Robert W. Teasell, MD, FRCPC, Physical Medicine and Rehabilitation, Lawson Health Research Institute, University of Western Ontario, London, ON.
Jeffrey W. Jutai, PhD, Cpsych, Physical Medicine and Rehabilitation, Lawson Health Research Institute, University of Western Ontario, London, ON.

Stroke rehabilitation is best provided by a specialized interdisciplinary team, and the benefits of such a program in improving functional outcomes and reducing disability have been well established in multiple randomized controlled trials (RCTs). There is also evidence that the intensity of therapy is important. The risk of not providing stroke rehabilitation, established in one RCT, is a marked increase in death and dependency for moderate to severe stroke patients. Rehabilitation is best provided early to take advantage of post-stroke brain plasticity. Increasing age has an impact on stroke recovery, and very old patients respond better to a slower, less intensive approach to rehabilitation. Insufficient attention is often given to the importance of assistive devices.

Key words: stroke rehabilitation, interdisciplinary stroke rehabilitation unit, older adult, assistive devices.

Christopher B. Johnson, MD, FRCPC, University of Ottawa Heart Institute, Ottawa, ON.

Older patients have a high prevalence of heart valve disease and prosthetic heart valves, and are therefore at particularly high risk for endocarditis. Streptococcus viridans and Staphylococcus aureus are the most common pathogens in older patients with endocarditis. While antibiotics may cure endocarditis, surgery is required on occasion to treat complications of endocarditis such as heart failure due to valvular regurgitation, systemic and cerebral emboli, and persistent bacteremia. Endocarditis can be accurately diagnosed in aging patients using clinical, microbiological, and echocardiographic criteria. Early diagnosis and prompt institution of antibiotic therapy can result in excellent outcome among older patients with endocarditis.

Key words: endocarditis, older adults, echo, heart valve, bacteria.

David B. Hogan, MD, FACP, FRCPC, Professor and Brenda Strafford Foundation Chair in Geriatric Medicine, University of Calgary, Calgary, AB.

Dementia is a common condition that places its victims at risk for injury. This article provides an overview of home safety for those with dementia. A conceptual approach to this management challenge is the Home Safety / Injury Model described by Hurley and colleagues. I focus on two common safety concerns: wandering and falls. Unfortunately, most recommendations are based on “common sense” (i.e., what seems reasonable). Whether these approaches actually decrease the likelihood of harm is largely unknown. It is anticipated that future research will lead to evidence-based recommendations.

Key words: dementia, home safety, wandering, falls.

Isabelle J. Dionne, PhD, Faculty of Physical Activity and Sports, University of Sherbrooke; Research Centre on Aging, Geriatric Institute of Sherbrooke University, Sherbrooke, QC.
Martin Brochu, PhD, Faculty of Physical Activity and Sports, University of Sherbrooke; Research Centre on Aging, Geriatric Institute of Sherbrooke University, Sherbrooke, QC.

There is a high prevalence of obesity in older adults up to the age of 80. While women generally gain body weight during the menopausal transition, men tend to accumulate an excess of fat mass earlier in life for as yet unknown reasons. Consequently, an increasing proportion of older adults are now obese. Obesity’s association with metabolic diseases such as metabolic syndrome, type II diabetes, and cardiovascular disease is widely recognized. However, recent evidence shows that, in older adults, obesity is also related to functional impairment and decreased quality of life. This review addresses the actual prevalence and definition of obesity in older adults, the energy-balance equation, and the known consequences of obesity. Finally, the heterogeneity of obesity in older adults regarding its association with metabolic diseases and functional capacity will be discussed, as well as how obesity treatment should be conducted in this population.

Key words: obesity, metabolic syndrome, diabetes, weight loss, impaired functional capacity.

George P. Chandy, MD, MSc, Department of Medicine, University of Ottawa, Ottawa, ON.
Shawn D. Aaron, MD, MSc, Department of Medicine and the Ottawa Health ResearchInstitute, University of Ottawa, Ottawa, ON.

