David J. Gladstone, BSc, MD, FRCPC; Lorne Zinman, MD, FRCPC; Jodie Burton, MD; Leanne Casaubon, MD; David Chan, MD; Neil Cashman, MD, FRCPC; Sandra E. Black, MD, FRCPC; Morris Freedman, MD, FRCPC.
From the Division of Neurology, University of Toronto, Toronto, ON.

At the Third Annual University of Toronto (U of T) Behavioural Neurology Clinic Day for residents, fellows and other trainees, presentations were given by faculty members from the U of T Department of Medicine (Divisions of Neurology and Geriatric Medicine) and the Department of Psychiatry. Highlights of this educational event are summarized herein by residents in the neurology training program.
Key words: dementia, diagnosis, fronto-temporal dementia, dementia with Lewy bodies, Creutzfeld-Jakob disease, vascular dementia.

Siobhan Ryan, MD, FRCPC, Dermatology Daycare & Wound Healing Centre, Women’s College Campus, Sunnybrook & Women’s College Health Sciences Centre, Toronto, ON.

Itch in the older patient is a common complaint, and one that must be approached in a systematic manner to determine the etiology. Deciding if the itchy older patient fits into one of two categories–itchy with a rash, versus itchy without a rash–will often help to establish the cause of the pruritus. Endogenous causes as well as exogenous causes of pruritus must be considered. Management depends on the etiology; however, regardless of the cause, control of xerosis and general skin care practices will help alleviate some of the distress of pruritus, especially in the aging population.
Key words: pruritus, itch, aging, skin assessment, scratching.

The itchy older adult represents a complex and somewhat convoluted path to diagnosis, and management may not always be that satisfying to the patient. However, there are a number of steps that can be followed in order to determine the etiology of pruritus in the older patient. A systematic approach to managing pruritus may lead to good symptomatic control, depending on the cause.

Pruritus, like pain, is a subjective and multifaceted symptom that can be affected by emotional, physiologic, environmental, cognitive and social factors, as well as comorbid illness and medications.¹ These features must be kept in mind throughout the assessment of the pruritic patient.

Gustavo A. Cardenas, MD, Carl J. Lavie, MD and Richard V. Milani, MD, Department of Cardiology, Ochsner Medical Institutions, New Orleans, LA, USA.

There is growing evidence that risk factors, which predict cardiovascular disease in younger people, are also predictive in older adults. Given the huge burden of cardiovascular disease in this latter population, older adults should not be excluded from primary or secondary prevention strategies, such as management of dyslipidemia. Low levels of high- density lipoprotein cholesterol (HDL-C) have a stronger association with cardiovascular disease than do high levels of low-density lipoprotein cholesterol (LDL-C). This article focuses on the importance of HDL-C as a risk factor for older patients, the evidence that exists supporting this association, the factors associated with low levels of HDL-C, and the mechanisms by which low HDL-C is related to an increased risk of cardiovascular diseases.
Key words: high-density lipoprotein cholesterol, aging, older adults, dyslipidemia, lipoprotein, atherosclerosis, cardiovascular disease.

Jacqueline Gardner-Nix, MBBS, PhD, MRCP(UK), Assistant Professor, Department of Anaesthesia, University of Toronto; Chronic Pain Consultant, Sunnybrook & Women’s College Health Sciences Centre; St. Michael’s Hospital Pain Clinic, Department of Anaesthesia, Toronto, ON.

Older adults pose additional challenges in pain management when noncancer pain has become chronic. Health care professionals are increasingly aware of the effect of past and current life stressors on the pain experience, and the roles of gender, genetics and culture. Reduced activity as individuals age often amplifies the disabling effects of pain. Pain medications are more problematic in this age group due to many factors, including polypharmacy, comorbidities and reduced renal function. However, judicious use of opioid analgesics in a subset of the population may allow increased function and access to activities, which become part of their pain management.
Key words: older adults, opioids, pain management, noncancer pain, holistic.

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.