D'Arcy Little, MD, CCFP
York Community Services,
Toronto, and
Department of Family Medicine
Sunnybrook Campus of
Sunnybrook and Women's
College Health Sciences Centre,
Toronto, Ontario

Chronic Obstructive Pulmonary Disease (COPD) is a general term for a group of conditions characterized by some or all of the following features: a chronic cough, increased sputum production, shortness of breath, airflow obstruction, and impaired gas exchange. Unlike asthma, which is usually episodic and reversible, the major characteristics of COPD are that it is chronically progressive and irreversible. Under the umbrella of COPD, there are two major disease categories: chronic bronchitis and emphysema. Chronic bronchitis is clinically characterized by a productive cough, lasting three months of the year for at least two consecutive years. Pathologically, chronic bronchitis is characterized by mucus gland and airway smooth muscle hypertrophy. Emphysema is clinically characterized by dyspnea, although the other features mentioned above may also be present in various degrees. Technically, emphysema is a pathological diagnosis characterized by destruction of the air spaces distal to the terminal bronchioles (respiratory bronchioles, alveolar ducts and alveoli). It is worthwhile to note that it may not be clinically important, or useful, to categorize a patient as having either chronic bronchitis or emphysema.

Lilia Malkin, BSc

The myriad of human physiological systems undergo change as the body grows older, and the respiratory system is no exception. For a more detailed look at the aging lungs, please see the Biology of Aging article, Age-related Changes to the Respiratory System Will Not Affect Healthy Elderly. It is worth noting, however, that the evaluation of the geriatric patient presenting to the physician's office with respiratory symptoms such as cough and shortness of breath is quite similar to that of a younger adult. The following is a two-part review of diagnostic and treatment approaches to the geriatric patient presenting to the primary care physician for the first time with symptoms of dyspnea and cough, respectively.

Part I. Dyspnea
Dyspnea may be defined as "abnormal or uncomfortable breathing in the context of what is normal for a person according to his or her level of fitness and exertional threshold for breathlessness."¹ However, upon presenting to the physician, patients will usually refer to the alarming feeling of "shortness of breath," or "difficulty breathing." The complaint is fairly common, owing to the plethora of conditions that give rise to this symptom.

Sharron Ladd, BSc
Managing Editor

"It is clear that the study of back pain has been overlooked in the geriatric community, perhaps relegated to second-class status behind health conditions like diabetes, heart disease and cognitive impairment," says Dr. Hart Bressler, the primary author of the landmark study entitled "The Prevalence of Low Back Pain in the Elderly." The study, co-authored by Dr. Warren Keyes, Dr. Paula Rochon and Dr. Elizabeth Badley appeared in the September 1st issue of the journal Spine. Several reasons are cited for the under-representation of elderly in back pain studies. One of the main reasons is the economic burden of maintaining worker's compensation programs; these programs are necessarily directed at the younger working population. Other reasons are listed in Table 1.

Using the key words low back pain, back pain, elderly, geriatrics and aged for their literature analysis, the researchers found only twelve studies on low back pain in the elderly, between 1966 and the present, that met their final selection criteria! The methodologies underlying some of these studies are dubious. "Many studies have grouped younger and older patients together, such as a 40 year old with an 82 year old.

Thomas Tsirakis, BA

Social isolation is common amongst the elderly. Socially isolated individuals display significantly higher suicide rates, a greater number of physical and cognitive impairments, and a lower life expectancy rate when compared to those who are socially active. European studies have shown that even minor interventions to break social isolation, such as friendly visitors or routine volunteer phone calls, improve survival in the socially isolated elderly. The Baycrest Centre for Geriatric Care in Toronto, Ontario offers a wide range of innovative programs that specifically address problems with withdrawal and social isolation.

Studies show that the elderly population in general feels that their contributions to society are deemed to be insignificant by younger generations. Being able to contribute to the lives of others is important for building self-worth, and ultimately increases the value placed on life itself. For many older persons, various physical ailments (such as osteoporosis, and reduced level of vision and hearing) can cause a reduction in mobility and communication with others, ultimately causing social withdrawal. If the person's withdrawal becomes prolonged, it can become increasingly difficult to break free of this isolation.

Nariman Malik, BSc

The word bronchiectasis is derived from the Greek words bronchos, meaning windpipe, and ektasis, which means extension or stretching.¹ Bronchiectasis is defined as the abnormal and persistent dilatation of bronchi due to destructive changes in the elastic and muscular layers of the bronchial wall.² It is a condition that can affect airways of all sizes but tends to mainly affect medium-sized airways. It can be either focal, affecting the air supply to a limited region of lung parenchyma, or diffuse in nature. Bronchiectasis most often is a consequence of chronic or recurrent infections and the associated secretions that pool in these airways.³

In North America, fewer and fewer patients present with gross disease.⁴ The advent of antibiotics has lead to a dramatic decrease in severe respiratory infections and the subsequent development of bronchiectasis. However, because its incidence has decreased in developed countries, it is now believed that low clinical suspicion is a factor in the underdiagnosis of bronchiectasis.⁵ Bronchiectasis is characterized by the production of large amounts of sputum, which is also a defining trait of chronic bronchitis. As such, patients who are producing copious amounts of sputum and who smoke are likely to be misdiagnosed with chronic bronchitis.

Mom and Dad are getting older, and guess what? You may be looking after them one day! But don't worry, help is on the way. Baycrest Centre for Geriatric Care and TV Ontario have teamed up on a show that is essentially a crash course in looking after an aging parent.

