The main reason I entered the field of geriatric medicine was that in my era of training, almost everybody in internal medicine sub-specialised if they were at all interested in an academic career (fortunately, this is no longer the case). Although I recognised this need for sub-specialisation, I wanted a field where I was responsible for an entire person, not just one disease or one organ. Geriatrics has allowed me to be a sub-specialist but with a generalist point of view, and I have been very happy with my choice.
The one area where my training let me down, however, was in neurology, and I have been scrambling to catch up ever since. It is impossible to provide good care for the elderly without some understanding of neurology and, most importantly, the ability to do an effective screening neurological examination (see "The Neurological Examination in Aging, Dementia and Cerebrovascular Disease", Parts 1-4, in Vol. 5, Nos. 7-10). I suspect that many other physicians are uncomfortable with neurology as well. When I am on the geriatric consultation service, I am always struck by how many significant neurological issues have been missed--or ignored--in the patients that I see. I do not know whether this reflects concern that neurological attention will delay discharge, or a lack of understanding of the benefits of current neurological interventions.
Of course, we do not want our patients to suffer because of missed or ignored neurological conditions. As generalists, we need to understand the common neurological issues in the elderly, learn how to deal with the simpler issues, and refer the more difficult problems to neurologists (whether they be diagnostic or therapeutic). Fortunately, this issue of Geriatrics & Aging will help us in these tasks. There are articles on epilepsy in the elderly, the causes of diplopia, and the etiology and evaluation of dizziness. The management of tinnitus, late-life migraine accompaniments, and numbness and paresthesias in the elderly are also included. These articles will be of particular interest to those caring for the elderly in ambulatory primary care settings.
Drs. Tara Morrison and James Perry have written a review of primary brain tumours in the elderly. The increasing incidence of brain tumours in the elderly (exact reason unknown), combined with the aging of the population, means that these tumours will be seen ever more frequently by all types of physicians. Dr. D'Arcy Little discusses a vexing clinical problem, the drug management of neuropathic pain in the elderly.
We have, as well, several non-neurological articles. Carotid endarterectomy is one of the relatively few surgical procedures that has been well studied in randomised trials, but the literature can sometimes be difficult to interpret. Drs. Claudio Cinà and Catherine Clase summarise the indications and limitations of this common surgical procedure. Two "veteran" social workers with extensive geriatric experience, Helen Levin and Zoë Levitt, review capacity assessment for admission to long-term care. To illustrate how difficult this issue can be, they have chosen some interesting cases. Dr. Maha Haroun has reviewed what is probably the most common dermatological complaint in the elderly, dry skin. The World Health Organization has struck a task force on the issue of elder abuse, and the key issue on which they are focusing is the training of health care providers to recognise elder abuse. Members of the Toronto RGP Elder Abuse Network describe a workshop that has been developed for this purpose.
Enjoy this issue.