I am writing this editorial shortly after returning from the 2nd Canadian Colloquium on Dementia (CCD2), held from October 16-18 in Montreal. This was one of the finest meetings I have ever attended, and if you are interested in cognitive disorders you should reserve time to attend the next meeting, planned for 2005 in Ottawa.

Several of the topics in this issue of Geriatrics & Aging also were addressed at the Colloquium. The crucial issue of recognizing delirium (and dementia and depression) is addressed here by Rola Moghabghab and her colleagues, as they describe the process of implementing nursing best practice guidelines for the recognition of these disorders.

Although there are proven strategies for handling these concerns, recognition is crucial in order for these to be implemented. Several of the speakers at the CCD2 also commented on the issue of what happens after delirium. Dr. Jane McCusker addresses this topic more systematically in her article on the long-term prognosis of delirium.

The theme of under-recognition of delirium and its consequences is addressed more comprehensively by Drs. James L. Rudolph and Edward R. Marcantonio, followed by articles that examine delirium in more specific settings. Dr. Yoanna Skrobik discusses the recognition and management of delirium in the critical care setting, while Dr. Lars S. Rasmussen reviews the detection and prevention of postoperative cognitive dysfunction in older adults. Although the incidence of postoperative delirium is quite variable, it can reach as high as 50% in certain circumstances (older patients with hip fractures), and is a considerable concern whenever it does occur. In fact, I am writing this editorial immediately after seeing a patient in clinic who says, with confirmation from her daughter, that her memory has never returned to normal since her coronary artery bypass surgery six years ago.

We also have our usual varied collection of columns in this issue. Dr. Joseph H. Friedman reviews the incredibly common issue of drug-induced parkinsonism in older adults, while Dr. Osman O. Al-Radi discusses the pathophysiology of mitral regurgitation and its implications for surgical management. Our senior editor, Dr. Shabbir Alibhai, and his colleagues Drs. Foster and Oughton have reviewed the literature on the role of calcium and vitamin D3 supplementation for the primary prevention of fractures.

Enjoy this issue, and I hope to see you in Ottawa for the 3rd Canadian Colloquium on Dementia.

When medical residents rotate through our geriatric service at the University Health Network, we provide a group of seminars on the "Geriatric Giants": confusion, instability and falls, incontinence, geriatric pharmacology and failure to thrive. I have to admit that my personal favourite among the geriatric giants is the topic of falls. I find it to be a perfect paradigm for the clinical practice of geriatric medicine, and thus an excellent tool for teaching the general principles of geriatric care.

What are those principles? I think the first is that any number of problems can result in falls, and that the overwhelming majority of falls in the elderly are not caused by a single factor but by the combination of a multitude of problems. This allows me to demonstrate to the students the various factors that can predispose to falls. These can be intrinsic to the patient (age-related changes or diseases), or external to the patient (environmental factors). The key for the doctor is to determine what factors are operant in a particular patient, and of these, which are modifiable. The next step is to determine which factors can be improved rapidly (e.g., stopping certain medications) and which require long-term strategies (e.g., proximal muscle strengthening). I also emphasize to the residents that there is no such thing as a trivial fall, although some falls only result in trivial injuries. That person's next fall might result in a devastating injury.

The nature of the scientific study of falls in the elderly took an exciting and dramatic turn in the early 1990s, with the article by Mary Tinetti in the New England Journal of Medicine.¹ Her study demonstrated that proper attention to falls risk factors in a primary care setting could actually reduce the number of falls these people would have (absolute risk reduction of 12%, number needed to treat to prevent one fall is 8). This demonstrated clearly that with a comprehensive interdisciplinary approach, complex functional issues in the elderly could be systematically approached and improved.

The new issue in falls prevention is how to reach all those at potential risk. With our rapidly aging population, the individual doctor-patient interaction, while very important, is not enough. The next step in falls prevention is the implementation of community-based programs (e.g., exercise programs) that can have a broader impact. These programs have shown clear efficacy in high quality clinical trials, and we now need to determine if they will be effective when introduced into the community at large.