Taking Care is a 13-part television series that will air Thursdays, starting September 30th at 2:00 p.m. EDT. Hosted by radio personality Mary Ellen Beninger, each half-hour program will address a different challenge along the caregiving road, such as identifying the early signs that a relative may need help, strategies for organizing homecare, coping with dementia, and shopping for a long-term care facility.

Beninger is no stranger to caring for a frail parent. When her mother suffered a series of debilitating strokes, Beninger's father cared for her mother at home. Beninger took time from her busy schedule to help out whenever she could.

"I've seen what elder care can do to families--both the ups and downs," says Beninger, who co-hosts the morning show on Energy Radio in Toronto. "It can be an enriching experience if we can find ways to help people cope better. The key is knowing what support services are out there."

Each of the 13 programs begins by taking viewers into the home of a family who candidly shares their experience caring for an elderly relative. This is followed by a studio discussion with community and health care professionals who provide insight and practical information. At the end of the program, viewers are given community resources and contacts that they can follow up with.

"By educating families with practical information, we're giving them a ray of hope that help is out there--they just have to know where to look for it," says Sorele Urman, Associate Director of Social Work at Baycrest Centre and a consultant on the series. Baycrest gets calls every day from family members who are concerned about their relative's physical or mental state and their ability to continue to live independently.

The premiere show on September 30th is aptly titled The First Signs. Three caregivers talk about the early signs of illness in their parents, how they reacted, what they did about it, family disagreements, and how they made plans for homecare and other supports. Additional topics in the series include transportation and mobility, depression and isolation, and maintaining good health in later year.

Taking Care airs Thursdays, starting September 30th at 2:00 p.m. EDT, repeated Saturdays at 4:00 p.m. and Sundays at 5:30 p.m. Produced by TVO and supported by Baycrest Centre for Geriatric Care.

Sonya Lytwynec, RegN, BScN
Nurse Clinician,
Southwestern Ontario Regional Geriatric Program,
Continence Outreach

Urinary incontinence can be successfully treated in some individuals.¹ There are, however, many individuals who remain unresponsive to behavioural, medical or surgical treatment and continue to experience chronic urinary incontinence. These individuals can benefit from improved continence management, using incontinence products that enable them to maintain social acceptability, skin integrity and comfort.

The focus of this article is to identify the factors that influence product selection and describe the key features of products that may guide the health care professional in meeting the specialized needs of individuals and caregivers.

Incontinence products may be utilized in addition to other treatment modalities to promote comfort and security. For example, supplementing toileting protocols with the use of absorbent disposable diapers and moisture barriers may be effective in reducing the risk for skin breakdown.²

Selecting the most appropriate product can be a complex task.

Anna Liachenko, BSc, MSc

The popularity of theophylline, a bronchodilator used in the treatment of asthma and other bronchospastic diseases for over 60 years, has been declining due to its narrow therapeutic index and the perceived lack of anti-inflammatory effects. Instead, newer therapies, such as inhaled long-acting corticosteroids, have been increasingly recommended. Although valued for their anti-inflammatory properties, these newer therapies can nevertheless produce serious side effects at therapeutic concentrations. Fortunately, the prescribed dosages can be decreased due to the recently discovered anti-inflammatory properties of theophylline, which is now recommended as an add-on therapy to corticosteroids. In this article, the beneficial effects and necessary precautions when using theophylline are examined, with particular emphasis on the elderly.

In Canada, theophylline is currently indicated for the symptomatic treatment of reversible bronchospasm associated with asthma, chronic bronchitis, emphysema, and associated bronchospastic disorders. Historically, asthma was treated mainly with bronchodilators. During the 1980s it became apparent that an unacceptably high rate of asthma-related hospitalizations and asthma deaths were partly attributed to the under-use of anti-inflammatory medications. For this reason, the use of inhaled corticosteroids increased. Unfortunately, there is some systemic absorption of inhaled corticosteroids.

Gail Elliot, MA
McMaster University
Office of Gerontological Studies

Canada consists of over 100 ethnocultural groups. The 65+ age group is comprised of a population that largely identifies with an ethnic origin other than Canadian.¹ Research has too often documented that the health care practices in this country are ethnocentric, focusing on westernized, scientific based practices that too often ignore the alternative methods of care and cure.^2,3,4

In a multicultural country such as Canada, cultural sensitivity should be intricately woven throughout all interactions in the health and social service delivery system. Not only should cultural sensitivity be considered for the purpose of providing patient-centred care, it must also be recognized that this country as a whole has adopted statutory and constitutional policy, and regulations that are intended to place "equality for all" at the forefront of individual rights and freedoms. In fact, Canada has spent nearly thirty years developing policies that are designed to encourage "all of us to work together to build a society in which the principles of multiculturalism are fully realized in practice.

Rhonda Witte, BSc

"I'm so out of breath! I must be getting old." Have you ever heard someone use that expression before? Chances are that you have. You may have even used it yourself. Sometimes it is used as an excuse for not having exercised enough. But is there truth to that statement? The answer is yes. With age, the respiratory system changes and may predispose us to shortness of breath in situations where we may not have been before.

Exogenous and endogenous factors play a role in age-associated changes to the respiratory system. Infection, climate, air pollution and mechanical injuries are a few of the exogenous insults the lungs incur over time.¹ System diseases and infectious diseases are endogenous factors that can often affect the lungs in elderly patients.¹ For example, COPD occurs more commonly in the elderly. Esophageal disorders and Parkinson's disease are other endogenous factors which are frequently associated with lung aspiration and pneumonia in elderly individuals.¹

Older and younger patients differ with respect to pulmonary function because of age-related changes of the respiratory system. Consequently, it is important that the physician in care is aware of the changes so that proper care is administered. Although much more work needs to be done to determine the exact consequences of these age-related changes, one should be aware of possible complications that may occur.