Gastroesophageal Reflux Disease: Approaching the Burning Issues

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

Introduction
Gastroesophageal reflux disease (GERD), the abnormal reflux of gastric and duodenal contents into the esophagus, is common. Almost 50% of the North American population experience symptoms once a month and 10% have symptoms daily.¹ Patients most commonly complain of pyrosis and regurgitation, but other symptoms such as dysphagia, chest pain and nausea are not rare.¹ As well, respiratory tract symptoms such as cough, hoarseness and asthma may be attributable to GERD (Table 1).^1,2

Acid reflux into the esophagus is a normal physiologic event. It occurs after meals when the lower esophageal sphincter (LES) tone is reduced. The LES opens, creating a common cavity with the stomach. Because stomach pressures are higher than esophageal pressures, gastric contents reflux into the esophagus. Formal measurement with 24-hour pH monitoring indicates that the pH of the esophagus should be < 4 for < 4% of the time. Factors that increase acid contact time with the esophagus promote GERD.

Evaluation and Treatment of Constipation

Marisa Battistella, BScPhm, Pharm D, Education Coordinator & Hemodialysis Pharmacist, Pharmacy Department, University Health Network, Toronto, ON.
Shabbir M.H. Alibhai, MD, MSc, FRCP(C), Staff Physician, University Health Network, Toronto, ON.

Constipation is a common symptom in patients of all ages, but its occurrence is highest among persons 65 years of age or older.^1,2 Constipation has been shown to diminish both quality of life and feeling of well-being.^3-5 Although constipation can have many causes, it is most often functional or idiopathic.^5,6 Furthermore, constipation can lead to serious complications such as malnutrition, fecal impaction, fecal incontinence, colonic dilation and even perforation of the colon.⁷

Definition
Constipation has different meanings to patients and physicians. A patient's perception of constipation may include not only the objective observation of infrequent bowel movements but also subjective complaints of straining with defecation, incomplete evacuation, abdominal bloating or pain, hard or small stools or a need for digital manipulation to enable defecation. Because the definition of constipation can be subjective, an international committee has recommended an operational definition of chronic functional constipation in adults.

Antibiotic Treatment of Community-acquired Pneumonia in Older Adults

Theodore K. Marras, MD, FRCPC, Division of Pulmonary and Critical Care Medicine, University of California, San Francisco, California, USA; Postdoctoral Fellow, Department of Medicine, University of Toronto, Toronto, ON.

Abstract
Community-acquired pneumonia (CAP) is a common disease in the older adult with significant mortality. The following review focuses on the antibiotic 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. The rationale behind initial empiric antibiotic therapy is discussed and recent guidelines for the selection of empiric antibiotic therapy are compared. A synthesis of guidelines for antibiotic selection and recommendations regarding the switch from parenteral to oral therapy are presented.

Introduction
Community-acquired pneumonia (CAP) is a common infectious disease, the incidence of which is consistently associated with increasing age. The overall incidence of CAP has been reported at 10 to 14 per 1,000 patients per year,^1,2 and 30 per 1,000 among those older than 75 years.^2,3 Compared with people 60-69 years of age, those 70 years or older had a relative risk of developing CAP of 1.5,⁴ independent of the additional risk conferred by heart disease and institutionalization.

The Aging Lung: Implications for Diagnosis and Treatment of Respiratory Illnesses in the Elderly

Benjamin Chiam, MD, Department of Medicine, Pulmonary Division, University of Alberta, Edmonton, AB.
Don D. Sin, MD, FRCP(C), Department of Medicine, Pulmonary Division, University of Alberta, and The Institute of Health Economics, Edmonton, AB.

Introduction
Respiratory conditions are among the leading causes of morbidity and mortality worldwide. Although they are currently listed as the fifth leading cause of death in Canada, respiratory diseases are predicted to be the third leading cause of mortality by the year 2020, following ischemic heart disease and stroke.¹ Furthermore, since the prevalence of these conditions increases with age, the adverse impact of respiratory illnesses on the Canadian health care system will grow enormously over the next few decades as the overall population ages² and treatments for other common conditions, such as ischemic heart disease, stroke and diabetes, improve. A good understanding of the aging process of the respiratory system is clearly needed to formulate better strategies to prevent, diagnose and manage respiratory conditions in Canada.