Chronic Obstructive Pulmonary Disease (COPD) has been increasing in prevalence over the past several decades. The impact of COPD on the health status of Canadians will continue to be a major issue, despite declining rates of smoking, as physiologic manifestations of COPD may only be evident decades after the initiation of smoking. Given the delay between the initiation of smoking and the development of significant disease, COPD is primarily a disease of the older population. While a cure for COPD is not available, a number of medications have been noted to have a significant impact on symptoms, exercise tolerance, and quality of life.

Key words: COPD, treatment, management, older adults.

David Fitchett, MD FRCP(C), St Michael’s Hospital, University of Toronto, Toronto, ON.

As a response to recent clinical trials of low-density lipoprotein (LDL) lowering, the Adult Treatment Panel III (ATP III) has proposed new thresholds and targets for treatment. In addition, the population that is considered to benefit from LDL lowering has been extended to include the diabetic and the older patient. This article reviews the clinical trial evidence, and the new recommendations, and provides commentary with special reference to management of the older person.

Key words: cardiovascular disease, LDL cholesterol, statin therapy, older patients, diabetes.

Post-Stroke Depression

Ricardo E. Jorge, MD, Department of Psychiatry, Roy J. and Lucille A. Carver College of Medicine, University of Iowa, Iowa City, IA, USA.
Robert G. Robinson, MD, Department of Psychiatry, Roy J. and Lucille A. Carver College of Medicine, University of Iowa, Iowa City, IA, USA.

In most western countries, 0.2 % of the population suffer a stroke each year. One-third of them die over the next year, one- third remain permanently disabled, and the other third make a good recovery. Depression is one of the most common emotional disorders associated with cerebrovascular disease. Longitudinal studies of stroke patients have shown that about 20% of these patients will develop major depression and another 20% will develop minor depression during the first year after stroke. Depression has also been demonstrated to significantly effect clinical recovery and mortality and, more important. Post-stroke depression responds to antidepressant treatment.

Key words: stroke, mood disorders, antidepressants, cognitive disorders, disability.

Colin P. Derdeyn, MD, Associate Professor, Mallinckrodt Institute of Radiology and the Departments of Neurology and Neurological Surgery, Washington University School of Medicine, St. Louis, MO, USA.

The brain requires the continuous delivery of oxygen and glucose for normal function. Even brief interruption or impairment of this supply can cause permanent injury, most dramatically and catastrophically in the form of stroke. There is emerging data that in addition to stroke, microvascular arterial obstructive disease may be a common cause of dementia. With normal aging, and as an effect of a number of diseases common in older adults such as hypertension, several pathological conditions of the brain vasculature may develop. This brief review will discuss a few common cerebrovascular diseases of older adults and recent data regarding their treatment. These conditions include intracranial aneurysms, atherosclerosis and atherosclerotic stenosis, and vascular dementia.

Key words: intracranial aneurysms, atherosclerosis, stroke, brain vasculature, vascular dementia.

Mitchell Sabloff, MD, Assistant Professor of Medicine, Ottawa Hospital, Ottawa, ON.

Non-Hodgkin’s lymphoma is on the rise in the older population. Traditional therapies have had limited impact upon this illness because they are compromised by toxicity and, in many cases, patients’ performance status is suboptimal at initial presentation. There has been some progress recently in addressing these issues with novel therapeutic options, permitting the delivery of more effective therapy while still limiting the toxicity.

Key words: non-Hodgkin’s lymphoma, immunotherapy, treatment, aging.

Lesley McKarney, PhD, Editorial Director, Geriatrics & Aging

The Canadian Geriatrics Society held its annual scientific meeting from May 28–30, 2004 at the Delta Chelsea Hotel in Toronto. The first day comprised a clinical and scientific conference for physicians working in the field of geriatrics, followed by a day and a half of research presentations and discussions on recruitment and training in geriatric education. The following are some highlights from day one of the meeting.

