Anna Liachenko, BSc, MSc
Managing Editor,
Geriatrics & Aging

Ensuring the safety of nursing home residents is a high priority for both families and health care personnel. To this end, various types of restraints have traditionally been used to protect residents from falls and injuries. Ironically, there is little documented evidence that restraints either prevent falls, or decrease the risk of injury from falls. In fact, studies demonstrate that restraints may precipitate or heighten this risk. In the United States, the Omnibus Budget Reconciliation Act of 1987 (OBRA-87) was passed in response to a host of consumer complaints in addition to state and federal reports criticizing nursing home quality. As part of the reforms, a restriction has been placed on the use of restraints. In the ensuing thirteen years there has been a 50% reduction in the use of restraints and, interestingly, also a significant reduction in the incidence of fall-related injuries. It is not clear whether Canadian nursing homes overuse restraints. Progressive institutions are currently moving towards reducing the use of restraining measures. It is crucial that physicians take into consideration the potential hazards of restraints when evaluating the management of an elderly patient.

Restraints have traditionally been categorized as either chemical or physical.

Understanding the Importance of Oral Health in the Elderly

David W. Matear, BDS, BMSc, DDPH, MSc, FRSH
Chief of Dentistry, Baycrest
Centre for Geriatric Care and Assistant Professor,
Department of Community Dentistry, University of Toronto

Abstract
Dental professionals in Canada have concerned themselves with the oral health of Canada's population as a whole; unfortunately, strategies and funding have not supported initiatives to address the growing needs of the elderly population. The oral health needs of older adults, and the potentially serious consequences of oral disease in the elderly, present a major challenge not only to members of the dental profession, but to all health care professionals and the general community. We can rise to the challenge successfully only by working together in an integrated and coordinated manner.

Introduction
Despite the advances in oral health care in developed countries, the oral health status of the elderly has not improved to the same extent as that of the younger members of the population.^1,2 This represents a failure on our part; it would seem that we are ill-informed and ill-prepared to meet the oral health needs of our elderly. This lack of preparedness in terms of providing the elderly with appropriate care contrasts sharply with the growing recognition that this is dentistry's fastest growing and most challenging area.

Mobility Devices and Good Caregivers Facilitate Recovery and Deter More Falls

Nariman Malik, BSc

Falls in the elderly are a common problem, and often can have serious sequelae. The physical injuries that may be sustained after a fall can lead to hospitalization or even institutionalization. Falls are often considered to be an inevitable consequence of aging; however, they may in fact signal the onset of an illness or an underlying cause of frailty.¹

Falls are a significant cause of disability and death in older persons.² Fractures are a result in 3-5% of cases.³ The most serious fracture in the elderly is the hip fracture, which often requires surgical repair, a procedure which itself is plagued by a high incidence of morbidity and mortality.³ A fall may also lead to immobility which can lead to dehydration, rhabdomyolysis and pressure ulceration. Falls can also often lead to a fear of falling, which may result in withdrawal from usual activities and even social isolation and/or depression which ultimately results in both decreased mobility and a loss of independence.^2,4 Primary care physicians managing elderly patients should be prepared to assess appropriately patients who have fallen, and strive to develop a management plan tailored to meet patients' needs.

Functional Tests Help Assess Treatment Efficacy in Dementia

Karl Farcnik, MD, FRCP(C)
Michelle Persyko, PhD

Functional assessments have been a very important component in the development of treatments for dementia, especially Alzheimer's disease (AD). This is due on the one hand to the complexity of the disease process, and on the other to the limited efficacy of current treatments. AD, for example, is associated with symptomatology occurring in three different domains: cognition, activities of daily living (ADL) and behaviour. Cognitive deterioration is of greatest significance in the earlier stages of the disease process. ADL are affected throughout the disease process but are of greatest signifi-cance during the mild to moderate stages of the disease. Behavioural problems, by contrast, tend to be much more significant as the severity of the disease increases. The challenge has been to develop instruments which measure the effectiveness of treatment in all three domains. Initially, the testing focused only on cognition and global functioning based on regulatory requirements. However, as treatment efficacy with drugs such as acetylcholinesterase inhibitors was noted, it became apparent that treatment had an impact on other domains. In fact, many of these instruments have been developed in the past few years.

Identifying Modifiable Risk Factors in Order to Prevent Future Falls

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

Introduction and Epidemiology
Falls are a major health problem for the elderly and have been referred to as one of the "Geriatric Giants."¹ The annual incidence of falls among the community-dwelling elderly is estimated to be 30% among those between 65 and 80 years of age, and 50% among those over 80 years of age.² The annual incidence of falls among elderly nursing home residents is estimated to be 50%, with 40% of residents suffering multiple falls each year.²

Falls are a cause of significant morbidity and mortality in the elderly. Accidents are the 6th leading cause of death in persons over 65, and falls are estimated to be responsible for two-thirds of these deaths.² As a result, falls directly or indirectly cause 12% of deaths within the geriatric population.³ In addition, up to 50% of falls in the elderly give rise to soft-tissue injury, with 5% of these being classified as serious. One percent of falls results in hip fractures, and two-thirds of these patients are unable to return to their pre-fracture functional level. Up to 5% of falls give rise to other varieties of fractures.

