Promoting Healing of Diabetic Foot Ulcers

Oksana Davidovich, BSc, DCh (Chiropodist), Private Practice: Davisville Foot Clinic; President of the Ontario Society of Chiropodists, Toronto, ON.

Diabetic neuropathic foot ulcers, often a precursor to amputation, occur in high-pressure areas on the sole of the foot. Ulcer healing can be achieved through a combination of wound management and a variety of offloading modalities. Total contact casts and removable cast walkers are effective methods for facilitating wound closure. Alternatively, a wide range of temporary, weight-relief shoes and healing sandals are also effective in resolving active ulcers. Once the wound has healed, prevention strategies typically include custom-made, modified, or premade orthopedic shoes used in conjunction with foot orthoses, as well as a regular podiatric examination to screen for potential complications.

Key words: diabetic foot, foot ulcer, cast, orthopedic footwear, foot orthoses.

Management of Diabetic Foot Ulcers

Madhuri Reddy, MD, MSc, FRCPC, Assistant Professor, Department of Medicine,
University of Toronto, Associate Editor, Geriatrics & Aging, Toronto, ON.

R. Gary Sibbald, BSc, MD, FRCPC (Med), FRCPC (Derm), MACP, DABD, Associate Professor and Director of Continuing Education, Department of Medicine, University of Toronto, Toronto, ON.

Prevention of diabetic foot wounds is of crucial importance. Diabetic foot wounds are basically pressure ulcers due to improper footwear, and therefore the most critical aspect of prevention is wearing proper shoes, checked regularly by a reputable orthotist. Once foot wounds have occurred in a person with diabetes, proper footwear continues to be
crucial. Also of importance are adequate vascular supply, treatment of infection, and surgical debridement, if necessary. All diabetic foot wounds should be probed in order to evaluate depth. If the wound probes to bone, osteomyelitis should be presumed unless proven otherwise.

Key words: diabetes, wounds, ulcers, vascular, infection.

Diagnosis and Management of Impaired Glucose Tolerance and Impaired Fasting Glucose

Shobha Rao, MD, Assistant Professor, Department of Family Practice and Community Medicine, UT Southwestern, Dallas, TX, USA.

Impaired glucose tolerance and impaired fasting glucose (prediabetes) form an intermediate stage in the natural history of diabetes. People with prediabetes are at high risk for developing diabetes and thus are a key target group for primary prevention of the disease. A structured program of lifestyle interventions that includes weight loss and regular exercise has demonstrated benefit in delaying or preventing diabetes among people with prediabetes. Lifestyle interventions are most effective. Pharmacotherapy with metformin, acarbose, orlistat, and thiazolidinediones has also shown success in preventing diabetes, although cost effectiveness of these agents in managing prediabetes has not been assessed.

Key words: prediabetes, screening, primary prevention, impaired glucose tolerance, impaired fasting glucose.

Treating Dyslipidemia and Hypertension in the Older Person with Diabetes: An Evidence-Based Review

Raymond Fung, MD, BSc, Fellow, Division of Endocrinology, University of Toronto, Toronto, ON.

Lorraine L. Lipscombe, MD, FRCPC, Clinical Associate, Research Fellow, Division of Endocrinology, Sunnybrook and Women’s College Health Sciences Centre, University of Toronto, Toronto, ON.

The prevalence of diabetes has been increasing significantly in the last several years, especially in the older population. Cardiovascular disease (CVD) represents the most important complication of diabetes in this age group, as up to 80% of persons with diabetes die from CVD. The treatment of dyslipidemia and hypertension are both key in ameliorating CVD risk. Recent randomized controlled trials have included older persons with diabetes and have demonstrated that both statin therapy for dyslipidemia and antihypertensive agents are highly effective and safe in preventing CVD in this population. This review will examine the evidence for treatment in both areas, outlining the special considerations in the aged.

Key words: diabetes mellitus, cardiovascular disease, statins, hypertension, cholesterol.

