Julie Dergal, MSc,
Baycrest Centre for Geriatric Care

Paula A. Rochon, MD, MPH, FRCPC
Baycrest Centre for Geriatric Care,
Assistant Professor of Medicine,
University of Toronto

Introduction
Older people often have multiple health conditions that require drug therapy. In Ontario in 1998, drug expenditure by people aged >65 years of age was estimated at 1.03 billion dollars, accounting for 74% of total drug costs to the Ontario Drug Benefit (ODB) Program. Prescribing drug therapy for older people presents a challenge to many physicians. Inappropriate prescribing such as the excessive and unnecessary use of drug therapy or the under prescribing of proven beneficial therapy, appears to be a common problem. Several factors place older people at risk for serious drug complications including advanced age, frailty, and increased drug use. Long-term care residents are a particularly vulnerable population, as they are primarily, older, frail women, who take an average of eight medications. Drug-related problems, including reaction to medication, are estimated to account for as many as 28% of hospital admissions.¹ With an increase in the aged population, and the associated increasing drug costs, it is imperative that older people receive optimal pharmacotherapy. Reducing drug related morbidity and mortality is, therefore, important both to improve the quality of life of older people, and to reduce health care costs.

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

Introduction and Epidemiology:
Peripheral vascular disease (PVD), a common and often disabling condition, usually results from the atherosclerotic occlusion of the arteries in the lower limbs.¹ Symptomatic PVD is rare in men before the age of 50, but prevalence increases dramatically with age. The Edinburgh Artery Study states that the prevalence of symptomatic PVD increases from 2.2% in men aged 50 to 59, to 7.7% in men aged 70 to 74.^2,3 Before the 7th decade, the prevalence in women is approximately half that seen in men, but this difference diminishes after that age.⁴

Definition and Diagnosis of Intermittent Claudication (IC)
Patients who suffer from intermittent claudication (IC) represent a subset of those patients with symptomatic lower extremity atherosclerotic disease. This review will focus on an approach to the investigation and management of this condition in the elderly population. Only 7-9% of patients with diagnosed lower extremity atherosclerosis suffer from intermittent claudication.5 In 1962, the Rose claudication questionnaire was developed as an epidemiologic instrument for the purposes of identifying patients with IC. It also serves as a good working definition of IC.

Blindness is a Result of Diabetic Macular Edema

Mark Mandelcorn, MD, FRCS(C)
Vitreo-retinal Surgeon
Toronto Western Hospital 

It is astonishing that in the year 2000, nearly 80 years after the discovery of insulin, diabetes became the most common cause of blindness in North America. Everyone who looks after diabetics, therefore, has an important role to play in helping these patients reduce their risk of suffering the microvascular and macrovascular complications arising from diabetes. Recent clinical trials have once again confirmed the link between good blood sugar control and the reduced incidence of complications, such as blindness. Consequently, it is accepted that the first goal of treatment is optimum control not only of blood sugar but of other supervening problems, like hypertension, that may aggravate any existing complication, particularly diabetic retinopathy.

Diabetic retinopathy is said to occur in over 90% of type 1 diabetics (characterized by juvenile onset and insulin-dependence) and in a slightly lower percentage of type 2 diabetics (characterized by late onset and lack of insulin dependence). However, only about 25% of patients with diabetic retinopathy develop visual loss and only about 5% become blind.

Serge Gauthier, MD, FRCPC
McGill Centre for Studies in Aging,
Montreal, Canada 

Alzheimer's disease (AD) is the most common cause of dementia, worldwide. It is well known that the incidence and prevalence of AD increase with age; therefore, because of the increasing longevity of our populations, and the large cohort of baby-boomers coming to maturity, more and more people will be affected by this condition. Fortunately, there are encouraging results from studies on symptomatic therapy and there is reason to hope that we may achieve long term stabilization and preventive treatment. This review will emphasize the important role of the primary care practitioner in the diagnosis and management of AD.

Clinical presentation of Alzheimer's disease
The Global Deterioration Scale describes the progression of AD as seven steps (Table 1), which is useful to describe the natural history of AD. This scale is familiar to most families who are caring for a patient with AD, and the primary care practitioner is often asked to describe the patient's current stage.

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 

Cardiopulmonary resuscitation (CPR) is commonly perceived as a miraculous treatment that averts death. For many, the understanding of CPR comes from television and movies where, inevitably, death is cheated by heroic resuscitation. North Americans especially have, since its discovery more than thirty years ago, been fascinated with CPR.¹ CPR, however, is not always an appropriate or humane medical procedure. For defined segments of the elderly population, especially those requiring long-term institutional care, it may be a last, undignified rite of passage in a world that has become mesmerized by technology. It is for the benefit of this elderly population that we must strive to tailor our resuscitation policies in order to realistically serve their needs, without exposing them to ineffective CPR attempts. The goal of institutional policy should be to define the framework by which we can provide appropriately humane care without denying CPR to those members of older populations who can, within reason, hope to benefit from it.

