Tess Montada-Atin, RN, CDE
Care Leader

Marilyn Mori, RD
Lina Medeiros, MSW
Diabetes Education Centre,
Toronto Western Hospital
University Health Network
Toronto, ON

Diabetes is a chronic illness with significant short and long term complications.¹ The Diabetes Education Centre (DEC) at the Toronto Western Hospital, University Health Network, supports people with diabetes, their family and friends to better understand and manage diabetes. The 1998 Clinical Practice Guidelines (CPG) for the management of diabetes in Canada, recommends initial and ongoing education for the person with diabetes as part of diabetes care and not just as an adjunct to treatment. Diabetes Education should be recognized as a life long commitment.² Comprehensive management of diabetes should be planned around an interdisciplinary diabetes health care team,^1-3 which can be through a DEC. To learn and use the varied complex skills required, people with diabetes need the support of such a team of expert professionals.¹ Interdisciplinary interventions have been shown to improve glycemic control in the elderly. Studies have suggested that a team approach toward older people with diabetes improves blood glucose control, quality of life and adherence to therapy.³

Factors that affect glycemic control are diet, diabetes medications and exercise.

Both the British Medical Journal and the Journal of the American Medical Association (JAMA) participate in the charming and instructive activity of reprinting short sections from their pages of 100 years ago. These pieces are often quaint, always entertaining and frequently outdated--but not always.

Many a time, and oft, in fact, they still speak to the heart of our clinical practice, even from over a century in which both the practice and face of medicine have changed so dramatically. For example, published in a recent issue of JAMA (Volume 182(17):1606i), and penned over a century ago by Dr. J.W. Bell in his prime as Professor of Physical Diagnosis and Clinical Medicine at the University of Minnesota, was an impassioned "Plea for the Aged".

It should be pointed out that, in 1899, geriatrics did not yet formally exist as a specialty and that Ignatz Naccher's seminal work, "Geriatrics: The Diseases of Old Age and their Treatment" would not come out in print for another 14 years. Marjorie Warren, considered the founder of modern hospital geriatrics in the UK for work in the 1940's, was then barely three years old.

Bell acknowledged that, despite the paucity of current American literature on the subject of the elderly, the French (Charcot, Pine) and British (Day, McLachlan) authorities had helped "to furnish the nucleus of our present knowledge of senile pathology". However, despite the interest of these eminent authorities, Dr. Bell offered a criticism that unfortunately is still quite relevant today: "The want of interest, as indicated by the scanty and fragmentary character of the literature on the subject, is largely responsible for the apathy existing today in our medical schools".

As we enter the new millenium, it must be acknowledged that there has been a modest improvement in the number of Canadian medical schools offering a course in geriatrics. Still, the growth is not at all proportional to the increase in the numbers of elderly. In 1899, less than 5% of the continent's population was over the age of 65. Today, that percentage has almost tripled and life expectancy has increased significantly throughout the developed world.

Despite his critique of the system, Bell understood the circular wars of the medical schools that still rage today. He offers that "It would seem criminal to even suggest that addition of another distinct course to the already overcrowded college [medical] cirriculum (sic)…." But he does offer two suggestions, the first of which still makes sense: "That the chairs of anatomy and physiology impart to the student the necessary primary instruction…". To the contemporary reader, his second suggestion may seem a bit quaint but it was obviously born out of desperation and the faint hope that colleagues might heed his plea. Here, Bell suggests that the "The chair of practice [Internal Medicine], or if deemed best, in order to contrast disease, the chair of pediatrics enlarge its scope and furnish the necessary…instruction…"

Were Dr. Bell to survey the situation today, he would also still have much room and justification for complaint. Despite improvements in our field, his words from one hundred years ago ring true today: "[the medical student] scarcely recalls reference by one of his teachers to old age, unless suggested in mitigation of the failure of some brilliantly planned but misjudged operation or equally ill-timed drug treatment".

JAMA's recent '100 Years Ago' column has helped us to realize that despite some improvement, at least in the field of treating the elderly, 'plus ça change; plus c'est le meme chose".

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

Sudeep Gill, MD and
Paula A. Rochon, MD MPH FRCPC
Baycrest Centre for Geriatric Care.

