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.

References

1. Gallo JJ and Lebowitz BD. The Epidemiology of Common Late-Life Mental Disorders in the Community: Themes for the New Century. Psychiatric Services. 50(9):1158-1166, 1999.
2. Klausner EJ and Alexopoulos GS. The Future of Psychosocial Treatments for Elderly Patients. Psychiatric Services. 50:1198-1204, 1999.
3. Hogland P. Psychotherapy Research: New Findings and Implications for Training and Practice. J of Psychotherapy Practice and Research. 8:257-263, 1999
4. Arean PA and J Miranda. Do primary care patients accept psychological treatments? General Hospital Psychiatry. 18:22-27, 1996.
5. Gallagher-Thompson D, NJ Osgood. Suicide in Later Life. Behaviour Therapy. 28:23-41, 1997.
6. d'Ardenne P. Who should you refer for psychotherapy? The Practitioner. 238:87-90, 1994.
7. Scogin F and L McElreath. Efficacy of psychosocial treatments for geriatric depression: a quantitative review. J of Consulting and Clinical Psychology. 62:69-74, 1994.
8. Blazer DG and E W Busse. Textbook of Geriatric Psychiatry, 2nd Ed.. American Psychiatric Press, Inc., 1996, 395-412.
9. Cornelia KB. Psychosocial and Behavioral Interventions for Alzheimer's Disease Patients and Their Families. Am J Geriatr Psychiatry. 6:S41-S48, 1998.
10. McCurry SM, Logsdon RG and L Teri. Behavioural treatment of sleep disturbance in elderly dementia caregivers. Clinical Gerontologist. 17:35-50, 1996.
11. Thompson LW, Gallagher-Thompson D and JS Breckenridge. Comparative effectiveness of psychotherapies for depressed elders. J of Consulting and Clinical Psychology. 55:385-390, 1987.
12. Gallagher-Thompson D, Hanley-Peterson P and Thompson LW. Maintenance of gains versus relapse following brief psychotherapy for depression. J of Consulting and Clinical Psychology. 58:371-374, 1990.
13. Breckenridge JS, Thompson L, Greckenridge JN, et al. Behavioural group therapy with the elderly. Handbook of Behavioural Group Therapy. New York: Plenum, 1985.
14. Beutler LE, Scogin F, Kirkish P, et al: Group cognitive therapy and alprazolam in the treatment of depression in older adults. J of Consulting and clinical Psychology. 55:550-556, 1987.
15. Beck JG and MA Stanley. Anxiety disorders in the elderly: the emerging role for behaviour therapy. Behavior Therapy. 28:83-100, 1997.
16. DeRubeis RJ, Gelfand LA, Tang T and Simons AD. Medications Versus Cognitive Behaviour Therapy for Severely Depressed Outpatients: Meta-analysis of Four Randomized Comparisons. Am J Psychiatry. 156:1007-1013, 1999.
17. Stanley MA, Beck JG and JD Glassco. Treatment of generalized anxiety in older adults: a preliminary comparison of cognitive-behavioural and supportive approaches. Behavior Therapy. 27:565-581, 1996.
18. Zeiss AM and A Steffen. Behavioural and cognitive-behavioural treatments: an overview of social learning. A Guide to Psychotherapy and Aging: Effective Clinical Interventions in a Life-Stage Context. Washington, DC: American Psychological Association, 1996.
19. Bryant RA, Sackville T, Dagn ST, Moulds M and R Guthrie. Treating Acute Stress Disorder: An Evaluation of Cognitive Behaviour Therapy and Supportive Counseling Techniques. Am J Psychiatry. 156:1780-1786, 1999.
20. Klerman GL Weissman MM, et al. Interpersonal Psychotherapy of Depression. New York: Basic Books, 1984.
21. Sloane RB, Staples FR, Schneider LS. Interpersonal therapy vs. nortriptyline for depression in the elderly. Clinical and Pharmacological Studies in Psychiatric Disorders. London: Libby, 1985.
22. Schneider LS. Efficacy of clinical treatment for mental disorders among older persons. Emerging Issues I Mental Health and Aging. Washington DC: American Psychological Association, 1995.
23. Reynolds CF, Frank E, Perel JM, et al. Combined pharmacotherapy and psychotherapy in the acute and continuation treatment of elderly patients with recurrent major depression: a preliminary report. Am J of Psychiatry. 149:1687-1692, 1992.
24. Miller MD, Wolfson L, Frank E, Cornes C, Silberman R, Ehrnepreis L, Zaltman J, Malloy J and Reynolds CF. Using Interpersonal Psychotherapy (IPT) in a combined Psychotherapy/Medication Research Protocol with Depressed Elders: A descriptive Report with Case Vignettes. J Psychother Pract Res. 7:47-55, 1998.
25. Hawton K and J Kirk. Problem solving in cognitive Behaviour Therapy for Psychiatric Patients. Oxford: Oxford University Press, 1989.
26. Arean PA, Perri MG et al. Comparative effectiveness of social problem-solving therapy and reminiscence therapy as treatments for depression in older adults. J of Consulting and clinical Psychology. 61:1003-1010, 1993.
27. Mynors-Wallis LM, Gath DH, Lloyd AR et al. Randomized controlled trial comparing problem-solving treatment with amitriptyline and placebo for major depression in primary care. BMJ: 310;441-445, 1995.
28. Woo BC, Mynors-Wallis LM. Problem-solving therapy in palliative care. Palliative Medicine. 11:49-54, 1997.
29. Gallagher-Thompson D, Thompson LW. Effectiveness of psychotherapy for both endogenous and non-endogenous depression in older adult outpatients. J of Gerontology. 38:707-712, 1983.
30. Hellerstein DJ, Rosenthal RN, Pinsker H, Wallner Samstag L, Muran JC and Winston A. A Randomized Prospective Study Comparing Supportive and Dynamic Therapies: Outcome and Alliance. J Psychother Pract Res. 7:261-271, 1998.
31. Fry PS. Structured and unstructured reminiscence therapy training and depression among the elderly. Clinical Gerontologist. 1:15-37, 1983.
32. Goldwasser AN, Auerbach SM and SW Harkins. Cognitive, affective and behavioural effects of reminiscence group therapy on demented elderly. International J of Aging and Human Development 10: 555-557, 1987.
33. Cook AJ. Cognitive-behavioral pain management for elderly nursing home residents. J of Gerontology. 53:P51-P59, 1998.

