Hannah Hoag, BSc

There are about 100 different forms of arthritis. Gout, lupus, and ankylosing spondylitis are members of the arthritis family, as are the better known osteoarthritic and rheumatic versions. Between birth and death, nearly 3.5 million Canadians are affected by some form of the disease. Osteoarthritis and rheumatoid arthritis (RA) are 2 forms of chronic arthritis that are observed in, but not restricted to, the aging population. Arthritis can be defined, most simply, as an inflammation of the joint, however, the severity of the condition varies significantly. Pain can be mild or severe, and the disease can remain isolated to one joint or have systemic effects. With so many variant forms of the disease, it is not surprising that the causes of arthritis are somewhat unclear. However, the importance of the interplay between cartilage, the immune system, heredity, and the environment has been recognized in the onset of disease. Much of current research has been devoted to understanding normal immune function and how dysfunction causes arthritis.

Osteoarthritis is identified as being of either primary or secondary origin. Primary osteoarthritis is viewed as a consequence of the aging process.¹ Over 85% of people over the age of 70 suffer from osteoarthritis. Secondary osteoarthritis is not associated with the aging process but due to other factors such as injury, obesity, and changes in cartilage chemistry.

Nariman Malik, BSc

Osteoarthritis is the most prevalent rheumatic disease.¹ It affects primarily the elderly and is rarely seen in individuals younger than 40. Osteoarthritis was believed to be an unavoidable consequence of aging, however, it is now believed to be a degenerative process that results from the interaction of metabolic, mechanical, genetic and other factors.

The disease is a heterogeneous disorder that affects different joints.² Each affected joint has different clinical manifestations, prognoses, and patterns of progression. The prevalence of osteoarthritis increases with age. It is more common in women than in men.² Women present more with osteoarthritis of the hand while men present more with problems of weight-bearing joints.³ In general, the management of osteoarthritis is coordinated by the family physician.² If there is any doubt about the diagnosis or any complications, a rheumatologist or geriatrician should be consulted. Physiotherapists and occupational therapists are key members of the multidisciplinary management team critical to the long-term management of this chronic illness.

Pathogenesis

Osteoarthritis is a disorder of the hyaline articular cartilage on the bony surface of joints (see Figure 1).² Hyaline articular cartilage is composed of type II collagen, proteoglycans, as well as chondrocytes and water.

Rhonda Witte, BSc

It is one thing to know how the body changes with age, but it is another to understand the effects of these changes on the body. Decreased kidney size? A smaller liver? They may sound like minor changes, but it is crucial to understand the significance of such age-related changes in terms of selecting appropriate drug therapy. Geriatric clinical pharmacology is not a large part of the general practice of medicine but with an increasing elderly population, greater knowledge in this area is required.¹ What must be kept in mind is that it is not just about what drugs should be prescribed to the elderly--it is about the right drugs that should be prescribed to a geriatric patient on an individual basis.

Pharmacokinetics

Fundamental to geriatric medicine is the understanding of age-related changes in pharmacokinetics. Such changes have profound impacts upon drug usage in the elderly population. When ignored, severe complications and even death can result from pharmacotherapy. What makes the situation even more complicated is that pharmacokinetic changes vary with the individual. Therefore, each patient must be treated with a highly individualized approach² and one patient's situation cannot set the standard for other patients to follow.

Pharmacokinetics refers to time-dependent changes of drug concentration and their metabolites in the body, or more simply, what the body does to a drug.

Sonya Lytwynec RegN, BScN
Michael J Borrie BSc, MD, ChB, FRCPC
Southwestern Ontario Regional Geriatric Program: Continence Outreach

Functional urinary incontinence is one of five types of incontinence.¹ The assessment and therapeutic interventions associated with functional incontinence are reviewed in this fifth and final article of a five part series on urinary incontinence. Functional incontinence is defined as the involuntary loss of urine associated with the inability to use the toilet because of impairments of cognitive or physical functioning, psychological unwillingness or environmental barriers.²

The existence of urinary incontinence has been estimated at 15% to 35% in community dwelling people over 60 years of age, with twice the prevalence in women compared to men. The prevalence increases to 53% in homebound individuals, and is reported at 30% in acute care hospitals and 40% to 60% in longterm care institutions.³ A study of incontinent people receiving home care services (mean age 74) reported that a total of 89% had at least one functional disability (cognition, mobility, transferring in and out of bed or chair, or undoing garments). The incontinence was moderate to severe in 41% of the patients, and 95% of the family caregivers viewed the incontinence as a problem.⁴

Functional incontinence should be a diagnoses of exclusion.

