Sharon Watanabe, MD, FRCPC and Yoko Tarumi, MD, Tertiary Palliative Care Unit, Regional Palliative Care Program, Edmonton, AB.

Cancer pain is a significant problem in older adults. Management in this population is made more challenging by issues such as comorbid conditions and age-related alterations in drug disposition. The first step is to perform a multidimensional assessment in order to identify the various factors that may influence the perception and expression of pain. The second step is to apply a process of targeted interventions, which optimizes the use of pharmacological and non-pharmacological therapies and takes into consideration the unique characteristics of the older patient.
Key words: cancer pain, pain assessment, opioids, adjuvant analgesics.

Arthur Bookman, MD, FRCPC, Senior Staff Physician, University Health Centre, Coordinator, Core Residency Rheumatology Program, University of Toronto, Toronto, ON.

Pain in the older adult is of diagnostic significance. The pattern of distribution reflects the dermatome of the same spinal root that supplies the irritated deep structure. The timing helps differentiate inflammatory and infiltrative from mechanical pathology. Certain diseases of the musculoskeletal system are seen in the older adult. These include osteoarthritis, pseudogout, gout, spontaneous osteonecrosis of the knee and polymyalgia rheumatica. Diagnosis is key to effective treatment. Although the patients in this age group are often “boxed in” by a series of relative contraindications to treatment, with care and perseverence, it is often possible to break open the box and find an effective therapeutic regimen.
Key words: musculoskeletal pain, arthritis, diagnosis, spinal disease, older adults.

Madhuri Reddy, MD, MSc, FRCPC, Assistant Professor, University of Toronto, Sunnybrook and Women's College Hospital, Toronto, ON.

Chronic wound pain adversely affects quality of life and causes functional impairment in the older adult. As the population ages and the prevalence of chronic illness increases, an explosion in the number of chronic wounds is expected in both long-term care and community care. Chronic wounds have a myriad of causes and complications, and care can be complex. The most common types of chronic wounds include venous stasis ulcers, diabetic ulcers and pressure ulcers. There is a paucity of clinical trials of chronic wound pain management in the older patient. In the absence of an adequate evidence base, we present a comprehensive clinical approach to chronic wound pain management.
Key words: chronic wounds, pain, venous stasis, diabetes, pressure.

Feisal A. Adatia, MD, Ophthalmology Resident and Philippe L. Bedard, MD, Internal Medicine Resident, University of Toronto, Toronto, ON.

According to a 2003 CMA Physician Resource Questionnaire, one-third of Canadian physicians currently use handheld computers in clinical practice, a 73% increase over the last two years.1 Skyscape Inc., a leading provider of handheld medical programs, recently found that more than half of U.S. physicians use handheld computers.2 Surprisingly, physicians’ use of handheld computers far exceeds use by the general public. Jupiter Research forecasts that only 7% of the general U.S. public will own a handheld computer by the year 2008.3 The ability to rapidly access software that can influence decision-making at the point of care is primarily responsible for the growing popularity of handheld computers among physicians.

ePocrates Rx (www.epocrates.com), a widely used free drug database reviewed elsewhere,4 initially was released only on the Palm OS platform. This is likely responsible, in part, for the dominance of the Palm OS over the Pocket PC platform in the medical arena. This article briefly reviews seven free and simple handheld programs that may be useful for the clinician with older patients.

MedCalc
(http://medcalc.med-ia.net/desc.html)
Mathias Tschopp’s MedCalc is a medical calculator for the Palm OS which includes 76 common medical formulas. It is available in both English and French and uses both SI and regular units. It is one of the most popular medical programs available and is frequently updated. Categorized formulas can be accessed through a drop-down menu, and clinical use tips, detailed information on the full formula and bibliographic references also are provided. For example, if one clicks to the top right-hand corner of the application screen and selects “Renal” from the drop-down menu, the creatinine clearance (Cockcroft) formula may be selected. By entering the patient’s age, weight, plasma creatinine and sex, the calculator can estimate the creatinine clearance. By hitting the “i” or detailed information icon on the right, tips on when this formula is valid will be seen, as well as the full formula and its bibliographic reference.

Eponyms
(http://eponyms.net)
Andrew Yee’s medical eponyms is another popular handheld program with more than 1,460 common and obscure medical eponyms, making it a favourite tool for the curious medical historian and superstar trainee alike. Like MedCalc, it uses a drop-down menu to categorize its database. Although the descriptions of eponyms are brief and there is a paucity of bibliographic references, the database is comprehensive and easy to read.

