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.

The results of the readership survey are in and the winners have been selected. Thanks to all of you who took the time to provide us with important feedback. As we said in the survey, we value your opinion!

Now, to the winners…

Reflecting our nationwide distribution, the winners of the survey come from across Canada.

Congratulations to our Grand-Prize winner of $1000, Dr. Rod Rabb of Richmond, ON and his administrative professional Mary Kavanaugh who wins $100. We hope you find a great way to spend the money!

Our runner-up was Dr. Wesley McKee of Saskatoon, SK and his administrative professional Nancy Downey, who will split $600 in winnings. In third-place was Dr. Jaime Caro of Dorval, QC and his administrative professional, Nicole Boyte, who will divide up $300.

Once again, thank you to the hundreds of people who participated in the survey and particularly those who identified topics, which are of particular interest to them. Those of you who specified surgery in the elderly as an area of interest no doubt enjoyed our surgery updates on Minimally Invasive Surgery and Total Joint Replacement. Keep your eyes open for the October issue on Perioperative Care.

The group who asked for more information on Skin Disorders and Nutrition will enjoy some upcoming articles this year but will be particularly pleased in 2002 when we will have entire issues dedicated to these topics. For those interested in Travel, see our Events and Conventions on page 10.

Many of you identified a problem with our current size and found the article continuations frustrating. We welcome additional commentary on this subject, as we are considering on moving to a regular magazine size for 2002. You can reach us at info@geriatricsandaging.ca.

Congratulations once again to our lucky prize-winners! Enjoy the rest of your summer!

Gina Bravo, PhD
Head, Department of Community
Health Sciences,
University of Sherbrooke
Researcher, Research Centre,
Sherbrooke University
Geriatric Institute,
Sherbrooke, QC.

Introduction
Over the past 30 years, as in all provinces across Canada, the population has aged rapidly in Quebec. From 1901 to 1971, a span of 70 years, the proportion of people aged 65 and over increased by only 2.1%: from 4.8%-6.9%. By comparison, it will rise by 21% in the next 70 years. In fact, according to recent projections, 28% of the people living in Quebec will be over 65 by the year 2041.¹

While a majority of older adults consider themselves to be in good health, a significant proportion suffers from impairments that require long-term care. The Canadian Health and Activity Limitations Survey established the prevalence of physical impairments among people aged 65-74 years old at 31%; it is 55% in those over 75. While most elderly individuals live with family members, partially compensating for their impairment, many live alone or with a spouse who also suffers from impairment.²

A Historical Perspective

Introduction of new services
In response to the increasing health care requirements of an aging society, provincial health authorities developed a broad range of services adapted to the needs of the aged.

David R. Thomas, MD, FACP, FAGS
John E. Morley, MB, ChB
Division of Geriatric Medicine
Saint Louis University Health Sciences Center and
GRECC, Veterans Administration Center
Saint Louis, MO, USA.

Abstract
Unintentional weight loss is a common problem among older adults, especially those in institutional settings. Physicians respond by prescribing increased oral calories, prescribing nutritional supplements or by considering enteral feeding. The response of patients to these interventions is often poor. For this reason, pharmacological agents that stimulate appetite or produce weight gain have attracted considerable attention. Should these agents be used? This review focuses on the benefits and risks of these orexigenic agents.

Introduction
Malnutrition is a major problem among residents in long-term care facilities.^1-4 The prevalence of protein-energy malnutrition in nursing home residents ranges from 23-85%.5,6 By comparison, the prevalence of protein-energy malnutrition ranges from 32-50% in acutely hospitalized patients.^7,8 The high prevalence of malnutrition in nursing homes may reflect a unique problem in elderly persons, the presence of chronic conditions, failure to address specific nutritional problems in this setting, or transfer of malnourished patients from acute care hospitals to long-term care facilities following an acute illness.

Peter Uhlenberg, PhD
Jenifer Hamil-Luker, MA
Department of Sociology,
University of North Carolina,
Chapel Hill, NC, USA.

Towards the end of life, many older people experience physical decline that forces them to depend upon others for care. This loss of independence, never an easy life transition, is often made more difficult by the limited opportunities that those in long-term care (LTC) have for interacting with other people. Yet, as all sensitive medical professionals know, older adults in LTC, like people at every other stage of life, need meaningful social relationships in order to thrive. Thus, it is unfortunate that long-term care institutions tend to be highly age-segregated, providing few chances for older residents to develop and enjoy friendships with children and young people. It is not necessary, however, that social isolation and age segregation be the common experience of those in LTC. This article reports on efforts to promote intergenerational relationships in LTC, the potential benefits of greater age integration, and research findings of what conditions facilitate positive outcomes from exchanges between children and older adults in LTC.

Benefits of Age Integration
Nursing homes, assisted living facilities and day care providers are increasingly bringing the young and old together on a regular, formally planned basis to build enduring, mutually beneficial relationships.

Jean Chouinard, MD
Medical Director,
Complex Continuing Care Program,
SCO Health Service,
Ottawa, ON.

Background
The likelihood of admission to a nursing home (NH) is very much age-related. Roughly 5% of patients over the age of 65 live in institutions; this proportion rises to 50% for people aged 90 and up. With cutbacks in health spending, and the rising demand for this type of care, the NH populations are becoming increasingly frail and often have multiple coexisting active health problems on a background of precarious homeostatic reserve. Currently, over 50% of our inpatients are totally dependent on help for their care. Only 15% of these inpatients can ambulate independently. Such patients are also at much higher risk of complications. In our facilities, the yearly incidence rate of pneumonia is 200% (!), with a case fatality rate of 30%. Between 5 and 10% of patients admitted to Ontario Chronic Care Facilities will develop a pressure sore every quarter. Annual mortality rates in institutions range from 15 to 30%.¹

Some definitions--in much abridged version²
A care process is a series of sequential or parallel interactions among clinicians and between clinicians and patients aimed at a given outcome.