Hearing Loss Traced to Age-related Changes in Cochlear Function and Central Auditory Processing

Nadège Chéry, PhD

In a society that extols the virtues of youth, hearing impairment in the elderly is often perceived as a graceless symbol of old age. Unfortunately, because of this attitude, most seniors would rather deny that, upon reaching their aged ears, even the most vibrant sounds fail to be heard. Hearing impairment affects over 50% of Canadians aged 60 years and over.¹ The incidence of hearing loss increases considerably with age, reaching 81% among persons 80 years of age or over.¹ Importantly, hearing impairment can have devastating consequences on the social life of an older person, and may profoundly alter their emotional wellbeing.^1,3,7 Although common among older adults, auditory processing defects are not an inevitable side effect of aging.^5,9 In fact, in most cases, hearing problems can be resolved,³ and yet, many older persons afflicted with hearing loss are unaware of this or simply choose not to deal with the problem.

Normal hearing is a complex mechanism that involves the transfer and subsequent conversion of sound into electrical impulses to be processed by the brain.

Target for a New Generation of Therapeutic Agents

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

The small southern Italian village of Nicastro, once again made it into International headlines when researchers at the University of Toronto discovered a new protein, nicastrin, which is involved in Alzheimer's disease (AD). Nicastrin was so named to honour a large family in Nicastro that has been plagued with AD for generations and played a key role in the 1995 discovery of two genes that cause early onset Alzheimer's. The same team, led by Peter St. George Hyslop, has found that nicastrin is a functional component of the g-secretase, which is involved in the formation of toxic plaques found in the brains of AD patients. More importantly, they have found an exposed and highly conserved domain of this protein that affects production of the amyloid-b (Ab) peptide and may serve as a potential target for pharmaceutical modulation of Ab production in patients with AD and other related disorders.

Much of the research into AD has been focused on the mechanism underlying the formation of the (Ab) peptide, which is a key component of the toxic amyloid plaques that are characteristic of brain tissue from patients with AD. In 1995, it was discovered that a mutation in a previously unknown protein could lead to an early-onset form of familial AD. This protein was subsequently discovered to be presenilin, a highly conserved, polytopic membrane protein. However, several studies have demonstrated that although mutations in presenilin may result in overproduction of the toxic Ab derivative, it is unlikely that the protein acts alone.

The Ab peptide is generated from a large precursor protein, the amyloid precursor protein (APP) in a two-step proteolytic pathway. Initially, the protein is cleaved near the cell surface in an extracellular domain either by a b- or a a-secretase to generate C-terminal stubs of the protein. These stubs are then further cleaved in their transmembrane domains by the presenilin-linked g-secretase to generate two different isoforms of the Ab peptide, one that is benign and one that is neurotoxic. The b-secretase enzyme appears to have a benign role; during development it may cleave a protein called Notch, which releases a fragment that activates gene transcription. Unfortunately it has been difficult to determine which proteins are directly responsible for the g-secretase activity, although evidence suggests that the presenilins are involved.

St. George-Hyslop's tream found that nicastrin binds to presenilins 1 and 2 and interacts with the APP carboxy terminal 'stub', the fragment that is produced by the initial, b-secretase cleavage. Mutations in an exposed and conserved domain of nicastrin, increase the production of both forms of the Ab peptide and deletions inhibit their production. The team also found that nicastrin is required for processing of the protein Notch, which is involved in gene activation.

So, nicastrin is structurally part of the g-secretase complex, but how does it interact with the other proteins? The team has suggested that nicastrin may bind to the APP stub and align it in the correct way to presenilin, so that it is cleaved at the right position. Another possibility is that nicastrin regulates the cleavage activity, in which case, compounds that interact with either nicastrin or the presenilins should effectively alter g-secretase and APP turnover; hence a site for pharmaceutical intervention.

Whether or not genetic variants in nicastrin are associated with inherited susceptibility to AD remains to be determined. Research in this field will be ongoing, but in the meantime pharmaceutical companies will no doubt devote a great deal of attention to this little 'Italian' protein.

Fayaaz Jaffer
Faculty of Dentistry,
University of Toronto.

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

Introduction
The oral health status of older adults is generally poorer than that of the rest of the population. In particular, those residing in institutions have very poor oral health.^1,2 The prevalence of systemic infection among the elderly is becoming an increasingly important health care issue, especially since age-related demographics show an increase in the numbers of aging and elderly individuals.

