Sir William Osler referred to pneumonia as “the old man’s friend,” correctly realizing that infection is a common cause of death in old age. Some hundred years later, even in this age of potent antimicrobial agents, Osler’s assessment still holds true. Disease frequently presents in an atypical manner in old age, and often fever in bacterial infections is a late manifestation, following delirium, falls, or “taking to bed.” Delay in treatment may result in poor outcomes but, on the other hand, overtreatment may be likely to harm an older person. One of the most difficult environments in which to accurately diagnose infection is the long-term care (LTC) facility. The residents tend to be more frail and more likely to be cognitively impaired than community-dwelling patients coming to their family doctor’s office; therefore, the utility of the history is much decreased. As well, the vast array of diagnostic tools available in the acute hospital is relatively inaccessible in LTC, and the transfer to acute care from LTC often results in deleterious consequences to the patient.

Our focus in this issue is infectious disease in the older adult, and our CME article addresses a major public health concern: “Long-term Care for Older Adults: Reservoirs of Methicillin-Resistant Staphylococcus Aureus and Vancomyin-Resistant Enterococci” by Drs. D.F. Gilpin, M.M. Tunney, N. Baldwin, and C.M. Hughes. We all know that we should not treat asymptomatic bacteriuria, but most of us are unsure whether our patients are truly asymptomatic or not. The article “Asymptomatic Bacteriuria: To Treat or Not to Treat” by Dr. Dimitri M. Drekonja will address this clinical conundrum. I still remember treating my first case of severe antibiotic-induced colitis as an intern. It was in the wife of my physician-in-chief and occurred two months before clindamycin-associated pseudomembranous colitis was first described in a classic article in the Annals of Internal Medicine. Since then, C. difficile infection has become a major problem in older patients, particularly for those in acute hospital or LTC. This important topic is addressed in the article “Treatment and Prevention of Clostridium difficile Infection in the Long-Term Care Setting” by Dr. Natasha Bagdasarian and Dr. Preeti N. Malani.

Further, we offer our usual collection of important and informative articles on medical care of older people. In geriatric medicine, it has been frequently noted that the risk factors for each of the “geriatric giants” overlap to a great degree. In our Cardiovascular column, our frequent and much valued contributor, Dr. Wilbert S. Aronow, asks the question “Bone Mineral Density: What Is Its Relationship to Heart Disease?” Our Dementia column reviews the difficult area of screening in the article “Screening for Dementia: First Signs and Symptoms Reported by Family Caregivers” by Dr. Mary Corcoran. There is more evidence arriving on a regular basis to show how important our teeth are for both quality of life and for good health, so it is very appropriate that our Biology of Aging column by Dr. Gregory An discusses “Normal Aging of Teeth.” Our Falls and Fitness column, “Psychoactive Medications and Falls” is written by Dr. James Cooper and Dr. Allison Burfield. Our featured geriatrician this month is Dr. Angela Juby, the president of the Canadian Geriatrics Society.

Enjoy this issue,
Barry Goldlist

Patrice Bourée, MD, Head of the Department of Tropical Medicine, Bicetre Hospital (AP-HP); Paris-XI University, Paris, France.

The older population continues to increase; these individuals generally have substantial leisure time and are in good mental and physical health. As a result, they take the opportunity to travel. To avoid unnecessary risks, trips should be carefully planned with regard to updating immunizations according to the destination. Some older individuals suffer from chronic diseases which, though not a contraindication to travel, should be considered. Their medication should be reviewed with regard to the climate; there may be a need for specific travel medication such as chemoprophylaxis of malaria. It may be necessary to seek the advice of different specialists related to the patient’s medical problem. With careful planning, older adults shall remember only the pleasant moments of the trip.
Key words: immunization, travel, older adults, infectious disease, advice.

In the early days of antibiotic therapy, clinicians started predicting the end of the plague of infectious diseases that had beset humankind for its entire history. Of course, medical science was completely wrong. We did not count on the adaptability of microorganisms, the medical interventions that increase immune deficiency, the global transmission of pathogens, and many other confounding difficulties. Most importantly, we forgot that the background microbial flora within which we live is essential for our survival, and that the prevention of illnesses from these pathogens is more dependent on broad public health measures (sanitation, water purification, nutrition) than the use of antibiotics in specifically affected individuals, even though antibiotic use is life-saving in certain circumstances. Notably, we are seeing more unusual infections in older people who are not immunosuppressed, and the reasons for this are quite simple. The population is aging, and older adults travel to unusual places. Novel infections are often transported to our country in a variety of ways.

Our CME article with this edition’s focus is ”Common Skin Infections in the Older Adult” by Chamandeep Thind and Dr. Simone Laube. The article ”West Nile Virus: A Pathogen of Concern for Older Adults,” by Drs. Michael A. Drebot and Harvey Artsob, reviews a disease that is new to Canada and has had a substantial impact on the health of older Canadians. It has certainly changed the summertime habits of many Canadians of all ages. Several travel companies now specialize in adventure travel for older adults, and if your patients are among those adventurous seniors, you will appreciate Dr. Patrice Bourée’s article ”Safe Foreign Travel for the Older Adult.”

