Evidence-Based Medicine Guidelines

Editor-in-Chief: Ilkka Kunnamo
Publisher: Duodecim Medical Publications (March 2005)
Reviewer: Meteb Al-Foheidi, Medical Resident, University of Toronto

When I was originally asked to review this book, I anticipated examining a pocket-sized guide, but I was surprised to receive a textbook-sized volume running1,311 pages.

When I started to review this book, I tried to cover some topics that I knew and others that I had little knowledge about. At the time I delved in I was doing my emergency medicine rotation, where I was exposed to a wide variety of surgical and medical emergencies in an urban academic hospital. I planned to check every case that I encountered in the Emergency Room with the information contained in the book. For instance, I had an allergic rhinitis case, and I went looking for this in the book. In this and other cases, the text proved to be a good resource: the material was informative and clear, and it provided me with the ARIA guidelines and classifications.

The guide is further enhanced by its thorough forward, preface, and list of abbreviations. It also features good-quality cover design and material.
However, readers should be aware of a few flaws. First, I noted several spelling mistakes (for example, the word “Pheo” was written as “feo”). Second, main chapters were not categorized properly for easy searching. Generally, each chapter dealt with a specialty (e.g., cardiology or pediatrics). But there were some chapters that should have been subchapters within specific specialties: diabetes should fall under endocrinology and birth control under obstetrics and gynecology. While they were likely allotted their own chapters because they are extensively studied conditions or categories, I found it poor on the level of organization.

Furthermore, sections under chapters were improperly categorized. This may cause confusion or even make it difficult to find the information easily without going through all of the contents’ subsections. For instance, page 89 featured material about Hospital Investigations. The first point referred readers to a page still further ahead, page 100, which was about “Secondary Hypertension.” Sending readers back and forth to read about one subject should be avoided.
Other examples of poor organization included chapter content. Some chapters were diseases and others were symptoms. For example, Pulmonary Diseases started with Hemoptysis. Etiologies such as infections, tumours, cardiovascular disease, trauma, etc., were discussed. Then under Differential Diagnosis, the authors addressed the importance of the patient’s history, clinical examinations, and chest x-ray, which are essential for differential diagnosis. As another example of disorganization, the writers opted to explore specific diseases of the respiratory system within a chapter dealing with a symptom.

Some chapters were not evidence-based such as Occupational Health and Pollution—a concern in a text devoted to evidence-based guidelines.
Regarding references: the textbook mentioned only grading references, but no tables or summary and references were listed at the end of each section. In my opinion, this kind of book should contain tables, easy-to-follow flow charts, and summaries that are specific to that section.

The book should have been devoted to guidelines only, based on the title, but the authors/editors went beyond that and added information that one would only find in general medical textbooks and reference guides, such as adding detailed definitions, epidemiology, clinical presentations, and investigations that lacked connection to either guidelines or to evidence-based medicine. Thus the book deviates from its title and is a hybrid of evidence-based guidelines and a standard textbook.

My overall assessment of this book: I believe it will be helpful for the generalists for whom this book was intended. As for me, I will keep this copy on my shelf and I will use it for topics outside my specialty, internal medicine. It will be more useful as a general reference for me in other areas such as surgery, pediatrics, and so forth.

Effective Physician-Patient Communication at The End of Life: What Patients Want to Hear and How to Say It

Wendy Duggleby, DSN, RN, AOCN, Associate Professor, College of Nursing, University of Saskatchewan, Saskatoon, SK.
David Popkin, BSc, MD, CM, FRCSC, FSOGC, FACOG, Executive Director, Saskatoon Cancer Center; Head, Division of Oncology, College of Medicine, University of Saskatchewan; Head, Department of Oncology, Saskatoon Health Region, Saskatoon, SK.

What is it that patients at the end of life want to know? What is the best way to provide the information? A review of the scientific literature was conducted to answer these two questions. The findings suggested that, regardless of age or culture, patients at the end of life wanted information about their illness and prognosis. The expertise of the physician, his/her relationship with the patient, and the use of hopeful communication styles were important factors in how patients understood the information provided. Honest and factual communication fostered hope and quality of life at the end of life.
Key words: physician-patient communication, end of life, literature review, palliative care.

Parenting Your Parents, 2nd Edition

Authors: Bart J. Mindszenthy and Michael Gordon, MD
Publisher: The Dundurn Group, Toronto, ON.

Reviewed by Hazel Sebastian, MSW, RSW, Social Worker, Regional Geriatric Program, Toronto Rehabilitation Institute, Toronto, ON.

Although “Parenting Your Parents” is directed to families, care providers, policy designers, and professionals who assist them can also learn from reading this remarkably moving book. Readers will find significant insight into end-of-life challenges faced by care receivers and providers. Since adult children often feel unprepared for the task of helping their aging parents, they will find the authors’ description and discussions of this daunting task through stories of nineteen Canadian families extremely useful. The authors--Dr. Michael Gordon, a renowned geriatrician, and his coauthor Bart Mindszenthy--reflect on the details of providing care with all of its struggles and rewards, blending their extensive professional and personal family experiences. The second edition includes an expanded personal parenting planner and an updated resource directory for every province in Canada.

