Oksana Davidovich, BSc, DCh (Chiropodist), Private Practice, Davisville Foot Clinic; President, Ontario Society of Chiropodists, Toronto, ON.

The incidence of foot problems increases with age, and may impair mobility and interfere with independent living. Although most podiatric conditions may be treated effectively with conservative measures by a chiropodist or podiatrist, older patients are often reluctant to report foot problems to their physician. Common structural foot ailments in the older population include digital deformities, metatarsalgia and heel pain. Skin and nail conditions also are prevalent, such as fungal or ingrown toenails, as well as corns and calluses. Given that osteoarthritic joint changes in the lower extremities may compromise gait and stability, foot orthoses and footwear have the potential to improve foot function.
Key words: chiropodist, podiatric, footwear, foot problems, gait.

Geoffrey F. Dervin, MD, MSc, FRCS(C), Associate Professor, University of Ottawa and the Ottawa Hospital, Orthopaedic Division, Department of Surgery, Ottawa, ON.

Understanding the options for treatment of osteoarthritis of the knee will allow physicians to help their patients realize the physical and social demands of healthy life. Weight loss, physical therapy and unloading braces are clinically proven strategies in the early stages of the disease. Acetaminophen remains the analgesic of choice, while COX-2 NSAIDs are reserved for flare-ups and short-term use. Oral glucosamine and chondroitin sulfate also may be helpful. Persistently swollen knees may respond to aspiration and corticosteroid injection or viscosupplementation with hyaluronic acid derivatives. Those with acute onset of mechanical symptoms may respond to arthroscopic débridement and resection of unstable meniscal tears. Osteotomy of the tibia or femur are options for isolated unicompartmental disease in younger and more active patients. Arthroplasty of one or all compartments of the knee is the definitive procedure for end-stage arthrosis with very dependable results in most clinical settings.
Key words: osteoarthritis, knee, arthroplasty, acetaminophen, older people.

Herbert P. von Schroeder, MD, MSc, FRCSC, University of Toronto Hand Program and Toronto Western Hospital, University Health Network, Toronto, ON.

Osteoarthritis is a highly prevalent and disabling condition of the hand in the geriatric population. It is commonly and effectively managed by surgical means. The interphalangeal joints and base of the thumb are most frequently involved, particularly in women, whereas post-traumatic osteoarthritis of the wrist is more common in men. Surgical procedures include simple debridement, soft tissue stabilization or osteotomies for milder cases. Joint arthroplasty, including excision procedures, and joint arthrodesis (fusion) are indicated for more severe arthritis. The type of procedure used depends on the location of the affected joint, patient age and physical demands placed on the hand. Surgery can effectively alleviate pain and improve hand function to improve an individual's quality of life.
Key words: osteoarthritis, hand, arthrodesis, arthroplasty, surgery.

Feisal A. Adatia, MD, MSc, First Year Ophthalmology Resident, University of Toronto, Toronto, ON.

The Internet has become the world's greatest information resource. Physicians have come to depend on sites such as MD Consult (www.mdconsult.com) and PubMed (www.pubmedcentral.org) for their clinical queries, and family physicians have found Family Practice Notebook (www.fpnotebook.com) to be a valuable resource. As well, journals such as the Canadian Medical Association Journal (www.ecmaj.ca) and Geriatrics & Aging (www.geriatricsandaging.ca) are available online to allow physicians to keep up with new developments in medicine.

With the SARS outbreak, the international community has used the Internet to share knowledge and information. The World Health Organization has responded to the threat of SARS by using its website to publish daily updates about the number of worldwide cases, thus allowing analysts to monitor the progress of this outbreak. In the U.S., the Centers for Disease Control and Prevention has posted dozens of fact sheets, travel advisories and a breakdown of domestic cases by state on its site.

Moreover, the Internet has become a trusted way to communicate, with e-mail having supplanted the use of the telephone in many regards. Given these changes, there is a great deal of excitement over new technologies that allow physicians to have the power of the Internet in a wireless device. Wireless systems also provide ways to share Internet connections and information between computers.

