Diagnosis and Management in the Elderly

Deirdre A. Jenkins, MD
Richard C. Woodman, MD
Division of Hematology and Hematological Malignancies,
University of Calgary and Tom Baker Cancer Centre, Calgary, AB.

Introduction
Chronic lymphocytic leukemia (CLL) is a monoclonal disorder of long-lived, mature lymphocytes. It is the most common leukemia in North America with an incidence of 2.7 cases per 100,000. CLL is primarily a disease of the elderly, with a median age of 70 at diagnosis and a slight male predominance. In patients older than 85 years, the incidence rises to 30.6 per 100,000.¹ There are no clear hereditary patterns; however, increased incidence is noted in families with other lymphoproliferative disorders. The etiology is unknown, and typical risk factors for other cancers (like viruses, radiation and chemicals) have no clear role in CLL. The importance of understanding the diagnosis and treatment of this disorder lies in the chronic nature of the disease, as patients may live years to decades after diagnosis. Knowing your treatment goals, and anticipating complications are fundamental for managing patients with CLL.

Diagnosis
While there has been a growing number of patients serendipitously diagnosed on routine blood tests, the majority of patients will present with symptoms referable to their disease (Table 1).

Lucia Gagliese, PhD
Assistant Professor, School of Kinesiology and Health Science, York University,
Staff Scientist, Department of Anaesthesia, University Health Network, and
Assistant Professor, Department of Anaesthesia, University of Toronto.

Brenda Kraetschmer, RN, BScN
Clinical Research Coordinator,
Department of Anaesthesia, Mount Sinai Hospital and
University Health Network, Toronto, ON.

As the population ages, health care workers will increasingly be called upon to provide effective pain assessment and management to elderly patients. Fortunately, information regarding age-related patterns of pain, disability and psychological distress has become more readily available over the past decade. However, this area of study remains in its infancy and further research is urgently needed. In this article, we present a brief overview of some of the most recent data about the epidemiology, assessment and management of chronic pain in elderly people.

Epidemiological Studies
There is no clear-cut pattern of age differences in the prevalence of pain. Results vary depending on the population and type of pain studied.¹ Epidemiological studies conducted in community settings have found that the prevalence of many pain complaints, including headache, migraine and low back pain, peaks in middle-age and decreases thereafter.

Gail A. Eskes, PhD
Department of Psychology,
Queen Elizabeth II Health Sciences Centre Assistant Professor,
Psychiatry and Medicine (Neurology),
Adjunct Professor, Psychology,
Dalhousie University, Halifax, NS.

Beverly C. Butler, BSc
Department of Psychology,
Dalhousie University, Halifax, NS.

Introduction
Unilateral neglect is a cognitive and behavioural syndrome after brain damage that can have serious consequences for patient recovery, rehabilitation success and long-term reintegration to independent living. Outcome studies commonly identify neglect and related sequelae as significant predictors of poor outcome in stroke patients in terms of increased need for assistance in self-care activities and decreased quality of life.

Definition and Clinical Presentation
Unilateral neglect is most commonly defined as a failure to orient, report or respond to stimuli located in the space or body contralateral to a brain lesion (often due to stroke or brain injury), despite adequate sensorimotor ability to do so.¹ The neglect syndrome is fundamentally different from, although sometimes confused with, hemianopia, hemisensory loss or hemiplegia.

Madhuri Reddy, MD, FRCPC
Associate Editor,
Geriatrics & Aging,
Toronto, ON.

Introduction
It is well documented that, throughout North America, a large percentage of elderly clients (10-52%) do not have the medical need or are not sufficiently disabled to justify placement in high level of care settings such as a nursing home (NH).^1,2,3,4

The placement of low-care clients in NH is often assumed to indicate inappropriate and inefficient use of NH resources.⁵ In addition, it is well established that disabled clients prefer home or community-based care rather than receiving care in NHs.⁶ So why do clients continue to be placed in high levels of care that they do not need?

Subjective Placement Criteria
The process of client placement does not always explore the possibility that the client may best be cared for outside of a long-term care (LTC) institution. In addition, even when clients truly do need NH care, the definitions of the various levels of care are often vague; thus, adherence by placement committees is often inconsistent. This lack of objective criteria regarding the level of care required by a particular patient leads to subjective decision-making by a placement panel; this can result in patients who require the same level of care being placed in different levels depending on who makes the decision.

Professor Michael S Roberts, DSc
Julie Stokes, BPharm, PG
Dip Clin Hosp Pharm.
Department of Medicine,
University of Queensland,
Ipswich Road,
Buranda, Qld, Australia.

Introduction
One of the most professionally satisfying scenes we have observed while working in nursing homes is an older person regaining his or her dignity and independence after unnecessary drugs have been ceased. It is often easy to add medications to the drug regimen of older people¹ to treat "new" conditions, some of which may in fact be the adverse effects of medications already prescribed. Drugs can cause subclinical diminution in function or their adverse effects can mimic almost any clinical syndrome.² It has been shown that the risk and frequency of adverse drug outcomes increase with the number of drugs prescribed--some residents may be on up to 22 medicines at a given time³ and not all of these are needed. Some classes of medications, most notably psychoactive drugs, are of particular concern in nursing homes.⁴ In a prospective cohort study of 1106 nursing beds in 12 nursing homes in Los Angeles, Beers et al.5 suggested that 40% of the residents received at least one inappropriate medication order, 10% received two or more inappropriate medication orders concurrently, and 7% of all medications were inappropriate. A similar finding has been reported for the UK.

Harold Parker, BSW, MSW, RSW
Social Worker, Outreach Team,
Southwestern Ontario Regional Geriatric Program,
London, ON.

