Dr. Ruth Hubbard
Lecturer

Dr. M. Sinead O'Mahony
Senior Lecturer,
University Department of Geriatric Medicine,
University of Wales,
College of Medicine, Wales, UK.

Introduction
Stroke is the second most common cause of mortality in much of the developed world and leads to an estimated 4.4 milllion deaths per year, worldwide.¹ It also causes significant morbidity. Thirty percent of patients with a stroke will die within the first three months and half of the remaining patients will have significant long-term disability.

Stroke is particularly a problem of older people. The risk of stroke doubles with each decade of life after 35 years, such that two thirds of all strokes occur in patients over the age of 65 years. People over 75 years are the fastest growing population in North America. Any treatment that improves outcomes in elderly patients with stroke is potentially of huge importance.

Until recently, there was no effective therapy or management strategy to reduce stroke mortality and disability. Two interventions have been shown to result in some benefit--stroke units and aspirin therapy. Stroke Unit care is associated with 70 fewer deaths or dependencies per 1000 patients treated.

Jocalyn P Clark, MSc, PhD candidate
Department of Health Sciences,
University of Toronto and
The Centre for Research in Women's Health,
Toronto, ON.

Stroke is the third leading cause of death for North American women and the leading cause of long-term disability in Canada. According to the Ontario Ministry of Health and Long-Term Care, in 1994/95 stroke-related costs in the province totaled $857 million. The Canadian Stroke Network estimates annual costs for stroke in Canada to be 2.7 billion dollars. Over the next five years the incidence of stroke is expected to increase by over 30%, and those figures could jump to 68% within two decades. Every year among women, stroke claims more than twice as many lives as does breast cancer. Indeed, according to Dr. Beth Abramson, a cardiologist at St. Michael's Hospital in Toronto and an expert in women and stroke, "The issue of stroke in women is a significant one. This is due to potential bias in treatment of female stroke patients, but also to the greater co-morbidity and health care costs associated with treating women when they suffer from stroke."

Like other cardiovascular conditions, stroke in women is highly age-dependent: women are, on average, several years older than men when they suffer their first stroke and tend to be sicker. Owing to this age dependence, the health burden of stroke will only magnify as the proportion of elderly women in the population increases over time.

Anna Gagliardi, MSc, MLS
Program Manager
Surgical Oncology, Cancer Care Ontario,
Toronto, ON.

A. Denny DePetrillo, MD, FRCSC
Division of Gynecological Oncology,
University Health Network-Princess Margaret Hospital Site,
Toronto, ON.

A projected 134,100 new cases of cancer and 65,300 deaths from cancer will occur in Canada in 2001.¹ Forty percent of men and 35% of women will develop cancer during their lifetime and just over 25% of men and 20% of women will die of cancer. Given better and more widely used screening tests such as mammography for breast cancer and the PSA blood test for prostate cancer, more cases of cancer are being detected. Moreover, mortality from these cancers has decreased because they are being caught at an earlier, more treatable stage.

The incidence of most cancers increases with age and it is estimated that 55% of human cancer occurs in individuals 65 years of age and older. The literature on cancer treatment for the elderly is limited but it has been suggested that this demographic may be subject to underscreening, understaging, less aggressive therapy, lack of participation in clinical trials, or no treatment at all.^2,3 It has been demonstrated that older adults desire curative surgical treatment as much as younger patients, but they believe more strongly that doctors should make treatment decisions, making them more vulnerable to possible age bias.

Katherine Sheehan
University of St. Andrews,
St Andrews, Scotland.

Michael Gordon, MD, MSc, FRCPC
Vice President of Medical Services,
Baycrest Centre for Geriatric Care,
Professor of Medicine,
University of Toronto,
Toronto, ON.

The infection control troops are preparing for battle, waiting for the declaration of war. Once again, it's nearly time for our annual fight against the influenza virus. This potential killer affects hundreds of thousands of Canadians each year, leading to the hospitalization of 75,000 and resulting in 6,700 deaths. Of those who die, 90% are over the age of 65 and about half are residents of long-term care facilities. Elderly residents are particularly vulnerable because of their advanced age, underlying illness, close quarters with other residents and extensive contact with many caregivers.

David J. Gladstone, BSc, MD
Stroke Fellow, Sunnybrook and
Women's College Health Sciences Centre,
University of Toronto,
Toronto, ON.

Cynthia Danells, BScPT
Physiotherapist and Research
Associate,
Sunnybrook and Women's College Health Sciences Centre,
University of Toronto,
Toronto, ON.

Sandra E. Black, MD, FRCPC
Head, Division of Neurology,
Sunnybrook and Women's College Health Sciences Centre, and
Professor of Medicine (Neurology),
University of Toronto,
Toronto, ON.

Delaina Walker-Batson, PhD
The Stroke Center-Dallas,
Professor,
Texas Woman's University, and
Associate Clinical Professor,
Departments of Neurology and Radiology,
The University of Texas Southwestern Medical Center,
Dallas, Texas, USA.

Stroke is a Treatable Condition
Together with advances in the prevention and acute treatment of stroke, the field of stroke rehabilitation is becoming an increasingly exciting frontier for basic science and clinical development (see Table 1). The scientific basis of stroke recovery is becoming better understood, and the post-stroke period is being viewed as an important target for improved therapeutic intervention.

Wilbert S. Aronow, MD, CMD
Department of Medicine,
New York, Medical College
Department of Geriatrics and Adult Development,
Mount Sinai School of Medicine,
New York, NY, USA.

