Brian Conway, MD, FRCPC
Staff Physician,
Centre for Excellence HIV/AIDS,
Assistant Professor, Pharmacology & Therapeutics,
University of British Columbia

Recently, the bulk of media attention has fallen on the global HIV pandemic, and on the impact it is having in Africa. In North America, although AIDS is still predominantly a disease of young adults, an aging but relatively healthy population of HIV positive individuals is slowly becoming a cohort of HIV positive elderly. A review of recent medical literature reveals few, if any, articles that deal with AIDS in elderly patients. The absence of research in this field will mean a medical community that is unprepared to treat and diagnose HIV in an older population. Consequently, elderly patients may not receive the degree of care and attention that they deserve. At Geriatrics & Aging, we strive to cover the latest medical developments and issues, even those that may be somewhat controversial. This month we are proud to present an article contributed by Dr. Brian Conway, an international leader in the field of HIV research, on how HIV is 'moving up the age ladder'.

Introduction
Although it may be assumed that the HIV epidemic is waning, it must be remembered that by the end of 1999 there were still over 33 million adults and children living with HIV/AIDS throughout the world.¹ Of these, the vast majority (32.4 million or so) are adults. In the United States, there are over 400,000 adults/adolescents living with this disease.

Brian E. Maki, PhD, PEng

Tai Chi has been shown to increase balance confidence and reduce risk of falling in elderly patients.1 Although direct effects on balance control have yet to be demonstrated, it seems likely that Tai Chi may improve the ability to control balance by training the mind and body to integrate balance-related sensory information and by helping an individual to develop a greater "awareness" of both body position and limits to stability. By requiring a series of movements that involve lateral weight transfer and narrowing of the base of support, Tai Chi may bring about specific benefits with respect to control of lateral stability and the consequent capacity to avoid lateral falls, which are the ones that are most likely to result in debilitating (and life-threatening) hip-fracture injuries. Tai Chi has a number of other positive features that may facilitate adherence to a program: it requires no special equipment, it is enjoyable to most participants, it can be performed either in social settings or at home, and it can be safely tailored to match the physical abilities of the individual.

Notwithstanding the above, it is likely that there is nothing "magical" about Tai Chi per se. It would seem that the key factor is developing an exercise program that trains balance, as opposed to strength, flexibility or endurance alone, and incorporating into the balance training a wide range of movements that allow the limits of anteroposterior and lateral stability to be challenged in a safe, enjoyable and convenient manner.

To be linked to a community program that may include Tai Chi please contact the Falls Prevention Program at Sunnybrook Hospital.

References

1. Wolf SL, Barnhart HX, Ellison GL, Coogler CE. The effect of tai chi quan and computerized balance training on postural stability in older subjects. Phys Ther 1997; 77:371-381.

Typically, the practice of Tai Chi requires the performance of a series of movements (comprising one 'form') which involve the shifting of weight from one leg to another in bent knee positions, accompanied by coordinated arm movements, and which must culminate in a final, well-balanced stance maintained for a brief period of several seconds.
In 1980, a book illustrating the 88 'forms' of Taijiquan (Tai Chi) reported the findings of an investigation carried out by the Beijing Sports Medical Research Centre on 88 elderly individuals ranging from 50 to 89 years of age. Group A, comprised of 32 regular practitioners of Taichi, had scores dramatically superior to Group B, the control group, in tests designed to asses cardiovascular function, including blood pressure and rate of arteriosclerosis (cardiographs confirmed the tests), spinal deformity, osteomalacia, and flexibility and range of movement. In Tai Chi, the waist is kept relaxed, the spine erect, and the body is held straight. Consequently, regular practice strengthens the spinal column, reinforcing postural balance and preserving strength and flexibility at the waist.

Source: Taijiquan in 88 Forms (5th ed.), Hai Feng Publishing Company, Hong Kong, 1988.

Brian E. Maki, PhD, PEng
Professor, Department of Surgery
and the Institute of Medical Science,
University of Toronto; and Senior Scientist,
Sunnybrook and Women's College Health Sciences Centre

Hip fractures and other physical consequences of falls in older adults have received a great deal of attention, both in the scientific literature and the popular press. It is only recently, however, that the psychosocial consequences of falling, such as fear of falling, have begun to receive due recognition. The injuries due to falls may well prove to be the "tip of the iceberg", with the psychosocial sequelae incurring even greater societal costs.

