Andrea Németh, MA, Managing Editor, Geriatrics & Aging.

Introduction
Australian researchers who conducted a randomized controlled trial of a targeted multifactorial intervention to prevent falls among hospitalized older adults have found that the approach was not effective for those with relatively short hospital stays.¹ Researchers gathered falls data from 24 acute and older adult rehabilitation wards in 12 Sydney, Australia, hospitals between October 2003 and October 2006. Investigators paired wards on the basis of type (acute care or rehabilitation), fall rates, length of stay, and patient age before randomization: each ward was studied for 3 months. All patients in the ward at the time of the study were included, and data were collected on the health, medication, and physical function of each patient from their medical records. A total of 3999 patients, mean age 79 years and with a median hospital stay of 7 days, were included in the study.

Method
A part-time nurse and a part-time physiotherapist delivered select interventions during the 3-month study. The interventions used were selected from published recommendations^2-4 that could be implemented with the available resources (additional staff time and alarms) of the study. The study nurse assessed patients; provided education to patients and their families; arranged for appropriate walking aids (together with the physiotherapist), eyewear, modifications at bedside, and increased patient supervision; and worked with other staff regarding the necessity of changing medications, managing confusion, and the possibility of foot problems. The study nurse also provided education to groups of staff and individual staff members.

The study physiotherapist saw those patients who were referred by the study nurse and other ward staff. She led patients, individually or in groups, through exercises designed to enhance balance and ability with functional tasks, and practiced safe mobility with patients around the ward.

Ambulant patients assessed to be at high risk of a fall due to delirium or cognitive impairment were fitted with a custom-designed alarm in the form of a neoprene rubber sock with a pressure switch under the heel and a small loudspeaker in a pocket in the sock. The alarm emitted a loud, high-pitched tone when weight was put on the pressure switch, indicating that the patient was standing and required support.

Results
Among the 24 hospital wards (12 acute and 12 rehabilitation), 3,999 patients were studied; the average total number per ward during the 3-month study period was 167 overall, 233 (range 113-332) for the acute wards and 100 (range 56-170) for rehabilitation wards.

During the study period, 381 falls occurred, with an overall rate of falls of 9.2 per 1,000 bed days. The authors saw no difference between the rate of falls in acute care wards (9.4 per 1,000 bed days) and rehabilitation wards (9.0 falls per 1,000 bed days), nor did they find a differing rate of falls in the intervention versus control wards during the period studied. The mean fall rate in the intervention wards was 9.26 per 1,000 bed days, while the control wards saw 9.20 falls per 1000 bed days.

The intervention was also found to have no effect on the rate of injurious falls, for which the unadjusted incidence rate ratio was 1.12 (95% confidence interval 0.71 to 1.77).

The study authors posit that previous falls prevention studies^5,6 may have demonstrated a positive effect of intervention due to the relatively long length of stay in those studies (30 days and 20 days). In this study, the median length of hospital stay for patients was just 7 days. The investigators suggest that prevention interventions such as exercise require longer than a few days to take effect. They conclude that preventing falls among older adults in the hospital may require innovative approaches, including better ways to assess cognitive impairment, the use of low beds and hip protectors for preventing injury, a redesign of wards so that high-risk patients are easily seen at all times by staff, continual supervision of those patients at highest risk of falling, and a system-wide approach to falls prevention led by ward staff themselves.

References

1. Cumming RG, Sherrington C, Lord SR, et al. Cluster randomized trial of a targeted multifactorial intervention to prevent falls among older people in hospital. BMJ 2008;336:758-60.
2. Shanely C. Putting your best foot forward: preventing and managing falls in aged care facilities. Sydney: Centre for Education and Research on Ageing, 1998.
3. Lord SR, Sherrington C, Menz H. Falls in older people: risk factors and strategies for prevention. Cambridge: Cambridge University Press, 2001.
4. Australian Council for Safety and Quality in Health Care. Preventing falls and harm from falls in older people. Best practice guidelines for Australian hospitals and residential aged care facilities. Canberra: Australian Council for Safety and Quality in Health Care, 2005.
5. Haines TP, Bennell KL, Osbourne RH, et al. Effectiveness of targeted falls prevention programme in subculture hospital setting: randomized controlled trial. BMJ 2007;334:82-7.
6. Healey F, Monro A, Cockram A, et al. Using a targeted risk factor reduction to prevent falls in older in-patients: a randomized controlled trial. Age Aging 2004;33:390-5.

