Chris MacKnight, MD, MSc, FRCPC
Division of Geriatric Medicine,
Dalhousie University,
Halifax, NS.

Dementia and hypertension are two of the most common conditions affecting older adults. A number of recent studies suggest that dementia is one of the long-term complications of hypertension. Studies also suggest that the treatment of hypertension may prevent dementia. This brief review will focus on the relationship between hypertension and dementia in older adults.

Epidemiology of Dementia
Eight percent of Canadians who are over the age of 65 suffer from dementia, with Alzheimer's disease being the most common cause (approximately 60% of cases).¹ Dementia is age-related, with the prevalence increasing from 2.4% of those from 65-74 years of age, to 34.5% of those 85 and older. Sixty thousand new cases occur each year in Canada.² The cost of providing care to these patients is substantial, at 3.9 billion dollars/year, in 1991 dollars.³ Vascular dementia is the second most common cause of dementia in Canada, accounting for 20% of cases. When discussing vascular dementia, it is important to recognize that the classic pattern of multiple infarcts is found only in approximately 1/3 of the cases. The other cases consist of patients who have changes in their white matter (likely on the basis of small vessel ischemia) with or without lacunar infarcts, or, rarely, single strategic strokes.

Dr. Bernard Isaacs, one of the great men of modern British geriatrics, died several years ago in Jerusalem. In order to commemorate this physician, A. Mark Clarfield has written the following piece.

Prof. Isaacs' untimely death, six years ago this month, robbed us all of a great man. First and foremost, he was a first-rate geriatrician, truly one of the "giants" in the field. In addition, he had a golden hand and was a beautiful writer. Finally, to me and to many others, he was a great friend. We will miss him.

In order to commemorate my beloved colleague, I will concentrate on bringing to you some of Bernard's words of wisdom and wit. I shall try to do so via judicious quotations from his third and final book, "The Challenge of Geriatrics Medicine" (Oxford University Press, 1992). In fact, Bernard had intended to call the book, "The Giants of Geriatrics", after his now famous formulation. He listed the giants via four "I's"-- namely immobility, instability, incontinence, and intellectual impairment. Unfortunately, the publisher, in its limited wisdom, thought otherwise and gave the book the less interesting title.

Bernard's published works included scores of articles, as well as three books. Merely perusing the titles of some of his works will testify to his humour and wit. For example, Bernard wrote a series of articles for Nursing mirror.

D'Arcy Little, MD, CCFP
Director of Medical Education,
York Community Services,
Toronto, ON

Munir A. Jamal, MD, FRCSC
Staff Urologist,
Credit Valley Hospital,
Mississauga, ON

Introduction

Epidemiology:
Cancer of the urinary bladder is essentially a disease of the elderly. The median age at diagnosis is 69 years for males and 71 years for females, and more than one-third of cases occur in patients over the age of 75 years of age.^1,2 The incidence of transitional cell carcinoma (TCC) of the bladder, the most common subtype of bladder cancer, accounting for over 90% of cases, is rising and currently ranks as the fourth highest new cancer diagnosis in men.³ However, the mortality rate of this disease has fallen over the last two decades.¹ The following review article will address the epidemiology, natural history, clinical presentation, and treatment of this disease, with an emphasis on issues pertaining to elderly patients. (See Figure 1)

Bladder cancer is unique among human neoplasms in that it has been associated with several distinct etiological factors.⁴ Risk factors related to the development of TCC, in addition to age, include tobacco smoking and occupational exposures in the dye, rubber, textile, and leather industries.

D'Arcy Little, MD, CCFP
Director of Medical Education,
York Community Services, Toronto, ON

Background
Coronary artery bypass grafting (CABG) is an accepted therapeutic intervention for the treatment of coronary artery disease (CAD). Depending on the clinical situation, CABG can improve the symptoms of angina, patient survival (triple vessel or left main disease), and quality of life. Over the last two decades, there has been a substantial growth in the use of CABG in Canada and it is now one of the most common surgical procedures performed in North America. Most of the overall increase in the frequency with which this procedure is performed has been seen in the elderly population.^1,2 However, this increase has not taken place without controversy. While some health critics have argued that the procedure is overused, patients often express concern about waiting lists.³ This article will discuss the costs of CABG in the elderly and potential avenues to reduce these costs and improve patient outcomes.

In Ontario, the overall rate of CABG grew 31% during the years 1981 to 1989, and in 1989-90 this surgery was performed at a rate of 66 procedures per 100,000 members of the population. Notably, during this period, the highest annual increase was in those patients aged 65 to 74 years. Thirty-seven percent of cases were performed in patients over 65 years of age.

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

Leigh Turner, Ph.D|
Baycrest Centre for Geriatric Care

Ethics Education in the Geriatric and Long-Term Care Setting
Baycrest Centre for Geriatric Care now has an innovative program in ethics education. Developing a well-rounded educational program in bioethics, intended to benefit all levels of staff within the geriatric and long-term health care setting, was a considerable challenge. With few models to emulate, this program was undertaken to provide the staff with the knowledge and means to respond to important ethical challenges in an appropriate manner. The system of unit-based ethics rounds, which has been implemented over the last several years, has been very successful and may serve as a prototype for other long-term care and geriatric facilities.

The Unit-based Model
The standard hospital model for providing assistance in resolving ethical issues includes an ethics committee that offers a consultation service. This structure, which exists at Baycrest, has been in existence for about a decade in the long-term care system, following its introduction to the acute care system years before.