MedRules
(http://pbrain.hypermart.net/medrules.html)
Kent Willyard’s Medrules allows for the calculation of 40 formulas using evidence-based criteria, such as deep vein thrombosis probability, pre-operative cardiovascular risk, and the electrocardiographic criteria for myocardial infarction with chest pain and pre-existing left bundle branch block. At the top right of the program there are 10 drop-down menus organized by medical subspecialty. Once a category is chosen, a number of relevant calculation options are displayed. By clicking on the desired formula, a screen with tick boxes appears with a calculation button at the bottom left. The top corner provides the reference upon which the calculation is based. However, the inclusion and exclusion criteria of the studies from which the formulas are derived are not listed.

STAT A-Fib Stroke Risk
(http://www.statcoder.com/a-fib_stroke.htm)
This program by Andre Chen is based on The Framingham Heart Study (JAMA 2003;290:1049-56). It consists of one screen with tick boxes that could be marked off, allowing for the calculation of a five-year risk of stroke and risk of stroke or death. This calculator is particularly useful when deciding if a patient should be offered long-term anticoagulation therapy instead of antiplatelet therapy. Unfortunately, the criteria of Chen, et al. does not include echocardiographic information such as left ventricular hypertrophy or ejection function. This program is one of many free programs offered by Statcoder.

ODB Limited Use Codes
(http://palmdatabases.tripod.com)
This is a database of the Ontario Drug Benefit (ODB) Plan pharmaceutical limited use codes put together by Greg Higgins. It features a searchable pharmaceutical list and uses a free reader program known as “List”. Each entry includes the limited use code number and a description of the indication under which patients may be covered by the ODB limited use plan. Greg Higgins also provides free downloadable databases of the OHIP fee schedule and the OMA Fee Schedule for uninsured services.

JournalToGo
(http://www.journaltogo.com)
This program allows users to download current peer-reviewed medical literature abstracts to their handheld computer with each hotsync operation. Users can choose from a variety of subject channels, such as Arthritis, Diabetes and Pain Management, and can obtain abstracts from selected journals on their handhelds. These abstracts can then be bookmarked and linked to the full-text article on the Internet. In addition, news content from Reuters Health can be downloaded to a handheld with JournalToGo.
GAC Clinical Practice

Guidelines
(http://gacguidelines.ca)
The Ontario Guidelines Advisory Committee reviews clinical practice guidelines (CPG) and publishes a series of CPG summaries. These brief CPG summaries are available in PDF format and can be downloaded to a handheld computer and viewed with a PDF reader, such as the free Adobe Acrobat PDF reader. These brief CPG summaries are given an overall quality rating out of 4, and recommendations are organized according to the strength of the evidence. In addition, the summaries provide the date of initial guideline review and when the guidelines are scheduled for re-appraisal. u

References

1. Shelley Martin. More than half of MDs under age 35 now using PDAs. Can Med Assoc J 2003;169:952-a.
2. Survey: Physicians using handheld computers can provide better care, though intergration with the enterprise is slow. http://www.skyscape.com/company/PressRelease.aspx?id=119.
3. Jupiter Research reports PDA penetration will only reach 7% of the overall U.S. population by 2008, yet sees opportunity for personal information management (PIM) devices. http://www.internet.com/corporate/releases/04.01.06-newjupresearch.html.
4. Feisal Adatia and Philippe L. Bedard. “Palm reading”: 2. Handheld software for physicians. Can Med Assoc J 2003;168:727-34.

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

Anu Singhal, MD, Resident, Metrohealth Medical Centre, Cleveland, OH, USA.
Ernane D. Reis, MD, Assistant Professor, Department of Surgery, The Mount Sinai Medical Center, New York, NY, USA.
Morris D. Kerstein, MD, Chief of Staff, V.A. Medical & Regional Office Center, Wilmington, Delaware; Professor of Surgery, Jefferson Medical College, Philadelphia, PA, USA.

Frequently found on the sacrum, pressure ulcers develop due to prolonged periods of unrelieved pressure on soft tissues, but can occur anywhere there is pressure, including trochanters and especially heels. In the bedridden patient, constant pressure causes ischemia and necrosis of subcutaneous tissues and skin. Most patients are elderly, immobile and have neurologic impairments, often associated with inability to sense pain and discomfort and/or incontinence. Sacral ulcers can be treated with debridement, dressings and skin grafts. However, preventive efforts—including a regular turning schedule, proper assessments, moisturizers and adequate diet—are the most cost effective and remain the foundation of management. Pressure ulcers can occur anywhere there is pressure, including trochanters and, especially, heels.

Key words: pressure ulcer, debridement, sacrum, risk factors, wound healing.

Introduction
Pressure ulcers develop under conditions of prolonged pressure and circulatory stasis, which damage the involved tissue by ischemia and necrosis.

Ekaterina Rogaeva, PhD, Assistant Professor, Department of Medicine, University of Toronto, Centre for Research in Neurodegenerative Diseases, University of Toronto, Toronto, ON.