Christian Werner, MD, Klinik für Innere Medizin III, Kardiologie, Angiologie und Internistische Intensivmedizin, Universitätsklinikum des Saarlandes, Homburg/Saar, Germany.
Michael Böhm, MD, Klinik für Innere Medizin III, Kardiologie, Angiologie und Internistische Intensivmedizin, Universitätsklinikum des Saarlandes, Homburg/Saar, Germany.

Cardiovascular disease represents a continuum that starts with risk factors such as hypertension and progresses to atherosclerosis, target organ damage, and ultimately to heart failure or stroke. Renin-angiotensin system (RAS) blockade with angiotensin converting enzyme (ACE) inhibitors or angiotensin II type 1 receptor blockers (ARBs) has turned out to be beneficial at all stages of this continuum. Several mechanisms govern the progression of myocardial damage to end-stage chronic heart failure (CHF). Chronic neuroendocrine activation, comprising the RAS, sympathetic nervous system and the release of cytokines, leads to remodelling processes and via forward / backward failure to clinical symptoms of CHF. Therefore, combined RAS inhibition is especially effective to improve neuroendocrine blockade in CHF patients with repetitive cardiac decompensations.
Key words: angiotensin converting enzyme inhibitors, angiotensin receptor blockers, renin-angiotensin system, chronic heart failure, clinical trials.

Joan Pleuss, RD, MS, CDE, CD, Director, Bionutrion & Body Composition Units, Clinical & Translational Research Institute, Medical College of Wisconsin, Milwaukee, WI.

The requirement for some nutrients changes as adults age. The Dietary Reference Intakes, the 2007 Canada Food Guide, and the 2005 Dietary Guidelines for Americans (MyPyramid.gov) provide guidance for the consumer and the professional for nutritional needs throughout the life span. The Guidelines provide recommendations in user-friendly messages. MyPyramid.gov and the Food Guide allow the public to access information on the internet that is individualized for age, gender, and physical activity. The Dietary Reference Intakes provide the health professional with nutrition requirements for gender and specific age groupings through the entire lifespan. This article will address those nutrients whose requirements significantly change with adult aging.
Key words: Dietary Reference Intakes, Canada Food Guide, Dietary Guidelines of America, MyPyramid, aging, nutrition.

Lesley J. Ritchie, MSc, Department of Psychology, Centre on Aging, University of Victoria, Victoria, BC.
Holly Tuokko, PhD, Department of Psychology, Centre on Aging, University of Victoria, Victoria, BC.

Mild cognitive impairment (MCI) is an intermediary stage in the cognitive continuum from normal aging to dementia. Six to 48% of individuals with MCI are estimated to develop dementia.1 As such, the conceptualization and operationalization of MCI present unique opportunities for the development and implementation of strategies to prevent or delay the conversion to dementia. Despite the lack of a “gold standard” case definition for MCI, information gathered from neuropsychological assessment may inform a diagnosis of MCI based on clinical judgment, as impaired performance on several neuropsychological measures is predictive of conversion to dementia for persons exhibiting cognitive decline but who are not demented.
Key words: mild cognitive impairment, dementia, conversion, neuropsychology, predictors of dementia.

Joel S. Hurwitz, MB, FRCPC, FRCP (London), Associate Professor, Department of Medicine (Division of Geriatric Medicine), University of Western Ontario, London, ON.

This article will assist the clinician in defining and categorizing tremor, also suggesting key questions and physical examination techniques to facilitate a probable diagnosis in an older adult. The role of many drugs in the causation and exacerbation of tremor is discussed and the treatment of several specific tremor disorders is reviewed.
Key words: essential tremor, postural tremor, kinetic tremor, enhanced physiological tremor, parkinsonism.

John R. Wherrett, MD, FRCP(C), PhD, Professor Emeritus, Division of Neurology, University of Toronto; consultant in Neurology, Toronto Western Hospital and Toronto Rehabilitation Institute; member, Memory Clinic, Toronto Western Hospital, Toronto, ON.

