Rajneesh Calton, MD, FACC, Division of Cardiac Electrophysiology, University Health Network, Toronto General Hospital, Toronto, ON.
Vijay Chauhan, MD, FRCPC, Division of Cardiac Electrophysiology, University Health Network, Toronto General Hospital, Toronto, ON.
Kumaraswamy Nanthakumar, MD, FRCPC, Division of Cardiac Electrophysiology, University Health Network, Toronto General Hospital, Toronto, ON.

Atrial fibrillation (AF) is the most common sustained cardiac rhythm disturbance for which patients seek medical attention. AF has a heterogeneous clinical presentation, occurring in the presence or absence of detectable heart disease or related symptoms. Depending upon the duration and response to pharmacological and electrical cardioversion, AF can be classified as paroxysmal, persistent, or permanent. AF can be isolated or associated with other arrhythmias, often atrial flutter or atrial tachycardia. Minimum clinical evaluation of a patient with AF includes history, physical examination, and ECG documentation by at least single-lead ECG recording during the dysrhythmia. Additional investigation may include Holter monitoring, exercise testing, transesophageal echocardiography, and/or electrophysiological study.
Key words: arrhythmia, atrial fibrillation, Holter monitoring, atrial tachycardia.

Lucia Gagliese, PHD, CIHR New Investigator, School of Kinesiology and Health Sciences, York University; Department of Anesthesia, University Health Network; Department of Anesthesia and Psychiatry, University of Toronto, Toronto, ON.
Rinat Nissim, MA, PhD Candidate, Department of Psychology, York University; Doctoral Fellow, Psychosocial Oncology & Palliative Care, University Health Network, Toronto, ON.
Melissa Jovellanos, BSc, MSc Candidate, School of Kinesiology and Health Sciences, York University; Department of Anesthesia, University Health Network, Toronto, ON.
Nataly Weizblit, BSc Candidate, Department of Psychology, York University; Department of Anesthesia, University Health Network, Toronto, ON.
Wendy Ellis, RN, Clinical Research Co-ordinator, Department of Anesthesia, University Health Network, Toronto, ON.
Michelle M. Martin, PhD, Postdoctoral Fellow, Department of Anesthesia, University Health Network, Toronto, ON.
Gary Rodin, MD, Professor, Department of Psychiatry, Director, Psychosocial Oncology & Palliative Care, Joint University of Toronto/University Health Network; Harold and Shirley Lederman Chair in Psychosocial Oncology and Palliative Care, Toronto, ON.

Both older adults and minority patients are at risk of undertreatment and mismanagement of pain. Caregivers report that many older adults are in pain before death, and doctors are often less willing to prescribe strong opioids to the dying. Underutilization of narcotics with older minority populations has also been reported. The Canadian population is aging rapidly, and Canada is home to one of the most ethnically diverse cities in North America. In this context, the above findings are unacceptable. Recommendations for improvements in the health care system are made.
Key words: end-of-life care, pain management, racial disparities.

Robert D. Helme, PhD, FRACP, FFPMANZCA, Barbara Walker Centre for Pain Management, St. Vincent’s Hospital, Melbourne, Australia.

Narcotics are commonly required for the treatment of severe pain due to malignancy at all ages. In recent years, it has been recognized that they may also benefit older people with nociceptor pain that is unresponsive to other management strategies. In this circumstance, narcotic treatment should be undertaken in the full knowledge of relevant laws and potential for side effects in patients who are fully informed and involved in their treatment program. The choice of narcotic depends on the preference and experience of the clinician. It must be recognized that both benefits and side effects of narcotics occur at lower doses in older people than in younger cohorts.
Key words: aging, pain, narcotics, comorbidity, side effects.

Elsa Marziali, PhD, Professor and Schipper Chair, Gerontological Social Work Research, University of Toronto and Baycrest Centre for Geriatric Care, Toronto, ON.

An internet-based psychotherapeutic support group for family caregivers of persons with dementia was developed in a series of pilot studies and evaluated in a feasibility study with 34 participants. A user-friendly website was developed that included video conferencing in two formats: group and one-on-one. Following 10 professionally facilitated sessions, each group evolved into a web-based self-help support group. Six-month follow-up interviews showed overall positive participant responses with regard to learning to use computers, negotiating the website, providing mutual guidance and support, and improving management of caregiver burden and stress.

Key words: internet, caregiver, support groups.

Introduction
Family caregivers, largely women, provide the health and social care for dependent family members who have long-term chronic illnesses. Family caregiving can span many years depending on the stage of illness progression and the family’s resources for managing the needs of the care recipient. Caregiver stress and negative health outcomes are common. Intervention programs for family caregivers typically focus on a) support and/or educational groups; b) individual psychotherapy; c) interventions focused on the care recipient such as respite care; or d) combinations of two or more of these approaches. Most models of intervention produce small-to-moderate improvements in caregiver stress, depressive mood, subjective well-being, and coping ability.^1-3 Intervention programs are delivered face-to-face in either group or individual formats and are either clinic based or provided in the home of the caregiver or care recipient. Providing similar services using technology such as the Internet presents significant challenges.