Murphy and Isaacs¹ first described the "post-fall syndrome" as an extreme fear of falling, characterized by a tendency to stagger, to clutch at objects, and to show hesitancy or alarm when asked to walk without assistance. Some researchers believe that such an anxiety syndrome can be viewed as a classic phobia, and in fact have coined the phrase "ptophobia" to refer to a phobic reaction to standing or walking.² While such a severe reaction may be relatively uncommon, a more moderate fear of falling is very widespread among older adults, with reported prevalence ranging from 20-60%.^3,4 The prevalence increases with age and is reportedly more common among women.4 One should note, however, that a gender-related bias in the willingness to report fear could confound the latter finding.

What Every Doctor Should Know About the Limits of Canada's Provincial Health Insurance Coverage in Foreign Jurisdictions

Tracey Tremayne-Lloyd
Lonny J. Rosen
Tremayne-Lloyd Partners,
Toronto, Ontario

Increasingly, primary care physicians are facing the stress of dealing with the wrath of patients who have incurred staggering and ruinous bills for medical attention while travelling outside of Canada. Notwithstanding the widespread publicity attracted by the amendments to the Health Insurance Act regarding out-of-province claims, enacted in 1992, patients continue to labour under the false impression that if they require emergency medical care outside of Canada, the provincial health insurance plan will pay for that care.

Considering the large number of rapidly aging individuals and their fixed income, an understanding of the provisions and limitations of the provincial health insurance reimbursements for the out-of-country medical services is a vital part of the practice of primary care physicians--particularly physicians who treat a significant number of geriatric patients. Physicians should offer counseling on the risks facing patients with pre-existing medical conditions who are preparing to travel out of the country. This may be considered a basic legal duty for every physician if they wish to avoid the possibility of being sued for negligence in case the patient falls ill and suffers financial ruin as a result of foreign medical bills.

Psychotropic Drugs and Polypharmacy are Proven Risk Factors for Falls

Tawfic Nessim Abu-Zahra, MSc

Many risk factors have been shown to contribute to falls suffered by the elderly, including the use of sedatives¹ and the concurrent use of several medications.^2-4 Evidence-based conclusions concerning the relationship between drugs and falls provide limited confirmation due to the studies results' variability, inconsistencies in classification schemes of drugs, and because of the small number of subjects participating in most studies.³ Thus, singling out specific agents and recommending guidelines for prescribing to the elderly is difficult. However, some studies have implicated psychotropic or CNS-active drugs, including sedatives, antidepressants and neuroleptics, as being especially high-risk in terms of leading to falls. Hence, special caution should be taken in prescribing these for the elderly.

Leipzig and colleagues reviewed^3,4 all existing literature dealing with the association between drugs and falling in the elderly. Pooled odds ratios that measure the likelihood that a person taking a drug will also experience a fall were calculated for different classes of drugs.

Christine Oyugi, BSc
Assistant Managing Editor,
Geriatrics & Aging

Statins are the most effective agents for lowering plasma levels of low-density lipoprotein cholesterol (LDL-C) that are currently available and are the mainstay therapy for the treatment of hyperlipidemia. The drugs are the most commonly prescribed agents for this condition because of their efficacy in reducing LDL, their safety, and their excellent tolerability. Recently, several studies have found that statins also have anabolic effects on bone and may substantially reduce the risk of fractures.¹

Mundy et al. were the first to discover the bone anabolic properties of statins.² Prompted by the observation that bone morphogenic protein 2 (BMP2) causes osteoblasts to proliferate, mature, and form new bone, the researchers screened a library of 30,000 natural compounds to find potential bone strengthening drugs. The study showed that lovastatin (a fungal metabolite); fluvastatin, simvastatin and mevastatin specifically activated the BMP-2 promoter. The researchers also found that oral administration of statins (simvastatin or lovastatin) to rats increased the volume of trabecular bone and the rate of bone formation even in ovariectomized mice.

