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.

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.