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.

Wilbert S. Aronow, MD, CMD
Department of Medicine,
Divisions of Cardiology and Geriatrics,
Westchester Medical Center/New York Medical College,
Valhalla, NY.

Cardiovascular disease (CVD) is the most common cause of death of older persons in a nursing home (NH). In a prospective study, we investigated the major clinical cause of death of all persons aged 60 years and older residing in a large NH with full-time staff physicians over a 15-year period.¹

CVD was the cause of death in 63% of the 2,372 persons who died. Another 25 persons (1%) died of bacterial endocarditis. Of the 2,372 persons who died, 25% died of sudden cardiac death, 18% died of a documented fatal myocardial infarction, 11% died of refractory congestive heart failure, 6% died of thromboembolic stroke, 1% died of cerebral hemorrhage, 2% died of pulmonary embolism, 1% died of mesenteric vascular infarction diagnosed at surgery, and <1% died of peripheral vascular disease including dissecting aneurysm of the aorta and ruptured abdominal aneurysm.¹

In a prospective study, we investigated the prevalence and incidence of CVD in 1,160 men, mean age 80 years, and in 2,464 women, mean age 81 years, residing in a NH.² Of the 3,624 persons, 60% were white, 26% African-American, 14% Hispanic, and <1% Asian. Follow-up was 46 months (range 1 to 196 months).

Lynn Hasher, PhD
David Goldstein, PhD
Baycrest Centre for Geriatric
Care and University of Toronto,
Toronto, ON.

Introduction
A variety of important biological, physiological and psychological functions show regular peaks and declines across 24-hour cycles. Such rhythms are present in plants and animals, from the cellular level to the level of organs and even entire organisms.¹ The characteristics and implications of these circadian rhythms have been the focus of a growing body of literature in the fields of chronobiology, chronopathology and chronotherapy. For example, because of underlying circadian rhythms in cortisol concentration in the blood stream, histamine, epinephrine, pulse rate, blood pressure and clotting factors, treatment efficacy varies with the time of administration for diseases such as arthritis, asthma, cancer and cardiovascular disease.^2-5 Recent work in the newly emerging area of chronocognition also shows that behavioural efficacy varies depending on the time of administration of tasks.⁶ Of special relevance is the clear suggestion of age differences in circadian arousal patterns, differences that raise a number of important issues for both research and clinical practice, including what patients are likely to understand and remember from a medical appointment.

Lisbeth Uhrskov Sørensen, MD, PhD, MSc.Econ,
Senior Registrar,
Department of Psychiatric Demography,
Psychiatric Hospital in Aarhus,
Aarhus University Hospital,
Risskov, Denmark.

Nils Christian Gulmann, MD
Chief Consultant Psychiatrist,
and Associate Professor,
Department D, Psychiatric
Hospital in Aarhus,
Aarhus University Hospital,
Risskov, Denmark.

Some of the most frequently prescribed drugs for nursing home residents are psychotropics, with a large proportion of the residents receiving at least one psychotropic medication (Table 1).

Carmel M. Hughes, PhD
Senior Lecturer in Primary Care,
Pharmacy and National Primary Care Career Scientist,
School of Pharmacy,
The Queen's University of Belfast,
Northern Ireland.

Populations in the developed world are aging and the greatest demographic change is seen in those over the age of 80 years. Although it is a remarkable achievement in human survival, this demographic shift does present major challenges to health policy makers and providers. Health care for older people will need to be delivered at many levels--i.e., acute, intermediate, residential and home settings. The long-term care sector (nursing and residential homes) represents one area that can expect to face greater demands for delivery of quality services.

Quality of care and its assessment have become major concerns in most health markets in the developed world and long-term care is no exception. Perhaps the best system for assessing quality exists in the United States (US). This paper will provide an overview of the approach taken in US nursing homes with respect to drug use and contrast this with strategies in other countries.

Legislating for better care: the US situation
In 1983, the US Congress asked the Institute of Medicine to make recommendations for improving the quality of care in nursing homes.¹ The report, published in 1986,2 revealed substantial evidence of appallingly bad care in many nursing homes in the USA.

Madhuri Reddy, MD, FRCP(C)
Associate Editor,
Geriatrics & Aging.

Background
Institutional long-term care (LTC) is expensive for both the individual and society.¹ As Canada's population ages, there will be growing pressure for institutional beds and greater interest in reducing or delaying admission to an institution.²

The structure and financing of LTC varies widely not only among, but also within countries.³ The Canadian health care system is federally-based, and although both federal and provincial levels of government contribute financially to the LTC system, individual provinces are ultimately responsible for the delivery of health care services.⁴

In anticipation of the growing population of frail elderly, several countries are in the process of reforming their LTC systems. There is a trend to change the purpose of nursing homes (NHs) to provide mostly for clients with complicated care needs.³ Researchers worldwide are investigating how to correctly determine clients' needs and how to create instruments that can appropriately assess these needs.⁵ LTC placement criteria are being optimized, alternatives to LTC are being explored, and many countries are expanding their community and home care services.³

Single-Entry System in Canada
In order to make the process of LTC placement more efficient and streamlined, a 'single-entry' system has been introduced in several Canadian provinces.