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.

Jane McCusker, MD, DrPH, Professor, Epidemiology and Biostatistics, McGill University; Head, Clinical Epidemiology and Community Studies, St. Mary's Hospital, Montreal, QC.

Nine published studies of the outcomes of delirium with at least six months of follow-up were reviewed. The results indicate that: 1) the symptoms of delirium are more persistent than previously thought; up to 15% of those without dementia and 49% of those with dementia continued to have core symptoms of delirium 12 months after the initial diagnosis; 2) a diagnosis of delirium is an independent predictor of increased mortality for up to three years after diagnosis and; 3) a diagnosis of delirium predicts continued poorer cognitive and physical functioning for up to 12 months after diagnosis.
Key words: delirium, prognosis, dementia, functioning, cognitive status.

James L. Rudolph, MD, SM, Division of Aging, Brigham and Women's Hospital and the Boston VA Geriatric Research, Education, and Clinical Center, Boston, MA.

Edward R. Marcantonio, MD, SM, Hebrew Rehabilitation Center for Aged and Beth Israel Deaconess Medical Center, Boston, MA.

Delirium is a common syndrome in hospitalized older patients that is frequently undiagnosed by health care professionals. This is particularly troubling because delirium is associated with poor outcomes such as increased nursing home placement, nosocomial infections and increased mortality. Criteria for the diagnosis of delirium are validated, reliable and can readily be applied to patients by health care professionals. Solid evidence exists that delirium can be prevented with educated prescribing of medications, practical in-hospital interventions and geriatric consultation.
Key words: delirium, differential diagnosis, prevention, Confusion Assessment Method.

Richard Long, MD, Professor, Department of Medicine, University of Alberta, Edmonton, AB; Chairman, Tuberculosis Committee, Canadian Thoracic Society.

The incidence of tuberculosis increases with age in Canadians. The prevalence of latent tuberculosis infection (LTBI) may also increase with age in Canadians, though information on the age distribution of LTBI is less precise. Chronic inflammatory conditions that currently constitute the major indications for new biologic therapies (tumour necrosis factor inhibitors), such as Crohn's disease and rheumatoid arthritis, often have an older age onset. Biologic therapies have the potential to cause LTBI to progress to active tuberculosis disease. Their use in older Canadians or other populations that may have a higher than average prevalence of LTBI poses a challenge to tuberculosis control.
Key words: tuberculosis, tumour necrosis factor inhibitors, age, rheumatoid arthritis, Crohn's disease.

Philippe L. Bedard, MD, and Feisal A. Adatia, MD, MSc, First Year Ophthalmology Resident; University of Toronto, Toronto, ON.

Many health care professionals use handheld computers to access medical reference information and drug databases at the point of care.¹ There are many specific infectious disease software applications for handheld computers, which combine information regarding specific microbial pathogens and sites of infections with antimicrobial databases and treatment guidelines. Infectious disease software may minimize medication prescription errors and promote more rational use of antimicrobials. This article briefly reviews the salient features of five popular infectious disease applications.

ePocrates ID
ePocrates ID is available with ePocrates Rx Pro, the purchase-based suite which includes the popular handheld drug database, ePocrates Rx. Users can search by location, bug or drug. ePocrates ID provides a numbered list of recommended antimicrobial regimens for both empiric and specific pathogen-based therapy. For each antimicrobial, users can tap on a hyperlink to be connected with ePocrates Rx for more detailed drug monographs. ePocrates ID offers the simplest and most intuitive interface of any available infectious disease handheld application. Busy clinicians can quickly find treatment recommendations and a wide range of well-organized antimicrobial information at the point of care. However, users should be aware that the manufacturer of ePocrates has the ability to track how information is accessed on ePocrates ID.² Another drawback is that ePocrates cannot be run from an expansion memory card. ePocrates Rx Pro is expensive and users must renew their subscription annually. Unlike the core drug database in ePocrates Rx, ePocrates ID is not automatically updated with each hotsync operation, although users can download quarterly updates.

The Sanford 2003 Guide to Antimicrobial Therapy
The Sanford Guide is the handheld version of the popular paper-based infectious disease handbook. The opening screen of the handheld version is split into a "rapid reference" section of 17 commonly used tables and a searchable alphabetical index. The Sanford Guide provides the most detailed coverage of antimicrobial spectra, adverse medication effects and drug interactions and the most extensive literature references. However, unlike other applications, the information in the Sanford Guide is not organized by individual drug monographs, making it difficult to find information about a particular antimicrobial or clinical infection quickly. The search feature in the Sanford Guide is also cumbersome, as scroll bars must be used extensively to find information.

Johns Hopkins Division of Infectious Diseases Antibiotic Guide
Information in this guide may be searched through three side tabs entitled diagnosis, pathogen or antibiotic. Of the reviewed programs, this is the only one which is free and that automatically updates when a handheld syncs with a desktop computer. While being quite comprehensive and having undergone vigorous review for accuracy, this program does not provide any pediatric dosing. As well, drug monographs cannot be accessed through diagnosis or pathogen tabs, adding time required to search for drug details.

The 5-Minute Infectious Diseases Consult
This program is one of the extensive catalogues of medical reference books available from Skyscape. For users of other Skyscape references, the link feature allowing cross-referencing of databases is an attractive benefit. There are four indices that can be searched: Main Index, Microorganisms, Medication Index and Table of Contents. The Main Index is organized into basics, clinical manifestations, diagnosis, treatment, follow-up and selected readings. Perhaps the best feature of this program is its speed and ease of navigation. It is the most expensive of the reviewed databases and provides less drug monograph information than the other alternatives.

Infectious Diseases and Antimicrobials Notes
This program is formatted to run in iSilo, an e-book reader. It has the following sections: antimicrobial spectra index, prophylactic therapy, normal flora, organisms and treatment, infectious disease and treatment and antimicrobial treatment. This program has several attractive features. Its prophylactic therapy section provides details on prevention of infection with chemotherapy and provides surgical antibiotic prophylaxis notes. Its inclusion of a normal flora section is also quite educational. However, it requires extensive scrolling and lacks sidebar tabs seen in other applications. Furthermore, it does not disclose author information or provide references for its citations.

Conclusion
There is a variety of alternatives for users in search of an infectious disease reference for their handheld computers. ePocrates ID and Johns Hopkins Division of Infectious Diseases Antibiotic Guide provide the most concise and easily navigable treatment guidelines for particular clinical scenarios. The Sanford 2003 Guide to Antimicrobial Therapy may be most appropriate for specialists well acquainted with the paper-based version of the guide. The 5-Minute Infectious Diseases Consult offers the most extensive diagnostic information and can be linked with other Skyscape applications. Finally, the Infectious Diseases and Antimicrobials Notes may appeal to those in search of information regarding microbial flora and antimicrobial prophylaxis.

References

1. Adatia FA and Bedard PL. "Palm reading": 1. Handheld hardware and operating systems. CMAJ 2002;167:775-80.
2. Adatia FA and Bedard PL. "Palm reading": 2. Handheld software for physicians. CMAJ 2003;168:727-34.
3. Miller SM, Beattie MM, Butt AA. Personal digital assistant infectious diseases applications for health care professionals. Clin Infect Dis 2003;36:1018-29.