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Hemoptysis in Older Adults: Etiology, Diagnosis, and Management

Samir Gupta, MD, FRCPC, Division of Respirology, Department of Medicine, St. Michael’s Hospital, University of Toronto, Toronto, ON.

Robert Hyland, MD, FRCPC, Division of Respirology, Department of Medicine, St. Michael’s Hospital, University of Toronto, Toronto, ON.

Hemoptysis is an important clinical problem that is especially ominous when seen in older patients. The main causes of hemoptysis in first world nations are bronchogenic carcinoma, bronchitis, and bronchiectasis. In older patients cancer remains the main concern, especially if there is a smoking history. The diagnostic approach to nonmassive hemoptysis starts with a chest x-ray, followed by a CT scan and then fibre optic bronchoscopy, which is well tolerated by older adults. In massive hemoptysis, chest x-ray is usually followed immediately by fibre optic or rigid bronchoscopy. Older patients require closer monitoring due to poor cardiopulmonary reserve; management options include endoscopic interventions, bronchial artery embolization,
surgery, and radiation.

Key words: hemoptysis, etiology, management, older adults, bronchiectasis.

Related Terms: Lung Diseases, bronchiectasis, etiology, hemoptysis, management, older adults

Concepts in Geriatric Clinical Pharmacology

Dror Marchaim, MD, Department of Internal Medicine A, Asaf-Harofeh Medical Center, Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv, IL.

Victor Dishy, MD, Department of Internal Medicine A, Asaf-Harofeh Medical Center, Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv, IL.

Ahuva Golik, MD, Department of Internal Medicine A, Asaf-Harofeh Medical Center, Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv, IL.

Geriatric clinical pharmacology is considered an established subdiscipline in the field of clinical pharmacology. This review will address some of the effects of aging on drug treatment in general, and will focus on specific classes of drugs commonly consumed by older adults: cardiovascular medications, non steroidal anti-inflammatory drugs, and psychoactive agents.

Key words: clinical pharmacology, older adults, drug metabolism, pharmacokinetics.

Related Terms: Drug Safety, clinical pharmacology, drug metabolism, older adults, pharmacokinetics

Management of Community-Acquired Pneumonia in Older Adults

Ashraf Alzaabi, MD, FRCPC, Respirology Fellow, University of Toronto, Toronto, ON.

Theodore K. Marras, MD, FRCPC, Respirologist, Toronto Western Hospital, University Health Network; Assistant Professor of Medicine, University of Toronto, Toronto, ON.

Community-acquired pneumonia (CAP) in the older adult is a common disease with significant mortality. This review focuses on the management of CAP, with specific reference to the older adult. Common etiologic organisms and organism-specific risk factors that tend to be associated with increasing age are presented. A systematic approach is described to help physicians decide on the best treatment site (ambulatory, long-term care facility, or acute care hospital). The rationale behind initial empiric antibiotic therapy and drug resistance are discussed. Recent guidelines for the selection of empiric antibiotic therapy are compared and a synthesis of guidelines for antibiotic selection and recommendations regarding parenteral to oral switch-therapy are presented. Guidelines are suggested to help the physician safely discharge the patient home.

Key words: pneumonia, management, older adults, guidelines, resistance.

Related Terms: Lung Diseases, guidelines, management, older adults, pneumonia, resistance

Gastroesophageal Reflux Disease in Older Adults: An Update

Mary Anne Cooper, MSc, MD, FRCPC, Assistant Professor, Department of Medicine, University of Toronto; Lecturer, Sunnybrook and Women's Health Sciences Centre, Toronto, ON.

Gastroesophageal reflux disease is a common condition responsible for significant morbidity in older adults. It causes disease in the esophagus, and it is increasingly recognized as a cause of extra-esophageal symptoms such as chronic cough, adult-onset asthma, and hoarseness. Despite significant symptoms, endoscopy may be negative. Endoscopy-negative reflux disease may be a unique disease entity within the acid reflux group of disorders that includes erosive esophagitis and Barrett’s esophagus. Regardless of the symptoms or endoscopic findings, treatment remains geared to reducing the contact time between acid and sensitive tissue through lifestyle modification measures, acid suppression, and improved upper gastrointestinal motility.

Key words: GERD, extra-esophageal reflux, endoscopy-negative reflux disease, acid suppression, older adults.

Related Terms: Gastrointestinal Diseases, acid suppression, endoscopy-negative reflux disease, extra-esophageal reflux, GERD, older adults

Irritable Bowel Syndrome in the Older Adult

The accredited CME learning activity based on this article is offered under the auspices of the CE department of the University of Toronto. Participating physicians are entitled to one (1) MAINPRO-M1 credit by completing this program, found online at www.geriatricsandaging.ca/cme.htm

Anil Minocha, MD, FACP, FACG, Division of Digestive Diseases, Department of Medicine, University of Mississippi Medical Center, Jackson, MS, USA.
Thomas Abell, MD, FACG, Division of Digestive Diseases, Department of Medicine, University of Mississippi Medical Center, Jackson, MS, USA.

Irritable bowel syndrome (IBS) in the older adult offers challenges for diagnosis and treatment; however, very little research has been done in this regard. IBS has significant impact on the quality of life, especially in frail individuals. The diagnostic criteria have not been validated in older subjects. Diagnostic strategy needs to be modified to account for the expanded list of differential diagnosis, including high prevalence of colorectal cancer. There is a lack of evidence related to the efficacy of the treatment regimens used. Therapy should focus on specific symptoms and be matched for the potential for side effects and drug interactions. The prognosis for IBS is excellent and in a majority of cases symptoms disappear within five years.

