Donepezil Every Day to Keep Nursing Homes Away

Results of a study presented at the 14th meeting of the American Association of Geriatric Psychiatry show that persistent treatment with donepezil may allow Alzheimer's disease (AD) patients to remain at home with their families for a longer period. 671 patients with mild to moderate AD, who had taken part in one of three placebo-controlled trials where patients received either donepezil or placebo, were then followed in open-label extension studies in which all patients had been treated with donepezil.

Researchers statistically analyzed the times to nursing home placement for dementia-related reasons as a function of the different periods of treatment. These estimates took into account the patient's age, gender and severity of illness--as measured by the MMSE--at the time of entry into a clinical trial, as well as changes in caregiver and the patient's use of other cholinesterase-inhibiting medication after completing participation in the donepezil trial.

What the study showed is that patients treated with donepezil for longer periods (from 9-12 months) had a 21-month longer delay to nursing home placement than did patients who received limited or no donepezil.

It is believed that a delay in the time to placement in nursing homes or health institutions of patients with dementia will have tremendous positive financial benefits for the Canadian Healthcare system.

Miraculous Findings from Study of Statins

Canadian heart attack patients may benefit from earlier treatment with statins, safeguarding them against future heart attacks. The Myocardial Ischemia Reduction with Aggressive Cholesterol Lowering (MIRACL) trial, results of which were published in the Journal of the American Medical Association, is the first study to demonstrate a clinical benefit from cholesterol-lowering therapy within 16 weeks following an acute coronary event. Previous studies had excluded patients who had experienced a recent heart attack or severe chest pain within the last three to six months; it is within this interval that most patients experience an acute coronary event and that the mortality rate is highest. Results of the MIRACL trial showed that treatment with atorvastatin significantly reduced the risk of experiencing a subsequent cardiovascular event when compared to placebo.

It is well established that statins benefit patients with heart disease but these are the first data to demonstrate that there is a benefit to giving patients statins within days of a heart attack. Currently, hospitalized heart attack patients are given a number of medications including aspirin, heparin, nitrates and beta-blockers, intended to target various aspects of the acute coronary condition. However, most patients do not receive cholesterol-lowering medication.

Source

1. Schwartz GG, et al. Journal of the American Medical Association 2001; 285:1711-18.

Enzyme Inhibitor May Cure Chronic Myeloid Leukemia

Studies of a novel therapeutic drug, STI571, have demonstrated for the first time that we have the potential to develop an anti-cancer drug based on a specific molecular abnormality in a human cancer.

Chronic myeloid leukemia (CML) is a cancer of the blood cells characterized by the replacement of bone marrow with malignant, leukemic cells. These cells all possess the same specific chromosomal abnormality, a translocation between chromosomes 9 and 22 that results in the formation of a hybrid gene know as BCR-ABL. BCR-ABL codes for a constitutively activated tyrosine kinase, the expression of which leads to uncontrolled cell growth. BCR-ABL is present in virtually all cases of CML throughout the course of the disease, and in some cases of acute lymphoblastic leukemia (ALL). Phase-1, dose-escalating, clinical trials of STI571 in patients with CML, who had failed treatment with interferon alpha, showed startling results. Complete hematologic responses were observed in 53 of 54 patients who were treated with daily doses of 300 mg or more of STI571, and this response occurred in the first four weeks of treatment. Fifty-one of these 53 patients remain in remission.

Unfortunately, the results of the second study, on patients with more advanced forms of the disease, were not as promising. Twenty-one of 38 patients in myeloid blast crisis had hematologic responses to the drug, with 4 of these having a complete response. Seven of these patients continue to receive treatment and remain in remission. However, all but one of the patients with lymphoid blast crisis or ALL have relapsed.

Patients treated with STI571 experienced only limited side-effects including nausea, myalgias, edema and diarrhea.

Source

1. Druker BJ, et al. New England Journal of Medicine 2001; 344:1031-37.
2. Druker BJ, et al., New England Journal of Medicine 2001; 344:1038-42.

Longevity Medicine Convention 2001

The first Canadian Longevity Medicine convention will be held in Kelowna, BC, on May 12-13, 2001. Currently, this may be the fastest growing area of medicine in North America. In the past six years, the membership of the American Academy of Anti-Aging Medicine has grown to include more than 6,000 MDs. The Canadian group, established as the Canadian Longevity and Anti-Aging Academy CLA4, has over 100 members. The convention in Kelowna will summarize some of the recent advances in longevity research and try to make sense of the overwhelming data, which are filling the journals and Internet.

