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

Epidemiology
Many studies and review articles have emphasized the fact that anxiety disorders, in general, are less prevalent among the elderly than among young adults.^1-5 However, some degree of controversy regarding the prevalence of anxiety among the elderly does exist in the literature. A recent review by A. Flint of the University of Toronto concludes that these disorders are rare in the elderly.¹ Fuentes and Cox of the University of Manitoba argue, on the other hand, that current research on anxiety in the elderly uses instruments and criteria that may not be valid vis-à-vis the elderly. It is their contention, therefore, that these instruments underestimate the validity of findings concerning anxiety in this age group.^1,2

Statistically, anxiety disorders are the second most common type of psychiatric disorder affecting older people next to cognitive impairment.² They are relatively common in late life, and are a cause of significant morbidity.⁸ While actual prevalence rates vary slightly from study to study, anxiety "feelings" reportedly occur in up to 20%² of the North American population of elderly people, and anxiety disorders in 3.5 to 5.5% in this population.

Reviewing Diagnostic Criteria for Differentiating FTLD from AD

Nadège Chéry, PhD

Frontotemporal lobar dementia (FTLD) is the third most common form of cortical dementia following Alzheimer's disease (AD) and Dementia with Lewy Bodies. It is often mistaken for AD, yet it presents strikingly different clinical and histopathological features and therefore, it must be managed distinctly. Discovered over a century ago by Arnold Pick¹, it was only recently identified as a specific type of degenerative illness.

FTLD is comprised of three prototypical clinical syndromes: Frontotemporal dementia (FTD), Primary Progressive Aphasia (PPA), and semantic dementia (SD).³ PPA is a disorder of expressive language, which manifests itself as the laboured production of speech, speech containing phonological and grammatical errors, and difficulties in word retrieval. SD is characterized by a severe impairment in naming and word comprehension during fluent, effortless grammatical speech output, with relative preservation of the ability to repeat, read aloud and write. FTD, on the other hand, is considered to be the most common clinical manifestation of FTLD.^2,3 This article will focus on FTD, and compare it with AD.

FTD affects men as frequently as it affects women.¹ It has a predominantly early age of onset, and most individuals affected are between 50-60 years of age.

Alexandra Nevin, BSc

It is predicted that 70% of all neoplasms will occur in the geriatric population by the year 2020.¹ Hematologic malignancies represent a significant and clinically devastating proportion of the cancers affecting the sixty-five-plus generation. Within the spectrum of lymphoid-derived hematologic tumors, the umbrella class referred to as non-Hodgkin's lymphoma (NHL) is particularly daunting in terms of both incidence and associated mortality in the general population. Since the 1970s, the National Cancer Institute reports that NHL is one of only five malignancies for which death rates have increased, while the American Cancer Society reports that the absolute incidence of NHL has increased over 65% in the past 30 years. The determination of age-adjusted incidence rates indicates that such trends are due primarily to increases in NHL among older persons.² From a clinical perspective, elderly NHL patients represent a unique group due to the demonstration of certain age-specific characteristics, including histology type predominance, prognosis, and response to current conventional treatment. Recent advances, such as monoclonal antibody treatment, represent a promising therapeutic avenue in future treatment of specific forms of NHL in the elderly.

The Etiology of NHL
The underlying etiology of most types of NHL is still unknown, regardless of the patient's age. However, a number of risk factors have been identified for the general population.

A. Mark Clarfield, MD

Last Scene of all,
That ends this strange eventful history,
In second childishness, and mere oblivion,
Sans teeth, sans eye, sans taste, sans everything

William Shakespeare (As You Like It. II, vii, 157)
(1564-1616)

The Bard, a noted gerontologist, described those at the extremes of life as having much in common. Both are more fragile than their counterparts mired in middle age. Each exhibits an easy perturbation from the physiologic norms of maturity. As has been said about nostalgia: "It ain't what it used to be"; thus with respect to the homeostasis of both the very young and extremely old. Both can swing out from their narrow organ reserves into failure very quickly indeed.

Many analogies can be drawn between the two ends of the age spectrum--some quite credible, others a bit more fantastic. This month's column will touch on some of these in hope that perhaps a few pediatricians will decide to transfer their allegiance and bolster the still slim ranks of Canada's geriatricians.

More and more I am struck by the similarities exhibited by patients at the extremes of life. For one thing, the older person suffering from severe dementia can no more be maintained at home with the help of community services, as good as they might be, than the average two-year-old.

Julia Krestow, BSc, MSc

Brain cancer has long been known as one of the most difficult neoplasms to treat. Since the 1970's there has been little change in its management despite considerable laboratory progress in understanding brain tumour biology. Recently, however, advances in imaging techniques have begun to result in earlier and more accurate diagnosis.¹ Correct diagnosis combined with the standardized World Health Organization (WHO) classification system for tumours constitute the first step in a successful treatment strategy. The primary challenge and rate-determining step in brain cancer treatment is understanding the underlying tumour biology. This will determine tumour resistance to radiation and chemotherapy, tumour location and the degree of vascularity and abnormal vessel formation within a tumour. Together these comprise the main challenges of brain cancer treatment. Current research areas include Magnetic Resonance Imaging (MRI), which increa-ses surgical safety, new chemotherapeutics, such as, small molecule targeting drugs, which selectively kill tumour cells, and the still theoretical field of immunotherapy. Together these offer considerable hope to physicians, patients and their families even for the most malignant cancers generally found in older patients.