Nadège Chéry, PhD

If physical appearance owes its beauty to strong, shapely muscles, it is a rather short-lived feature of human charm, as nice biceps, sculpted thighs and other graceful or bulging aspects of our musculature eventually wither as we age. Far more than our attractive physique is altered, unfortunately, since with advancing age the loss of muscle strength and mass also greatly contributes to frailty (resulting in falls and fractures).¹ Nevertheless, this undeniable consequence of the aging process is not entirely unavoidable. Indeed, simple, effective strategies that can significantly slow (or perhaps reverse) the age-related decline in muscular performance exist, yet they are often overlooked (or even feared) by the elderly.

In an individual between 30 and 80 years of age, muscle, the largest tissue of the human body,1 undergoes important decreases (up to 40%) in both strength and mass.¹⁰ This age-related loss of muscle strength and mass is typically referred to as "sarcopenia".^3,9,10 The expression "muscle wasting" is also used in geriatric medicine in reference to unintentional loss of weight, when fat mass and fat-free mass decrease, as occurs following starvation (at any age) or in geriatric failure to thrive.^7,8

The extent of the loss of strength is not the same across different types of muscles, and also varies greatly among individuals.

Fall Avoidance Dependent on Exquisitely Sophisticated Neural Control System

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

It is well known that aging brings an elevated risk of falls and serious injuries, as well as other adverse medical and psychosocial outcomes. In recent years, exercise has been widely promoted as a potential means of reducing the risk of falling in older adults. There is no doubt that exercise and physical fitness is associated with a myriad of health benefits, and that older adults are able to improve strength, flexibility, aerobic capacity and other fitness measures as a result of exercise programs.^1-4 Even the very frail and very old have shown that they can improve their functional fitness through exercise.⁵ But what is the evidence to support the view that exercise and fitness could actually help to prevent falls and their consequences?

Certainly, there is evidence supporting an association between strength and falling risk. Severe compromise in the strength of the ankle dorsiflexors has been documented in nursing home residents with a history of falling.⁶ Other studies of less impaired individuals have also found evidence of associations between leg muscle weakness and an increase in the risk of falling.

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

Elder abuse is an unfortunate and undiscussed phenomenon in our society, yet it is one that many physicians will encounter in the treatment of their elderly patients. Although there is little agreement on the definition of elder abuse, it can generally be defined as 'any act of commission or omission that results in harm to an elderly person.'¹ The types of harm suffered by elderly patients generally include physical, psychological, and financial abuse as well as neglect. Various studies conducted throughout North America have reported the incidence of elder abuse to be anywhere from 1%-10%. Since elder abuse is such a prevalent problem, it is critical for physicians to be aware of their statutory and professional reporting obligations.

Statutory Reporting Obligation
At present, there is no federal statutory obligation on the part of physicians across Canada to report elder abuse. Such obligations are set by provincial governments, and each of the provinces of Newfoundland, New Brunswick, Nova Scotia and Prince Edward Island have enacted some type of adult protection legislation. These laws impose on all persons the obligation to report a situation where a person is suffering from abuse or is otherwise in need of protection. The legislation in these provinces includes not only abuse of the elderly, but also usually covers all adults over the age of 16 or 18 years, who are in need of protection.

Lilia Malkin, BSc

Throughout the centuries, people have turned to medicinal substances to improve their health and quality of life. Today, medi-cations continue to be invaluable partners in humanity's war against disease. However, each person has a unique response to his or her medication(s). The differences among patients' reactions to pharmaceutical therapy can be at least partially explained by the inter-individual variation in drug metabolism. As biotechnology continues to make progress, the genetic foundation for illness and the consequent response to treatment is becoming increasingly apparent.^1,2 The basis for patient-to-patient variability in the effects of pharmaceutical agents has thus far been attributed predominantly to the drug-metabolizing capacity of the liver.¹ Accordingly, this article will focus on the hepatic biotransformation enzymes and the contribution of genetic polymorphism to individuals' thera-peutic responses and to treatment-related complications. It should be noted that tissue receptors and transporter proteins are also often subject to polymorphic variations, contributing to the variable response to medications and toxins; a discussion of this topic is, however, beyond the scope of this paper.

Hepatic Drug Metabolism Enzymes: An Overview
The metabolism and elimination of pharmaceutical agents may occur at several sites in the human body, including the liver, kidneys, gastrointestinal (GI) tract, lungs, and skin.

Down's Syndrome, a potential model for the pathogenesis of Alzheimer's disease

Nariman Malik, BSc

Alzheimer's disease (AD) is the most common cause of dementia in the elderly.¹ It affects more than 5% of all people age 65 and over and about 25% of those aged 85 and over.^2,3 This devastating disease is characterized by a progressive loss of cognitive abilities, usually beginning with short-term memory difficulties and progressing to include language, visuospatial and executive dysfunction.¹ Mean survival time following a diagnosis of Alzheimer's disease is about 8 years and death usually occurs as a result of intercurrent disease.⁴ In 1991, the Canadian Study of Health and Aging estimated that over 160,000 Canadians met the criteria for Alzheimer's disease.⁵ If the current trends continue, by the year 2031 the number of cases are predicted to triple while the population will have only increased by a factor of 1.4.⁵

The main risk factors for developing AD are advancing age and family history. The disorder can be classified as familial or sporadic. Familial cases are usually early-onset (onset before age 65), while sporadic cases are usually late-onset (onset after 65). The majority of cases of AD are sporadic. Individuals with a first degree relative with sporadic AD, are at twice higher risk of developing the condition.