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.

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.

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.