Jane Oshinowo, RNEC, Primary health care Nurse Practitioner,
York Community Services, Toronto, ON.

Introduction
Pain is more than the perception of a nociceptive stimulus in the peripheral or central nervous system. It is "what the person says it is."¹ Ferrell1 developed a conceptual model that identifies four dimensions of pain and their impact on a person's quality of life (Figure 1). This model can be used to enhance the caregiver's understanding of the patient's experience of pain. Pain can be acute, chronic or chronic malignant in nature. In the elderly, illness tends to be chronic and the pain is often related to a degenerative condition. However, the elderly do experience acute pain. Whether acute or chronic, pain is more difficult to assess in the cognitively impaired elder. Despite our recognition of the global impact of pain on the individual, and the morbidity and mortality associated with inadequately managed pain, 25-50% of community dwelling elders are living in pain.²

Chronic pain management today is multidimensional. Analgesics tend to be the mainstay of therapy. However, non-pharmacological therapies are currently under investigation and in practice as complementary or alternative therapies to medications. This field is very large and continues to expand. For the purposes of this article, only the more commonly used and better-researched therapies will be discussed.

Kathryn M. Yorkston, Ph.D., BC-NCD, Department of Rehabilitation Medicine, University of Washington, Seattle, WA.
David Beukelman, Ph.D., Department of Special Education and Communication Disorders, University of Nebraska, Lincoln, Munroe-Meyer Institute for Genetics and Rehabilitation, University of Nebraska, Omaha, NE.
Laura Ball, Ph.D., Munroe-Meyer Institute for Genetics and Rehabilitation, University of Nebraska, Omaha, NE.

Summary
This article describes intervention for dysarthria associated with amyotrophic lateral sclerosis (ALS). Five critical periods are presented including a stage with normal speech, detectable speech disturbance, behavioural intervention, use of augmentative communication, and loss of useful speech. Intervention strategies at each of these stages are outlined with the goal of maintaining functional communication regardless of the severity of dysarthria.

ALS is a rapidly progressive degenerative disease of unknown etiology involving the motor neurons of both the brain and spinal cord.¹ The symptoms characteristic of ALS are generally classified by site of involvement (that is, upper motor neuron versus lower motor neuron) and by whether spinal nerves (those innervating the arms and legs) or bulbar nerves (those innervating the muscles of speech and swallowing) are involved.

Jan Bruder, MD, Assistant Professor and Director of Osteoporosis Metabolic Bone Clinic, Division of Endocrinology, University of Texas Health Science Center, Department of Medicine, San Antonio, TX, USA.

Introduction
Osteoporosis is a disease characterized by low bone mass and bone strength, resulting in an increase in bone fragility and susceptibility to fractures.¹ It is asymptomatic prior to fractures, which most commonly occur in the vertebral body, hip and forearm.

Dual energy x-ray absorptiometry is the technology used to measure bone mineral density at the sites of interest. This technology has revolutionized our approach to this disease. In 1994, the World Health Organization (WHO) published diagnostic guidelines for osteoporosis, which are based on an individual's bone mineral density (BMD) according to a T-score.² The T-score is defined as the number of standard deviations (SD) above or below the mean BMD at peak bone mass at age 30 years. A T-score of -2.5 or lower defines osteoporosis. At risk individuals can now be diagnosed early, thereby allowing the use of highly effective interventional strategies which prevent further bone loss and potentially debilitating fractures. Unfortunately, currently once significant bone mass has been lost, there are no commercially available therapies that are proven to increase bone density. This will likely change in the next few years.

Bill McCarberg, MD
Director of Pain Services, Board of Directors, American Pain Society
Department of Family Medicine, Kaiser Permanente Medical Center, San Diego, CA, USA.

As humans age, they invariably become more susceptible to disease, which can impair function and enjoyment of life and pose significant challenges to the health care system. Osteoarthritis, the most common joint disease, affects over 18% of adults in Ontario.¹ Pain has also been associated with a three- to seven-fold increased prevalence of inability to perform daily tasks in the non-institutionalized elderly in Canada.²

More than half of elderly persons in the US are estimated to experience pain daily,³ and recent initiatives in the US have focused attention on the need to treat pain. The Joint Commission on Accreditation of Healthcare Organizations recently introduced new pain management standards to require better pain medicine in hospitals and other institutions as part of their accreditation process.

Non-pharmacologic Therapy
Although medications are commonly required to manage pain and maintain function in elderly patients, non-pharmacologic therapy remains a cornerstone of treatment. It should be started prior to the initiation of pharmacologic therapy, when possible, and be maintained throughout the pain management process.