Bluetooth™ Wireless Technology
Bluetooth and Wireless Fidelity, or Wi-Fi, technologies are reshaping the way the Internet can be accessed. Bluetooth provides a means for devices to communicate with one another. This short-range technology allows for a wireless voice and data link between a broad range of devices, including desktops, notebooks, handheld computers, printers, mobile phones and digital cameras. Bluetooth creates a Wireless Personal Area Network (WPAN) consisting of all the Bluetooth-enabled electronic devices immediately surrounding a user, allowing these devices to communicate with one another. With this technology, desktop computers can send files to a printer, handhelds can synchronize with a notebook computer, one can surf the web via a mobile phone, and a wireless headset can be used to talk on a cell phone while driving. Physicians can use a Bluetooth-enabled notebook or handheld computer, such as the Palm Tungsten T, Sony TG50, iPAQ h5455 or Toshiba e740, to connect to the Internet via a Bluetooth-enabled cell phone, from companies such as Nokia, Motorola, Samsung and Sony Ericsson. However, to communicate, these devices need to be in close proximity, usually less than 10 metres.

Wireless Fidelity Technology
Wi-Fi technology allows one to develop a network, linking enabled devices through radio waves transmitted from a base station or access point. With this technology files can be shared between computers, and a single Internet connection can be shared by many computers. A larger range of approximately 100 metres allows this technology to become more feasible for broad access in public places.

It seems likely that many of us will adopt this technology, with mainstream pushes from suppliers such as Intel whose Pentium M chip, branded Centrino, includes Intel's Pro Wireless 2100 802.11b (Wi-Fi) module, expected to be included in 125 models of notebook computers by the end of this year. Palm's Tungsten C and certain HP iPAQ and Toshiba handhelds are currently Wi-Fi enabled. Intel is also teaming with Hilton Hotels and Resorts, Borders Group and McDonald's restaurants to offer wireless access to customers in certain areas. Mainstream Wi-Fi access is even available at Starbucks locations in the U.S., with 2,000 cafes expected to be wired for Wi-Fi by this year's end. AT&T and IBM have formed a company called Cometa Networks Inc. and plan to blanket the 50 largest U.S. metropolitan areas with public wireless access points, or "hot spots". Toshiba and Accenture also plan to have 10,000 hot spots across North America by the end of the year. In Canada, Toshiba has announced plans for a nationwide pay-per-use network of hot spots in more than 1,000 locations, including coffee chains, hotels and travel terminals. Bell Canada, Toronto-based Rogers Cable Inc. and Calgary's Shaw Cable Inc. also are expected to provide Wi-Fi access points, with Bell Canada having recently run a pilot project offering free wireless access at 19 public places in Montreal, Toronto, Kingston and Calgary.

In the health care setting, U.S. hospitals are using this technology to help provide working environments that will attract nursing staff. Internet Protocol (IP) wireless headset phones can use a Wi-Fi network to make and receive telephone calls. This allows nurses to answer doctors' pages on the spot, rather than having to hustle to a nursing station telephone. They can also use laptops or phones to update medical charts at bedsides. In fact, even north of Toronto at the Markham-Stouffville hospital, nurses use Wi-Fi-enabled laptops to feed information into the hospital's electronic documentation system from a patient's bedside. Although the employment of this technology is just beginning in the hospital environment, it is likely to become increasingly important in health care.

Technologies such as Wi-Fi are going mainstream and, perhaps more intriguingly, may revolutionize the accessibility of hospital staff and data access in our hospitals. In the future, wireless networks and everywhere access to the Internet may be a standard in clinical practice and in our homes.

Robert S. Sheldon, MD, PhD, FRCP(C) and Satish R. Raj, MD, FRCP(C), Cardiovascular Research Group, University of Calgary, Calgary, AB.

Implantable cardioverter-defibrillators are pacemaker-like devices that sense and treat ventricular tachycardia and ventricular fibrillation, and are generally used in an aging population. They have been proven in large randomized clinical trials to prevent death in patients who have already survived a life-threatening episode of ventricular arrhythmias. Recent studies have expanded their indications to the prevention of arrhythmic death in patients who have risk factors for this disorder. How widely they will be used, and at what cost, is unknown.
Key words: implanted defibrillator, arrhythmia, sudden death, anti-arrhythmic therapy, heart disease.

