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.

Chris Chan, MD, FRCPC
Fellow in Nephrology,
University of Toronto

Over the past two decades, the main strategies that have been used to protect patients against the loss of renal function include lowering their blood pressure and restricting the intake of dietary protein. The efficacy of the above treatments has been limited and a novel therapeutic target is required. In the past decade, landmark clinical trials with pharmaceutical agents that inhibit the renin-angiotensin system (RAS) have demonstrated a dramatic attenuation of the decline in renal function that is associated with diabetic and non-diabetic nephropathies. It is now recommended that inhibition of the RAS should be standard care for patients with proteinuric nephropathies.

Theoretical Basis of Renoprotective Benefits of RAS inhibition
Several authors have reviewed this topic in detail and interested readers should review the articles cited in the references.¹ The seminal studies were performed by Brenner et al. using the 5/6 nephrectomy animal model.^2,3 In these rats, extensive renal parenchyma is destroyed, which results in a compensatory increase in single nephron glomerular filtration rate and in the elevation of glomerular capillary hydraulic pressure. Pathologically, the rats developed focal glomerulosclerosis and proteinuria. This proteinuria was prevented, following treatment with enalapril.

Dimitrios G. Oreopoulos
Nada Dimkovic
Toronto Western Hospital,
University Health Network

Introduction
The elderly (>65 years) are the fastest growing group of patients who require dialysis. In 1988, of the more than four thousand new dialysis patients, one thousand nine hundred and fifty eight were 65 years or older, giving an approximate rate of 515 new patients per million members of the population.

Once an elderly patient has developed end-stage renal disease (ESRD), his/her therapeutic options become limited to the various modes of dialysis that are available and, to a lesser degree, to renal transplantation.

Here we should mention a word of caution with regards to using serum creatinine as a guide for the point at which to begin dialysis. Because of the decrease in muscle mass that is associated with age, serum creatinine is disproportionately low for the degree of renal failure. Rather than relying on serum creatinine, either a creatinine clearance, or the Cockroft-Gault formula should be used to assess the severity of renal failure.

Although renal transplantation may be successful in the elderly person with ESRD, and they may have renal graft and patient survival rates comparable to those of younger recipients, only a small percentage (0.5-3%) of these patients are undergoing transplant procedures. The main reason for this is the shortage of donor kidneys.

Medications May be of Limited Use for Treatment of Sexual Aggression in Dementia

Kiran Rabheru, MD, CCFP, FRCP(C)
Active Staff, Geriatrics
Psychiatry, London Psychiatric Hospital, London, ON

Until recently, most studies in dementia have focussed almost exclusively on cognitive dysfunction, rather than on the behavioural and psychological disturbances that occur in dementia (BPSD), which are often far more disturbing to the patient's caregivers. Specifically, there is very little published literature on inappropriate sexual behaviour in dementia (ISBsD). A stereotypic view of older adults as sexless, as well as relative disinterest in studying their patterns of sexual behaviour, have probably contributed to this lack of research into this important area.

From the neurologic viewpoint, the limbic system is the source of libido. Illnesses that damage the limbic system, with few exceptions, reduce the libido. Hence, in up to one third of patients with dementia, the change in sexual behaviour is one of sexual apathy. However, in patients with Alzheimer's dementia, hypersexuality and inappropriate sexual expression can also occur, and has been reported in 2 to 7% of these patients. Changes in the frontal lobe can cause alterations in personality such as disinhibition. Damage to the bilateral temporal lobe as a result of trauma, Herpes simplex, encephalitis, infarctions, and rarely, Alzheimer's or frontal lobe dementia (FLD) (e.g.

Dr. Michael J. Taylor

"Apocalyptic demography", "bankruptcy hypothesis of aging", "population aging crisis scenario"--these are only three of the many catch phrases currently being used to describe the impact that an aging population will have on our limited health care resources as we enter the first decade of the new millennium. Almost daily the news media reports stories of emergency departments filled to capacity, lengthy waiting lists for elective surgery and diagnostic imaging, and nation-wide shortages of long-term care beds. Public opinion polls consistently reveal that concerns about the future of health care are uppermost for many Canadians. Whether and how our national health care system, apparently already faltering, will survive the increase in demand that an aging population will impose is already the subject of intense national debate. Some form of health care reform over the upcoming years seems inevitable, but instituting reforms that will ensure the survival of our universally accessible health care system, the pride of many Canadians since its inception in the 1960s, will no doubt prove to be a great challenge to policy makers. This article will attempt to shed light on the complex issue of just how an aging population will affect our health care system; it will also present various perspectives regarding the directions that health care reform could take.

Special commentaries by:
Pierre Larochelle¹,
Ellen P. Burgess²,
Ernesto L. Schiffrin³,
Simon Kouz⁴, and
Michael Adams⁵

¹Assistant Director, Clinical Research Centre,
Centre Hospitalier de l'Université de Montréal-Campus Hôtel-Dieu,
Professor of Pharmacology,
Université de Montréal, Montreal, Quebec.

²Active Staff & Director, Foothills Medical Centre,
Associate Professor of Medicine,
University of Calgary, Calgary, Alberta.

³Director, Multidisciplinary Hypertension Group,
Hypertension & Lipid Clinic and Clinical Research Institute of Montreal, and
Professor of Medicine, Université de Montréal, Montreal, Quebec.

⁴Chief, Cardiology Service & Director,
Clinical Research Unit in Cardiology,
Centre Hospitalier Régional de Lanaudière, Joliette, Quebec.

⁵Head, Department of Pharmacology and Toxicology,
Queen's University, Kingston, Ontario.

Did the Results of the HOPE Trial Come as a Surprise?
Dr. Ernesto L. Schiffrin. Not at all. Our research group has been conducting numerous studies on ACE inhibitors for a number of years.