Screaming in Dementia

Nages Nagaratnam, MD, FRCP, FRACP, FRCPA, FACC, Consultant Physician in
Geriatric Medicine, Formerly of Department of Geriatric Medicine, Blacktown-Mt-Druitt Health, Blacktown, NSW, AUS.
Kujan Nagaratnam, MB, FRACP, Consultant Physician in Geriatric Medicine, Department of Geriatric Medicine, Blacktown-Mt Health, Blacktown, NSW, AUS.

Screaming is widely viewed as a common behavioural disturbance in dementia. It influences the performance in daily life of the patient, adds to the burden and embarrassment experienced by the caregiver and the frustrations encountered by the treating physician, and is a decisive factor for institutionalization. This article outlines an approach to screaming and its possible neuroanatomical substrates and neurotransmitter systems. The ultimate basis for discussion will be the strategies available for management of this challenging behaviour.

Key words: screaming, disruptive vocalization, dementia, limbic system, frontal-subcortical circuitry.

Surgical Interventions for COPD

Max Huang, MD, FRCPC, Respirology Fellow, Division of Respirology, Department of Medicine, University of Toronto, Toronto, ON.
Lianne G. Singer, MD, FRCPC, Medical Director, Toronto Lung Transplant Program, University Health Network; Assistant Professor, Department of Medicine, University of Toronto, Toronto, ON.

Chronic obstructive pulmonary disease (COPD) often has a profound effect upon the quality of life and mortality of the older adult. Despite numerous medical treatments, surgery may be considered for the symptomatic patient with medically-optimized, end-stage COPD. Bullectomy, lung volume reduction surgery (LVRS), and lung transplantation have all proven to be important surgical therapies. This article reviews the current state of these interventions, and the criteria when deciding on the best surgical option for a given patient.

Key words: emphysema, COPD, lung transplant, lung volume reduction surgery, bullectomy.

Diagnosis and Treatment of Pericarditis in the Aged

Kristopher S. Cunningham, MD, PhD, University Health Network, University of Toronto, Department of Pathology, Toronto, ON.
Sharmi Shafi, BSc, University of Toronto, Toronto, ON.
Mellitta Mezony, MD, FRCPC, Mount Sinai Hospital, Department of Cardiology, Toronto, ON.
Molly Thangaroopan, MD, FRCPC, University Health Network, University of Toronto, Department of Cardiology, Toronto, ON.
Jagdish Butany, MBBS, MS, FRCPC, University Health Network, University of Toronto, Department of Pathology, Toronto, ON.

Pericardial inflammation is a familiar but uncommon cause of chest pain. The classic triad of retrosternal chest pain, pericardial friction rub, and serial ECG changes facilitates diagnosis of pericarditis, the etiology most often being idiopathic in nature. Because older adults more frequently contend with multiple conditions that may require cardiovascular surgical intervention, receive numerous medications, or result in an immunocompromised state, other important causes of pericarditis need to b e considered. This article considers pericarditis in the older population and emphasizes diagnosis and management of this condition. Situations common to this age group that require special attention to the appropriate treatment are also discussed.

Key words: pericarditis, pericardium, heart, inflammation, tamponade.

Lumbar Spinal Stenosis: Evidence for Treatment

David L. Snyder, PhD, Senior Research Analyst, Evidence-Based Practice Center, ECRI, Plymouth Meeting, PA, USA.
David Doggett, PhD, Senior Research Analyst, Evidence-Based Practice Center, ECRI, Plymouth Meeting, PA, USA.
Charles Turkelson, PhD, Chief Research Analyst and Director, Evidence-Based Practice Center, ECRI, Plymouth Meeting, PA, USA.

Degenerative lumbar spinal stenosis is a common problem among older adults. Stenotic compression of spinal nerves can result in low back pain, disabling leg pain, and greatly restricted walking capacity. Conservative therapies are usually prescribed for mild symptoms and surgery is prescribed for severe symptoms, while patients with moderate symptoms may not have an obvious treatment choice. The clinical evidence supporting these treatment options has been criticized because of problems with study design and quality that complicate their assessment. Despite the poor quality of most of the literature, recent studies provide better information and a means of starting to judge the effectiveness of treatment.

Key words: lumbar spinal stenosis, neurogenic claudication, conservative therapy, surgical intervention.

The Evaluation and Treatment of Low Back Pain in Older Adults

Arto Herno, MD, PhD, Senior Consultant, Department of Physical and Rehabilitation Medicine, Kuopio University Hospital, Kuopio, Finland.

The degeneration of the lumbar spine is strongly associated with aging, but this does not mean that pain is an unavoidable accompaniment (though the recorded incidence of low back pain suggests otherwise). Recently, more attention has been drawn to the problem of changes related to the aging of our musculoskeletal system and the associated socioeconomic implications. We now have advanced equipment to examine patients and our store of knowledge is enormous, but the application of this knowledge to a working practical plan at the individual level is problematic. Understanding the automatism of the normal function of the lumbar spine is essential for treating mechanical low back pain because the main goal is to correct this functional disorder. However, the long-term goal of treatment should be to involve patients in their back disorder management.

Key words: aging, degeneration, lumbar spine, low back pain, exercise.

