A.D. Baines, MD, PhD, FRCPC, Professor, Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON.

This article presents a summary of recent recommendations for the diagnosis and treatment of Type 2 diabetes in the elderly. Onset of nephropathy, neuropathy and retinopathy can be slowed by treatment designed to reach realistic target values for fasting plasma glucose and HbA1c. Therapy also should minimize the dangers of hypoglycemia. Hepatic and renal function must be monitored when selecting drugs and dosages. Significant reductions in renal function may be associated with serum creatinine within the normal reference range. A stepwise approach to therapy beginning with diet and exercise and proceeding to single and multidrug treatment is outlined. The mode of action, advantages, disadvantages and contraindications for five groups of hypoglycemic agents are summarized.
Key words: Type 2 diabetes, diagnosis, stepped treatment, oral drugs, elderly.

David C.W. Lau, MD, PhD, FRCPC, Professor of Medicine, Biochemistry and Molecular Biology; Director, Julia McFarlane Diabetes Research Centre, University of Calgary, Calgary, AB.

As the population ages, the diagnosis of Type 2 diabetes is expected to skyrocket over the next two decades. Diabetes is diagnosed by a fasting venous plasma glucose level of equal to or greater than 7mmol/L or, in the presence of classic symptoms of hyperglycemia, a casual plasma glucose value greater than 11.1mmol/L. Early diagnosis, screening and prevention of diabetes in the elderly will greatly reduce the burden of this serious chronic disease that is associated with increased morbidity and mortality.
Key words: impaired glucose tolerance, diagnosis, screening, prevention, Type 2 diabetes

The Diabetes Epidemic
Diabetes is now reaching epidemic proportions in Canada and the U.

Benjamin Chiam, MD, Department of Medicine, Pulmonary Division, University of Alberta, Edmonton, AB.
Don D. Sin, MD, FRCP(C), Department of Medicine, Pulmonary Division, University of Alberta, and The Institute of Health Economics, Edmonton, AB.

Introduction
Respiratory conditions are among the leading causes of morbidity and mortality worldwide. Although they are currently listed as the fifth leading cause of death in Canada, respiratory diseases are predicted to be the third leading cause of mortality by the year 2020, following ischemic heart disease and stroke.¹ Furthermore, since the prevalence of these conditions increases with age, the adverse impact of respiratory illnesses on the Canadian health care system will grow enormously over the next few decades as the overall population ages² and treatments for other common conditions, such as ischemic heart disease, stroke and diabetes, improve. A good understanding of the aging process of the respiratory system is clearly needed to formulate better strategies to prevent, diagnose and manage respiratory conditions in Canada.

Why are Respiratory Diseases so Prevalent in the Elderly?
The lungs of elderly persons are subject to a lifetime of exposure to known and unknown harmful agents. Decades may pass before the physical manifestations of cigarette smoke, pollution and other noxious environmental agents become clinically apparent.

Mercè Roqué, MD, Cardiovascular Institute, Hospital Clínic de Barcelona, Spain.

Ernane D. Reis, MD, Department of Surgery, Mount Sinai School of Medicine, New York, U.S.A.

Introduction
Tricuspid valve disease is rarely an isolated condition. Most cases are associated with other valvular or myocardial disease, pulmonary hypertension or systemic disorders. The tricuspid valve is located in the outflow tract of the right ventricle, and is the largest heart valve with an area of approximately 11cm². The valvular apparatus includes the fibrous annulus, the leaflets (anterior, septal and posterior), the tendinae chordae and the papillary muscles. Given that the tricuspid valve's main function is to regulate inflow to the right ventricle, conditions affecting the tricuspid valve generally have an impact on the right atrium and the venous circulation. Similarly, disorders affecting the left or right ventricle or the pulmonary arterial system can impair tricuspid valve function.

This review focuses on the most common causes of tricuspid stenosis (TS) and regurgitation (TR) in older adults. In these patients, functional tricuspid regurgitation is by far the most frequent tricuspid disorder. In the evaluation of tricuspid valve disorders, a thorough physical examination is essential to provide information for a correct diagnosis. An overview of the most useful ancillary tests and treatment options is also presented.

Dr. Marie-Josée Filteau, MSc, MD, FRCPC, Clinical Professor, Department of Psychiatry, Laval University, Clinical Researcher, Laval University-Robert-Giffard Research Centre, and Director, Clinique Marie Fitzbach, Quebec City, QC.

Patricia Gravel, BA, Department of Psychiatry, Laval University, Quebec City, QC.

Although depression is a highly prevalent psychiatric disorder and the focus of much research and discussion, it remains underdiagnosed and undertreated in the primary care setting. One of the key reasons for the underdiagnosis of depression is the tendency among physicians to focus on the emotional and psychological symptoms of the disorder at the expense of its physical symptoms. Although elderly patients with depression are more likely than their younger counterparts to present with physical rather than psychological symptoms, little emphasis is placed on physical symptoms in diagnostic tools and rating scales. Additionally, the understanding of the role and etiology of physical symptoms in depression remains poor.

Diagnosis can be especially challenging in the elderly population, since both patients and health care professionals often perceive depression to be a normal consequence of age-associated changes, such as physical illness or social or economic difficulties.

Roland R. Tremblay, DSc, MD, PhD, Professor Emeritus of Medicine, Laval University, Quebec City, QC.

