Herbert P. von Schroeder, MD, MSc, FRCSC, University of Toronto Hand Program and Toronto Western Hospital, University Health Network, Toronto, ON.

Osteoarthritis is a highly prevalent and disabling condition of the hand in the geriatric population. It is commonly and effectively managed by surgical means. The interphalangeal joints and base of the thumb are most frequently involved, particularly in women, whereas post-traumatic osteoarthritis of the wrist is more common in men. Surgical procedures include simple debridement, soft tissue stabilization or osteotomies for milder cases. Joint arthroplasty, including excision procedures, and joint arthrodesis (fusion) are indicated for more severe arthritis. The type of procedure used depends on the location of the affected joint, patient age and physical demands placed on the hand. Surgery can effectively alleviate pain and improve hand function to improve an individual's quality of life.
Key words: osteoarthritis, hand, arthrodesis, arthroplasty, surgery.

Cataracts are the leading cause of blindness in the world and account for 15% of blindness in Canada. The condition, which results in deficits in acuity and contrast sensitivity and increased disability glare, is present in half of adults over the age of 65 years. Older drivers with cataract are more likely to have a history of recent driving accidents compared with older drivers without impaired vision, yet it has not been determined whether the surgical removal of cataracts--a highly successful treatment--reduces the likelihood of crashing. Investigators set out to determine the impact of cataract surgery on the crash risk for older adults in the years following surgery, compared with that of older adults with cataracts but who opted not to have surgery.

The prospective cohort study recruited 277 patients aged 55 to 84 with cataract, 174 of whom elected to undergo surgery. Researchers followed the patients for four to six years and compared vehicle crash occurrence involving patients who elected to have surgery versus those who did not.

Results showed that people who underwent surgery were 53% less likely to be involved in a car crash than those who did not have surgery, which translated to five crashes per million miles of travel among recipients of surgery compared to nine crashes per million miles for those who declined surgery. However, the authors, aware of the study's limitations, caution against the inference that surgery can make people better drivers. Patients who opted out of surgery may have had other medical risk factors that influenced both their decision to avoid the procedure and their risk of car crashes. Therefore, while the study may indicate that driving performance of older drivers with cataracts might improve after surgery, the threat of selection bias prevents more firm conclusions.

Source

1. Owsley C, McGwin G, Sloane M, et al. Impact of cataract surgery on motor vehicle crash involvement by older adults. JAMA 2002;288:841-9.

Shabbir M.H. Alibhai, MD, MSc, FRCP(C)
Staff Physician, University Health Network,
Instructor, University of Toronto,
Toronto, ON.

The last few decades have seen major advances in the surgical management of numerous illnesses. As the proportion of the elderly in the general population continues to increase, the prevalence of many chronic conditions also increases. Given the number of available surgical therapeutic options to cure or palliate these chronic conditions, more and more elderly patients are undergoing surgery. Conventional wisdom suggests that, compared to younger or middle-aged patients, older individuals have a higher risk of perioperative and postoperative complications, including death. This increased risk has been attributed to aging itself. This article will examine this relationship in greater detail.

Dozens of studies have suggested that advanced age leads to an increased risk of experiencing surgical complications. This includes an increased risk of postoperative complications such as deep venous thrombosis, infections (including wound, urinary tract, and lung), delirium and mortality.¹ In preoperative assessment clinics, internists and anesthetists utilize risk indices or algorithms to determine an individual patient's surgical risk and potentially modifiable risk factors.

A recent study suggests that patients with non-ST-elevation acute coronary syndrome (ACS) may want to hold off on invasive cardiac surgery soon after hospitalization.

A total of 18,151 patients with non-ST-elevation ACS were enrolled in the Organization to Assess Strategies for Ischemic syndromes (OASIS) and the OASIS-2 trials. Data from the two studies were pooled and analyzed to determine the prognostic factors for stroke in this group of patients. Overall, over a 6-month follow-up period, 238 patients had a stroke and multivariate regression analysis identified coronary artery bypass graft (CABG) as the most important predictor of stroke. Furthermore, patients who underwent early CABG surgery were at a substantially increased risk when compared with those who had later CABG. Other prognostic factors identified included history of stroke, diabetes mellitus older age, higher heart rate and on-site catheterization facility. No increased stroke risk was identified for patients who underwent percutaneous coronary intervention.

