Geoff Fernie, PhD, PEng, CCE
Centre for Studies in Health and
Aging, Sunnybrook Hospital and Women's College Hospital, North York, Ontario

Does anyone know why toilets are so low in North America? Many elderly people find it really difficult to stand up from them. They are also too low for an easy lateral transfer from a wheelchair. What are the solutions to this common problem?

The problem is twofold:

1. How can the toilet seat be raised?
2. How can a grab bar be provided as an effective aid to rising?

The typical height of a toilet bowl without the seat is 14.5" whereas the optimal height of the seat is about 19". This corresponds to the height of a typical wheelchair seat and to the Canadian Barrier-Free Design code.

There are three solutions to the seat height problem:

1. The most common solution is to purchase an add-on raised toilet seat. About 500,000 people do this in North America every year. These are hollow plastic units that fit on top of the toilet. Usually they replace the existing toilet seat. They come in various thicknesses. Four to Five inches is generally about right. The manufacturers claim that they fit most toilets but it is important to check the security of the fit since accidents do occur. Some of them come with clamping mechanisms, some bolt through the toilet seat attachment holes, and others have no attachment system. Some can be filled with sand or water to increase stability.
2. An alternative Canadian product, Toilevator®, fits under the toilet to raise it. This product was recently voted as the best new product for the year 2000 by the Canadian Hardware and Housewares Manufacturers Association. It has the advantage of being inconspicuous and does not create instability or cleaning problems. Since the regular toilet seat is still used, Toilevator® only needs to be 3.5" thick. It has the disadvantage of requiring installation by a handy-person or a plumber. Please note that Toilevator® is another of our inventions from The Centre for Studies in Aging; for this reason, I must declare a conflict of interest.
3. Buy an extra high toilet. These are available, but this is a more expensive solution and does not allow for reversal to the original height. The reasons for wanting to return to the low height may include progression to the use of a rollover commode or moving from one house to another.

Elimination is made easier by a more flexed hip posture. If this is a consideration then it may be appropriate to have a light foot stool available. Toilevator® can be installed to create deliberately a small step at the front that may be adequate for this purpose.

There are several solutions to providing a grab-bar to help in transferring on and off the toilet.

1. The most flexible solution is to use one of the vertical pole devices. These are held in place by compression between the floor and the ceiling and will not work if the bathroom ceiling is made of a grid of suspended removable panels. However, they can be tried in different locations until the optimum position is found
2. Grab-bars can be attached to the wall. We will cover the topic of selecting and installing wall grab bars in a later article. The problem is that they are often too far off to the side to provide enough assistance.
3. Horizontal rails that are attached to the back wall and can be swung up out of the way are often used in institutions but are rarely used at home because of the difficulty and cost of installation. They have the advantage of providing room for a caregiver to stand to one side of the toilet and give assistance when needed.
4. Numerous frame designs are on the market that attach to the toilet or raised toilet seat. Be very careful to select one that is firm enough and big enough to be truly safe and functional. The ones that come as part of a raised seat are often inadequate.

The ability to manage the toilet with safety and dignity is key to independence. These simple adaptations should cost no more than $300 in total and can be done very successfully or very poorly--choose wisely.

Neil Fam, BSc, MSc

Hepatitis refers to acute or chronic inflammation of the liver, with the majority of cases resulting from either viral infection or drugs. In Canada, hepatitis B and C infections are the most common cause of viral hepatitis, and may be associated with considerable morbidity and mortality. Globally, chronic viral hepatitis is the leading cause of chronic liver disease, cirrhosis, and hepatocellular carcinoma and is the most common indication for liver transplantation. This article provides an outline of the natural history of hepatitis B and C infections, and describes current approachs to diagnosis, treatment, and prevention. Unique aspects of hepatitis in the elderly are highlighted.

Epidemiology and Risk Factors
Hepatitis B virus (HBV) is a DNA virus that infects over 350 million people worldwide. Although HBV infection is extremely common in parts of Asia and Africa, Canada has a relatively low level of endemicity. In North America, HBV infection occurs mainly in sexually active young adults. Important risk factors for HBV include sexual activity, IV drug use, occupational exposure, travel or residence in an endemic area and previous blood transfusion. The route of transmission may be sexual, parenteral, or vertical, with an incubation period of 6 weeks to 6 months.

Ruwaida Dhala, MSc, BSc

Patients with advanced dementia often develop eating difficulties and undergo weight loss.¹ In order to sustain ongoing nutrition in these patients the question of using enteral feeding can be raised. Although benefits of enteral feeding are still largely unclear, there is an increasing frequency of its use especially in patients with dementia.² This article will examine the risks of this procedure in order to identify whether enteral feeding is necessary and beneficial in all cases.

