Selecting Initial Antihypertensive Therapy for Older Adults

Norm Campbell, MD, FRCPC, Departments of Medicine, Community Health Sciences, and Pharmacology and Therapeutics, University of Calgary, Calgary; Libin Cardiovascular Institute, Calgary, AB.
Sailesh Mohan, MD, MPH, Departments of Medicine, Community Health Sciences, and Pharmacology and Therapeutics, University of Calgary, Calgary; Libin Cardiovascular Institute, Calgary, AB.

As over 9 in 10 older adults will develop hypertension, it is important for clinicians to routinely assess blood pressure. It is as important to treat hypertension in older adults as it is in younger people. In general, select a low-dose diuretic. Beta-blockers are not as effective at preventing stroke as other major antihypertensive drug classes. Specific indications for drug classes are provided. Target the blood pressure levels to <140/90 mmHg in general, <130/80 mmHg in people with diabetes or chronic kidney disease, and focus on systolic blood pressure control. If blood pressure control is not achieved using a moderate dose of your initial selection, add a second antihypertensive drug.
Key words: hypertension, antihypertensive drugs, pharmacotherapy, cardiovascular disease, stroke.

Update on the Management of Atrial Fibrillation in Older Adults

Hatim Al Lawati, MD, FRCPC, Cardiology Resident, Division of Cardiology, Faculty of Medicine, University of Toronto, Toronto, ON.
Fatemeh Akbarian, MD, Dermatologist, Research Fellow, University of Toronto, Toronto, ON.
Mohammad Ali Shafiee, MD, FRCPC, General Internist, Nephrologist, Department of Medicine, Toronto General Hospital, University Health Network; Clinician Teacher, University of Toronto, Toronto, ON.

Atrial fibrillation (AF) is by the far the most common cardiac rhythm disturbance encountered in clinical practice. It is associated with significant morbidity and mortality and has potentially lifelong implications in terms of therapy and complications. This disease is more commonly seen now given the increased life expectancy and the remarkable advances made in health care. The already at-risk older adult population is particularly vulnerable to complications from AF, especially embolic cerebrovascular events. This article reviews the evidence-based management of AF with a particular focus on the older adult population.
Key words: atrial fibrillation, older adults, stroke, rate control, rhythm control, stroke prophylaxis, anticoagulation.

Functional Gains for Stroke Survivors in Response to Functional Electrical Stimulation

Janis J. Daly, PhD, MS, Director, Cognitive and Motor Learning Laboratory; Associate Director, FES Center of Excellence, Louis Stokes Cleveland Department of Veterans Affairs Medical Center; Research Career Scientist, DVA, Washington, DC; Associate Professor, Department of Neurology, Case Western Reserve University School of Medicine, Cleveland, OH, USA.

For those with persistent gait and upper limb deficits after stroke, it is difficult to obtain recovery of motor control and functional capability in response to standard care methods. Functional electrical stimulation (FES) is a promising intervention. Surface FES for wrist and hand muscles can result in improved impairment sufficient to produce important gains in functional capability. In addition, an FES gait training system with multiple channels and implanted electrodes has shown a statistically significant additive advantage for the recovery of coordinated gait components versus a comparable comprehensive gait training treatment without FES. Results were sufficiently robust to show important gains in quality of life.
Key words: stroke, functional electrical stimulation, neuromuscular electrical stimulation, functional neuromuscular stimulation, functional recovery, rehabilitation.

Initial Evaluation of Causes of Stroke in Frail Older Adults

Pippa Tyrrell, FRCP, Salford Royal Foundation Trust and University of Manchester; UK NICE Guidelines Development Group, Acute Stroke and TIA, London, UK.
Sharon Swain,PhD, National Coordinating Centre for Chronic Conditions, Royal College of Physicians; UK NICE Guidelines Development Group, Acute Stroke and TIA, London, UK.
Anthony Rudd, FRCP, St Thomas’s Hospital London; UK NICE Guidelines Development Group, Acute Stroke and TIA, London, UK.

The investigation and management of stroke has changed beyond recognition in the last two decades. The management of frail older patients with stroke represents a particular clinical challenge. Recognition of symptoms in people with significant comorbidities may be difficult and while intensive investigation may be inappropriate for a very frail aging patient, older people can gain a great deal from expert treatment and secondary prevention following stroke.
Key words: stroke, frail older adults, ischemic stroke, intracerebral hemorrhage.