One of the goals of long-term care is to provide the patient with an appropriate level of care without unnecessarily disrupting his or her comfort and living situation. Older long-term care residents often suffer from acute intercurrent illnesses for which fluid replacement is an important component of treatment. If intravenous (IV) fluid replacement is not possible in these frail seniors, either because of regulations or due to staffing issues in the long-term care facility, it is often necessary to transfer them to an acute-care hospital setting.

In the institutionalized older patient, hypodermoclysis, which is the subcutaneous infusion of fluids, is an attractive alternative to the use of intravenous therapy for fluid replacement. It is a method that has been used since near the turn of the century. Although it has been employed with success for years at the Baycrest Centre for Geriatric Care, and a few other institutions, it remains under-recognized and underutilized as a valuable method for the management of mild to moderate dehydration in the long-term care setting.

Leslie Goldenberg, BSc, MD, FRCPC
Internal, Geriatric and Podologic Medicine
Assistant Professor of Medicine, University of Toronto
Medical Director, The Walking Mobility Clinics 

The first principle in the care of the diabetic foot is to recognize the primacy of prophylactic care. Indeed, an ounce of prevention is worth the proverbial pound of cure, even in the patient who appears to be low risk and does not suffer from peripheral neuropathy or vasculopathy. Physicians and other health care professionals have a critically important role to play when it comes to educating their diabetic patients regarding daily foot care, with particular attention paid to the care of skin, nail and callus, proper footwear and strategies to prevent foot trauma and infection. Diabetes remains the most common cause of non-traumatic limb loss, and there is considerable suffering and economic impact associated with the management of chronic diabetic foot pain and sepsis. Two-thirds of diabetic amputations follow complications that are related to foot ulcers.

Pressure platform studies demonstrate that the patient placing a diminished load on the toes is an early finding in diabetic neuropathy. This reduction in the load on the toes leads to a corresponding increase in metatarsal head loads. In addition, there is a shift of loading on the forefoot, away from the medial side, with increasing load now borne under the mid-foot, a characteristic of weakness of the longitudinal arch (mid-tarsal loading).

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

Last year, the diabetes surveillance system reported that approximately 2 million Canadians suffer from diabetes, although as many as 600 000 of these might be unaware that they have the condition. It is now estimated that, by the year 2010, approximately four million Canadians will have diabetes and, that by the year 2020, there will be approximately 250 million people affected by type 2 diabetes, worldwide.¹

What factors contribute to the development of this terrible disease? A few diabetic subjects suffer from type 1 diabetes mellitus, which is caused by failure of the pancreatic b-cells, and leads to an absolute loss of insulin. Type 2 diabetes is far more common and is swiftly increasing in prevalence in industrialized societies. It is believed that the main factor contributing to the increase in the number of patients with type 2 diabetes is the aging of the baby boomer population, a population that is becoming more sedentary and, as a result, more obese. An interesting question then is how do obesity and a sedentary lifestyle lead to the development of type 2 diabetes?

Type 2 diabetes is almost invariably preceded by the development of insulin resistance. Insulin resistance is defined as a state of reduced responsiveness to normal circulating concentrations of insulin, and is now recognized as a characteristic trait of type 2 diabetes.

Julie Dergal, MSc,
Baycrest Centre for Geriatric Care

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

Introduction
Older people often have multiple health conditions that require drug therapy. In Ontario in 1998, drug expenditure by people aged >65 years of age was estimated at 1.03 billion dollars, accounting for 74% of total drug costs to the Ontario Drug Benefit (ODB) Program. Prescribing drug therapy for older people presents a challenge to many physicians. Inappropriate prescribing such as the excessive and unnecessary use of drug therapy or the under prescribing of proven beneficial therapy, appears to be a common problem. Several factors place older people at risk for serious drug complications including advanced age, frailty, and increased drug use. Long-term care residents are a particularly vulnerable population, as they are primarily, older, frail women, who take an average of eight medications. Drug-related problems, including reaction to medication, are estimated to account for as many as 28% of hospital admissions.¹ With an increase in the aged population, and the associated increasing drug costs, it is imperative that older people receive optimal pharmacotherapy. Reducing drug related morbidity and mortality is, therefore, important both to improve the quality of life of older people, and to reduce health care costs.

