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Elderly Patients Rely on Dialysis for Treatment of Renal Failure

Elderly Patients Rely on Dialysis for Treatment of Renal Failure

Teaser: 

Dimitrios G. Oreopoulos
Nada Dimkovic

Toronto Western Hospital,
University Health Network

Introduction
The elderly (>65 years) are the fastest growing group of patients who require dialysis. In 1988, of the more than four thousand new dialysis patients, one thousand nine hundred and fifty eight were 65 years or older, giving an approximate rate of 515 new patients per million members of the population.

Once an elderly patient has developed end-stage renal disease (ESRD), his/her therapeutic options become limited to the various modes of dialysis that are available and, to a lesser degree, to renal transplantation.

Here we should mention a word of caution with regards to using serum creatinine as a guide for the point at which to begin dialysis. Because of the decrease in muscle mass that is associated with age, serum creatinine is disproportionately low for the degree of renal failure. Rather than relying on serum creatinine, either a creatinine clearance, or the Cockroft-Gault formula should be used to assess the severity of renal failure.

Although renal transplantation may be successful in the elderly person with ESRD, and they may have renal graft and patient survival rates comparable to those of younger recipients, only a small percentage (0.5-3%) of these patients are undergoing transplant procedures. The main reason for this is the shortage of donor kidneys.

Steering Through Murky Ethical Waters

Steering Through Murky Ethical Waters

Teaser: 


Is it Ethical to Use Foetal Tissue for the Treatment of PD?

David Kaplan, MSc(HA)
Joint Centre for Bioethics
Faculty of Medicine,
University of Toronto

Surgical transplantation of foetal brain cells has been reported to substantially improve the symptoms associated with Parkinson's Disease. Parkinson's disease, which is characterized by tremors, muscular rigidity, and akinesia, is believed to result from the deterioration of the brain's dopamine producing cells in the substantia nigra (the neural centre for the initiation and control of movement). This disease afflicts 70,000 Canadians, and unfortunately, approximately ten percent of these patients are refractory to conventional medical therapy. Clearly, new methods to control the disease would be of substantial benefit to these patients. In 1995, the Canadian government introduced legislation that would have made it difficult, if not illegal, to conduct research into foetal tissue transplant. Although this Bill died on the parliamentary order desk, there remains the prospect of reintroducing such legislation. The purpose of this article is to examine the murky ethical waters that surround the topic of research and therapy involving foetal tissue. However, I will not attempt to validate the merits of this therapy in this brief analysis.

Procurement
Obviously, a source of foetal tissue is required, in order to perform foetal tissue transplantation surgery. There are three potential sources for this tissue.

Amyotrophic Lateral Sclerosis (ALS): The Diagnosis and Treatment of this Debilitating Disease

Amyotrophic Lateral Sclerosis (ALS): The Diagnosis and Treatment of this Debilitating Disease

Teaser: 

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.

Serendipity and the Origin of the Lens Implant in Cataract Treatment

Serendipity and the Origin of the Lens Implant in Cataract Treatment

Teaser: 

In 1942, a young British flight surgeon, Ridley, made an outstanding discovery that was to shape the future of cataract treatment. Cataracts result from the clouding of the lens of the eye, which leads to blurred vision. As with the lens of a camera, the lens of the eye functions by focussing light rays onto the retina at the back of the eye, which then transmits this visual information to the brain. For the light to pass through and reach the retina, the lens must remain clear. Cataracts result when the natural lens of the eye becomes cloudy; they are not the product of a growth or the accumulation of film over the eye.

While examining injured fighter pilots, Ridley noted that when plastic slivers from the shattered windshield of an airplane cockpit entered the eye, some pilots had a severe reaction, whereas other pilots had no reaction at all. At the time, the accepted belief was that any foreign material entering the eye would cause a severe reaction until it was removed. Ridley wanted to understand why some pilots showed no reaction to the presence of a piece of plastic in their eye. Further investigation led him to realize that it was only the pilots of Spitfires who did not suffer any complications, whereas pilots flying all other British fighter planes--including captured German pilots flying Messerschmitts--were all severely affected. The young surgeon then discovered that Spitfire plastic came from a different company, ICI, that produced a type of plastic material, polymethyl methacrylate, which could be tolerated by the human eye.