Long term enteral feeding commonly involves the administration of nourishment through a tube that is put directly into the stomach (percutaneous endoscopic gastrostomy tube). Enteral tube feeding is regarded as a safe, efficient and inexpensive method of feeding patients who have difficulty swallowing. Although enteral feeding is widely used, there is evidence that points to the negative effects of enteral feeding. Proponents of enteral nutrition usually identify its benefits as prevention of aspiration pneumonia, reducing risks of infection and prolonging survival.¹ However artificial feeding carries risks which include aspiration, infection, fluid overload, removal of the tube by the patient, and overall patient discomfort.²

A 1996 review looking at the use of tube feeding to prevent aspiration pneumonia found that there is no evidence to support this.

Alejandro Floh, BSc

Echocardiography has long been recognized as one of the most valuable non-invasive methods of investigating the heart. With recently-acquired understanding of the importance of cardiac disease in the pathogenesis of stroke, the role of echocardiography, whether transthoracic or transesophageal, in the management of stroke patients has become an area of extensive study. The Canadian Task Force on Preventive Health Care has therefore released their recommendations for the use of this imaging technique in newly diagnosed stroke patients.

Cerebral ischemia, a form of cerebral vascular disease, is caused by the reduction of blood supply to the nervous tissue of the brain. The result is often a rapid onset of focal neurological deficit or global impairment; this is commonly referred to as a stroke or cerebral vascular accident (CVA).¹ Despite similar presentations, the etiology of ischemic strokes vary considerably, and must be differentiated rapidly in order to provide appropriate care.

Despite new diagnostic and treatment modalities, stroke continues to be the third largest cause of mortality in Canada and the leading cause of disability.^2,3 Currently, approximately 50,000 new cases of strokes emerge annually, leading to an overall prevalence of 200,000 cases.³ Furthermore, strokes continue to be a leading cause of hospital admissions, even higher than acute myocardial infarctions, costing the Canadian health care system $2.

Tawfic Nessim Abu-Zahra, BSc MSc

Since their introduction into clinical practice 20 years ago, angiotensin converting enzyme (ACE) inhibitors have proven to be safe, well-tolerated drugs, effective in the treatment of a variety of cardiovascular disorders. Large clinical trials have established the efficacy of ACE inhibitors in treating hypertension, in reducing the incidence of myocardial infarction, and in decreasing mortality from heart failure in patients with left ventricular dysfunction.^1-5 Additionally, evidence suggests that ACE inhibitors reduce the occurrence and progression of nephropathy in patients with diabetes mellitus.^6,7 In two recently published clinical trials of the Heart Out- comes Prevention Evaluation (HOPE) study and the Microalbuminuria, Cardiovascular and Renal Outcomes (MICRO HOPE) substudy, investigators have demonstrated that the ACE inhibitor ramipril (Altace) significantly reduces the rates of death, myocardial infarction, and stroke in a broad range of high-risk patients, including those with diabetes and the elderly.^8,9 A brief interview was conducted with Dr. Hertzel C. Gerstein, the principal MICRO HOPE investigator, for the purpose of writing this article. His comments have been included here.

ACE is responsible for the conversion of angiotensin I to angiotensin II (Ang II), the principle hormone mediating the effects of the renin-angiotensin-aldosterone system (RAAS). (Please see Figure 1.

Anna Liachenko, BSc, MSc

Aging is associated with hair loss, which may cause considerable anxiety and distress in an elderly patient. The general belief is that aging men are much more prone to hair loss than aging women. The belief is due to the frequently observed receding hairline known as "male-pattern baldness". In reality, aging women also experience significant hair loss but in a much less visible pattern. Hair loss in women generally goes "unnoticed". Nonetheless, possibly due to the belief that women do not bald, female patients are much more likely than their male counterparts to fear alopecia and to develop related psychiatric problems. Thus, it is important for physicians to explain to female patients the age-related changes in hair physiology and to inform them about the potential causes as well as available measures for prevention and treatment of balding.

Several age-related changes are responsible for the decreased hair volume in the elderly. Between early and late adulthood, the linear growth rates of hair decrease by approximately 30 to 50 percent. Women in particular experience a significant decline in growth of axillary hair after the fourth decade. Also, many hair follicles undergo gradual atrophy or fibrosis.

