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.

Dr. J. David Spence, FACP, FRCPC
Professor, Neurology and Clinical Pharmacology,
University of Western Ontario,
Director, Stroke Prevention and Atherosclerosis Research Centre,
Siebans-Drake/Robarts Research Institute,
London, ON.

Hypertension is such a common and important problem that Canadian physicians should be good at treating it. Unfortunately, our performance is pathetic: only 16% of Canadians have well-controlled blood pressure.¹ This is a huge care gap, particularly for the elderly, since they have the most to gain. Perhaps the biggest missed opportunity in medicine today is the treatment of isolated systolic hypertension. I puzzle over why doctors do so badly at treating this condition, although I have my suspicions. I think one reason is that many doctors have several elderly patients in their practice with pseudohypertension;² these patients feel unwell when their blood pressure is treated, and physicians may generalize from these unusual patients to elderly patients in general. Another reason may be that the elderly may be on many medications and there is (appropriately) reluctance to add more. The elderly may also be harder to treat because of missed secondary hypertension. Renovascular hypertension is much more common in the elderly, and adrenocortical hyperplasia also gets worse with age. The physiology and diagnosis of these problems are discussed below.

Kiran Rabheru, MD, CCFP, FRCP(C)
Active Staff, Geriatrics Psychiatry,
London Psychiatric Hospital, London, ON.

Psychotic disorders in older adults, characterized by a loss of touch from reality, are common and challenging to manage in primary care. Symptoms include delusions, hallucinations, thought disorder and bizarre behaviour. As psychiatric wards many of which still house many older patients with psychosis, close across the country, nursing homes are quickly taking over their role as the "psychiatric hospitals of tomorrow." Nursing homes are often not well equipped to care for older patients with psychosis, many of whom also suffer from dementia, depression and other medical conditions. There are virtually no demographics available on older people with psychosis who live on our streets. The social and economic burden of these disorders is high. The spectrum of psychotic disorders in the elderly is broader than that in younger adults, with some important clinical and epidemiological differences.

DSM-IV differentiates between primary psychotic disorders and disorders with secondary delusions. Although the secondary causes of psychosis in older adults are extremely important to consider, the focus of this article will be on the most common causes of primary psychotic disorders.

Cynthia Jackevicius, BScPhm, MSc
Practice Leader,
Pharmacy Department,
Associate, Women's Health Program,
University Health Network-Toronto General Hospital,
Assistant Professor,
University of Toronto, Toronto, ON.

Coronary heart disease (CHD) is a major economic burden on the health care system, with the total cost of the morbidity and mortality associated with cardiovascular disease in Canada estimated at $18.0 billion in 1994.¹ Effective prevention and treatment decrease morbidity and mortality associated with CHD. A controversial issue in recent years has been whether the reduction of cholesterol results in a decline in subsequent CHD events and mortality in patients older than 65 years of age.² Several observational studies have suggested that elevated cholesterol levels may not be a significant cardiovascular risk factor in older people. However, a recent study investigated this hypothesis and found that after adjustment for risk factors and indicators of frailty, such as low serum albumin, elevated total cholesterol levels do predict increased risk for death from CHD in older adults.³

Three recently published, landmark trials focusing on the benefits of statins in the prevention of secondary coronary events showed that statins improve patient outcomes with minimal adverse effects.

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

What do you do when you are having problems communicating with the surrogate decision-maker of one of your dependent long-term care patients? It is not uncommon for health care providers to have conflicts with surrogates. Often it is about relatively minor, easily rectifiable issues, such as deciding who will be the official spokesperson for a large family, many members of which want to receive information or have their individual concerns addressed. Sometimes such a conflict may force staff to suggest that, if the family cannot make a decision amongst themselves, a legal solution will be sought. Most families will find ways to agree on decision-making, rather than leaving such important decisions to outsiders such as court-appointed guardians.

Unfortunately, the challenges that are sometimes posed by surrogates can leave even the most experienced clinical staff in turmoil. Some years ago, the nursing and medical staff of a palliative care unit appealed to the Baycrest ethics committee to intervene, on behalf of their patient, between themselves and the patient's surrogate spouse, with whom they were having serious problems.