When the war ended in 1945, Ridley turned his attention to cataract surgery. Treatment at the time involved removing the diseased cataract lens and giving the patient thick, heavy glasses that limited their peripheral vision and magnified objects by 30 %. Ridley decided that a better technique for cataract treatment would be to replace the human lens with a lens made of the plastic that he had discovered during the war. On 19 November 1949, at St. Thomas's Hospital in London, he performed the first lens implant on a cataract patient.

Today the treatment of cataracts still relies solely on surgical techniques; there is no medication or diet that can stop a cataract once it has begun to form. A cataract may develop rapidly over a period of a few months or it may grow very slowly over several years. Typically, this process only occurs in a single eye, although eventually, often after months or years, a cataract may develop in the second eye. Most cataracts are related to aging, although they may also be congenital, the result of a medical problem such as diabetes or of a trauma to the eye.

A cataract rarely causes damage if it is left in the eye, except in cases in which there is blurred vision. There are very rare cases, however, of cataracts, when left in the eye long past the stage of blindness, causing inflammation and glaucoma. With the current methods of removal, surgery can be performed successfully at any stage of cataract development.

The only treatment for a cataract is the removal of the cloudy lens. There are various methods of surgically removing a cataract, and the specialist must decide which method is most suitable for each individual patient. For a description of the three main surgical procedures that are available for cataract extraction, and a list of the advantages and disadvantages of these techniques, please see the full article by Dr. Marvin Kwitko on our web site at www.geriatricsandaging.ca.

Dr. Marvin Kwitko performed his first lens implant operation at Bellechasse Hospital in Montreal in 1967. In 1968 he joined St. Mary's Hospital, and under the former chief, Dr. Gaston Duclos, continued this work there. Dr. Kwitko has trained more than 350 surgeons from Canada, the U.S. and abroad. He is currently the Chief of Opthalmology at St. Mary's Hospital in Montreal and an Associate Professor of Ophthalmology at McGill University.

Therapeutic Approaches for Treatment of Alzheimer’s Disease

Therapeutic Approaches for Treatment of Alzheimer’s Disease

Teaser: 


Reviewing the Benefits and Limitations of Psychotropics and Cholinesterase Inhibitors

Wafa Harrouk, PharmD

The following are brief summaries of salient points from presentations in the session on Therapeutic Approaches for the Treatment of Alzheimer's disease, Sunday July 9th, 2000.

Clinical Status of Therapy for Behavioral Disturbances
Dr. Jeffrey L. Cummings, MD, from the Alzheimer's Disease Center, University of California, highlighted some of the most salient therapeutic interventions that are currently available for treatment of behavioural disturbances associated with AD. Alzheimer's disease (AD) is associated with a variety of neuro-psychiatric disturbances, including delusions, hallucinations, anxiety, depression, apathy, irritability, disinhibition, and agitation. Patients may also suffer from aberrant motor behaviours such as rummaging, pacing and wandering. These behavioural disturbances are stressful to the patient as well as to their caregivers. Appropriate treatment of these disturbances would improve the patients' quality of life, alleviate their caregiver's stress, and delay their placement in a nursing home. Relatively few double blind, placebo control trials of psychotrophic medications have been conducted on patients with AD.

Discrepancies in Treatment of Heart Attacks between Men and Women

Discrepancies in Treatment of Heart Attacks between Men and Women

Teaser: 

A new study in the New England Journal of Medicine finds that women receive somewhat less aggressive treatment during the early management of acute myocardial infarction as compared to the treatment that is received by men. The study also found that women are more likely to be assigned a "do-not-resuscitate" order, or DNR. However, it was not clear from this study whether health care providers are more likely to recommend DNR status for women or whether women are more likely to make this request themselves. Although the differences in treatment found in this study were small and there is no apparent effect on mortality, the results raise questions about how closely doctors follow the guidelines for treating heart attacks in general. Approximately 240, 000 American women die from heart disease every year, a number fivefold higher than that of women who die from breast cancer.