Management of Type 2 Diabetes in the Elderly
The conference opened with Dr. Bernard Zinman’s overview of the type 2 diabetes epidemic in North America and the latest Canadian Diabetes Association practice guidelines for management of the disease.

Diabetes, Zinman reminded the audience, is the fourth leading cause of death due to disease and a major cause of premature disability.
As stipulated in the Canadian Diabetes Association guidelines, the target for hemoglobin A1C levels in type 2 diabetic patients is less than seven. However, in the United States, Canada, and Europe, the majority of type 2 diabetes patients have an A1C level well above seven and thus have inadequate glycemic control. Zinman cited the United Kingdom Prospective Diabetes Study (UKPDS) as clearly demonstrating the benefits of decreased A1C levels in type 2 diabetes patients: a 1% reduction in A1C resulted in significant reductions in diabetes mellitus endpoints, death related to diabetes, and all-cause mortality among participants. The study also showed that diabetes is a progressive disease: with traditional monotherapy, the patients’ condition deteriorated over time due to continued loss of beta cell function, and after three years of therapy, patients needed more than one pharmacological agent for adequate glycemic control. A key conclusion of this extensive clinical trial, Zinman noted, was that multiple agents are likely to be required for glycemic control, and physicians need to more aggressively initiate combination therapies or administer a second drug at the diagnosis of type 2 diabetes in order to decrease the risk of complications.

According to Zinman, the old methods of managing type 2 diabetes failed to control or reduce A1C to a satisfactory level in the early stages of the disease. The new CDA recommendations focus on a diabetes treatment paradigm by A1C level, and involve diet and exercise when the A1C level is seven or lower, followed by monotherapy (A1C >8), combination oral agents (A1C >9), and insulin therapy when A1C reaches 10 or higher. Furthermore, the most recent Canadian Diabetes Association guidelines (CDA 2003) recommend that if glycemic targets are not achieved using lifestyle management within two to three months, antihyperglycemic agents should be initiated, and if a single antihyperglycemic agent is not able to achieve target A1C level, agents from other classes should be added. The aim is to reach target A1C level of less than seven within 6–12 months of treatment to reduce the risk or micro- and macro-vascular complications. The new guidelines have also upgraded thiazolidinediones from third-to second-line therapy for type 2 diabetes because of their ability to decrease plasma insulin, ambulatory blood pressure, hyperglycemia, and visceral fat, in addition to their positive effects on HDL and endothelial function.

In addition to encouraging better metabolic control, using therapeutic interventions that target pathophysiology, using additive or combination therapy earlier, and targeting lipid and blood pressure abnormalities for better management of diabetes, the CDA advocates lifestyle interventions and weight reduction/nutrition therapy for those at risk in the 40+ age group. Moreover, relatively healthy older patients with diabetes should be treated to achieve the same glycemic, blood pressure, and lipid profiles as younger patients. The
full list of recommendations can be found on the CDA website (www.diabetes.ca/cpg2003/).

Quality of Life, COPD, and the Elderly
Dr. Roger Goldstein’s presentation focussed on chronic obstructive pulmonary disease (COPD) in the older population and took the form of a question-and-answer session.

The first question related to why the symptoms of COPD appear much later in life after a long history of smoking, or even many years after an individual has quit. The most likely explanation for this, Goldstein replied, was that the lungs have a tremendous capacity to be “insulted,” and there can be a large degree of damage to the airways and lung parenchyma before symptoms occur; why symptoms appear later, he offered, is a combination of both the chronic inflammatory changes that progress and age-associated changes, such as diminished elasticity. In addition, the FEV1 declines at the rate of about 40cc per year; if a patient is a heavy smoker and is susceptible to cigarette smoke, their FEV1 is declining at an accelerated rate of 80–120cc per year, and the reduced flow of air becomes much more problematic in later life when chronic inflammatory changes become more evident.