E-Health Programs for Family Caregivers
Technology has been used in the past to enhance intervention strategies with family caregivers of persons with dementia. ComputerLink is an Internet-based support network including a public bulletin board, private e-mail, and a text-based question-and-answer forum facilitated by nurses.^4,5 The participants benefit in the short term but participation lags in the long term. REACH (Resources for Enhancing Alzheimer’s Caregiver Health),⁶ a comprehensive multisite research program, evaluated the benefits of interventions designed to enhance family caregiving for Alzheimer’s disease and related dementias. In addition to face-to-face support services, two of six participating sites used digital telephone systems to enhance the delivery of information and consultation to caregivers. The Internet was not used for service delivery in any of the REACH programs. Overall, the intervention programs showed benefits to caregivers in terms of reduced stress and higher skill acquisition.

Virtual Support Groups
Our intervention program for dementia caregivers was developed through a series of pilot studies and subsequently evaluated in a feasibility study implemented in two remote areas: Timmins, Ontario and Lethbridge, Alberta. For the pilot studies, three groups of six spousal caregivers agreed to participate with informed signed consent. The groups were facilitated by two experienced social workers, initially in face-to-face format and subsequently via Internet-based video conferencing. The overall aim of the intervention was to decrease the amount of stress experienced by the caregivers as well as enhance their knowledge and skills in managing the care of the dependent relative. The professional facilitators provided the intervention online for 10 sessions, and continual feedback was solicited from the participants regarding both the technical and clinical aspects of the program.

The pilot studies yielded several modules. The first was an easy-to-use, password-protected website with links to a) online disease-specific information handbooks and self care strategies for the caregiver; b) e-mail; c) a question-and-answer forum; and d) video conferencing for one-on-one communication or virtual group interactions. Secondly, we used an intervention training manual that included a theoretical framework and strategies for facilitating an online virtual group. Next, a computer training manual presented a simplified way of understanding the basic steps for using computer hardware and software (Figure 1).

These program modules were used to implement the feasibility study. In all, 34 caregiver-care recipient dyads were recruited (17 at each site with five to six caregivers of persons in each of three disease groups--Alzheimer’s, Parkinson’s, and stroke). With informed, signed consent the caregivers agreed to baseline and follow-up interviews as well as having the video conferencing sessions archived for subsequent analyses. Technicians at each site installed computer equipment and software in the homes of all participants and used the computer training manual to train the users. A clinician at each site was trained to facilitate the groups according to the intervention training manual. Subsequent to the 10 facilitated sessions, in each group a member assumed the facilitator role and the groups continued to meet weekly for an additional period of three months. Research assistants interviewed the caregiver participants in their homes prior to participating in the online group intervention and six months later.

Caregivers’ Responses
At six month follow up, over 90% of the caregivers reported benefiting from their participation in the virtual support group either “extremely” or “very” positively. They formed strong, mutually supportive bonds within the group and acquired new knowledge and psychosocial support that enhanced their caregiving role functions. All reported a decrease in levels of stress associated with caregiving and several reported that their participation in the group supported a decision to delay admission of their family member to institutional care.

When asked about their experiences using the website for communication, 78% indicated that it was very easy to use. When asked what they liked most about the website, some of the caregivers responded “that it was accessible,” and appreciated the opportunity to “have visual contact with other group members.”

Conclusions
Overall, the project results demonstrated that an online, video conferencing based intervention program for caregivers is feasible. The older caregivers with no prior experience with computers readily learned to manage both the hardware and software. This program is replicable because of the emphasis placed on careful development and evaluation of both the clinical intervention and the “Caring for Others” website through which it was delivered.

This project was supported by grants from CANARIE, Canada, Bell Canada University Laboratories at the University of Toronto, Canada, and the Katz Centre for Gerontological Social Work, Baycrest Centre for Geriatric Care. Renee Climans and Arlene Consky, social workers at the centre, provided clinical expertise throughout the implementation of the project.

References

1. Bourgeois MS, Schulz R, Burgio LD. Interventions for caregivers of patients with Alzheimer’s disease: a review and analysis of content, process, and outcomes. Int J Aging Hum Dev 1996;43:35-92.
2. Sörenson S, Pinquart M, Duberstein P. How effective are interventionswith caregivers? An updated meta-analysis. Gerontologist 2002;42:356-72.
3. Schulz R, O’Brien A, Czaja S, et al. Dementia caregiver research: in search of clinical significance. Gerontologist 2002;42:589-602.
4. Brennan P, Moore S, Smyth K. The effects of a special computer network on caregivers of persons with Alzheimer’s disease. Nursing Research 1995;44:166-72.
5. Payton FC, Brennan PF. How a community health information network is really used. Communications of the ACM 1999;42:85-9.
6. Schulz R, Burgio L, Burns R, et al. Resources for enhancing Alzheimer’s caregiver health (REACH): overview, site-specific outcomes, and future directions. Geronologist 2003;43:514-31.