M.D. Minden, M.D., Ph.D., FRCPC
Princess Margaret Hospital
University Health Network
Toronto, ON

Introduction
Leukemias are malignancies of the blood and bone marrow and are classified as either acute or chronic malignancies of the myeloid--red blood cell, granulocyte, platelet lineage--or lymphoid--T or B lymphocyte. In this article we will focus on acute myeloblastic leukemias (AML) and recent advances in their classification and therapy.

In the United States, approximately 10,100 cases of AML are diagnosed each year and the yearly mortality rate from this disease is approximately 6,900 individuals. The incidence of AML is low in children (<1/100,000) and increases with age, such that by the time a person reaches the age of 80 the incidence is approximately 15/100,000 (Figure 1).¹ Over 60% of patients are 55 years of age or older, making this a significant problem in the aging population.

AML develops as the result of genetic changes in hematopoietic stem cells of the bone marrow.² These changes block the ability of the cell to undergo normal differentiation resulting in a blast-like morphology. In some cases, the patient may have large numbers of circulating leukemic blast cells compromising blood flow to vital organs.

Jolie Ringash, MD, MSc
Department of Radiation Oncology,
Princess Margaret Hospital
University Health Network,
Toronto, ON

Background
Esophageal and gastric carcinomas are primarily diseases of older persons. Of 498 new cases of esophageal cancer in Ontario in 1997, 237 (48%) occurred in individuals aged 65 to 79, and 101 (20%) in those over the age of 80. The corresponding numbers for gastric cancer are (of a total of 1,032 cases) 492 (48%) for those aged 65 to 79, and 200 (19%) for those over 80.¹ For all age groups, gastric cancer is decreasing in incidence, with only 2, 800 cases in Canada in the year 2000. In contrast, the incidence of esophageal cancers is gradually increasing (1,350 cases in 2000).^2,3 Adenocarcinoma, primarily of the distal esophagus, has replaced squamous cell carcinoma as the most frequent histology. Tumours of the gastroesophageal junction pose a particular challenge, since management may differ depending on whether the tumour is felt to originate in esophagus or stomach.

Canadian oncologists frequently face difficult treatment decisions in the elderly. Unfortunately, since older patients are usually excluded from clinical trials, evidence for their tolerance of, and response to, therapeutic radiation is limited. Existing reports are limited to retrospective reviews and subgroup analyses, many of which originate in Japan.

Haim Cohen, Ph.D
Department of Pathology,
Harvard Medical School,
Boston, MA

The incidence of cancer increases as we age: during the last decade of life, the risk of developing cancer is a startling 50% for men and 33% for women.¹ What is the underlying link between aging and cancer? This link may be found by investigating diseases that are associated with both a high frequency of cancer and premature signs of aging. Such diseases, known collectively as RecQ syndromes, are caused by mutations in genes encoding RecQ-like proteins.² The RecQ family of proteins has a high degree of homology to the helicase domain of the RecQ helicase of E. coli. The helicase region is required for all RecQ helicases to unwind duplex DNA from 3' to 5' direction in vitro; however, the in vivo function of the eukaryotic RecQ is unknown.

At least three inherited human diseases are caused by mutations in RecQ-like genes: Werner syndrome (WS), Bloom syndrome (BS), and Rothmund-Thomson syndrome (RTS).³ These diseases share two main features: premature aging and a high level of genomic instability that manifests itself as a high incidence of cancer.

The hallmark of Bloom syndrome is an increased level of sister chromatid exchange, and patients present with sun-sensitive skin pigmentation and a predisposition to certain malignancies.

Dr. Christine I. Chen, MD, FRCPC
Princess Margaret Hospital,
University Health Network,
Toronto, ON

Introduction
Multiple myeloma arises from a malignancy of plasma cells in the bone marrow which typically produce an immunoglobulin, also referred to as a monoclonal protein (M-protein), that is detectable in the patient's blood and/or urine. Myeloma is not a common disease (incidence of 1400/year in Canada), typically affecting older individuals (median age 65 years). It is more common in blacks and slightly more prevalent in males. Since myeloma is a relatively slow-growing malignancy, many patients will have the disease for months or even years before a diagnosis is made and may continue to follow an indolent course. The pathogenesis of the disease is poorly understood.

Clinical Features
Characteristic clinical features of multiple myeloma are anemia, renal failure, bony lesions with pathologic fractures and associated pain, hypercalcemia, and recurrent infections (See Table 1). Many patients, however, will present with asymptomatic anemia or a monoclonal gammopathy, which is usually discovered during incidental lab testing.

Tawfic Nessim Abu-Zahra, BSc, MSc

Elderly people (i.e. those over 65 years of age) tend to be excluded from clinical research trials in areas such as cancer and heart disease.^1-4 Physicians wishing to make evidence-based treatment decisions for elderly patients may have to extrapolate clinical data from studies that have been conducted in a younger population. However, given that there are age-related changes that occur even in healthy elderly people, any such extrapolation may not be scientifically sound.^1-3 Changes in physiological parameters that occur with increasing age, such as decreases in renal and cardiovascular function, blood flow and hepatic volume, make the disposition of drugs more variable in the elderly and predispose them to drug toxicities and adverse drug reactions.³ The result is that geriatric patients may not receive the newest therapies or may receive a treatment whose efficacy and safety in the elderly is not known.^1-3

In a study published in the New England Journal of Medicine, Hutchins and colleagues5 determined the enrollment rate of cancer patients aged 65 years or older in clinical trials, and compared this with the corresponding rate of elderly cancer patients in the general population. Overall, the authors reported that the elderly were significantly underrepresented in all cancer trials and in 14 of the 15 types of cancer that were individually investigated.