Anna Liachenko, BSc, MSc
Managing Editor,
Geriatrics & Aging

Due to a favourable side effect profile and high efficacy when compared with typical antipsychotics, atypical drugs are becoming increasingly recommended as first-line treatments for agitation and psychosis related to schizophrenia, manic depression, and behavioural disturbances associated with dementia. At the recent XXII International Congress of Neuro- psychopharmacology (CINP) in Brussels, a new study evaluating an intramuscular (IM) form of Olanzapine (Zyprexa) was presented. An IM form of antipsychotics can be crucial for the rapid control of a patient's psychotic symptoms in an emergency setting. This is the first time that an atypical antipsychotic is available in IM form. The study has just been completed and will be published shortly. Dr. Karena Meehan, M.D., clinical research physician for Eli Lilly and Company and the lead physician for the IM project with responsibility for the Canadian and American groups, agreed to answer a few questions about recent studies on Olanzapine and the use of this drug in the elderly.

Q: Your group has recently presented data comparing the effect of a new IM-formulation of the antipsychotic olanzapine with IM-haloperidol. What were the objectives and the results of your study?

A: The study was designed to compare olanzapine with an older typical antipsychotic.

Anna Liachenko, BSc, MSc
Managing Editor,
Geriatrics & Aging

The relationship between aging and cancer has its basis in cell cycle alterations. While multiple factors affect cell cycle progression, recent research has directed a great deal of attention to telomere length as a key factor affecting mammalian cell proliferation. This article discusses recent findings with respect to the role of telomeres and telomerase in cancer, cellular aging, and longevity.

Telomeres are short DNA repeats located at the ends of eukaryotic chromosomes. Telomeres cap chromosomal ends preventing the loss of important genes during cell division. With every cell division, the length of telomeres decreases unless it is corrected by telomerase, a ribonucleoprotein enzyme that extends the telomeres by adding hexameric nucleotide repeats to the ends of chromosomes. In humans, telomeres are short, and telomerase activity is low in many somatic tissues but is present in germ cells, activated leukocytes, and stem cells from a variety of organs. The study of telomeres has been hampered by the fact that classical animal models, such as mice, have highly active telomerase. This results in long telomeres that do not shorten enough during the animal lifespan to play a significant role in cellular aging. Recently, a genetically altered telomerase-deficient mouse model has been created by a group of researchers at Harvard.

Choice of Treatment is not Limited by Age but is Case-Specific

Robert M Schertzer, MD, FRCSC
Glaucoma & Anterior Segment Surgery
Multimedia Technology
Medical Director Visual Field and Optic Nerve Head Imaging Units
VHHSC/UBC Eye Care Centre

When pharmaceutical treatment of glaucoma proves ineffective, several surgical options remain available. In fact, some types of glaucoma may be best handled with immediate surgical intervention, even without prior medical management. Ocular surgery is any procedure that causes an alteration in the structure of the eye and can be laser (using a light) or incisional (using microsurgical blades). The type of surgical intervention indicated will depend on the mechanism of the glaucoma.

Laser surgery
There are three types of laser surgery used in treating glaucoma: trabeculoplasty, iridotomy, and cycloablation.

Trabeculoplasty, usually performed with an Argon green laser, is the application of laser energy next to the drainage channels (trabecular meshwork) around the circumference of the iris inside the eye (the coloured part of the eye.) This is used only for open-angle types of glaucoma, especially chronic ("primary") open angle glaucoma, pseudoexfoliation glaucoma, or pigmentary glaucoma.

Reviewing the Major Classes of Antiglaucoma Medication

Catherine M. Birt, MA, MD, FRCSC
Sunnybrook & Women's College
Health Science Centre,
Assistant Professor,
University of Toronto

Medical management of glaucoma is a field that has expanded dramatically over the past five or six years. Since aging is one of the major risk factors for the development of glaucoma, it is an area that is of great relevance to anyone managing geriatric patients. The purpose of this article is to review the five major classes of antiglaucoma medications, the drugs that are currently available in each class, their indications and their side effects.

Glaucoma is considered to be an optic neuropathy with characteristic optic nerve damage (with loss of the neuroretinal rim and an increased cup-to-disc ratio) and visual field changes (with arcuate field defects progressing to complete loss of peripheral vision). Intraocular pressure (IOP) is not part of the definition of the disease, as many people with statistically elevated IOP do not develop the neuropathy, and many patients with statistically normal IOP do. Intraocular pressure is considered a major risk factor for the development of glaucoma. Other risk factors include advanced age, race, positive family history, myopia, and systemic factors such as diabetes and hypertension. Glaucoma is generally divided into open versus closed angle, and each of these can be subdivided into primary and secondary subtypes.

Kathleen Jaques Bennett, BSc, BSc, MSc

In Ontario, 71% of the individuals with poor vision are over 65 years of age. To make matters worse, these seniors often suffer from additional sensory deprivation in the form of hearing loss.¹ Sensory deprivation can be defined as the partial or complete loss of any of the five senses. It can lead to embarrassment, social isolation, depression, or the labelling of the patient as demented or infantile by family and caregivers. Vision and hearing loss are strongly correlated to an increased risk of mortality over a five-year period,² probably because the psychosocial effects take an enormous toll on the afflicted individual. The partial or complete loss of the senses can lead to diminished quality of life, and may predispose an elderly person toward other conditions.

Types of Sensory Deprivation
Sensory deprivation can involve the loss of only one sense, or the combined loss of several senses. The loss of visual acuity associated with age often begins with the development of presbyopia. Presbycusis, the loss of hearing, is more prevalent among men than women.7 As well, touch, taste and smell become less acute with time. All of these forms of sensory deprivation undermine an elderly person's ability to live independently, increasing dependence on caregivers, and can result in the infantilization of the elderly individual. When sensory loss is coupled with another condition such as diabetes, the handicap becomes even more severe.