The nineteen case studies delve into the everyday life of family caregivers and their parents, their journey of love and pain, and the hope that they have made appropriate decisions along the way. There is plenty of room to make mistakes while venturing into this unfamiliar world of care providing. A close partnership between the family caregivers and health care professionals will prevent premature institutionalization, and increase the longevity of the caregiver and care recipient relationship.

These stories of families are selected from diverse family backgrounds, faiths, and cultures from different provinces of Canada. The end-of-life care concerns and trials they face often test the true strength of the family relationships. These intimate stories describe unpredictable events in their lives and the need for flexible, creative ways to deal with them. They inform the caregivers to pace themselves to go through a journey of caregiving that may last decades; in addition, caregivers will feel that these stories validate their expectations and personal feelings of failures and successes. The book identifies some of the controversies encountered with siblings and health care professionals, and it captures the unanticipated emotions experienced in the huge responsibility of providing daily care.

The caregiving experiences in this book chronicle different paths but they do not claim to cover every family situation. Still, families facing completely different problems can benefit from reading the book and discovering helpful advice in various segments; it may stimulate lateral thinking to address unique issues that confront other families.

The “Healthcare Professional Point of View” presented after each case study offers alternative approaches to resolving crisis points and emphasizes the usefulness of seeking early professional interventions. A delay in seeking professional assistance can unnecessarily increase the stress on parents and care providers. Timely assistance from home health care providers, learning the strategies targeting challenging behaviours, and environmental modifications can contribute to more successful coping. The professionals reading the book may find the richness of the text gently probing the limit of their knowledge and skill level. It will encourage a professional to find creative ways to work around restrictive agency policies and improve his or her repertoire.

The “Personal Parenting Planner” is particularly important for use in care mapping. It creates a cognitive and conceptual space for caregivers to raise questions and resolve problems. It strengthens the planning by focusing on the areas and details not always included. The use of the parenting planner is therapeutic for those who feel overwhelmed by the responsibilities and consumed by caring duties. It brings a sense of control and direction to the whole process.

The updated directory of resources will assist in finding the help needed. It will reduce the time spent to identify services in the community. The list includes a wide range of general resources, services for special needs, driving capability assessments, and home modification. It outlines the procedures to follow to access publicly funded federal and provincial services, and private agencies that can supplement the care. The suggestions for long-term care placement planning assist anyone who is helping the parents, either locally or from a long distance.

The title Parenting Your Parents suggests the role adult children have to assume to assist parents when they become frail. According to the authors of this book it is a common phenomenon around the world, but this book examines the familial and societal issues in Canada. To be successful, it advocates for a balance in all areas of a care provider’s life and careful planning. The help given effectively and lovingly to parents has many similarities to the role of parenting children. There are also important differences. Since the parents enjoy the authority and advantage of many more years of life experience, they will expect to have the final say in all the decisions affecting them or they may delegate. To minimise the role conflict and the parent’s feelings of loss of control, there is a need to respect the boundaries of the parent-child relationship.

The personal experiences of parents depending on their adult children at the end of their life to provide physical and emotional care fill the pages of this extraordinary book. The value of the book is in its creation as a guide for seasoned caregivers who are struggling to cope at times with the responsibilities, and to give practical advice to future caregivers. It’s also an invaluable resource for administrators of long-term care facilities, home care coordinators, and health care professionals. The contributions of this easy-to-read book are a definite addition to the existing information on caring. As a professional working with frail older rehabilitation clients and as a family caregiver for my mother, the book has inspired some new thinking and enabled me to reflect on ways to share the caregiving responsibilities with my siblings. It has also improved the quality of our interactions.

The Medical Professional’s Guide to Handheld Computing

Author: Chris Helopoulos
Publisher: Jones and Bartlett

Reviewed by Paul Arnold, MD, MCFP, Emergency Physician, University Health Network;
Faculty, Faculty of Medicine, University of Toronto, Toronto, ON.

If you were considering purchasing and using a handheld computer for professional use, what would you need to know to make good choices? The Medical Professional’s Guide to Handheld Computing by Chris Helopoulos makes a noble attempt to meet the challenge.
Mr. Helopoulos is a physician assistant and the assistant director of the Barry University Physician Assistant Program. He is a firm adherent of the “less can be more” school of writing. The text is brief, with an accessible writing style that avoids technical jargon. Its chapter structure is well organized by topic. The author encourages you to dip into the book and sample it like a buffet, partaking only of what you need or want. However, it is compact enough to read in an evening. The result is a very effective and enthusiastic primer on Palm™ handheld computing for medical workers. Regrettably, it isn’t made clear until one is well into the second chapter that the author intends to focus solely on Palm™ Personal Digital Assistants (PDAs), excluding Pocket PC devices altogether. This is a pity, as much of the medical software reviewed later in the book is applicable to both platforms, and Pocket PCs are a legitimate choice for health care workers.