Inflammatory Musculoskeletal Conditions in Older Adults

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

Jerry Tenenbaum, MD, FRCPC, Professor of Medicine, University of Toronto; Consultant in Rheumatology, Mount Sinai Hospital, University Health Network, Baycrest Geriatric Centre, Toronto, ON.

Musculoskeletal inflammatory conditions in the older patient cover the spectrum of those conditions affecting all age groups to those that are associated with advanced age. Polymyalgia rheumatica and pseudogout are two conditions which are seen predominately in older adults. While gout occurs more often in males in younger patients, both genders may present in the older population. Myositis in an older patient is more likely to be associated with neoplasia, so a search for common tumours should comprise part of the workup of that patient. Hypertrophic pulmonary osteoarthropathy associated with malignancy should be considered in the older patient who presents with arthritis, long bone pain, and clubbing. Osteoarthritis is by far the most common arthritis in the older population. It is important to identify those patients who have clinical features of inflammation in order to provide that subgroup with appropriate anti-inflammatory treatment.

Key words: polymyalgia rheumatica, pseudogout, synovitis, osteoarthritis, myositis.

Translating Evidence into Clinical Practice: A Falls Prevention Program for Community-Dwelling Seniors

Susan Maddock, RPT, Specialized Geriatric Services, Sunnybrook & Women’s College Health Sciences Centre, University of Toronto, Toronto, ON.

Susan Gal, BScPE, BHScPT, Specialized Geriatric Services, Sunnybrook & Women’s College Health Sciences Centre, University of Toronto, Toronto, ON.

MaryJane McIntyre, BScPT, Specialized Geriatric Services, Sunnybrook & Women’s College Health Sciences Centre, University of Toronto, Toronto, ON.

Rory H. Fisher, MB, FRCP(Ed)(C), Division of Geriatric Medicine, Department of Medicine, Sunnybrook & Women’s College Health Sciences Centre, University of Toronto, Toronto, ON.

Barbara A. Liu, MD, FRCPC, Division of Geriatric Medicine, Department of Medicine, Sunnybrook & Women’s College Health Sciences Centre, University of Toronto; Program Director, Regional Geriatric Program of Toronto, Toronto, ON.

The Falls Prevention Program at Sunnybrook & Women’s College Health Sciences Centre was developed to provide patients with an evidence-based, multidisciplinary intervention to prevent falls. The goals of the program are to decrease the incidence of falls and improve patient confidence. Participants in the program are 65 or older with a history of falls or near-falls and are living in the community. Participants complete a 45-minute exercise circuit, twice a week for six weeks. In addition, patients undergo geriatric medical assessment and are seen by an occupational therapist for home safety education. Patients report fewer falls during the intervention and at follow-up, and subjectively report that they benefit from the program. The positive effects of this program support existing evidence that multidisciplinary intervention plays an important role in fall prevention.

Key words: falls prevention, older adults, exercise, balance, multidisciplinary, physiotherapy.

Management of the At-Risk Patient with Osteoarthritis

Alan D. Bell, MD, Department of Family and Community Medicine, Humber River Regional Hospital, Toronto, ON.

Douglas C. Conaway, MD, Section of Rheumatology, Carolina Health Specialists, Myrtle Beach, SC, USA.

Recent disclosures of cardiovascular safety issues with medications that have become mainstays of osteoarthritis management have compelled clinicians to reconsider treatment approaches. This new information must be taken into account along with the well-known risk of gastrointestinal complications associated with nonsteroidal anti-inflammatory drugs. Consequently, clinical management of osteoarthritis pain in older patients requires careful evaluation and consideration of the individual patient’s risk factors. Co-therapy with proton pump inhibitors has demonstrated reductions in endoscopic gastropathy, but clinical outcome trials are lacking. For all treatment decisions, monitoring of patients’ responses to therapy is crucial for optimizing long-term safety and efficacy outcomes.

Key words: osteoarthritis, drug therapy, nonsteroidal anti-inflammatory drugs, cyclo-oxygenase-2 inhibitors.

Using the C.A.R.E. Approach: Supporting Family Caregivers of Dementia Patients

Penny Pashby, MSW, RSW, Social Worker, Geriatric Program, Toronto Rehabilitation Institute, Toronto, ON.

Marcia Zalev, MSW, RSW, Social Worker, University Health Network Memory Clinic, Toronto, ON.

The complex issues faced by the family caregivers of dementia patients present many challenges for their physicians. The C.A.R.E. strategy provides a guideline for an effective approach to these challenges while strengthening the relationship of physicians with the caregivers in their practice.

Key words: family caregivers, well-being, stress, dementia care, physician role.

ABCs of Prescribing Antianginal Therapy in Chronic Stable Angina

David Fitchett MD, FRCP(C), Cardiologist, St Michael’s Hospital, Associate Professor of Medicine, University of Toronto, ON.

Chronic stable angina is a common condition in older patients. Although lifestyle modifications such as weight loss, smoking cessation, and risk factor control remain fundamental components of the management strategy, pharmacological agents are necessary to prevent and control anginal symptoms. Sublingual nitroglycerin (either as tablets or a spray) is the most effective agent to terminate an episode of anginal pain. Anginal frequency and exercise tolerance are improved with beta-adrenergic blockers, calcium channel blockers, and long-acting nitrate preparations. A strategy for the optimal use of these agents both alone and in combination is discussed.

Key words: angina pectoris, nitrates, beta-blockers, calcium channel blockers.