This issue of Geriatrics & Aging has been designed to provide the tools for primary care physicians to assess the risk factors for falls in their elderly patients, and to allow them to prevent some of these devastating occurrences. Gabriele Meyer, Andrea Warnke and Ingrid Mühlhauser tackle the general topic of fall and fracture prevention in the elderly, and Dr. Fiona E. Shaw addresses the thorny problem of falls in those with dementia. Drs. Nadine Gagnon and Alastair Flint review one of the crippling consequences of falls, namely fear of falling, which dramatically reduces function and quality of life. Dr. Boyd Swinburn and Richard Sager give some practical advice in their article on the promotion of exercise prescriptions for elderly populations. Dr. Margaret Grant provides treatment strategies for one of the most potent risk factors for falls, orthostatic hypotension, while Dr. Karim Khan, et al. present strategies for the optimal delivery of falls prevention programs to the elderly in the community.

Enjoy this issue.

Reference

1. Tinetti ME, Baker DI, McAvay G, et al. A multifactorial intervention to reduce the risk of falling among elderly people living in the community. N Engl J Med 1994;331:821-7.

Warren T. Blume, MD, FRCPC, London Health Sciences Centre, University Campus, Epilepsy Unit; Professor, University of Western Ontario, London, ON.
David J. Harris, LRCP(Lond), MRCS(Eng), FRCPC, MRCPsych, London Health Sciences Centre, South Street Campus, Geriatric Mental Health Program; Associate Professor, University of Western Ontario, London, ON.

Management of epilepsy in an elderly person requires accurate classification of seizures, a sufficient neurologic assessment to define etiology, and awareness of the patient's health and social situation. Treatment with an antiepileptic drug requires an understanding of the general health of the patient and the nature of all medications being given to the patient by other physicians. Effective communication with the patient, spouse, any adult children or other caregivers aims to ensure that all understand the goals of treatment, medication side effects and monitoring methods. Concomitant illness such as neurological, psychiatric, metabolic or cardiac disorders will require individualization of treatment plans.
Key words: epilepsy, elderly, differential diagnosis, management.

Kelly B. Zarnke, MD, MSc, Departments of Medicine, Epidemiology & Biostatistics, University of Western Ontario, London, ON, and on behalf of the Canadian Hypertension Education Program (CHEP).

Poor blood pressure control, particularly among the older Canadian population, remains an important cause of preventable cardiovascular morbidity and mortality. It behooves Canadian health care workers to identify, treat and control hypertension. Recent trials, including ALLHAT and LIFE, add to the information clinicians need to achieve these targets. ALLHAT establishes the central role of thiazide-like diuretics for many hypertensive patients. ALLHAT demonstrates that good blood pressure control can be achieved in the majority of hypertensive patients if a systematic effort is maintained. LIFE adds important information regarding angiotensin receptor blockers as an effective alternative to the other commonly used classes of antihypertensive drugs, particularly among patients with diabetes or isolated systolic hypertension. Finally, the Canadian Hypertension Education Program will continue to produce and disseminate annually updated systematic reviews and recommendations related to the assessment and management of hypertension.
Key words: hypertension, recent clinical trials, clinical practice guidelines.

Clarence K.W. Wong, MD, FRCPC, Gastroenterologist and Clinical Lecturer, Division of Gastroenterology, University of Alberta; Consultant, Cross Cancer Institute, Alberta Cancer Board, Edmonton, AB.

Introduction
Gastrointestinal malignancies collectively account for the greatest number of cancer deaths in Canada.¹ This is particularly evident in the elderly population in which 90% of all new cancers are diagnosed in individuals over the age of 45.² Of these new cancers, one in five are gastrointestinal cancers. As these malignancies are often lethal, improved survival depends on preventive strategies to effectively detect and manage the associated precursor conditions. This paper will review the premalignant conditions associated with three common gastrointestinal cancers. Effective management of conditions leading to esophageal, gastric and colon cancers can greatly reduce the burden of disease among the geriatric population.

Esophageal Cancer
Cancers of the esophagus are lethal, with a death to case ratio of 1.11.¹ Although this estimate is high due to incomplete registration of new cases, it underscores the lack of effective treatment for this disease. Until recently, squamous cell carcinomas were the most common type of esophageal cancer. However, in the last few decades the incidence of esophageal adenocarcinomas has increased exponentially. It is likely that this increase is linked to a rise in incidence of its only known risk factor, Barrett's esophagus.

Marisa Battistella, BScPhm, Pharm D, Education Coordinator & Hemodialysis Pharmacist, Pharmacy Department, University Health Network, Toronto, ON.
Shabbir M.H. Alibhai, MD, MSc, FRCP(C), Staff Physician, University Health Network, Toronto, ON.