With that said, the book addresses the needs of its target audience. Beginners will find solid suggestions and advice to help them choose a handheld. The more sophisticated user will find useful programs and medical references. The author also shares many insightful tips and tricks with a focus on medical users, making the book a useful reference tool.

The text is copiously illustrated with black and white screen shots so that the reader can gain an appreciation of what software is like during use. The illustrations lack descriptive captions but all are numbered and referenced in the text. There is no index of images.
Most of the book is devoted to exploring software. The chapter on the Palm™ built-in applications is thorough but repeats what can already be found in the Palm™ manuals. A broad range of third party programs is described, including utilities that enhance the functionality of Palm™ handheld computers. Beginners and experts alike will certainly find useful ideas and software in these chapters.
The accompanying CD has a wealth of programs, most of which date from 2003 and a few from 2002. Of course, newer versions of many of these programs have been released since the CD was prepared for publication, but the beauty of this compendium is that you can try out many programs without ransacking the Web. Updates are easily located online if a program seems promising. Note that some of the software is limited until a registration fee is paid to the developer (not the author of this book) but this won’t prevent one from thoroughly exploring the functions of most of them.

Time can be cruel to medical computing reference texts. For the most part, the author has wisely avoided detailed coverage of specific models. However, some material in this book is already out of date. For example, the author refers extensively to the defunct Handspring brand. These comments and instructions are not helpful to prospective owners. The book was also prepared before the latest versions of the Palm™ operating system were released. This is important because “hacks,” handy little utility programs that receive well-deserved attention in the book, won’t work on the newest devices.

It is also disappointing that Mr. Helopoulos neglects to mention how important it is to protect data before testing new software, in case things go awry. Backup software is one of the few important categories that aren’t included in the chapter on third party utilities. This is critically important for people who do serious work on their PDAs. There is very little discussion of patient tracking or charting SW, which is not acceptable in a guide for medical professionals. Moreover, there is no consideration of the topic of securing the data on handhelds, a particularly relevant subject in view of HIPAA and equivalent Canadian legislation regarding patient records and privacy.

A few words of caution for Canadian doctors and nurses: no mention is made of reference texts that use Canadian drug names, so the reader is required to look elsewhere for information on these products. Moreover, while the guide contains a modest glossary and an adequate index in the text, there is no index of web addresses (URLs) for the companies and software described in the book. That information is available on the CD but is poorly configured. One has to open Windows Explorer to find instructions on how to get at the software and to access the list of web sites that the author has included. This is an excellent resource but it is too well hidden.

This slim volume has some deficiencies if one is looking for help with data security or patient tracking software, but otherwise is a worthwhile tool for someone contemplating the purchase of a Palm™ handheld within the next year or so. To those interested in other handheld computer systems, this book will provide only some hints of what is possible, not what is actually available, for Pocket PC, Linux, or RIM Blackberry. Nonetheless, the guide offers substantial help to aid decision making and avoid setbacks. New or experienced PDA users will also appreciate the information about software and online resources that will enhance their use of these devices.

The reviewer has no commercial interest or conflict of interest with any developer of handheld computing equipment or software, but does publish a free monthly newsletter about Palm computing for medical professionals. The Medical Palm Review can be found online at medpalmrev.medtau.org.

Medical Meanings

A. Mark Clarfield, MD, Chief of Geriatrics, Soroka Hospital, Beersheba, Israel; Sidonie Hecht Professor of Geriatrics, Ben Gurion University of the Negev, Beersheba, Israel; Staff Geriatrician, Division of Geriatric Medicine, Sir Mortimer B. Davis - Jewish General Hospital, McGill University, Montreal, QC.

I am a great lover of words and, by extension, word origins. As a result, I own all kinds of dictionaries, thesauri, books of slang, and collections of aphorisms, quotations, and proverbs. Beside my bed on my night table all the days of my reading life has rested a dictionary. This silent sentinel awaits the moment that a word appears for which I do not know the meaning and/or origin.

And so it was that when I cast my eyes on a book dedicated to the etymology of medical terms, I actually read it from end to end.

The book, Medical Meanings, contains more than 3,000 entries over 253 pages from “A,” an abbreviation used in writing prescriptions and which means “of each,” all the way to “zyzzya,” which, as the author points out, is not really a medical term. It refers to a tropical American weevil destructive of plants and is not known to be harmful of itself to man. The astute reader may well ask, what has this term to do with medicine? The author, with a whimsy typical of the book, acknowledges the lacuna yet offers us the convincing rejoinder, “...but what better word with which to end a lexicon.”