Source

  1. Gan SC, Beaver SK, Houck PM, MacLehose RF, Lawson HW, Chan L. N Engl J Med. 2000 Jul 6;343(1):8-15.
  2. American Heart Association http://www.americanheart.org.

Hepatitis B and C Incidence Among Elderly: Diagnosis and Treatment

Hepatitis B and C Incidence Among Elderly: Diagnosis and Treatment

Teaser: 

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.

Chronic Mitral Regurgitation: An overview of Etiology, Diagnosis and Treatment

Chronic Mitral Regurgitation: An overview of Etiology, Diagnosis and Treatment

Teaser: 

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

TABLE 1

ETIOLOGY

Mitral regurgitation is often classified by its underlying etiology.

The Elderly Diabetic--Combatting the Nihilistic Attitude that Treatment Won’t Make a Difference

The Elderly Diabetic--Combatting the Nihilistic Attitude that Treatment Won’t Make a Difference

Teaser: 

Barry J Goldlist, MD, FRCPC, FACP

Type II diabetes mellitus is an important health problem in the elderly. Rockwood et al., in data derived from the Canadian Study of Health and Aging, reported a prevalence of diabetes of 12% in community living elderly and 17.5% in institutionalized elderly (Age and Ageing, 1998). In the Rotterdam study (American Journal of Epidemiology 1997), by the age of 85 close to 20% of the populations fulfilled diagnostic criteria for diabetes.

The real issue in dealing with the elderly who have diabetes is the nihilistic attitude that treatment will make no difference. It is important to recognize that a healthy 70-year-old woman has a life expectancy of almost 17 years (and about 13 years for her less hardy male counterpart). This is clearly a substantial length of time in which to develop diabetic complications. The report of the United Kingdom Prospective Diabetes Study Group (Lancet, 1998) gives persuasive evidence in favor of intensive control of blood sugar in patients with Type II diabetes. There is no reason to suspect that older patients do not benefit as well. The development of new drugs, and new combinations of drug therapy, will make good control of diabetes mellitus in the elderly ever more feasible.

If diabetes is common in the elderly, and treatment beneficial, should we be screening for the disease in our patients? No careful analysis has been done for this particular segment of the population, but it seems possible that screening might be beneficial in those over the age of 65. Until more data is available, most physicians will only screen those patients with other risk factors. The two most important risk factors are family history and obesity, however, there is also persuasive evidence that hypertension should also be considered an indication for diabetes screening in the elderly (KC Johnson et al, JAGS 1997).

Once the diagnosis of diabetes mellitus is made, a complete investigation for other risk factors for cardiovascular morbidity (hypertension, lipids, etc.) is mandatory. Management of the patient with diabetes mellitus means much more than just controlling the blood sugar. Readers of this editorial are advised to obtain a copy of the 1998 clinical practice guidelines for the management of diabetes in Canada. This excellent publication appeared as a supplement to the Canadian Medical Association in 1998;159(8 Suppl). It is an extremely valuable resource for those of us who treat patients with diabetes mellitus.

Back Pain Should Be A Priority in the Overall Treatment of the Elderly

Back Pain Should Be A Priority in the Overall Treatment of the Elderly

Teaser: 

Sharron Ladd, BSc
Managing Editor

"It is clear that the study of back pain has been overlooked in the geriatric community, perhaps relegated to second-class status behind health conditions like diabetes, heart disease and cognitive impairment," says Dr. Hart Bressler, the primary author of the landmark study entitled "The Prevalence of Low Back Pain in the Elderly." The study, co-authored by Dr. Warren Keyes, Dr. Paula Rochon and Dr. Elizabeth Badley appeared in the September 1st issue of the journal Spine. Several reasons are cited for the under-representation of elderly in back pain studies. One of the main reasons is the economic burden of maintaining worker's compensation programs; these programs are necessarily directed at the younger working population. Other reasons are listed in Table 1.

Using the key words low back pain, back pain, elderly, geriatrics and aged for their literature analysis, the researchers found only twelve studies on low back pain in the elderly, between 1966 and the present, that met their final selection criteria! The methodologies underlying some of these studies are dubious. "Many studies have grouped younger and older patients together, such as a 40 year old with an 82 year old.