Jeffrey Kwong, BSc

Anemia, a common problem in the elderly, warrants thorough investigation. Among those aged 85 years and older, the prevalence of the disorder ranges between 27% and 40% in men and between 16% and 21% in women.^1,2 Anemia has been defined by the World Health Organization as a hemoglobin concentration below 120 g/L in women and below 130 g/L in men.³ This definition was recently confirmed to be clinically relevant in the elderly, with increased risk of mortality (especially from malignant and infectious causes) linked to lower hemoglobin concentrations.⁴ Thus, it is important not to dismiss anemia as a normal aspect of aging, and to make efforts to determine and treat the underlying cause.

Kathleen Jaques Bennett, BSc, MSc

Drug-induced depression is a type of depression that is caused by a drug or combination of drugs. It can be difficult to diagnose and manage, especially in the elderly. A depression must first be diagnosed and a temporal relationship with a drug or drugs must be identified in order to make an accurate diagnosis of drug-induced depression. While there are a number of treatment options, the management of drug-induced depression is complicated if the drug is an indispensable medication. The management of this type of depression is further complicated if there is no substitute for the offending medication. Elderly people consume large numbers of prescription and non-prescription drugs. This group of people is often taking several drugs concurrently and has less tolerance for medications.¹ The elderly are particularly susceptible to drug interactions and adverse drug reactions (ADRs) which can lead to drug-induced depression.¹ This group also presents more difficulty in terms of managing the condition.

Joyce So, BSc
Co-author:
Dr. Sidney Radomski,
Urology, Toronto Western Hospital

In 1992, the National Institutes of Health Consensus Development Conference¹ suggested the use of the term "erectile dysfunction" instead of "impotence" to describe one of the most common chronic medical problems affecting men over the age of 40. Erectile dysfunction is defined as the persistent inability to attain or maintain a sufficient penile erection for sexual intercourse in at least 50% of attempts. The prevalence and degree of erectile dysfunction increases with age, with men in their fifties being three times more likely to have this condition compared to men in their twenties.² By the age of 65, 25% of men are afflicted with erectile dysfunction, a number which increases to 55% among 75-year-olds and 65% among 80-year-olds.² However, erectile dysfunction should not be considered part of the normal aging process.

The multi-disciplinary, community-based Massachusetts Male Aging Study (MMAS)³ of men aged 40 to 70, conducted between 1987 and 1989, showed that 35% of the men reported moderate to complete erectile dysfunction, with 52% reporting at least some degree of dysfunction. They also reported a decrease in libido and the number of sexual thoughts, fewer nocturnal or morning erections, and less frequent intercourse with age.

Kimby Barton, BSc, MSc
Assistant Editor, Geriatrics & Aging

The hematopoietic system is comprised of all the elements of the blood, together with the stem and progenitor cells that give rise to these elements, and these play a vital role in the functioning of a healthy person. The hematopoietic system is unusual in that most of its components have a short life span, a multiplicity of cell types are required for its normal function, and a wide dispersion of cells perform specific functions throughout the body. The short life span of many of its components renders necessary the continuous production of enormous numbers of cells. Consequently, stem and progenitor cells must be maintained in adequate numbers to meet this demand for cell production throughout a person's lifetime.

Age-related alterations have been found in almost all components of the hematopoietic system but historically it has been difficult to distinguish between changes that occur with advanced age and changes that occur as a result of an illness. This article will review some of the literature dealing with the effects of age on the hematopoietic system. Conflicting studies will leave some questions unanswered and a paucity of information in other areas suggests the need for further research.

Dr. Tabo Sikaneta, MD
Clinical and Research Fellow
Massachusetts General Hospital
Harvard Medical School

Chronic myeloid leukemia (CML) and chronic lymphocytic leukemia (CLL) are malignant hematologic disorders that predominantly affect the middle-aged and elderly. Although they share certain features in their clinical presentations, these two neoplasms differ significantly with regard to epidemiology, pathogenesis, prognosis, and management issues. This article will compare and contrast CML with CLL in order to highlight these important clinical differences. Particular attention will be given to the treatment issues faced by elderly patients with these chronic leukemias, and to the role that primary care physicians may play in the management of these diseases.