The book’s author, William S. Haubrich, a gastroenterologist, is the author of more than 115 original and review articles in major medical journals. In addition to his other tasks, he put this book together as a labour of love. With typical irony, he quotes the 18th-century writer and dictionarist Samuel Johnson who defined a lexicographer as “a harmless drudge.” Dr. Haubrich asks aloud whether one who has compiled such a medical etymology as he has done “merits flattery as a lexicographer”.

In his introduction the author explains that he has chosen to offer us a word’s provenance rather than its precise definition, which is available in the less entertaining (my words) standard medical dictionary. He provides us examples of the fact that words may or may not maintain their meaning through the ages; examples: amnesia and artery. The former, originally from ancient Greek, meant “forgetfulness” and does to this day connote a lapse of memory.

In contrast, “artery” today obviously describes a vessel that conveys blood from the heart towards the periphery. However, its Greek precursor was derived from aer, “air,” and tereo, “I carry.” Thus to Greeks, arteria was a “windpipe.” The explanation for this discrepancy lies in the fact that before Harvey, early anatomists who dissected a human corpse would find the large arteries empty and mistakenly believed that they must have acted as air conduits.

As a geriatrician, I turned first to those words relevant to my specialty. Of interest is the fact that neither “age,” “aged,” nor “old” appear but both “geriatrics” and “gerontology” do. As I already did know, the former was coined by combining the Greek geron, “old man,” with iatreia, the “treatment of disease.” Of greater interest was the fact that the primitive Indo-European root of geron may have been gar, “to wear away”, or ger, “to mature, to grow old.” From these origins came the Latin granum, “grain”, in the sense that the grain is the ripe fruit of the mature plant.

Speaking of “iatro,” one of the classes of illnesses that plagues older adults, the term iatrogenic diseases is described. While “polypharmacy,” the most common form of doctor-induced illness, does not appear in the book, “pharmacy” does and comes from the Greek pharmakan, “a drug” meaning, in its day, a designation for remedies that were applied externally as salves and ointments but also as charms and poison. Given that geriatricians are so often called upon to treat older patients poisoned by the well-meant prescriptions of other doctors, the etymology of pharmacy does seem apt.

Two of my favourite terms given the subtle message implied by their word origins must be “dementia” and “delirium.”

The former is the Latin term for “madness” and is derived from a combination of de, “out of”, and mens, “mind,” and in neither the modern nor ancient word origins is there any suggestion of potential reversibility or treatability (from the point of view of “cure” to this day still regrettably the case).

On the other hand, “delirium,” a condition that is, at least sometimes, treatable (via the underlying cause) and even curable, enjoys a Latin derivation that implies a more optimistic prognosis.
De-, “away from”, and lira, “a furrow”, suggests, as Haubrich points out, that one who is acutely confused will not be capable of ploughing a straight furrow; alternatively, as someone who has gone off the track. In contradistinction to “dementia,” the word origin of delirium does offer some hope in that one may well be able to return to the straight and narrow.

Pressure sores comprise another of the geriatric giants, and the medical term “decubitus” ulcer is derived from the Latin verb decumbere, “to lie down,” and is related curiously enough to the Latin cubitum, “the elbow” (recall the “ante-cubital fossa”).

The connection to pressure sores? The Romans (and others in the ancient world--one recalls the pillows used during the Passover seder to allow one to recline as a “free man” at dinner) would rest on their elbows while reclining. Hence “decubitus” is a reclining position, often further specified as in the “left lateral decubitus position.”

Of the diseases that accompany but are not related specifically to old age, we find “angina,” “claudication,” and “cataract.” “Angina,” once again from the Latin for sore throat (my years of practice in la belle province taught me about “l’angine” for pharyngitis), is derived from the Latin verb angere, “to choke or throttle.” Add pectus, Latin for “chest,” and you have the crushing retrosternal pain associated with myocardial ischemia.

“Cataract” probably derives from the Greek kataraktes, meaning “something that rushes down.” To me, the connection seems a bit far-fetched with the idea being that the loss of vision associated with such pathology is likened to a closing window.

Lest the reader think that all medical terms originate from Latin and Greek roots, there are a goodly number listed that hail from other linguistic parts. Take for example “fart,” which, as pointed out, has a venerable origin in Old Teutonic as fertan, to break wind. Dr. Haubrich adds, in his own understated way, “I find euphonious Chaucer’s phrase, ‘...to flee a fart’.”

Further afield linguistically can be found bezoar, derived from medieval Arabic, which in turn entered that language from the ancient Persian podzahr. For the uninitiated, this term was the name given to a hairball extracted from the rectum of the wild Asiatic mountain goat. Why these ancient shepherds would feel the need to fiddle in these parts is not dealt with specifically.

Kalaazar is the Hindi name for “black fever,” endemic in the Assam province of India. Kuru is a word of the Fore people who live in the highlands of Papua, New Guinea, and Kwashiorker is a Ghanaian term for “displaced or strange child.”

