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.

Jane Oshinowo, RNEC,
Primary health care Nurse Practitioner,
York Community Services,
Toronto, ON.

Sharon Dolman, RN
Medical copy writer,
HEADCAN,
Toronto, ON.

Introduction
Cardiovascular disease (CVD) is the leading cause of death in Canada and the second leading cause of disability. Since the mid-1960's there has been a gradual decline in overall mortality rates due to heart disease; however, there has been little improvement in the mortality rates from ischemic heart diseases (HD) and acute myocardial infarction (MI).¹ Abookire²⁷ noted that many physicians failed to adhere to the guidelines designed to reduce CVD risks. One strategy in this arena is to expand collaborative practice with nurse practitioners and other health care providers.

This paper will review the epidemiology of coronary heart disease (CHD) and the evidence about primary prevention designed to reduce cardiovascular risk factors, highlighting the role of the primary health care provider.

Epidemiology of Cardiovascular Disease
CVD is responsible for 36% of the deaths in Canada every year. Of these deaths, 21% are attributed to ischemic heart disease, and half of those are ascribed to acute MI (See Figure 1).¹ Huge costs are accrued to society from CVD.

Is there a Role for Primary and Secondary Prevention Strategies?

Ruth E Heisey, MD, CCFP, FCFP
Assistant Professor,
University of Toronto,
Family physician and Clinical Associate,
Department of Surgical Oncology,
Sunnybrook and Women's Health Science Centre, and
Princess Margaret Hospital Site,
University Health Network,
Toronto, ON.

H Lavina A Lickley, MD, PhD, FRCSC, FACS
Professor of Surgery and Physiology,
University of Toronto,
Surgeon (special interest in Breast Disease),
Women's College Campus of Sunnybrook and Women's College Health Science Centre,
Toronto, ON.

"Old age is like everything else. To make a success of it, you've got to start young."¹ Fred Astaire

Breast cancer is the most common cause of cancer death in women over the age of 65.² Between the ages of 30 and 80 years, the annual incidence of breast cancer rises from 1:5900 to 1:290.^3,4 It has been estimated that by the year 2030, almost two-thirds of women with a diagnosis of breast cancer will be 65 years of age or older.⁵

The incidence of breast cancer among Canadian women has been rising steadily over the past decade, probably due in part to improved detection with mammographic examinations.

Dr. Denis DeSilvey
Associate Professor of Clinical Internal Medicine,
Department of Internal Medicine,
Division of Cardiovascular Medicine,
University of Virginia,
Charlottesville, VA.

Thrombolytic therapy for the management of acute myocardial infarction is one of the major advances in cardiovascular medicine in the last fifteen years. Beginning in the mid 1980s, an increasing body of literature supported the concept of the early administration of a thrombolytic agent, either streptokinase or tissue plasminogen activator (TPA), to salvage ischemic myocardium. The concept that 'time is muscle' took hold and has dominated our thinking about the management of acute ST segment elevation injury.

The guidelines of the American Heart Association and the American College of Cardiology¹ as well as the review in the Fibrinolytic Therapy Trialists' Collaborative,² show that fibrinolytic therapy reduces mortality for 18-30% of patients with acute myocardial infarction when given within 6 to 12 hours of the onset of pain. These excellent results were supported by subsequent studies such as the Second International Study of Infarct Survival (ISIS-2)³ and the Gruppo Italiano per lo Studio dell Streptochinasi nell'Infaarcto Miocardico (GISSI).⁴

Nariman Malik, BSc
Contributing Author,
Geriatrics & Aging.

Lou Gehrig: A Brief History
Lou Gehrig was born June 19, 1903 in New York City. He played for the New York Yankees from 1923 to 1939 and was one of the most famous first basemen in the history of major league baseball.¹ The man known as the 'iron horse of baseball' and 'Columbia Lou' was originally recruited for only two games in 1923.² However, this durable athlete went on to play in 2,130 consecutive games.³ In fact, he never missed a game until he voluntarily benched himself on May 2, 1939.

Gehrig had an impressive career. He had a lifetime batting average of .340, hit 493 home runs and was a four-time winner of the Most Valuable Player award.³ He was also inducted into the Baseball Hall of Fame. The 1938 season had proven to be a bad one for Gehrig as he was not playing up to his usual standard. During spring training for the 1939 season, he began having trouble getting power behind the ball and had difficulty with his movements.² Unhappy with his performance, Gehrig voluntarily benched himself.

Six weeks later, Gehrig was referred to the renowned Mayo Clinic where he was diagnosed with amyotrophic lateral sclerosis (ALS). Gehrig was never told his true diagnosis and was unaware that the outcome was fatal. Only his wife and a few of her confidantes knew the true nature of Gehrig's illness.

A. Mark Clarfield

Several years ago at a public ceremony, a member of Europe's royalty forgot where she had put her reading glasses. Her husband may have thought that his regal spouse was showing signs of early Alzheimer's disease. However, Her Royal Highness clearly remembered that she wore glasses. In this distinction lies the difference between normal aging and dementia.

However, when the family doctor is concerned that a patient is suffering from one of the dementias--an insidious loss of higher cerebral functions including memory, judgment, affect, orientation, behaviour and language skills--further differentiation must be made. Most demented patients suffer from Alzheimer's disease or from brain damage resulting from multiple strokes. Unfortunately, in either of these situations there are few available treatments that can either reverse or limit the ongoing brain damage. For a fortunate few with a reversible cause for the dementia, early treatment can actually result in a significant improvement in the cognitive dysfunction.

Only a decade ago, the highest medical authorities held that anywhere from 20-40% of dementias were reversible. However, meta-analyses of the data indicated that reversibility occurred in no more than 11% of cases.^1,2 Even more recent community-based studies indicate that, unfortunately, most dementias are incurable (although certainly not unmanageable); probably less than 1% fall into the reversible category.

Rubina Sunderji, Pharm.D., FCSHP
Pharmacotherapeutic Specialist&emdash;Cardiology,
Pharmaceutical Sciences CSU,
Vancouver General Hospital,
Clinical Assistant Professor,
Faculty of Pharmaceutical Sciences,
University of British Columbia,
Vancouver, BC.

Kenneth Gin, MD, FRCPC
Director, Post Graduate Cardiology,
Training Program, and Clinical Assistant, Professor, Faculty of Medicine,
University of British Columbia,
Director, Coronary Care Unit, and Assistant, Director, Echocardiography Laboratory,
Vancouver General Hospital,
Vancouver, BC.

Amiodarone is a class III antiarrhythmic agent with a unique and complex pharmacological profile. The drug was originally used as an antianginal agent due to its potent coronary vasodilating activity.¹ It has subsequently been shown to be effective for both supraventricular and ventricular arrhythmias. The risk of inducing proarrhythmia is lower than with other antiarrhythmics and, unlike the class I antiarrhythmic agents, it has not been associated with increased mortality.² However, amiodarone can cause a variety of side effects and close monitoring of the patient is necessary.

Pharmacology
Amiodarone is a di-iodinated benzofuran compound containing 37.3% iodine by weight.