Lin Perry, MSc, RGN, RNT,
Faculty of Health & Social Care Sciences,
Kingston University and St. George's Hospital Medical School:
Sir Frank Lampl Building, Kingston University,
Kingston upon Thames, Surrey, UK.

Introduction
Stroke is a major cause of mortality and morbidity in all industrialized countries¹--incidence of a first-in-a-lifetime stroke in the UK is estimated at 2.4 per 1,000 population per year, with all strokes combined having an incidence 20-30% higher.²

Dysphagia is a frequent accompaniment to stroke.^3-5 Depending upon manner and timing of assessment, dysphagia is detected in 30-65% of acute stroke patients^6-10 with a small proportion experiencing clinically 'silent' aspiration of food/ fluids.^9,10 Dysphagia is associated with increased morbidity and mortality. Whilst this may partly be explained by its relationship with increased stroke severity, dysphagia also exerts an independent effect revealed by the tripling of mortality rates in alert dysphagic stroke patients compared to similar groups with intact swallow.⁸ It is associated with chest infection independent of aspiration⁷ which also risks chemical pneumonitis, infection and airway obstruction.^11,12 Although dysphagia frequently resolves rapidly, for a minority it produces enduring disability and handicap. Stroke-related impaired swallowing has been found in 5.

A. Mark Clarfield

The fact that dementia is finally beginning to receive the attention that it deserves is evidenced by the editors of Geriatrics & Aging wisely deciding to devote most of this issue to the subject. Dementia is primarily associated with memory loss; this means, unfortunately, that professionals often pay far less attention to the other symptoms that can accompany the syndrome. In fact, caregivers tell us that their loved one's problem with memory is usually far less burdensome than are the behavioural symptoms. Two of these symptoms are featured in this issue: agitation, by Dr. Elizabeth Sloan (a resident in Psychiatry at the U of T); and wandering, written by Dr. Bob Chaudhari, of the same department.

Dr. Sloan reminds us that agitation--sometimes accompanied by other symptoms such as screaming and aggression--is not a diagnosis per se but rather consists of a "constellation of symptoms." In geriatric care we are not afraid of such terminology, even if the terms are not always easily found in the index of Harrison's Textbook of Medicine. The same, of course, would hold for falls or incontinence.

As is the case with many of the non-specific ("atypical") presentations of disease in the elderly, Sloan points out, an underlying medical illness must never be overlooked as a possible causal factor. As I like to teach my medical students, "Take a history before prescribing haldol." (Unfortunately, now that the older anti-psychotic medications are increasingly being replaced by less toxic molecules, I'll have to figure out a new alliteration to go with, for example, risperidone--now what starts with an "r"? "rectum", no; "respiratory system"--doesn't ring true.) But I digress.

Dr. Sloan goes on to offer a great deal of good advice and the interested reader is advised to consult the references in her comprehensive bibliography.

Dr. Chaudhuri tackles the related problem of wandering, where he offers an interesting tri-partite classification which I admit that I have not seen before: volitional (depressive), motivational (anxious) and repetitive behavioural (irritable) wandering. Perhaps as a geriatrician, I am used to a more "medical" classification; but the author, not surprisingly as he is a psychiatrist, offers a more psychodynamic approach.

Like Sloan, Dr. Chaudhuri points out that management must take into account the patient's environment. Appropriately, he does not spend much time on a pharmacological approach, which is not usually an effective method unless, of course, your aim is to drug the patient into a stupor.

My own experience is that the wandering (pacing) patient with dementia must be allowed his/her own space. Obviously, as is also the case at the other end of the age spectrum with the toddler, wanderers must be protected against the obvious dangers involved. However, when all is said and done, the milieu extérieur seems to me to be of more importance than the milieu intérieur.

Dr. Clarfield is the Chief of Academic Affairs at the Herzog Hospital in Jerusalem, Director of Geriatrics in the Ministry of Health, and on staff in the Division of Geriatric Medicine, Sir Mortimer B. Davis-Jewish General Hospital, McGill University, Montreal.

It is a particular pleasure for me to write the editorial for this month's edition of Geriatrics & Aging. I recently had a mini- reunion with some friends from medical school whom I had not seen in several years. We spent a wonderful evening reminiscing, and I was thrilled to find that my colleagues knew of G&A, and found it very helpful in their clinical practice! I had no idea that the things in which I am involved actually make a difference, although the real credit goes to the full-time editorial staff and the knowledgeable contributors who are so willing to share their expertise. Next, the topic, dementia, is one that is close to my heart. For the last three years, I have been working in the Memory Clinic at the Toronto General Hospital. At first I was shocked at how little I really knew about dementia, but I think I have learned a fair amount in the interim. Now I realize how little anybody really knows about dementia. I have also learned, through personal experience, how different are the professional and personal roles in dementia care. The professionals have it easy!

However, what thrills me most about this edition is our guest editor, A. Mark Clarfield. Mark and I trained together (too many years ago to count), and I still use the example of his dedication to demonstrate what commitment to patient care really means. Prior to his 'half day back for clinic', Mark would come in to the hospital at 6:00 a.m. to ensure that all the needs of his patients had been met. He also left detailed instructions on what his colleagues should do while he was away. I knew Mark would be successful in whatever he decided to do, and it was a thrill that both of us selected careers in geriatric medicine--perhaps inspired by the chief medical resident, Michael Gordon. A decade after training together, we both shared in the Munk Geriatric Award, which was instrumental in shaping our respective careers. Within three years of that award being presented, Mark had written his breakthrough article in the Annals of Internal Medicine, puncturing the myth of the reversible dementia. Mark's work changed the focus in this field from one simply of diagnosis, to one of diagnosis and then the provision of appropriate care, whether the cognitive impairment was reversible or not. This theme of management, regardless of whether the underlying process is modifiable or not, runs through this entire issue of G&A. In our society, health care looks to either high technology or 'magic' bullets. An example of this is the famous article in JAMA several years ago that showed a positive effect for Gingko Biloba in patients with dementia. Although it was a very flawed study, it received widespread media coverage, while an excellent adjacent article on occupational therapy interventions in dementia was completely ignored. Similarly, the possible benefits of vitamin E in preventing nursing home placement has received widespread attention, while the more robust research finding of caregiver education to prevent premature institutionalization is all but ignored.

This edition of G&A has some excellent articles on managing the behavioural problems associated with dementia. Dr. Bob Chaudhuri talks about the treatment of wandering in demented patients, while Dr. Eileen Sloan talks about screaming and agitation. Currently, we try to remember that people with dementia are still people. This means that they must be treated with the same respect for ethical standards that are applied to non-demented people. However, there are specific issues particular to patients with dementia (e.g. to tell or not to tell the diagnosis), that are addressed by Dr. Michael Gordon and Dr. David Goldstein. Dr. Clarfield addresses the issue of treatment in Alzheimer's disease, and Dr. Chris MacKnight highlights the role of the treatment of hypertension in preventing dementia. Margaret MacAdam, from the Baycrest Centre, discusses housing options for patients with dementia. This is particularly appropriate since Baycrest is a world leader in the field. As well, we have our usual assortment of articles. There is an interview with Dr. Judes Poirier, Director of the McGill Centre for Studies in Aging, and articles on the genetics of ALS, atrial fibrillation and hepatocellular carcinoma in the elderly. Enjoy.