Returning to Latin for my penultimate example, we find the ever-entertaining penis, which originally meant “tail” (pendere, “to hang down”). Not unlike their modern counterparts, the ancient Romans enjoyed and employed multiple monikers for the male sex organ. Listed are clava (“club”), gladum (“sword”), radix (“root”), ramus (“branch”), and vomer (“plough”).

Dr. Haubrich offers us a truly delightful compendium. In the book’s blurb, we are informed that he is the “Senior Consultant Emeritus” with the Scripps Clinic and he has considerately examined “emeritus” for us: “An honorific addition to the title of a person who has retired from the active ranks of the profession. The Latin emeritus is the past participle of emereri, (to earn by service). But I like the jocose explanation...derived from the Latin ex--meaning, out, and meritus, deserves to be.” (There is much truth to this self-
deprecating point. A letter that I wrote to Dr. Haubrich at the Scripps Clinic expressing how much I had enjoyed his book was first returned unceremoniously to me--with the word “moved” scrawled across the envelope).

Despite his modesty, the author deserves our admiration and thanks. My only criticism of the book is that it is too short. Even that nitpicking point is probably not justified as Dr. Haubrich offers us in the introduction that “[r]eaders who wish to dispute points....or who can suggest additions...are invited to write me forthwith. Your advice will be most kindly considered.”

And as Alice said (after Humpty stated that “There’s glory for you”), “I don’t know what you mean by ‘glory’.” Humpty: “I meant ‘there’s a nice knock-down argument for you!’ ” Alice objects: “But ‘glory’ doesn’t mean a ‘nice knock-down argument’.”

Humpty, in his most scornful tone: “It means just what I choose it to mean--neither more nor less.”

Highlights of the Geriatric Psychiatry and Geriatric Medicine Conference 2004: Bridging the Gap

Lesley McKarney, PhD, Editorial Director, Geriatrics & Aging

April 23-24, 2004
The conference explored ways in which the fields of geriatric medicine and geriatric psychiatry can work together more effectively to identify common grounds, share information, form vision and goals, build good relationships, integrate services and build a more comprehensive approach to health care.

Bridging the Gap (Dr. Goran Eryavec and Dr. Gabriel Chan)
In their opening presentation, Eryavec and Chan observed that individuals over the age of 85 are now the fastest growing segment of the Canadian population. Physicians and nurses are more often facing seniors with multiple disabilities and diseases such as dementia, delerium, arthritis, fall fractures and so on. The over 65 age group is placing a greater demand on community services, acute and long term care, yet there are inadequate resources to meet their needs in terms of medical expertise, funding, assessment and treatment beds. They proposed that

– In geriatric medicine, more focus is needed on prevention and early detection of diseases of the older population.

– In geriatric psychiatry, the rapid expansion of new medications and treatments for the mentally ill, and the increasing complexity of their medical conditions and comorbidities of the older population, require constant medical attention and review.

Emphasizing the theme of the conference, 'Bridging the Gap', Drs Chan and Eryavec suggest that different disciplines could work together to provide excellent overall health care to older adults through a more multidisciplinary approach to health promotion and detection, by providing more integrative health care delivery and better education of health care professionals, and by supporting family caregivers and encouraging more research.

Reducing the Risk of Dementia (Dr. Kam-Tong Yeung)
In his presentation, Yeung cited the risk factors for Alzheimer's Dementia (AD) as being a positive family history of dementia, gender (females are at greater risk than males), APOE genotype, less than six years of education, and Down's Syndrome. Arthritis, on the other hand, appears to be a protective factor.

According to a recent community autopsy series, the most common pathology in demented individuals is combined AD and CVD, and common risk factors for AD and Vascular dementia (VaD) include age, APOE 4 genotype, midlife hypertension, and cholesterol. Other risk factors that are modifiable include education, head injuries, vitamin B12 intake, alcohol consumption, and smoking, among others. Stroke increases the risk and severity of AD, Yeung explained, and stroke patients tend to present earlier and with more severity. He proposed that stroke prevention and hypertension treatment are logical strategies for reducing the risk of dementia. Lifestyle modifications (e.g., diet, exercise, weight reduction, alcohol consumption) and the use of statins and NSAIDs can also reduce stroke and AD risk.

Management of Behavioural Disturbances in Dementia (Dr. Nathan Herrman)
A long list of behavioural disturbances that are often associated with patients with dementia, including physical violence and aggression, are not included as part of the DSM IV diagnostic criteria of dementia, yet they pose a very serious management problem for caregivers, explained Herrman. Non-pharmacological approaches to behaviour management in dementia patients include altering the level of stimulation, bright light, environmental white noise, music therapy, pet therapy, activities, exercise, social interaction, and behaviour modification. He pointed out that there is very little evidence in the literature that these behavioural interventions are effective. Moreover, some studies have demonstrated that none of the pharmacologic, non-pharmacologic, or behavioural intervention techniques available are necessarily superior to one another.