Elana S. Lavine, BSc

Irritable bowel syndrome (IBS) is a very common gastrointestinal disorder typically characterized by abdominal pain, bloating, and constipation and/or diarrhea. There is no known organic disease process in the gastrointestinal tract, and no pathology is observed when the colons of patients with IBS are examined via endoscopy. IBS can, therefore, be categorized as a functional illness. However, certain differences have been observed experimentally between the colons of IBS patients and normal controls (see pathophysiology). The onset of novel IBS-like symptoms in the elderly patient merits a thorough investigation. Successful management may require both symptomatic treatment and emotional support from a physician.

Epidemiology
IBS is considered a syndrome of the young and middle-aged; in the elderly, it may be a reluctant diagnosis.¹ Fifty percent of patients experience an onset of symptoms before age 35, and another 40% between the ages of 35 to 50.2 One recent study followed a cohort of 2,956 newly-diagnosed IBS patients, ranging in age from 20-79, and noted that only 12% were above 60 years of age.³ One national study conducted in the UK indicated that prevalence rates dropped between 78% and 92% from middle to old age.⁴ The question has been raised as to whether such statistics reflect a true decline in incidence with age, or an underreporting.

Sheldon Singh, BSc

Constipation is a very common complaint. In the United States, it accounts for over 2.5 million physician visits annually. The occurrence is highest among individuals 65 years and older.¹ Constipation has been shown to diminish the quality of life and well-being of individuals. It may also lead to complications such as fecal impaction, fecal incontinence, dilatation and even perforation of the colon.

Defining Constipation
Constipation is not easily defined. Since more than ninety-five percent of the population have between three bowel movements a day and three bowel movements a week, constipation has historically been defined as the passage of fewer than three bowel movements a week. However, most would agree that the effort needed to pass stool and the consistency of the stool are more important; difficulty passing stool, even if one passes stool daily, may constitute constipation. Thus, constipation may be defined as persistent symptoms of difficult, infrequent, or seemingly incomplete evacuation.

Leora Horn, MSc

Inflammatory bowel disease (IBD) is the general term used to describe idiopathic chronic disorders that cause inflammation or ulceration of the gastrointestinal system. Canada is believed to have one of the highest incidences of IBD in the world with an estimated one hundred thousand people suffering from the disease (Crohn's and Colitis Foundation of Canada). The majority of IBD cases are characterized by periods of remission and exacerbation of symptoms often requiring long-term drug therapy, hospitalization, and recurrent surgery. IBD may develop at any age in the geriatric population, but the peak incidence falls between ages 60 and 80. IBD is a chronic disease; people who develop IBD when they are young will carry the disease into old age. Within the elderly population, two-thirds of IBD patients develop the disease in their sixties, a quarter of patients develop IBD in their seventies, and one tenth of patients develop IBD in their eighties.

IBD is classified as either ulcerative colitis (UC) or Crohn's disease. UC is three times more likely than Crohn's disease to occur in the elderly, with twelve percent of UC patients developing the disease when they are over sixty years of age. Approximately four percent of people with Crohn's disease develop symptoms when they are over sixty with incidence among women being higher than among men.¹

The "Nine Ds" of Determining the Cause of Weight Loss in the Elderly

David M. Kaplan, MScHA

Weight loss in the elderly should always be a great concern for the clinician because it can be an indicator of malnutrition. Involuntary weight loss has been shown to be highly predictive of morbidity and mortality.¹ All physicians who treat geriatric patients need to have a framework for identifying and evaluating weight loss in this patient population. One Canadian study found that 40% of elderly persons receiving home care services reported involuntary weight loss over a period of one year.² This practical approach to involuntary weight loss in the elderly will begin with a definition and then present a simple and organized approach to diagnosis and evaluation.

Definition and Risk Factors
Weight loss in the elderly becomes worrisome when the patient has involuntarily lost five percent of their body weight over a six-month period.³ Social Isolation has been identified as a risk factor for weight loss. While the mechanisms are not clearly understood, it is thought that poor physical functioning may be linked to a decrease in social support.⁴ Social isolation has been demonstrated to be detrimental to health and health outcomes.^3,4,5 Sensory decline, poor oral hygiene, disease, polypharmacy, drug-nutrient interactions, poverty, and alcohol abuse have been found to be risk factors for involuntary weight loss in the geriatric population.

