Eleanor Brownridge

Who does a patient call when wondering why a drug is not working, when concerned about an adverse reaction to a drug, or when hearing on the radio that green vegetables interfere with Coumadin?

Faced with absorbing so much verbal advice about their disease, diet, and life-style changes, it is no wonder that so many patients experience information overload. Once home and starting on a treatment, new questions arise.

Thirteen years of experience by the Medication Information Line for the Elderly (MILE) in Manitoba suggests that many older people are reluctant to call their physician with a drug-related concern for fear of being an economic burden to the healthcare system or just appearing foolish. They do not consult their regular pharmacist either because it did not occur to them that the pharmacist could provide such information, or because they thought the pharmacist was too busy.

Ruby Grymonpré, PharmD, associate professor at the Faculty of Pharmacy, University of Manitoba started MILE in January 1985, to fill a drug information gap for elderly consumers in Manitoba, many of whom are housebound or living in isolated rural areas. Funding for the annual $85,000 budget has come from Manitoba Health, University of Manitoba and individual drug manufacturers. Available weekdays from 9 am to 3 pm, MILE pharmacists log an average of 200 calls a month.

Lilia Malkin, BSc

Adverse drug reactions (ADRs) account for a significant proportion of morbidity and mortality in the geriatric population. According to the 1993 Canadian Medical Association (CMA) Policy Summary, over 20 percent of acute care hospital admissions of Canadian seniors may result directly from ADRs. Other studies have reported the incidence of ADR-related admissions ranging from 8 to 35 percent.

The World Health Organization (WHO) defines an adverse drug reaction as "a noxious, unintended effect of a drug that occurs in doses normally used in humans for the diagnosis, prophylaxis, or treatment of disease." ADRs can be divided into two categories: predictable (Type A) and unpredictable (Type B). Predictable reactions make up the vast majority of ADRs at 80 percent. Type A reactions are frequently dose-dependent and related to the augmented pharmacologic action of the medication: toxicity, side effects, indirect effects, and drug interactions. Unpredictable ADRs are less common, and include intolerance, allergy or hypersensitivity, idiosyncrasy, and psycho-genic reactions. Recognition of the pertinent risk factors for both predictable and unpredictable ADRs has direct application to ADR prediction, prevention, and management in the geriatric population.

ADR Prediction: Risk Factors

Older Canadians have a four- to seven-fold higher risk of suffering an ADR compared to younger individuals. According to Dr.

Jocalyn P Clark, MSc

The National Council on the Aging in Washington, D.C. recently released the findings of its landmark study entitled Healthy Sexuality and Vital Aging.¹ This unprecedented look at older people's sexuality will surely debunk many long-held views about the sexual lives of elderly North Americans. For one, older people appear to be both having sex and enjoying it. Over half of the older people in this study were found to have engaged in sexual activity within the last month, and 40% reported wanting sex more frequently. Only 4% wanted sex less often. Among those who were sexually active, over three-quarters said that maintaining an active sex life is an important aspect of their relationship with their partners. In addition, more than 70% said they were as satisfied or more sexually satisfied than they were in their 40s.

Lilia Malkin, BSc

Although many men consider a decline in sexual desire and sexual function a part of the "normal" aging process, this common misconception is being replaced by the increasingly positive outlook on sexuality that is becoming more prevalent among the geriatric population. A large proportion of older men regularly engage in sexual activity and many are addressing physical and emotional barriers, as well as some prevalent myths about sexuality.

A recent study conducted by The National Council On the Aging (NCOA) surveyed 1,300 older Americans and found that 61 percent of American males aged 60 and over are sexually active. The percentage of men who enjoy an active sex life does decline with increasing age; while 71 percent report being sexually active in their sixties, only 27 percent remain so in the 80 and over age group. However, lack of a steady partner presents one of the major barriers to continued sexual activity in the elderly, since 50 percent of men over 80 years of age who do have a partner engage in sex. Furthermore, while 39 percent of American men aged 60 and over stated that they were satisfied with how often they participated in sexual activity, the same percentage of respondents wished to increase the frequency of occasions in which they have sex.

Jaye Waggoner, BAA

It is a rigorous and demanding schedule by anyone's standards, never mind the fact that Ms. Geisler is 76 years old. What is her secret to staying so active and participating fully in her life and the lives of others? Well, according to her the answer is in the question. "I am out everyday, seven days a week." She has a routine that she follows and by doing that and through helping others she is fueled to continue doing the same. "If I sat at home with nothing to look forward to I would get depressed," she said. She went on to say, with a smile, just how important it is to "get moving and keep moving" even if it is just a walk around the block.

The pattern is certainly working for her. In the past she has only had to deal with an ulcer, that has since healed and a hip operation, which has somewhat limited what she can do physically. At 76, she is happy to say, she takes no prescription medications. She believes that physicians should put their foot down and try to limit the drugs they prescribe to seniors and in turn seniors should find other ways to feel good. "Doctors should talk to seniors and listen. Everyone relies too heavily on prescription drugs, especially seniors," she said. "This is not to say that drugs are the enemy, obviously in some cases like heart medication they are very necessary. But some," she went on to list, "like sleeping pills, tranquilizers, and those used to treat depression, may not be."

Ms. Geisler takes a multi-vitamin, vitamins E, C, B complex, calcium and magnesium, and drinks a lot of water, as she does not always feel like shopping and cooking. She also recognizes the value of exercise. She believes you can get exercise in a variety of ways. It does not have to be structured classes. "The only exercise I get is walking, and I feel good," she said. Not only does she bus and walk everywhere, she encourages other seniors, even those with limited mobility, to get out.

