in middle-aged people, a clear result on stroke would require a longer period of treatment if indeed statins are even beneficial for this indication in the elderly.

Source

1. Shepherd J, Blavw GJ, Murphy MB, et al. Pravastatin in elderly individuals at risk of vascular disease (PROSPER): a randomised controlled trial. Lancet 2002;360:1623-30.

David C.W. Lau, MD, PhD, FRCPC, Professor of Medicine, Biochemistry and Molecular Biology; Director, Julia McFarlane Diabetes Research Centre, University of Calgary, Calgary, AB.

As the population ages, the diagnosis of Type 2 diabetes is expected to skyrocket over the next two decades. Diabetes is diagnosed by a fasting venous plasma glucose level of equal to or greater than 7mmol/L or, in the presence of classic symptoms of hyperglycemia, a casual plasma glucose value greater than 11.1mmol/L. Early diagnosis, screening and prevention of diabetes in the elderly will greatly reduce the burden of this serious chronic disease that is associated with increased morbidity and mortality.
Key words: impaired glucose tolerance, diagnosis, screening, prevention, Type 2 diabetes

The Diabetes Epidemic
Diabetes is now reaching epidemic proportions in Canada and the U.

Cardiovascular disease continues to reign as the leading health-related killer of Canadians. Survivors of myocardial infarction (MI) run a high risk of suffering a subsequent attack, thus necessitating a thorough investigation into potential therapies for secondary prevention.

While the antiplatelet action of Aspirin is currently favoured for the prevention of recurrent cardiac complications, the role of the coagulation cascade in causing thrombosis implicates oral anticoagulants, such as warfarin, as agents of potentially similar or superior therapeutic benefit. The results of the recent Warfarin, Aspirin, Reinfarction Study (WARIS II) suggest that the use of warfarin on its own, or in combination with Aspirin, may be more effective than Aspirin alone in reducing the incidence of reinfarction or thromboembolic stroke following an initial event of MI.

In this randomized, multicentre study, 3,630 MI survivors were assigned to treatment with either Aspirin (160mg daily), warfarin, or Aspirin (75mg daily) in combination with warfarin for a mean duration of four years. Primary outcome was a composite of death, nonfatal reinfarction or thromboembolic cerebral stroke.

The primary outcome was observed in 241 of 1,206 patients on the Aspirin-only regiment (20%), 203 of 1,216 patients receiving warfarin only (16.7%), and 181 of 1,208 patients receiving the combination treatment (15%). These results indicate the superiority of warfarin alone and in combination with Aspirin over Aspirin alone in the prevention of nonfatal reinfarction and nonfatal thromboembolic stroke. However, the data failed to show significant statistical difference in effect on mortality.

Despite the apparent benefits of warfarin in the WARIS II study, the two groups receiving warfarin experienced approximately four times as many major bleeding events as the Aspirin-only group. Given this observation, anticoagulant therapy may be considered in patients especially at risk for thromboembolic events or who demonstrate resistance to Aspirin treatment.

Source

1. Hurlen M, Abdelnoor MPH, Smith P, et al. Warfarin, aspirin, or both after myocardial infarction. N Engl J Med 2002;347:969-74.

June M. Chan, ScD, Assistant Adjunct Professor, Departments of Epidemiology & Biostatistics and Urology, University of California, San Francisco, CA, USA.

Prostate cancer is the most commonly diagnosed cancer and is second only to lung as the most fatal cancer among men in the United States. It is the ninth most common cancer in the world, with higher rates predominating in North America, Europe and Australia, and lower rates reported in Hong Kong, Japan, India and China. The main non-modifiable risk factors include age, race and family history.

The incidence of prostate cancer increases exponentially with age, with men age 75-79 experiencing an incidence rate more than 100-times greater than that of men age 45-49 (age-specific prostate cancer incidence rate for men age 75-79 = 1400/100,000 person-years; for men age 45-49 = 11/100,000 person-years).¹

African Americans have the highest recorded age-standardized rates in the world, estimated at 137 cases per 100,000 persons in 1997 according to Surveillance, Epidemiology, and End Results (SEER) data.² In contrast, the rate among Caucasians in the U.S. was 101/100,000. Europeans tended to have rates in the range of 20-50 cases/100,000.

Dr. Gabriel Chan, MBBS(HK), FHKAM, MRCP(UK), ABIM, FRCP(C), FRCP(EDIN),
Director of Geriatric Medical Services and Program Medical Director of Long-Term Care, North York General Hospital, Lecturer of Medicine, University of Toronto, Toronto, ON.

Frances Simone, BSc, MHA, Director, Geriatric Ambulatory Care Services, North York General Hospital, Toronto, ON.

The POWER (Promoting Osteoporosis Wellness through Education, Exercise and Resources) program is a collaborative, multi-site initiative designed to empower older adults with osteoporosis to improve their quality of life and prevent falls. POWER consists of a seven-week, culturally sensitive education, exercise and nutrition program developed by North York General Hospital, Baycrest Centre for Geriatric Care, Toronto Public Health and Yee Hong Centre for Geriatric Care. POWER is an effective health promotion model for osteoporosis management and falls prevention that can be replicated in other communities across the country.

Health promotion and disease prevention are very important concepts that support our collective goal for a healthy society. Currently, there is a need to develop models that fully integrate health promotion activities into our 'illness treatment' oriented health system. Without such models, we will face significant challenges as our population ages and our health system attempts to cope with the impact of chronic diseases.

Sophie Jamal, MD, FRCPC, Osteoporosis Research Fellow, Sunnybrook and Women's College Health Sciences Centre, Toronto, ON.

Osteoporosis, defined as a reduction in bone mass leading to an increased susceptibility to fracture with minimal trauma, affects 1.4 million Canadians.¹ Osteoporotic hip and vertebral fractures are major causes of disability and premature death. For example, the average length of stay in an acute care hospital after a hip fracture is three weeks, and one in four patients must remain in long-term care institutions for at least one year. Furthermore, patients with hip and vertebral fractures face a 20% increased risk of mortality.² Osteoporosis is also costly--in Canada, in 1993, the total expenditure for fractures was estimated to be 1.3 billion dollars.³ As the population of Canada ages, the impact of osteoporosis will increase. As such, health care providers should be aware of techniques to prevent fractures due to osteoporosis.

In addition to encouraging physical activity and ensuring adequate calcium and vitamin D intake, several medications can be used to prevent osteoporotic fractures. These drugs, which have been studied predominantly in postmenopausal women, include bisphosphonates, estrogen, selective estrogen receptor modulators and calcitonin. The evidence that supports the use of these agents to prevent bone loss and fractures in postmenopausal women is reviewed below.