One of the primary portals of entry into the body for infectious agents is the oral cavity, which is home to over 500 bacterial species alone.³ Although most oral microbes are non-pathogenic, decreased host resistance and/or environmental factors, such as institutionalization, can increase the risk of systemic infection among the elderly. Furthermore, once a focal infection has been established, it can open the way to colonization by more virulent organisms. Some of the systemic diseases reported to result from oral infections include pneumonia, meningitis, osteomyelitis, bacterial endocarditis, as well as abcesses of the brain, lung, and liver. This article will provide examples of the impact of oral diseases on general health in the elderly.

Among Seniors there is a High Prevalence of Hearing Loss but Low Incidence of Disclosure

Nadia Sandor, MSc
Audiologist, Mt. Sinai Hospital

Elderly listeners often have difficulties with their hearing in typical, everyday situations. For example, they may fail to hear faint sounds, especially in an area with a great deal of background noise. They may also have difficulty ascertaining the direction from which a sound is coming--for instance, determining whether the telephone is ringing in the kitchen or whether the ringing is coming from a television program.¹ Finally, they may have trouble distinguishing between or understanding persons talking in a restaurant or at the dinner table. Moreover, these difficulties with hearing become more apparent and more debilitating when the listening environment is more complex (such as at a large noisy gathering in a highly reverberant room).¹

Hearing loss starts as early as the third or fourth decade of life, and it is well known that both its incidence and prevalence increase with advancing age.² Auditory deficits, which differ from hearing loss in that they encompass hearing threshold changes and changes in temporal and spectral resolution, also increase markedly with age, beginning in the fourth decade. Hearing loss has been identified as the most prevalent chronic disability among older adults, exceeded only by arthritis and hypertension.

Rachel L. Panton¹,
Catharine Ramsey, Brenda L. Gallie^1,2,3
1Department of Ophthalmology,
²The Hospital for Sick Children; Cancer Informatics, Ontario Cancer Institute/Princess Margaret Hospital, University Health Network;
³Departments of Ophthalmology and Molecular and Medical Genetics, University of Toronto.

Only as a grandmother, did Catharine Ramsey learn what had caused the loss of her eye in infancy, information that was to change the life of her entire family.

"I was born on January 19, 1939, adopted as an infant and raised in Kirkland Lake, Ontario. On September 26, 1940 my left eye was removed due to 'eye problems'. Throughout my life, I was told 'you were sick when you were a baby and had to have your eye out!'

I often asked my ophthalmologist why this had happened to me, but I did not receive any clear answers. When my daughter Margaret married, I asked again if there was any information I needed to pass along to my children. I was told that there wasn't any.

My beautiful granddaughter, Jennifer, was born November 6, 1988. She was perfect, or so we thought. My daughter repeatedly questioned the baby's doctor about why Jennifer's eyes were not tracking together. This appearance was barely noticeable and the doctor assured her that 'the baby was only trying to look at the bridge of her nose and would grow out of it.

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

Macular degeneration (MD) is the leading cause of legal blindness in the Western world, the leading cause of poor eyesight in Canada, and has been described as one of the great 'epidemics' of the twentieth century. The Canadian National Institute for the blind registers almost 50,000 people as legally blind as a result of MD. This month, Geriatrics & Aging is very pleased to present an article by Dr. Mark Mandelcorn, a leading vitreo-retinal surgeon, on the various treatment options that are available for patients suffering from MD.

Macular degeneration is the most likely diagnosis when an elderly patient has poor reading vision that cannot be corrected with either glasses or cataract surgery. Not all cases presenting in this way, however, constitute true macular degeneration, currently referred to as age-related macular degeneration (AMD). Some may, in fact, be cases of macular hole; others could be premacular fibrosis; finally, a case resembling macular degeneration may actually be related to a systemic disorder, such as, diabetic macular edema.

It is important to be certain that the disorder is true age-related macular degeneration. In the case of AMD, the prognosis and management of the affected eye are entirely different and perhaps more difficult, and the fate of the other eye more uncertain, than would be the case with any of the other disorders mentioned above.

