Gena Piliotis, MD¹
William H. Geerts, MD^1,2
1Departments of Medicine and
²Health Policy, Management and Evaluation;
Sunnybrook & Women's College Health Sciences Centre,
University of Toronto, Toronto, ON.

Abstract
Venous thromboembolism is predominantly a disease of the elderly. However, geriatric patients often fail to receive appropriate thromboprophylaxis because of under-recognition of age as an important risk factor for thromboembolism and perhaps, in part, because of the perception of a greater potential for bleeding complications associated with anticoagulants. Although there is a paucity of literature specifically addressing thromboprophylaxis in geriatric populations, it is suggested that elderly patients with thromboembolic risk factors receive similar prophylaxis to that recommended for younger patients with the same risk factors. Routine prophylaxis should, therefore, be provided to elderly patients undergoing general, urologic and gynecologic surgery, neurosurgery, hip or knee arthroplasty, surgery for hip fracture, to those who experience major trauma, and to elderly patients with acute medical illnesses plus additional risk factors.

D'Arcy Little, MD, CCFP
Director of Medical Education,
York Community Services, Toronto, ON.

Introduction
The nurses inform you that the elderly woman in Bed 140-B is agitated, and is complaining that a ghost-like man has been frightening her in her room at night. She is recovering from hip surgery that took place the day before yesterday. When you examine her in the morning, she is drowsy. Later that afternoon she is awake but has difficulty attending to your questions. You begin a work-up for postoperative delirium.

At one time or another, all physicians have faced the challenge of treating a delirious elderly patient in hospital. Delirium is a common, serious, yet potentially preventable cause of morbidity and mortality that primarily affects the elderly and is very common in the elderly post-surgical patient.^1-3 The condition is characterized by a disturbance of consciousness and a change in cognition that develops over a short period of time and tends to have a fluctuating course over the day. It is caused by the direct physiological consequences of a general medical condition (See Table 1).^2,4 The following article will review the epidemiology and etiology of delirium with a view to presenting an approach to the prevention of postoperative delirium in the elderly surgical patient.

M. Clare Robertson, PhD
Research fellow,
Department of Medical and Surgical Sciences,
University of Otago Medical School,
Dunedin, NZ.

A. John Campbell, MD, FRACP
Professor of Geriatric Medicine,
Department of Medical and Surgical Sciences,
Dean, Faculty of Medicine,
Dunedin, NZ.

Introduction
Falls are a common problem in older people and substantial healthcare resources are required for the treatment of injuries, for rehabilitation and for long-term care after a fall. For the older person and their family or caregivers, a fall can have serious consequences: trauma, pain, impaired function, loss of confidence in carrying out daily activities, loss of independence and autonomy, or even death.

Falls prevention strategies have been based on the multiple risk factors for falls and these are well defined in the literature.¹ There is now good evidence from randomized controlled trials that carefully designed, single or multiple interventions can reduce falls in older people living in the community.² There are fewer reports on the cost effectiveness of these strategies--useful information for making informed decisions on the allocation of scarce healthcare resources.

Figure 1 gives a list of the falls prevention strategies for community living older people that have been tested in randomized, controlled trials.

Jane Oshinowo, RNEC,
Primary health care Nurse Practitioner,
York Community Services,
Toronto, ON.

Sharon Dolman, RN
Medical copy writer,
HEADCAN,
Toronto, ON.

Introduction
Cardiovascular disease (CVD) is the leading cause of death in Canada and the second leading cause of disability. Since the mid-1960's there has been a gradual decline in overall mortality rates due to heart disease; however, there has been little improvement in the mortality rates from ischemic heart diseases (HD) and acute myocardial infarction (MI).¹ Abookire²⁷ noted that many physicians failed to adhere to the guidelines designed to reduce CVD risks. One strategy in this arena is to expand collaborative practice with nurse practitioners and other health care providers.

This paper will review the epidemiology of coronary heart disease (CHD) and the evidence about primary prevention designed to reduce cardiovascular risk factors, highlighting the role of the primary health care provider.

Epidemiology of Cardiovascular Disease
CVD is responsible for 36% of the deaths in Canada every year. Of these deaths, 21% are attributed to ischemic heart disease, and half of those are ascribed to acute MI (See Figure 1).¹ Huge costs are accrued to society from CVD.

Chris MacKnight, MD, MSc, FRCPC
Division of Geriatric Medicine,
Dalhousie University,
Halifax, NS.

Dementia and hypertension are two of the most common conditions affecting older adults. A number of recent studies suggest that dementia is one of the long-term complications of hypertension. Studies also suggest that the treatment of hypertension may prevent dementia. This brief review will focus on the relationship between hypertension and dementia in older adults.

Epidemiology of Dementia
Eight percent of Canadians who are over the age of 65 suffer from dementia, with Alzheimer's disease being the most common cause (approximately 60% of cases).¹ Dementia is age-related, with the prevalence increasing from 2.4% of those from 65-74 years of age, to 34.5% of those 85 and older. Sixty thousand new cases occur each year in Canada.² The cost of providing care to these patients is substantial, at 3.9 billion dollars/year, in 1991 dollars.³ Vascular dementia is the second most common cause of dementia in Canada, accounting for 20% of cases. When discussing vascular dementia, it is important to recognize that the classic pattern of multiple infarcts is found only in approximately 1/3 of the cases. The other cases consist of patients who have changes in their white matter (likely on the basis of small vessel ischemia) with or without lacunar infarcts, or, rarely, single strategic strokes.