CME: Stepwise Approach to the Treatment of Diabetes 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

Diabetes mellitus (DM) is a very common condition in the older population. The disease may interact with other medical conditions that increase the degree of frailty in aging adults. Nonpharmacological and pharmacological interventions are the usual steps in managing of DM. In this article, a stepwise treatment strategy will be suggested after a review of the pertinent literature.

Key words: diabetes mellitus, older adult, diet, exercise, pharmacotherapy.

Daniel Tessier MD, MSc, Head of Geriatric Services, Sherbrooke Geriatric University Institute, Sherbrooke, QC.

Diagnosis and Management of Diastolic Heart Failure

Diego H. Delgado, MD, Division of Cardiology and Transplant, Toronto General Hospital, Toronto, ON.

The incidence of heart failure is rising rapidly, and it is currently the most common cardiovascular disease. Approximately 20–40% of patients with heart failure have preserved left ventricular systolic function, and an impairment of ventricular relaxation is considered the primary cause. There is controversy surrounding the definition of diastolic dysfunction and the diagnostic criteria for diastolic heart failure. Moreover, there are few studies on therapy for diastolic heart failure, which makes the management of these patients a real challenge.

Key words: heart failure, treatment, diagnosis, diastolic dysfunction.

Bronchiectasis in Older Adults

Nasreen Khalil, MD, FRCPC, FCCP, Associate Professor of Medicine, The University of British Columbia, Jack Bell Research Centre, Vancouver, BC.

Bronchiectasis is an anatomic abnormality of the airway characterized by irreversible dilatation and thickening of the airway wall. The most common etiology in older patients appears to be a previous pulmonary infection. Prior to the antibiotic era the age group most frequently affected by bronchiectasis was young children. Currently, bronchiectasis is seen primarily in individuals between the ages of 60 and 80. Pseudomonas aeruginosa and Hemophilus influenza are the most commonly isolated pathogens in the sputum of bronchiectatic patients. Treatment consists of ruling out reversible or correctible causes, commencing antibiotic therapy, and improving bronchial hygiene.

Key words: bronchiectasis, chronic cough, chronic sputum, mucociliary, immunodeficiency.

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.

Radiation Therapy in Older Adults

Loren K. Mell, MD, Department of Radiation and Cellular Oncology, University of Chicago and the University of Illinois at Chicago, Chicago, IL, USA.

Arno J. Mundt, MD, Department of Radiation and Cellular Oncology, University of Chicago and the University of Illinois at Chicago, Chicago, IL, USA.

Radiation therapy (RT) is commonly used in the treatment of older cancer patients. RT may be used as definitive therapy for benign or malignant tumours, as adjuvant therapy with surgery and/or chemotherapy, as palliative therapy when cure is no longer possible, and as alternative to surgery in patients with multiple comorbidities. However, RT is often not given to older patients who might benefit from it, due to biases, misapprehensions about potential toxicity, and social factors particular to this patient population. The preponderance of data suggest that RT is well tolerated in older adults and treatment decisions should be based on prognostic factors irrespective of age. Emerging RT technologies may particularly benefit aged patients by reducing potential toxicities, shortening treatment times, and improving tumour control.

Key words: age, radiation therapy, toxicity, cancer, procedures.

Artificial Nutrition and Hydration in the Management of End-Stage Dementias

Rory Fisher, MB, FRCP(Ed)(C), Professor Emeritus, Department of Medicine, University of Toronto, Toronto, ON.

Eoin Connolly, MA, Clinical Ethics Fellow, Joint Centre for Bioethics, University of Toronto, Toronto, ON.

Canada's aging population makes appropriate end-of-life care a priority. Alzheimer's disease and related dementias become increasingly common with aging. The terminal stages are characterized by severe cognitive and physical incapacity with a poor prognosis. Artificial nutrition and hydration may be provided by feeding tubes; however, there is no
evidence of benefit, and there are significant side effects to be considered. Barriers to appropriate end-of-life decision making are identified, and current evidence indicates that this patient population should be treated with appropriate palliative care.

Key words: Alzheimer’s disease, artificial nutrition and hydration, dementia, end-of-life care, ethics.