Why are Respiratory Diseases so Prevalent in the Elderly?
The lungs of elderly persons are subject to a lifetime of exposure to known and unknown harmful agents. Decades may pass before the physical manifestations of cigarette smoke, pollution and other noxious environmental agents become clinically apparent.

Issues in the Treatment of Osteoarthritis

Dr. Shafiq Qaadri, MD, Family Physician and CME Lecturer, Toronto, ON.

Introduction
With the demographic shift in Canada--the "greying" of its population--arthritis is a growing health concern. A leading cause of long-term disability in Canada, arthritis and other musculoskeletal diseases result in $17.8 billion in lost productivity annually.¹ Currently, four million Canadians are affected by arthritis, and the number of people afflicted is expected to double in the next 20 years.² Already, 33% of Canada's seniors have osteoarthritis,2 the most common form of arthritis in older adults.

Effective osteoarthritis care requires a spectrum of approaches on the biopsychosocial model including: advice on carrying out daily activities (coping with fatigue, protecting joints, using orthotics); controlling pain through approaches such as relaxation therapy, massage therapy, hydrotherapy or acupuncture; using walking/assistive devices; and learning more about arthritis from organizations or websites. Self-help groups are a particularly valuable resource for arthritis patients.

Many patients ask about alternative remedies such as glucosamine or chondroitin, which have shown some effectiveness in studies. A full discussion of complementary therapies for arthritis is presented on the Arthritis Society website at www.arthritis.ca.

Medication remains the mainstay for controlling arthritis pain of all types.

Cholinesterase Inhibitors in the Treatment of Vascular Dementia

Chris MacKnight, MD, MSc, FRCPC, Division of Geriatric Medicine, Dalhousie University, Halifax, NS.

Introduction
Vascular dementia is common, and currently there is no accepted therapy aimed at the cognitive symptoms. Prevention of further strokes is, of course, well established.¹ Evidence is accumulating that the cholinesterase inhibitors, proven therapy in Alzheimer disease (AD), may also be of use in vascular dementia (VaD). This paper will summarize that evidence.

Epidemiology of Vascular Dementia
Vascular dementia can be diagnosed when there is a high degree of suspicion that cognitive impairment and stroke are related. Various criteria exist, which unfortunately do not overlap to any great extent, but all share several features.² These include: the presence of stroke, either clinical or found on neuroimaging; the presence of focal neurologic signs, such as asymmetric power or a positive Babinski response; and a characteristic course, with a sudden onset or stepwise progression. For the highest degree of confidence in the diagnosis, a temporal relationship between the stroke and the dementia is required.

In most surveys of older adults, vascular dementia is the second most common cause of dementia in the community, after AD. In Canada, the prevalence of VaD is 1.5% in people 65 and over, and 5.1% for AD.³ Other surveys have found similar values.

Aggressive Treatment for Prostate Cancer in the Elderly: When is it Appropriate?

James Brown, MD, Minimally Invasive Urologic Oncology Fellow
Department of Urology, Thomas Jefferson University, Assistant Professor of Urology
Medical College of Georgia, Augusta, GA, USA.

Leonard G. Gomella, MD, Bernard Godwin Associate Professor of Prostate Cancer
Director of Urologic Oncology, Department of Urology, Kimmel Cancer Center,
Thomas Jefferson University, Philadelphia, PA, USA.

Abstract
The treatment options for localized prostate cancer are extensive and highly controversial. Although there is general agreement that symptomatic metastatic disease should be treated by hormonal ablation, there is no consensus on how to treat patients with localized disease. While an argument can be made not to screen any patient for prostate cancer, many organizations, including the American Urological Association, support both screening and the treatment of prostate cancer in men with a life expectancy of greater than 10 years. In the asymptomatic, older man with localized, low-risk disease, characterized by a low Gleason score, low PSA and low clinical stage, observation may be the treatment of choice. However, in the older man with localized prostate cancer and high-risk features such as a high Gleason score, aggressive treatment is warranted since many of these men will progress and ultimately die of prostate cancer.