Physiological Aging Occurs throughout the Eye and can bring about the Loss of Vision

Cindy M.L. Hutnik, MD, PhD, FRCSC
Department of Ophthalmology,
University of Western Ontario
Active Staff, St. Joseph's Health Centre, London, ON

Introduction
In 1942, Sir W. Stewart Duke-Elder published his classic ophthalmic text series.¹ The first paragraph eloquently describes his thoughts on the genesis of vision and the evolution of the eye "from remote and lowly origins, far removed in form and in function from the highly specialized mechanism we find in man; indeed, it is no easy matter to decide where its origin lay or when the sense of vision first became a factor in conscious behaviour." He begins by stating that "either in fact or in fiction there are few stories more fascinating than the history of the evolution of the visual apparatus from primitive undifferential protoplasm into a system of the highest delicacy and intricacy of structure." Recognizing the complexity of the human eye, the following is a summary of how this intricate structure withstands the physiological stresses of a normal human life span.

The eye is not exempt from the relentless process of aging. Structurally, changes can be observed in all parts of the eye, both macroscopically and microscopically. The key is to recognize when these structural changes begin to threaten function.

Bioinformatics--Role in Future of Science and Medicine in Canada

Dr. Jamie Cuticchia is the Head of the Bioinformatics program at the Hospital for Sick Children in Toronto. Since 1997, Dr. Cuticchia has actively and successfully developed this program, which is designed to turn trillions of pieces of biological information into usable knowledge. In the June issue of Geriatrics & Aging, Dr. Cuticchia shared his thoughts on the Human Genome Project and Canada's role in this project. This month he has shared his thoughts on the field of bioinformatics and its role in the future of science and medicine in Canada.

Q: What is meant by the term 'bioinformatics'?

A: Bioinformatics is the joining together of hardware, software, and communications devices with the objective of solving a biological question.

Q: What are the origins of bioinformatics and what have been some of the critical milestones in the development of this field?

A: The origins of the field are rooted in the human genome project. Most of the funding for bioinformatics has been attained for purposes of collecting, disseminating, assembling, and analyzing human genomic data (and those of model organisms). There have been several milestones to date. These include: The creation of large databases, such as GenBank and the Genome Database (GDB); the production of rapid-comparison tools, such as BLAST, which is used to determine sequence homology; the current milestone is that phase of bioinformatics which looks to co-ordinate data from hundreds of widely distributed biological databases.

Q: Do you see biology and medicine becoming increasingly driven by computation?

A: The position of biology today is similar to where physics stood over a decade ago. The field of physics underwent a shift, splitting research into two directions. There were the large centres that acted as the providers of massive amounts of data (the light sources) and the smaller research groups who pooled information from them and worked on analysis and theories. In the field of biology, the independent, small research lab with a technician, a post-doc, and a student, will no longer be competitive research-wise. There will have to be either larger groups, such as the genome centres in the US, with hundreds of researchers, or, alternatively, smaller groups that will rely on the Internet data and software tools to make new discoveries.

Q: How did the Supercomputing Centre for Bioinformatics come to be established here in Toronto? What has your role in all of this been?

A: Luck. I came to Toronto in August, 1997 to form a small group whose mandate was to set up an infrastructure enabling the hospital researchers to handle more effectively scientific data and to use bioinformatic tools. Canada was very far behind the US in acknowledging the importance of this field, and after a few attempts at fund-raising it became clear that bioinformatics programs couldn't be funded through any traditional granting programs in Canada. However, the philanthropists of the hospital's foundation, and members of the information technology industry, had enough vision to see the important role bioinformatics would play in the future of research. With the first endowments coming in from companies like SGI, IBM, and Oracle we were off to the races. Eventually infrastructure monies from the Federal and Provincial governments of Canada were awarded and I went from $200,000 of funding to $50,000,000 in about 2 years.

Q: Did the prominence of the role of Canada and Toronto (and in particular, that of The Hospital for Sick Children) in genetic research play a part in the establishment of the Centre? How significant is this genetic work in the international context?

A: HSC has been recognized worldwide as a place for discovery of genetic information. Given its level of funding, it is probably the most efficiently run genetic group in the world. However, with groups in the US and Europe getting $10 or even $20 for every $1 the Canadian genomics group receives, it is only a matter of time before its reputation drops unless significant Canadian funding is provided.

Q: What is the capacity of the Supercomputer facility? Why is bioinformatics so computationally intensive?