Definition and Epidemiology
CML is the clonal proliferation of hematopoietic stem cells. CLL is the clonal proliferation of small, long-lived, mature B lymphocytes. CML is less common, with an annual incidence of 1-2 per 100,000 members of the general US population. It has an equal distribution among both sexes.¹ Both CML and CLL affect whites more than blacks, are not familial, and are not related to a history of known carcinogenic agent exposure.² Although the median age of onset of CML is 53, a sizeable minority (10-30%) contract CML after age 60.

Part II of Patients Suffer When Consultant & Consultee Beg to Differ

A. Mark Clarfield, MD

For those FRCPC's who felt aggrieved by my last month's column, take heart. In this month's column, I shall address the sins of the CCFP consultee. I am attempting this here because these examples of malfeasance pertain most especially to the elderly--patients who are the most vulnerable when caught in the crossfire between those that seek and those that give advice.

As I mentioned in my last epistle on the subject of consultation, the older person tends to have multiple, chronic diseases that may present atypically, often making it difficult, at least at first, to make an accurate diagnosis. As a result, many elders are subjected to the perils of polypharmacy. In addition, older patients, when admitted to hospital, have an increased length of stay and often present with a more complicated history than their younger counterparts. Thus, appropriate consultation is of great importance to the older patient.

I will now endeavor to discuss the mistakes in the consulting practices of Canada's family doctors, especially with relation to the geriatric patient.

I feel well qualified to write on the subject, since I practiced family medicine for several years before becoming a geriatrician. During this period, I committed all (and perhaps more) of the obliquities that are discussed below.

Geoff Fernie, PhD, PEng, CCE
Centre for Studies in Health and
Aging, Sunnybrook Hospital and Women's College Hospital, North York, Ontario

Does anyone know why toilets are so low in North America? Many elderly people find it really difficult to stand up from them. They are also too low for an easy lateral transfer from a wheelchair. What are the solutions to this common problem?

The problem is twofold:

1. How can the toilet seat be raised?
2. How can a grab bar be provided as an effective aid to rising?

The typical height of a toilet bowl without the seat is 14.5" whereas the optimal height of the seat is about 19". This corresponds to the height of a typical wheelchair seat and to the Canadian Barrier-Free Design code.

There are three solutions to the seat height problem:

1. The most common solution is to purchase an add-on raised toilet seat. About 500,000 people do this in North America every year. These are hollow plastic units that fit on top of the toilet. Usually they replace the existing toilet seat. They come in various thicknesses. Four to Five inches is generally about right. The manufacturers claim that they fit most toilets but it is important to check the security of the fit since accidents do occur. Some of them come with clamping mechanisms, some bolt through the toilet seat attachment holes, and others have no attachment system. Some can be filled with sand or water to increase stability.
2. An alternative Canadian product, Toilevator®, fits under the toilet to raise it. This product was recently voted as the best new product for the year 2000 by the Canadian Hardware and Housewares Manufacturers Association. It has the advantage of being inconspicuous and does not create instability or cleaning problems. Since the regular toilet seat is still used, Toilevator® only needs to be 3.5" thick. It has the disadvantage of requiring installation by a handy-person or a plumber. Please note that Toilevator® is another of our inventions from The Centre for Studies in Aging; for this reason, I must declare a conflict of interest.
3. Buy an extra high toilet. These are available, but this is a more expensive solution and does not allow for reversal to the original height. The reasons for wanting to return to the low height may include progression to the use of a rollover commode or moving from one house to another.

Elimination is made easier by a more flexed hip posture. If this is a consideration then it may be appropriate to have a light foot stool available. Toilevator® can be installed to create deliberately a small step at the front that may be adequate for this purpose.

