Potential Herb-Drug Interactions in Older People

Julie Dergal, MSc
Kunin-Lunenfeld Applied Research Unit,
Baycrest Centre for Geriatric Care,
Toronto, ON.

Paula A. Rochon, MD, MPH, FRCPC
Baycrest Centre for Geriatric Care,
Assistant Professor of Medicine,
University of Toronto, Toronto, ON.

Introduction
The use of herbal medicines has recently gained a great deal of acceptance in North America. In 1996 in the United States, an estimated two billion dollars was spent on herbs, tablets, extracts, capsules, and teas, in health food stores.¹ In 1997, Eisenberg conducted a telephone survey of 2055 people and found that 12% used herbal medicines, a 4-fold increase from 1991.² Despite the widespread use of herbal medicines in North America, little research has examined the safety of these alternative medicines, particularly when taken in conjunction with conventional medicines. A common misconception about alternative medicines is that they are "natural" and are, therefore, safe. However, herbal medicines are marketed as dietary supplements and, as such, are not subject to the rigorous standards established for conventional drug therapies. This means that the quality and content of herbal medicines are largely unregulated and uncontrolled.

Nizar N. Mahomed, MD, ScD, FRCSC
Toronto Western Hospital,
University Health Network,
Assistant Professor, Department of Surgery, University of Toronto,
Toronto, ON.

Gillian Hawker, MD, MSc, FRCSC
Sunnybrook and Women's
College Health Sciences Centre,
Associate Professor,
Department of Medicine,
University of Toronto,
Toronto, ON.

Arthritis is the number one cause of disability in any age group. It is estimated that over half of those over the age of 75 suffer from this condition.^1,2 The prevalence of arthritis increases with age; current estimates indicate that the number of people with arthritis-related disability will double by the year 2020.³ Pain and the loss of physical function result in a reduction in quality of life and a loss of independence for these patients. This in turn causes a significant burden to society in terms of lost productivity and the utilization of health care resources.^4,5 Studies have shown long-term improvement in joint pain, physical functioning and quality of life in patients following total hip and knee replacement.^6,7 Total joint replacement (TJR) is cost-effective and, in some cases, even cost saving.⁸ Currently there are over 35,000 hip and knee replacements performed annually in Canada.

Findings of a Provocative New Meta-Analysis

Jason M. Burstein, MD
Internal Medicine Resident,
University of Toronto,
Toronto, ON.

Shabbir M.H. Alibhai, MD, MSc, FRCP(C)
Clinical Assistant, Internal
Medicine & Geriatrics,
University Health Network, Toronto, ON.

Introduction
Atrial fibrillation is a common cardiac condition that challenges many physicians, including primary care and emergency doctors, general internists, geriatricians and cardiologists. One of the best-understood and most studied complications is cardio-embolic stroke. While management of atrial fibrillation may seem straightforward, it is interesting to note that there are still large variations in practice patterns, and a recent meta-analysis was contradictory to many previous studies and guidelines. This paper will focus on the epidemiology and treatment of atrial fibrillation in the older population and will examine both the reasons for variations in practice pattern and the conflicting evidence in major medical journals.

Epidemiology and Causes of Atrial Fibrillation
Age is perhaps the most important influence on the incidence and prevalence of disease. The prevalence rate of atrial fibrillation is 2-3% at age 60 to 65 and 8-10% at age 80. Up to 70% of all affected patients are at least 65 years old. The incidence of atrial fibrillation before age 50 is 0.

D'Arcy Little, MD, CCFP
Director of Medical Education,
York Community Services,
Toronto, ON.

Introduction and Historical Background
Although first described in 1888 as "senile rheumatic gout," it wasn't until the 1950s when more cases were described in the literature that Barber coined the term "Polymyalgia rheumatica" to describe a syndrome of myalgias, stiffness of the shoulder and pelvic girdle muscles, and concomitant constitutional symptoms. A case of Temporal arteritis was first described by Thomas Hutchinson in 1890 when an 80-year-old man presented with a painful, inflamed temporal artery. In 1932, Horton first described the typical histological features of temporal artery from biopsies in patients with this condition, and the term "Giant cell arteritis" was first used.^1,2,3

Giant cell arteritis (GCA) and polymyalgia rheumatica (PMR) are closely related conditions that are almost always seen in patients over the age of 50 years. These conditions are relatively common and may represent a continuum of disease.^3,4 The following review will provide a framework for consideration of these diagnoses, as well as a review of their treatments.

Epidemiology
Once considered uncommon, PMR and GCA are among the most common, chronic inflammatory illnesses affecting the elderly, primarily as a result of raised awareness of the conditions.⁴ PMR has an incidence in North America of 52.

Glucosamine and Chondroitin in Osteoarthritis

Gerlie C. de los Reyes, BSc, MSc
Department of Pharmaceutical
Sciences, University of Southern California, Los Angeles, CA, U.S.A.

Robert T. Koda, PharmD
Department of Pharmaceutical
Sciences, University of Southern California, Los Angeles, CA, U.S.A.

Eric J. Lien, PhD
Department of Pharmaceutical
Sciences, University of Southern California, Los Angeles, CA, U.S.A.

"Medicine provides the means to treat diseases. Knowledge is the foundation of good health." E. J. Lien

Osteoarthritis (OA) is a chronic joint disease that is estimated to affect almost 5 million Canadians (16% of the population) by the year 2016.¹ This degenerative disorder is one of the primary causes of pain and long-term disability in the elderly. The disease is characterized by the progressive deterioration of the articular cartilage, the protective "cushion" at the articulating surfaces of bones. This degenerative process is caused primarily by a defect in the metabolism of the component macromolecules including proteoglycans (aggrecans) and type II collagen.