Poststroke Dementia among Older Adults

Aleksandra Klimkowicz-Mrowiec, PhD, Department of Neurology, University Hospital Cracow, Poland.

Stroke and dementia are major health problems affecting older people. Cerebrovascular disease is the second-leading cause of dementia after Alzheimer’s disease, the third- leading cause of death, and one of 10 leading causes of physical disability. In parallel with the increased prevalence of stroke in aging populations and the decline in mortality from stroke, the rate of diagnosed poststroke dementia has increased, causing a growing financial burden for health care systems. This article discusses the epidemiology, etiology, and determinants of poststroke dementia and outlines the search for a suitable treatment.
Key words: dementia, stroke, cognition, risk factors, cognitive impairment.

“Brain at Risk”:Vascular Dementia Revisited and Redefined

Ashok Devasenapathy, MD, Assistant Professor of Medicine and Neurology, Penn State University, Milton S. Hershey Medical Center, Hershey, PA, USA.
Rathna Muthukumaran, MD, Graduate Student, Faculty of Psychology, Penn State University, Harrisburg, PA, USA.
Vladimir Hachinski, MD, Distinguished Professor Emeritus, Professor of Neurology, Clinical Neurosciences, University of Western Ontario, London, ON.

The term “vascular dementia” should be considered obsolete, a reflection of the 20th century concept that dementia does not respond to preventive measures, is always a neuro-degenerative disease, is not reversible, and has no treatment. A new approach necessitates the redefinition of vascular dementia as vascular cognitive impairment (VCI), with “dementia” as the terminal manifestation of a treatable process. Vascular cognitive impairment encompasses the vascular component of all dementias and is hence the only treatable element of a disease that has a highly significant impact on the health of older adults at risk for both strokes and coronary artery disease (cardiovascular disease).
The principal aim of this article is to illustrate the relationship between cognitive loss among older adults with vascular risk factors, stroke, and cardiovascular disease. Such an approach should help in understanding the basis for VCI, its prevention, and treatment.
Key words: vascular cognitive impairment, preventable senility, brain at risk, dementia, stroke.

Gender Differences in Stroke among Older Adults

Guido Falcone, MD, Department of Neurology, Raul Carrea Institute for Neurological Research (FLENI), Buenos Aires, Argentina.
Ji Y. Chong, MD, Assistant Professor of Neurology, Columbia University, New York, NY, U.S.A.

Stroke is a common disease in the older population. Many gender differences are seen in the epidemiology, outcomes, and treatment of geriatric stroke. Although these differences are not fully understood, recognition of gender differences may help with appropriate treatment and improve outcomes.
Key words: stroke, gender, outcomes, prevention, treatment.

Post-Stroke Depression: Focus on Diagnosis and Management during Stroke Rehabilitation

Elizabeth A. Johnson, RN, PhD(c), Board Certified Geriatric Clinical Nurse Specialist, Doctoral Candidate, Indiana University School of Nursing; Department of Adult Health, Indiana University School of Nursing, Indianapolis, IN, USA.
Tamilyn Bakas, RN, DNS, FAHA, Associate Professor, Department of Adult Health, Indiana University School of Nursing, Indianapolis, IN, USA.
Linda S. Williams, MD, Chief of Neurology, Roudebush Veterans Administration Medical Center; Research Coordinator, VA Stroke QUERI; Associate Professor of Neurology, Indiana University School of Medicine; Research Scientist, Regenstrief Institute, Indianapolis, IN, USA.

Depression, the most frequent neuropsychological problem after stroke, is greatly influenced by the complex relationships between the neurobiological and psychological changes that occur after stroke. Post-stroke depression leads to negative rehabilitation outcomes including less participation in therapy, extended recovery time, significantly decreased quality of life, and increased utilization of health care resources. Because of the high prevalence of post-stroke depression, all stroke survivors should be screened early in the rehabilitation process. Use of a biopsychosocial framework acknowledges the multifactorial etiology of post-stroke depression and contributes to effective, evidence-based treatment. Attention to the needs of the family caregivers further promotes successful post-stroke rehabilitation.
Key words: stroke, depression, risk factors, recovery, treatment.

