A. Mark Clarfield

The fact that dementia is finally beginning to receive the attention that it deserves is evidenced by the editors of Geriatrics & Aging wisely deciding to devote most of this issue to the subject. Dementia is primarily associated with memory loss; this means, unfortunately, that professionals often pay far less attention to the other symptoms that can accompany the syndrome. In fact, caregivers tell us that their loved one's problem with memory is usually far less burdensome than are the behavioural symptoms. Two of these symptoms are featured in this issue: agitation, by Dr. Elizabeth Sloan (a resident in Psychiatry at the U of T); and wandering, written by Dr. Bob Chaudhari, of the same department.

Dr. Sloan reminds us that agitation--sometimes accompanied by other symptoms such as screaming and aggression--is not a diagnosis per se but rather consists of a "constellation of symptoms." In geriatric care we are not afraid of such terminology, even if the terms are not always easily found in the index of Harrison's Textbook of Medicine. The same, of course, would hold for falls or incontinence.

As is the case with many of the non-specific ("atypical") presentations of disease in the elderly, Sloan points out, an underlying medical illness must never be overlooked as a possible causal factor. As I like to teach my medical students, "Take a history before prescribing haldol." (Unfortunately, now that the older anti-psychotic medications are increasingly being replaced by less toxic molecules, I'll have to figure out a new alliteration to go with, for example, risperidone--now what starts with an "r"? "rectum", no; "respiratory system"--doesn't ring true.) But I digress.

Dr. Sloan goes on to offer a great deal of good advice and the interested reader is advised to consult the references in her comprehensive bibliography.

Dr. Chaudhuri tackles the related problem of wandering, where he offers an interesting tri-partite classification which I admit that I have not seen before: volitional (depressive), motivational (anxious) and repetitive behavioural (irritable) wandering. Perhaps as a geriatrician, I am used to a more "medical" classification; but the author, not surprisingly as he is a psychiatrist, offers a more psychodynamic approach.

Like Sloan, Dr. Chaudhuri points out that management must take into account the patient's environment. Appropriately, he does not spend much time on a pharmacological approach, which is not usually an effective method unless, of course, your aim is to drug the patient into a stupor.

My own experience is that the wandering (pacing) patient with dementia must be allowed his/her own space. Obviously, as is also the case at the other end of the age spectrum with the toddler, wanderers must be protected against the obvious dangers involved. However, when all is said and done, the milieu extérieur seems to me to be of more importance than the milieu intérieur.

Dr. Clarfield is the Chief of Academic Affairs at the Herzog Hospital in Jerusalem, Director of Geriatrics in the Ministry of Health, and on staff in the Division of Geriatric Medicine, Sir Mortimer B. Davis-Jewish General Hospital, McGill University, Montreal.

Clinical and Ethical Perspectives

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

David Goldstein, PhD
Director, Centre for Knowledge Transfer,
Baycrest Centre for Geriatric Care,
Professor of Psychology,
University of Toronto,
Toronto, ON.

The daughter told me (MG) that Dr. L. was prescribing Donepezil to her 87-year-old mother. "Do you agree with her decision?" she queried, then added, "We won't use the "A" word will we?" This recent exchange reflects the anxiety and fear that accompanies the communication of a diagnosis of Alzheimer's disease. It presents many complex clinical, legal and ethical problems, which may be challenging to many physicians.

Physicians are generally expected to communicate honestly and directly with their patients on matters of clinical significance. For patients suffering from Alzheimer's and other dementias, such straightforward communication may not always be appropriate. The patient may not be aware of his or her own cognitive changes and family members may balk at the idea of communicating such a devastating diagnosis. The physician may be left with a clinical and ethical conundrum: the desire to communicate honestly with the patient may conflict with the compelling desire to concur with the wishes of the patient's family.

Since I have my pen in hand, I hope that you will indulge me if I make a couple of personal remarks in response to our Editor-in-Chief's kind words about me.

It is true that Barry and I trained together but he is senior to me by a year or two. And, as those of us who have worked with and were trained by him can attest, he is no slouch himself! Physician, teacher, administrator and editor--each role acted out with his usual calm and panache. But perhaps the highest compliment that I can pay the good doctor is to recount a short anecdote. When I was an intern, and Barry a medical resident, I brought my father--who was suffering from chest pain--into the ER of Toronto's Mt. Sinai Hospital, where Barry and I were both in training. As my mother and I waited anxiously in the anteroom for word of his fate, I was scared to death that my dad would die.

To my great relief and good fortune, who should rush past but Dr. Goldlist, who had been called in by the ER staff to have a look at my father. As Dr. Goldlist walked through the ER doors on his way to examine my father, I turned to my mother and said, "Don't worry, Mom, one of the hospital's best doctors is going to be taking care of Dad. We've got nothing to worry about."

And so it was. Almost 30 years later--there Barry, it's out--my father is still hale and hearty.

By coincidence, another important influence on my professional life and career choice is also well represented in this issue. The prolific and dynamic Dr. Michael Gordon, Medical Director of the world-renowned Baycrest Hospital, was a couple of years senior to both Barry and me and, as Barry points out, in his role as chief medical resident at Mt. Sinai, he had a powerful effect on all of us. It would be safe to say that no one had more influence on my decision to enter the field than did Michael, and all of us continue to enjoy his special blend of qualities.

I encourage the readers to read Dr. Gordon's articles and the rest of the informative articles in this special issue of Geriatrics & Aging. Thanks again to the editors for allowing me to blather on and, above all, for the opportunity to contribute to this important issue.

A. Mark Clarfield

Margaret MacAdam, PhD
Senior Vice President and Vice President,
Community Services,
Baycrest Centre for Geriatric Care,
Toronto, ON.

Two of the biggest problems facing patients with cognitive impairment and their families are access to a safe and appropriate physical environment, and access to supportive services throughout the course of the patient's disease. These problems arise because it may become increasingly difficult for the patient to obtain an appropriate level of care in his or her original residence. The options that are currently available to these patients vary widely from province to province but include staying at home, moving to one of the supportive housing projects that are becoming available in many communities, or moving to a long-term care facility. To determine which of these options is most appropriate, one must take into account the needs of the individual patient, his or her prognosis and the resources that are available to the family for maintaining their relative in the community. Because of the progressive nature of many forms of cognitive impairment, housing and care decisions are subject to change during the patient's life span.

The first step in deciding what type of housing is most appropriate is to make an assessment of the individual's needs.

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

The husband looked to his wife when he was asked if he would allow me to refer him to participate in a research trial. He admitted that he had some "memory" problems but was not really aware of the degree of his cognitive decline. His wife said she would consider it and discuss it with her husband and their children. She was distraught about the diagnosis of Alzheimer's disease and the future implications for his function and the requirements for his care. She wanted to know if the trial might help him. I explained the principles of a double-blind randomized drug trial and suggested that she discuss her concerns with the researcher conducting it.

Without research there is no progress in Medicine. Most people support the concepts of, and need for, medical research. Throughout history, some form of medical research has occurred. As an outcome of the horrific experiments done on involuntary subjects during the Nazi regime, and the more contemporary American studies on poor black syphilis victims in the Tuskegee experiment and the Willowbrook hepatitis study, a more rigorous and protective approach to human research has been developed.

Contemporary medical researchers are expected to understand the basic ethical principles that govern clinical research.

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.