Easy and Inexpensive Management

Dr. Scott Murray, MD, FRCPC, Dermatology, Assistant Professor Dermatology, Dalhousie University, Halifax, NS.

As you observe the geriatric patient, a variety of visual cues--posture, body habits, energy level and hair colour--can provide the observer with clues to the patient's age. However, in many ways it is the skin that is the first giveaway of the effects of aging. The skin is the most accessible organ for treatment and can be considered the parameter of aging most easily affected by intervention--at least cosmetically. As a result, there is huge interest in remedies to reverse age-associated skin changes. This has led to the development of an immense industry, both in medicine and in cosmetics, to defy these effects.

Skin Aging
Some changes to aging skin occur as a result of intrinsic effects such as genetics and racial types. There is little we can do to control these variables.¹ For instance, the variable ability of skin to deal with sun exposure is predetermined to some extent in this way. Some visual changes of the skin also result from sagging of underlying muscles (sagging) and repetitive motion (grooves or "laugh lines"). These lines add to the lines on the skin that we visually identify with advancing years.

Extrinsic factors such as ultraviolet light, nutrition, underlying illness, smoking and stress can also contribute to skin aging.

Marvin Lester, BA, MD, FRCPC, The Fitness Institute, Mississauga, ON.

Bullous Pemphigoid (BP) is essentially a disease of the elderly with the average age of onset usually in the sixties to seventies. However, this is not a hard and fast rule and it can occur in other ages, including children, although rarely.

BP is thought to be an autoimmune reaction, with circulating basement membrane zone (BMZ) and antibodies of the IgG class present in the majority of cases.

BP has occasionally been reported to be associated with other diseases including Ulcerative Colitis, Dermatomyositis, Diabetes Mellitus, Rheumatoid Arthritis and multiple autoimmune diseases involving organs other than the skin. Drugs have also been reported as possible causes for this condition and include medications such as Furosemide, Enalapril, Captopril, Penicillin and Sulfasalazine.

Clinical Features
The disease is characterized by large, tense, very firm, fluid-filled bullae as opposed to the more flaccid lesions that are seen in bullous diseases such as Pemphigus Vulgaris. In Pemphigus Vulgaris these may be widespread over the skin surface or may be localized to one part of the body including the groin, axillae and flexural surfaces of the forearms. Oral involvement has been reported and varies anywhere from 10-40%; usually an average of about 20% is quoted. Involvement of other mucosal surface such as the throat, nose, vulva, urethra and eye are not common.

John E. Adam MD, FRCPC, Professor of Medicine (Dermatology), University of Ottawa, Ottawa, ON.

The annual number of new cases of skin cancers reported in Canada is estimated to be about 40,000. With the aging of the baby boomer generation, this figure is anticipated to increase because of the ease of travel to the south in winter and increased exposure to the sun during outdoor activities. Dermatoheliosis or photodamage is most prevalent in people over 40 years of age who have had excessive sun exposure over their lifetime (Table 1). Epidemiological studies have identified sunlight exposure as the major risk factor for skin cancer.

There are three major types of skin cancer. The most common non-melanocytic skin cancers are Basal Cell Carcinoma and Squamous Cell Carcinoma. The less frequently occurring melanocytic skin cancer is Malignant Melanoma.

Basal cell carcinoma
Basal Cell Carcinoma (BCC) is the most common form of skin cancer but also the least likely to metastasize. It can be very destructive locally if not diagnosed and treated early.

Clinically it presents in several forms on sun-exposed areas (Table 2). The classic and most common presentation is the nodulo-cystic variety--a shiny elevated dome shaped nodule with a raised border often with telangiectatic blood vessels on the surface. The tumour is described as shiny or of a "mother-of-pearl colour.

Prevention is the Best Form of Care

Madhuri Reddy, MD, Dermatology Day Care (Wound Healing Clinic) Sunnybrook and Women's College Health Care Centre, Toronto, ON, Associate Editor, Geriatrics & Aging.

R. Gary Sibbald, BSc, MD, FRCPC (Med), FRCPC (Derm), MACP, DABD,
Associate Professor and Director of Continuing Education
Department of Medicine, University of Toronto, Toronto, ON.