Some dementia-related behaviours (for example, wandering) do not respond to pharmacological intervention, said Herrmann, and it is therefore advisable to carefully identify target symptoms that could benefit from pharmacological intervention. He stressed that particular caution must be used with the administration of typical antipyschotics due to numerous, well-documented side effects such as orthostatic hypotension, anticholinergic, and extrapyramidal effects.

There is also new evidence for a small but significant increased risk for cerebrovascular adverse events in dementia patients treated with the atypical antipsychotics, in particular olanzapine and risperidone. Nevertheless, atypical antipsychotics are still considered first-line therapy for behavioural disturbances in dementia patients, as well as SSRI's (citalopram), and cholinesterase inhibitors (donepezil). Second-line therapies include anticonvulsants (carbamazepine and possibly valproate), heterocyclic antidepressants (trazodone), SSRIs, and cholinesterase inhibitors. Lastly, Herrmann suggested that beta-blockers, benzodiazepines, and anxiolytics only be considered as third-line therapies in dementia patients.

Treatment of Geriatric Depression (Dr. Franklin Wong)
Wong highlighted the complexities surrounding the diagnosis and treatment of depression in older patients. It can be particularly difficult, he conveyed, to distinguish between depression as a result of bereavement and clinical depression. Wong often recommends a "wait and see approach" in such cases, except where patients are expressing suicidal ideation. Particular attention must be paid to suicide risk among all elderly patients, he stressed, as 12% of suicides in Canada each year occur in the over 65 age group, and this figure is largely considered an underestimate.

The question of whether the patient is exhibiting symptoms of depression, dementia, or both can often confound doctors. Wong suggested that any signs of depression should be treated first with medication, and the patient should be reassessed at a later time for continuing memory problems, which would indicate underlying dementia.

He also outlined the medical conditions and medications strongly associated with depression in older adults, and pointed out that when left untreated, depression can increase both the morbidity and mortality rates in patients with debilitating medical illnesses like cancer, IHD, CHF, post MI, and post CVA. If there is uncertainty around a diagnosis of depression in the medically ill, he added, it is better to treat than not treat, and to focus on mood and depressive cognitions such as decreased self-esteem, excessive guilt, sense of hopelessness and worthlessness, and death wishes.

Driving and Dementia (Dr. Goran Eryavec)
Given that 110,000 new cases of dementia are diagnosed in Canada each year, and that the number of older drivers on Canadian roads expected to more than double by 2020, the increased risk of accidents in older drivers and drivers with dementia, and the risk for public safety in general, is a growing concern. Eryavec discussed the problems and challenges MDs and allied health professionals face in accurately assessing driving ability in the older population without unfairly penalizing seniors.

Currently, the Canadian Consensus Conference guidelines recommend that individuals with a MMSE of less than 24 be prohibited from driving. However, there is a growing body of literature that suggest the MMSE as a poor predictor of crash rates or on-road driving performance, according to Eryavec. While the MMSE still has plays an important role in alerting physicians to 'drivers at risk' and those who need an on-road assessment, it should not be the only measure of driving ability. Similarly, the on-road assessment, in its present format, is not a surefire way of testing individuals, as patients deemed unsafe to drive by their physicians can often pass standard driving tests. Driving and dementia is a complicated issue, says Eyravec, and requires a screening procedure using patient interviews and medical history, caregiver reports, and assessment of current medications and medical conditions that can increase the crash risk in older patients.

End-of-Life Care and the Management of Dyspnea

Pippa Hall, MD, CCFP, MEd, FCFP, Assistant Professor, Department of Family Medicine, Program Director, Palliative Medicine Residency Program, University of Ottawa, SCO Health Service, Ottawa, ON.

Dyspnea is experienced by patients with advanced lung and heart disease and cancer. When conventional therapy has been optimized, dyspnea can be managed in a systematic, evidence-based approach, involving an inter-professional team. The patient and family contribute to optimal care plan development. Non-pharmacological approaches are important. Compressed air, oxygen and steroids may be helpful. Strong evidence supports the use of opioids, while some evidence supports the use of neuroleptics and anxiolytics. Escalating distress in the last hours of life may necessitate interventions that improve dyspnea control at the price of deeper sedation. If upper airway congestion develops, anticholinergics are recommended.
Key words: dyspnea, terminal care, refractory symptom, palliation.

Introduction
Dyspnea, defined as a subjective sense of shortness of breath or uncomfortable breathing, is a common symptom in patients with advanced lung and heart disease, as well as in patients with cancer.^1,2 Dyspnea has been reported to be as distressing a symptom as pain, with patients often feeling they are about to die from suffocation or choking.

Book Review: Issues in Palliative Care Research

Editors: Russell K. Portenay and Eduardo Bruera
Publisher: Oxford University Press
Reviewed by: Madhuri Reddy, MD, MSc, FRCPC, Associate Editor.

