Dr. Angela G. Juby, MBChB, Cert Geriatrics
Associate Clinical Professor, Division of Geriatrics,
Department of Medicine, University of Alberta, Edmonton, AB.

Dr. Paul Davis, MBChB, FRCP, FRCPC
Associate Dean, Faculty of Medicine, University of Alberta,
Professor, Division of Rheumatology,
Department of Medicine, University of Alberta, Edmonton, AB

Introduction
Rheumatoid arthritis most commonly presents in the 3rd and 4th decades of life; elderly patients with initial presentation and patients whose disease persists into the later decades of life can present interesting challenges. In particular, the differences in clinical presentations of rheumatoid disease in the elderly when compared to younger patients may lead to difficulty in making a definitive diagnosis. There may be diagnostic challenges related to the interpretation of laboratory findings, particularly serological tests. Elderly patients often have comorbidities; therefore, pharmacologic management of rheumatoid disease must be undertaken with caution to reduce interference with the stability of other organ system therapies, and the potential for drug-disease and drug-drug interaction and polypharmacy must be addressed. Finally, it is important to dispel the attitude that "arthritis" is a process associated with "normal aging.

Seniors Benefit from Being Online

David Patrick Ryan, PhD, C.Psych
Director of Education, Regional
Geriatric Program of Toronto,
Faculty of Medicine,
University of Toronto, Toronto, ON.

There is an interesting paradox at the heart of Internet use by seniors which is: Although seniors are under-represented among Internet users, when they do get online, they become its most frequent users. Only 16% of seniors use the Internet, compared to the national average of 44%. Yet, once online, Canadian seniors use the Internet, on average, for 12 hours weekly. This is more than the average for teenagers (7 hours) and 80 minutes more than for any other age group. Given the emerging realization that the Internet expands the world of seniors, particularly disabled seniors, at a time when it would otherwise be contracting, and the developing evidence that computers and the Internet can be powerful tools for maintaining health and well-being, it is imperative that an attempt be made to reduce the digital divide amongst seniors.¹

The Obstacles to Internet Use for Seniors
What are the obstacles to seniors' use of the Internet? Anxiety is one obstacle.

Sydney C. Lineker, MSc, BScPT
Affiliated Scientist,
Toronto Western Research Institute;
Research Coordinator,
The Arthritis Society, Consultation and Rehabilitation Service, Toronto;
President, Arthritis Health Professions Association,
Toronto, ON.

Linda C. Li, BSc(PT), MSc
Arthritis & Autoimmunity Research Centre,
University Health Network;
The Arthritis Society,
Consultation and Rehabilitation Service, Toronto; Board Member,
Arthritis Health Professions Association,
Toronto, ON.

Introduction
Arthritis, in its many forms, is the most common cause of long-term disability in the elderly,^1-4 often resulting in functional problems, the loss of leisure, social and vocational activities, isolation and depression. Osteoarthritis (OA) is the most common type of arthritis in this population.¹

Pain, disability and psychosocial and educational needs are often underestimated by health care providers.^5,6 Pain is the most frequently reported symptom6 and is a complex phenomenon requiring a multidimensional approach. Pain may be under-reported by the elderly.^6,7 Signs of inflammation--redness, pain and swelling--may be less marked8 and it may be difficult to attribute pain to a specific cause.² Comorbidity, polypharmacy and complications of pharmacological interventions unique to the elderly add to the mix.

Klaus Turnheim, MD
Department of Pharmacology,
University of Vienna,
Vienna, Austria.

Introduction
Hyperuricemia is present in approximately 5% of asymptomatic adults and 10% of hospitalized patients. The prevalence of hyperuricemia and gout increases with age because of changes in body composition, renal excretory function and treatment with diuretics.¹ In addition, risk factors for crystal deposition, for instance degenerative joint diseases and osteoarthritis, are magnified in old age.² Gout found in the elderly differs from classical gout in middle-aged men in several respects. These include the fact that it has a more equal gender distribution, a frequent polyarticular presentation with an involvement of the joints of the upper extremities, fewer acute gouty episodes, a more indolent chronic clinical course, and an increased incidence of tophi.³ Decreased renal excretion of uric acid appears to be a major cause for hyperuricaemia and gout in advanced age.⁴

David K. Conn, MB, BCh, BAO, FRCPC
Head, Dept. of Psychiatry,
Baycrest Centre for Geriatric Care,
Assistant Professor,
Department of Psychiatry,
University of Toronto,
Toronto, ON.

A variety of studies have raised concerns about the quality of medication prescribing to elderly residents of long-term care facilities. Despite the fact that criteria for "inappropriate prescribing" can be debated, there is general agreement that considerable improvement is required to ensure optimal prescribing. Beers et al.¹ brought together a panel of national experts in the United States in an attempt to reach consensus on defining inappropriate medication use in the nursing home. Having developed specific criteria, they subsequently reported that more than 40% of residents in a group of California nursing homes had at least one inappropriate prescription. The term "silent epidemic" has been used to describe the problems caused by adverse drug reactions. A 1998 report from the United States consisting of a meta-analysis of 39 studies estimated that more than two million hospitalized patients had serious adverse drug reactions over a one-year period.

Jerry Tenenbaum, MD, FRCPC
Rheumatologist,
Mount Sinai Hospital and
Baycrest Centre for Geriatric Care,
Associate Professor,
University of Toronto,
Toronto, ON.