Introduction
The most common reason for hospitalization of individuals with diabetes is a foot wound. Persons with diabetes are forty times more likely than are non-diabetics to have a non-traumatic amputation, and the most common precipitating events are infection in a non-healing ulcer and gangrene. Those who undergo a lower-extremity amputation have a 50% chance of amputation in the contralateral limb within five years.¹

The systemic nature of diabetes requires a team approach, involving wound care specialists (e.g. physicians, nurses) and foot care specialists (e.g. chiropodists, podiatrists, occupational therapists, pedorthists). Prevention of ulcers is the best form of care for the diabetic foot. Teaching prevention should occur in the setting of comprehensive diabetic care.

D'Arcy Little, MD, CCFP, Director of Medical Education, York Community Services, Toronto, ON and Academic Fellow, Department of Family and Community Medicine, University of Toronto, Toronto, ON.

Introduction
Movement disorders have a high prevalence in the elderly. In fact, disorders of gait and mobility are second only to cognitive impairment as the most prevalent neurologic disorders of aging.¹ Huntington's disease (HD) is an inherited neurodegenerative disorder characterized by alterations in mood, memory and movement first described by George Huntington in 1872.^2,3 Recent advances in the elucidation of the pathophysiology of this disease may have implications in the development of more specific and effective treatments. The following article will review the epidemiology, pathophysiology, clinical presentation, diagnosis and treatment of HD, including novel treatments currently under development.

Epidemiology
HD is the most important cause of hereditary chorea. Its prevalence in the Caucasian population is thought to be as high as 10 per 100,000.⁴ However, because many gene carriers have yet to develop symptoms, the actual prevalence is more than twice the number of symptomatic cases. HD is uncommon in Finland, Norway, Japan, China, and in persons of African descent, but is greatly increased along the western shore of Lake Maracaibo, Venezuela.⁵ The condition affects both genders equally.

Christopher Hyson MD, FRCPC, Clinical Fellow, Movement Disorders Program, London Health Sciences Centre, London, ON.

Mandar S Jog MD, FRCPC, Director, Movement Disorders Program, London Health Sciences Centre, London, ON.

Epidemiology
Idiopathic Parkinson's Disease (IPD), which results from degeneration of substantia nigra neurons, is characterized by the typical motor symptoms of rest tremor, rigidity, bradykinesia and postural instability. The estimated prevalence, which has been rising with the aging of the population, is 187/100,000 in the United States, with an annual incidence of 20/100,000. In addition to the well recognized motor disability, neuropsychiatric symptoms, such as depression, anxiety disorders and psychosis, are common, yet under-recognized in patients with IPD.¹ It is, therefore, important that primary care physicians, internists and neurologists who care for patients with IPD be familiar with the occurrence and management of this important symptom.

Depression is the most common neuropsychiatric symptom seen in patients with IPD. It is estimated that approximately 40% of patients with IPD will experience depression at some point over the course of their illness. For 4-6% of these patients, the episode will meet the Diagnostic and Statistical Manual of Mental Disorders' (DSM-IV) definition of major depression. The remainder will meet the diagnostic criteria for minor depression.

ALS, sometimes called Lou Gehrig's disease or Motor Neuron Disease (MND), is characterized by degeneration of a select group of nerve cells and pathways in the brain and spinal cord, leading to progressive paralysis of the muscles.

ALS involves the loss of motor nerve cells. The nerves affected are in the spinal cord and those that travel to the voluntary muscles, with weakness and wasting in the arms, legs and mouth, throat and respiratory system. The loss of nerve cells results in atrophy, or wasting of the muscles served by those cells.

Although symptoms of ALS usually present on one side of the body, both sides are involved and the effects usually become more symmetrical as the disorder progresses.

ALS does not discriminate. Anyone can get ALS--male or female of any race. It usually becomes evident as one approaches middle age. There is a very rare form transmitted from generation to generation and a very rare juvenile form.

ALS progresses relentlessly. There is no recovery or reversal and few plateaus; it is merely a rapid decline in motor capacity. For many, there is little impairment of the intellect and the senses remain intact.

Approximately 2000 Canadians live with ALS at any one time. Ninety percent of people with ALS will die within six years and the progression of the disease will remove them from society for much of that time. Two to three Canadians die of ALS every day.

What can be done?
Nation-wide, ALS clinics employ a team approach to the treatment of disease symptoms and assisting the person with ALS to live as fully as possible. Along with neurologists and other physicians, the team may include a physiatrist, respiratory therapist, occupational therapist, physiotherapist, dietitian, speech-language pathologist, social worker and pastoral care provider.