We have our usual columns featuring articles on other topics. Our Cardiovascular column this month is “The Role of Revascularization in Older Patients with Acute Coronary Syndromes” by Anna J.M. van de Sande, Dr. Paul W. Armstrong, and Dr. Padma Kaul. Our skin article is entitled ”Nonmalignant Photo Damage” by Drs. Joseph F. Coffey and Gordon E. Searles. Ever since the APOE 4 allele, involved in lipoprotein metabolism, was discovered to have a relationship to Alzheimer’s disease, hypotheses as to the relationship of cholesterol and dementia have been explored. For those interested in cognitive impairment, the article ”Is Cholesterol a Memory Thief?“ by Dr. D. Larry Sparks, will be particularly interesting. Our Cancer column features the second part of Patricia K. Long and Dr. David Ollila’s article entitled “Cutaneous Melanoma, Part Two: Management of Patients with Biopsy-Proven Melanoma.” Neuropathic foot ulcers are a serious issue for diabetic older adults, and Drs. Timothy Daniels and Evan Timir review “Surgical Treatment of Diabetic Foot Complications.” As well, this issue features a book review, ”Evidence-Based Medicine Guidelines” by Meteb Al-Foheidi.

Enjoy this issue,
Barry Goldlist

The last few months in Canada have seemed almost biblical in character. We have had plagues, cattle disease, insect infestations, fire, darkness and, if we go back a few years, the Walkerton water disaster could substitute for blood in the Nile. I have put my eldest son on full alert!

For physicians, the most important of these modern "plagues" are those caused by infections. Not unexpectedly, new infectious diseases, like the older more established ones, often have their most devastating effects on older patients. We have known for years that the deaths attributed to influenza outbreaks are most common in older adults. The case fatality ratio for SARS increases quickly with advancing age, and the most serious consequences of last year's West Nile Virus outbreak in southern Ontario also were seen most frequently in older adults.

It is thus very timely that this issue of Geriatrics & Aging focuses on infections in the older adult. During the first wave of SARS in Toronto, a colleague in the U.S. contacted me. He is a specialist in emergency medicine who has developed a successful business providing medical coverage to cruise lines. He was desperately seeking information about SARS to inform the cruise lines about proper infection control procedures. It is perhaps not surprising that infection control is becoming a major issue for cruise lines, since cruises are essentially the confinement of a population the size of a small town to a relatively small area. I found out from my American colleague that Canadians in general, and Torontonians in particular, are high-frequency cruisers. Thus, I think the article "Prevention of Tropical Illness in Older Travellers: The Older Cruiser" is particularly relevant as we head into the first "post-SARS" cruise season.

Everybody agrees that asymptomatic bacteriuria in older adults should not be treated. The more difficult question, however, is how to know whether the patient is truly asymptomatic. One of the few people qualified to address this topic properly is Dr. Lindsay Nicolle, one of North America's leading infectious disease specialists with a long-standing interest in urinary tract infections in older adults. New treatments often come with new risks, and Dr. Richard Long discusses the new biologic therapies and the risk of tuberculosis in older patients. Dr. Shelly McNeil and colleagues focus on long-term care facilities in their review of methicillin-resistant Staphylococcus aureus and vancomycin-resistant enterococci, while Dr. Lona Mody examines the clinical manifestations and treatment options for skin and soft tissue infections. Dr. I.W. Fong discusses one of the most interesting and prevalent "infectious" diseases--atherosclerosis. Although not yet confirmed, evidence for the relationship between infection and atherosclerosis, reviewed here, continues to accumulate.

Finally, I am pleased to announce that three prominent Canadian physicians (and previous contributors to Geriatrics & Aging) have joined our Advisory Board. Dr. Serge Gauthier is an internationally renowned neurologist with a special interest in dementing disorders, Dr. Jagdish Butany is a leading expert in cardiovascular diseases and cardiovascular pathology, and Dr. Rory Fisher is probably the single most important person in the development of Geriatric Medicine as a specialty in Canada. The entire editorial staff at Geriatrics & Aging is pleased to have such distinguished members join our team.

Enjoy this issue.

Kimby N. Barton, MSc
Assistant Editor,
Geriatrics & Aging

I have to admit that I was feeling more nervous than I had expected as I placed the mask over my face. Until this point the reality of my being about to enter a unit with patients who have active tuberculosis (TB), and are capable of infecting me with the disease, had not really sunk in. Suddenly, it seemed vitally important for the mask to form a proper seal around my nose and under my chin to ensure that no bacteria could enter any gap left between the mask and my face. Tuberculosis is an infectious disease caused by the bacterium Mycobacterium tuberculosis. Infection may result from the inhalation of minute droplets of infected sputum; hence the need for a sealed mask to protect me from accidentally inhaling any bacteria. Having secured the mask, I was ready to enter the inpatient tuberculosis clinic at West Park Hospital.

