Serge Gauthier, MD, FRCPC, McGill Centre for Studies in Aging, Montréal, QC.

Functional disability is an important component of Alzheimer’s disease. A number of scales are available to measure activities of daily living (ADL) throughout the course of disease, including instrumental as well as self-care activities. A randomized clinical study comparing donepezil to a placebo in moderate-to-severe stages of AD showed a stabilization of ADL decline over six months for patients on donepezil. Less time for ADL care was required by caregivers of patients on donepezil compared to those on placebos.

Key words: Alzheimer, therapy, activities of daily living, donepezil, caregiving time

Introduction
The importance of decline in activities of daily living (ADL) in older adults with dementia has been recognized in the condition’s diagnostic criteria, described as “significant impairment in social or occupational functioning” in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV).

Scott R.A. Walsh PhD, MD, Division of Dermatology, Department of Medicine, Sunnybrook & Women’s College Health Sciences Centre, University of Toronto Medical School, Toronto, Ontario.

Dermatitis herpetiformis (DH) is a pruritic and chronic autoimmune blistering skin disease associated with varying degrees of gluten-induced enteropathy. Associated symptomatic celiac disease (CD) occurs in a minority of patients, but the pathogenesis of both diseases shares several features. In addition to some features of enteropathy, patients with DH also form specific antibodies to epidermal transglutaminase not typically found in patients with only CD. Although incidence is highest in middle age, because it is a life-long condition its prevalence is highest in the older population. Chronic complications of DH, including gastrointestinal lymphomas, are more likely to present in the geriatric group. Similarly, common comorbid disease associations including pernicious anemia, splenic atrophy and thyroid disease should be routinely assessed in this population. Long-term treatment of DH requires strict adherence to a gluten-free diet. Symptomatic treatment of this skin disease commonly uses dapsone to inhibit neutrophil accumulation and disease expression. Older patients may be more susceptible to toxic side effects of dapsone metabolites, and both careful patient selection and close monitoring should be undertaken with dapsone treatment.

Key words: dermatitis herpetiformis, autoimmunity, anemia, comorbidities, dapsone.

G.A.E. Wong, MBChB, MRCP(UK), and N.H. Shear, MD, FRCP(C), Divisions of Dermatology and Clinical Pharmacology, Sunnybrook & Women’s College Health Sciences Centre, University of Toronto, Toronto, ON.

Cutaneous adverse drug reactions are a common problem affecting ambulatory and hospitalized patients. Older patients may be predisposed to adverse drug reactions due to inappropriate medication prescription, age-associated changes in pharmacokinetics and pharmacodynamics, altered homeostatic mechanisms, multiple medical pathologies, and use of drugs with a narrow therapeutic margin. In this second of two articles, the management of cutaneous adverse drug reactions
is reviewed.

Key words: adverse drug reaction, skin, cutaneous, rash, drug eruption, treatment, management.

Michelle A. Ghert, MD, Clinical Fellow in Musculoskeletal Oncology, University of Toronto, ON, Mount Sinai Hospital, Toronto, ON. and Peter C. Ferguson, MD, MSc, FRCSC, Assistant Professor of Surgery, University of Toronto, Division of Orthopaedic Surgery, Mount Sinai Hospital, Department of Surgical Oncology, Princess Margaret
Hospital, Toronto, ON.

Primary bone and soft tissue tumours are rare in the general population. While bone malignancies in the geriatric age group are most often due to metastases or multiple myeloma, primary tumours can occur. These are treated with surgical resection and occasionally chemotherapy. Soft tissue sarcomas are more common and are usually treated with a combination of radiation and surgery. The outcome of treatment for bone sarcomas is poorer in the geriatric age group, but this is not true of soft tissue sarcomas. Patients with both primary bone and soft tissue malignancies should be referred to regional cancer centres for management.

Key words: sarcoma, surgery, radiotherapy, chemotherapy, cancer

Introduction
Musculoskeletal complaints are common in the geriatric population, but rarely are these complaints attributable to malignancies.

Sue O’Hara, RN, MScN, ACNP, GNC(C), Nurse Practitioner/Clinical Nurse Specialist, Specialized Geriatric Services, St. Josephs Health Care London, Parkwood Hospital, London, ON.; Michael J. Borrie, BSc, MB, ChB, FRCPC, Professor, Department of Medicine, Division of Geriatric Medicine, The University of Western Ontario, London, ON.

Urinary incontinence is a significant problem in older women. Prevalence rates vary from 4.5–44% in healthy older women and increase to 22–90% in patients in long-term care facilities. Canadian Continence Guidelines have recently been developed to assist patients and health care professionals in assessment, treatment and follow-up of urinary incontinence. Urinary incontinence can be treated successfully, improved or better managed in most patients. Treatment falls into four major categories: behavioural, pharmacologic, surgical and supportive measures. Education, the key to effectively addressing the needs of women with incontinence, is aimed at the patient and/or their caregiver, as well as health care professionals.
Key words: urinary incontinence, older women, assessment, treatment, Canadian Continence Guidelines.

