Amish Parikh, MD and I. George Fantus, MD, FRCPC, Division of Endocrinology and Metabolism, Department of Medicine, University of Toronto, Toronto, ON.

Microvascular complications of both Type 1 and Type 2 diabetes mellitus (DM) can be classified into three major categories: retinopathy, nephropathy and neuropathy. Numerous studies have consistently shown that the development of complications in both Type 1 and Type 2 diabetes is related to several factors. The most important ones, however, include glycemic control (as measured by hemoglobin A1c) and the duration of diabetes. This article reviews the details of screening and management of diabetic microvascular complications in older adults. It incorporates guidelines from both the Canadian and American Diabetes Associations, as well as reviews of recently published literature.
Key words: diabetes mellitus, retinopathy, nephropathy, neuropathy, screening, management.

Ellie Chuang, MD and Mark E. Molitch, MD, Division of Endocrinology, Metabolism and Molecular Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.

The worldwide prevalence of diabetes is expected to double to 300 million people by 2025, and nearly 40% of those currently diabetic are older than 65 years. In those who are at high risk for diabetes, including older adults, intervention with diet and exercise has been shown to markedly reduce the development of diabetes. Medications such as metformin, acarbose, troglitazone, pravastatin, ramipril, losartan and estrogen/progestin also have been shown to be effective, although benefits in older patients have not always been demonstrated. Implementation of lifestyle changes in people of all ages could dramatically reduce the size of the developing diabetes epidemic.
Key words: diabetes, primary prevention, impaired glucose tolerance, impaired fasting glucose, older adults.

Stuart Ross, MB, ChB, FRACP, FRCP(C), Clinical Professor of Medicine, University of Calgary, Calgary, AB.

With glucose targets becoming more stringent, there is a growing need for insulin therapy. The prevalence of diabetes is rising and many of these new diabetic patients will be older and will require insulin as part of their management. When commencing the older patient on insulin, the advantages and concerns of treatment need to be reviewed. Aspects such as physical, mental and visual problems must be carefully assessed; practical and safe glucose targets must be established based on the individual patient's needs and capabilities. Insulin can initially be commenced at nighttime and slowly increased to reach safe morning glucose targets and, if required, fast-acting analog insulins can be added during the day. Complex insulin regimens should be avoided unless essential.
Key words: insulin, analog insulin, glucose targets, hypoglycemia.

Ophthalmologists in Dallas, TX. are among the first to try a new, less invasive surgical technique for glaucoma that offers quicker recovery times.

The recently approved shunt, no larger than a grain of rice, is surgically implanted in the eye to allow an escape route for the pressure-causing fluid, thereby reducing intraocular pressure.

Its tiny size requires an incision 2-4 mm long, about half the size necessary to accommodate other shunts. Thus, surgery is less invasive and causes less scar tissue, and postoperative inflammation is minimal. The ophthalmologists also have observed an average 40% reduction in intraocular pressure, and that patients experience shorter healing times.

Heart Patient's Underwear Phones 911
An invention developed by a Dutch electronics company may one day improve the assessment of patients with arrhythmias and perhaps even improve their chances of survival in the event of a myocardial infarction. Sensors that measure body signals, such as heart rate, have been developed that can be sewn straight into clothing and even laundered. The sensors are connected to a thin chip module that monitors these body signals, storing up to three months of data.

The inventors hope the module will help physicians assess cardiac abnormalities. Furthermore, should the patient have a myocardial infarction, the system can trigger local alarms or even wirelessly link with a mobile phone to contact emergency services.

Sonar Canes Guide Visually Impaired
Bats' use of echolocation to hunt for food has inspired a British zoologist to develop a sonar cane for the visually impaired. The lightweight cane emits 60,000 sound pulses per second, undetectable to the human ear, and picks up reflections of these waves to map obstacles up to three meters away in three dimensions. Four gently pulsating pads on the walking stick's handle allow visually impaired people to feel the strength of the ultrasound reflections, thereby assisting them in navigation.

The sonar cane has thus far received positive feedback from the 25 visually impaired people in whom it has been tested, and it required just 30 minutes of training. The cane is expected to be made commercially available at the end of this year and to cost £400, or approximately $880 CAD.

Optimal Stroke Treatment May "REACH" Rural Residents

Due to the scarcity of neurologists in the more remote areas of the country, patients who have an acute stroke often may not receive thrombolytic tissue-type plasminogen activator (tPA), which must be administered within three hours of stroke onset to derive a benefit. The development of REACH, a remote video evaluation tool, may aid in precise and timely treatment for those who live in rural areas in the event of an acute stroke by means of teleconsultation.

The tool consists of a video camera, a PC workstation and monitor, and an ethernet connection, all assembled onto a mobile cart, and is a key component of the Remote Evaluation in Acute Ischemic Stroke (REACH) system developed by specialists at the Medical College of Georgia's Department of Neurology, GA. The consulting physician uses a custom-designed Web application that allows him to view the patient via the video camera, review lab data and CT scan results, and monitor a clock indicating how much time remains before the critical decision of tPA administration must be made. The program also calculates the proper dosage of tPA based on the patient's weight.

To evaluate REACH's precision and timeliness, neurologists from the Medical College of Georgia performed bedside evaluations of 20 patients with acute stroke symptoms. Within one hour, a second neurologist performed a remote evaluation with the REACH tool. They discovered that bedside and remote evaluations did not differ by more than three points on the National Institutes of Health Stroke Scale, and 6.43 minutes and 9.11 minutes were required for each, respectively.

Although the remote evaluation tool has been installed in only five hospitals in rural Georgia, its widespread use my help ease the burden currently assumed by physicians working in rural hospital emergency rooms.

