Volume 8, Number 1

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Read more about JCCC 2018 Issue 1

Michael Gordon, MD, MSc, FRCPC, Geriatric Consultant, Palliative Care, Baycrest Geriatric Health Care System, Professor of Medicine, University of Toronto, Toronto, ON.

The current medical technologies that appear each year must be examined within the context of the demographic imperative: the reality of an increasingly aging population that wishes to stay active and engaged within their community beyond comparative ages of previous generations. The focus on using medical advances to improve quality of life for this population affords possibilities that are novel and promising to the current and likely future senior community.

In this special educational supplement, Dr. Alfonso Fasano's first article focuses on the prevalence normal pressure hydrocephalus (NPH) which occur in aging populations: yet are under-diagnosed and under-treated. His article emphasizes that "NPH is one of the few reversible chronic neurological conditions which causes dementia": the success of recent trials of shunt surgery in ameliorating or even reversing patient symptoms points to the importance in identifying this condition. He advocates greater clinician awareness that could in turn lead to early diagnosis and treatment which could improve outcomes in selective members of the aging patient populations.

Dr. Fasano's second article addresses Deep Brain Stimulation (DBS) in which he notes that exciting advances in neuromodulation technologies that have provided clinicians with improvements in targeting, programming, and management of a number of conditions with heretofore limited options of other treatments. It follows that refining the procedures has made patient selection more directed. Additional studies of this procedure will hopefully improve these the elements necessary to select patient and thereby provide symptom relief for patients currently and in the future using this exciting, technologically advanced therapy.

Dr. Phillip Chan's article considers the preponderance of opiate use to alleviate chronic pain, which is recognized in North America where these drugs are misused and abuse has reached almost epidemic proportions. He proposes and alternative: The use of Spinal Cord Stimulation (SCS). Dr. Chan champions a progressive model of pain management and highlights the necessity of a multidisciplinary approach for treating chronic pain.

Dr. Allan Ho's article revisits the perpetual problem of hearing loss in aging patients: offering a glimpse at how effectively technological advances in hearing aids can improve quality of life for patients who have had limited improvement with conventional hearing devices. Dr. Ho outlines how to best determine which patients could benefit from bone-conduction hearing devices, a patient group that might have not had such an efficacious solution in decades past, but who can now enjoy improved hearing.

Dr. Dean Elterman discusses the employment of sacral neuromodulation (SNM) as an innovative way to treat overactive bladder (OAB) and fecal incontinence when other more conventional therapies prove unsuccessful. Using SNM to treat fecal incontinence was only approved by the FDA in 2011 and thus has a shorter history than using the same procedure to treat OAB. Several large studies have consistently demonstrated a marked improvement in symptoms for patients. Both disorders can be debilitating and can severely limit quality of life for the aging patient. Elterman notes that SNM technology has provided many with a significant improvement of their symptoms.

Drs. Edward P. Abraham and Hamilton Hall carefully examine the issue of the degenerating spine and consider how best to diagnose and treat the many and varied conditions that can affect the aging patient and impact quality of life. Abraham and Hall emphasize how much today's aging patient wishes to stay active and engaged well into their eighties and nineties. They advocate thoughtful diagnoses, a multidisciplinary approach to support those with spinal degeneration, and careful preoperative counselling—including exercise, diet, and managing co-morbid conditions—should surgery prove necessary. Theirs is a whole-patient approach and draws from the very best of innovative patient-management models.

The authors whose rigorous work is included in this educational supplement are experts in their fields, and all incorporate the very best in medical technological advances to advocate for superior medical care. With their approach to using the most innovative medical breakthroughs to shape their research and clinical practice, this group of specialists is leading the way to providing superior patient care for our aging population.

This article was published as part of <a href="/rh">Managing the Health of Your Aging Patient: Therapies that Could Help Improve Quality of Life </a> eCME resource. The development of <a href="/rh">Managing the Health of Your Aging Patient: Therapies that Could Help Improve Quality of Life </a> eCME resource was supported by an educational grant from Medtronic Canada.

