Aspiration Pneumonia among Older Adults

R.A. Harrison, MD, FRCPC, Department of Internal Medicine and Division of Infectious Diseases, University of Alberta, Edmonton, AB.
T.J. Marrie, MD, FRCPC, Department of Internal Medicine and Division of Infectious Diseases, University of Alberta, Edmonton, AB.

Among older adults, aspiration pneumonia is associated with higher rates of morbidity and mortality than community-acquired pneumonia. Individuals admitted to acute care from continuing care facilities are at increased risk for aspiration pneumonia. Risk factor assessment forms a cornerstone in diagnosing aspiration pneumonia syndromes. Monitoring for timely clinical response to therapy and for potential complications is an important step in the care of patients with aspiration pneumonia. Further high-quality research is needed to better delineate the effects of risk factor modification on the incidence of aspiration pneumonia. Aiming to prevent aspiration pneumonia poses health care providers with an opportunity for ongoing development, study, and implementation of preventive strategies for older adults.
Key words: aspiration, pneumonia, older adults, geriatric, risk factor.

The Tuberculin Skin Test in Long-Term Care Facilities

Miguel G. Madariaga, MD, Assistant Professor of Medicine, Section of Infectious Diseases, University of Nebraska Medical Center, Omaha, NE, USA.
Philip W. Smith, MD, Professor of Medicine and Division Chief, Section of Infectious Diseases, University of Nebraska Medical Center, Omaha, NE, USA.

Tuberculosis is a re-emerging public health threat. This article discusses the particular characteristics of tuberculosis among older adults and the use of the tuberculin skin test as a tool for diagnosis of tuberculosis infection with emphasis in long-term care facility residents. An overview of new diagnostic tests based on gamma interferon release is also included.
Key words: tuberculosis, tuberculin skin test, long-term care facilities, purified protein derivative.

Pulmonary Arterial Hypertension in Older Adults: An Update

Suzanne Bridge, MD, Internal Medicine Program, University of Toronto, Toronto, ON.
John Granton, MD, FRCPC, Associate Professor of Medicine, Faculty of Medicine, University of Toronto; Director, Pulmonary Hypertension Program, Toronto General Hospital, Toronto, ON.

Pulmonary arterial hypertension is a rare but incurable disease characterized by a progressive increase in pulmonary vascular resistance and ultimately dysfunction of the right ventricle. Clinically, the reduction in right ventricular output and ensuing right ventricular failure causes severe physical limitation, reduced quality of life, and increased mortality. With the present use of directed therapies such as prostanoids, prognosis is slowly improving. Currently, unique challenges in both clinical assessment and management arise as the population of patients with pulmonary arterial hypertension ages and we better recognize the spectrum of this disease in older adults.
Key words: Pulmonary arterial hypertension, echocardiogram, dyspnea, bone morphogenic protein receptor type-2, prostanoids, endothelin.

Long-term Care–acquired Pneumonia among Older Adults

Mohammed Al Houqani, MBBS, Department of Medicine, University of Toronto, Toronto, ON.
Theodore K. Marras, MD, FRCPC, Attending Staff, Division of Respirology, Department of Medicine, University Health Network and Mount Sinai Hospital; Assistant Professor of Medicine, University of Toronto, Toronto, ON.

Long-term care-acquired pneumonia is a clinical syndrome of pneumonia that develops in a resident of a long-term care facility who has not been recently hospitalized. It is one of the leading causes of mortality and morbidity among the residents of long-term care facilities. Streptococcus pneumonia, Haemophils influenza, and Moraxella catarrhalis are the most frequently identified bacterial causative. Poor oral hygiene increases the risk of long-term care-acquired pneumonia. In this review, we discuss the risk factors, pathogenesis, etiology, management, and the preventive measures for long-term care-acquired pneumonia.
Key words: Long-term care, nursing home, health care facilities, pneumonia, fluoroquinolones.

Chronic Obstructive Pulmonary Disease in the Older Adult: New Approaches to an Old Disease

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

Andrew McIvor MD, MSc, FRCP, Professor of Medicine, McMaster University; Firestone Institute for Respiratory Health, St Joseph’s Healthcare, Hamilton, ON.