This article was reproduced from the CMAJ 1998;159 (6 Suppl), with permission of the Heart and Stroke Foundation of Ontario. Please visit the Heart and Stroke Foundation at www.hsfpe.org to view the complete Stroke: Costs, practices and the need for change supplement.

 

Internet Resources on Stroke
Heart and Stroke Foundation of Ontario:	www.hsfpe.org
Canadian Neuroscience Network:	www.cns.ucalgary.ca
American Academy of Neurology:	www.aan.com
Neurosurgery//On-Call:	www.aans.org
American Heart Association:	www.amhrt.org
American Medical Association:	www.ama-assn.org
National Stroke Association:	www.stroke.com
Neurosciences on the Internet:	www.neuroguide.com
The Journal of Neuroscience:	www.jneurosci.org
Stanford Stroke Center:	www.med.stanford.edu/school/stroke
Columbia University:	www.columbia.edu/~dwd2/
National Library of Medicine:	www.nlm.nih.gov

Thomas Tsirakis, BA

The use of selective serotonin reuptake inhibitors (SSRI) as a first-line of treatment for depression in the elderly has become the standard of choice in clinical practice. The widespread preference of initiating treatment with an SSRI versus the more traditional tricyclic antidepressants (TCA) has been largely due to the belief that SSRIs have a safer profile, are better tolerated, and have a lower drop-out rate than TCAs. An accumulating number of studies published in the last few years, however, have begun to question this rationale, and have demonstrated that SSRIs are neither as advantageous, nor as safe as previously believed.

There are four SSRIs currently available [fluoxetine (Prozac), paroxetine (Paxil), sertraline (Zoloft), and fluvoxamine (Luvox)], each possessing both similar and unique side-effect profiles. Though SSRIs have been the main-stay of first-line treatment in recent years, it is important to be aware that they are not without risk. The belief that SSRIs exhibit fewer side-effects than TCAs is misleading in that TCAs have been studied far more extensively than SSRIs, and nearly every study comparing an SSRI with a TCA has used one of the most poorly tolerated TCAs in the comparison, thus making the SSRIs look remarkably tolerable.

Sherene Chen See is a freelance writer from Toronto, Ontario. We regret that Sherene Chen See's articles are not available on-line.

Guidelines for treating Insomnia In The Older Person

Use the lowest effective dose of a single agent Use intermittent dosing Short-term use (do not use hypnotic mediation on a regular basis for >3-4 weeks) Limited use of sedative-hypnotics (2-4 times per week) Gradual discontinuation Monitor for reoccurence of insomnia following discontinuation of medication Avoid ultra-short-acting benzodiazepines (e.g. triazolam)

 

Age-related Decline in Melatonin Levels

Anna Liachenko, BSc, MSc

Although anti-psychotic medications produce substantial side effects in the elderly, these drugs are extensively prescribed in nursing homes. Nursing home studies conducted in the United States in the 1980s showed that anti-psychotics were often used to manage disturbing behavior that did not fall into the clinical definition of psychosis. In 1987, the use of anti-psychotics was restricted by the Nursing Home Reform Amendments of the Omnibus Budget Reconciliation Act (OBRA87). The reform spelled out the exact guidelines for the use of each anti-psychotic drug in the elderly, thereby substantially reducing the amount of prescribed medication in nursing homes. Whether Canadian physicians also overprescribe anti-psychotic drugs is not clear. At present, clinical studies are being conducted to estimate the extent of anti- psychotic use and to find strategies to safely reduce the amount of medication when possible.