Nonneurologist practitioners faced with the diagnosis of dementia cannot be expected to conduct the detailed assessments for which neurologists are trained. Nonetheless, they should be able to diagnose the most common forms of neurodegenerative dementia and identify individuals that require more detailed neurologic workup. A neurologic examination algorithm is described that allows the practitioner, in a stepwise and efficient manner, to elicit findings that distinguish the main categories of neurodegenerative and vascular dementia, namely, Alzheimer’s disease, dementia with Lewy bodies, vascular dementia, and frontotemporal lobar degenerations. Patients are assessed for gait, frontal signs, signs of parkinsonism, signs of focal or lateralized lesions, neuro-ophthalmologic signs, and signs characteristic of frontotemporal lobar degeneration.
Key words: neurologic, examination, neurodegenerative, dementia, diagnosis, gait, frontal dysfunction, cognitive impairment.

Svante Östling, MD, PhD, Sahlgrenska Academy at Göteborg University, Institute of Clinical Neuroscience and Physiology, Psychiatry Section, Mölndal, Sweden.

The growing proportion of older adults in the population has increased the interest in psychiatric symptoms and disorders that seriously compromise the quality of life in this age group. Psychotic symptoms are common among both demented and nondemented older adults and demand resources from the social and health care systems. There are different etiologies of these symptoms, and different possible underlying medical contributing illnessess, concomitant medications, dementia, delirium, and psychiatric comorbidities should be identified before a specific antipsychotic treatment is considered.
Key words: psychosis, hallucinations, delusions, paranoid older adults.

Sonal Singh, MD, Department of Medicine, Wake Forest University School of Medicine, Winston-Salem, NC, USA.
Yoon K. Loke, MBBS, MD, University of East Anglia, School of Medicine, Health Policy and Practice, Norwich, UK.

Cardiovascular disease is the leading cause of mortality among older adults with type II diabetes. The thiazolidinediones (rosiglitazone and pioglitazone) lower blood sugar levels among individuals with type II diabetes. The thiazolidinediones have favourable effects on surrogate markers of cardiovascular disease such as microalbuminuria, carotid intimal thickness, and blood pressure. Emerging evidence from recent randomized clinical trials has confirmed both that thiazolidinediones increase the risk of heart failure, and that rosiglitazone increases the risk of myocardial infarction among those with type II diabetes. Clinicians should avoid thiazolidinediones for older individuals with type II diabetes who are at risk for cardiovascular events as the negative cardiovascular effects of the thiazolidinediones outweigh any potential benefits on surrogate markers.
Key words: thiazolidinediones, pioglitazone, rosiglitazone, heart failure, myocardial infarctions.

Mario Masellis, MSc, MD, FRCPC, Clinical Associate & Research Fellow, L.C. Campbell Cognitive Neurology Research Unit, Division of Neurology, Department of Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON.
Sandra E. Black, MD, FRCPC, Brill Professor of Neurology, L.C. Campbell Cognitive Neurology Research Unit, Division of Neurology, Department of Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON.

Cognitive impairment occurs along a continuum from mild subjective memory complaints occurring during the normal aging process to severe memory and other cognitive deficits due to dementia, the most common subtype being mixed Alzheimer’s disease and vascular dementia. Due to the significant growth of the older adult population, the incidence of dementia is on the rise and is posing significant challenges for health care systems worldwide. Primary care practitioners are on the front lines of this battle against dementia and will play an increasingly important role in the early identification of disease. Cognitive screening tests are helpful in detecting people in the early stages of dementia and facilitate further clinical and diagnostic evaluations. Primary care practitioners should aggressively treat known cardiovascular risk factors for dementia and institute early symptomatic therapy when appropriate.
Key words: dementia, cognitive screening test, cognitive reserve, neuroimaging, biomarkers.

Nicholas J. Giacomini, BS, Research Assistant, University of California, San Francisco, School of Nursing, Department of Community Health Systems, San Francisco, CA, USA.
Roberta K. Oka, RN, ANP, DNSc, Associate Professor, University of California, San Francisco, School of Nursing, Department of Community Health Systems, San Francisco, CA, USA.

Peripheral arterial disease (PAD) is a common but frequently undetected and undertreated condition among older adults. Untreated PAD and cardiovascular disease (CVD) risk factors results in functional impairment, poor quality of life and increased risk for cardiovascular disease morbidity and mortality. The increased risk for CVD events associated with PAD necessitates raising public awareness of PAD and the potential impact on health, and placing greater emphasis by providers on detection and management of PAD to maximize survival and life quality. This article briefly describes the detection and medical management of PAD, with greater emphasis on lifestyle modification among older adults with PAD.
Key words: vascular disease, cardiovascular disease, risk factor reduction, lifestyle modification.