Alfonso Fasano, MD, PhD

Authors' Affiliations

Morton and Gloria Shulman Movement Disorders Clinic and the Edmond J. Safra Program in Parkinson’s Disease, Toronto Western Hospital and Division of Neurology, University of Toronto, Toronto, Ontario, Canada, Krembil Research Institute, Toronto, Ontario, Canada.

CLINICAL TOOLS

Abstract: Deep brain stimulation has become widely accepted as a treatment for Parkinson's disease (PD), dystonia and tremor, and as an off-label treatment for many other movement disorders. In recent years, new official indications have been approved: obsessive-compulsive disorder and focal epilepsy with secondary generalization.
This field is expanding exponentially in two not mutually exclusive fields: clinical and technological. Clinically, we have achieved a deeper understanding of outcomes, thus facilitating the process of target and patient selection. In fact, we have gained a better understanding of established indications, particularly with respect to the debate on whether subthalamus or globus pallidus pars interna should be the target of choice for PD. In addition, the role of DBS for treating dystonia has been further defined in terms of patient selection and surgical outcome. Other established (e.g. essential tremor, epilepsy) and novel indications (e.g. Tourette syndrome) have been addressed as well. Finally, recent technological advantages in neuromodulation have opened new avenues towards new targets and indications.

Key Words: Deep brain stimulation, movement disorders, Parkinson's disease, tremor, dystonia.

Deep brain stimulation (DBS) is an established neuromodulation technique made possible by the neurosurgical placement of electrodes which deliver a mild electrical current to stimulate areas in the deep brain.

DBS has become widely accepted as a treatment for Parkinson's disease (PD), dystonia and tremor, and as an off-label treatment for many other movement disorders.

We have gained a better understanding of established indications, particularly with respect to the debate on whether subthalamus or globus pallidus pars interna should be the target of choice for PD.

In recent years, new official indications have been approved: obsessive-compulsive disorder and focal epilepsy with secondary generalization.

The advance of neuromodulation technologies has provided clinicians with new tools making targeting, programming, and overall management easier.

Nevertheless, we still fail to have reliable methods predicting the surgical outcome even in established indications, such as epilepsy or dystonia. In fact, the surgical outcome always relies on patient selection, which is mainly driven by the trade off between surgical risk and expected benefits.

DBS cannot cure or change the progression of the disease but it can help relieve symptoms and improve quality of life.

In PD, DBS can help symptoms that respond to levodopa with two exceptions: speech responds to levodopa, but does not usually improve with DBS (and might get worse) whereas tremor not responding to levodopa improves with DBS.

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This article was published as part of <a href="/rh">Managing the Health of Your Aging Patient: Therapies that Could Help Improve Quality of Life</a> eCME resource. The development of <a href="/rh">Managing the Health of Your Aging Patient: Therapies that Could Help Improve Quality of Life</a> eCME resource was supported by an educational grant from Medtronic Canada.

Dr. Allan Ho, MBBS, MSc, FRCS(ORLHNS), FRCSC,¹ Co-author: Brendan McDonald MA, MClSc, R.Aud, ²

Authors' Affiliations

¹Grey Nuns Hospital, Edmonton, AB.

²Clinical Audiologist, Edmonton Ear Clinic in Sherwood Park, AB.

CLINICAL TOOLS

Abstract: Hearing loss has a profound impact on an individual. A hidden disability, hearing loss disrupts the way we communicate and ultimately limits our ability to socialize and engage with others. Hearing loss is the most common communication disorder in the older adult population. Our aim is to update readers about types of hearing loss, and to provide specific information on intervention options for conductive hearing loss. This article will address implantable hearing devices used to correct conductive loss and recent technological advances in these devices.

Key Words: hearing loss, hearing aids, bone-conduction device, hearing implant, osseointegration.

Any patient with a conductive hearing loss or mixed hearing loss should be referred to an otolaryngologist.

Choosing the right candidate for a bone-anchored hearing system involves a multidisciplinary approach.

Otolaryngology and audiology must work together to evaluate the best surgical and audiological candidates for these devices.

Bone conduction hearing devices are a viable option for patients with conductive and mixed hearing losses where a conventional hearing aid is not a good choice.