A: We have a 128 cpu Origin 2800 supercomputer and an IBM-SP3 supercomputer. The combined performance of these systems is about the same as having 3000 desktop PCs working in unison. An example: We recently performed a clustering of DNA sequences (1.5 million) and it took over 5 days using the entire supercomputer. If we tried to do this on a PC the program would still be running long after the genome project was completed!

Q: How much information is being generated by the Human Genome Project? Are the means of organizing this data sufficient to meet the demands and the complexity of the task?

A: Right now, very little "information" is being generated; however, it is generating a great deal of data. We generated over 1 billion bases of DNA in one year and, in the end, we will have over 3 billion in total. The organization of this data is not particularly complex when compared to the analysis of this data, which will be going on for the next 5-15 years.

Q: The Supercomputer Centre was established to house the GDB. What function does the GDB serve in the overall Genome project?

A: There has always been some confusion about GDB. GenBank is a database of raw sequences of all sequenced organisms and is merely a listing of the nucleotide bases. GDB is the repository for biological knowledge and maps about the human genome. Using the GDB, researchers can see what probes are available for a gene or region of the genome, what mutations exists, and what polymorphisms have been studied. Best of all, unlike MOST biological databases, GDB is curated by a group of nearly 100 leading researchers in the genome field. Our data are high quality.

Q: What database source is of greatest value to physicians and clinicians?

A: That would probably be OMIM, the online version of Victor McKusick's Mendelian Inheritance in Man. It is a free text version of the catalogue, which has been a staple for medical geneticists for decades. GDB provides links to OMIM where appropriate.

Q: What role do you see Canada playing in Genomics and bioinformatics ten years down the road?

A: I fear that Canada will take its investments in these areas and, because of the enforced socialism within research, dilute them so much that we will have a greater number of 2nd class scientists. The body of research will be bigger, but will not necessarily improve. Unless the funding agencies, or the venture capitalists, see that the "big science" requires significant investment, we will continue to plod along. However, if investments are made in select groups with significant intellectual capital, I have no doubt Canada could be a worldwide leader in both of these fields.

Chris Overgaard, MD, MSc

Introduction
Pressure ulcers are common in elderly patients who suffer from an acute illness causing immobility, and for those patients with chronic disabilities who are confined to a bed at home, or in a chronic care facility.¹ The development of these ulcers represents a major medical problem that can, by itself, necessitate admission to hospital, or significantly prolong the length of stay in a hospital in patients who were admitted with other illnesses. In this brief review, the scope of the medical problem associated with pressure ulcers is examined, etiology and risk factors are discussed, and preventative measures and treatment options, based on recently published consensus guidelines, are summarized.

Psychotherapy: An Introduction for a Family Physician

Betty Hum, BSc

As the Canadian population ages, depression, dementia and other mental conditions such as anxiety, alcohol abuse, bereavement, and suicide will become increasingly prevalent.¹ Traditionally, it was thought that the elderly were unsuitable candidates for psychotherapy due to the belief that they have an impaired ability for abstraction and new learning.¹ Geriatric psychotherapy has gained more attention over the years because medical comorbidities in the elderly can complicate the use of pharmacotherapy.² Moreover, psychotherapy has the added benefit of providing the elderly with skills to cope with late-life stressors, such as newly acquired disabilities or the loss of a loved one.²

Dr. Michel Silberfeld, a geriatric psychiatrist at the Baycrest Centre for Geriatric Care in Toronto, who has practiced psychoanalysis since 1982, believes that psychotherapy can be very effective in the elderly. However, he suggests that an important factor in its success is the alliance between the patient and the therapist, as some personal matters of deep importance can only be dealt with in the context of a strong attachment, fostered by frequent visits.

Studies in geriatric patients have found most psychotherapeutic modalities to be effective, not only in reducing psychopathology, but also in reducing physical needs, pain, disability, and in improving compliance with medical and psychiatric regimens.² On average, 63% of patients achieve successful outcomes with systematic psychotherapy compared to 38% of those receiving no treatment or placebo.³

OHIP covers the costs of the psychotherapy sessions, which can be provided by a psychiatrist or a trained primary care physician. Some psychologists also practice psychotherapy and their services may also be covered by other insurance benefits. Most elderly patients with psychiatric problems, however, prefer to be treated by primary care physicians.^4,5 Therefore, it is important that these health care professionals become more familiar with psychotherapeutic techniques, and know when it is appropriate to refer a patient to a psychotherapist. There are, unfortunately, very few guidelines available to help a therapist decide which technique, out of several possibilities, would be of most use on a particular patient. This article will review the current indications for the use of psychotherapeutic interventions in the elderly.

