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He was an Old Dog and this was a New Trick
Seniors Benefit from Being Online
David Patrick Ryan, PhD, C.Psych Director of Education, Regional Geriatric Program of Toronto, Faculty of Medicine, University of Toronto, Toronto, ON.
There is an interesting paradox at the heart of Internet use by seniors which is: Although seniors are under-represented among Internet users, when they do get online, they become its most frequent users. Only 16% of seniors use the Internet, compared to the national average of 44%. Yet, once online, Canadian seniors use the Internet, on average, for 12 hours weekly. This is more than the average for teenagers (7 hours) and 80 minutes more than for any other age group. Given the emerging realization that the Internet expands the world of seniors, particularly disabled seniors, at a time when it would otherwise be contracting, and the developing evidence that computers and the Internet can be powerful tools for maintaining health and well-being, it is imperative that an attempt be made to reduce the digital divide amongst seniors.1
The Obstacles to Internet Use for Seniors What are the obstacles to seniors' use of the Internet? Anxiety is one obstacle.
David R. Urbach, MD, MSc, FRCSC Division of General Surgery, University Health Network, Assistant Professor, Departments of Surgery and Health Administration, University of Toronto, Toronto, ON.
Minimally invasive surgery (MIS) has revolutionized the way that surgeons perform many operative procedures in the chest and abdomen. MIS generally refers to the use of a variety of new technologies and techniques that reduce the size of the incisions required for performing a surgical procedure. It is important to recognize that minimally invasive procedures are not new operations; rather they are novel approaches to performing the same procedures that have been done for decades. The most frequently cited advantages of MIS over conventional surgery include a reduction in postoperative pain, shorter post-operative hospital stay and a quicker return to full activities. Some procedures, such as cholecystectomy (removal of the gall bladder), are commonly performed using MIS techniques. For many other surgical procedures, there is large variation in the use of MIS. Some applications of MIS, such as minimally invasive cancer surgery, are controversial.
Laparoscopic surgery is especially relevant to the care of elderly persons. Because most gastro-intestinal diseases become more prevalent with increasing age, many of the patients treated by general surgeons are elderly.
Jerry Cott, PhD Research Pharmacologist, Scientific Advisor to the Health Professions, College Park, MD.
St. John's Wort (Hypericum perforatum; SJW) is a common roadside plant that has gained much popularity in Europe and the United States as an alternative to synthetic antidepressants. The market for SJW in 1998 was $330 million in Europe and $210 million in the U.S. Hypericum appears to be an effective antidepressant with an excellent safety profile (with the interaction caveat discussed here). The NIH has just completed a multi-centre study comparing the efficacy of SJW to sertraline and placebo for treating patients with moderate to severe depression. This study was completed in December 2000, and results should be available in the summer of 2001.
Although SJW has been shown to inhibit monoamine oxidase (MAO) in vitro, this effect has not been demonstrated in vivo, nor have there been any reported cases of MAOI-associated hypertensive crises in humans using SJW.1 Although SJW has been reported to inhibit uptake of serotonin, norepinephrine and dopamine in vitro,2 the concentrations required to attain these effects are quite high and the chance of a patient attaining equivalent blood concentrations is low. In fact, a recent study suggests that the uptake inhibition is only an artifact of the assay since, in contrast to other inhibitors, it does not bind to the serotonin uptake site but does deplete storage vesicles in a similar fashion to reserpine.
Start Exercising Already! A Physician's Step-by-step Guide to Prescribing Exercise for Elderly Patients
Dr. A. S. Abdulla, BSC, MD, LMCC, CCFP, DipSportMed
Introduction I have spent many years counselling patients on the merits of dietary modifications in diabetes, hypercholesterolemia, and obesity. I have advocated the avoidance of salt and caffeine for hypertensives, adequate calcium and vitamin D intake for the prevention of osteoporosis, cessation of smoking for the improvement of cardiac and pulmonary risk factors, and cognitive therapy for depression and anxiety disorders. However, I have never found anything to have a more profound impact on all of the above medical conditions, as well as on a patient's general well-being, than a properly prescribed and facilitated exercise regimen. This article will briefly review the epidemiology of sedentarianism and the general benefits and risks of exercise, and will include a short primer on types of exercises along with a step-by-step approach to exercise prescription. The aim of this article is to help you increase the level of activity among your geriatric patients safely and to work through the basics of exercise prescription. The medical approach to dealing with more advanced levels of physical activity is beyond the scope of this article.