Introduction
In both sexes, aging is associated with a progressive reduction in skeletal muscle mass and strength, although this may be masked by increases in subcutaneous fat or abdominal obesity that give the impression of stable body weight. Progressive frailty, however, occurs on a more global level with seniors "affected by multiple chronic diseases which cause physical and functional limitations."¹ These comorbid diseases may cause a systemic stress, which by itself (excess cortisol secretion), or by virtue of its suppressive action on the pituitary-gonadal axis, leads to a decline in androgen production. While the tendency to associate andropause and androgens has become increasingly common, the causal link between male hormone deficiency and the clinical disorder andropause still remains a weak one. A medical anthropologist is certainly likely to qualify the association as a reductionist vision of the frailty syndrome. In a sense, this vision serves the interests of both patients and physicians: it facilitates the diagnostic approach and the treatment strategies in an aged population, estimated at 20%, that seeks medical attention because of frailty, low mental and physical energy, depression-like symptoms and sexual hypofunction.

Ali Rajput, MBBS, FRCPC and Alex Rajput, MD, FRCPC
Division of Neurology, University of Saskatchewan, Saskatoon, SK.

The terms parkinsonism and Parkinson syndrome (PS) are used interchangeably. Two of the three cardinal features--bradykinesia, rigidity and tremor--are necessary to make a diagnosis of PS. Several pathological entities and neuroleptic drugs may produce PS, the most common being Parkinson's disease or idiopathic Parkinson's disease (PD), which is characterized by marked neuronal loss in the substantia nigra and Lewy body (LB) inclusions (Figure 1 is not available online). The prevalence of PS in the Canadian general population is estimated at 300 per 100,000.¹ The mean age of onset is 62 years, with both incidence and prevalence rates increasing with age. In a Canadian survey of a community population over age 65 years, 3% had PS.²

Alzheimer disease (AD) is the most common dementing illness in the industrialized countries. Marked cortical neuronal loss, plaques and intraneuronal neurofibrillary tangles are pathological features of AD (Figures 2A and 2B are not available online). More than 5% of the general population over 65 years of age have AD.

Because both PD and AD occur in old age, some individuals will have both. Pathological studies suggest that this overlap is higher than expected in unselected large autopsy series.

D'Arcy Little, MD, CCFP
Director of Medical Education, York Community Services, Toronto, ON,
and Academic Fellow, Department of Family and Community Medicine,
University of Toronto, Toronto, ON.

Introduction and Epidemiology
While symptom complaints tend to increase as the population ages due to age and comorbid conditions, the prevalence of headaches actually decreases in the elderly compared to their younger counterparts.^1,2,3 However, headache is still very common in this age group and causes significant morbidity. It is the 10th most common reported symptom in women, and the 14th most common symptom in men over the age of 65 living in the community.^1,2,3 A large cohort study found that 11% of women over the age of 65 years and 5% of men over this age reported frequent headaches.¹

While most (two-thirds of) headaches in the elderly result from benign causes such as tension-type, migraines and cluster headaches, one-third of headaches in this age group arise secondary to systemic disease and primary intracranial lesions.^2,4 This is significantly different from the situation in younger patients, where only 10% of headaches are caused by such significant conditions (Table 1).^2,4 Another difference in headaches between the young and old is the fact that even benign dysfunctional headaches (e.g. migraine, tension-type, cluster) can have an atypical presentation in the elderly.

Rodrigo B. Cavalcanti, MD, FRCP(C)
Clinical Assistant, Internal Medicine, University Health Network.

Shabbir M.H. Alibhai, MD, MSc, FRCP(C)
Staff Physician, Internal Medicine and Geriatrics,
University Health Network, Lecturer, Dept. of Medicine,
University of Toronto, Toronto, ON.

Introduction
Syncope is defined as a transient loss of consciousness accompanied by a loss of postural tone, followed by complete, spontaneous recovery.¹ Population-based studies, such as the Framingham study, indicate that the overall incidence of syncope is 3% per year for men and 3.5% per year for women.² Moreover, syncopal events become more frequent with age, with the incidence rising to 6% per year in persons over 75 years of age.²

It is important to note that syncope is fundamentally a symptom, rather than a disease process, with multiple conditions giving rise to this symptom. The common step in most etiologies is a transitory compromise in cerebral blood flow. Impairment in blood flow to the reticular activating system in the brainstem results in loss of consciousness, while lack of perfusion to the corticospinal pathways impairs motor tone.

Currently, it is estimated that between 2-6% of all hospital admissions are for evaluation of syncope or treatment of associated falls, 80% of which are in persons aged 65 years or older.

Jennifer M. Jones, PhD
Research Scientist,
Psychosocial Oncology Program,
Princess Margaret Hospital, University Health Network,
Toronto, ON.

Gary Rodin, MD, FRCP(C)
Head, Psychosocial Oncology,
Princess Margaret Hospital & Psychiatrist-in-Chief,
University Health Network,
Toronto, ON.

Psychological Response to Illness: Coping with a Diagnosis of Cancer
The diagnosis of cancer is inevitably experienced as a traumatic event, although the individual response to it depends upon the nature and stage of the disease, the associated disability, the life stage of the individual affected, its personal meaning and the sociocultural context in which the individual is situated. In the elderly, who commonly experience concerns about self-sufficiency, the onset of a serious medical illness such as cancer may trigger intolerable feelings of helplessness and dependence.

Most patients experience shock when they first learn of their diagnosis of cancer. In some cases, there may be profound anxiety with symptoms of hyperarousal and vigilance arousal, and an oscillation between intrusive thoughts of the cancer and avoidance of the frightening reality. These symptoms represent a stress response syndrome, which may be reactivated following a recurrence of the cancer, which can be even more traumatic than the original diagnosis.