ALS Societies across the country make a valuable contribution, providing information and referral, access to specialized equipment in a timely manner, support groups for all concerned and advocacy for those affected by the disease.

These teams help those affected with ALS to make decisions that will assist in the management of ALS and to improve quality of life at each stage. Care-giving and caregiver support become vital as the person quickly progresses from independence to dependence.

ALS research in Canada is advancing toward treatment and a cure and research funding is increasing. For example, the ALS Society of Canada's participation in the Neuromuscular Research Partnership, working with the Muscular Dystrophy Association of Canada and the Canadian Institutes of Health Research, has funded nearly $6 million of research in the past two years.

Internationally respected, Canadian researchers are focussing on several areas including proteomics (the study of protein chemistry) to determine the cause of cell death and developing trials of potentially useful drug combinations.

These initiatives in stimulating research and provision of care will eventually result in increased longevity for those with ALS, with improved quality of life, and the hope of a cure for this devastating disease.

More information is available from the ALS Society of Canada site--www.als.ca.

Madhuri Reddy, MD, Associate Editor, Geriatrics & Aging.

In order to effectively plan future long-term care (LTC) environments, it is important to ascertain the natural history of clients once placed in these environments. What, for instance, are the predictors of client mortality and the probability of a change in function, either to improve or deteriorate, once placed in a certain level of care? Environments need to be flexible and, most of all, promote independence and an enhanced quality of life.

Changes in Care Requirements Over Time
It is well established that the functional status of many nursing home (NH) clients improves after NH placement or after transitions between different levels of care. Some aspects of functional status (hygiene, dressing, grooming and transferring), as well as depressed mood, are likely to improve shortly after NH admission.¹ One study of over 9,500 elderly clients admitted to a NH for at least 100 days found that 51.5% experienced a change in function during the first 90 days. This change usually represented an improvement rather than a decline. In fact, thirty-seven percent of this long-stay client sample was able to return home.²

Predictors of Mortality
Several studies have indicated that predictors of mortality in the elderly are increased age, male sex, poor physical status, poor social supports and poor cognitive functioning.^3,4,5 Few studies, however, have investigated the predictors of mortality specific to the NH population.

Robert W Teasell, MD, FRCPC, Professor and Chair-Chief, Department of Physical Medicine & Rehabilitation, St Joseph's Health Care, London, University of Western Ontario, London, ON.

Timothy J Doherty, MD, PhD, FRCPC, Assistant Professor, Department of Physical Medicine and Rehabilitation, The University of Western Ontario, London, ON.

Defining Stroke Rehabilitation
Rehabilitation has been defined as an active process by which those disabled by injury or disease can realize their optimal physical, mental and social potential with integration into the most appropriate discharge environment. Comprehensive stroke rehabilitation programs are staffed by a full range of rehabilitation professionals--nurses, physical and occupational therapists, speech-language pathologists, psychologists, social workers, recreational therapists and physicians. An interdisciplinary team skilled in the care of stroke patients provides a comprehensive rehabilitation program for each patient. Brandstater and Basmajian,¹ and Roth et al.

Ali Rajput, MBBS, FRCPC and Alex Rajput, MD, FRCPC
Division of Neurology, University of Saskatchewan, Saskatoon, SK.

The terms parkinsonism and Parkinson syndrome (PS) are used interchangeably. Two of the three cardinal features--bradykinesia, rigidity and tremor--are necessary to make a diagnosis of PS. Several pathological entities and neuroleptic drugs may produce PS, the most common being Parkinson's disease or idiopathic Parkinson's disease (PD), which is characterized by marked neuronal loss in the substantia nigra and Lewy body (LB) inclusions (Figure 1 is not available online). The prevalence of PS in the Canadian general population is estimated at 300 per 100,000.¹ The mean age of onset is 62 years, with both incidence and prevalence rates increasing with age. In a Canadian survey of a community population over age 65 years, 3% had PS.²

Alzheimer disease (AD) is the most common dementing illness in the industrialized countries. Marked cortical neuronal loss, plaques and intraneuronal neurofibrillary tangles are pathological features of AD (Figures 2A and 2B are not available online). More than 5% of the general population over 65 years of age have AD.

Because both PD and AD occur in old age, some individuals will have both. Pathological studies suggest that this overlap is higher than expected in unselected large autopsy series.