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

Introduction
Of all the symptoms associated with illnesses that commonly affect geriatric patients, the most difficult to manage--for the patient and his or her physician--are those that affect the patient's mental faculties. Physicians attempting to treat geriatric patients who suffer the onset of mental illness, must deal with such issues as the patients' capacity to consent to treatment and their ability to participate in the management of their symptoms, including the regular taking of prescribed medication. While physicians always had tools embedded in provincial mental health legislation to assist them in the care of their mentally ill patients, these tools offered practically no alternative to committing patients to a psychiatric facility, something physicians have been loath to do.

After years of confusion within the mental health system, provincial governments in Mani-toba, Saskatchewan, British Columbia and now Ontario, have passed amendments to their mental health legislation which could lead to better care for people with serious mental disorders, including the elderly.

One of the main purposes of mental health legislation is to allow a medical practitioner to admit, or recommend for admission, to a psychiatric hospital for the purpose of an assessment, persons viewed by the practitioner as constituting a danger to themselves or others.

Hearing Loss in the Elderly Often Coincides with CAPD, Making Diagnosis More of a Challenge

Shechar Dworski, MSc

Hearing is an important part of our sensory system; it enables us to interact with our environment and to communicate verbally with others. Twenty percent of those over the age of 65, and 40% of those over the age of 75, have significant hearing loss, and at least 80% of nursing home residents have some degree of hearing loss.¹ There are two types of hearing impairment: peripheral and central. Peripheral damage to the ears can be caused by anything from the build up of cerumen to a perforated eardrum (for a description of peripheral hearing loss, see the articles on Hearing Loss and on Biology of the Aging Ear). Central processing impairment involves the dysfunction of certain areas of the brain's higher auditory centres that are responsible for hearing, language and comprehension. Causes of hearing loss include tumours, ototoxi-city from certain drugs, noise exposure and injury to the cochlear nerve and brain, as well as age-related degeneration of the ear and the associated neural pathways.

Impairments to the hearing process which occur in the brain are called central auditory processing disorders (CAPDs). With CAPDs, hearing impairment seems apparent even in the absence of any peripheral causes of hearing loss. CAPD can be defined as an impaired ability to recognize, discriminate, and/or comprehend auditory information.

Hearing Aid Devices are Tiny Yet Offer Greater Sound Amplification & Less Distortion

Cory Soal, RHAD
Registered Hearing Aid Dispenser

Hearing loss is as individual as a fingerprint. Generally, its progression is so slow that it remains undetected until it has become a real concern. Like any other medical problem, early detection of hearing impairment is important. A proper and thorough hearing test is crucial not only for purposes of diagnosis--it is key to determining what type of hearing aid technology will be the most suitable for a patient.

With the advent of micro-technology, hearing aids have become greatly improved. It is now possible to place more circuitry in a smaller package. Hearing aids can be fitted far into the ear canal and have internal controls that automatically adjust in extreme noise conditions.

First and foremost, a successful fitting of a hearing aid is dependent upon a complete hearing evaluation. A proper hearing test consists of the following components: Pure Tone Air and Bone Conduction tests, Speech Reception Threshold tests, and Speech Discrimination testing. The more accurately hearing is evaluated, the more suitable is the prescription for a hearing aid. There are two important concerns when selecting a hearing instrument. Firstly, the patient must be comfortable with the size of the hearing aid chosen: a patient can be fitted with a Behind-The-Ear (BTE), In-The-Ear (ITE), or the smallest hearing aid that fits Completely-In-The-Canal (CIC).

Kimby N. Barton, MSc
Assistant Editor,
Geriatrics & Aging

With recent advances in medical interventions for the treatment of cardiovascular diseases, including the introduction of ACE inhibitors and the use of b-blockers for left ventricular dysfunction, the role of coronary revascularization in managing elderly cardiovascular patients has become more difficult to define. Unfortunately, the bulk of research in this area has either failed to compare treatments directly, or has excluded patients who are 65 years or older. Research in this field has also focussed on long-term benefits of surgery over medical treatment, which may not be as germane to an elderly patient as symptomatic improvements, given that this patient's life expectancy may be considerably shorter than that of someone younger. In addition, with the increased frailty that accompanies old age, perioperative mortality and postoperative complications are a much greater concern for elderly patients. They are at an increased risk for stroke, acute renal failure, and other major complications. All of these factors suggest that caution should be exercised when extrapolating data from younger patients and applying it to older ones.

Common Presentations, Diagnostic Strategies, and Principles of Treatment

Michael A. Gardam MSc, MD, CM, FRCPC
Medical Director,
Tuberculosis Clinic,
Associate Hospital Epidemiologist,
University Health Network,Toronto.

The elderly are one of four sub populations in Canada, which also include the foreign born, homeless persons, and Native Canadians, that are at high risk for developing active tuberculosis. There are several reasons why tuberculosis is common among the elderly: Firstly, today's elderly have a high possibility of being infected with M. tuberculosis. They are survivors of the earlier part of the twentieth century in which an estimated three-quarters or more of the population were infected with tuberculosis by the time they were 30 years of age. Secondly, the elderly often suffer from other conditions which predispose them to reactivation of tuberculosis, such as diabetes mellitus, chronic renal failure, malnutrition, and diseases requiring prolonged corticosteroid therapy. Finally, residents of nursing homes and long-term care facilities may become infected or reinfected through contact with other residents with active disease.

Symptoms
While the clinical symptoms of tuberculosis may be vague and non-specific in any age group, this is particularly true in elderly persons. Fever, malaise, weakness, and failure to thrive are the most consistent symptoms.