Multiple System Atrophy: An Update

Felix Geser, MD, PhD, Clinical Department of Neurology, Innsbruck Medical University, Innsbruck, Austria.
Gregor K. Wenning, MD, PhD, Clinical Department of Neurology, Innsbruck Medical University, Innsbruck, Austria.

Multiple system atrophy (MSA) is a sporadic neurodegenerative disorder characterized clinically by various combinations of parkinsonian, autonomic, cerebellar, or pyramidal signs and pathologically by cell loss, gliosis, and a-synuclein-positive glial cytoplasmic inclusions in several brain and spinal cord structures. The clinical recognition of MSA has improved, and the recent consensus diagnostic criteria have been widely established in the research community as well as in movement disorders clinics. Although the diagnosis of this condition is largely based on clinical expertise, several investigations have been proposed in the last decade to assist in early differential diagnosis. Symptomatic therapeutic strategies are still limited.
Key words: multiple system atrophy, clinical presentation, diagnosis, treatment.

Ophthalmic Interventions to Help Prevent Falls

John G. Buckley, PhD, Senior Research Fellow, Vision & Mobility Laboratory, Department of Optometry, University of Bradford, Bradford, UK.
David B. Elliott, PhD, MCOptom, FAAO, Professor of Clinical Vision Science, Department of Optometry, University of Bradford, Bradford, UK.

There is mounting evidence that visual impairment is significantly associated with the increased incidence of falling in the older adult. Surprisingly, the leading causes of visual impairment in the aging adult population are correctable and due to undercorrected refractive errors and/or cataract. This highlights that, to reduce fall risk, older people should be encouraged to have regular eye examinations to detect and subsequently correct such problems as early as possible.
Key words: falls prevention, visual impairment, ophthalmic intervention, older adult.

An Office Diagnosis of Mild Cognitive Impairment

Andrew R. Frank, MD, Alzheimer’s Disease Center, Mayo Clinic College of Medicine, Rochester, MN, U.S.A.
Ronald C. Petersen, MD, PhD, Alzheimer’s Disease Center, Mayo Clinic College of Medicine, Rochester, MN, U.S.A.

Mild Cognitive Impairment (MCI) describes a state of abnormal cognitive functioning that is insufficient to warrant a diagnosis of dementia. While dementia requires that activities of daily functioning be compromised due to cognitive symptomology, the diagnosis of MCI can be made earlier, in the absence of such functional impairment. In MCI, the patient must present with cognitive complaints (or someone who knows the patient well must present them on the patient's behalf), and these complaints must be corroborated by abnormalities on standardized cognitive testing. The diagnosis of MCI alerts the clinician to a higher risk of future development of dementia and provides an ideal target population that may benefit the most from “disease-modifying” cognitive therapies currently in development.
Key words: mild cognitive impairment, MCI, Alzheimer’s disease, dementia, early diagnosis, treatment.

Treatment of Pain in the Older Adult

Hershl Berman, MD, FRCPC, Department of Internal Medicine, Department of Psychosocial Oncology and Palliative Care, University Health Network, Toronto, ON.
Shawna Silver, BASc, PEng, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON.

Pain in the older adult can present unique challenges. Cognitive impairment and polypharmacy can make assessment and treatment difficult. An interdisciplinary team that includes family caregivers is essential. A rational approach to the ambulatory older patient with nociceptive pain would be to begin with regularly dosed acetaminophen, then add an NSAID if appropriate. The next step would be to add a low-dose opioid. If the patient uses a sufficient quantity of the opiate, dosing should be spread out throughout the day. Once a stable dose is reached, one can use a sustained-release formulation. Nonopioids should be continued throughout the titration process.
Key words: pain, analgesia, opioids, older adult, pain assessment.

A Review of the Efficacy of Cardioverter-Defibrillators||in Older Adults

Abdul Razakjr Omar, MBBS, MMed (Int Med), MRCP (UK), FAMS (Cardiology) Consultant Cardiologist, National University Hospital, Singapore.
Kumaraswamy Nanthakumar, MD, FRCPC, Staff Cardiologist, Cardiac Electrophysiologist, University Health Network, Toronto General Hospital; Assistant Professor of Medicine, University of Toronto, Toronto, ON.

In older patients the aging process is complicated by underlying comorbid diseases. An implantable cardioverter-defibrillator (ICD) has been shown to reduce mortality due to sudden cardiac death and improve survival in patients at risk of lethal arrhythmia. However, its role in older adults with coronary artery disease (CAD) is less well understood. A literature review of ICD trials was conducted, assessing efficacy and feasibility of the device in older adults.
The use of an ICD should be individualized in older patients. ICD therapy is feasible and safe in preventing sudden cardiac death. Age is insufficient to exclude an older adult with CAD from ICD therapy.
Key words: coronary artery disease, implantable cardioverter-defibrillator, sudden cardiac death, ventricular tachycardia, cardiac resynchronization therapy.