Assessment and patient selection for bone-conduction hearing implants require a multidisciplinary approach with otolaryngologists and audiologists. Best candidates meet criteria both surgically and audiologically.

Softband bone-conduction trials with an audiologist can be used to demo and counsel patients on the device and technology. It is non-invasive, only requiring the external processor and a specialized headband to demonstrate its function.

This article was published as part of <a href="/rh">Managing the Health of Your Aging Patient: Therapies that Could Help Improve Quality of Life</a> eCME resource. The development of <a href="/rh">Managing the Health of Your Aging Patient: Therapies that Could Help Improve Quality of Life</a> eCME resource was supported by an educational grant from Medtronic Canada.

Dean Elterman, MD, FRCSC,¹ Co-author: Brandon Van Asseldonk B. Eng ²

Authors' Affiliations

¹Assistant Professor, University of Toronto, Toronto Western Hospital, Toronto, ON.

²Faculty of Medicine, University of Toronto, Toronto, ON.

CLINICAL TOOLS

Abstract: Sacral neuromodulation (SNM) is Health Canada authorized for the management of chronic intractable (functional) disorders of the pelvis and lower urinary or intestinal tract. A minimally invasive procedure, it has excellent symptom reduction and quality of life improvement in carefully selected patients and its effects are shown to be of extended duration in long-term follow up.

Key Words: sacral neuromodulation, overactive bladder, urge incontinence, fecal incontinence.

Sacral neuromodulation (SNM) is peripheral nerve stimulation used for the treatment of overactive bladder (OAB) and fecal incontinence.

SNM is recommended by both the American Urological Association (AUA) and the Canadian Urological Association (CUA) as third-line therapy for the treatment of OAB.

Given the large number of implantations and history of SNM, improvements in urinary symptoms are established and of long duration in those who respond to treatment.

SNM use in patients with fecal incontinence is more recent, but several large studies have demonstrated significant improvement in symptoms.

Fecal incontinence and overactive bladder are both debilitating medical conditions that can impair quality of life and limit day-to-day activities.

Sacral neuromodulation is authorized by Health Canada and the FDA as treatment for both bladder and bowel conditions.

SNM is a minimally invasive out-patient surgery that has consistently been demonstrated to improve symptoms and quality of life in patients with OAB or fecal incontinence.

This article was published as part of <a href="/rh">Managing the Health of Your Aging Patient: Therapies that Could Help Improve Quality of Life</a> eCME resource. The development of <a href="/rh">Managing the Health of Your Aging Patient: Therapies that Could Help Improve Quality of Life</a> eCME resource was supported by an educational grant from Medtronic Canada.

Alfonso Fasano, MD, PhD

Authors' Affiliations

Morton and Gloria Shulman Movement Disorders Clinic and the Edmond J. Safra Program in Parkinson's Disease, Toronto Western Hospital and Division of Neurology, University of Toronto, Toronto, Ontario, Canada, Krembil Research Institute, Toronto, Ontario, Canada.

CLINICAL TOOLS

Abstract: Normal pressure hydrocephalus (NPH) is a relatively frequent but underdiagnosed geriatric disorder with symptoms of impaired gait and balance, overactive bladder, and cognitive decline in the presence of neuroimaging evidence of ventriculomegaly. Cerebrospinal fluid shunting is an effective treatment, although patients' response is variable, sometimes of short duration, and not always predictable. This might be due to poor patient selection or delayed surgery. Nevertheless, recent trials have indicated that shunt surgery is cost-effective and should therefore be recommended. Family physicians and general neurologists play a crucial role in ensuring a proper diagnosis and timely intervention.

Key Words: normal pressure hydrocephalus, diagnosis, treatment.