What is psychotherapy?
Psychotherapy is the treatment of abnormal behavior or a mental disorder by psychological means, usually, but not exclusively, through patient interaction with a trained therapist. A psychotherapist has expertise in interpreting the past and in supporting the patient through current difficulties, with the goal of improving the patient's sense of well-being, personal and social functioning, and personality integration.⁶

Indications for Psychotherapy in the Elderly
There are more than 250 different forms of psychotherapy, but we will focus only on those that have been most influential and are supported by research.

Individual Therapies: Standardized
Standardized therapies are focused and time-limited types of psychotherapy that are based on treatment manuals that have been developed with the goal of reducing psychopathology and improving quality of life.² A meta-analysis of 17 studies, comparing the use of a variety of brief standardized therapies, including cognitive, behavioral, supportive, interpersonal and reminiscence interventions in geriatric depression, showed that all were more efficacious than no treatment.⁷ Brief introductions to these therapies as well as their primary documented indications in the elderly are provided below.

Behavioral psychotherapy
Behavioral psychotherapy was developed from the learning theory which states that human behaviour is acquired through processes of association, reinforcement and observation.⁶ This type of therapy involves the use of these very same processes to help the patient unlearn maladaptive behaviour and to maintain or learn more favourable responses.⁶ Behavioral psychotherapy encompasses many types of therapies including systematic desensitization (flooding), aversive therapies involving punishment schedules, relaxation training, anxiety management, social skills training and token economies (systematic sets of contingencies like "star charts" that involve earning objects or symbols, as a result of certain behaviours, that are then exchanged for meaningful positive responses).⁶ Unlike psychodynamic psychotherapy, behaviour therapy is more effective in elderly patients with advanced dementia because patients do not have to verbally articulate or be motivated for change.² However, there has to be a consistent approach to a particular behaviour, which can be difficult with several health care providers being involved in a patient's care. Research has substantiated its usefulness in managing behavioral disorders in patients with dementia, like Alzheimer's, particularly in outpatient and residential care settings such as nursing homes.^8,9 Psychosocial interventions targeting caregivers of the patient with dementia not only reduces the burden on the caregiver, but also influences the quality of life of both the patient and caregivers.¹⁰

Cognitive-behavioral therapy (CBT)
Cognitive behavioral therapy is based on the theory that irrational beliefs and distorted attitudes toward the self, the environment and one's future lead to depression.⁸ This type of therapy allows an individual to identify his/her distorted and dysfunctional beliefs and thoughts, and to learn how these thoughts bring about negative feelings and behaviours.^6,8 Its superior ability to reduce symptoms of depression in elderly patients, as compared with drug therapy and placebo, has been demonstrated in several studies.^11-14 Research also suggests that CBT is beneficial in the treatment of elderly patients with depression and dementia.¹⁵ A recent meta-analysis of four randomized trials has also shown that CBT is just as effective as antidepressant medication in treating severely depressed patients (those who scored >20 on the Hamilton depression scale or > 30 on the Beck Depression Inventory scale).¹⁶ Although these studies were not conducted exclusively on the elderly (the age of the patient population ranged from 18-65 years¹⁶), CBT has also been shown to be effective in the treatment of other disorders, including anxiety disorders,^15,17 and insomnia.¹⁸ Prolonged CBT in patients ranging in age from 18-60 years, with acute stress disorder, can also prevent post-traumatic stress disorder if given early.¹⁹ With advanced dementia in the elderly, behavioural therapy becomes more useful than the cognitive behavioural model.⁶

Interpersonal psychotherapy (IPT)
Interpersonal psychotherapy was developed to deal with depression and was based on the belief that problems that people have in relating to others, causes, contributes to, or worsens depression.²¹ This form of therapy is focused on grief, role disputes, role transitions and interpersonal deficits, which are common problem areas for the elderly. Controlled treatment trials have suggested that IPT either alone or in combination with medication are as effective as pharmacotherapy, and both treatments have been shown to be more effective than placebo in acute, maintenance, and continuous treatment of late-life major depression.^21-23 However, more controlled trials are still required to demonstrate the superiority of combination therapy. Studies have also demonstrated its effectiveness in managing recurrent depression in the geriatric population.²⁴

Problem-solving therapy
Problem-solving therapy enables the elderly patient to cope with current and future difficulties, in order to reduce the possibility of developing psychopathology. This is done by improving their social problem-solving skills.²⁵ It has been found to work better than reminiscence therapy in depressed geriatric patients, and is especially helpful in individuals undergoing palliative care for terminal illnesses.^26-28

Non-standardized therapies
Non-standardized therapies, like psychodynamic psychotherapy, reminiscence therapy and group therapy, are not based on treatment manuals, as by contrast with the standardized modalities.

