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.

Richard W. Shulman, MDCM, FRCPC
Geriatric Psychiatrist, Trillium
Health Centre, Mississauga, Ontario
Member, Division of Geriatric Psychiatry,
University of Toronto, Toronto, Ontario

In elderly patients suffering from schizophrenia, psychosis due to Alzheimer's disease, or other illnesses, first line treatment with a second-generation (atypical) antipsychotic--as compared to a first generation (conventional) antipsychotic--should be considered standard therapy. The advantage of treatment with a second-generation antipsychotic is, at least in part, due to improved neurologic side effect profiles. The Canadian Clinical Practice Guidelines for the Treatment of Schizophrenia state that treatment with clozapine, olanzapine, quetiapine, and risperidone (at lower doses) markedly reduces acute extra-pyramidal side effects (EPSE).¹

Elderly patients treated with relatively low doses of first-generation antipsychotics have been shown to have a 29% cumulative annual incidence of tardive dyskinesia (TD). The incidence of TD in patients treated with atypical antipsychotics is likely to be lower given that EPSE has been found to be a risk factor for TD.²

Olanzapine (Zyprexa‚) is a second-generation antipsychotic that has shown promise as a safe and effective drug for the treatment of elderly patients suffering from either schizophrenia or psychosis secondary to dementia.

Nadège Chéry, PhD
Contributing Author,
Geriatrics & Aging

The human body undergoes important physiological changes as it ages^1,2 and the urinary system is no exception to this trend.³ A major consequence of this decline in urinary function is urinary incontinence, which is defined as the inability to control urination.⁴ Urinary incontinence affects approximately 50% of all nursing home residents and frail, homebound, elderly individuals.³ It may be temporary or permanent, and can result from one of a variety of dysfunctions that occur in the urinary tract.⁴ Urinary incontinence may cause impaired healing of perineal pressure sores and rashes, and may eventually lead to psychosocial effects, including embarrassment, social isolation and depression of the affected elder.³

The pathophysiology & clinical presentation of urinary incontinence
Urinary incontinence results from defects in neurologic or anatomic aspects, and it is these defects that interfere with normal urinary micturition.⁴ Alteration of the normal contraction and emptying of the bladder is one important cause of urinary incontinence. Normally, both the somatic and the autonomic nervous system innervate the bladder. The relaxation and filling of the bladder are both under sympathetic control, which produces an increase in the b-adrenergic tone of the bladder.

Tracey Tremayne-Lloyd
and Lonny J. Rosen
Tremayne-Lloyd Partners
Toronto, Ontario

Introduction
Genuine and personal care, trust and friendship often characterize the relationship between a physician and his or her geriatric patient. In fact, your patient's regard for you may become so strong that a situation arises where you, as an attending physician, may be named as a beneficiary of his or her Will. This may place you in an awkward position, and indeed, if the patient's family complains, may attract College scrutiny. It is not unknown for a family to contest such a bequest on the grounds that the physician exercised undue influence, that the testator was incompetent, or both. The fact that a bequest is challenged, however, does not mean that the gift will be declared invalid.

Undue Influence

Undue influence is more than persuasion; it is tantamount to coercion to the extent that another person overbore the volition of the person making the gift.

Karl Farcnik, BSc, MD, FRCPC
Michelle Perskyo, Psy.D, C.Psych
Psychiatrist,
Division of Geriatric Psychiatry,
University Toronto
Part-time staff,
Toronto Western Hospital

Introduction
In 1912, Frederic H. Lewy first described a disease associated with the formation of lesions, which are now known to be intracytoplasmic inclusions, in the brains of affected individuals. Evidence now suggests that this disease, Lewy body Dementia (DLB), may be the second most common cause of dementia after Alzheimer's disease (AD).¹

In 1980, K. Kosaka described the first clinical case of DLB. However, since a number of different entities associated with Lewy bodies have been described, clinical diagnosis of DLB remains challenging. These entities include diffuse Lewy body disease, cortical Lewy body disease, senile dementia of Lewy type, and a Lewy body variant of Alzheimer's Disease. For this reason, efforts have been made to standardize a single set of criteria to make a diagnosis of DLB. In addition, over the past ten years there has been a concerted effort to better characterize this condition, as well as to focus on aspects of its treatment. This article will review the pathophysiology, diagnostic features, and treatment of DLB.

Dr. Richard Lee, MD, CCFP(EM), FRCPC
Undergraduate Program Director
Emergency Medicine,
University of Alberta

Introduction
Approximately 13% of our population is comprised of persons who are aged 65 years or older. This age group represents the fastest growing segment of our population and it is expected that by the year 2030, it will amount to 20% of the total population. On average, the older person tends to visit the emergency department (ED) more frequently, stays longer, is more likely to be admitted, and also consumes more health care resources than does the younger person. Up to 10% of these elderly patients will present with their chief complaint being abdominal pain. Results from one survey found that 78% of emergency physicians believe that abdominal pain is more difficult to manage in the elderly when compared to a younger age group, and 86% found it more time consuming to treat elderly patients.¹

Fifty to sixty-three percent of elderly patients required admission--versus 10% in the younger age group--and 22.1-42% required surgery--versus 16% in the younger group.^1-3 The ability of the physician to correctly diagnose abdominal pain decreases dramatically as the age of the patient increases. Concurrently, there is a subsequent rise in the morbidity and mortality in this age group.