The next question put forward by a member of the audience regarded the projected prevalence of COPD among the older population. In terms of disability-adjusted life years, Goldstein replied, the World Bank estimates that COPD will be the fifth leading cause of disability by 2020. While no firm numbers are available, people aged 65 and over account for two-thirds of those reporting COPD as their main disabling condition. COPD in Canada mirrors the global situation; however, there is an epidemic of COPD among Canadian women, according to Goldstein, which can be attributed more to the high rate of smoking in this population rather than to greater longevity. In 1999, he added, more women were diagnosed with COPD than men in Canada, and data from Health Canada suggest that between now and 2020 women will outrank men with this disease globally.

Regarding the influence of urban pollution and second-hand smoke on the development of COPD, Goldstein suggested that while the medical community in general is confident that both factors play a role in COPD, the data do not provide strong evidence for increased morbidity related to these factors. However, these factors should not be disregarded completely, he stressed.

Goldstein closed by discussing the value of pulmonary rehabilitation for COPD patients. He explained that the effectiveness of this therapy, which was previously only supported anecdotally, has been verified recently by well-controlled trials that show significant improvement in various outcomes, including increased exercise capacity, improved quality of life, increased pulmonary capacity, and fewer hospital admissions when rehabilitation is used. Pulmonary rehabilitation is now increasingly recognized as an important component of the comprehensive management of patients with COPD in the older population. The real challenge, he concluded, was to prevent the diminutive benefit over time of rehabilitation and maintain patient adherence to the program.

Prevention and Management of Stroke 2004
Dr. Frank Silver presented a talk on the management of stroke in terms of secondary prevention following transient ischemic attack. Most older adults, he reminded the audience, are less fearful of dying of stroke than of becoming disabled by the condition. Stroke is the leading cause of adult disability in North America, costing Canadian society three billion dollars annually, in addition to
the intangible costs to families and caregivers.

MRI remains a very important tool for diagnosing stroke, said Silver, but vigilance regarding secondary stroke prevention post-transient ischemic attack is crucial. Depending on underlying comorbidities, the risk of recurrent stroke within 30 days of the initial stroke event is 3–8%; within five years of the first stroke, the risk is 25–40%. Carotid endartectomy is the mainstay of secondary stroke prevention. Older patients derive greater benefit from such stroke treatment, particularly older men and when there is a high degree of stenosis. Silver also noted that the sooner that carotid endartectomy is performed (i.e., within two weeks), the better the outcome; while the surgical risk of operating is the same at seven days as compared to seven weeks, earlier surgery significantly reduces the risk of a second stroke. As a preventative measure, he emphasized the importance of referral to a specialist as soon as possible when the patient presents with symptomatic carotid disease. Regarding treatment, most patients with small vessel disease where the underlying mechanism of the stroke is not known, or who have large vessel disease, will be treated with antiplatelet therapy; warfarin should only be prescribed when there are clear cardiac sources of stroke (e.g., prosthetic valves or atrial fibrillation).

Silver is commonly asked what the optimum dose of ASA for stroke prevention is. Recent studies have shown that a lower dose of ASA (e.g., 81mg/day) prevents stroke just as effectively as larger doses. Current alternatives to ASA include dipyridamole, ASA and dipyridamole in combination, clopidogrel, and ticlopidine, although the latter is generally not prescribed for new patients because of the associated risk of bleeding. Silver drew attention to the recent results of the Management of Athrombosis with Clopidogrel in High-Risk Patients with Recent Ischemic Attack or Ischemic Stroke (MATCH) trial, presented at this year’s 13th European Stroke Conference, which demonstrated that ASA in combination with clopidogrel did not confer any advantage over clopidogrel alone in preventing recurrent ischemic events. In fact, the combination of ASA and clopidogrel significantly increased the patient’s risk of a life-threatening hemorrhage.