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

Introduction and Epidemiology:
Peripheral vascular disease (PVD), a common and often disabling condition, usually results from the atherosclerotic occlusion of the arteries in the lower limbs.¹ Symptomatic PVD is rare in men before the age of 50, but prevalence increases dramatically with age. The Edinburgh Artery Study states that the prevalence of symptomatic PVD increases from 2.2% in men aged 50 to 59, to 7.7% in men aged 70 to 74.^2,3 Before the 7th decade, the prevalence in women is approximately half that seen in men, but this difference diminishes after that age.⁴

Definition and Diagnosis of Intermittent Claudication (IC)
Patients who suffer from intermittent claudication (IC) represent a subset of those patients with symptomatic lower extremity atherosclerotic disease. This review will focus on an approach to the investigation and management of this condition in the elderly population. Only 7-9% of patients with diagnosed lower extremity atherosclerosis suffer from intermittent claudication.5 In 1962, the Rose claudication questionnaire was developed as an epidemiologic instrument for the purposes of identifying patients with IC. It also serves as a good working definition of IC.

Blindness is a Result of Diabetic Macular Edema

Mark Mandelcorn, MD, FRCS(C)
Vitreo-retinal Surgeon
Toronto Western Hospital 

It is astonishing that in the year 2000, nearly 80 years after the discovery of insulin, diabetes became the most common cause of blindness in North America. Everyone who looks after diabetics, therefore, has an important role to play in helping these patients reduce their risk of suffering the microvascular and macrovascular complications arising from diabetes. Recent clinical trials have once again confirmed the link between good blood sugar control and the reduced incidence of complications, such as blindness. Consequently, it is accepted that the first goal of treatment is optimum control not only of blood sugar but of other supervening problems, like hypertension, that may aggravate any existing complication, particularly diabetic retinopathy.

Diabetic retinopathy is said to occur in over 90% of type 1 diabetics (characterized by juvenile onset and insulin-dependence) and in a slightly lower percentage of type 2 diabetics (characterized by late onset and lack of insulin dependence). However, only about 25% of patients with diabetic retinopathy develop visual loss and only about 5% become blind.

Serge Gauthier, MD, FRCPC
McGill Centre for Studies in Aging,
Montreal, Canada 

Alzheimer's disease (AD) is the most common cause of dementia, worldwide. It is well known that the incidence and prevalence of AD increase with age; therefore, because of the increasing longevity of our populations, and the large cohort of baby-boomers coming to maturity, more and more people will be affected by this condition. Fortunately, there are encouraging results from studies on symptomatic therapy and there is reason to hope that we may achieve long term stabilization and preventive treatment. This review will emphasize the important role of the primary care practitioner in the diagnosis and management of AD.

Clinical presentation of Alzheimer's disease
The Global Deterioration Scale describes the progression of AD as seven steps (Table 1), which is useful to describe the natural history of AD. This scale is familiar to most families who are caring for a patient with AD, and the primary care practitioner is often asked to describe the patient's current stage.

Michael Gordon, MD, FRCPC
Vice President Medical Services and
Head Geriatric and Internal Medicine
Baycrest Centre for Geriatric Care
Head, Division of Geriatrics
Mt. Sinai Hospital
Professor of Medicine
University of Toronto 

Cardiopulmonary resuscitation (CPR) is commonly perceived as a miraculous treatment that averts death. For many, the understanding of CPR comes from television and movies where, inevitably, death is cheated by heroic resuscitation. North Americans especially have, since its discovery more than thirty years ago, been fascinated with CPR.¹ CPR, however, is not always an appropriate or humane medical procedure. For defined segments of the elderly population, especially those requiring long-term institutional care, it may be a last, undignified rite of passage in a world that has become mesmerized by technology. It is for the benefit of this elderly population that we must strive to tailor our resuscitation policies in order to realistically serve their needs, without exposing them to ineffective CPR attempts. The goal of institutional policy should be to define the framework by which we can provide appropriately humane care without denying CPR to those members of older populations who can, within reason, hope to benefit from it.