The Geriatric Giants

Dr Hannah Seymour

Consultant Geriatrician

RPH

Aknowledge slides from

• Dr Kate Ingram

• Dr Mark Donaldson

• Dr Chris Beer

• Dr Sean Maher

GIANTS OF GERIATRICS (Isaacs 1970)

• Immobility

• Instability

• Intellectual Impairment

• Incontinence

• Iatrogenesis

I’m going to talk about

• Cognition – Forgetfulness vs Delirium vs Dementia

• Falls – Reversible causes in the community

• Immobility – How to avoid and manage it

• Incontinence – Especially reversible causes

• Iatrogenic Conditions – Especially Polypharmcy & Malnutrition

Cognition

Cognitive Screening Tests

• Screening

Detection amongst “healthy” community members of (unsuspected) disorders or risk factors

• Case Finding

Detection of cognitive impairment where high probability of disease in particular population or setting

Cognitive Screening Tests

• Normal ageing vs MCI vs early dementia?

• No perfect test for early detection

• Case for detection of mild cognitive impairment unclear

Risks vs benefits, costs, no effective therapies

May change with new therapies

• Emphasis on detection of dementia

Benefit from interventions

• Should always be done if memory complaints or history suggestive of dementia

Cognitive Screening Tests

• Detect cognitive impairment from any cause

• Don’t diagnose dementia!

• Generally test orientation, recall of short and long term memory, personal information, attention and other domains eg visuospatial

Cognitive Screening Tests: MMSE

•Standardised MMSE Molloy et al 1991

•Floor and ceiling effects

•Western background, education, language

•No test of executive function

•Orientation

•Registration, Recall

•Attention

•Calculation

•Language

•Visual construction

Cognitive Screening Tests: Geriatric Depression Scale (GDS) Yesavage 1983

•30 Questions

Cut off 11

Sens 84%

Spec 95%

Cut off 14

Sens 80%

Spec 100%

•15 Question version

•4 & 10 Question versions

•Yes or No responses to questions about depression symptoms

•Depression an important cause of cognitive impairment

Dementia

• Global cognitive impairment

• Irreversible

• Clear sensorium

• Usually progressive

Dementia: Causes

•Alzheimer’s

•Lewy Body

•Frontotemporal

•Parkinson’s

•Other extrapyramidal syndromes

•Huntington’s

•Vascular

Stroke

Small vessel ischaemia

•Cushing’s, Addison’s, Thyroid, parathyroid, diabetes

•Vitamin B12, thiamine, nicotine deficiency

•Normal pressure hydrocephalus, Head injury, space occupying lesion, multiple sclerosis

•Syphilis, HIV, encephalitis, CJD

Adapted from Eastley R., Assessment of Dementia, in Dementia, Eds Burns, O’Brien & Ames

Dementia: Some “Reversible or partly reversible” Causes

•Drugs

•Depression

•Metabolic causes

•Thyroid Disease

•Vitamin B12 deficiency

•Hypercalcaemia

•Liver disease

•Normal pressure hydrocephalus

•Subdural haematoma

•Neoplasm

Adapted from Eastley R., Assessment of Dementia, in Dementia, Eds Burns, O’Brien & Ames

Dementia: Diagnostic features

•development of multiple cognitive deficits

•impairment in occupational or social functioning

•decline from a previously higher level of functioning

•memory impairment

•And at least one of:

aphasia

apraxia

agnosia

disturbance in executive functioning.

Adapted from Diagnostic and Statistical Manual of mental disorders IV edition revised 2000, American Psychiatric Association

Diagnostic features: Memory

•Memory impairment needed for diagnosis

•early prominent symptom

•new learning impaired

•forgets previously learned material

•loses valuables, forget food cooking, lost in unfamiliar territory, poor medication compliance

•forgets personal details eg family, occupation, address, own name

Adapted from Diagnostic and Statistical Manual of mental disorders IV edition revised 2000, American Psychiatric Association

Diagnostic features: Aphasia

•Language difficulty

•Loss of complexity

•Naming people or objects

•Repetition

•Comprehension (verbal and written)

•eventually mute

Adapted from Diagnostic and Statistical Manual of mental disorders IV edition revised 2000, American Psychiatric Association

