HealthPlexus.net

Other

Disclaimer:  While every attempt is made to ensure that drug dosages provided within the text of this journal and the website are accurate, readers are urged to check drug package inserts before prescribing. Views and opinions in this publication and the website are not necessarily endorsed by or reflective of those of the publisher.

Comprehensive Textbooks of Geriatric Medicine: The Continuing Saga

Geriatric Medicine: An Evidence-based Approach. Fourth Edition
Editor: Christine K. Cassel
Springer-Verlag, 2003.

Principles of Geriatric Medicine & Gerontology
Editors: William R. Hazzard, John P. Blass, Jeffrey B. Halter, et al.
McGraw-Hill, 2003.

Reviewed by: Barry Goldlist, MD, FRCPC, FACP, AGSF, Editor in Chief.

In the past three years, Geriatrics & Aging has reviewed the two major British textbooks of Geriatric Medicine. Dr. Shabbir Alibhai reviewed the 2nd edition of the Oxford Textbook of Medicine in our July/August 2000 issue (Vol. 3, No. 6) and Dr. Christopher MacKnight reviewed the 6th edition of Brocklehurst's Textbook of Geriatric Medicine and Gerontology in our June 2003 issue (Vol. 6, No. 6). Both reviews are still available on our website (www.geriatricsandaging.ca).

Unlike the more balanced international contributions of the British texts, the contributors for the texts Geriatric Medicine: An Evidence-based Review and Principles of Geriatric Medicine & Gerontology are overwhelmingly from one country, the United States, and all the editors are American as well. There are several interesting individuals who have contributed to both texts, and one of these is the distinguished Canadian scientist, Paula Rochon. She has co-authored the chapters dealing with drug usage in the elderly for both texts, certainly an indication of her international stature.

Both texts have similar tables of contents, although the order is somewhat different. The opening section of each text is on the basics of gerontology, and both are quite good. Geriatric Medicine benefits from an initial chapter on evidence-based medicine and its specific application to geriatrics, written by Rosanne Leipzig.

Dr. Alibhai would be pleased to note that both of these textbooks have substantial sections on cancer in the elderly. Some of the chapters in both texts, however, read as though they were written for a standard textbook of medicine, and thus do not address the difficult issues in the field, including how representative the trials are, whether frailty was factored in somehow, and whether there is evidence of age discrimination. Fortunately, both books have an introduction to the cancer section by Harvey Jay Cohen that addresses some of these issues in general. Professor Cohen has more space in Principles of Geriatric Medicine & Gerontology, and thus does a better job there.

The various types of dementia are covered in a rather superficial manner in comparison to the last text I reviewed (Clinical Neurology of the Older Adult, July/August 2003, Vol. 6, No. 7, page 65), but this is a more general text. Geriatric Medicine does a better job with Alzheimer disease, but I suspect that Dr. MacKnight would not be impressed by the sections on vascular dementia in either text (it should be noted that he is a well regarded investigator in this area). I personally feel that the area of cholinesterase therapy is a perfect area for the contributor to discuss statistical versus clinical significance, but neither text addresses that issue. Both texts have chapters on delirium authored or co-authored by Dr. Sharon Inouye and are well written, with as much evidence presented as possible.

Principles of Geriatric Medicine & Gerontology is generally more comprehensive than Cassel's text for cardiovascular disorders, but neither is very strong on the management of atrial fibrillation. I feel a geriatrics textbook should be exploring the barriers to anticoagulation as well as patients' perceptions of treatment, and should be including more detail on the exact benefits in various circumstances to better allow the practitioner to counsel her patients. The Hazzard, et al. text has a larger section on cardiac pacing than it does on atrial fibrillation in the elderly. I suspect that few readers of this text will be making pace-maker insertion decisions, but many will be providing full care to patients with atrial fibrillation.