The purpose of the conference is to present the evolving models of longevity. Invited speakers come from across Canada and the United States. Dr. Edmund Chein will be speaking about the future of anti-aging medicine, and Dr. Donald McLeod will provide an update on anti-oxidants.

Dr. Bob Yong, urologist, will present some recent material in the field of andropause. Dr. Philip White will discuss the pros and cons of replacing Human Growth Hormone, including a discussion of safer secretagogues and the use of hormones in sports today. Dr. White is a clinician with the International Health and Longevity Centres in Kelowna, BC.

Dr. Vincent DeMarco will discuss aspects of brain health and the prevention of both Alzheimer's and Parkinson's disease, with a focus on medications and nutraceuticals important to this field. Dr. Steven Aung will discuss the impact of Natural Medicine and acupuncture on modern medical practice. Dr. Dick Lewis will be discussing the aging skin from a dermatological perspective, and Dr. Ben Gelfant, a renowned plastic surgeon, will provide an update on the latest cosmetic surgeries.

Dr. Farquhar, with his expertise in diabetic issues, will discuss insulin resistance and the crucial role of glycemic control for longevity. Dr. Caroline DeMarco will discuss hormone replacement and the roles of estrogen and progesterone in the maintenance of health for both pre- and post-menopausal women. There will be further presentations by Dr. Barbara Fischer, a dedicated anti-aging physician with a great deal of clinical experience. Updates on the agenda include the progress of stem cell research and the latest on the human genome.

The Continuing Medical Education accreditation has granted 12 Mainpro-M1 credits from the CFCP for this course. Any enquiries about this course may be directed to C. Dooley RN, Tel.250-378-5115, Fax.250-378-6424 or by emailing: age_reversal@hotmail.com.

A Multidisciplinary Approach to Aging

A Multidisciplinary Approach to Aging
An interview with Dr. Judes Poirier, Director of the McGill Centre for Studies in Aging

Hannah Hoag, MSc
Contributing Author,
Geriatrics & Aging.

What is the McGill Centre for Studies in Aging? "It's an opportunity", explains Dr. Judes Poirier, current director of the MCSA. The MCSA is a non-academic department affiliated with McGill University that draws scientists and professors out of their specific academic departments and into a group formed around their common interest: the biology of aging. Since studying aging from a solitary point of view (from within an insular academic department) prohibits a comprehensive understanding of this multifarious process, the MCSA has created an infrastructure which allows its members a multidisciplinary approach to the aging process.

The MCSA arose from a mandate delivered by the Dean of Medicine of McGill University in 1985 to establish a gerontology centre that would allow McGill to remain competitive with American Schools. At that time, there were few gerontology programs in Canada. Those that did exist dealt primarily with the social or psychological aspects of aging; the biochemical and biomedical aspects of aging remained a largely untouched field.

Dr. Clarfield Responds to Dr. Goldlist’s Editorial

Since I have my pen in hand, I hope that you will indulge me if I make a couple of personal remarks in response to our Editor-in-Chief's kind words about me.

It is true that Barry and I trained together but he is senior to me by a year or two. And, as those of us who have worked with and were trained by him can attest, he is no slouch himself! Physician, teacher, administrator and editor--each role acted out with his usual calm and panache. But perhaps the highest compliment that I can pay the good doctor is to recount a short anecdote. When I was an intern, and Barry a medical resident, I brought my father--who was suffering from chest pain--into the ER of Toronto's Mt. Sinai Hospital, where Barry and I were both in training. As my mother and I waited anxiously in the anteroom for word of his fate, I was scared to death that my dad would die.

To my great relief and good fortune, who should rush past but Dr. Goldlist, who had been called in by the ER staff to have a look at my father. As Dr. Goldlist walked through the ER doors on his way to examine my father, I turned to my mother and said, "Don't worry, Mom, one of the hospital's best doctors is going to be taking care of Dad. We've got nothing to worry about."

And so it was. Almost 30 years later--there Barry, it's out--my father is still hale and hearty.

By coincidence, another important influence on my professional life and career choice is also well represented in this issue. The prolific and dynamic Dr. Michael Gordon, Medical Director of the world-renowned Baycrest Hospital, was a couple of years senior to both Barry and me and, as Barry points out, in his role as chief medical resident at Mt. Sinai, he had a powerful effect on all of us. It would be safe to say that no one had more influence on my decision to enter the field than did Michael, and all of us continue to enjoy his special blend of qualities.

I encourage the readers to read Dr. Gordon's articles and the rest of the informative articles in this special issue of Geriatrics & Aging. Thanks again to the editors for allowing me to blather on and, above all, for the opportunity to contribute to this important issue.