Laura Diachun, BASc, MD, FRCP(C)
Geriatrician,
Southwestern Ontario Regional Geriatric Program,
London, ON.

As an Outreach Team that provides service to the frail elderly for the Southwestern Ontario Region (10 counties), our ongoing challenge is how to respond to the needs of cognitively-impaired older persons living at some degree of risk. The perception and assessment of risk vary depending upon the lens through which we are looking. A living situation that may be perceived as risky by some may be quite unproblematic to others. Caring family members can often rationalize paternalism toward their elderly loved one so as to err on the side of safety--a value that can often take precedence over issues of quality of life and self-determination. A lifetime of responsible decision-making is no guarantee of the continued exercise of free will at the latter end of the life cycle. The 'assailants' to independence can be many, including paternalism and the presence of disease beyond normal aging, which can affect both function and cognition. It is often unclear where to draw the line between granting the individual the freedom to make poor lifestyle decisions and deeming that someone is exceeding family/community standards of acceptable lifestyle choices.

Morris D. Kerstein, MD
Professor and Vice-Chairman,
Director of Research and Education,
Department of Surgery, Mount Sinai School of Medicine,
New York, NY, USA.

Ernane D. Reis, MD
Assistant Professor
Department of Surgery,
Mount Sinai School of Medicine,
New York, NY, USA.

Venous leg ulcers influence the physical, financial and psychological well-being of patients, and result in an estimated two million workdays lost, annually. Despite a variety of therapeutic options, venous leg ulcers remain a substantial management challenge to the health-care professional. Some form of lower extremity venous disease is present in nearly 30% of the American adult population. Venous leg ulcers are often debilitating sequelae of venous insufficiency, and account for 80-90% of leg ulcers reported. A quality-of-life study reported that 65% of chronic-leg-ulcer patients had severe pain, 81% experienced reduced mobility, and nearly 100% reported a negative impact of their disease on work capacity.

Manifestations of venous insufficiency may include dilated superficial veins, with or without dilated tributaries of the deep vein system, swelling, leg pain, heaviness and changes in the skin (hyperpigmentation, venous dermatitis, eczema with dryness and itching). Ultimately, the adverse effects of venous disease appear as skin ulceration of lipodermatosclerosis.

Isao Shimokawa, MD, PhD
Pathology & Gerontology,
Department of Respiratory and Digestive Medicine,
Nagasaki University School of Medicine,
Nagasaki, Japan.

Introduction
Caloric restriction (CR)--the restriction of food intake while maintaining adequate supplies of essential nutrients (i.e. not malnutrition)--is widely recognized as the most powerful intervention for the extension of lifespan in organisms. CR slows the aging process, prevents or retards age-related diseases and extends the mean and maximum lifespan in laboratory organisms.^1,2 In the 66 years since the seminal report of McCay,³ many studies have confirmed its life-extending effects. These effects do not depend on the restriction of specific nutrients or food contaminants.4 Despite numerous efforts, our knowledge of the mechanisms underlying the effects of CR is not yet complete. The present article focuses on several possible mechanisms. Other historic and recent research can be found in more comprehensive reviews^1,2 and a recent update.⁴

An Evolutionary Perspective
It has been suggested that the anti-aging effects of CR might derive from adaptive responses that evolved to maximize organism survival during periods of food shortage. In order to avoid extinction, organisms have evolved neuroendocrine and metabolic response systems to enhance survival during natural periods of food shortage.

D'Arcy Little, MD, CCFP
Director of Medical Education,
York Community Services, Toronto, ON.

Introduction
Thrombocytopenia is a common hematologic problem in the elderly.¹ A classic survey indicated that over 50% of patients with thrombocytopenia were over 50 years of age, and 25% were over 70 years of age.² The elderly patient with thrombocytopenia presents the clinician with both diagnostic and management challenges. Because the disorders and mechanisms that lead to decreased numbers of platelets in the circulation are varied, the spectrum of differential diagnoses is broad and includes decreased platelet production and accelerated destruction.³ In addition, the clinical implications of thrombocytopenia fall into a wide spectrum, from a benign condition picked up incidentally in an asymptomatic patient to a life-threatening disorder.⁴ The following article will present an approach to the evaluation of thrombocytopenia in the elderly patient (Figure 1).

Definition and Clinical Significance
Thrombocytopenia is a condition in which there is a deficient number of circulating platelets. The cutoff for diagnosis is 150 x 10⁹/L of blood, which represents the platelet count two standard deviations below the mean obtained when sampling a large number of persons from the general population.

Jeffrey Zonder, MD
Ulka Vaishampayan, MD
Division of Hematology/Oncology,
Department of Medicine
Wayne State University School of Medicine/Barbara Ann Karmanos Cancer Institute
Detroit, MI, USA.

Introduction
The incidence of hematologic malignancies, especially lymphoma, is steadily rising in the elderly. These diseases and their complications pose specific problems for older patients. Factors that contribute to increased toxicity in the elderly include diminished marrow reserve, impaired renal and hepatic metabolism and, perhaps most importantly, poor performance status as a result of comorbidities.¹ This article will focus on the management of common complications of hematologic malignancies, particularly as they pertain to older patients.

Febrile Neutropenia

Risk of Neutropenia in the Elderly
The incidence of life-threatening neutropenia (absolute neutrophil count, ANC, <0.5x 10⁹/L) in elderly patients following chemotherapy for hematologic malignancies is 40% or higher.² The risk of infection is affected by the duration and severity of neutropenia with a steep rise in infection incidence at a neutrophil count of less than 0.5x 10⁹/L.