To date, four genes responsible for Alzheimer disease (AD) have been identified. However, in about 50% of the familial AD cases, there is no known cause of the disease. The majority of AD cases are sporadic with onset after 65 years of age. The apolipoprotein E gene is the only well-replicated risk factor for late-onset AD. Up to 5% of AD cases are early-onset AD, for which genetic analyses have found three causal genes: b-amyloid precursor protein, presenilin-1 and presenilin-2. Treatment and diagnostic strategies based on genetic knowledge are now about to reach the clinic.
Key words: Alzheimer disease, presenilin, gene, bAPP, apolipoprotein E.

Introduction
Alzheimer disease (AD) is a progressive dementia and is the fourth leading cause of death in industrialized countries. AD brain pathology is characterized by neuronal loss, intra-neuronal tau-accumulation and extracellular amyloid plaques. The plaques consist mainly of Ab40/42 peptides generated by cleavage of the b-amyloid precursor protein (bAPP) (Figure 1). The longer and more neurotoxic isoforms, Ab42, appear to be elevated in the brains of individuals affected with either sporadic or familial AD, implying that they have a shared pathogenetic mechanism.

Ging-Yuek Robin Hsiung, MD, MHSc, FRCPC and Howard Feldman, MD, FRCPC, Division of Neurology, Department of Medicine, University of British Columbia, Vancouver, BC.

In the past decade, there have been numerous advances in our understanding of the molecular biology and pathogenesis of Alzheimer disease (AD). Although to date no pharmacological treatments have been shown to alter the pathology of AD, several medications have been proven to offer symptomatic improvement and to delay the progression of cognitive, behavioural and functional deficits. This article reviews the currently available medications for management of cognitive symptoms in AD, as well as other promising drugs that are under investigation.

Key words: Alzheimer disease, management, cholinesterase inhibitors, donepezil, memantine.

Introduction
An estimated 8% of the Canadian population over age 65 suffers from dementia, of which 60–70% is caused by Alzheimer disease (AD). The incidence of dementia doubles for every five years of increased age between 65 and 85 years.¹ The management of dementia is a significant burden to our health care system, with an estimated annual cost of $3.9 billion in 1991.² Epidemiologic studies suggest that if the symptoms of dementia can be delayed by just two years, prevalence will decrease by 25%, with significant savings to the long-term care of these individuals.

Bob McCormack, MD, FRCSC, Dip Sport Med, Assistant Professor, Head of Division of Arthroscopy and Athletic Injuries, Department of Orthopaedic Surgery, University of British Columbia, Vancouver, BC.

Frozen shoulder, or adhesive capsulitis, is a frustrating condition for both patients and physicians. Pain and a limited range of motion restrict upper extremity function and significantly affect the patient’s quality of life. The goal of this article is to present an organized review of the assessment and management of a frozen shoulder, so the physician can formulate a treatment algorithm. Special considerations for the older patient will be highlighted.

Key words: shoulder, stiffness, capsulitis, older people, treatment.

Introduction
Frozen shoulder is a descriptive term for a clinical syndrome whereby soft tissue contractures cause a limitation of both active and passive range of motion of the glenohumeral joint. The primary role of the shoulder is to place the hand in space; to achieve this, it is necessary to maintain shoulder mobility.

Classification
As outlined in Figure 1, frozen shoulder can be divided into primary and secondary types. The primary, or idiopathic, form is commonly referred to as adhesive capsulitis. Secondary forms are important to identify as they often require a different treatment approach.

Michihisa Jougasaki, MD, PhD, Institute for Clinical Research, National Hospital Kyushu Cardiovascular Center, Kagoshima, Japan.

Congestive heart failure (CHF) has become an increasingly important health care issue in the older population. The prevalence of cardiovascular diseases such as hypertension, coronary artery disease and valvular heart disease increase with advancing age. In addition, age-related structural and functional changes in the cardiovascular system, such as impaired ventricular diastolic relaxation, altered energy metabolism, decreased sympathetic nervous activities and increased systemic vascular resistance, predispose older people to the development of CHF. Renal function decreases in older people, and the adequacy of renal function is important in delaying progression of CHF. Renal condition should be carefully monitored to prevent adverse effects in the treatment of CHF in older patients.

Key words: heart failure, renal function, aging, heart, kidney.

Jane Oshinowo, RN(EC), BScN, PNC, Primary Health Care Nurse Practitioner, York Community Services, Staff Nurse, St. Michael’s Hospital, Toronto, ON.

Heart failure is a serious illness characterized by impaired quality of life, decreased survival and frequent hospitalization, which mainly affects older adults. As the population ages, there is concern that congestive heart failure-related costs will place an undue strain on the health care system unless more cost-effective management is implemented. Various multidisciplinary strategies researched have demonstrated improved quality of life, reduced hospitalization, a trend towards decreased mortality, and a potential for cost savings.
Key words: heart failure, quality of life, cardiac nurse, disease management, cost.