Pauline T. Truong, MDCM, FRCPC, Radiation Therapy Program, Vancouver Island Centre, British Columbia Cancer Agency and the University of British Columbia, Victoria, BC.

Rohit Pai, BSc, Radiation Therapy Program, Vancouver Island Centre, British Columbia Cancer Agency and the University of British Columbia, Victoria, BC.

Ivo A. Olivotto, MD, FRCPC, Radiation Therapy Program, Vancouver Island Centre, British Columbia Cancer Agency and the University of British Columbia, Victoria, BC.

Breast conserving surgery (BCS) and postoperative radiation therapy (RT) achieve local control and survival equal to mastectomy in women with early stage breast cancer. The incidence of breast cancer increases with age and the number of older women in Canada continues to rise, but the under-representation of older women in BCS trials limits the evidence on which to base optimal therapy decisions. This article reviews breast conservation in older women, with a focus on the necessity of radiation therapy. Multiple randomized trials with and without age subgroup analyses demonstrate that RT after BCS should be considered standard therapy. A low-risk subset in whom radiation therapy may be omitted without compromising local control has not been defined. In women with early breast cancer, age alone should not preclude treatment that optimizes local control. Efforts to include representative samples of older breast cancer subjects in modern clinical trials with endpoints that include cancer control, survival, function, and quality of life are needed.

Key words: age, breast conserving surgery, breast cancer, breast conservation, radiotherapy.

Wojciech P.Olszynski, MD, PhD, FRCPC, Clinical Professor of Medicine,University of Saskatchewan, Director, Saskatoon Osteoporosis Centre, Saskatoon, SK.

Though osteoporosis occurs less frequently in men than in women, it is nonetheless a significant medical problem. Osteoporotic vertebral fractures in particular are as common for men as for women, and about one-third of all hip fractures occur in men. As a consequence of fragility fractures, the associated morbidity and mortality are higher in men than women, particularly after fracture of the hip. Idiopathic osteoporosis is common; however, secondary causes are found in about 50% of cases. Bone density measurements should be advised for every man over 65 years of age and for younger men in the presence of osteoporosis risk factors. For practical purposes, the use of T-score <= 2.5 for men over age 65 should be used for the diagnosis of osteoporosis.

Key words: osteoporosis, men, fracture, diagnosis, treatment

Epidemiology
Osteoporosis is a skeletal disorder characterized by compromised bone strength predisposing a person to an increased risk of fracture.

G.A.E. Wong, MBChB, MRCP(UK), and N.H. Shear, MD, FRCP(C), Divisions of Dermatology and Clinical Pharmacology, Sunnybrook & Women’s College Health Sciences Centre, University of Toronto, Toronto, ON.

Cutaneous adverse drug reactions are a common problem affecting ambulatory and hospitalized patients. Older patients may be predisposed to adverse drug reactions due to inappropriate medication prescription, age-associated changes in pharmacokinetics and pharmacodynamics, altered homeostatic mechanisms, multiple medical pathologies, and use of drugs with a narrow therapeutic margin. In this second of two articles, the management of cutaneous adverse drug reactions
is reviewed.

Key words: adverse drug reaction, skin, cutaneous, rash, drug eruption, treatment, management.

Sue O’Hara, RN, MScN, ACNP, GNC(C), Nurse Practitioner/Clinical Nurse Specialist, Specialized Geriatric Services, St. Josephs Health Care London, Parkwood Hospital, London, ON.; Michael J. Borrie, BSc, MB, ChB, FRCPC, Professor, Department of Medicine, Division of Geriatric Medicine, The University of Western Ontario, London, ON.

Urinary incontinence is a significant problem in older women. Prevalence rates vary from 4.5–44% in healthy older women and increase to 22–90% in patients in long-term care facilities. Canadian Continence Guidelines have recently been developed to assist patients and health care professionals in assessment, treatment and follow-up of urinary incontinence. Urinary incontinence can be treated successfully, improved or better managed in most patients. Treatment falls into four major categories: behavioural, pharmacologic, surgical and supportive measures. Education, the key to effectively addressing the needs of women with incontinence, is aimed at the patient and/or their caregiver, as well as health care professionals.
Key words: urinary incontinence, older women, assessment, treatment, Canadian Continence Guidelines.

The accredited CME learning activity based on this article is offered under the auspices of the CE department of the University of Toronto. Participating physicians are entitled to one (1) MAINPRO-M1 credit by completing this program, found online at www.geriatricsandaging.ca/cme.htm

Lianne Tile MD, FRCPC, M Ed, Staff Physician, Osteoporosis
Program and Division of General Internal Medicine, University Health Network, Toronto, ON

Osteoporosis and fractures are a common cause of morbidity in postmenopausal women. Women age 65 and older, and those with risk factors for bone loss, should be screened by DEXA. When osteoporosis is diagnosed, secondary causes need to be considered. Fracture risk is determined by bone mineral density, age, prior fracture, and family history of osteoporosis. Adequate calcium and vitamin D intake and regular exercise are essential for the prevention and treatment of osteoporosis. Pharmacologic therapy should be used based on fracture risk. Patient preferences and side effect profile must be considered in choosing among several effective treatment options.
Key words: osteoporosis, treatment, postmenopausal, diagnosis, guidelines

Definition and Epidemiology
Osteoporosis is a skeletal disorder characterized by compromised bone strength predisposing to an increased risk of fracture.