This text is an evidence-based review of palliative care research and its challenges. Over the last several years, there has been an increasing need for improvements in the scientific basis of palliative care. There is a wide range of types of research in palliative care, including clinical epidemiology, treatment trials, psychosocial research, quality of life studies and systems research. This book examines not only the range of conventional medical interventions, but also a variety of concerns that have mostly been at the periphery, such as ethics, communication and the nature of suffering. The book offers an overview of the most important research issues and includes updated proceedings of a 1998 meeting that focused on research that took place in Washington D.C., at the National Institutes of Health, as well as additional chapters on selected topics.

The book is well organized and is divided into nine sections. The first section focuses on research in the area of pain, and primarily covers methodological issues in the design of pain control clinical trials. It is pointed out that there are many challenges in analgesic trials, including the large placebo effects and difficulty of symptom measurement.

The second section focuses on research on anorexia and gastrointestinal disorders. It reviews information regarding developing, conducting and analysing trials investigating agents for treating cancer-related anorexia/cachexia. Methodological challenges regarding anorexia/ cachexia trials are examined and 10 such trials are reviewed. The final chapter in this section makes the point that little work has been done in the area of anti-emetics, and the author reviews the etiology of emesis and the research that has been published to date.

The third section examines respiratory symptoms research, with a focus on the multidimensional assessment of dyspnea. Because dyspnea is not a single sensation, it is challenging to measure quantitatively. The author reviews some qualitative measures of dyspnea (e.g., visual analogue scale, Likert scales) as well as quality of life instruments. Another chapter in this section reviews research into nonpharmacological interventions for dyspnea. The fourth section looks at research in fatigue/asthenia. It discusses fatigue measurement and causes (e.g., anemia, anxiety, depression) and reviews various interventions and treatments. There is significant discussion surrounding the evaluation of the causal relationships between fatigue and psychiatric symptoms in cancer patients and the respective treatment implications. The fifth section examines neuropsychiatric and psychosocial research. It discusses the undertreatment of depression in the terminally ill, as well as the challenges of quantitative and qualitative measurement of depression.

The sixth and seventh sections inspect quality of life research, including an assessment of decision making capacity and end of life care. The author reviews the medical literature on patient utility, cost utility and effectiveness of using Medline. He reviews the studies defining patient and family member quality of life as well as instruments used to measure quality of life. The chapters on decision making capacity and advance care planning are probably the most useful for physicians involved in geriatrics and care of the elderly research. Even though there is a focus on cancer research, the frequency of cognitive impairment, particularly delirium, in the final days and months of life is also discussed.

The next section examines research in practice change and reviews the barriers to and opportunities for changing end of life care within the medical school environment, as well as in hospitals and cancer centres. The ninth and final section examines research issues in special populations, particularly pediatric palliative care and HIV/AIDS.

Throughout “Issues in Palliative Care Research”, there is little reference to palliative care of older patients, as the book focuses mostly on cancer palliative care. Even the “special population” sections do not include the older population. However, this is doubtless a testament to the paucity of research in this area rather than an omission by the authors. This book is a must for any researcher in the palliative care field. For the rest of us, it is an excellent reference and review of current palliative care research, and the possible future directions of such research.

Storytelling Brings Truth to Aging Matters

A. Mark Clarfield, MD, FRCPC, Dept. of Geriatrics, Soroka Hospital, Ben Gurion University of the Negev, Beer Sheva, Israel.

Most of us enjoy stories. They instruct, inform, involve and, above all, entertain. Who cannot remember sitting on a parent's lap listening to one. For those of us with enough mild cognitive impairment to cloud recollections of our own youth, surely we can see how much our children and grandchildren appreciate a good yarn. The telling of tales goes beyond the Brothers Grimm, television and the movies, full of (usually awful) stories that continue to attract our attention and empty our wallets.

In medicine, "the narrative" also has great appeal. We take a patient's history, after all, and we have long been told by Sir William Osler that if we let the patient tell us her story, we will come to diagnosis sooner rather than later.

The journals also have caught on to storytelling. The British Medical Journal, Annals of Internal Medicine, Canadian Medical Association Journal and Journal of American Medical Association each offer, respectively, a "Personal Column", "On Being a Doctor", "A Room With a View" and "A Piece of My Mind" in every issue. Of the big five, only the New England Journal of Medicine is still too grey to offer such a column.

Novels also have dealt with medical and doctor-related themes: Thomas Mann explored tuberculosis in "The Magic Mountain", Sinclair Lewis the life of the physician in "Arrowsmith" while Samuel Shem's "House of God" caricatured the life and loves of the harried and harassed house staff. In our field of geriatrics there have been only a few gems. In "The Stone Angel", for example, Margaret Laurence tells the tale from the perspective of an 90-year-old woman.

One of the best books addressing the theme of aging that I have read in many years came off of the pen of Canadian writer Rohinton Mistry. His most recent endeavor, "Family Matters", addresses the many issues of aging through the device of a mildly dysfunctional lower-middle class unit in Bombay. Just shy of 80, the protagonist, Nariman Vakeel, is a Parsi widower and a somewhat powerless patriarch of the family. As long as he is healthy, his stepdaughter Coomy agrees to look after him, not altogether distinterestedly, given that she lives in his house. However, while healthy he really needs very little care.