The accredited CME learning activity based on this article is offered under the auspices of the CE department of the University of Toronto. Participating physicians are entitled to one (1) MAINPRO-M1 credit by completing this program, found online at www.geriatricsandaging.ca/cme.htm

Lianne Tile MD, FRCPC, M Ed, Staff Physician, Osteoporosis
Program and Division of General Internal Medicine, University Health Network, Toronto, ON

Osteoporosis and fractures are a common cause of morbidity in postmenopausal women. Women age 65 and older, and those with risk factors for bone loss, should be screened by DEXA. When osteoporosis is diagnosed, secondary causes need to be considered. Fracture risk is determined by bone mineral density, age, prior fracture, and family history of osteoporosis. Adequate calcium and vitamin D intake and regular exercise are essential for the prevention and treatment of osteoporosis. Pharmacologic therapy should be used based on fracture risk. Patient preferences and side effect profile must be considered in choosing among several effective treatment options.
Key words: osteoporosis, treatment, postmenopausal, diagnosis, guidelines

Definition and Epidemiology
Osteoporosis is a skeletal disorder characterized by compromised bone strength predisposing to an increased risk of fracture.

Wilbert S. Aronow, MD, Department of Medicine, Divisions of Cardiology and Geriatrics, Westchester Medical Center/New York Medical College, Valhalla, NY; Clinical Professor of Medicine and Chief, Cardiology Clinic, Westchester Medical Center/New York Medical College, and Adjunct Professor of Geriatrics and Adult Development, Mount Sinai School of Medicine.

In older women, ischemic heart disease (IHD) is diagnosed if there is coronary angiographic evidence of significant IHD, a documented myocardial infarction, a typical history of angina with myocardial ischemia diagnosed by stress testing, or sudden cardiac death. Clinical manifestations of acute myocardial infarction in older women include dyspnea (the most common presenting symptom), chest pain, neurological symptoms and gastrointestinal symptoms. The prognosis of Q-wave myocardial infarction is not significantly different if the myocardial infarction is clinically recognized or unrecognized. IHD should be treated with intensive risk factor modification, antiplatelet therapy, beta-blockers and angiotensin-converting enzyme inhibitors.

Key words: ischemic heart disease, myocardial infarction, antiplatelet drugs, beta-blockers, angiotensin-converting enzyme inhibitors.

The most common cause of death in older women is ischemic heart disease (IHD). The prevalence of IHD is similar in older women compared to older men.¹ In one study of 2,464 women with an average age of 81 years, the prevalence of IHD was 41%.

Anne-Chantal Braud, Institut Paoli Calmettes, Marseille, France,
Martine Extermann, MD, H. Lee Moffitt Cancer Center and Research Institute and the University of South Florida, Tampa, FL,USA.

Half of breast cancers occur in patients older than 65 and 25% in patients aged 75 or older. Prevention and early diagnosis are a societal but also an individual issue in this population. Good guidelines for screening and prevention are available for patients up to 70, but few data are available for older patients. The present article reviews these data in an effort to provide some guidance to geriatricians and primary physicians about screening and prevention of breast cancer in their older patients. Age alone should not be used to determine when to screen; rather, life expectancy estimates can help decision-making. Patients with a life expectancy of 10 years or more are likely to benefit from mammography screening. Very few data are available for tamoxifen prevention in women older than 70. There is a need for further randomized controlled trials to clarify a host of outstanding issues in improving the prevention and the care of breast cancer in older people.
Key words: older women, breast cancer, mammography, prevention.

Alex Mihailidis, PhD, PEng; Tracy Lee, MASc, Intelligent Assistive Technology and Systems Lab, Department of Occupational Therapy, University of Toronto, Toronto, ON.

Introduction
It is estimated that one in three older adults will experience a fall over a one-year span, with one-third of these falls occurring in the home.¹ Providing immediate response and care when a fall occurs is a key concern and is becoming increasingly difficult to convey as more older adults choose to remain in their own homes, often alone. Situations involving the person left lying on the floor after a fall for an extended period of time before receiving assistance have been reported. This often drastically reduces their probability of recovery, and survival.²

Worn fall detectors (e.g., Tunstall Group Ltd., www.tunstall.co.uk) and emergency response systems (ERS) (e.g., Lifeline Systems Inc., www.lifelinesys.com) are some examples of currently available commercial technologies that attempt to address the problem of fall detection in the older population. Worn fall detectors, mechanical sensors that are worn on the hip, are triggered when both the orientation and acceleration forces of the person reach a pre-set threshold. A common form of ERS is a telephone-based personal system consisting of the person wearing a small help button as a necklace or wristband, which the person pushes manually when an accident has occurred. A two-way telephone system connects the user to emergency services. A primary limitation of these devices is that they require effort from the user in order to be effective. For example, the user must remember to wear the device, which may become less reliable as people age and/or develop cognitive impairments. Furthermore, if a fall causing serious injury occurs, the user may be incapable of pushing the button, thus rendering the device ineffective.