Bob McCormack, MD, FRCSC, Dip Sport Med, Assistant Professor, Head of Division of Arthroscopy and Athletic Injuries, Department of Orthopaedic Surgery, University of British Columbia, Vancouver, BC.

Frozen shoulder, or adhesive capsulitis, is a frustrating condition for both patients and physicians. Pain and a limited range of motion restrict upper extremity function and significantly affect the patient’s quality of life. The goal of this article is to present an organized review of the assessment and management of a frozen shoulder, so the physician can formulate a treatment algorithm. Special considerations for the older patient will be highlighted.

Key words: shoulder, stiffness, capsulitis, older people, treatment.

Introduction
Frozen shoulder is a descriptive term for a clinical syndrome whereby soft tissue contractures cause a limitation of both active and passive range of motion of the glenohumeral joint. The primary role of the shoulder is to place the hand in space; to achieve this, it is necessary to maintain shoulder mobility.

Classification
As outlined in Figure 1, frozen shoulder can be divided into primary and secondary types. The primary, or idiopathic, form is commonly referred to as adhesive capsulitis. Secondary forms are important to identify as they often require a different treatment approach.

D'Arcy Little, MD, CCFP, Director of Medical Education, York Community Services; Lecturer and Academic Fellow, Department of Family and Community Medicine, University of Toronto; 2002-3 Royal Canadian Legion Fellow in Care of the Elderly, Toronto, ON.

Neuropathic pain is a relatively common and challenging entity in the elderly, with a wide differential diagnosis and numerous treatments available. In general, damage to peripheral nerves via an injury or as a result of abnormal functioning is thought to trigger a cascade of events in sensory neurons that is responsible for the generation of pain. Potential treatments include tricyclic antidepressants, serotonin re-uptake inhibitors, venlafaxine, ion channel blockers, opioids, capsaicin and the Lidocaine patch. This article reviews the relative efficacy of these treatments, with specific reference to considerations in the elderly.
Key words: neuropathic pain, peripheral neuropathy, treatment, anticonvulsant, antidepressant.

Mary Anne Cooper MSc, MD, FRCPC, Department of Medicine, University of Toronto; Lecturer, Sunnybrook and Women’s Health Sciences Centre, Toronto, ON.

Introduction
Gastroesophageal reflux disease (GERD), the abnormal reflux of gastric and duodenal contents into the esophagus, is common. Almost 50% of the North American population experience symptoms once a month and 10% have symptoms daily.¹ Patients most commonly complain of pyrosis and regurgitation, but other symptoms such as dysphagia, chest pain and nausea are not rare.¹ As well, respiratory tract symptoms such as cough, hoarseness and asthma may be attributable to GERD (Table 1).^1,2

Acid reflux into the esophagus is a normal physiologic event. It occurs after meals when the lower esophageal sphincter (LES) tone is reduced. The LES opens, creating a common cavity with the stomach. Because stomach pressures are higher than esophageal pressures, gastric contents reflux into the esophagus. Formal measurement with 24-hour pH monitoring indicates that the pH of the esophagus should be < 4 for < 4% of the time. Factors that increase acid contact time with the esophagus promote GERD.

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.

Theodore K. Marras, MD, FRCPC, Division of Pulmonary and Critical Care Medicine, University of California, San Francisco, California, USA; Postdoctoral Fellow, Department of Medicine, University of Toronto, Toronto, ON.

Abstract
Community-acquired pneumonia (CAP) is a common disease in the older adult with significant mortality. The following review focuses on the antibiotic management of CAP, with specific reference to the older adult. Common etiologic organisms and organism-specific risk factors that tend to be associated with increasing age are presented. The rationale behind initial empiric antibiotic therapy is discussed and recent guidelines for the selection of empiric antibiotic therapy are compared. A synthesis of guidelines for antibiotic selection and recommendations regarding the switch from parenteral to oral therapy are presented.

Introduction
Community-acquired pneumonia (CAP) is a common infectious disease, the incidence of which is consistently associated with increasing age. The overall incidence of CAP has been reported at 10 to 14 per 1,000 patients per year,^1,2 and 30 per 1,000 among those older than 75 years.^2,3 Compared with people 60-69 years of age, those 70 years or older had a relative risk of developing CAP of 1.5,⁴ independent of the additional risk conferred by heart disease and institutionalization.