A. Mark Clarfield

Prof. Bernard Isaacs--One of the Giants of Geriatrics

Dr. Bernard Isaacs, one of the great men of modern British geriatrics, died several years ago in Jerusalem. In order to commemorate this physician, A. Mark Clarfield has written the following piece.

Prof. Isaacs' untimely death, six years ago this month, robbed us all of a great man. First and foremost, he was a first-rate geriatrician, truly one of the "giants" in the field. In addition, he had a golden hand and was a beautiful writer. Finally, to me and to many others, he was a great friend. We will miss him.

In order to commemorate my beloved colleague, I will concentrate on bringing to you some of Bernard's words of wisdom and wit. I shall try to do so via judicious quotations from his third and final book, "The Challenge of Geriatrics Medicine" (Oxford University Press, 1992). In fact, Bernard had intended to call the book, "The Giants of Geriatrics", after his now famous formulation. He listed the giants via four "I's"-- namely immobility, instability, incontinence, and intellectual impairment. Unfortunately, the publisher, in its limited wisdom, thought otherwise and gave the book the less interesting title.

Bernard's published works included scores of articles, as well as three books. Merely perusing the titles of some of his works will testify to his humour and wit. For example, Bernard wrote a series of articles for Nursing mirror.

Research, Evaluation, and Evidence-Based Medicine

Christine Oyugi, BSc
Managing Editor,
Geriatrics & Aging

On Friday, January 19th, the Baycrest Centre for Geriatric Care presented the first webcast of its continuing medical education (CME) accredited Grand Rounds program. The webcast featured an exhilarating one-hour talk on research, evaluation, and evidence-based medicine presented by Dr. David Streiner, Director of the Kunin-Lunenfeld Applied Research Unit.

Dr. Streiner began his presentation by providing a definition of the terms, research and evaluation. He defined research as the search for knowledge, where the emphasis is on the outcome and the underlying intention of the research is publication. The results from research are usually peer-reviewed and the recommendations from the study can be generalized to other patients and other institutions. Evaluations, in contrast, are not generalizable; usually they are targeted to local clinicians and administrators who use the results of the evaluation to change clinical programs within the given institution. The results in an evaluation are usually not peer-reviewed, but are vetted internally by the organization where the study took place. Often, the distinguishing factor between research and evaluation is that, in the latter case, there is no intention to publish the results of the study.

The idea of evidence-based medicine (EBM) has been around for some time, but recently, there appears to be surge of interest in this topic. EBM is the conscious, explicit, and judicious use of the current best evidence for making patient care decisions. Part of EBM is integrating individual clinical practice experience, with the best available evidence and the values and expectations that each patient brings to a clinical encounter. Individual clinical experience should rely on the clinical skill and judgement of the clinician. This is vital in determining if the evidence applies to the patient being treated and, if it does, in determining how to apply it to that patient. Best evidence should always come from clinical research done with patients.

Physicians need a way to quickly evaluate studies and understand the potential applications of high-quality research to their clinical practice. This involves tracking down the best evidence by using electronic searches (e.g. medline). If judiciously used, EBM can replace currently accepted diagnostic tests and treatments with ones that are more accurate, effective, and better tolerated.

The Baycrest Centre for Geriatric Care is one of the leading institutions in the field of Geriatrics and Gerontology. The webcast is part of an ongoing health information strategy that aims to create and share knowledge to a broad spectrum of individuals and groups. To this end, Baycrest offers a number of on-line resources to facilitate your clinical practice. For more information on CME accredited courses, as well as other useful resources provided at Baycrest, please contact Mariana Catz, Chief Information Officer, at the Baycrest Centre for Geriatrics Care at (416) 785-2500 ext. 2503.

Acknowledgements
We would like to thank Mariana Catz and Stephen Tucker, from the Baycrest Centre for Geriatrics Care, for taking the time to be interviewed for this article.

Acute Emergencies and Critical Care of the Geriatric Patient

Edited by Thomas T. Yoshkawa & Dean C. Norman
Marcel Dekker, New York 2000
ISBN 0-8247-0345-6

Reviewed by Barry Goldlist

This book is an effort by multiple authors. Of the 43 contributors, all are from the United States, and 29 are from California. As a result, the approach is distinctly American. Despite this fact, it is an excellent work. The editors have imposed a structured approach on each chapter, making for an easier read, and there is less repetition than is found in most multi-authored texts. Even more impressively, authors of individual chapters have actually focused their comments on truly geriatric issues, rather than merely repeating the contents of more general texts. The result is that the book is not comprehensive; nor is it meant to be. It should be considered an accompaniment to more comprehensive textbooks on emergency and critical care.