Diagnostic features: Apraxia

•Difficulty performing motor task despite intact

comprehension

power

Sensation

•Trouble with everyday tasks eg cleaning teeth, washing

Adapted from Diagnostic and Statistical Manual of mental disorders IV edition revised 2000, American Psychiatric Association

Diagnostic features: Agnosia

•Difficulty recognising objects or people

•Trouble recognising ordinary objects, family members, even themselves in photographs or mirrors

Adapted from Diagnostic and Statistical Manual of mental disorders IV edition revised 2000, American Psychiatric Association

Diagnostic features: Executive Functioning

•ability to think abstractly

•judgement, reasoning, insight

•plan, initiate, sequence, monitor, and stop complex behaviour•difficulty coping with novel tasks or complexity

•poor choices

•financial problems

•at risk behaviour due to lack of insight

Adapted from Diagnostic and Statistical Manual of mental disorders IV edition revised 2000, American Psychiatric Association

Diagnostic features: Behaviour

•Delusions, especially paranoia

•Hallucinations, especially visual

•Irritability, aggression (verbal and physical)

•Resistiveness

•Agitation, wandering, getting lost

•Social withdrawal

•Neglect of personal care, home, nutrition

•Apathy

•Sleep disturbance

•Mood disturbance

Anxiety

Depression

•Demanding, attention seeking, repetitive

Adapted from Hecker J., Dementia and Alzheimer’s Disease in A Practical Guide to Geriatric Medicine. Ratnaike R

Dementia: Assessment• History – most important

• Examination

• Neuropsychometric testing

• Laboratory tests

FBP, U&E, TFT, B12, folate, BSL, syphilis serology, ESR, Urinalysis, calcium +/- lumbar puncture, EEG

• Imaging

CT, MRI

SPECT, PET

Dementia: Alzheimer’s Disease• Accounts for 60% of Dementia in Australia

• Neuronal degeneration with plaques of beta amyloid and neurofibrillary tangles

• Early onset forms due to gene mutations

• Main feature is memory loss, plus other domains, gradually progressive

• Treatment with cholinesterase inhibitors (donepezil, galantamine, rivastigmine) or memantine

• New therapies seem promising

Adapted from Hecker J., Dementia and Alzheimer’s Disease in A Practical Guide to Geriatric Medicine. Ratnaike R

Alzheimer’s Disease: Natural History

Adapted from Hecker J., Dementia and Alzheimer’s Disease in A Practical Guide to Geriatric Medicine. Ratnaike R

Dementia: Lewy Body Disease

• Lewy bodies = neuronal inclusions of neurofilament protein ubiquitin

• Found in basal ganglia in PD, diffusely through cerebral cortex in DLB - spectrum of same disease?

• Classic features of cognitive impairment plus

Fluctuation in cognition, alertness, attention

Visual hallucinations

Parkinsonism

• Respond to cholinesterase inhibitors

• Very sensitive to antipsychotics => rigidity

Adapted from Hecker J., Dementia and Alzheimer’s Disease in A Practical Guide to Geriatric Medicine. Ratnaike R

Dementia: Vascular Dementia• Cognitive impairment due cerebrovascular disease

Small vessel ischaemic changes - gradual decline

Recurrent stroke - stepwise deterioration

• Evidence of vascular changes on CT/MRI

• Vascular risk factors - HTN, cholesterol, diabetes, smoking, existing cardiac disease

• Often early onset gait disturbance (balance and/or gait dyspraxia), falls, urinary incontinence

• Often frontal lobe features, emotional lability, pseudobulbar palsy with speech/swallowing problems

Adapted from Hecker J., Dementia and Alzheimer’s Disease in A Practical Guide to Geriatric Medicine. Ratnaike R

Dementia: Frontotemporal Dementia

• Probably represents several diseases

• Early loss of personal and social awareness

• Disinhibition often prominent

• Mental rigidity, inflexibility, “concrete”

• Depression and anxiety prominent

• Speech and language disturbance

Reduced in complexity

Echolalia, stereotypy

• Early primitive reflexes and urinary incontinence

• Late rigidity, tremor

Adapted from Hecker J., Dementia and Alzheimer’s Disease in A Practical Guide to Geriatric Medicine. Ratnaike R

Dementia: Management

• Treat reversible causes!