Approach to Weight Loss
Before the clinician adopts an approach to determine the cause of weight loss in a specific patient, she must first be astute enough to perceive a problem. Recognizing weight loss in the elderly can often be problematic. Our pediatric colleagues place great importance on following and charting weight and height parameters in all their patients. It is best to follow their example in this regard. Geriatricians, family physicians, and other primary care providers should, at the very least, record the patient's weight and height at every visit. By adopting this practice ritual, they will become aware of subtle weight loss in their elderly patients.

Once established, involuntary weight loss can be handled by utilizing a broad-approach differential diagnosis. Bianchi divides weight loss into three possible, but not mutually exclusive, etiologies.⁵ Of the three basic causes of weight loss, decreased intake (table 1) is the most common in the elderly. The second cause, increased fluid-nutrient loss (table 2), is caused predominantly by malabsorptive disorders and by diabetes. Lastly, states of excess metabolic demand (table 3) resulting from gastrointestinal, genitourinary and breast carcinomas are also a basic cause of weight loss.

TABLE 1 CAUSES OF DECREASED FOOD INTAKE LEADING TO INVOLUNTARY WEIGHT LOSS
Mechanism of weight loss	Example
Disease Gastrointestinal Malignancy Eating Disorders Infection Systemic diseases	Peptic Ulcer, Cholelithiasis GI, Ovarian Anorexia, Bulimia Nervosa HIV
Depression Dysphagia Dysgeusia Dentition Dysfunction Dementia	Primary illness or concurrent with failing medical condition May be caused by disease May be caused by disease Poor Dentition Primary illness
Drugs Substance Abuse Medications	Alcohol Beta-blockers Anticholinergics Benzodiazepines Neuroleptics SSRIs Tricyclic antidepressants
Poverty	Unable to afford food
Social Isolation	Multiple mechanisms

A second, and perhaps, more practical approach to a differential diagnosis of weight loss in this specific population, is the "Nine Ds of weight loss in the elderly."⁷ Robbins first identifies whether the cause of weight loss is due to acute or chronic disease. The different diseases that lead to weight loss have been discussed above and in the accompanying tables. Depression has also been implicated in weight loss and health outcomes. Depression is linked to social isolation and, therefore, depression affects health outcomes.^3,5 Depression in the elderly is correlated to lower socioeconomic status, female gender, older age, martial status, frequency of visits to physicians, lower functional status, and poor self-reported health.^5,7 Clinicians must realize that these patients often present with physical, rather than emotional, complaints.⁴ While it is the most common psychiatric illness in this population, it is under-diagnosed and under-treated.

Diarrhea, dysphagia, dysgeusia (impaired taste), and abnormal dentition are obvious causes of weight loss in any population and must be kept in mind while examining the patient. Numerous studies have linked dementia to weight loss in the elderly.⁴ One of the outcomes of dementia, dysfunction (problems in physical, cognitive and psychosocial function), is itself an independent cause.4 Food shopping, and the preparation and eating of food are integral parts of our daily life. And yet, Markson reports that 23% of older people in the community have health-related difficulties with activities of daily living (ADLs) such as bathing, dressing, feeding, and using the bathroom.⁸ Moreover, 28% of the same population has difficulties with independent activities of daily living (IADL) (using the telephone, shopping, banking, laundry, and transportation).⁸ Clearly, patients who have had a decline in their functional ability are at risk for involuntary weight loss.

Whether due to a single pharmaceutical agent or to polypharmacy, drugs can also cause weight loss in the elderly.⁴ Beta-blockers and anticholinergic agents cause cognitive changes, which lead to functional decline. Narcotics, benzodiazepines, neuroleptics, and selective serotonin reuptake inhibitors (SSRIs) can produce anorexia. Lastly, use of tricyclic antidepressants to treat depression can cause dysgeusia and dry mouth. Now that a general approach to diagnosing the cause of weight loss in the elderly patient has been described, we can begin to illustrate a more individualized approach to a particular patient in the office.

TABLE 2 CAUSES OF INCREASED FLUID/NUTRIENT LOSS LEADING TO INVOLUNTARY WEIGHT LOSS
Mechanism of weight loss	Example
Disease Malabsorption Recurrent vomiting Fistulous drainage Pancreatic	Celiac disease
Insufficiency Infection Inflammatory bowel disease	Giardiasis Crohn's disease
Drugs Medications	Cholestyramine, laxatives

The Patient Encounter
The medical interview is fundamental to the patient encounter. The best method of initiating an investigation of a patient who has had clinically noted weight loss is to take a complete history. Specifically, one should focus on determining the following: First, what is the patient's daily oral intake; secondly, are there symptoms characteristic of malabsorptive conditions or malignancy; thirdly, is there a history of heart, lung, or kidney failure. As explicated previously, a depression-screening exam may also be beneficial in the work-up of a patient with involuntary weight loss. As is usually the case, one should conclude the history with a complete review of systems to elicit whether the patient may be having any additional symptoms.