An Aging Population will Lead to Mounting Fall-Related Health-Care Costs

Brian E. Maki, PhD, PEng
Professor, Department of Surgery and Institute of Medical Science,
University of Toronto; and Senior Scientist,
Sunnybrook and Women's College Health Sciences Centre

It is well established that falling is a common occurrence in persons aged 65 and older. Among those living independently, 30-60% will fall one or more times each year,^1-3 and the falling rate is even higher among those living in long-term or acute-care institutions.^4,5 Although the degree to which the falling rate among older adults differs from that among younger adults has not been well established, it is clear that falls in older persons are much more likely to result in serious physical and psychosocial consequences. The first part of this two-part article dealt with the fear of falling and other psychosocial correlates of falls, which has tended to be an under appreciated aspect of the problem. The now forthcoming second part, will focus on what has, historically, received the most attention-the physical consequences of falls.

Although the majority of falls do not result in serious physical injury, the societal costs associated with fall-related injuries are immense. Falls are, in fact, the leading cause of fatal injuries among seniors, accounting for twice as many deaths in this population as motor vehicle accidents.

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

Introduction
Influenza, an acute respiratory illness, causes more adults to seek medical attention than any other respiratory infection. In Canada, influenza is a seasonal disease, causing annual epidemics that affect 10-20 percent of the population and result in approximately 4,000 deaths, 70,000 hospitalizations, and 1.5 million days of lost work.¹ The elderly (people aged 65 years and older), and those with chronic cardiopulmonary disorders, diabetes and other metabolic diseases, have an increased risk of developing influenza complications. Hospitalization rates among elderly patients increase markedly during major influenza epidemics, and 90% of the deaths attributed to influenza and pneumonia are observed in this population.²

Vaccination remains the most reliable means of preventing an influenza infection and the resultant morbidity and mortality. Despite the significance of influenza, efforts to vaccinate the elderly remain suboptimal. A large study conducted in the Netherlands revealed that healthy elderly people avoid influenza vaccination because they fear the side effects, and because they believe that their general health is good and that the benefits of vaccination are, therefore, minimal.

An 'Achilles Heel' in Viral Replication Helps Researchers Develop a Universal Cure for Influenza

Nadège Chéry, PhD

When influenza attacks, it may infect anyone, regardless of his or her age. But when influenza kills, it usually takes the lives of individuals, like the elderly, who are less able to fight back.² In Canada, 6000 deaths are attributable to influenza every year³ with the highest rate of mortality occurring among people over 65 years of age.² Thus, when it comes to older individuals, both early diagnosis, and prevention are imperative. Because the influenza virus continuously changes, strategies for the prevention of flu outbreaks, although thoughtfully planned, have had limited success. Recently, however, scientists have found a "weakness" in influenza's ability to escape traditional flu therapies. This discovery has set the stage for the design of new antiviral drugs which, potentially, may constitute a cure for the flu.

What is Influenza?
Influenza is a member of the Orthomyxoviridae family,1 and causes disease by infecting the epithelial cells that compose the lining of the respiratory tract. Influenza produces symptoms similar to other viruses which infect the respiratory tract. Flu outbreaks are common among elderly persons, particularly in nursing homes.⁴ Since the immune systems of elderly people in a nursing home may be compromised,⁵ their ability to fight an influenza infection can be severely undermined.

Physiologic Vs. Ventricular Pacing--Which is More Appropriate for Your Elderly Patient?

Tawfic Nessim Abu-Zahra, BSc, MSc

Cardiac pacemakers are widely used to treat the symptoms of cerebral hypoperfusion and hemodynamic decompen-sation that are caused by bradycardia.¹ Pacemaker implantation is indicated for diseases of the sino-atrial (SA or sinus) and the atrioventricular (AV) nodes. There are two different modes of cardiac pacing, ventricular and physiologic. Ventricular pacing involves the direct stimulation of the ventricular myocardium without interaction with the atria, whereas physiologic pacing stimulates either the atria alone (atrial pacing) or both the atria and ventricles together (dual pacing).

There are many theoretical reasons why physiologic pacing should be superior to ventricular pacing. Physiologic pacing maintains the synchrony of atrial and ventricular contraction and the dominance of the sinus node by stimulating both the atria and ventricles.² Physiologic pacing may prevent the pacemaker syndrome--a collection of symptoms associated with the asynchronous contraction of the heart that occurs with ventricular pacing.² In comparison to ventricular pacemakers, however, physiologic pacemakers are more expensive, and are more difficult to monitor.³

Despite the theoretical advantages of physiologic pacemakers, this mode of pacing is not widely used.