A. Mark Clarfield, MD,FRCPC, Chief of Geriatrics, Soroka Hospital, Beer-sheva, Israel; Sidonie Hecht Professor of Geriatrics, Ben-Gurion University of the Negev, Beer-sheva, Israel; Staff Geriatrician of the Division of Geriatric Medicine, Sir Mortimer B. Davis Jewish General Hospital, McGill University, Montreal, QC.

Recent research has shown that close to 10% of the older population have at least one potentially inappropriate prescription, placing them at risk of acute hospitalization due to overdose or harmful drug interactions. The problem of polypharmacy in the aged is growing. Primary care physicians are obliged to take responsibility for coordinating the patient’s care and must be aware of various aspects of medication use such as cumulative drug exposure, chronic comorbidities, changing pharmacokinetics, and prescribing habits of consultants.

Key words: polypharmacy, older adult, adverse drug reaction, compliance.

D’Arcy Little, MD, CCFP, Lecturer, Department of Family and Community Medicine, University of Toronto, Toronto, ON.

The few studies that have been done suggest that the prevalence of allergies in the older adult population is underestimated. Geriatric rhinitis is also underdiagnosed and under-treated. Though allergy must be considered in this population, therapy must be appropriately tailored.

Key words: allergy, rhinitis, aging, adult, skin testing, treatment.

Linda Boise, PhD, MPH, Director, Education/Information Transfer Core, Layton Aging & Alzheimer Disease Research Center, Oregon Health & Science University, Portland, OR, USA.
Cathleen M Connell, PhD, Professor, Department of Health Behavior and Health Education, School of Public Health; Director, Education/Information Transfer Core, Michigan Alzheimer’s Disease Research Center, University of Michigan, Ann Arbor, MI, USA.

The high prevalence of dementia and the increased availability of treatments for Alzheimer’s disease and related dementias have increased the need to find optimal approaches to disclosing the diagnosis of dementia. In this article, relevant research is reviewed on physician practices and perspectives, and on older patients’ and family members’ preferences. Research suggests that, in general, patients and families want an accurate and clearly explained diagnosis, and that they desire guidance from the physician in understanding the course of the illness over time as well as resources that will help them to cope. Considerations in disclosing a dementia diagnosis and recommendations on how to disclose a dementia diagnosis are offered.

Key words: dementia, Alzheimer’s disease, disclosure, physicians, diagnosis.

Sohel Somani, MD, FRCSC, Clinical Instructor, Department of Ophthalmology and Vision Sciences, University of Toronto; Associate Staff, Princess Margaret Hospital, Toronto, ON.

Age-related macular degeneration (ARMD) is a progressive disease affecting the central vision of patients older than 55 years. ARMD is classified as atrophic (dry) or exudative (wet) forms based on clinical characteristics. Management of atrophic ARMD includes vitamin supplementation with high-dose antioxidants in appropriate patients. Patients who develop exudative ARMD may be eligible for treatment depending on flourescein angiogram characteristics. Options available to close a choroidal neovascular membrane include thermal laser photocoagulation or photodynamic therapy. Other treatment modalities are currently under investigation that may lead to more therapeutic options in the future.

Key words: macular degeneration, vitamins, laser, photodynamic therapy, angiogenesis.

Eric M. Morrow, MD, PhD, Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA.
William E. Falk, MD, Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA.

Anxiety in older patients, when excessive in degree and duration, can cause significant impairment and, if left untreated, may result in profound comorbidity--in particular, depression. Anxiety symptoms emerging in the older patient necessitate an extensive medical and psychosocial workup. There is a paucity of data for pharmacological treatment of anxiety disorders in older adults. In this review, we will discuss some of the research in the area of diagnosis and treatment of anxiety in older adults. We will also summarize some practice parameters common in our clinic when data are absent or lacking. The use of psychotherapies (such as cognitive behavioural therapy) and of medications such as the SSRIs, as well as benzodiazepines and other agents including the atypical antipsychotics, are discussed. The differential diagnosis of anxiety symptoms in the older patient, including careful attention to underlying medical and neurologic causes of anxiety, are emphasized.

Key words: SSRIs, benzodiazepines, psychotherapy, anxiety, depression, dementia.

JE Simon, MB, ChB, MRCP (UK), Calgary Stroke Program, Seaman Family MR Research Centre, Department of Clinical Neurosciences, University of Calgary, Calgary, AB.
MD Hill, MD, MSc, FRCPC, Director, Stroke Unit, Associate Professor, Calgary Stroke Program, Departments of Clinical Neurosciences / Medicine / Community Health Sciences, University of Calgary, Calgary, AB.

Despite the fact that stroke is both common and devastating in older patients, very little randomized controlled data is available on the efficacy or safety of thrombolysis in older age groups. We review literature from both randomized control studies and case series data treating older patients, and look at the hemorrhage rate and mortality associated with thrombolysis. In addition, we examine risk markers, other than age, for a poor outcome. We suggest that older age alone is not a contraindication to thrombolytic therapy.

Key words: ischemic stroke, tPA, thrombolysis, hemorrhage risk.