In summary, these are both excellent texts, each with its own blend of strengths and weaknesses. Both are well written with excellent use of tables and figures. I find that Geriatric Medicine: An Evidence-based Review has an easier typeface to read; however, I would be satisfied with owning either of these two texts.

Related Terms: Other, book review

Clinical Neurology of the Older Adult

Editors: Joseph L. Sirven, Barbara L. Malamut.
Lippincott Williams & Wilkins, 2002.

Reviewed by: Barry Goldlist, MD, FRCPC, FACP, AGSF, Editor in Chief.

In this era of rapid medical and scientific advances and with the wide availability of information over the Internet, is the medical textbook still relevant? Some of my colleagues, in their book reviews, have attempted to use the text to answer actual clinical questions that arose in their practice during the period they were evaluating the book. While seemingly quite fair, it avoids the more difficult issue of what type of question we should expect any textbook to answer.

Most practising physicians read a medical textbook for three reasons: to aid them in diagnosing medical disorders, to inform them of the course and prognosis of disease, and to give advice on disease management. I will review how this textbook fulfils these three mandates. In general, for this text a group of distinguished experts (all based in the U.S.) carefully review the available evidence for each topic. The current dogma is that we should distrust expert opinion, but value expert evaluation of the current evidence (e.g., Cochrane Collaboration). This text clearly meets this first hurdle, so on to the three general mandates.

1. Diagnosis of Disease
There are two chapters that lay the basis for the normal aging process and the clinical examination: the neurologic examination of the older adult, and cognitive changes associated with normal aging. These are co-authored by the two editors, and are predictably excellent and refreshingly concise. As well, other chapters lay a strong foundation for dealing with older patients (e.g., imaging of the aging brain, diagnostic tests in the older adult). The chapter on age-related pharmacology is one of the best I have ever seen in a non-geriatric medicine text.

With this basic introduction, how does the text perform? I selected two chapters for a more intense review. The chapter on back and neck pain does have the obligatory table on all causes of back and neck pain, but the text is extremely practical. The issue of comorbidity in the elderly is well handled, as is the issue of adverse effects of specific medications (including cost). The algorithm for management is quite reasonable, and eminently practical. Specific physical examination manoeuvres to help in diagnosis are clearly described--a great help to the non-neurologist.

The second disease entity I selected was dementia with Lewy bodies (DLB). To get a full understanding of the disorder requires reading two chapters (diagnostic evaluation and treatment of dementia and; dementia disorders--behavioural and cognitive aspects), which realistically reflect how a physician would approach a patient with cognitive impairment. The differences from Alzheimer disease and other dementing conditions is clearly expressed and the consensus criteria for the clinical diagnosis of DLB are included in an easy to read table. Diagnostic information for the other dementias is similarly easy to retrieve.

2. Course and Prognosis of Disease
After we give our patients their diagnosis, they quite reasonably want to know what the future holds for them. To answer their questions, a physician must know something of the natural history and treated history of the disease. Once again, I selected two common disorders in the elderly, depression and primary brain tumours. The "naturalistic" course of depression is clearly explained, as are the benefits of both treatment and continuous maintenance therapy. There are similarly excellent discussions on the outcome of brain tumours and the benefits (or lack thereof) of various treatment modalities.

3. Management of Disease

This is the most problematic area for all textbooks. The lag between the writing of a text and its publication always results in newer treatment modalities being missed. The real issues, in my opinion, are as follows:

  1. Are non-drug treatments thoroughly discussed (these tend to change more slowly)?
  2. Are the benefits of current therapies clearly quantified and their pathophysiologic base explained, so that when the reader searches for newer treatments she can put the results of journal articles into the proper context?

For this challenge, I reviewed the chapter on movement disorders in the elderly for the treatment of Parkinson's disease. Although details are not given, the importance of multidisciplinary care and exercise is stressed and placed before the section on pharmacotherapy. The various drugs and their rationale are clearly discussed, and an excellent table is available that summerizes the mode of action, usual dose range, common side effects, warnings and contraindications for the most useful medications. A physician reading a current journal article on management of Parkinson's disease in the elderly would easily be able to put the newest therapy into the proper context.

