Muammer Kendirci, MD, Tulane University, School of Medicine, Department of Urology, Section of Andrology and Male Infertility, New Orleans, LA, USA.
Wayne J. G. Hellstrom, MD, FACS, Tulane University, School of Medicine, Department of Urology, Section of Andrology and Male Infertility, New Orleans, LA, USA.

Sexual dysfunction in the older man is common and has a significant impact on quality of life. In the aging man, erectile dysfunction (ED) has been encountered frequently due not only to associated comorbidities such as heart disease, hypertension, medications, diabetes, smoking, and depression, but also as a result of the aging process itself. Aging may impair molecular and structural components of erectile function. The introduction of effective oral erectogenic drugs has led to increased awareness of sexual issues and advancement in the methods used by clinicians to diagnose ED. Over the last twenty years, the approach for identification and evaluation of ED has transformed from invasive techniques to patient self-reporting and minimally invasive office procedures.

Key words: erectile dysfunction, aging, diagnosis, evaluation.

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

Introduction
Thrombocytopenia is a common hematologic problem in the elderly.¹ A classic survey indicated that over 50% of patients with thrombocytopenia were over 50 years of age, and 25% were over 70 years of age.² The elderly patient with thrombocytopenia presents the clinician with both diagnostic and management challenges. Because the disorders and mechanisms that lead to decreased numbers of platelets in the circulation are varied, the spectrum of differential diagnoses is broad and includes decreased platelet production and accelerated destruction.³ In addition, the clinical implications of thrombocytopenia fall into a wide spectrum, from a benign condition picked up incidentally in an asymptomatic patient to a life-threatening disorder.⁴ The following article will present an approach to the evaluation of thrombocytopenia in the elderly patient (Figure 1).

Definition and Clinical Significance
Thrombocytopenia is a condition in which there is a deficient number of circulating platelets. The cutoff for diagnosis is 150 x 10⁹/L of blood, which represents the platelet count two standard deviations below the mean obtained when sampling a large number of persons from the general population.

Laurie G. Jacobs, MD
Head, Unified Division of Geriatrics,
Albert Einstein College of Medicine & Montefiore Medical Center,
Bronx, NY, USA.

Introduction
Increasingly, older adults are undergoing invasive procedures and surgery. Surgery in the elderly has been associated with a greater morbidity and mortality than in younger patients due to the physiologic changes of aging, concurrent medical conditions and an increased rate of emergency procedures. Age alone is often a determining factor in whether a procedure or surgery should even be undertaken. Preoperative evaluation and perioperative care of the elderly patient requires evaluating the risk of complications, maximizing functional and physiologic parameters, instituting preventative measures, and focused management to assess potential risk and benefit for an individual patient.

Surgical Stress and Operative Risk
Noncardiac surgery in adults is associated with an incidence of postoperative myocardial infarction of 1-2%. Those with known heart disease, advanced age and serious comorbid conditions have a significantly greater risk for MI and other serious complications. Cardiovascular complications represent 50% of the causes of postoperative morbidity and mortality. In older adults, pulmonary, renal, infectious and cognitive adverse events are also extremely common.

Dr. Robert van Reekum, MD, FRCPC
Department of Psychiatry and KLARU,
Baycrest Centre for Geriatric Care,
Assistant Professor,
Department of Psychiatry,
University of Toronto, Toronto, ON.

Neuropsychiatric assessment in dementia is important as changes in mood and behaviour are common, cause suffering, impact on disability and handicap, influence diagnosis, have prognostic implications and are often treatable. Behaviour may be conceptualized as affecting 'the ABCs': affect, behaviour, cognition, disability, economics, family and goals. Important premorbid factors to assess include a past history of medical, psychiatric, personal, neurodevelopmental, social support/stressors and response to previous treatments. Important current factors to assess include medical status (e.g. metabolic, infections, nutrition, pain, medications), arousal (e.g. delirium), antecedents/precipitants/patterns, cognitive status (e.g. insight), neurologic status (e.g. localizing signs, Parkinsonism). Common behaviours in dementia include agitation, wandering, panic attacks/catastrophic reactions, mood disorders, affective lability, hallucinations, delusions, disinhibition, sexual behaviours, compulsions/perseveration and incontinence. CNS disease may mimic or mask psychiatric disorders (e.g. Parkinson's disease causing the slowing seen in depression, expressive aprosodia masking expression of dysphoria) so that the evaluation of psychiatric illness in this population needs to take into account direct effects of CNS disease. Major Depression is not simply sadness, but is a syndrome of behaviours, which are persistent, severe and have an impact. "Mild depression" does not imply the use of low-dose antidepressants. Given the potential for masking and potential for improvement with the treatment, many clinicians "over-diagnosis" this condition (beware of risks due to antidepressants). Psychotic symptoms include hallucinations and delusions (e.g. of stealing) and are often associated with distress and changes in behaviour (e.g. agitation) which warrant pharmacological intervention. There are many anxiety disorders (e.g. panic, social phobia etc.) which are common in dementia and often warrant treatment. Anxiety may affect cognitive performance, as may depression and psychoses. Apathy (decreased interest, initiation and motivation plus flat affect) is also common in the dementias; rule out sleep disorders, metabolic disturbance (e.g. thyroid), decreased arousal (e.g. side effects of medication) and effects of role loss (e.g. institutionalization). Disinhibition (i.e. behavioural impulsivity, affective lability) is also common and contributes to other problems (e.g. aggression). Finally, this presentation stressed the need for the use of structured, reliable and valid Behavioural inventories to improve consistency of communication and quantification of behaviours (e.g. to allow for improved monitoring of the treatment response) and often to save time (e.g. it can be quicker to complete a structured inventory than it is to write a detailed progress note). The Neuropsychiatric Inventory (NPI) was reviewed, and its use encouraged for clinicians working with dementia populations.