Wilbert S. Aronow, MD, Divisions of Cardiology and Geriatrics, New York Medical College, Valhalla, NY, USA.

The American College of Cardiology/American Heart Association guidelines recommend that patients with asymptomatic left ventricular systolic dysfunction or with congestive heart failure (CHF) be treated with angiotensin-converting enzyme (ACE) inhibitors plus beta-blockers unless there are contraindications to the use of these drugs. Beta-blockers have been demonstrated to significantly reduce all-cause mortality associated with abnormal or normal left ventricular ejection fraction in older and younger patients with CHF. An angiotensin receptor blocker should not be administered to patients with CHF who are being treated with a beta-blocker plus ACE inhibitor, but should be given to patients with CHF treated with beta-blockers who cannot tolerate ACE inhibitors due to cough, angioneurotic edema, rash or altered taste sensation.
Key words: congestive heart failure, left ventricular ejection fraction, beta-blockers, angiotensin-converting enzyme inhibitors, angiotensin receptors blockers.

Ali Ahmed, MD, MPH, FACP, FACC, Division of Gerontology and Geriatric Medicine, Department of Medicine, School of Medicine, Department of Epidemiology and International Health, School of Public Health and Geriatric Heart Failure Clinic, University of Alabama at Birmingham; Section of Geriatrics and Geriatric Heart Failure Clinic, VA Medical Center; and Alabama Heart Failure Project, Alabama Quality Assurance Foundation; Birmingham, AB, USA.
Phillip L. Thornton, PhD, CGP, FASCP, Department of Pharmacy Practice, Auburn University James I. Harrison School of Pharmacy and Department of Medicine, Division of Gerontology and Geriatric Medicine and Geriatric Heart Failure Clinic, University of Alabama at Birmingham; Birmingham, AB, USA.

Heart failure is common in older adults and is associated with high mortality and hospitalization rates, and is the only cardiovascular syndrome with increasing incidence and mortality. Angiotensin-converting enzyme (ACE) inhibitors and beta-blockers reduce mortality and hospitalization rates for heart failure patients with left ventricular systolic dysfunction. Unfortunately, these life-saving drugs continue to be underutilized. ACE inhibitors and beta-blockers should be prescribed to all eligible systolic heart failure patients. Generalist physicians, who care for most heart failure patients, are perfectly capable of prescribing these life-saving drugs to older adults with systolic heart failure and should be encouraged to do so.

William J. Kostuk MD, FRCPC, FACC, FACP, Professor of Medicine, University of Western Ontario; Cardiologist, University Campus London Health Sciences Centre, London, ON.

Heart failure is the most rapidly rising cardiovascular condition in Canada. At times, the clinical presentation of heart failure may not make the diagnosis obvious. The diagnosis of heart failure should be considered when an older individual presents with complaints of exertional dyspnea or fatigue. In such individuals, the physician should not assume the symptoms are merely the result of age, obesity or chest disease. Physical examination and a few simple investigations,reviewed here, can be extremely helpful and may delay or even prevent the progression to symptomatic disease.
Key words: heart failure, diagnosis, dyspnea, fatigue, evaluation in older adults.

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

"The best predictor of successful guideline implementation is the provision of guideline-based recommendations that are patient specific at the time and place of the patient consultation."¹

The need for relevant and timely information at the point of patient care is paramount in primary medicine. The routine care of patients necessitates having, at the clinician's fingertips, up to date information about the diagnosis, prognosis and treatment of many illnesses.² In fact, it is estimated that two important clinical questions are generated for every three patients seen in the office.^2,3 However, it is increasingly difficult to keep up to date; physicians who want to keep up with relevant journals in their field would need to review 19 articles per day, 365 days per year.^2,4

The development and dissemination of clinical practice guidelines (CPGs) is one attempt to consolidate and make available information that clinicians can easily use in clinical decision-making.⁵ However, many guidelines may be in a format that is not user-friendly for busy daily practice.^6,7 The purpose of this article is to review the role of Personal Digital Assistants (PDAs) in the implementation of CPGs, including a review of the available evidence for this practice.

PDAs and Evidence-Based Medicine
It is important to note that the use of PDAs does not replace any of the steps involved in practising evidence-based medicine (EBM), but it may make some of them easier. Table 1 reviews the steps devised by Straus and Sackett that are necessary to practice EBM.² PDAs have the potential to make the best evidence available at the point of care in a fast and easily digestible format,⁶ thus facilitating steps 2, 3 and 4.

Barriers to Guideline Implementation
The four-stage Pathman Model has been used to delineate the barriers that exist in guideline implementation. The steps include awareness, agreement, adoption and adherence.⁸ For a guideline to be implemented, a physician must become aware of the guideline, then intellectually agree with it, decide to adopt it in the care he provides, and finally regularly adhere to it at appropriate times.⁹ Some physicians consider clinical guidelines to be akin to "cookbook medicine". As such, they balk at the idea of using decision support tools in their practice.¹⁰ PDAs may not leverage these physicians at the agreement stage; however, PDAs may have a role in the other three steps of guideline implementation.