I think it is clear that I consider this an excellent text. It would be extremely useful for a geriatrician or a family physician involved in health care of the elderly. The book is very specific in its focus on the elderly, and does not attempt to replicate an entire neurology text. Because of this, and its excellent section on psychosocial issues in the elderly, I suspect that general neurologists who care for older adults would also find this a useful textbook.

Related Terms: Other, book review

Brocklehurst’s Textbook of Geriatric Medicine and Gerontology, 6th Edition

Editors: Raymond C. Tallis and Howard M. Fillit.
Churchill Livingstone, 2003.

Reviewed by: Chris MacKnight, MD, MSc, FRCPC,
Dalhousie University, Halifax, NS.

The world of the geriatric medicine textbook is a crowded one. Why, then, should one choose this text, which claims to be the leader? For the reasons discussed here, I believe that it would be a good choice.

Brocklehurst's is an attractive work, full of figures and pictures, and there is a nice mix of European and North American authors. An innovation since the 5th edition--one that aids readability--is the addition of summary boxes to each chapter, listing the key points of that chapter. This textbook follows the usual order of most texts in the field, with an introductory section on various features of aging, system-specific sections and then chapters on geriatrics and geriatric services worldwide (there are even a few pages on Canada!). One of my criticisms that applies to most of these works is that they are more texts of the internal medicine of old age than of geriatrics, which I see as the care of the frail older adult. This textbook, however, does concentrate on frailty, with almost every chapter at least nodding towards frailty and the older adult, who suffer with multiple comorbidities and disabilities.

Most texts should accomplish two functions: they should provide an introduction to and comprehensive overview of a field for the novice, and provide a resource for the expert. I recently used this text as a resource for the first few patients I saw on March 3, 2003. My first was a home visit to a patient who had had an episode of syncope. Although there was little information provided on home visits (less than in the 5th edition), there was a detailed and up-to-date chapter on syncope by a recognised world leader in the field. The next consultation was on a woman with Diogenes Syndrome, with the inpatient team wondering about her competency to return home. The section on Diogenes Syndrome was much improved from the 5th edition, and very useful. Unfortunately, I could find nothing related to assessing competency, either in the index or after a hand search of the chapters I thought might be relevant. There also is no chapter on legal issues, although this would likely be difficult in an international text.

I then saw a patient with a postoperative delirium and pre-existing vascular dementia. The chapter on vascular dementia is a great improvement over the section in the 5th edition, where it was lumped in with the other dementias. The section on postoperative delirium also was very helpful and lucid, though there was some repetition between the discussion in the chapter on Delirium and that in the chapter on Surgery.

As with all texts, currency is a problem. There are some references to the 21st century, but not many. New issues, such as West Nile Virus, are nowhere to be found. The editors do recognise this limitation, and realise that for up-to-date information they cannot compete with electronic resources. Where they can compete, however, is in offering a comprehensive overview and foundation, and I believe they have succeeded admirably. This text is useful for trainees, libraries and those healthcare professionals who need either an introduction or a refresher to geriatric medicine.

Related Terms: Other, book review

Anti-Aging Medicine and Science: An Arena of Conflict and Profound Societal Implications

Robert H. Binstock, PhD, Professor of Aging, Health, and Society, Eric T. Juengst, PhD, Associate Professor of Bioethics, Maxwell J. Mehlman, JD, Professor of Law, and Stephen G. Post, PhD, Professor of Bioethics; Case Western Reserve University, Cleveland, OH, USA.