Much Needed Inpatient and Outpatient Fitness Programs Available in Toronto
Kathleen Jaques Bennett, BSc, BSc, MSc
Seniors, especially those over 75 years of age, are far more likely to be hospitalized for their illnesses and injuries and stay longer in the hospital than their younger counterparts.1 Canadian seniors are also less likely to engage in regular exercise despite its benefits in preventing or relieving a variety of illnesses.2,3 Inpatient and outpatient fitness programs for the elderly play an important role in health maintenance, pain reduction and rehabilitation after illness and injury.
Programs available The availability of geriatric fitness programs may vary considerably with the size of the community. In the Toronto area, a number of geriatric fitness programs are available through Sunnybrook and Baycrest Hospitals, and outpatient programs for seniors with osteoporosis are also available through clinics such the Pro Program at the Toronto Rehabilitation Institute.4 In smaller communities, exercise programs are not always designed specifically for geriatric rehabilitation and fitness; nor is every program offered at every hospital in an area. Some less popu-lated areas have adopted the approach of assigning specialized programs to different hospitals within the region.
There are many types of exercise programs which are aimed at prevention, rehabilitation or maintenance.
Joyful Social and Cultural Activities Offered at Baycrest’s Special Daycare Program for the Elderly
Kathryn Walker, MA
Dancing and clapping, music and singing, jokes and laughing--this is what I found at the end of the day on my visit to the Baycrest Centre Special Day Program. There was a spontaneous tap dance demonstration by one of the student social workers. The tap dance drew a rowdy crowd, eliciting cheering, clapping hands and keeping time with canes. Daycare programs for elders, among other things, offer a social environment that can help improve a participant's quality of life.
Daycare programs offer many benefits to the patients. Social workers and nurses can provide health monitoring and counseling. Upon admittance, most daycare programs generally require that the participant be assessed both physically and cognitively and most also offer some form of continual assessment. A program with a nurse on staff is able to monitor changes in a participant's condition. For example, it may be determined that a participant's condition has changed and that they now require a cane or walker. This timely recognition of a newly developed need could prevent a potential accident. However, most daycare programs have limited nursing involvement and the participants are expected to be medically stable. Daycare programs offer activities designed to improve the quality of life for the participants.
Physical Activity Found Beneficial in Oncology Rehabilitation
Nat Jackson
The benefits of physical activity are well known throughout the health care profession. Exercise has found its way into programs for patients with conditions such as heart disease, and it is becoming part of standard care. Studies have now begun to look at whether or not the success of programs which include exercise can also be realized with cancer patients. This form of care seems to have met with success.1,2,3,4
It now appears that rehabilitation has been defined as the process by which a person is restored to an optimal physiological, psychological, social and vocational status.2 In the case of cancer patients, rehabilitation can be a challenge due to the significant side-effects of cancer treatment: fatigue, weakness, impaired nutritional status, difficulty sleeping and nausea. The patient often sees a decrease in normal physical performance, and the resumption of regular activities after therapy is often delayed. New studies have shown that including exercise within the rehabilitation program reduces the above-mentioned side effects, and even shortens the length of stay in the hospital following treatment.1 In one study, patients who participated in an exercise program during high-dose chemotherapy were discharged, on average, sooner than patients in a control group.