• Education

• Cholinesterase inhibitors (AD, LBD)

• Control of vascular risk factors

• Maintain cognitive and physical activity

• Treat depression

Dementia: Practical Issues

•Education

•Counselling

•Community Resources

Alzheimer’s Assoc

Respite in home, day centres & residential

Crisis Care

Care packages

•Strategies for managing behaviour

•Memory aids

•Home safety

•Driving

•Enduring Power of attorney

•Testamentary capacity

•Advanced directives

•Continence

•Residential Care

Adapted from Hecker J Dementia and Alzheimer’s Disease in A Practical Guide to Geriatric Medicine. Ratnaike R

Dementia: Take home messages

• Cognitive screening tools only detect cognitive impairment - they don’t diagnose

• History suggestive of dementia or abnormal cognitive test result should result in suggestion for further evaluation

• A diagnosis of dementia requires decline in occupational and social functioning, at least one other cognitive domain impaired (aphasia, agnosia, apraxia, executive dysfunction), as well memory

• Interventions usually beneficial

• Carer support vital to management

Delirium in Older People

Delirium: Definition

• de lira “to wander”

• Clinical syndrome characterised by

rapid onset of altered consciousness

and cognition

that fluctuates

Delirium: Epidemiology

• Prevalence in elderly hospital admissions

10 - 24%

• Incidence during hospital stay

6 - 56%

• Post operative incidence

10 - 61%

Delirium: Aetiology

• Geriatric syndrome

• Multiple factors acting in concert

• Patient vulnerability

• Predisposing factors

• Precipitating factors

Delirium: Predisposing factors

•Dementia

•Multiple medications

•Visual and hearing impairment

•Severe/multiple chronic medical conditions

•Dehydration

•Advanced age

•Neurological damage

•Functional disability

•Alcohol abuse

•Depression

•Chronic renal impairment

Delirium: Clinical Features

• Prodrome sometimes recognised

irritable, angry, evasive, bewildered

• Develops over hours to days

• Fluctuates

lucid periods during day

maximal disturbance at night

Delirium: Clinical Features

• Inattention

• Disorientation

• Short term memory impairment

• Thinking is disordered

• Speech rambling and incoherent

• Delusions, misperceptions and visual hallucinations

• Distress

Delirium: Clinical Features

• Disturbance of consciousness

• Hyperactive delirium

Repetitive behaviours e.g. plucking at sheets, wandering, verbal and physical aggression

• Hypoactive delirium

quiet, withdrawn patient, often mistaken for depression

• Mixed pattern

Delirium: Detection

• Delirium often missed

• 32 – 67% of delirious patients are not diagnosed

• Cognitive assessment should be standard

MMSE or AMTS

• Serial testing to monitor progress and to detect delirium arising during an admission

• Mental status = a “vital sign”

Delirium: Detection

Confusion Assessment Method

(Inouye et al Ann Int Med 1990;113:234-42)

1 Acute onset and fluctuation of cognition

AND

2 Inattention

with EITHER

3 Disorganised thinking

OR

4 Altered level of consciousness

Delirium: Management

• Treat underlying causes

• Correct dehydration

• Review medications

• Non Pharmacological

• Pharmacological

• Monitor progress

Delirium: OutcomesDuration

• More persistent than previously realised

• up to one week in 60%

• two weeks in 20%

• four weeks in 15%

• more than four weeks in 5%

• Others report delirium still present at 6 monthsO'Keeffe S The prognostic significance of delirium in older hospital

patients J of the Am Geriatr Soc 1997;45(2):174-8

Delirium: OutcomesCognitive decline

• Early cognitive impairment unmasked by acute illness

• May be acute and permanent deficits due to ischaemia, hypoxia or mediated by glucocorticoids or cytokines

Francis J Prognosis after hospital discharge of older medical patients with delirium. J Am Geriatr Soc 1992;40(6):601-6

Delirium: Take Home Messages

• Common

• Distressing

• Often Missed

• Cognitive testing should be routine

• Complex Geriatric Syndrome

• Preventable

• Predicts adverse outcomes

Falls -Prevention and Management

Definition

• “A fall occurs when environmental hazards or demands exceed an individual’s ability to maintain postural stability”