An international group of more than 50 biogerontologists--scientists who conduct research on the biology of aging--have launched a war on a burgeoning anti-aging medicine movement. They seek to discredit what they regard as the pseudoscience of practitioners and entrepreneurs that purvey hormone injections, special mineral waters and other services and products purported to combat the effects of aging. Yet, an unintended consequence of the biogerontologists' campaign against anti-aging medicine is that they are diverting attention from the potentially radical societal implications of their own anti-aging efforts--implications that should be widely discussed in nations throughout the world.
Key words: anti-aging, biology of aging, life extension, research funding, science policy.

Related Terms: Other, anti-aging, biology of aging, life extension, research funding, science policy

Letter to the Editor--May 2003

Dear Editor,

I am grateful for your summary of ALLHAT (Feb. 2003, pp. 14-20) and the rest of this issue, which is invaluable for a mainly geriatric practice like my own. ALLHAT gave diuretics the edge, but I am not sure what these results mean to Canadian physicians.

The diuretic used was chlorthalidone, which is seldom prescribed in Canada. Other medications included the fossil reserpine and the rarely prescribed clonidine, hydralazine and doxazosin. Essentially, the choice of first drug prescribed for hypertension becomes irrelevant in moderate to severe cases. These patients require a combination of two to five classes of drugs for success, a juggling game that leaves a lot of collateral damage in the form of very predictable adverse drug reactions.

Diuretics remain justly popular and belong in most combinations, even in diabetics. Beta-blockers, being mostly generic, are virtual orphans these days, yet they are invaluable with comorbid arrhythmias and coronary heart disease. Calcium channel blockers and angiotensin II inhibitors have suffered a beating at the hands of the HOPE trial, which gave ACE inhibitors the edge. However, the very common and intractable ACE cough guarantees a place for the other classes.

Dr. D. Rapoport
Family Physician, Downsview, ON.

 

Creatinine Clearance Slide Ruler Calculator: Practical Tool for GPs
Dear Editor,
When evaluating elderly patients for secondary causes of hypertension, Drs. Feng and Campbell recommended that certain laboratory examinations be performed (Feb. 2003, pp. 31-33). Among these tests were a serum creatinine and urinalysis to exclude underlying renal parenchyma disease or renal artery stenosis. However, serum creatinine determination in the elderly is a poor reflection of creatinine clearance, as elderly patients frequently have low muscle mass. Normal serum creatinine values are seen in elderly patients who may have significant renal impairment. It is imperative that age, weight and sex of the patient be considered along with the actual serum creatinine measurements in order to adequately assess renal function. The Cockcroft-Gault formula can predict the creatinine clearance when these parameters are known.

GPs are unlikely to calculate creatinine clearance using the Cockcroft-Gault formula and are equally unlikely to obtain 24-hour urine samples in the elderly to determine creatinine clearance. We have developed a practical solution to the creatinine clearance calculation by creating a creatinine clearance slide rule calculator, based upon the Cockcroft-Gault formula. The ruler has five different logarithmic scales. The scale for weight and sex are fixed, whereas the scales for serum creatinine and creatinine clearance are placed on a movable insert. By aligning the serum creatinine against the weight of the patient, and then looking down at the patient's age and sex, one can obtain the appropriate creatinine clearance values (Figure).

The formula takes into consideration not only the patient's serum creatinine, but also their age, weight and sex. For instance, a serum creatinine of 130 mmol/L in a 70 kg, 75 year-old male would yield a creatinine clearance of approximately 0.7mL/sec, whereas a female of similar age and weight would have a creatinine clearance of 0.58mL/sec. The latter value approaches the critical point of avoiding many drugs in patients with compromised renal function (defined as < 30 mL/min, or 0.5mL/sec).

The slide ruler was developed by members of the Second Canadian Consensus Conference on the Use of NSAIDs. Its production and distribution have been made possible by Merck Frosst Canada. For further information concerning the creatinine clearance ruler and how to obtain a copy, please contact Foresee Technology Inc., at ForeseeInc@aol.com.