Stroke: It’s No Accident

In academic medicine, July 1st is the beginning of a new educational year, bringing new trainees eager to learn. Every year, one of the first things I teach these trainees is the word “stroke.” For some reason, this common term that both health care providers and health care recipients understand is replaced in medical school by the term “cerebrovascular accident,” or even worse, CVA. Not only is this term incomprehensible to most speakers of the English language, it is very inaccurate as well. Some of the articles in this month’s edition of Geriatrics & Aging clearly demonstrate the predictable and preventable pathogenesis of stroke, thus making the term “accident” a complete misnomer. The past decade has seen tremendous improvements in stroke care from the emergency room to the rehab centre. Much more remains to be learned, and currently one of the great challenges in health care is ensuring that everyone who has had a stroke receives rapid and coordinated care.

Clearly it is better to prevent a stroke than to provide even the most optimal treatment. The use of acetylsalicylic acid in the setting of transient ischemic attack (or prior ischemic stroke), anticoagulants in atrial fibrillation, and control of hypertension are the mainstays of stroke prevention. Dr. Nikolai Steffenhagen and Dr. Michael Hill explore the topic further in our CME article “Prevention of Ischemic Stroke among Older Adults: Primary and Secondary.”

Depression can complicate stroke and impair functional recovery, and the article “Post-Stroke Depression: Focus on Diagnosis and Management during Stroke Rehabilitation” by Elizabeth Johnson, Tamilyn Bakas, and Dr. Linda Williams will be helpful for those of us who are involved in stroke rehabilitation. As well, as the population gets older, the proportion of women becomes larger. Thus, the article “Gender Differences in Stroke among Older Adults” by Drs. Ji Chong and Guido Falcone, is particularly important for those of us who care for older adults. Even two of our regular columns this month deal with our focus on stroke. Our dementia column this month is on “Brain at Risk: Vascular Dementia Revisited and Redefined” by Drs. Ashok Devasenapathy, Rathna Muthukumaran and Vladimir Hachinksi. Dr. Hachinski, a Canadian neurologist, is one of the world’s foremost experts in the field of stroke and vascular dementia, and it is truly an honour for us to count him among our contributors. Our Drugs & Aging column this month is on the topic of stroke prevention and is entitled “Ischemic Stroke Prevention: Are Two Antiplatelet Agents Better than One in Older Adults?” by Dr. Sheri L. Koshman and Dr. Glen Pearson.

We also have our usual collection of articles on other geriatric topics. Particularly in family practice, the complaint of swollen legs is extremely common. Dr. Karen Yeates and Dr. Daniel Tascona provide an approach to this topic in our CVD feature “Leg Edema among Older Adults.” Our nutrition column this month is on “Zinc Deficiency among Older Adults” and is written by Dr. Maitreyi Raman, Dr. Elaheh Aghdassi, and Dr. Johane P. Allard. Physicians who work in long-term care settings know that pain is frequent among residents, but the communication with patients and thus the diagnosis of pain can be quite problematic. This difficult but important area is addressed in the article “Optimizing Pain Management in Long-Term Care Residents” by Dr. Evelyn Hutt, Dr. Martha Buffum, Dr. Regina Fink, Dr. Katherine Jones, and Dr. Ginette Pepper.

Enjoy this issue,
Barry Goldlist

Post-Stroke Depression -- July/August 2007

Lana S. Rothenburg, BSc(Hons), Neuropsychopharmacology Research Program, Department of Pharmaceutical Sciences, University of Toronto, Toronto, ON.
Nathan Herrmann, MD FRCP(C), Neuropsychopharmacology Research Program; Department of Psychiatry, Sunnybrook Health Sciences Centre; Department of Psychiatry, University of Toronto, Toronto, ON.
Krista L. Lanctôt, PhD, Neuropsychopharmacology Research Program; Department of Psychiatry, Sunnybrook Health Sciences Centre; Departments of Psychiatry and Pharmacology, University of Toronto, Toronto, ON.

Depression is a common sequela of stroke, occurring in approximately 33% of all patients. Post-stroke depression (PSD) is associated with greater cognitive and functional impairments, excess mortality, and increased health care costs, although symptoms are often mild. Diagnosis of PSD can be made using standard clinical criteria, despite the potential overlap with the somatic and vegetative symptoms of stroke. Post-stroke depression responds to standard antidepressant pharmacotherapies, but use of tricyclic antidepressants may result in increased cardiac adverse events. Given the high prevalence and major negative impact of PSD, active screening of all stroke patients for depression and aggressive treatment is recommended.
Key words: stroke, depression, diagnosis, risk factors, treatment.