Canada Provides Information Bridge to East African Physicians

Physicians in East African countries now have access to thousands of online medical publications due to the efforts of a Toronto-based surgeon. The unique project with the University of Toronto, called Ptolemy after the ancient ruler Alexandria who aspired to collect a library of the worlds' literature, allows the African physicians to access up to date medical literature from over 20,000 journals.

Those physicians in East Africa who are using Ptolemy have thus far spoken highly of the project, and 60% report that information they have received through the program has changed the way they practice medicine.

Joseph H. Friedman, MD, Professor, Clinical Neurosciences, Brown University School of Medicine; Chief, Neurology; Director, Parkinson's Disease and Movement Disorders Center, Memorial Hospital of Rhode Island, Pawtucket, RI, USA.

Drug-induced parkinsonism, an often overlooked condition, is frequently an iatrogenic result of antipsychotic medications, particularly in older adults. Spontaneous features of parkinsonism are common in the community-dwelling older adult as well as in patients with the common dementing illnesses. Parkinsonism is associated with increased mortality and morbidity, and a greater need for support services. This article reviews current knowledge of parkinsonism and stresses the need for diligence. The newer antipsychotics, while reducing the incidence of tardive dyskinesia, are not all completely free of inducing extrapyramidal side effects, with parkinsonism being the most common.
Key words: drug-induced parkinsonism, atypical antipsychotics, extrapyramidal syndromes.

3 Supplementation For Primary Prevention of Fractures
A Review of the Literature

Ryan Foster, MD, Department of Medicine, University of Toronto, Toronto, ON.

Matthew T. Oughton, MD, Department of Medicine, McGill University, Montreal, PQ.

Shabbir M.H. Alibhai, MD, MSc, FRCP(C), Staff Physician, Department of Medicine, University Health Network, Toronto, ON.

Fractures are a significant cause of morbidity and mortality in older adults. Previous studies indicated that fracture prevention with vitamin D supplementation, with or without calcium, was achievable only in limited populations. The most recent trial in this field, a randomized, placebo-controlled study by Trivedi, et al., found that large vitamin D doses given every four months are effective for primary prevention of fractures in the community-based older population. This study is critically reviewed in the context of previous studies, and recommendations are made about the role of calcium and vitamin D supplementation in fracture prevention.
Key words: osteoporosis, fracture prevention, vitamin D, calcium, supplementation.

Osman O. Al-Radi, MBBS, Division of Cardiac Surgery, University of Toronto, Toronto, ON.

Mitral regurgitation is a frequent complication of coronary artery disease (CAD), and it also frequently co-exists with CAD. The surgical management of mitral regurgitation is dependent on its clinical presentation as well as the pathophysiology of regurgitation. A brief discussion of the pathophysiology of mitral regurgitation and a modified version of the Carpentier classification are presented.
Key words: mitral regurgitation, echocardiography, Carpentier classification.

Rola Moghabghab, RN, MN,¹ Lori Adler, RN, MHSc,² Carol Banez, RN, MAN,¹ Faith Boutcher RN, MSc,³ Athina Perivolaris, RN, MN,³ Donna-Michelle Rancoeur, RN, MSc(A),³ Donna Spevakow, RN, MSN,³ Sandra Tully, RN, MAEd,¹ Susan Wallace, RN, MSc³ and Kevin Woo, RN, MSc.<sup>4

1</sup>Advanced Practice Nurse, University Health Network; ²Administrative Director, Regional Geriatric Program, Toronto Rehabilitation Institute; ³Advanced Practice Nurse, Toronto Rehabilitation Institute; ⁴Advanced Practice Nurse, Mount Sinai Hospital; Toronto, ON.

Confusion related to dementia, delirium and/or depression is a common concern in the older adult. The Registered Nurses Association of Ontario Best Practice Guideline (BPG),"Screening for Delirium, Dementia and Depression in the Older Adult", was implemented as a pilot project by Advanced Practice Nurses on eight different units at Toronto Rehabilitation Institute, University Health Network and Mount Sinai Hospital. This article describes the development of the BPG and its implementation, including the design of an education program and a screening process to assist nurses. Discussion focuses on the facilitators and barriers to BPG implementation and effecting sustainable change in practice.

Lars S. Rasmussen, MD, PhD, Department of Anaesthesia, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark.

Postoperative Cognitive Dysfunction (POCD) is a decline in cognitive function detected days or weeks after surgery. It is usually subtle and lasts for weeks or months. The impairment must be evidenced by neuropsychological testing that is, unfortunately, associated with many problems related to its administration, statistical analysis and the interpretation of the test results. Risk factors for POCD are increasing age and type of surgery, with a very high risk after cardiac surgery (incidence 30-70% one week after surgery) and a low risk after minor, non-cardiac procedures, especially if performed on an outpatient basis.
Key words: cognitive function, postoperative, anesthesia, neuropsychological testing.

Yoanna Skrobik, MD, FRCP(C), Director, Adult Critical Care Training Program, Université de Montreal; Associate Professor, Faculty of Medicine, Université de Montreal, Montreal, QC.

Delirium is a morbid and common complication in the critically ill patient. Its recognition is made more difficult by the inability to interview the intubated patient, and by the presence of drugs and confounding comorbidities. Delirium screening (described with the ICDSC and the CAM-ICU) with tools specifically designed for the acute care setting can help the nurse or clinician identify its presence. Risk factors for delirium in the critical care setting differ from those described in other populations. Treatment is currently empiric.
Key words: delirium, critical care, outcomes, intensive care, screening.