Mary Tinetti ASGM ASM 2001

Enormity of the Problem

• 33% over 65yrs fall annually

• 50% of these have repeat falls

• In nursing homes 50-65% fall annually

• 10-15% of falls result in serious injury

• 1% hip fracture rate

Breakdown of Discussion

• Falls in community dwelling elderly

• Compliance problems

• Unanswered questions

Modifiable Risk Factors for Falls in the Community

•Psychotropic drugs – especially benzodiazepines

•Multiple drugs

•Postural Hypotension

•Environmental hazards

•Vision

•Poor balance or gait

•Poor functioning with ADLs

•Footwear

Preventing Falls in the Community

• Independence model of care

• Screening of home environment by OT / health worker

• Psychotropic medication withdrawal

• Medication review/ minimization

• Appropriate vision aids & footwear

• Balance and exercise program

• Avoiding Injury - Treating Osteoporosis

Falls Clinic ProcessMultidisciplinary- everyone assessed by the following:

• Geriatrician- full history, examination, investigation, including osteoporosis workup

• Nurse-lying and standing BP, vision, continence, community supports

• Physiotherapist- administers Fallscreen, ?need for walking aid, teaches patient to get up off floor, strength and balance exercise program, sets home program, general footwear advice

• OT- ADL assessment, 50% get home visit, group education sessions

+/- social work assessment for package of care, hostel/ N/H

+/- clinical psychologist to address fear of falling or podiatry

Falls Clinic Process Contd.

• All new patients discussed at a multidisciplinary meeting at the end of the clinic, and management plan formulated

• Length of time attending the clinic approx 6-10 weeks.

• On discharge, given home exercise program

• Followed up 4 months following discharge

What about in the Kimberley

• No research in remote or Indigenous settings

• Moving to single multiskilled professional in metro areas

• Can do great functional assessments and improve reversible risk factors

• Independence model of care very important

Who Should Have a Comprehensive Falls Assessment?

• All older persons to be asked once a year about falls

• If 1 fall -GP assessment, and observe the ‘Get up and go” test

• Triggers for further assessment

>1 fall in last year

A fall resulting in injuries

Abnormalities in gait or balance

Symptoms of dizziness

Evidence of a fear of falling

Hip Protectors

• Reduce hip fracture rate (by 50%) for those in nursing homes with a high risk of falling

• Compliance is problematic- 38 –57% in various studies

Vitamin D Deficiency and Falls

• Causes muscle weakness and probably falls

• Leads to osteoporosis and increased risk of fracture

• Very common in elderly, community dwelling population (? Indigenous)

• Almost universal in residential care

• Replacement with calcium reduces fractures in residential care and in those who are deficient in the community

Patient Compliance with Fall Initiatives

• Survey in Aust (Whitehead, 2003)

72% reluctant to do exercises

57% reluctant to stop sleeping tablets

43% reluctant to have a home assessment

• Campbell, JAGS, 1999

Study demonstrated reduced falls with psychotropic withdrawal program and home based exercises

47% had restarted their psychotropics within 1 mth

Patient Compliance with Fall Initiatives

• Simpson

UK study investigated barriers to a falls program

The elderly patients involved had reduced understanding of the benefits of exercise

Home visits were considered intrusive, and felt that there was inadequate negotiation about the necessary changes resulting in resentment

Summary

• Falls are a hallmark of the frail elderly

• Falls are usually multifactorial in origin

• DON’T be pessimistic- multidisciplinary treatment can prevent up to 60% of falls

• The elderly have the most to gain by treating their osteoporosis

Immobility

How to avoid it?

• Encourage functional mobility

• Educate family and carers

• Early rehabilitation

• Appropriate use and maintenance of mobility aids

• Physiotherapy if possible

Management of the Immobile Patient

• Ensure no reversible causes can be identified

• Encourage Independence within limits of mobility

Avoiding Pressure Ulcers

• Regular assessment of bony prominences

• Regular turning to relieve pressure – ideally 2 hourly

• Use pillows if no air mattresses available

• Avoid friction and shearing forces (safe manual handling)

• Skin Hygeine and Moisture

• Leave blisters intact

• Get help early – for example Donna Angel at RPH will advise

Urinary Incontinence in the Elderly

Incontinence in the Elderly

• Prevalence in community dwelling elderly

-women 30%

-men 15%

• 60% of nursing home residents

• Risks

-parity (association is weak in women over 65yrs)

-hysterectomy

-obesity

Continence requires:

• Adequate mobility

• Mentation

• Motivation

• Manual dexterity

• Intact lower urinary tract function

Medical Complications

• Rashes

• Pressure ulcers

• UTI

• Falls

• Fractures

Psychosocial complications

• Embarrassment

• Stigmatisation

• Isolation

• Depression

• Institutionalisation risk

A Normal Bladder

• First urge to void occurs when bladder volume is 150 – 300mls

• Normal bladder volume 300 – 600mls

• Bladder capacity declines with age and post void bladder volumes increases (up to 50 – 100 mls)

• Involuntary bladder contractions also increase with age

• Lose the ability to concentrate urine at night (ADH secretion) with nocturia 1 – 2 x)

Causes of Transient Incontinence

• Delirium

• Infection (symptomatic UTI)

• Atrophic vaginitis/ urethritis

• Pharmaceuticals

• Psychological

• Excessive urine output

• Restricted mobility

• Stool impaction

Drugs Affecting Continence

• Diuretics

• Anticholinergics

• Psychotropics

• ACE inhibitors (cough)

• Narcotics

• Alpha blockers (urethral relaxation)

• B agonists (retention)

• Calcium channel blockers (retention)

Persistent Incontinence-Stress

• Involuntary loss of urine (usually small amounts) with increases in intra- abdominal pressure (coughing, sneezing, laughing, exercising)

• In women, causes include lack of oestrogen, obesity, previous vaginal deliveries, previous surgery

• In men (rare) causes include radiotherapy and prostatectomy.

Persistent Incontinence-Urge

• Leakage of urine (larger volumes) due to inability to delay voiding after sensation of bladder fullness is felt

• Associated symptoms include nocturia, urinary frequency

• Causes

Ideopathic (Detrusor overactivity)

Local pathology- tumour, stone, diverticuli, outflow obstruction

CNS disorders- stroke

Detrusor hyperactivity with Impaired Contractility (DHIC)

• A subset of patients will have this, emptying less than 1/3 of bladder volume

• Are predisposed to urinary retention

Persistent Incontinence-Overflow

• Leakage of urine (small amounts) resulting from mechanical forces on an overdistended bladder

• Causes

Anatomical obstruction by prostate, stricture, cystocoele

Acontractile bladder associated with diabetes or spinal cord injury

Medication related

Assessment• History

Characteristics of incontinence

Medical problems, medications, bothersomeness

• Bladder chart

• Examination

General- esp CCF, venous insufficiency

Abdominal

PR

lumbosacral innervation

In women- inspect for prolapse, cough test, atrophic vaginitis

Assessment of mental state and mobility

Assessment

• Urinalysis

the relationship of asymptomatic bactiuria with incontinence is controversial.

No benefit from treating the nursing home population

? Eradicate bactiuria once and assess it effect on incontinence

• Post Void Residual Volume – Important to rule out significant retention

<100 mls normal

>200 mls abnormal

Assessment- selected patients

• Urine culture, cytology

• Blood glucose, calcium, renal function

• Abdominal ultrasound

• Urodynamics

Recent data suggest that it has little clinical utility in urge incontinence

Management

• Supportive measures

• Education

• Environmental changes eg toilet light on

• Use of toilet substitutes eg bottle, commode

• Modification of fluid intake patterns

• Alcohol, caffeine avoidance

• Management of constipation

• Smoking cessation, treatment of cough

Management- Behavoural

• Pelvic floor exercises- useful for urge

and stress incontinence

• Bladder Retraining

Urge incontinence

Progressive lengthening of intervoiding interval

Management- Behavoural

Institutionalised patients

• Scheduled toiletting- 2 hrly during day, 4 hrly at night

• Habit training- variable schedule depending on patients voiding patterns

• Prompted toiletting- prompted to toilet 2 hrly, only toiletted on request, positive reinforcement (25 -40% of nursing home residents respond)

Management Urge Incontinence- Drugs

• Anticholinergics eg. Oxybutinin 2.5- 5 mg tds

have 60 – 70% reduction in frequency of incontinence episodes

Probably work via afferent pathways

S/Es: dry mouth, constipation, confusion, urinary retention

• Oestrogen vaginal cream 0.5-1g nightly for 1 month, then 2-3x/ week (NB oral oestrogens worsened incontinence in the WHI study)