Ms. Geisler believes that like herself, if other seniors stay active physically, keep their minds busy, eat reasonably healthy and find someone who will listen and understand them, they could significantly improve their overall long-term health. "They may not find themselves needing so many prescription drugs down the road," she said. The recipe for good health, she says, could be as simple as talking, listening and really living, not simply existing.

Sonya Lytwynec, RegN, BScN,
Hassan Razvi, MD, FRCSC,
Southwestern Ontario Regional Geriatric Program: Continence Outreach

Overflow urinary incontinence is one of five types of incontinence.¹ The assessment and therapeutic interventions associated with overflow incontinence are reviewed in the fourth article of a five-part series on urinary incontinence. The first article in this series provided an overview of the prevalence, types, and treatment of incontinence in the frail elderly.

Overflow incontinence is defined as the involuntary loss of urine associated with over-distension of the bladder.² It is reported to comprise up to 30% of diagnoses in a geriatric continence clinic.³ Aging is associated with several physiologic and anatomic changes to the urinary tract which may predispose the older person to overflow incontinence. Both bladder outlet obstruction and detrusor muscle weakness may manifest alone or in combination as overflow incontinence. It has been estimated that up to 60% of men between 70 and 87 years of age develop clinical symptoms of benign prostatic hypertrophy (BPH).¹ BPH is the most common cause of voiding dysfunction in elderly males and may first present as urinary retention and overflow incontinence. Overflow incontinence occurs less often in women, but may develop following pelvic surgery or as a result of pelvic organ prolapse.

Shechar Dworski, BSc

As the North American geriatric population steadily increases, a greater emphasis is being placed on primary prevention in the form of screening and counseling, to avoid onset and/or advancement of disease. Treatment of advanced disease often requires much more invasive and time-intensive procedures, and is more stressful and risky for the patient. The periodic health exam is an opportune setting for a primary care physician to screen asymptomatic elderly patients for diseases commonly associated with aging or with a high-risk group. The physician's role is moving from treatment to prevention in our current social climate, since early detection often reduces onset and progression of disease, or at least reduces complications and increases survival rates.

Unlike their younger counterparts and the stronger elderly, when frail elderly become ill, early symptoms of chronic disease are rarely specific and localized ones. Instead, older patients usually manifest nonspecific symptoms, which quickly lead to loss of function. This creates dependency in a previously independent older person without giving any clues as to the cause of the problem. The functional expressions of disease include cessation or reduction of eating and drinking, dizziness, urinary incontinence, falling, weight loss, acute confusion, failure to thrive, and new onset or worsening of previous dementias.

Roger YM Wong, BMSc, MD, FRCPC,
Division of Geriatric Medicine, Department of Medicine,
University of British Columbia, Vancouver, BC

For many adults age 65 years or above, their point of entry into the health care system often begins with an office visit to their family practitioners. In some instances, proper assessment of these elderly patients may become quite a daunting task for the primary care physician in a busy office. Two common barriers to conducting a comprehensive geriatric assessment (CGA) in the office setting include the lack of a systematic approach to screen for common geriatric problems, and more importantly, the paucity of time. The challenge therefore becomes how one can assess a frail older patient with multiple medical and functional problems quickly and effectively. This article will highlight some simple ways to incorporate important concepts of geriatric assessment into one's busy outpatient practice.

CGA and health promotion

The United Nations has declared 1999 as the Year of the Older Person. CGA is one of the ways to promote healthy living in the older adult. Simply defined, CGA refers to the multi-faceted approach of diagnosing and managing complex physical, psychological and functional problems.

Margaret Grant, MD,
Geriatric Medicine Resident, University of Toronto, Toronto, Ontario

Definition and Prevalence

In response to the confusion surrounding the existence of multiple definitions of orthostatic hypertension (OH), a consensus statement was developed to standardize the meaning of this medical condition. OH is defined as a reduction of systolic blood pressure (BP) of at least 20 mm Hg, or a reduction of diastolic BP of at least 10 mm Hg within 3 minutes of standing or lying on a tilt table at an angle of at least 60 degrees.¹ The prevalence of OH in the elderly ranges from 5 to 33 %.^2-4 This variability may be the result of different definitions used and the range of populations considered, from frail older nursing home patients to healthy older people living in the community. The prevalence of OH can be as high as 50% in frail older nursing home patients.²

In a study by Ooi et al., which looked at nursing home patients' BP taken at 8 different times, OH was found to be variable depending on the time of day, with a higher prevalence just before breakfast.

Eleanor Brownridge, RD, FDC

The nutrition priorities of the elderly (over age 75) go against the grain of mainstream nutrition messages believes Dr. Katherine Gray-Donald, Associate Professor at the School of Dietetics and Human Nutrition, McGill University in Montreal. "These people shouldn't be worrying about fat and cholesterol. Rather than tons of vegetables and fruit and skim milk, they need omelettes, milk shakes and cream soups."

"We've been able to show that for the homebound elderly declining body weight is a predictor of mortality," says Dr. Gray-Donald. "People who lose weight die sooner."

Moreover, a recent 5-year mortality study of 4300 nonsmoking men and women, aged 65 to 100 years, indicated that being overweight later in life does not pose a significant health risk.¹ Rather the risks associated with significant weight loss should be the primary concern.

Traditionally physicians have asked patients: "Have you unintentionally lost ten pounds or more in the past year?" But even intentional weight loss in an elderly person suggests nutrition problems. Because of low energy needs, it is very difficult for an elderly person to lose weight by dieting and still maintain adequate nutritional status.

By the time a 10-pound weight loss has occurred it may be too late to reverse muscle deterioration. Dr.