Family physicians have a crucial role in ensuring a proper diagnosis and timely intervention. In this respect, a few rules should be remembered:

1. NPH is common among elderly populations in Western countries, but it is largely underdiagnosed and undertreated.⁸

2. NPH is one of the few reversible chronic neurological conditions in the elderly because neurosurgical shunting is an effective treatment, especially if performed early.³⁶

3. Gait and balance impairment are early signs of NPH and not all 3 of the triad symptoms should be present in order raise a suspicion of NPH and refer the patient to a neurologist.³⁶

4. Any patient with at least one symptom of the NPH triad should undergo a brain MRI or computed tomography CT (if MRI is contraindicated).³⁶

5. Important MRI/CT findings are an Evans index >0.3 and DESH, which should be investigated because it might mimic brain atrophy.³³

A suspicion of NPH should be raised for those patients with gradually progressive gait disorders characterized by instability (broad base) and shuffling steps; no other parkinsonian signs should be noticed, particularly in the upper body. Urinary dysfunction might be absent and cognitive problems are typically less severe than the motor problem (particularly at onset). In a patient with a clinical suspicion of NPH, brain MRI should be ordered and a referral to a neurologist should be made.

The neurologist will exclude other neurodegenerative conditions and other clinically relevant diseases affecting gait (e.g. neuropathy, spinal stenosis). Afterwards a tap test will be arranged, bearing in mind that the sensitivity of the test is far from ideal and that patients are prone to placebo response. When the suspicion of NPH remains high (also in case of negative tap test) a referral to neurosurgeon is made by the neurologist. In less clear-cut cases, another tap test or prolonged lumbar drainage can be done. Some other cases are only clinically followed-up, however taking into account that a delayed intervention might not provide the benefit of early surgery.

This article was published as part of <a href="/rh">Managing the Health of Your Aging Patient: Therapies that Could Help Improve Quality of Life</a> eCME resource. The development of <a href="/rh">Managing the Health of Your Aging Patient: Therapies that Could Help Improve Quality of Life</a> eCME resource was supported by an educational grant from Medtronic Canada.

	Edward P Abraham, MD, FRCSC, Associate Professor of Surgery, Department of Orthopaedics, Dalhousie University Medical School, Saint John Campus, Saint John NB Canada Canada East Spine Centre, Horizon Health Network.
	Hamilton Hall, MD, FRCSC, Professor, Department of Surgery, University of Toronto, Executive Director, Canadian Spine Society, Toronto, ON.

CLINICAL TOOLS

Abstract: In spite of the slightly increased incidence of infections, malignancies and systemic illnesses affecting the older spine, about 90% of back pain in the elderly, as in younger patients, is mechanical. This article covers several of the common problems: neurogenic claudication, degenerative disc disease, degenerative spondylolisthesis, disc herniation, spinal deformity and osteoporotic compression fractures. Treatment is both non-operative and surgical and the decisions about which to choose and therefore when to refer depend as much on the age and functional capacity of the patient as upon the specific pathology.

Key Words: neurogenic claudication, degenerative disc disease, degenerative spondylolisthesis, disc herniation, spinal deformity, osteoporotic fractures, imaging.

The diagnosis of neurogenic claudication is made on the history of intermittent leg dominant pain brought on by activity, usually walking, and relieved by rest in flexion, usually by sitting down. The physical examination while the patient is at rest is often normal.

Mechanical back pain associated with disc degeneration is seldom an indication for surgery and can usually be adequately managed through a combination of education, activity modification, general fitness and exercises selectively tailored to improve the pain-producing positons and movements.

Disc herniation producing acute sciatica is uncommon in the older patient and the diagnosis should be made with caution. True radicular pain is constant and leg dominant. Referred, intermittent leg pain frequently accompanies back dominant pain and should not be treated as sciatica.

Enduring spine surgery is a major challenge for the elderly patient. The decision to operate must be made after comprehensive consultation, emphasizing the prolonged recovery and weighing the potential benefits against the inevitable risks, including the risk to life.

Osteoporotic vertebral body compression fractures frequently occur without a recognized history of trauma. The pain, often in the thoracic or upper lumbar area, appears suddenly, is aggravated by movement (particularly bending forward) and is reduced but not eliminated by lying down. The acute phase can last several weeks but usually subsides without specific treatment. Multiple compression fractures over time will produce a kyphotic spine.