Pathology
Brain tumours are classified according to the tumour type and cell of origin. They are also classified as primary and secondary depending on the absence or presence of metastases.

Tawfic Nessim Abu-Zahra, BSc, MSc

Presently, the standard therapy for heart failure consists of treatment with an angiotensin-converting enzyme (ACE) inhibitor, furosemide (Lasix) or other loop diuretic, and the possible use of a b-blocker or a positive inotropic agent such as digoxin (Lanoxin).¹ The goals of this therapy are to decrease blood volume, increase cardiac contractility and inhibit the neuroendocrine effects of the renin-angiotensin-aldosterone system (RAAS). Since ACE inhibition suppresses aldosterone release, treatment with ACE inhibitors was considered sufficient for blocking the effects of aldosterone in patients with heart failure.^1,2 Thus, the addition of the aldosterone receptor antagonist spironolactone (Aldactone) was considered unnecessary and, given the threat of hyperkalemia, continued to be contraindicated.1 However, contrary to this conventional view, results of the Randomized Aldactone Evaluation Study (RALES) have shown that spironolactone treatment can reduce morbidity and mortality in patients with severe heart failure.

Shechar Dworski, MSc

Aspirin has been the traditional drug of choice for preventing cardiovascular events in cerebrovascular, cardiovascular, and peripheral vascular disease. However, many recent studies comparing aspirin to ticlopidine and clopidogrel in terms of efficacy and side effects, have produced results which favor these new antiplatelet drugs. Clopidogrel is the newer of the two drugs, and consequently, fewer studies have been done with it. Still, clopidogrel has shown promise as an alternative to ticlopidine; it is safer and has similar efficacy. However, studies are lacking to show that clopidogrel works equally well in all possible clinical situations, whereas ticlopidine's effectiveness has been proven in settings such as post-coronary stent insertion. Nevertheless, studies done with clopidogrel have shown it to be useful in many instances, such as secondary prevention after an initial cerebrovascular (TIA/ stroke) event. Most studies compare the two drugs against aspirin, but not directly against each other. Even so, it has become clear that clopidogrel produces fewer side effects, and is safer than ticlopidine. This article will present some of the information available about these two drugs to help the reader decide which antiplatelet agent to use.

Nariman Malik, BSc

Introduction
Prostate cancer is the most frequently diagnosed cancer in Canadian men,¹ and is the second leading cause of death due to cancer among North American men, just after lung cancer.³ In the early nineties, the number of prostate cancer cases diagnosed increased dramatically. By 1995, the incidence had peaked and has since leveled off in both Canada and the United States. In 1999, it was estimated that there would be approximately 16,600 new cases of prostate cancer in Canada.² This increase can be at least partially attributed to newer methods for detecting the disease earlier, particularly since the introduction of routine serum prostate specific antigen (PSA) testing in the early 1990s.¹

The risk of developing prostate cancer increases with age. Sixty to seventy-five percent of cancers are diagnosed in men who are over 65 years of age.³ Because of Canada's aging population, primary care physicians will see an increasing number of prostate cancer cases in their practices. It is, therefore, of utmost importance that physicians dealing with the elderly have a clear understanding of the various aspects of this disease. This article focuses on these various aspects of prostate cancer: risk factors, screening techniques, diagnosis and treatment modalities.

Philip Dopp, BSc

Dementia manifests itself in many ways within elderly populations. Given that symptoms associated with dementia, such as psychosis or behavioral disturbances, are common reasons for nursing home placement, it is not surprising that between 40% and 90% of residents of such institutions have some degree of dementia.^1,2 In recent years, atypical antipsychotics such as risperidone and olanzapine have been used with increasing frequency to deal with these distressing symptoms of dementia. Because of their favorable side effect profile, when compared to typical antipsychotics, and because studies have shown them to have equal, if not greater efficacy than typical antipsychotics, many geriatric psychiatrists recommend atypical antipsychotics as first-line treatment for psychosis and aggression in dementia.

The behavioral problems associated with dementia can be categorized as either non-aggressive or aggressive. Nonaggressive behavior includes wandering, pacing, bossiness, complaining and attention-seeking acts, while aggressive behavior includes hitting, pushing, scratching, biting, kicking and screaming. Management of these problems depends upon both the severity of the problem and the potential for the patient to harm themselves or others. In all cases, nonpharmacologic interventions, such as distracting the patient from the problem behavior, creating a structured environment for the patient and developing support groups for the caregiver, are appropriate.

David M. Kaplan, MScHA
Joint Center for Bioethics
Faculty of Medicine, University of Toronto

Alzheimer's disease (AD), a disorder characterized by a progressive loss of cognitive function, affects approximately five and a half million North Americans.¹ Advances in the Human Genome project and genetic testing over the last decade have allowed clinicians and researchers to assess an individual's genetic risk of developing AD.² This paper examines the practical and ethical implications of using genetic testing in order to screen for an individual's risk of developing AD. A useful screening test should be able to exclude unaffected individuals--that is, it should have a high sensitivity and be able to identify affected individuals. It should also have a high specificity. Traditionally screening tests have only been applied for diseases for which preventive measures were available.