At present, some 750,000 Canadians are known to have chronic obstructive pulmonary disease (COPD). This number is believed to represent the tip of the iceberg, as COPD is often only diagnosed in the advanced stage. Respiratory symptoms or a previous smoking history are common among older adults yet they seldom trigger further assessment for COPD. Objective demonstration of airflow obstruction by spirometry is a simple procedure, even in older adults, and is the gold standard for diagnosis of COPD. Early intervention with routine nonpharmacological management includes partnering with the patient and family, providing education, smoking cessation, vaccination, collaborative self-management, and advice on exercise and pulmonary rehabilitation. Anticholinergic inhalers remain the gold standard for optimal bronchodilation and dyspnea relief in COPD, and new long-acting agents have underpinned new treatment algorithms, improving quality of life and exercise capacity as well as reducing exacerbations. For those with advanced disease, recent trials have reported further benefits with the addition of combination inhalers (inhaled corticosteroid and long-acting B2-agonist) to core anticholinergic treatment. Physicians and patients can expect a promising future for COPD treatment as significant advances in management and improved outcomes in COPD are now being made.
Key words: chronic obstructive pulmonary disease, older adults, spirometry, diagnosis, management.

Focus on Lung Disease: Reducing Morbidity and Mortality among Older Adults

When I was an intern, my first attending physician was a respirologist, who taught me that the major function of the heart was to separate the two lungs. As he later went on to become a physician-in-chief, then the Eaton Professor of Medicine at University of Toronto, and finally Dean of Medicine, he must have been correct. Although cardiovascular disease and cancer remain the most common causes of death among older adults, lung disease causes substantial morbidity and mortality as well. Cigarette smoking, the single most important factor in lung disease among older adults, remains a major societal problem despite a substantial decrease in prevalence over the last 40 years.

Our CME program this month is based on the article by Dr. Andrew McIvor, “Chronic Obstructive Pulmonary Disease in the Older Adult: New Approaches to an Old Disease.” For those of us who see patients in the emergency room, or work in long-term care or complex continuing care, the issue of long-term care-acquired pneumonia is incredibly common. Dr. Ted Marras and Dr. Mohammed Al Houqani review this topic in their article “Long-term Care-acquired Pneumonia among Older Adults.” Dr. John Granton and Dr. Suzanne Bridge have collaborated in an article on a disorder that is frequently diagnosed very late in its course titled “Pulmonary Arterial Hypertension in Older Adults: An Update.”

Our cardiovascular disease column this month is on “Syncope in Older Adults” and is written by Dr. Maxime Lamarre-Cliche. We also have the second of a two-part series on dementia by Dr. Abi Rayner entitled “Managing Psychotic Symptoms in the Older Patient.” Our Drugs & Aging feature this month is on “Incontinence among Older Adults” by Drs. David Staskin, Edward Zoltan and Alan Wein. We have an article on technology in medicine by Pooja Viswanathan, Jennifer Boger, Dr. Jesse Hoey, Pantelis Elinas and Dr. Alex Mihailidis called “The Future of Wheelchairs: Intelligent Collision Avoidance and Navigation Assistance.”

Enjoy this issue,

Barry Goldlist

Diagnosis and Management of Lung Cancer in Older Adults

Natasha B. Leighl, MD, FRCPC, Assistant Professor of Medicine, Division of Medical Oncology, Princess Margaret Hospital/University Health Network; Department of Medicine, University of Toronto, Toronto, ON.

Lung cancer is the leading cause of cancer-related mortality in North America and most commonly affects older patients. Patterns of investigation and treatment in older individuals differ, which may compromise outcome. Older patients should be carefully evaluated, using comprehensive geriatric assessment, to assess for function, functional reserve, comorbidities, polypharmacy, and other issues. Fit patients with few or no comorbidities should be offered standard treatments such as surgical resection for early-stage lung cancer with adjuvant chemotherapy, combined modality treatment (chemotherapy and radiation) for locally advanced disease, and systemic chemotherapy with supportive care for metastatic disease. Frail patients should be reviewed to optimize function and comorbid illnesses, and then considered for other treatment alternatives aimed at minimizing toxicity while still trying to maximize the curative or palliative potential of lung cancer therapy depending upon disease stage.
Key words: lung cancer, aging, chemotherapy, surgery, radiation, treatment.

Asthma in Older Adults

Sidney S. Braman, MD, FACP, FCCP, Professor of Medicine, Division of Pulmonary and Critical Care Medicine, Brown Medical School & Rhode Island Hospital, Providence, RI, USA.

Asthma is an inflammatory disease of the airways manifested by diffuse airflow obstruction, complete or partial reversibility of the airflow obstruction, and bronchial hyper-responsiveness. Asthma may occur at any age and is more prevalent in older compared to younger adults. Unfortunately, the diagnosis of asthma is frequently overlooked as patients underreport their symptoms, physicians underutilize pulmonary function testing, and symptoms are mistaken for other diseases such as COPD and heart failure. The medications used to treat the older asthmatic are effective, well tolerated, and the same as those used to treat younger patients.
Key words: asthma, reversible airflow obstruction, airway remodelling, beta-agonist therapy, inhaled corticosteroids.