Evidence for the Use of PDAs for Guideline Implementation
Approximately 30% of physicians now use PDAs, a number expected to increase to 50% by 2005.¹¹ A recent systematic review of PDA use in medicine has acknowledged that despite the explosion in their use, there is a paucity of evidence-based information.¹² The available evidence is discussed here.

Sackett and Straus have shown that the availability of a mobile "evidence cart"--consisting of EBM and medical reference material stored in laptops or paper inventories--in a busy inpatient medical service increased the extent to which evidence was sought and used in patient care decisions.^13,14 However, the cart was found to be too bulky to take on bedside rounds. PDAs have the potential to serve as an optimally-mobile "evidence cart". Commonly used medical applications for PDAs include textbooks, rules and calculators, pharmacopoeias as well as scheduling and patient tracking programs. Recently, sites which have CPGs in PDA format also have become available ("A Brief Guide to Some Free Evidence-based Medicine Resources for the PDA" is available online at www.geriatricsandaging.ca).

Because many of the studies describing the use of PDAs in implementing guidelines are continuing, often only descriptive reports are available. There is, however, one randomized trail suggesting that the use of PDAs can enhance guideline implementation. A before-after trial with randomly selected pediatricians assessed the effect of the use of PDAs with respect to asthma guideline adherence.¹⁵

In the control and intervention phases, physicians collected data from 10 patient encounters for acute asthma. During the intervention phase, PDAs provided structured documentation and offered recommendations based on the asthma guidelines of the American Academy of Pediatrics. Patients were followed up by telephone in 7-14 days to assess outcomes. Nine physicians enrolled 91 patients in the control phase and 74 patients in the intervention phase.

The use of PDAs was found to increase physician guideline adherence. Specifically, there was more measurement of peak expiratory flows and oxygen saturation, as well as increased administration of nebulized B-2 agonists and inhaled corticosteroids.

Patients in the intervention group tended to have a greater immediate clinical improvement, but this was not the case with intermediate term outcomes, which were similar between the groups. There were no differences in patient outcomes with respect to emergency room visits, hospitalizations or missed days of school at seven days post-visit. This may have been a power issue, as the study was relatively small. In addition, the visits in the intervention group were found to be slightly longer and more costly.¹⁵

A prospective controlled pilot trial randomized family physicians to receive PDA software to help manage suspected angina or conventional care. The software consisted of an algorithm that converts the patient's demographics, risk factors and findings into the probability of having coronary artery disease, and hence directs the clinician to the appropriate investigations and treatment. The software was found to increase overall use of cardiac stress testing, with a trend toward more appropriate use of stress testing. The conclusion that PDA software may lead to improvement in the primary care management of suspected angina will be further examined in a larger trial.^16,17

Conclusion
Handheld devices are gaining wide acceptance among physicians. Sites are available that literally put evidence-based medicine in the hands of physicians at the point of care. PDAs are a viable way to increase physician awareness of guidelines by allowing guideline programs to be easily downloaded and searched, and to increase physician adoption of and adherence to guidelines because the required information and reminders are close at hand and usable during patient encounters.

However, the actual guidelines that are chosen for implementation must be carefully selected. For example, several of the guideline steps in the Asthma study above, such as the administration of oxygen during an asthma exacerbation, are consensus statements without qualification of the evidence or the strength of the recommendations. All guidelines, particularly those that are to be implemented on PDAs, should be rigorously assessed with respect to their scope and purpose, stakeholder involvement, rigour of development, clarity and presentation, applicability and editorial independence.^18,19 Finally, the current lack of randomized controlled evidence for guideline implementation via the PDA will likely be remedied with time, as more such studies are completed and reported.

Acknowledgements: The author wishes to thank Laure Perrier of the Knowledge Translation Program at the Faculty of Medicine, University of Toronto, for assisting in some of the literature search for this article, and Dr. Michelle Greiver for providing her abstract regarding the pilot trial of PDAs to help manage suspected angina.

References

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15. Shiffman RN, Freudigman M, Brandt CA, et al. A guideline implementation system using handheld computers for office management of asthma: effects on adherence and patient outcomes. Pediatrics 2000;105(4 Pt 1):767-73.
16. News. FP uses PDA to ease angina diagnosis. CMAJ 2001;165:1085.
17. Greiver M. Angina on the Palm. Pilot randomized controlled trial of a new PDA-based software application for the diagnosis of suspected angina in primary care. Abstract. North American Primary Care Research Group Annual Conference (NAPCRG), Banff, AB. Oct 26, 2003.
18. Lohr KN, Field MJ. A provisional instrument for assessing clinical practice guidelines. In: Field MJ, Lohr KN, editors. Guidelines for clinical practice. From development to use. Washington D.C.: National Academy Press, 1992.
19. Cluzeau F, Littlejohns P, Grimshaw J, et al. Development and application of a generic methodology to assess the quality of clinical guidelines. Int J Quality Health Care 1999;11:21-8.

Kristine N. Williams, RN, CS, FNP, PhD, University of Kansas School of Nursing, Kansas City, KS, USA.