Gareth R. Jones, PhD, Director, Canadian Centre for Activity and Aging, London, ON.
Jessalynn A.B. Frederick, BHK Honors Co-op, University of Windsor, Windsor, ON.
Canadian Centre for Activity and Aging is affiliated with St. Joseph's Health Care, London and the University of Western Ontario, London, ON.

"Homeboundness" is defined as never or almost never leaving one's home except for emergencies, not going beyond one's door without assistance, or going out of one's home less than once a month, and it is estimated to affect as much as 50% of the population who are 85+ years old.¹ The older homebound adult is more likely to live alone, have mobility limitations, experience incontinence problems, and be considered at high risk for falling and fear of falling, as well as more likely to receive home support services.² Frail seniors living at home are particularly difficult to reach and are at high risk for loss of functional independence and for institutionalization.³

Home exercise is an effective means to prevent falls, to maintain functional independence and to promote rehabilitation following injury or illness.⁴ However, for an older adult faced with mobility challenges and/or other medical problems, attending a traditional community-based exercise program may not be a suitable option.

Barbara Liu, MD, FRCPC, Sunnybrook &Women's College Health Sciences Centre and the Kunin-Lunenfeld Applied Research Unit, Baycrest Centre, Toronto, ON.

Falls are a common problem among older patients. Medications in general, and psychotropic drugs in particular, have been shown to increase the risk of falls. The possible mechanisms whereby psychotropic drugs increase this risk include sedation, orthostatic hypotension, arrhythmias, confusion due to anticholinergic effects, and dopaminergic effects on balance and motor control. Several epidemiological studies have identified antidepressant use--both tricyclic and selective serotonin re-uptake inhibitors--as a risk factor for falls. When treating a patient with an antidepressant, efforts should be made to reduce other modifiable risk factors for falls by optimizing intrinsic and extrinsic risk factors for falls.
Key words: falls, antidepressant, hip fracture, tricyclic antidepressant, selective serotonin re-uptake inhibitor.

Heike A. Bischoff, MD, MPH, Robert B. Brigham, Arthritis and Musculoskeletal Diseases Clinical Research Center, Brigham and Women's Hospital and Division on Aging, Harvard Medical School; Boston, MA, USA.

There is increasing evidence that vitamin D supplementation may improve musculoskeletal function and prevent falls in older persons at risk for vitamin D deficiency. One basic concept appears to be the direct effect of vitamin D on muscle strength. Highly specific receptors for 1,25-dihydroxyvitamin D are expressed in human muscle tissue and it has been suggested that these nuclear receptors promote protein synthesis in the presence of 1,25-dihydroxyvitamin D, eventually leading to improved strength.
Key words: vitamin D, muscle strength, function, elderly, falls.

Fiona E. Shaw, MRCP, PhD, Consultant Physician and Geriatrician, Newcastle General Hospital, Westgate Road, Newcastle upon Tyne, UK.

Older people with dementia are at increased risk of falls and their adverse consequences. Postural instability (impaired gait and balance), medication, environmental hazards and neurocardiovascular instability, in particular orthostatic hypotension, are commonly identified as risk factors for falls in this patient group. It is possible to modify risk factors for falls in older people with dementia. However, to date it has not been possible to demonstrate conclusively that intervention can prevent falls in patients with dementia.
Key words: accidental falls, dementia, cognitive impairment, postural instability, neurocardiovascular instability (syncope).

Margaret Grant, MD, FRCPC, Geriatrician and Medical Director, Geriatric Assessment Unit, Credit Valley Hospital, Mississauga, ON.

This article focuses on the treatment of orthostatic hypotension (OH) in the elderly. OH is a common problem that can affect an elderly person's function and quality of life. A careful history and physical examination must be done to make an accurate diagnosis and to determine the causes of OH. Treatment should focus on the causes of OH. Both nonpharmacological and pharmacological interventions are reviewed.
Key words: orthostatic hypotension, fludrocortisone, midodrine, octreotide, erythropoietin.