Back pain in the elderly should be managed with a minimum of medication. Mechanical pain can usually be controlled with the appropriate mechanical measures and additional analgesia is not required. Recourse to pain medication as a first line of treatment is not recommended and when employed should be limited to non-narcotic formulations. With the possible exceptions of acute sciatica and recent vertebral compression fractures, opioids should not be used.

This article was published as part of <a href="/rh">Managing the Health of Your Aging Patient: Therapies that Could Help Improve Quality of Life</a> eCME resource. The development of <a href="/rh">Managing the Health of Your Aging Patient: Therapies that Could Help Improve Quality of Life</a> eCME resource was supported by an educational grant from Medtronic Canada.

Philip Chan, MD, FRCPC (Anesthesiology, Pain Medicine), FIPP,

Authors' Affiliations

Director, Chronic Pain Clinic, Department of Anesthesia/Chronic Pain Clinic, St. Joseph's Healthcare, Hamilton, Ontario, Assistant Clinical Professor, Department of Anaesthesia, Faculty of Health Sciences, McMaster University, Program Director, Pain Medicine Residency Program, McMaster University, Medical Director, Neuromodulation Program, Hamilton Health Sciences Corporation, Hamilton, ON.

CLINICAL TOOLS

Abstract: There is increasing concern in Canada about the overuse and misuse of opioids. While there are no simple answers to this complex societal problem, adequate and timely access to proper multidisciplinary chronic pain care is important in decreasing the reliance on opioids when treating chronic pain in Canada. Neuromodulation therapy, especially spinal cord stimulation (SCS), offers patients the potential for pain relief without repeated injections or ongoing medication use. SCS is effective in the treatment of persistent postoperative neuropathic pain and complex regional pain syndrome. Prospective SCS candidates should undergo a full multidisciplinary assessment to evaluate both physical and psychological factors that may adversely affect results.

Key Words: chronic pain, spinal cord stimulation, opioids, neuropathic pain, persistent postoperative neuropathic pain.

The best studied indications for SCS are persistent postoperative neuropathic pain (so-called failed back surgery syndrome [FBSS]) and complex regional pain syndrome (CRPS).

The key to success with SCS is to generate a pattern of paresthesia that overlaps with the patient’s area of pain while avoiding extraneous paresthesia that may cause discomfort.

SCS is a cost-effective treatment, whereby the long-term savings in terms of diagnostic imaging, physician visits, medications, and rehabilitative services outweighed the higher upfront cost.

Contraindications for SCS implantation include: systemic infection, cognitive impairment, and low platelet counts.

Well-accepted positive predictive factors for long-term success with SCS include: patients whose etiology of pain have a predominately peripheral neuropathic pain component, treatment early in the course of the pain syndrome, and the presence of allodynia and other features suggestive of neuropathic pain. Significantly depressed mood, low energy levels, somatization, anxiety, and poor coping skills are important predictors of poor outcome.

SCS is a non-destructive procedure; the device can be explanted at any point if it no longer provides pain relief, and it does not preclude other treatment modalities, including spinal surgery, in the future.

This article was published as part of <a href="/rh">Managing the Health of Your Aging Patient: Therapies that Could Help Improve Quality of Life</a> eCME resource. The development of <a href="/rh">Managing the Health of Your Aging Patient: Therapies that Could Help Improve Quality of Life</a> eCME resource was supported by an educational grant from Medtronic Canada.

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JCCC 2018 Issue 1

JCCC 2018 Issue 1

What’s New? Improving Quality of Life for Aging Patients

Deep Brain Stimulation

Authors' Affiliations

CLINICAL TOOLS

Hearing Loss in the Older Adult

Authors' Affiliations

CLINICAL TOOLS

Improving Quality of Life with Neuromodulation: A Novel Treatment for Incontinence

Authors' Affiliations

CLINICAL TOOLS

Normal Pressure Hydrocephalus: Diagnosis and Treatment Options

Authors' Affiliations

CLINICAL TOOLS

Clinical Disorders of the Aging Spine

CLINICAL TOOLS

Spinal Cord Stimulation: An Under-utilized and Under-recognized Pain Treatment Modality

Authors' Affiliations

CLINICAL TOOLS