Diagnosis and Management of Bipolar Disorder

Patricia Hall, MD, Department of Psychiatry, University of Western Ontario, London, ON.
Verinder Sharma, MB, BS, FRCPC, Professor, Faculty of Medicine and Dentistry, University of Western Ontario, London, ON.

Bipolar disorder is less common in the older adult population. However, the quality of life for older adults with bipolar disorder is significantly impacted. Older patients with bipolar disorder have more cognitive and functional impairment than younger patients. Studies show that older adults with bipolar disorder also have an increased risk of suicide, dementia, and medical illness, as well as a higher mortality rate. This article provides a review of the epidemiology, clinical features, suicide risk, comorbidities (including dementia), and management of bipolar disorder in older adults.
Key words: bipolar disorder, mania, bipolar depression, treatment.

Atypical Presentations of Depression

James L. Silvius, MD, FRCPC, Calgary Health Region, Clinical Associate Professor, Department of Medicine; Head and Chief, Division of Geriatric Medicine, University of Calgary, Calgary, AB.

Depression is common in older adults. This condition is often under-recognized and undertreated in this patient segment as it may present differently than in younger individuals. A number of risk factors for depression have been identified and may help increase recognition. Altered presentations include generalized anxiety/worry, somatisation, presence of a disability gap, subjective but not objective memory complaints, pseudodementia, hopelessness, change in adherence to medical regimens or change in function not otherwise explained. For individuals with dementia syndromes, excess disability may indicate depression. A high index of suspicion, recognition of risk factors, and asking about specific aspects of depression may increase diagnosis.
Key words: depression presentation, risk factors, function, dementia.

Psychiatric Side Effects of Nonpsychiatric Medications

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

Kannayiram Alagiakrishnan, FRCP(C), Associate Professor, Division of Geriatric Medicine, Department of Medicine, University of Alberta, Edmonton, AB.
Cheryl A. Wiens, PharmD, Associate Professor, Faculty of Pharmacy & Pharmaceutical Sciences, University of Alberta, Edmonton, AB.

Numerous medications are capable of causing psychiatric side effects. Drug abuse or misuse, polypharmacy, or physiological changes due to aging may lead to these adverse effects. Drug-induced effects on mental health is a topic of considerable clinical importance and yet it is poorly recognized by health care professionals. This article is a review of psychiatric side effects of prescription and over-the-counter medications, problem recognition, and what can be done to manage and prevent these adverse events. Prevention of drug-induced psychiatric side effects can be aided by avoiding, where possible, medications that can cause these effects; evaluating renal and hepatic function on a regular basis; avoiding agents that can cross the blood-brain barrier; and conducting brief cognitive and behavioural assessments at baseline with follow up on a periodical basis.
Key words: psychiatric side effect, renal insufficiency, nonpsychiatric medications, adverse drug reactions, cognitive impairment.

Cardiac Rehabilitation in the Older Population

Terence Kavanagh, MD, FRCPC, DSc(Hon), Associate Professor, Faculty of Medicine; Professor, Graduate School of Exercise Science, Faculty of Physical Education and Health, University of Toronto, Toronto, ON.

Coronary heart disease is a major cause of morbidity and mortality in older patients. For this population cardiac rehabilitation offers an improvement in functional capacity, alleviation of symptoms, enhanced mood state and quality of life, and a modification of coronary risk factors. The components of a comprehensive programme specific to older adults are the same as for younger patients, with exercise training the mainstay. However, the changes that accompany the aging process require some modification in both the aerobic and resistance exercise programmes. Unfortunately, the referral rate of older patients, particularly women, is poor. Hopefully, this could be rectified if physicians come to realize that this segment of the population is the most likely to benefit from cardiac rehabilitation.
Key words: cardiac rehabilitation, aging, exercise training, coronary heart disease, referral patterns.

Medication Review for Older Adults

Richard Holland, BA, BM BCh, DA, DPH, MFPH, PhD, Senior Lecturer in Public Health Medicine, School of Medicine Health Policy & Practice, University of East Anglia, Norwich, UK.
David Wright, BPharm, PhD, Senior Lecturer in Pharmacy Practice, School of Chemistry and Pharmacy, University of East Anglia, Norwich, UK.

Older people consume a disproportionate quantity of drugs compared to younger people. Furthermore, the volume and cost of these drugs is increasing markedly. In theory, drugs are prescribed to reduce both morbidity and mortality but can also cause harm, particularly amongst older people. Medication review has been advocated as a technique to reduce such problems, whilst at the same time ensuring patients gain maximum benefit from their drugs. Whilst medication review seems a logical solution to inappropriate prescribing in general and adverse reactions in particular, evidence that specific interventions are effective at reducing morbidity or mortality is lacking.
Key words: medication review, adverse drug reactions, medication appropriateness, pharmacists, background.