Mental illnesses, dementia in particular, are often accompanied by behavioral disturbances. This is often the primary reason for placing the older person in a nursing home. Thus, the prevalence of behavioral disturbances in nursing home residents is high and is estimated to be close to 60%. Only 10% of these behaviors are psychotic, i.e. accompanied by "delusions or prominent hallucinations, with the hallucinations occurring in the absence of insight into their pathological nature" (DSM-IV).

Falls are the leading cause of injury admissions to Ontario acute care hospitals, especially for people over 65, according to figures released by the Canadian Institute for Health Information (CIHI).

Of the 68,222 injury admissions to Ontario's acute care hospitals in 1996/97, 58% were caused by falls, followed by motor vehicle collisions (14%) and intentional injuries (6%).

In 1996/97, Ontario residents spent 628,211 days in acute care hospitals due to injuries. Of these patient days, 72% were due to falls. The average length of stay in hospital was 11 days for falls compared to 9 days for all injury hospital admissions.

"Falls account for 86% of hospital admissions for people 65 years of age and older [with an injury] and the statistics are quite striking for older women. In fact, twice as many older women are admitted to hospital because of falls than men of the same age," explains CIHI spokesperson Daria Parsons.

Slipping, tripping, stumbling and falling from one level to another are the most common causes of injury admissions due to falls, in all ages and particularly for people aged 65 and older. The majority of falls occur in January, February and March. The most frequent type of injury is orthopaedic, largely bone fractures and dislocations, which are seen more often in the elderly.

CIHI's analysis shows that from 1992/93 to 1996/97, the number of injury admissions due to falls has remained relatively stable, with women representing more than half of the hospital admissions.

Causes of Injury Admissions for People Aged 65 and Older, 1996/97

In 1996/97, there were 27,650 injury admissions in people aged 65 and older, accounting for: 41% of all injury admissions 67% of hospital days due to injury 86% of admissions in people aged 65 and older were due to falls, totalling 23,689; 5% (1,439) were due to motor vehicle collisions; and other causes accounted for 9% (2,522) majority of injury admissions due to falls, for those 65 years of age and over, occur in women

These figures come from the Ontario Trauma Registry's (OTR) 1998 report on hospital injury admissions for the one-year period, April 1, 1996 to March 31, 1997. Managed by CIHI, the registry is funded by the Ontario Ministry of Health and provides current provincial and regional data on hospitalization resulting from injury in Ontario.

Information from the OTR is used by researchers and injury prevention specialists to develop and monitor injury prevention programs. The Ontario Ministry of Health has identified falls in the older population as a priority theme for injury prevention.

The Canadian Institute for Health Information

Created in 1994, CIHI is a national, not-for-profit organization with a mandate to develop and maintain Canada's integrated health information system. To this end, CIHI is responsible for providing accurate and timely information that is needed to establish sound health policies, manage the Canadian health system effectively and create public awareness of factors affecting good health.

The CIHI can be found on the world wide web at www.cihi.ca.

Neil P. Fam, BSc

Arthritis has been called the sleeping giant of Canadian health care. According to Statistics Canada, over 3 million Canadians suffer from osteo-arthritis (OA), with another 300,000 affected by rheumatoid arthritis (RA).¹ Together, these diseases represent one of the leading causes of chronic disability, lost productivity and worker absenteeism in Canada.² As our population ages, more patients are presenting to physicians with musculoskeletal complaints, most of which center around chronic joint pain.

Treatment of the pain of arthritis involves both pharmacologic and non-pharmacologic approaches. Traditionally, treatment of OA and RA has revolved around the use of non-steroidal anti-inflammatory drugs (NSAIDs). Although these medications are often effective in relieving pain, they are associated with significant gastrointestinal and renal complications. Elderly patients are particularly prone to life-threatening complications such as GI bleeding and perforation. For these reasons, other treatment modalities are often utilized. This article presents an overview of pain management strategies, with a focus on OA, the single most common cause of arthritis in seniors.

OA pain

In the management of osteoarthritic pain in the elderly, the best approach is to begin with therapies that are inexpensive and have a low risk of side effects. The following is a stepwise approach, summarized in Table 1.