Meals on Wheels: Combating Malnutrition in the Elderly
Philip Dopp, BSc
The nutritional status of the elderly can be helpful in examining the health of this population. One study found that malnutrition among the elderly is associated with a variety of problems such as the development of pressure sores and fractured femurs.1 Others have found that poor nutrition predisposes the elderly to infections, as those who are malnourished are 3.3 times more likely to be infected with a community-acquired bacterial pneu-monia.2 Of even greater importance, is the demonstrated fact that poor nutritional status, as measured by body mass index, is an important predictor of mortality in the elderly.3 Given that studies have found that among population of seniors, the prevalence of malnutrition can be as high as 60%, and considering the consequences which can ensue, malnutrition represents a problem that warrants concern.4 In an attempt to deal with this problem, programmes such as Meals on Wheels® (MOW) have been developed to provide nutritional services for the elderly.
the philosophy of MOW was to help frail elderly and disabled persons in the community avoid premature or unnecessary institutionalization.
Nutritional Requirements: Meeting the Altered Macro- and Micro-nutrient Requirements of the Elderly
Lilia Malkin, BSc
Nutritional status has been widely acknowledged to play a key role in the maintenance of health and recovery from disease. Malnutrition has been linked to increased morbidity and mortality, while nutritional support through enteral or parenteral routes has been demonstrated to contribute to reduced morbidity and shorter hospital stays.1 It is also recognized that while several vitamins and minerals are essential to the human body, nutrient intake requirements do vary across age groups. Unfortunately, it may be difficult to obtain the necessary nutrients from food products alone. The challenge of maintaining a well-balanced diet with appropriate caloric and nutritional intake is made more difficult in the ill and the elderly, resulting in malnutrition. This article will focus on the unique nutrient requirements of the geriatric population and the potential contribution of oral nutritional supplements in ensuring a well-balanced diet among both community-dwelling and hospitalized members of this age group.
Nutrient requirements As the body grows older, it undergoes a multitude of physiologic alterations, resulting in changes in macro- and micro-nutrient requirements.
Good Nutrition is Often Key to Functional Recovery
Barry Goldlist, MD, FRCPC, FACP
There is more and more evidence accumulating in recent years that demonstrates the critical importance of nutrition in the elderly. The negative consequences of being overweight have long been known. Much of the modern 'pandemic' of type II diabetes mellitus is secondary to this. As well, hypertension and hyperlipoproteinemias are related to obesity. Recent evidence has confirmed the long suspected relationship between arthritis of the knee and excess weight. Despite this, the average weight of North Americans continues to rise. My personal belief is that this does not simply reflect a lack of personal self-discipline, but rather a societal structure that constrains physical activity in day-to-day existence. Irregular trips to the gym are no substitute for walking each day, even if only to the bus stop. Our cities in North America, with their sprawling suburbs, seem designed specifically to discourage walking and encourage driving. A rethinking of how we design our living spaces might help in controlling the occurence of obesity.
We understand even less about the causes of under-nutrition in old age. Is it a consequence of disease and decline, or is it a factor that causes functional decline? Certainly the causes of weight loss in old age are almost always multifactorial. The various factors range from poor dentition, loss of ability to smell, the effects of drugs, to specific disease processes, such as cancer. Eating is also an intensely social process, and isolated seniors are particularly at risk for under-nutrition. Regardless of whether under-nutrition is the 'chicken or the egg', once an elderly person becomes ill, careful attention to nutritional issues is often the key to ultimate functional recovery. Thus, in any geriatric service, the clinical dietitian is a key member of the team. For any physician following elderly patients in their own practice, the easiest way to detect problems at an early stage is to carefully record the patient's weight at regular intervals. This is particularly important in nursing homes, where weights should be recorded on a monthly basis. In the USA, intense research interest has been focused on this issue, particularly on the fact that protein loss seems to predominate in some patients. The resulting loss of muscle mass has been called 'sarcopenia', and is clearly a factor in functional decline.
It is ironic, that as a geriatrician, even though I have seen wonderful therapeutic advances in care of the elderly, the best strategy for maintaining quality of life in old age, continues to consist of regular exercise and good eating habits.
Start Exercising Already!
Kathryn Walker, MA