Sources

  1. Cockcroft DW, Gault MH. Prediction of creatinine clearance from serum creatinine. Nephron 1976;16:31-41.
  2. Tannenbaum H, Peloso PMJ, Russell, AS, et al: An evidence-based approach to prescribing NSAIDs in the treatment of osteoarthritis and rheumatoid arthritis: The Second Canadian Consensus Conference. Can J Clin Pharmacol Autumn 2000;7;4A-13A.

Dr. Hyman Tannenbaum
Rheumatic Disease Centre of Montreal,
McGill University, Montreal, QC.

 

Dr. Norm R.C. Campbell, co-author of the article "Screening for Secondary Causes of Hypertension in the Elderly", offered the following response to Dr. Tannenbaum:

Renal Impairment in Elderly Hypertensive Patients
We agree with Dr. Tannenbaum that renal impairment is frequently overlooked in the elderly when assessed with serum creatinine and that asking family physicians to routinely request 24-hour urine collections is unlikely to be implemented.

Even if implemented, such advice may not be effective due to incomplete urine collection, and even if effective, it may not be cost-effective. The use of a validated formula such as the Cockcroft-Gault has had limited uptake by family physicians, likely due to the complexity of the formula, the lack of systematic computerised support and the breadth of knowledge required to practice family medicine. Educational programs to increase awareness of the decline in renal function with age and simple tools to detect renal impairment may be useful in avoiding adverse drug reactions associated with prescribing drugs that are cleared by the kidneys and have a low therapeutic threshold.

The Canadian Hypertension Education Program (CHEP), a group of close to 40 Canadian hypertension specialists, systematically reviews and grades evidence in the area of hypertension every year. CHEP has recommended a history and physical examination and assessment of serum creatinine and a urinalysis to assess for renal target organ damage and renal hypertension in uncomplicated hypertensive patients. Antihypertensive treatment based on CHEP recommendations will reduce complications, especially in the elderly and in those who have other risk factors, such as renal impairment. Further, if advice to start at lower doses and titrate to response is followed when treating the elderly, adverse events related to renal accumulation of antihypertensive therapy are unlikely in those whose serum creatinine is in the "normal range". For those patients with resistant hypertension or additional features of renal hypertension, the CHEP program recommends additional renal investigations as outlined in our article.

I would encourage family physicians to take heed of Dr. Tannenbaum's advice regarding renal impairment and serum creatinine in the elderly, especially when prescribing drugs that reduce renal function (e.g., NSAIDs) and those with low therapeutic thresholds that rely on renal clearance (e.g., methotrexate).

Norm Campbell, MD, FRCPC
University of Calgary, Calgary, AB.

Related Terms: Other,

The Romanow Report: Implications for the Elderly

Rory H. Fisher, MB, FRCP(Ed)(C), Director, The Regional Geriatric Program of Toronto and Interdepartmental Division of Geriatrics, Faculty of Medicine, University of Toronto, Toronto, ON.

The impact of the Romanow Report on the elderly is reviewed here. Recommendations for a Health Council, modernization of the Canada Health Act, improved home care and a National Drug Agency would benefit all elderly Canadians. However, the current unmet needs of the elderly, the value of specialized geriatric services and the developments in other jurisdictions are not recognized. The Romanow Commission fails senior citizens by ignoring their current unmet needs.
Key words: Romanow Report, recommendations, elderly.

Related Terms: Other, elderly, recommendations, Romanow Report

Letter to the Editor February 2003

I would like to thank you and express my appreciation for having received the journal Geriatrics & Aging. I have been a practising family physician since 1996 after having completed a Fellowship in the Care for the Elderly at McGill University. I continue to actively work in geriatric care and have used your journal as an important source of information. Thank you once again.

Dr. Peter Blusanovics,
St. Mary's Hospital Centre, Montreal, QC.

I am a little puzzled by the overview of HRT trials in the article "Menopause: Current Controversies in Hormone Replacement Therapy" (Jan. 2003, Vol. 6, No. 1), which uses percentages to compare strategies. A large proportional change in a presently small value may mean little in practice, with the converse being the case.