There are conflicting data regarding the association of abnormal serum lipids with stroke in older men and women.^1-4 Despite these conflicting data, simvastatin and pravastatin have been demonstrated to cause a significant reduction in the incidence of stroke in older men and women with coronary artery disease (CAD) in the Scandinavian Simvastatin Survival Study,⁵ in the Cholesterol and Recurrent Events Trial,^6-10 and in the Long-Term Intervention With Pravastatin in Ischaemic Disease Study (Table 1).^11,12

Scandinavian Simvastatin Survival Study
The Scandinavian Simvastatin Survival Study was a prospective double-blind, placebo-controlled trial which randomized 4,444 men and women (2,282 of whom were 60 to 70 years of age) with CAD and hypercholesterolemia to treatment with either 20 mg to 40 mg of simvastatin daily or placebo.⁵ Simvastatin significantly reduced serum total cholesterol by 25% from 261 mg/dL to 196 mg/dL, serum low-density lipoprotein (LDL) cholesterol by 35% from 188 mg/dL to 122 mg/dL, and serum triglycerides by 10% from 133 mg/dL to 120 mg/dL. It significantly increased serum high-density lipoprotein (HDL) cholesterol by 8% from 48 mg/dL to 52 mg/dL.⁵ At 5.

James Kennedy, MB, MRCP(UK)
Clinical Stroke Fellow,
University of Calgary, Calgary, AB.

Alastair M Buchan, MB, FRCP
Professor of Stroke Neurology,
University of Calgary, Calgary, AB.

"It is in the nature of stroke to partly take away the use of a man's limbs and to throw him on the parish if he had no children to look to."¹

While treatments have changed since George Eliot's time, attitudes to the consequences of stroke have not. Stroke, when mild, is viewed by the elderly as a devastating event; when severe it is viewed as being worse than death itself.²

Stroke is the third most common cause of death and the leading cause of disability in most of the developed world.³ It is one of the most common causes for the elderly to be admitted to a chronic care facility, such as a nursing home. Ischemic stroke increases in incidence as people age, rising from 2.1 per 1000 for men aged 55 to 64 to 9.4 per 1000 for men aged 75 to 84.⁴ Age is also one of the major determinants of outcome from stroke. Older patients are less likely to recover than are younger patients with similar sized infarcts and, following a stroke, are more likely to decline physically than to recover.

Endocarditis Prophylaxis

D'Arcy Little, MD, CCFP
Director of Medical Education,
York Community Services,
Toronto, ON.

Introduction
Endocarditis is a relatively uncommon but potentially life-threatening infection.¹ The condition was first described by Lazare Rivere in 1646, although William Osler's name has a more current association given that the clinical feature, "Osler's nodes," bears his name.² Prior to the development of antibiotics, endocarditis was almost universally fatal; despite recent advances in diagnosis and treatment, the condition continues to have a 37% mortality rate.^1,3 Endocarditis is also associated with significant morbidity, including the development of valvular dysfunction, congestive heart failure, and focal neurologic or septic complications associated with embolic phenomena.^1,3

Due to the considerable morbidity and mortality associated with endocarditis, where possible, primary prevention is the optimal goal. Although the details are controversial, endocarditis prophylaxis with antibiotics is directed towards this goal. However, studies have revealed that compliance with endocarditis prophylaxis guidelines is less than complete.⁴ The following article will review some of the controversies associated with, and the details of, endocarditis prophylaxis.

Congestive Heart Failure

Nariman Malik, BSc, MD
Contributing Author,
Geriatrics & Aging.

Congestive heart failure (CHF) is a condition that affects individuals of all ages but is predominantly a medical condition of the elderly. In the elderly, it reflects the consequences of age-related changes in the cardiovascular system compounded by an increasing prevalence of hypertension, coronary artery disease and valvular heart disease.¹ Heart failure is a complex clinical syndrome characterized by cardiac function that is inadequate to meet the circulatory demands of the body or only does so at abnormally elevated filling pressures.^2,3 The ventricular dysfunction is either systolic or diastolic. A wide variety of etiologies is involved in heart failure; however, the underlying cause is an inability of the heart to properly fill or empty the ventricle. In general, the etiologies of heart failure in the elderly are the same as those in younger patients, although the clinical presentation can be quite different.³

CHF is the leading cause of admissions to hospital in individuals over the age of 65.^2,4 In the United States, it is considered the most expensive cardiovascular disorder because of its high incidence and intensive use of medical resources; estimated costs related to this condition are in excess of $20 billion per year.

Stable Coronary Artery Disease

D'Arcy Little, MD, CCFP
Director of Medical Education,
York Community Services, Toronto, ON.

Introduction
A recent, large, retrospective study concluded that anti-ischemic therapy in nursing home patients with coronary artery disease (CAD) is often suboptimal. When the medical regimens of 72,263 patients aged 65 years or older with a diagnosis of CAD were evaluated, beta-adrenergic blockers were the least likely anti-ischemic agent (of nitrates, calcium channel blockers and beta-adrenegic blockers) to be administered regardless of age, gender, cognitive or physical function.¹ The following article will review the management of coronary artery disease in this population with the goal of providing the busy clinician with a practical, evidence-based approach.

Epidemiology
Coronary artery disease is a major clinical problem in the elderly,² and the prevalence is increasing as the population ages.⁴ It is the leading cause of death in Canada, responsible for 56% of deaths related to cardiovascular disease, and 21% of all deaths.³ The incidence of CAD increases significantly in both sexes above the age of 65 years.