Source

1. Cronin LC, Mehta SR, Zhao F, et al. Stroke in relation to cardiac procedures in patients with non-ST-elevation acute coronary syndrome. Circulation. 2001;104;269-274.

Kimby N. Barton, MSc
Assistant Editor,
Geriatrics & Aging

With recent advances in medical interventions for the treatment of cardiovascular diseases, including the introduction of ACE inhibitors and the use of b-blockers for left ventricular dysfunction, the role of coronary revascularization in managing elderly cardiovascular patients has become more difficult to define. Unfortunately, the bulk of research in this area has either failed to compare treatments directly, or has excluded patients who are 65 years or older. Research in this field has also focussed on long-term benefits of surgery over medical treatment, which may not be as germane to an elderly patient as symptomatic improvements, given that this patient's life expectancy may be considerably shorter than that of someone younger. In addition, with the increased frailty that accompanies old age, perioperative mortality and postoperative complications are a much greater concern for elderly patients. They are at an increased risk for stroke, acute renal failure, and other major complications. All of these factors suggest that caution should be exercised when extrapolating data from younger patients and applying it to older ones.

Sheldon Singh, BSc

Valvular heart disease is an increasingly common cause of congestive heart failure in the elderly population. Stenosis of the aortic valve is one type of valvular heart disease that can lead to congestive heart failure. Approximately 28,000 aortic valve replacements were performed in the United States in 1994. Sixty-one per cent of these were performed in individuals over age 65. This procedure is the second most common open-heart procedure performed in the elderly after coronary bypass grafting.

In adults, aortic stenosis may be due to previous rheumatic disease or calcification of a congenital bicuspid valve or normal tricuspid aortic valve. Although common worldwide, rheumatic disease is uncommon in North America and Europe. However, because of the increasing aging population, degenerative aortic valve calcification constitutes a substantial health problem.¹

Anatomy
A normal aortic valve is tricuspid. Each leaflet is flexible and composed of three layers covered with endothelium on each side. Degenerative calcific disease is characterized by discrete focal lesions on the aortic side of the leaflet. It is typically an active inflammatory process that bears some resemblance to atherosclerosis; there are protein and lipid infiltration as well as macrophages, foam cells, and the occasional T cell.² The risk factors for aortic valve disease include age, male gender, lipoprotein a, hypertension, smoking, cholesterol and diabetes.

Barry Goldlist, MD, FRCPC, FACP

The most common causes of death in old age are, as expected, cardiovascular disease and cancer. However, for those involved in health care of the elderly, it is no surprise to learn that the elderly consider arthritis the greatest cause of disability. Osteoarthritis, rather than diseases such as rheumatoid arthritis, causes most of the burden of joint disease in old age. The major problems are generally pain and functional limitation. Medical management in the past has generally depended on limitation of activity and intermittent use of analgesics. Often, physicians neglect first principles in dealing with this chronic disease. The patient must be educated about the disease (therapy, exercise, weight reduction, use of assistive devices, etc.), and then the doctor and patient must agree on appropriate goals of therapy. If the patient is expecting total pain relief, and the doctor's goal is only to maintain mobility, neither party will be satisfied. There is much evidence now that excessive rest is harmful in osteoarthritis, and that therapy and exercise can improve function and decrease pain. Currently, regularly administered acetaminophen is the drug of choice for significant pain in osteoarthritis. Non-steroidal anti-inflammatory drugs (NSAIDs) are also beneficial, but their use is limited by side effects that are most prevalent in the elderly. The threshold for regular use of NSAIDs might be lowered as the new generation of more specific COX-2 inhibitors become more widely available. The exact role of other modalities, such as oral glucosamine and injections of hyaluronic acid, is not really clear at the present time.

For severe joint disease, the use of surgical joint replacement has been an incredible development. It is clear, however, that the availability of the procedure is greatly restricted in Canada. It is unclear to me how coronary artery surgery (CABG) has prospered in its availability in comparison to joint replacement surgery. Both are primarily done for quality of life issues, not longevity, and CABG is more easily available despite the fact that the elderly say that their joints are a greater source of impaired functional ability than their hearts. Until joint replacement surgery is more widely available, many of our seniors will continue to suffer unnecessarily.