Start Exercising Already!
A Physician's Step-by-step Guide to Prescribing Exercise for Elderly Patients

Dr. A. S. Abdulla, BSC, MD, LMCC, CCFP, DipSportMed

Introduction
I have spent many years counselling patients on the merits of dietary modifications in diabetes, hypercholesterolemia, and obesity. I have advocated the avoidance of salt and caffeine for hypertensives, adequate calcium and vitamin D intake for the prevention of osteoporosis, cessation of smoking for the improvement of cardiac and pulmonary risk factors, and cognitive therapy for depression and anxiety disorders. However, I have never found anything to have a more profound impact on all of the above medical conditions, as well as on a patient's general well-being, than a properly prescribed and facilitated exercise regimen. This article will briefly review the epidemiology of sedentarianism and the general benefits and risks of exercise, and will include a short primer on types of exercises along with a step-by-step approach to exercise prescription. The aim of this article is to help you increase the level of activity among your geriatric patients safely and to work through the basics of exercise prescription. The medical approach to dealing with more advanced levels of physical activity is beyond the scope of this article.

Chris Brymer, MSc, MD, FRCPC
University of Western Ontario,
London, Ontario

Falls are the leading cause of injury admissions to acute care hospitals in Ontario, and are a common cause of admission to an inpatient geriatric assessment unit. Although falls prevention has been an active, ongoing area of geriatric research for many years, the publication of the results of 4 randomized controlled trials in 1999, addressing falls prevention in the outpatient setting, suggests we may be 'turning the corner', going from research to actual practice.

Close et al's January 1999 study published in Lancet, randomized 397 patients, 65 years of age and older, who had presented to an emergency department with a fall and who were provided with either usual care (n=213), or a detailed falls assessment (n=184).¹ Intervention patients underwent a detailed assessment of their visual acuity, balance, cognition, affect, and medication use by a physician in a day hospital setting, and had their functional status and home environment assessed by an occupational therapist. Although the intervention was essentially a 'one-time' assessment, follow-up care was recommended in 84% of cases. During a one-year follow-up period, self-reported falls, recurrent falls, and hospital admission were 61%, 67%, and 39% lower, respectively, in the intervention group by comparison with the usual-care group. Follow-up data was available after one year for approximately 77% of the patients in each group.

Much Needed Inpatient and Outpatient Fitness Programs Available in Toronto

Kathleen Jaques Bennett, BSc, BSc, MSc

Seniors, especially those over 75 years of age, are far more likely to be hospitalized for their illnesses and injuries and stay longer in the hospital than their younger counterparts.¹ Canadian seniors are also less likely to engage in regular exercise despite its benefits in preventing or relieving a variety of illnesses.^2,3 Inpatient and outpatient fitness programs for the elderly play an important role in health maintenance, pain reduction and rehabilitation after illness and injury.

Programs available
The availability of geriatric fitness programs may vary considerably with the size of the community. In the Toronto area, a number of geriatric fitness programs are available through Sunnybrook and Baycrest Hospitals, and outpatient programs for seniors with osteoporosis are also available through clinics such the Pro Program at the Toronto Rehabilitation Institute.⁴ In smaller communities, exercise programs are not always designed specifically for geriatric rehabilitation and fitness; nor is every program offered at every hospital in an area. Some less popu-lated areas have adopted the approach of assigning specialized programs to different hospitals within the region.

There are many types of exercise programs which are aimed at prevention, rehabilitation or maintenance.

A. Mark Clarfield, MD

Although I am a doctor, I have fought a long and more or less successful battle against becoming my own family's doctor. I know that I am not alone in struggling with this dilemma. It is not that we physicians don't love our old relatives, and certainly, it is not that we don't want to help out. The reason we wish to stay out of family health matters is, simply put, fear. As medical practitioners we are afraid that since family members are so near and dear to us, our judgment might be impaired if we acted as their physician.

Of course in an emergency, most MDs would do whatever became necessary. Dr. Howard Bergman, Chief of Geriatrics at Montreal's Jewish General Hospital declared, "A Heimlich manoeuvre or cardiac massage would be accomplished almost as a reflex, should--G-d forbid--anyone close to me need such an intervention."

Personally, I have, on occasion, gently steered family members away from certain operations and diagnostic procedures when my advice was sought. I have even viewed and passed judgment on my own father's cardiac angiogram before he underwent coronary artery bypass surgery several years ago. Like most physicians, I have looked into my children's ears, and have, albeit reluctantly, prescribed antibiotics for my offspring.

Dr. Ilan Benjamin, a Montreal family physician, agrees but offers, "Whenever I can, I duck the issue and get my family off to a real doctor, someone who may well like them enough, but does not love them too dearly.