That being said, Coomy, a most embittered woman, worries constantly lest he fall and do himself an injury. His biological daughter, Roxana, a much sweeter person than her older stepsister, tries to avoid conflicts over their shared pater familias.

"I can't believe my eyes."
"What is it, wrong colour?" asked Roxana, for her sister was superstitious about such things.
"Think for a moment," said Coomy. "What are you giving, and to whom? A walking stick? To Pappa."
"He likes to take walks," said Yezad. [Roxana's husband]. "It'll be useful".
"We don't want him to take walks! He has osteoporosis, Parkinson's disease, hypotension--a walking medical dictionary!"¹

All is stable until the old man, suffering from the abovementioned diseases but with absolutely no cognitive impairment, falls and breaks his ankle. Here we are let into the world of Indian medicine--harrowing for members of the lower-middle class who cannot afford health insurance and will not stoop to suffer the care under the terrible conditions of the almost non-existent public health service.

Nariman does spend two days at the Parsi General Hospital for a brief admission to have his ankle set and a cast applied. On his first (and only) night in hospital, Mistry describes the old man's thoughts:

He did not mind being alone. The wardboy on the night shift was an older man, much older than the dynamic day fellow. Early sixties at least, thought Nariman, and wondered if his shaking hands were also due to Parkinson's or something else. He made up for the imperfection of his hands with the perfection of his smile. A smile of enlightenment, thought Nariman, so like Voltaire's in old age, in the portrait that graced the frontispiece in his copy of Candide.

And how did one acquire such enlightenment, he wondered, here, in a grim ward, collecting faeces and urine from the beds of the lame and the halt and the diseased? Or were these the necessary conditions? For learning that young or old, rich or poor, we all stank at the other end?²

On returning home, at first Nariman is cared for by Coomy, but she is clearly not up to the task, neither emotionally nor physically. At first, Coomy and her ineffectual brother Jal tried to move Nariman onto a commode whenever necessary. But it is too much for them. A decision is made to utilize a bedpan and urinal which Nariman "… welcomed… as though they were the vessels of salvation."³ Coomy continues to have trouble coping. As she rightly muses, "It was ridiculous… that with so much technology, scientists and engineers still hadn't invented a less disgusting thing than a bedpan. 'Who needs mobile phones and Internet and all that rubbish? How about a high-tech gadget for doing number two in bed?'".³

The book goes on to tell the tale of how difficult it is to nurse an old man at home with a fracture and Parkinson's disease. And yet, in Mistry's India, there seems to be a glaring lack of any kind of formal services. Gerontologists in wealthy North America inform us that up to 90% of the care of the elderly is borne by the "informal sector". If that is true, then in India it must be 99.99%.

The story is indeed a bleak one, although written with great sensitivity, clarity and beauty. From it we learn how lonely illness can be for an older person and how humiliating and frustrating, especially in the face of a profound absence of expert medical and nursing help.

The book also underlines another theme: how difficult it is for the poor of the world, especially in the less developed countries, to cope with the sick elderly. As well, a novel like "Family Matters" illustrates the universality of the challenges and problems of age-related disease, and how the fate of most of the world's elderly, when they do fall sick, is thrust entirely into the willing or not-so-willing hands of an immediate family. In most parts of the world, for the majority of older persons, there is simply no other choice. Through Nariman's story, Mistry lets us in on this not so well kept secret.

Sources

1. Mistry, R. Family matters. Toronto: McClelland and Stewart Ltd., 2002, p. 32.
2. Ibid, p. 56.
3. Ibid, p. 75.

What Is a Geriatric Syndrome Anyway

Jonathan M. Flacker, MD, Division of Geriatric Medicine and Gerontology, Emory University School of Medicine, Atlanta, GA, USA.

The term "Geriatric Syndrome" is commonly used but ill defined. In publications, authors claim that all sorts of conditions are a "Geriatric Syndrome", including, but not limited to, delirium,¹ dementia,¹ depression,² dizziness,³ emesis,⁴ falls,¹ gait disorders,¹ hearing loss,¹ insomnia,¹ urinary incontinence,¹ language disorders,¹ functional dependence,⁵ lower extremity problems,⁶ oral and dental problems,⁶ malnutrition,¹ osteoporosis,¹ pain,¹ pressure ulcers,¹ silent angina pectoris,⁷ sexual dysfunction,⁶ syncope⁶ and vision loss.¹ Can this be possible? Can any condition commonly encountered in older adults be a "Geriatric Syndrome"?

The Origins of "Syndrome"
The word syndrome seems to have appeared in an English translation of Galen in about 1541.⁸ Derived from the Greek roots "syn" (meaning "together") and "dromos" (meaning "a running"), this term generally refers to "a concurrence or running together of constant patterns of abnormal signs or symptoms".