Leora Horn, BSc, MSc

Over three hundred thousand Canadians currently suffer from Alzheimer's disease (AD) and the related dementias. AD is a degenerative disorder associated with a progressive decline in cognitive function. There is significant neuronal loss and impairment of metabolic activity in the cerebral cortex, hippocampus and subcortical structures affecting memory, language and emotion. At present, there are limited drugs used to treat the symptoms associated with the disease but there is no cure. In a recent Nature publication, Schenk et al., reported results that take the treatment of AD in a new direction by raising the possibility of vaccination as prevention against disease development. In two separate sets of experiments scientists were able to prevent the occurrence or reduce the presence of Alzheimer-like pathology in genetically engineered mice immunized with one of the proteins that may be responsible for disease evolution.¹

According to the Alz-heimer's Association of Canada, AD is the fourth leading cause of death in adults. The prevalence of AD increases exponentially with age. AD affects 1 in 100 Canadians between the ages of 65 and 74, 1 in 14 Canadians between the ages of 75 and 84 and 1 in 4 Canadians over 85. Symptoms of AD range from forgetfulness to disorientation to people, time and place resulting in an inability to function without assistance.

Neil Fam, BSc, MSc

Pneumonia is a common and serious condition that claims over 6,000 lives in Canada annually. The elderly are particularly at risk, with individuals over 65 accounting for 50% of all pneumonia cases and 90% of deaths due to lower respiratory tract infection.¹ Indeed, elderly patients with pneumonia have a mortality rate 3-5 times that of young adults. A combination of factors contribute to the increased incidence of pneumonia in the elderly, including the presence of comorbid illness and the effects of aging on the lungs and immune system (see Age-related Changes to the Respiratory System Will Not Affect Healthy Elderly). Recent advances in our understanding of pneumonia have led to a re-evaluation of traditional approaches to the disease. This review outlines disease presentation, common pathogens and current diagnostic, treatment and preventive options in the care of elderly patients with pneumonia.

Lilia Malkin, BSc

Adverse drug reactions (ADRs) account for a significant proportion of morbidity and mortality in the geriatric population. According to the 1993 Canadian Medical Association (CMA) Policy Summary, over 20 percent of acute care hospital admissions of Canadian seniors may result directly from ADRs. Other studies have reported the incidence of ADR-related admissions ranging from 8 to 35 percent.

The World Health Organization (WHO) defines an adverse drug reaction as "a noxious, unintended effect of a drug that occurs in doses normally used in humans for the diagnosis, prophylaxis, or treatment of disease." ADRs can be divided into two categories: predictable (Type A) and unpredictable (Type B). Predictable reactions make up the vast majority of ADRs at 80 percent. Type A reactions are frequently dose-dependent and related to the augmented pharmacologic action of the medication: toxicity, side effects, indirect effects, and drug interactions. Unpredictable ADRs are less common, and include intolerance, allergy or hypersensitivity, idiosyncrasy, and psycho-genic reactions. Recognition of the pertinent risk factors for both predictable and unpredictable ADRs has direct application to ADR prediction, prevention, and management in the geriatric population.

ADR Prediction: Risk Factors

Older Canadians have a four- to seven-fold higher risk of suffering an ADR compared to younger individuals. According to Dr.

Shechar Dworski, BSc

As the North American geriatric population steadily increases, a greater emphasis is being placed on primary prevention in the form of screening and counseling, to avoid onset and/or advancement of disease. Treatment of advanced disease often requires much more invasive and time-intensive procedures, and is more stressful and risky for the patient. The periodic health exam is an opportune setting for a primary care physician to screen asymptomatic elderly patients for diseases commonly associated with aging or with a high-risk group. The physician's role is moving from treatment to prevention in our current social climate, since early detection often reduces onset and progression of disease, or at least reduces complications and increases survival rates.

Unlike their younger counterparts and the stronger elderly, when frail elderly become ill, early symptoms of chronic disease are rarely specific and localized ones. Instead, older patients usually manifest nonspecific symptoms, which quickly lead to loss of function. This creates dependency in a previously independent older person without giving any clues as to the cause of the problem. The functional expressions of disease include cessation or reduction of eating and drinking, dizziness, urinary incontinence, falling, weight loss, acute confusion, failure to thrive, and new onset or worsening of previous dementias.

Anna Liachenko, BSc, MSc

While non-pharmacological approaches are clearly beneficial for prevention of osteoporosis (OP), for many women these measures are not enough and a pharmacological treatment is required. Until early this decade, this meant one choice, hormone replacement therapy. Now, non-hormonal bisphosphonate treatments are also available. Both approaches are comparably efficient in preventing bone loss, at least on repeat bone mineral density testing. Some experts are also advocating slow-release fluoride, and combination therapy is also increasing. However, treatment choice is a complex decision which should only be made after careful consideration of the risks and benefits of each treatment, by the patient and her physician.

Before reviewing particular classes of drugs, physicians need to remember that all patients at risk for OP or with proven OP should be taking calcium and vitamin D in appropriate doses (see Fracture Prevention Part 1).