The risk of thromboembolism is said to be increased 111% by HRT, which indeed it was found to be. However, "in the trenches", what we really need to know is that 9,966 women out of 10,000 will be clot-free in one year even on HRT, while 16 will clot without it. Thus, 9,982 will have futures unaffected by the decision to "go/no-go" on HRT. A problem for only 0.2% of women would perhaps not be justification for denying at least symptomatic benefits to all women.

Also puzzling is the evaluation that the increased/ decreased risks of breast and colorectal cancer are respectively said to be significant and nonsignificant. The U.S. Preventive Services Task Force (Ann Intern Med 2002;137:834-9) found just the opposite from the same numbers!

Most family physicians, like myself, are quite willing to practice "evidence-based medicine", if only we may be certain of what the evidence is.

Dr. George Ford,
Preston Medical Centre, Cambridge, ON.

Dr. Marla Shapiro, author of the article "Menopause: Current Controversies in Hormone Replacement Therapy", offered the following response to Dr. George Ford:

As family physicians, it is critical that we do practice evidence-based medicine. Physicians must have the knowledge base to inform their patients of the risks and benefits of available therapeutic options. With that base, an informed decision can be made not only on numbers, but also on how these numbers apply to that individual patient given their symptoms, their family history and alternate treatment options.

All of us practising medicine "in the trenches" are faced with the daily concerns of offering the best evidence-based medicine to our patients in a context that is relevant and useful. Ultimately, a patient is relying on her physician's expertise to interpret how a "nonsignificant increased risk of breast cancer at 26%, or eight more events per 10,000 women treated on an annual basis", applies to her. The intent of this article was to review our current state of knowledge following the Women's Health Initiative, so that as physicians we can use this information accurately.

Please note that the increased risk of breast cancer was found to be nonsignificant in WHI and HERS, and the decreased risk of colon cancer was found to be significant by WHI but nonsignificant by HERS (NAMS Advisory Panel, October 3, 2002).

Dr. Marla Shapiro,
Department of Family Medicine,
University of Toronto, Toronto, ON.

We want to hear from you! Please send letters to Geriatrics & Aging at 20 Eglinton Ave. W., Suite 1109, Toronto, ON M4R 1K8; Fax: (416) 480-2740 or email: info@geriatricsandaging.ca.

Related Terms: Other,

Putting More Heart in the Nursing Home: What We Learned from the Dogs

William A. Banks, GRECC, Veterans Affairs Medical Center and Saint Louis University School of Medicine, Division of Geriatrics, Department of Internal Medicine, St. Louis, MO.
Marian R. Banks, Center for Human Nutrition, Washington University School of Medicine, St. Louis, MO.

The term "nursing home" is often a misnomer. The typical nursing home is more institution than home and run more like a hospital than a household. Indeed, the American Heritage dictionary defines "nursing home" as "a hospital for convalescent or aged people" (emphasis ours). Yet many of us will spend a good portion of the last part of our lives in these institutions. How can these last years be made as enjoyable and meaningful as possible? We recently published a study examining the effects of animal-assisted therapy (AAT) on loneliness among nursing home residents. The statistical aspect of that study has been published elsewhere and it showed, among other things, that AAT can reduce loneliness.1 However, during the course of that study we learned several lessons that couldn't be reduced to statistics. Here, we review some of the things we learned about making long-term care facilities more comfortable and enjoyable for residents.

There are many movements afoot to improve life in long-term care facilities. Pet therapy, music therapy, activities and holiday events are all assumed to be progressive programs. Since these programs are considered to be good, they are assumed to be good for all.