Tuberculosis is a devastating disease. It is suspected that TB has plagued humankind for more than 2000 years, and in fact, several reports describe Egyptian mummies, almost 4000 years in age, showing signs of tubercular decay in their skeletons! It is estimated that almost one third of the global population is infected and that there are 7 to 8 million new cases per year. In Canada, approximately 2000 new cases of TB occur each year, almost one-quarter of these in Toronto. In almost 90% of these cases the patients are recent immigrants from areas where TB is still a common problem.

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

Introduction
Influenza, an acute respiratory illness, causes more adults to seek medical attention than any other respiratory infection. In Canada, influenza is a seasonal disease, causing annual epidemics that affect 10-20 percent of the population and result in approximately 4,000 deaths, 70,000 hospitalizations, and 1.5 million days of lost work.¹ The elderly (people aged 65 years and older), and those with chronic cardiopulmonary disorders, diabetes and other metabolic diseases, have an increased risk of developing influenza complications. Hospitalization rates among elderly patients increase markedly during major influenza epidemics, and 90% of the deaths attributed to influenza and pneumonia are observed in this population.²

Vaccination remains the most reliable means of preventing an influenza infection and the resultant morbidity and mortality. Despite the significance of influenza, efforts to vaccinate the elderly remain suboptimal. A large study conducted in the Netherlands revealed that healthy elderly people avoid influenza vaccination because they fear the side effects, and because they believe that their general health is good and that the benefits of vaccination are, therefore, minimal.

An 'Achilles Heel' in Viral Replication Helps Researchers Develop a Universal Cure for Influenza

Nadège Chéry, PhD

When influenza attacks, it may infect anyone, regardless of his or her age. But when influenza kills, it usually takes the lives of individuals, like the elderly, who are less able to fight back.² In Canada, 6000 deaths are attributable to influenza every year³ with the highest rate of mortality occurring among people over 65 years of age.² Thus, when it comes to older individuals, both early diagnosis, and prevention are imperative. Because the influenza virus continuously changes, strategies for the prevention of flu outbreaks, although thoughtfully planned, have had limited success. Recently, however, scientists have found a "weakness" in influenza's ability to escape traditional flu therapies. This discovery has set the stage for the design of new antiviral drugs which, potentially, may constitute a cure for the flu.

What is Influenza?
Influenza is a member of the Orthomyxoviridae family,1 and causes disease by infecting the epithelial cells that compose the lining of the respiratory tract. Influenza produces symptoms similar to other viruses which infect the respiratory tract. Flu outbreaks are common among elderly persons, particularly in nursing homes.⁴ Since the immune systems of elderly people in a nursing home may be compromised,⁵ their ability to fight an influenza infection can be severely undermined.

Michael A. Gardam MSc, MD, CM, FRCPC
Medical Director, Tuberculosis Clinic
Associate Hospital Epidemiologist
University Health Network

What is a Skin Test and How is it Administered?
Tuberculin skin testing is the most established method of diagnosing tuberculosis infection, that is both active disease and asymptomatic latent infection. Different skin testing techniques have been developed over the past 70 years. The Mantoux test, however, is the standard procedure in North America. The Mantoux test involves the intradermal injection of 0.1 ml of purified protein derivative (PPD--a precipitate prepared from filtered heat-sterilized cultures of Mycobacterium tuberculosis). The only absolute contraindication to administering the test is a history of anaphylaxis induced by any of the components. Those with a history of BCG vaccination may be skin tested.

The test is usually administered in an area that is free of blood vessels, hair or edema, on the flexor surface of the forearm, but it may also be administered on the upper chest or back. The needle should be inserted just under the skin with the bevel facing up until the bevel is fully inserted. A bleb should be raised when the PPD is injected. If this is not accomplished, or the PPD leaks out onto the skin, the test should be readministered in a different site. The test must be read at 48 to 72 hours by a trained healthcare professional.

Brian Conway, MD, FRCPC
Staff Physician,
Centre for Excellence HIV/AIDS,
Assistant Professor, Pharmacology & Therapeutics,
University of British Columbia

Recently, the bulk of media attention has fallen on the global HIV pandemic, and on the impact it is having in Africa. In North America, although AIDS is still predominantly a disease of young adults, an aging but relatively healthy population of HIV positive individuals is slowly becoming a cohort of HIV positive elderly. A review of recent medical literature reveals few, if any, articles that deal with AIDS in elderly patients. The absence of research in this field will mean a medical community that is unprepared to treat and diagnose HIV in an older population. Consequently, elderly patients may not receive the degree of care and attention that they deserve. At Geriatrics & Aging, we strive to cover the latest medical developments and issues, even those that may be somewhat controversial. This month we are proud to present an article contributed by Dr. Brian Conway, an international leader in the field of HIV research, on how HIV is 'moving up the age ladder'.

Introduction
Although it may be assumed that the HIV epidemic is waning, it must be remembered that by the end of 1999 there were still over 33 million adults and children living with HIV/AIDS throughout the world.¹ Of these, the vast majority (32.4 million or so) are adults. In the United States, there are over 400,000 adults/adolescents living with this disease.