Introduction
Osteoarthritis (OA) is a chronic disease of the joint that results in degeneration of the cartilage and bone. However, in osteoarthritis, it is not uncommon to see intermittent or even chronic evidence of inflammation in the affected joint. Patients may experience stiffness after immobility (in the morning or after sitting for a long time), warmth and erythema of the joint, and soft tissue swelling and/or synovial effusion. On history taking and physical exam, these findings attest to the inflammatory nature of the involved osteoarthritic joint at the time. A microscopic examination of the synovium of patients with osteoarthritis will often show the presence of inflammation. Though cartilage and bone seem to be the primary targets of damage, it is likely that inflammation within the synovium may play an important role in the progressive damage to these joint tissues. Primary involvement of synovium may occur in some patients and secondary synovitis is commonly seen. This is associated with the intermittent or chronic presence of crystals (calcium pyrophosphate dihydrate, hydroxyapatite) or synovitis associated with stimulation by joint damage debris.

Alexandre Kalache, MD, PhD,
Chief, Ageing and Life Course (ALC),
World Health Organization,
Geneva, Switzerland.

Ingrid Keller, MSc, MPH
Associate Professional Officer, ALC,
World Health Organization,
Geneva, Switzerland.

Introduction
Within the next few decades, one of the defining features of the world population will be the rapid increase in the absolute and relative numbers of older people in both developing and developed countries. We are currently at the threshold of global aging. Worldwide, the total number of older people--defined as those over 60 years of age--is expected to increase from 605 million in 2000, to 1.2 billion by the year 2025.¹ Currently, approximately 60% of older persons live in the developing world, a number that is expected to increase to 75% (840 million) by the year 2025. Figure 1 shows the proportional increase of older persons among the total population for some developing countries as compared to the Canadian population.

In the year 2000, in a number of developed countries, there were, for the first time, more people aged 60 and older than there were children under the age of 14.¹ Population aging could be compared with a silent revolution that will impact on all aspects of society. It is imperative that we are adequately prepared for it: the opportunities and the challenges are multiple.

Aly S. Abdulla, BSC, MD, LMCC, CCFP, DipSportMed(CASM)
Faiza Abdulla, CDA
Contributing Authors,
Geriatrics & Aging.

Introduction
Unlike female menopause, which has been at the forefront of the medical community for over a decade, male menopause has been ignored and its very existence contested. This article will review this controversial topic in terms of its definition, mechanisms, evidence, symptoms, diagnosis, treatment options and follow-up.

Definition
Andropause is a clinical condition characterized by a partial deficiency of circulating androgens in blood and/or a decreased sensitivity to testosterone or its active metabolites in target tissues. This state of hypogonadism leads to a decline of energy, an altered sense of well-being, sexual dysfunction and various metabolic alterations. These issues may have effects on muscle mass, bone density, lipid profile and eventually cognitive function.^1,2 This syndrome tends to begin around age 50. Its insiduous onset can predate the finding or suspicion of symptoms by ten years.1 There is large overlap between andropause and other entities like neuro-vegetative dystonia, sleep disorders, mood disorders (anxiety and depression being the predominant two), hypothyroidism, drug abuse including alcoholism, medications, anemia, diabetes, obesity, hyperprolactinemia and erectile dysfunction due to non-hormonal factors (i.e. stress).

David R. Urbach, MD, MSc, FRCSC
Division of General Surgery,
University Health Network,
Assistant Professor,
Departments of Surgery and Health Administration,
University of Toronto,
Toronto, ON.

Minimally invasive surgery (MIS) has revolutionized the way that surgeons perform many operative procedures in the chest and abdomen. MIS generally refers to the use of a variety of new technologies and techniques that reduce the size of the incisions required for performing a surgical procedure. It is important to recognize that minimally invasive procedures are not new operations; rather they are novel approaches to performing the same procedures that have been done for decades. The most frequently cited advantages of MIS over conventional surgery include a reduction in postoperative pain, shorter post-operative hospital stay and a quicker return to full activities. Some procedures, such as cholecystectomy (removal of the gall bladder), are commonly performed using MIS techniques. For many other surgical procedures, there is large variation in the use of MIS. Some applications of MIS, such as minimally invasive cancer surgery, are controversial.

Laparoscopic surgery is especially relevant to the care of elderly persons. Because most gastro-intestinal diseases become more prevalent with increasing age, many of the patients treated by general surgeons are elderly.

Jerry Cott, PhD
Research Pharmacologist,
Scientific Advisor to the Health Professions,
College Park, MD.

St. John's Wort (Hypericum perforatum; SJW) is a common roadside plant that has gained much popularity in Europe and the United States as an alternative to synthetic antidepressants. The market for SJW in 1998 was $330 million in Europe and $210 million in the U.S. Hypericum appears to be an effective antidepressant with an excellent safety profile (with the interaction caveat discussed here). The NIH has just completed a multi-centre study comparing the efficacy of SJW to sertraline and placebo for treating patients with moderate to severe depression. This study was completed in December 2000, and results should be available in the summer of 2001.

Although SJW has been shown to inhibit monoamine oxidase (MAO) in vitro, this effect has not been demonstrated in vivo, nor have there been any reported cases of MAOI-associated hypertensive crises in humans using SJW.¹ Although SJW has been reported to inhibit uptake of serotonin, norepinephrine and dopamine in vitro,² the concentrations required to attain these effects are quite high and the chance of a patient attaining equivalent blood concentrations is low. In fact, a recent study suggests that the uptake inhibition is only an artifact of the assay since, in contrast to other inhibitors, it does not bind to the serotonin uptake site but does deplete storage vesicles in a similar fashion to reserpine.