Related Terms: Other, nursing home

A One Minute Survey of Learning Needs for Regional Geriatric Program Central Personnel

David Jewell, MSW, MHSc, Irene Turpie, MB, ChB, MSc, FRCP(C),
Christopher Patterson, MD, FRCP(C), David Lewis, PhD, Julia Baxter, BScHK,
affiliated with the Regional Geriatric Program Central Ontario.

Objective: To determine the top learning needs of local specialized geriatrics services staff.
Participants: Health care professionals within the Regional Geriatric Program central area.
Methodology: A snowball sample (n=67) ranked five of 20 possible learning needs (derived from a literature review) by priority.
Analysis: Responses were sorted by those listing a particular subject in any priority, those making it the top priority, and Q-sort.
Results: The top three learning needs--scoring highest on all techniques--were management of dementia, risk and discharge from hospital to community.
Conclusion: This appears to be a viable method of appraising needs for education planning.
Key words: geriatrics, continuing education, survey, needs assessment, Q-sort

Related Terms: Other, continuing education, geriatrics, needs assessment, Q-sort, survey

Integration of Best Practice Guidelines into Daily Care


Step 1: Assessing Top Learning Needs

Irene Turpie and Christopher Patterson, Regional Geriatric Program Central Ontario.

This editorial aims to focus readers on the issues involved in the development and implementation of best practice recommendations. Physicians and other health care professionals in the course of their clinical practice are confronted with large amounts of data. They are assailed daily by ever-increasing volumes of information about clinical topics by electronic and other means. Evidence-based recommendations are designed to clarify and distill the plethora of information into usable formats.

Twentieth century clinical practice is replete with many guidelines, best practice recommendations and consensus statements. Clinical practice guidelines are "systematically developed statements designed to assist the decision making of practititioners and patients about appropriate health care for specific clinical circumstances".1 Best practice "is not a specific practice per se but rather a level of agreement about research-based knowledge and an integrative process of embedding this knowledge into the organization and delivery of health care".2 Consensus statements are those which reflect the collective opinion of the participants in the process. All of the above are designed to provide practitioners with practical, unambiguous advice about health care problems.3

The accepted method of developing evidence-based recommendations of any type follows a structured sequence, usually initiated by stakeholders, journals, specialist societies and interest groups who regularly publish guidelines or statements of best practices in their area of interest and endeavor to update them on a regular basis.

Unfortunately, the development of good guidelines does not guarantee their incorporation into clinical practice.3 Passive methods of dissemination rarely lead to behaviour change. For a change in practice to be achieved by an individual practitioner or institution, there has to be complex change. The study of knowledge transfer is evolving and aims to find the best ways of incorporating practice advances into regular care.

In the Regional Geriatric Program of Central Ontario, we have established a group to promote and generate best practice recommendations. We began with a process to identify practice recommendations of relevance. We realized that to evaluate the complexity and strength of available information was not enough; we also had to understand the most effective means of translating these guidelines into multidisciplinary practice.

What does it take to change practice in long-term care institutions and in those who provide the primary care to most of the frail elderly people in the province? While the best methods of achieving this are still uncertain, we do know that involving stakeholders at an early stage in the process is an essential step. Not only practitioners, but also administrators must be given the opportunity to realize the benefits of adopting best practice recommendations.

The accompanying article (A One Minute Survey of Learning Needs for Regional Geriatric Program Central Personnel) may help other readers facing similar challenges to consider the issues involved and further explore the best processes of knowledge transfer for interdisciplinary specialized geriatric teams to fulfill the educational mandate that is part of their role.

References

  1. Audet AM, Greenfield S. Medical practice guidelines--current activities and future directions. Ann Intern Med 1990;113:709-14.
  2. Driever MJ. Are evidence based practice and best practice the same? West J Nurse Res 2002;24:591-7.
  3. Barratt A, Irwig L, Glaziou P, et al. Users Guide to the Medical Literature XVII. How to use guidelines and recommendations about screening. Evidence based Medicine Working Group. JAMA 1999;281:2029-34.
Related Terms: Other,
Subscribe to Other