Daniel Tessier, MD, MSc, FRCPC, CSPQ
Sherbrooke Geriatric University Institute
Associate Professor, Faculty of Medicine
University of Sherbrooke

Introduction
The most recent Health and Nutrition survey in the United States demonstrated that the prevalence of diabetes is approaching 20% in Caucasian patients over the age of 70, and in certain ethnic groups, may be as high as 50%.¹ Currently, the over 65 age group represents about 13 % of the total population, a percentage which is expected, by the year 2020, to increase to approximately 21% of the population. The majority of elderly diabetic patients have type 2 diabetes mellitus (DM), characterized by a gradually increasing glycemia that results from a combination of a resistance, at the cellular level, to the action of insulin, and a gradual decline of insulin secretion by the pancreas. A few years of asymptomatic disease may have elapsed prior to the diagnosis of DM being made, especially in the case of elderly patients. The following article will provide a brief review of the acute complications related to DM in the elderly with a particular focus on the evolution of the disease, side effects of treatment, and the vascular problems and acute infections that are often associated with this health problem.

Sheldon Tobe, MD, FRCPC

Case
The patient is an 80-year-old man, weighing 60 kg. He has a long standing history of hypertension and a more recent history of type 2 diabetes mellitus. He is taking an ACE inhibitor for the treatment of hypertension and microalbuminuria. The patient presents to the local ER suffering from colicky flank pain of 1-day duration. Past medical history includes a remote episode of kidney stones and he says that the pain was similar. He has vomited twice that day and has not taken food or drink since the previous night. He complains that the ER is cold and the nursing notes indicate that he seems peripherally shut down, with hands that are cold and pale. His blood pressure is 110/74 supine and 100/70 standing. His heart rate is 90. A dipstick urinalysis reveals blood and trace protein. Microscopy of the urine reveals hemegranular casts. An IVP is arranged after a KUB suggests the presence of a kidney stone. Ketoprofen, a non-steroidal anti-inflammatory (NSAID) is administered for pain relief. The IVP is non-diagnostic and the patient is admitted for further investigation. The following morning, an urgent call from the lab tells you that the patient's potassium is 6.8 mmol/L, his bicarbonate 14, his urea 15 and his creatinine 200 µmol/L. His ER lab results showed that the urea was 10 mmol/L and the creatinine 120 µmol/L the night before. You are coming on service and find yourself responsible for his care.

Karen Yeates MD,
Vanita Jassal MB, MSc, MD (UK)

It is well known that, with increasing age, physiologic and anatomic changes occur in the human kidney. However, in the geriatric patient it is not always easy to distinguish "normal" age associated changes from abnormalities in renal function. It is important for clinicians to recognize reduced renal function in their patient because of important implications for both its management and treatment. This review aims to answer three questions:

1. What is considered normal versus abnormal in the aged kidney?
2. How can we predict which patients are at risk of decline?
3. Who should be referred for further work up?

Anatomically, many age-related changes are believed to occur simultaneously in the kidney. Most striking is the reduction in the size of the kidney and in the number of nephrons. This decrease is reflected in the decrease in kidney size from roughly 250g at age 60, to 190g at age 80.^1,2 Age-related changes in the renal vasculature are responsible for most of the decrease in nephron mass. These changes occur independently of hypertension, and include sclerosis in the walls of larger renal vessels and further increases in the presence of hypertension.³

Functionally, there is a reduction in renal plasma flow of approximately 10% per decade, from 600ml/min in young adults, to 300ml/min by age 80 years.

Tooth Loss has Profound Effects on the Wellbeing of Elderly Individuals

Dr. David W. Matear
Associate Professor
Director of Clinics
Faculty of Dentistry
University of Toronto

Fayaaz Jaffer
Faculty of Dentistry
University of Toronto

David Lam
Faculty of Dentistry
University of Toronto

Introduction
Teeth are supported by the surrounding peridontium, which is composed of both soft (periodontal ligament and lamina propria) and hard connective tissue (cementum and bone).

It is the periodontium that provides attachment of the teeth to the jaw and, when the periodontal tissues become diseased, the resultant lack of support results in tooth loss. Age is a definite factor in such loss, although other obvious causes are decay and physical trauma.

The loss of teeth decreases the preservation of an individual's dentition and also detracts considerably from a socially acceptable appearance. In such cases, the replacement of missing teeth is accomplished by the fabrication of either a complete or partial denture, or both. Regrettably, dental care in the elderly population is often neglected. This may be due to other physical handicaps, which may restrict the patient's ability to travel or in situations where the patients are confined to their homes.

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

Introduction
Proteinuria, defined as the presence of urinary protein in concentrations greater than 0.3 g/d on a 24-hour collection, or greater than 1+ protein on a dipstick, is a common finding, which occurs in approximately 10% of elderly patients.¹ Although proteinuria has been regarded as "the first sign of serious renal disease",² its presence can represent anything from a benign abnormality to the signpost of significant disease,¹ with the potential for progressive renal insufficiency.³ Because of the variable significance and multiple causes of proteinuria, the clinician requires a systematic approach for the work-up of this condition in the older patient. This paper will review the renal physiology associated with proteinuria, the classification of proteinuria, and an approach to the diagnosis of proteinuria in the older patient.

Renal Physiology
Approximately 15 kilograms of protein passes through the adult kidney in a single day.³ However, in a healthy adult, only up to 150 mg of protein should be excreted per day, for protein excretion levels to be considered normal.