Today's health care provider works to promote health and successful aging of the growing population of older adults. Unknowingly, younger care providers may communicate messages of dependence, incompetence and control to older adults through the use of elderspeak, a common intergenerational speech style. This article describes elderspeak, its underlying negative messages and strategies for clinicians to use in evaluating and enhancing their own interpersonal communication with older patients. Issues critical to communication with older adults are examined and the importance of communication as a therapeutic tool for health care providers is explored.
Key words: communication, provider-client relationship, elderspeak.

Daniel Tessier, MD, FRCPC, Professor, Head of Geriatric Service, Sherbrooke Geriatric University Institute, Sherbrooke University, Sherbrooke, QC.

The concept of insulin resistance is a major field of interest in the medical literature. The basic science research has significantly increased our knowledge of this phenomenon, which has become a silent killer in our society. The main factors involved in insulin resistance are obesity (mainly abdominal), lack of physical activity, loss of muscle mass and secondary diminution in insulin action followed by diabetes mellitus. The changes in lifestyle and diet observed in many older subjects increases the risk of insulin resistance and diabetes. This paper will underline the main elements for primary and secondary prevention of insulin resistance in older adults.
Key words: insulin resistance, older adults, diabetes mellitus, obesity, free fatty acid, pharmacotherapy.

Lucie Lavoie, MD, FRCP(C), Resident in Geriatrics, Faculty of Medicine, Université Laval, Quebec City, QC.
Claude Gagné, MD, Service of Lipidology, Department of Medicine, Université Laval, Quebec City, QC.

Complications of coronary artery disease are the leading causes of morbidity and mortality in older persons of both sexes. The control of risk factors may prevent, retard and reverse the evolution of atherosclerosis in older adults, as in younger persons. Thus, treatment of hypercholesterolemia should not be negated on the pretext of age. In addition to non-pharmacological approaches, pharmacological tools are available. Recently, ezetimibe, an inhibitor of intestinal cholesterol absorption, has been launched. We will discuss the usefulness and the potential place of this medication for the treatment of hypercholesterolemia in the older population.
Key words: cholesterol absorption inhibitor, ezetimibe, dyslipidemia, atherosclerosis.

Allen R. Dobbs, PhD, DriveABLE Assessment Centres Inc.; Professor Emeritus, University of Alberta, Edmonton, AB.
Jean A. Caprio Triscott, MD, CCFP, FAAFP, Geriatrics, Program Director, Care of the Elderly Program; Associate Professor, Department of Family Medicine, Department of Medicine, University of Alberta, Edmonton, AB.
Peter N. McCracken, MD, FRCPC, Professor of Medicine, University of Alberta, Edmonton, AB.

The high and increasing crash rates of older drivers is of growing concern, and the role of physicians is coming under greater scrutiny. This is because age per se is unlikely to be the cause of many older driver crashes. The more likely causes are medical conditions, and physicians are well placed to identify patients with medical conditions that may impair the ability to drive safely. Although guidelines are available, these have limitations which reduce their utility in daily practice. This review discusses these limitations and suggests different approaches that are appropriate for evaluating fitness-to-drive for medical conditions having acute episodes vs. chronic outcomes.
Key words: fitness-to-drive, driving assessment, older drivers, physician responsibilities and driving.

Demosthenes B. Panagiotakos, PhD, Department of Nutrition and Dietetics, Harokopio University, Athens, Greece.
Christos E. Pitsavo, MD, PhD, FESC, FACC, First Cardiology Clinic, School of Medicine, University of Athens, Greece.

The beneficial effect of the Mediterranean diet on human health has been advocated since the Renaissance. There are now several scientific evidences that relate this traditional dietary pattern with the incidence of coronary heart disease, various types of cancer and other diseases. However, only in the past few years have several observational and clinical studies suggested mechanisms by which this traditional diet may affect coronary risk. This review underlines the importance of the Mediterranean dietary pattern in the primary prevention of coronary heart disease.
Key words: Mediterranean diet, risk, coronary heart disease.

Cherdchai Nopmaneejumruslers, MD, Senior Clinical and Research Fellow, Division of Respirology, University of Toronto, Toronto, ON.
Charles K.N. Chan, MD, FRCPC, FCCP, FACP, Head, Division of Respirology, University Health Network, Mount Sinai Hospital, Sunnybrook & Women's College Health Sciences Centre, University of Toronto, Toronto, ON.

A diagnostic dilemma of a solitary pulmonary nodule (SPN) is a common clinical problem in the older population. Most pulmonary nodules are discovered incidentally on chest radiographs. Signs and symptoms are rarely present until the disease has become advanced and unresectable. Therefore, a timely and accurate diagnosis of the etiology of an SPN in early stage is essential to provide an excellent prognosis following surgical resection. Based on the best evidence, the algorithm presented in this article was made to provide the clinician with a clinical management pathway of the solitary lung nodule in older adults.
Key words: solitary pulmonary nodule, lung cancer, PET scan, diagnostic workup, VATS.