The non-steroidal anti-inflammatory drugs (NSAIDs) like aspirin, ibuprofen, indomethacin and piroxicam are the most widely used medications for the treatment of patients with symptomatic OA.

Dr. Angela G. Juby, MBChB, Cert Geriatrics
Associate Clinical Professor, Division of Geriatrics,
Department of Medicine, University of Alberta, Edmonton, AB.

Dr. Paul Davis, MBChB, FRCP, FRCPC
Associate Dean, Faculty of Medicine, University of Alberta,
Professor, Division of Rheumatology,
Department of Medicine, University of Alberta, Edmonton, AB

Introduction
Rheumatoid arthritis most commonly presents in the 3rd and 4th decades of life; elderly patients with initial presentation and patients whose disease persists into the later decades of life can present interesting challenges. In particular, the differences in clinical presentations of rheumatoid disease in the elderly when compared to younger patients may lead to difficulty in making a definitive diagnosis. There may be diagnostic challenges related to the interpretation of laboratory findings, particularly serological tests. Elderly patients often have comorbidities; therefore, pharmacologic management of rheumatoid disease must be undertaken with caution to reduce interference with the stability of other organ system therapies, and the potential for drug-disease and drug-drug interaction and polypharmacy must be addressed. Finally, it is important to dispel the attitude that "arthritis" is a process associated with "normal aging.

Seniors Benefit from Being Online

David Patrick Ryan, PhD, C.Psych
Director of Education, Regional
Geriatric Program of Toronto,
Faculty of Medicine,
University of Toronto, Toronto, ON.

There is an interesting paradox at the heart of Internet use by seniors which is: Although seniors are under-represented among Internet users, when they do get online, they become its most frequent users. Only 16% of seniors use the Internet, compared to the national average of 44%. Yet, once online, Canadian seniors use the Internet, on average, for 12 hours weekly. This is more than the average for teenagers (7 hours) and 80 minutes more than for any other age group. Given the emerging realization that the Internet expands the world of seniors, particularly disabled seniors, at a time when it would otherwise be contracting, and the developing evidence that computers and the Internet can be powerful tools for maintaining health and well-being, it is imperative that an attempt be made to reduce the digital divide amongst seniors.¹

The Obstacles to Internet Use for Seniors
What are the obstacles to seniors' use of the Internet? Anxiety is one obstacle.

Sydney C. Lineker, MSc, BScPT
Affiliated Scientist,
Toronto Western Research Institute;
Research Coordinator,
The Arthritis Society, Consultation and Rehabilitation Service, Toronto;
President, Arthritis Health Professions Association,
Toronto, ON.

Linda C. Li, BSc(PT), MSc
Arthritis & Autoimmunity Research Centre,
University Health Network;
The Arthritis Society,
Consultation and Rehabilitation Service, Toronto; Board Member,
Arthritis Health Professions Association,
Toronto, ON.

Introduction
Arthritis, in its many forms, is the most common cause of long-term disability in the elderly,^1-4 often resulting in functional problems, the loss of leisure, social and vocational activities, isolation and depression. Osteoarthritis (OA) is the most common type of arthritis in this population.¹

Pain, disability and psychosocial and educational needs are often underestimated by health care providers.^5,6 Pain is the most frequently reported symptom6 and is a complex phenomenon requiring a multidimensional approach. Pain may be under-reported by the elderly.^6,7 Signs of inflammation--redness, pain and swelling--may be less marked8 and it may be difficult to attribute pain to a specific cause.² Comorbidity, polypharmacy and complications of pharmacological interventions unique to the elderly add to the mix.

Klaus Turnheim, MD
Department of Pharmacology,
University of Vienna,
Vienna, Austria.

Introduction
Hyperuricemia is present in approximately 5% of asymptomatic adults and 10% of hospitalized patients. The prevalence of hyperuricemia and gout increases with age because of changes in body composition, renal excretory function and treatment with diuretics.¹ In addition, risk factors for crystal deposition, for instance degenerative joint diseases and osteoarthritis, are magnified in old age.² Gout found in the elderly differs from classical gout in middle-aged men in several respects. These include the fact that it has a more equal gender distribution, a frequent polyarticular presentation with an involvement of the joints of the upper extremities, fewer acute gouty episodes, a more indolent chronic clinical course, and an increased incidence of tophi.³ Decreased renal excretion of uric acid appears to be a major cause for hyperuricaemia and gout in advanced age.⁴

David K. Conn, MB, BCh, BAO, FRCPC
Head, Dept. of Psychiatry,
Baycrest Centre for Geriatric Care,
Assistant Professor,
Department of Psychiatry,
University of Toronto,
Toronto, ON.

A variety of studies have raised concerns about the quality of medication prescribing to elderly residents of long-term care facilities. Despite the fact that criteria for "inappropriate prescribing" can be debated, there is general agreement that considerable improvement is required to ensure optimal prescribing. Beers et al.¹ brought together a panel of national experts in the United States in an attempt to reach consensus on defining inappropriate medication use in the nursing home. Having developed specific criteria, they subsequently reported that more than 40% of residents in a group of California nursing homes had at least one inappropriate prescription. The term "silent epidemic" has been used to describe the problems caused by adverse drug reactions. A 1998 report from the United States consisting of a meta-analysis of 39 studies estimated that more than two million hospitalized patients had serious adverse drug reactions over a one-year period.