Constipation is a common symptom in patients of all ages, but its occurrence is highest among persons 65 years of age or older.^1,2 Constipation has been shown to diminish both quality of life and feeling of well-being.^3-5 Although constipation can have many causes, it is most often functional or idiopathic.^5,6 Furthermore, constipation can lead to serious complications such as malnutrition, fecal impaction, fecal incontinence, colonic dilation and even perforation of the colon.⁷

Definition
Constipation has different meanings to patients and physicians. A patient's perception of constipation may include not only the objective observation of infrequent bowel movements but also subjective complaints of straining with defecation, incomplete evacuation, abdominal bloating or pain, hard or small stools or a need for digital manipulation to enable defecation. Because the definition of constipation can be subjective, an international committee has recommended an operational definition of chronic functional constipation in adults.

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.

Prevention is the Best Form of Care

Madhuri Reddy, MD, Dermatology Day Care (Wound Healing Clinic) Sunnybrook and Women's College Health Care Centre, Toronto, ON, Associate Editor, Geriatrics & Aging.

R. Gary Sibbald, BSc, MD, FRCPC (Med), FRCPC (Derm), MACP, DABD,
Associate Professor and Director of Continuing Education
Department of Medicine, University of Toronto, Toronto, ON.

Introduction
The most common reason for hospitalization of individuals with diabetes is a foot wound. Persons with diabetes are forty times more likely than are non-diabetics to have a non-traumatic amputation, and the most common precipitating events are infection in a non-healing ulcer and gangrene. Those who undergo a lower-extremity amputation have a 50% chance of amputation in the contralateral limb within five years.¹

The systemic nature of diabetes requires a team approach, involving wound care specialists (e.g. physicians, nurses) and foot care specialists (e.g. chiropodists, podiatrists, occupational therapists, pedorthists). Prevention of ulcers is the best form of care for the diabetic foot. Teaching prevention should occur in the setting of comprehensive diabetic care.

David J Burn, MD, MA, FRCP, Consultant & Senior Lecturer in Neurology, Regional Neurosciences Centre, Newcastle General Hospital, Westgate Road Newcastle upon Tyne, UK.

Ian G McKeith, MD, FRCPsych, Professor of Old Age Psychiatry, Department of Old Age Psychiatry, Institute for Ageing and Health Wolfson Research Centre, Newcastle General Hospital, Newcastle upon Tyne, UK.

Introduction
Parkinsonism is a common problem, particularly in the elderly. One percent of the population over the age of 65 has Parkinson's Disease (PD), rising to 2% over the age of 80. Parkinsonism is also a core feature of dementia with Lewy bodies (DLB), the second most common cause of neurodegenerative dementia, after Alzheimer disease (AD). To differentiate patients with PD who develop cognitive impairment from DLB, Consensus Criteria stipulate that parkinsonism must be present for 12 months or less for a patient with dementia to qualify for a diagnosis of DLB.¹ If the extrapyramidal features are present for longer than this before the dementia develops, the diagnosis is referred to as PD with dementia.

Although parkinsonism occurs in numerous other neurodegenerative diseases, including multiple system atrophy, progressive supranuclear palsy and corticobasal degeneration, as well as AD, hallucinations are less common.

Natalie S. Gould MD, Fellow and Clinical Instructor
D. Scott McMeekin MD, Assistant Professor Section of Gynecologic Oncology,
Department of Obstetrics and Gynecology
University of Oklahoma Medical Center, Oklahoma City, OK, USA.

Ovarian cancer is a disease of older women, with 48% over the age of 65 at diagnosis.¹ It is also the most deadly of gynecologic malignancies, accounting for more deaths than cervical and endometrial carcinoma combined in the US. An estimated 23,400 new cases of ovarian cancer will be diagnosed in 2001 with 13,900 deaths in the US.² As our population ages, the number of women affected by ovarian cancer will increase. Cancer limited to an ovary is typically silent and discovered incidentally on exam or at surgical exploration for other reasons. Patients with disease that has spread beyond the ovaries may present with vague gastrointestinal symptoms, bloating, diarrhea, pain and changes in bowel or bladder habits. On physical exam, patients will have a pelvic mass and often ascites. Due to the absence of symptoms until the malignancy has spread beyond the ovaries, and the lack of good screening tests, approximately 70% of patients present with advanced disease and overall survival is poor.³ (Table 1).

Initial management involves cytoreductive surgery aimed at removal of the greatest volume of tumour (Table 2).