The text is divided into four sections: principles of geriatric critical care, surgical emergencies, medical emergencies, and special issues of aging. The principles section is quite solid, and has a superb chapter on acute and critical nursing care, which may be particularly useful for non-geriatricians. It is easy to argue that specialized geriatric nursing is in fact more important than specialized geriatric medical care. I suspect that the chapter on surgical emergencies would be most useful for non-surgeons involved in the care of these patients. I found the discussion of hip fracture particularly clear and helpful. The chapter on emergency anaesthesia is well written but there are a few minor quibbles. For example, the author discusses the unreliable blood levels of meperidine when the drug is given intramuscularly, but does not even mention that meperidine is a poor choice of narcotic for the elderly, and should rarely, if ever, be prescribed in that group.

The medical section is quite strong. The chapter on cardiac emergencies has a superb segment on the atypical presentation of acute myocardial infarction in the elderly. The neurology chapter is also very useful, but should have provided some hints on the non-pharmacological management of the symptoms of delirium, as well as a more detailed description of the pharmacological management of this syndrome. This is poorly managed by many physicians, and is worthy of more detail.

The final section on special issues of aging covers vision, hyper- and hypothermia, and diagnoses of abuse and neglect. The highlight of this section is Robert Palmer's chapter entitled 'Acute Hospital Care: Future Directions'. For those of us who have repeatedly been a witness to the unnecessary functional decline that occurs in hospitalized elderly patients, the description and the rationale for ACE (acute care of the elderly) units are very encouraging.

In summary this is an excellent book. It will appeal most to physicians who work in the emergency department or care for sick elderly patients on hospital wards.

Evidence-Based Medicine

EVIDENCE-BASED MEDICINE
How to Practice & Teach EBM, 2nd Edition

David L. Sackett, Sharon E. Straus,
W. Scott Richardson,
William Rosenberg, R. Brian Haynes
Churchill Livingstone 2000
Edinburgh, London, New York, Philadelphia, St. Louis, Sydney, Toronto
ISBN 0 443 06240 4

Reviewed by Barry Goldlist

This is a new edition of the classic text on evidence-based medicine, first published in 1997 by Sackett and his colleagues. The question for the prudent (i.e. penny wise) physician is this: should I buy this book if I already own the wonderful first edition? To answer this question I pulled my first edition off the shelf, and started comparing. My first edition is from the United Kingdom, so results of your own comparison test might vary slightly.

The new edition is wider, but is not as thick as its predecessor. This results in much better "page appeal" with a less cluttered look. Despite this, it still fits easily into a standard lab coat pocket, an important point for trainees in particular. A new author has also been added, Sharon E. Straus, a Canadian Geriatrician and expert on evidence-based medicine. The "cheat" cards tucked into a slot on the back cover are organized in a more logical manner than they were in the first edition, and are larger and more legible and of better quality. Some cards have been much improved and have even been expanded to two cards. New cards on "Screening and Case-finding" and "Useful URLs on the Internet" have been added. The one quibble with the cards is that the chart of the likelihood ratio nomogram is much smaller than the chart in the earlier edition, and is the only card in the new edition which is harder to read than its predecessor.

The new edition has a CD-ROM tucked into the front cover. The entire contents of the book are contained on the CD-ROM, which is very easy to set up and use. As well, it has clinical examples, critical appraisals, and background papers from 14 other health disciplines. The section on EBM in Geriatrics is written by Dr. Straus and, as expected, is superb. As well, the CD-ROM has extended descriptions and sample web pages of many of the current evidence sources regularly consulted by the authors. The book even has a website (www.library.utoronto.ca/medicine/ebm/>), where updates to the text, links to other evidence-based sites, and communication to the authors can occur. This should suffice until the 3rd edition is published!

However, a text of this kind is likely to be most frequently used in a more traditional manner. I use it to review particular aspects of EBM, or when I am reading an article and want to critically appraise it. For these functions, the cards and the written text are most useful. In this edition the introduction is shorter and, to my view, more positive and effective. The chapters are broken down into more manageable sections (5 in the old text, 9 in the new) and are extensively updated. The section on teaching methods is new and helpful for those in academic medicine, and the section on evaluation is helpful to all physicians.

In summary, an already excellent text has been significantly revised and upgraded. The new edition is easier to read and easier to use. The addition of a CD-ROM is also helpful. You will not regret buying the 2nd edition.