Key words: Irritable bowel syndrome, Functional bowel disorder, Rome II criteria, older adults, spastic colon

Related Terms: Gastrointestinal Diseases, Renal Diseases, Functional bowel disorder, Irritable Bowel Syndrome, older adults, Rome II criteria, spastic colon

Psoriasis in Older Adults: Issues and Treatment

Scott RA Walsh, MD, PhD, Division of Dermatology, Sunnybrook and Women’s College Health Sciences Centre, University of Toronto Medical School, Toronto, ON.

Madhuri Reddy, MD, MSc, FRCPC, Divisions of Dermatology and Geriatric Medicine, Department of Medicine, Sunnybrook and Women’s College Health Sciences Centre, University of Toronto Medical School, Toronto, ON.

Psoriasis is a chronic, recurring T-cell- mediated skin disease that causes significant morbidity. The disease is often life-long and thus prevalence is highest in older adults. Severe clinical variants are also more frequent. Complicating psoriasis presentation and treatment in older adults are issues related to polypharmacy, including a higher frequency of drug-induced or drug-exacerbated disease and potential drug interactions. Treatment should be tailored to the individual with his/her respective limitations and reflect disease severity. This review examines suitable treatment protocols, including patient education and topical and systemic medications in older populations coping with psoriasis.

Key words: psoriasis, older adults, complications, treatment, immunologic disease

Related Terms: Dermatology, complications, immunologic disease, older adults, psoriasis, treatment

Cervical Cancer in the Older Patient: Diagnosis and Management

Nimesh P. Nagarsheth, MD, Division of Gynecologic Oncology, Department of Obstetrics, Gynecology and Reproductive Science, Mount Sinai Medical Center, New York, NY, USA.

Jamal Rahaman, MD, Division of Gynecologic Oncology, Department of Obstetrics,
Gynecology and Reproductive Science, Mount Sinai Medical Center, New York, NY, USA.

The diagnosis and management of cervical cancer in the older patient presents important challenges to the geriatrician and oncologist. Cervical cancer almost never occurs in older patients who have followed screening guidelines and have had a history of normal Pap smears prior to age 70. Early stage disease is best managed by radical surgery. While radical pelvic surgery has been proven safe in selected older patients, the current management of early cervical cancer depends upon the resources available to the geographical location. For locally advanced cervical cancer and early stage patients who are not surgical candidates, radiation therapy with concurrent platinum-based chemotherapy is the standard of care. Radiation therapy and chemotherapy can be safely administered to older patients once allowances are made for age-related physiologic changes. Advanced age should not be used as justification to alter the standard of care for the management of cervical cancer.

Key words: cervical cancer, older adults, chemotherapy, radiation therapy, radical pelvic surgery.

Related Terms: Cancer, Urogenital Disorders, Women’s Health, cervical cancer, chemotherapy, older adults, radiation therapy, radical pelvic surgery

Approaches to Treating the Older Substance User

Randy Harris, MSW, RSW, Mental Health Therapist, Community Geriatric Mental Health Services, Calgary Health Region, Calgary, AB.

Substance abuse experienced by older clients is frequently seen in medical practices. This article reviews approaches to assessing and treating older adults, including practical ideas for conducting interviews with older clients. A philosophical stance that recognizes a client’s readiness to change is also discussed.

Key words: older adults, substance use, stages of change, assessment, intervention.

Related Terms: Drug Safety, assessment, intervention, older adults, stages of change, substance use

Insomnia in Older Adults, Part II: Treatment

Amit Morris, BSc, School of Medicine, Queen’s University, Kingston, ON; Department of Psychiatry, Sleep and Alertness Clinic, Toronto Western Hospital, University of Toronto, Toronto, ON.

Henry J. Moller, MD, FRCP(C), DABSM, Department of Psychiatry, Sleep and Alertness Clinic, Toronto Western Hospital, University of Toronto, Toronto, ON.

Colin M. Shapiro, MBBCh, PhD, FRCP(C), Department of Psychiatry, Sleep and Alertness Clinic, Toronto Western Hospital, University of Toronto, Toronto, ON.

Chronic insomnia is common among older adults and has significant negative consequences for health and well being. A comprehensive approach to treatment begins with identification and management of any underlying conditions. Treatment of insomnia includes both non-pharmacologic and pharmacologic options. Non-pharmacologic approaches form the foundation of treatment; hypnotic medications can also be effective but may be associated with adverse drug effects. Zopiclone and zaleplon appear to be associated with fewer side effects than benzodiazepines.

Key words: insomnia, older adults, drug therapy, behavioural therapy, hypnotics.

Related Terms: Mental Health, behavioural therapy, drug therapy, hypnotics, insomnia, older adults

Outcomes Following Delirium in Critically Ill Older Persons: Need for Future Research

Lynn McNicoll, MD, FRCPC, Department of Internal Medicine, Brown University School of Medicine, Providence, RI.

Delirium in older hospitalized persons in non-critical care settings is associated with higher morbidity, mortality, and worse long-term outcomes. Delirium in critically ill persons is a growing field of research. This article presents recent research indicating a high frequency of delirium in critical care. Several studies have shown that delirium in critical care is associated with poor short-term as well as long-term outcomes, including increased length of stay, persistent cognitive deficits, and hospital and one-year mortality. Further research on strategies to prevent delirium in critical care may improve short- and long-term outcomes.

Key words: delirium, critical care, aging, outcomes, older adults.

Related Terms: Mental Health, aging, critical care, delirium, older adults, outcomes
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