Psychodynamic therapy
Psychodynamic psychotherapy is based on the concept that problems arise from unresolved conflicts in early childhood, which have remained in one's subconscious mind by a process of repression.⁶ The clinician helps the patient to understand and resolve their problems by increasing awareness of their inner world, and its influence over relationships in the past and present.⁶ This tends to require a long-term relationship with the therapist and is very intensive in nature.

The type of therapy most likely to benefit a patient is dependent upon the physical health and functioning of the individual.² When the elderly patient is disabled, the goal is to focus on resolving interpersonal conflicts, reconciling personal accomplishments and disappointments, and adapting to current losses and life stressors.² Psychodynamic psychotherapy is comparable to CBT in terms of its ability to prevent recurrence of depression-related symptoms in the elderly over the course of one and two year periods.²⁹

In recent years, brief dynamic and supportive psychotherapies have emerged to deal with more focused problems that are expected to become resolved in limited periods of time. In contrast to longer-term therapies, in these brief interventions the goals are much more focused and less of an attempt is made to reconstruct the developmental origin of conflicts. The overall efficacy of these brief programs is lower than that of other psychotherapies, but much of this has been attributed to the limited number of studies conducted in this area.¹ It is thought that supportive therapy may be more familiar and comfortable for elderly patients even though both the dynamic and supportive modes are successful approaches.³⁰

Reminiscence Therapy
Reminiscence therapy was first designed specifically to treat the elderly. Therapy involves reflecting on positive and negative aspects of life experiences in order to overcome feelings of depression and despair.¹ It has been found to be more effective than no treatment in the management of depression among cognitively impaired patients in nursing homes and among elderly individuals in the community.^31,32 However, it is thought to be less effective in treating late-life depression in the outpatient setting, than problem-solving therapy.²⁶ The advantage of reminiscence therapy is being able to use it in both moderately cognitively impaired and cognitively intact individuals.¹

Group Therapy
Psychodynamic, interpersonal, supportive, cognitive-behavioral, reminiscence and expressive (e.g. music, dance, art, drama) strategies can also be used in a group therapy setting. Patients are referred to group therapy when they need the force of a group experience to motivate them and to give them a social experience, or when they need to see that they are not alone in their difficulties (as with a critical medical illness). Group therapy has been used on geriatric individuals in hospitals, residential facilities, nursing homes and outpatient environments.¹ Very few studies have been done to compare the effectiveness of the different group therapy strategies.

Conclusion
It is possible that either group or individual psychotherapy will play an increasingly important role, either alone or in combination with medication, in the treatment of psychiatric syndromes and symptoms that affect our aging population. Psychotherapy, in its multiple forms, has the capacity to deal with a broad spectrum of problems encountered in the elderly, and it has the potential for having its usefulness expanded as more controlled clinical trials are conducted.

Primary care physicians not only need to be aware of these treatment strategies as they emerge, but also need to recognize when psychotherapy is indicated. Psychotherapeutic effects on depression in the elderly have been the most extensively studied; however, various modalities of psychotherapy have also been used in the treatment of many conditions that are common in an aging population, including anxiety, insomnia and bereavement. Psychotherapy has also been shown to be successful in reducing physical needs, pain and disability, improving compliance with medical and psychiatric regimens, and in dealing with late-life stressors such as adjustment to a newly-acquired medical illness. Regrettably, given our present understanding of the indications and effectiveness of psychotherapies in the elderly, it is difficult to be highly confident in the choice of one therapy over another.

Acknowledgements
I would like to acknowledge the contribution of Dr. Silberfeld to this article. Dr. Silberfeld is a practicing geriatric psychiatrist and the Coordinator of the Competency Clinic at the Baycrest Centre for Geriatric Care.

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