To overcome some of the difficulties associated with aging-in-place and with currently available devices, we have been developing an intelligent home environment that can monitor and assist older adults during activities of daily living. As part of this work, we are developing an intelligent ERS that can automatically and confidently detect if an emergency situation has occurred, such as the person becoming ill or falling, and that subsequently calls for appropriate assistance. Here we focus on the fall detection component of this system.

Fall Detection System
Currently, the fall detection component of this new ERS uses computer vision consisting of a ceiling-mounted digital camera to locate and track the occupant when he or she enters the room. Using simple background subtraction algorithms³ combined with a connective-component labelling technique,⁴ the image is processed and the shape of the person is determined and extracted as a silhouette. Various features and geometric properties of this silhouette are then calculated by the system, which are used to characterize the person’s posture—i.e., depending on whether the person is standing, sitting or lying down, the silhouette will adopt different shapes and sizes. Once these data have been determined the collected images are then discarded by the system, thus preserving privacy. Combining information on the change in properties such as the area or perimeter of the silhouette with reduced motion of the person, and then comparing these values with pre-set thresholds, the sensing agent is able to detect a fall. Once a fall has been detected, the system prompts the user to check if he or she is okay. It uses voice recognition software to “listen” for the user’s response, or lack thereof, upon which it decides the appropriate actions/responses to execute. For example, if the person has fallen and does not respond, the system will automatically contact the closest emergency facility. However, if the person responds that he or she is fine, no action is necessary and the system learns that that incident was a false alarm.

Initial pilot studies conducted with the system have shown that it can reliably detect falls with an 85% accuracy rate based on a sample of 100 varied actions and postures. However, it should be noted that these preliminary results were obtained in ideal conditions and are constrained to the limitations of the system, which will be further discussed.

Future Work and Implicationsto the Health Care Community
Although the current system has shown promising results, there are issues that need to be considered. For example, the shape parameters identified to characterize a fall are user-dependent (specifically on the height of the user) and may be affected if the person uses assistive devices such as a walker. The system also is currently constrained to track a single person. If another person or a large pet were introduced to the environment, the system may be confused and sound a false alarm.

Future work will focus on addressing these and other limitations, as well as expanding the current system to include other required features of the ERS. For example, new algorithms will be developed to improve the intelligence of the system so that it can intrinsically recognize areas of acceptable inactivity (e.g., the bed or sofa) and eventually learn the living patterns of the person. Learning such patterns and detecting deviations may be used by the system to indicate the onset of health problems.

Work to date has provided some evidence that using intelligent computer systems to ensure the safety of seniors in their homes and to monitor their daily activities offers both a practical and feasible solution. Environments and homes that can intelligently aid in caregiving could play a very significant role in enhancing aging-in-place and thus help to reduce the burden of care on the health care industry.

References

1. Johnson M, Cusick A, Chang S. Home-Screen: A short scale to measure fall risk in the home. Public Health Nursing 2001;18:169-77.
2. Tinetti ME, Liu W, Claus EB. Predictors and prognosis of inability to get up after falls among elderly persons. JAMA 1993;269:65.
3. Wren C, Azarbayejani A, Darrell T, et al. Pfinder: Real-time tracking of the human body. IEEE transactions on pattern analysis and machine intelligence. 1997;19:780-5.
4. Ronse C, Denijver PA. Connected components in binary images: the detection problem. Hertfordshire, England: Research Studies Press, 1984.

Pippa Hall, MD, CCFP, MEd, FCFP, Assistant Professor, Department of Family Medicine, Program Director, Palliative Medicine Residency Program, University of Ottawa, SCO Health Service, Ottawa, ON.

Dyspnea is experienced by patients with advanced lung and heart disease and cancer. When conventional therapy has been optimized, dyspnea can be managed in a systematic, evidence-based approach, involving an inter-professional team. The patient and family contribute to optimal care plan development. Non-pharmacological approaches are important. Compressed air, oxygen and steroids may be helpful. Strong evidence supports the use of opioids, while some evidence supports the use of neuroleptics and anxiolytics. Escalating distress in the last hours of life may necessitate interventions that improve dyspnea control at the price of deeper sedation. If upper airway congestion develops, anticholinergics are recommended.
Key words: dyspnea, terminal care, refractory symptom, palliation.

Introduction
Dyspnea, defined as a subjective sense of shortness of breath or uncomfortable breathing, is a common symptom in patients with advanced lung and heart disease, as well as in patients with cancer.^1,2 Dyspnea has been reported to be as distressing a symptom as pain, with patients often feeling they are about to die from suffocation or choking.