The physical exam is guided by what one uncovers during the interview. While working up these patients from a general standpoint, the physical exam should include the measurement of vital signs, the patient's weight and height, and a calculated body-mass index (BMI: weight(kg)/height (m)²). Healthy, elderly people should have stable weights and a BMI higher than 23 kg/m². One should look for evidence of dementia by doing cognitive tests such as repeated Folstein Mini-Mental State Examinations. The presence of lymph nodes, evidence of previous chest or abdominal surgery, abdominal masses, abdominal distention, ascites, or organomegaly should be noted. A digital rectal exam should also be performed along with fecal occult blood testing. Next, a full musculoskeletal exam should be conducted to observe evidence of osteoarthritis, which could be affecting the patient's ADLs and IADLs. Lastly, a screening neurological exam should be done to elicit any focal neurological lesions.

Armed with the data from the complete, focused history and physical, the basic laboratory screening tests may include a complete blood count, electrolytes, blood glucose, urinalysis, liver and renal function tests, calcium, thyroid function, hemoccult stool tests, and a chest radiograph. The special tests, which may be necessary based on history and physical exam findings include: ESR, HIV test, blood cultures, upper GI series, esophagealgastroduodenoscopy, and colonoscopy.^3,7 A CT scan or ultrasound study may be indicated to investigate abdominal masses or abscesses.

TABLE 3 CAUSES OF EXCESS METABOLIC DEMAND LEADING TO INVOLUNTARY WEIGHT LOSS
Mechanism of weight loss	Example
Disease Hyperthyroidism Tumour of adrenal gland Malignancy Fever/infection Systemic disease	Pheochromocytoma Disseminated metastatic Malaria, TB, HIV
Depression/dementia and other psychiatric disorders Trauma Excessive exercise	Mania Burns

Treatment
While the purpose of this article was to elucidate an approach to the patient who presents with involuntary weight loss, the final section will briefly describe the general management of these patients. If the results of the basic screening do not reveal an underlying disease, a waiting period to see how the patient fares would be prudent; serious disease will likely, if present, reveal itself within half a year.³ Once the cause of the weight loss is evident, treatment is based on the underlying medical or psychological conditions. One should continue to monitor height and weight throughout the course of treatment. A reassessment of the patient's medications is also warranted. Finally, the proper use of community resources (Meals on Wheels, Assisted living, nursing homes), a dietician, social worker, and an occupational therapist should also comprise part of a comprehensive treatment plan for these patients.

Summary
Involuntary weight loss, defined as a five percent of body weight reduction over a six-month period, has been shown to be a cause of poor health outcomes in the elderly patient. This approach highlighted the necessity for clinicians to be cognizant of the many etiologies of weight loss in this population. A good history and physical followed by appropriate laboratory tests is necessary in order to diagnose and successfully develop a comprehensive treatment plan.

References

1. Wallace, JI, Schwartz RS. Involuntary Weight Loss in Elderly Outpatients: Recognition, Etiologies, and Treatment. Clinics in Geriatric Medicine: Failure to Thrive in Older People 1997;13(4):717-736.
2. Payette H, Gray-Donald K. Risk of malnutrition in an elderly population receiving home care services. Facts and Research in Gerontology 1994;2(suppl):71-85.
3. Verdery RB. Clinical evaluation of Failure to Thrive in Older People. Clinics in Geriatric Medicine: Failure to Thrive in Older People 1997;13(4):717-736.
4. Markson, EW. Functional, Social, and Psychological Disability as Causes of Loss of Weight and Independence in Older Community-Living People. Clinics in Geriatric Medicine: Failure to Thrive in Older People 1997;13(4):717-736.
5. Berkman LF, Berkman CS, Kasl S et al. Depressive symptoms in relation to physical health and functioning in the elderly. Am J Epidemiol 1986;124:372-388.
6. Bianchi A, Toy EC, Baker B III. "The Evaluation of involuntary weight loss." Primary Care Update Ob/Gyns 1998; 5:263-267.
7. Robbins LJ. Evaluation of weight loss in the elderly. Geriatrics 1989;44:31-37.
8. American Association of Retired Persons and Administration on Aging, U.S. Department of Health and Human Services: A Profile of Older Americans, 1996. Washington, DC, Program Resource Department, American Association of Retired Persons, 1996.