A 12 month, double-blind, placebo-controlled, randomized, multicentre study by Jencen and colleagues demonstrated that 5 mg/day of risedronate (Actonel) given for twelve months was effective in significantly increasing bone mineral density and lowering the risk of vertebral fractures, for patients on chronic corticosteroid therapy. From the abstract it is unclear if these fractures were clinically symptomatic, radiologically detected, or both. Risedronate prevents bone loss by inhibiting bone resorption. It represents a new type of biphosphonate which is hoped to have less gastrointestinal complications than other bisphosphonates, however, residronate is not available in Canada at this time.

Adachi and colleagues pooled results from two similarly designed, randomized, double-blind, placebo controlled trials examining the effectiveness of Etidronate (Didrocal) (which is available in Canada). Intermittent cyclical therapy with etidronate in patients recently starting corticosteroids proved to be effective in preventing bone loss in men, pre- and post-menopausal women. This data supports previously published studies employing a bisphosphonate to decrease the loss of bone mineral density with chronic systemic corticosteroid use.

Abstracts are available at http://ex2.excerptamedica.com/98ac

Margaret Grant, MD,
Geriatric Medicine Resident, University of Toronto, Toronto, Ontario

Definition and Prevalence

In response to the confusion surrounding the existence of multiple definitions of orthostatic hypertension (OH), a consensus statement was developed to standardize the meaning of this medical condition. OH is defined as a reduction of systolic blood pressure (BP) of at least 20 mm Hg, or a reduction of diastolic BP of at least 10 mm Hg within 3 minutes of standing or lying on a tilt table at an angle of at least 60 degrees.¹ The prevalence of OH in the elderly ranges from 5 to 33 %.^2-4 This variability may be the result of different definitions used and the range of populations considered, from frail older nursing home patients to healthy older people living in the community. The prevalence of OH can be as high as 50% in frail older nursing home patients.²

In a study by Ooi et al., which looked at nursing home patients' BP taken at 8 different times, OH was found to be variable depending on the time of day, with a higher prevalence just before breakfast.

Thomas Tsirakis, BA

Late Onset Schizophrenia (LOS) is a rare disorder with a prevalence rate of less than 1 percent within the general population. LOS applies to those individuals who develop schizophrenia after the age of 40. The existence of LOS as a disorder separate from schizophrenia has been wrought with controversy, due mostly to a lack of consensus between European and North American medical standards. The general lack of agreement between the world's medical communities, as well as the overlapping of clinical features between LOS and other psychiatric disorders, has often resulted in misdiagnosis and confusion. In North America, LOS was completely eliminated from the third revised edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IIIR) of the American Psychiatric Association after the release of DSM-IV in 1994, and is now classified utilizing the same criteria as schizophrenia. The European medical community, however, still considers it to be a separate, yet related entity, with its own distinct symptomatology, and continues to define it utilizing DSM-IIIR criteria.

Michele Kohli, BSc

Congestive heart failure (CHF), a clinical syndrome caused by failure of the left or right ventricle, is a leading cause of chronic illness in older persons. In the United States, CHF is the most common cause of hospitalization among those aged 65 years and above. Each year, approximately 400,000 Americans are diagnosed with CHF. Few statistics regarding CHF in Canada have been compiled, but the Heart and Stroke Foundation estimates that 200,000 to 300,000 Canadians have the syndrome. The incidence of CHF appears to be increasing in both Canada and the United States.

An individual's risk of developing CHF increases exponentially as a person ages (See Figure 1), due to age-related changes in the heart structure and function. Physiological and pathological alterations affecting heart rate, preload, afterload and contractile states of the heart reduce cardiac output (See More Fat, Less Specialized Cells in Old Heart). Concurrent changes in the kidney, respiratory and nervous systems may further impair the function of the heart. Congestive heart failure is a syndrome with multiple etiologies.

Early diagnosis of CHF greatly improves the success of treatment.