Management Stress Incontinence- Drugs

Little role for medications

Imipramine 25-50 mg tds (anticholinergic as well, so there is an argument for using it for mixed urge/ stress incontinence) Efficacy date is lacking, though and has side effects ++ in elderly

Duloxitene- serotonin and noradrenaline reuptake inhibitor (results in 50-54% reduction in frequency of incontinence). Causes initial nausea

Management of Overflow Incontinence

Catheter if significant retention then:

Refer to urology who may advise medication and or surgery

Drugs - Prazosin, Tamsulosin, Terazosin

Management- other strategies

• Surgery - TURP- Bladder neck elevation, peri-urethral

collagen injections

• Catheters- IMCs, IDCs

• Botulinum toxin injection into detrusor muscle or bladder neck

• Continence pessaries- for women with large prolapses when surgery is contraindicated

• Desmopressin for large volume nocturia

Iatrogenic Problems

Polypharmacy

Objectives

• Understand why Polypharmacy is common in older people

• Identify the problems caused by polypharmacy in older people

• Monitor and manage Polypharmacy

• Understand inappropriate versus appropriate Polypharmacy

The Challenge of Geriatric Clinical Pharmacology

‘to balance an incomplete evidence base for efficacy in frail, older people against the problems related to adverse drug reactions without denying older people potentially valuable pharmacotherapeutic interventions’

Le Couter et al

Polypharmacy

• 5 or more drugs

• 20-40% of older people

Causes of Polypharmacy

•Comorbidities

•Age

•Prescriber (what influences prescribers?)

•Reluctance to cease another prescriber’s prescription

•‘Rational Polypharmacy’

Risks of Polypharmacy

• Adverse drug reactions common cause of

hospital admission

morbidity and mortality

• Falling, delirium and the other geriatric syndromes may be drug-related

• Medication errors

polypharmacy, per se, appears to be a risk factor for adverse outcomes

What are the goals of care?

• Often different in frail person

• Risks of polypharmacy higher in frail person with limited homeostatic reserve

Eg antihypertensives

Weigh risks and benefits

•Efficacy

•Risk of ADR

•Pt wishes

Common difficult areas

• Include Benzodiazepine and psychotropic polypharmacy

• Antihypertensives

Medication Withdrawal Can be Achieved

Is Discontinuation Safe?

•Psychotropic withdrawal reactions

•Anti anginals

•Anticonvulsant medications

Other Difficult Areas - Under treatment

• Analgesics

• Osteoporosis therapy

(Anticoagulants)

(ACE-inhibitors and B-blockers)

Under treatment Continued

•Ca and Vit D (v bisphosphonates)

Reviewing Medications

• View and Record all medications, including OTC’s, herbs, dietary supplements

• Ask about other prescribers

• Cautious medication withdrawal where indicated

Use aids

•Simplify regimens

•Medication cards

•Dosette Boxes

•‘Webster Pack’

•Supervised medications

•Involving caregivers

Conclusions

• Avoid polypharmacy

• Weigh risks and benefits

• Scrutinise all medication prescriptions critically

• Monitor therapy carefully in elderly patients

Malnutrition

Prevalence

• Increases with frailty and physical dependance

• Estimated 4.8% recipients of domiciliary aged care clients

• 27.7% Sub-acute crae

Consequences• More GP consultations

• More prescriptions

• Higher hospital admission rate

• Increased risk of:

Falls

Prolonged hospitalisation

Institutionalisation

Infections

Pressure Ulcers

Death

Nutritional Frailty

• Disability due to unintentional loss of body weight and sarcopenia

• Search for medical causes

• Low Socioeconomic status significant risk factor

• As are poor health, polypharmacy, low mood, low cognition.

Non Physiological Causes

• Social Factors – Poverty, Inability to shop, cook or feed

• Psychological Factors – Alcohol, Depression, Dementia

• Medical Factors – Cancer, Chronic Disease

• Medications – Side Effects common

Screening

• Two Question Rapid Screen

Positive if : Body Mass Index <22kg/m2

Weight loss > 7.5% over 3 months

Management

• Treat/Manage reversible causes

• Educate individual and family – www.nhmrc.gov.au/publications/synopses/n23syn.htm

• Oral supplements with macronutrients

• Lack of evidence for most vitamin supplements

• Ref : Malnutrition in older people - Australian Family Physician Vol 33, No 10 October 2004