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.

Morris D. Kerstein, MD
Professor and Vice-Chairman,
Director of Research and Education,
Department of Surgery, Mount Sinai School of Medicine,
New York, NY, USA.

Ernane D. Reis, MD
Assistant Professor
Department of Surgery,
Mount Sinai School of Medicine,
New York, NY, USA.

Venous leg ulcers influence the physical, financial and psychological well-being of patients, and result in an estimated two million workdays lost, annually. Despite a variety of therapeutic options, venous leg ulcers remain a substantial management challenge to the health-care professional. Some form of lower extremity venous disease is present in nearly 30% of the American adult population. Venous leg ulcers are often debilitating sequelae of venous insufficiency, and account for 80-90% of leg ulcers reported. A quality-of-life study reported that 65% of chronic-leg-ulcer patients had severe pain, 81% experienced reduced mobility, and nearly 100% reported a negative impact of their disease on work capacity.

Manifestations of venous insufficiency may include dilated superficial veins, with or without dilated tributaries of the deep vein system, swelling, leg pain, heaviness and changes in the skin (hyperpigmentation, venous dermatitis, eczema with dryness and itching). Ultimately, the adverse effects of venous disease appear as skin ulceration of lipodermatosclerosis.

Jeffrey Zonder, MD
Ulka Vaishampayan, MD
Division of Hematology/Oncology,
Department of Medicine
Wayne State University School of Medicine/Barbara Ann Karmanos Cancer Institute
Detroit, MI, USA.

Introduction
The incidence of hematologic malignancies, especially lymphoma, is steadily rising in the elderly. These diseases and their complications pose specific problems for older patients. Factors that contribute to increased toxicity in the elderly include diminished marrow reserve, impaired renal and hepatic metabolism and, perhaps most importantly, poor performance status as a result of comorbidities.¹ This article will focus on the management of common complications of hematologic malignancies, particularly as they pertain to older patients.

Febrile Neutropenia

Risk of Neutropenia in the Elderly
The incidence of life-threatening neutropenia (absolute neutrophil count, ANC, <0.5x 10⁹/L) in elderly patients following chemotherapy for hematologic malignancies is 40% or higher.² The risk of infection is affected by the duration and severity of neutropenia with a steep rise in infection incidence at a neutrophil count of less than 0.5x 10⁹/L.

Diagnosis and Management of Acute Coronary Syndromes

Nariman Malik, BSc, MD
Medical Writer,
Geriatrics & Aging

Coronary heart disease (CHD) is one of the leading causes of death in individuals over the age of 65¹ and, through a variety of syndromes, is responsible for symptomatic and asymptomatic functional abnormalities. The prevalence of cardiovascular disease increases with age and is a major cause of death and disability in the elderly population.² CHD is the most prevalent cardiac illness in this population: it accounts for 85% of all deaths due to heart disease in persons over the age of 65.³ By age 70, 15% of men and 9% of women have coronary artery disease (CAD) and are at an increased risk of suffering an acute coronary syndrome (ACS).⁴ By age 80, the severity of lesions becomes nearly equal for men and women.⁴ An estimated 40% of all individuals over the age of 80 have symptomatic cardiac disease.²

Despite advances in cardiology, CHD is still the leading cause of death in older individuals, especially those aged over 75.¹ Nevertheless, there is wide variation in the severity of coronary illness and in the functional status of elderly patients.

Pamala D. Larsen, PhD, CRRN
Associate Dean for Academic Affairs,
College of Nursing and Health Professions,
The University of North Carolina at Charlotte, NC, USA.

Although the elderly compose a significant percentage of the surgical patient population, postoperative pain management for this population has received little attention.¹ According to 1990 data, more than 4,000 documents are published annually about pain, but fewer than 1% focus on pain in the older adult.² Lack of published information and research about geriatric pain results in most patients' pain being managed by trial and error.

Considerable evidence suggests that pain is undertreated in older patients. This may be due in part to the misconception that pain sensation diminishes with increasing age or that the elderly patient cannot tolerate narcotic analgesia.³ The perception that older adults have less pain sensitivity than do younger patients is influenced somewhat by the silent myocardial infarctions and emergent 'painless' intra-abdominal surgical events that frequently occur in older adults.⁴ The research involving pain perception in the elderly client provides mixed results. These conflicting results make it difficult to fully establish the relationship or connection between aging and the sensory pain component.

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.