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.

Olya Lechky

Making the home safe and secure for people with Alzheimer's Disease (AD) is one of the biggest challenges confronting families and caretakers.

Protecting people with AD from physical hazards and providing them with emotional and psychological security is a fine balancing act, says Linda LeDuc, director of support services for the Alzheimer Society of Canada in Toronto. The key is to find a way to optimize safety and security, while fostering as much independence and dignity as possible according to a person's cognitive abilities.

Simple, small changes are usually enough to create a safe environment that remains familiar and comforting. Stripping the home of all potential hazards can create a bleak, depressing and frustrating environment that may prematurely foster dependence. "If a person can still safely use a knife to cut bread, there's no point in stripping the kitchen counters bare," says LeDuc. "It can be very frustrating if the person wants to cut a bagel and can't find a knife."

Safety and security issues are of paramount importance to the 29% of people with AD who live alone, supported by family, friends, paid workers and volunteers. Of concern are the periods of time when the person is alone, most frequently at night.

Dr. A. Mark Clarfield is the Chief of Academic Affairs at the Sarah Herzog Hospital in Jerusalem and a staff geriatrician of the Division of Geriatric Medicine, Sir Mortimer B. Davis-Jewish General Hospital, McGill University, Montreal. We regret that Dr. Clarfield's articles are not available on-line.

David Yap, BSc

The area of complementary medicine in Geriatrics is important, as the use of complementary practices grows along with the expanding elderly population. Complementary medicine consists of a wide range of health care services, which are offered outside the mainstream of orthodox western medicine. Some types of complementary health services are: Acupuncture, T'ai Chi, Herbal Medicine, Homeopathy and Chiropractic.

In complementary medicine, health is viewed as the result of interactions between positive life building forces and negative destructive forces. To treat an illness complementary medicine attempts to improve the positive forces by incorporating a holistic conception of health. Complementary medicine lacks the emphasis on determining a specific pathophysiological diagnosis. The assessment of an individual is based on history and physical exam without a heavy reliance on laboratory tests to confirm a particular diagnosis. Lastly, in complementary medicine the individual actively takes part in their well being and is at least an equal partner in the practitioner-patient relationship.

It is important for family doctors and general internists to have a basic understanding and background in complementary medicine due to the increasing use of complementary services and the potential benefits.

Michelle Durkin, BSc

According to the Addiction Research Foundation tobacco use is still considered Canada's greatest public health concern even though the percentage of cigarette smokers is declining. Approximately 35,000 Canadians die prematurely each year due to smoking.¹ Despite the increased risk of heart disease, lung cancer, emphysema and other health problems, patients are reluctant to stop smoking and attempts to stop often fail. This is because of nicotine, a naturally occurring alkaloid. It can cause both a physical and psychological dependence that can be compared closely with addiction to substances such as heroin and cocaine.¹

Nicotine in the Body

Nicotine is rapidly absorbed into the body through the respiratory tree, buccal membranes, as well as percutaneously. Once in the body, it will mimic the effects of acetylcholine at nicotinic receptors (see Figure 1). These receptors are found at autonomic ganglionic synapses of the sympathetic and parasympathetic branches of the nervous system as well as neuromuscular junctions. Due to the wide distribution of these receptors in the body, nicotine can illicit a wide variety of effects and can act as a stimulant or a depressant.

Nicotine Substitution Therapy

Although the majority of smokers want to reduce or stop smoking, attempts to do so often fail.¹ It is the powerful addiction to nicotine that can make quitting so difficult.

Shechar Dworski, BSc

Despite ongoing criticism, many consider the Canadian drug regulation process to be one of the most respected and effective regulatory approaches in the world. The legislation governing drug approval in Canada is under constant scrutiny and comparison with other leading countries, especially the United States. While critics have pointed out weaknesses, new initiatives have been placed to correct these deficiencies. Some critics claim that the process is too slow. Others rebut by saying that our system is much more scrutinizing and prove this by citing numerous examples of drugs (e.g. several vaccines) not given approval in Canada, that were approved and subsequently recalled in other countries due to adverse reactions. Despite the longer and more intense screening and approval process, critics state that post-approval monitoring in Canada is insufficient, and cite numerous examples of drugs initially approved, but later recalled in other countries due to deaths, to which the Canadian boards did not respond to in a timely manner. There are also claims that the drug industry's close proximity to drug legislative boards results in their own economic interests superceding the public's best interest. To understand the nature and reasoning behind these claims, a closer look at the drug approval process in Canada is needed.