There are several solutions to providing a grab-bar to help in transferring on and off the toilet.

1. The most flexible solution is to use one of the vertical pole devices. These are held in place by compression between the floor and the ceiling and will not work if the bathroom ceiling is made of a grid of suspended removable panels. However, they can be tried in different locations until the optimum position is found
2. Grab-bars can be attached to the wall. We will cover the topic of selecting and installing wall grab bars in a later article. The problem is that they are often too far off to the side to provide enough assistance.
3. Horizontal rails that are attached to the back wall and can be swung up out of the way are often used in institutions but are rarely used at home because of the difficulty and cost of installation. They have the advantage of providing room for a caregiver to stand to one side of the toilet and give assistance when needed.
4. Numerous frame designs are on the market that attach to the toilet or raised toilet seat. Be very careful to select one that is firm enough and big enough to be truly safe and functional. The ones that come as part of a raised seat are often inadequate.

The ability to manage the toilet with safety and dignity is key to independence. These simple adaptations should cost no more than $300 in total and can be done very successfully or very poorly--choose wisely.

Neil Fam, BSc, MSc

Hepatitis refers to acute or chronic inflammation of the liver, with the majority of cases resulting from either viral infection or drugs. In Canada, hepatitis B and C infections are the most common cause of viral hepatitis, and may be associated with considerable morbidity and mortality. Globally, chronic viral hepatitis is the leading cause of chronic liver disease, cirrhosis, and hepatocellular carcinoma and is the most common indication for liver transplantation. This article provides an outline of the natural history of hepatitis B and C infections, and describes current approachs to diagnosis, treatment, and prevention. Unique aspects of hepatitis in the elderly are highlighted.

Epidemiology and Risk Factors
Hepatitis B virus (HBV) is a DNA virus that infects over 350 million people worldwide. Although HBV infection is extremely common in parts of Asia and Africa, Canada has a relatively low level of endemicity. In North America, HBV infection occurs mainly in sexually active young adults. Important risk factors for HBV include sexual activity, IV drug use, occupational exposure, travel or residence in an endemic area and previous blood transfusion. The route of transmission may be sexual, parenteral, or vertical, with an incubation period of 6 weeks to 6 months.

Ruwaida Dhala, MSc, BSc

Patients with advanced dementia often develop eating difficulties and undergo weight loss.¹ In order to sustain ongoing nutrition in these patients the question of using enteral feeding can be raised. Although benefits of enteral feeding are still largely unclear, there is an increasing frequency of its use especially in patients with dementia.² This article will examine the risks of this procedure in order to identify whether enteral feeding is necessary and beneficial in all cases.

Long term enteral feeding commonly involves the administration of nourishment through a tube that is put directly into the stomach (percutaneous endoscopic gastrostomy tube). Enteral tube feeding is regarded as a safe, efficient and inexpensive method of feeding patients who have difficulty swallowing. Although enteral feeding is widely used, there is evidence that points to the negative effects of enteral feeding. Proponents of enteral nutrition usually identify its benefits as prevention of aspiration pneumonia, reducing risks of infection and prolonging survival.¹ However artificial feeding carries risks which include aspiration, infection, fluid overload, removal of the tube by the patient, and overall patient discomfort.²

A 1996 review looking at the use of tube feeding to prevent aspiration pneumonia found that there is no evidence to support this.

Alejandro Floh, BSc

Echocardiography has long been recognized as one of the most valuable non-invasive methods of investigating the heart. With recently-acquired understanding of the importance of cardiac disease in the pathogenesis of stroke, the role of echocardiography, whether transthoracic or transesophageal, in the management of stroke patients has become an area of extensive study. The Canadian Task Force on Preventive Health Care has therefore released their recommendations for the use of this imaging technique in newly diagnosed stroke patients.

Cerebral ischemia, a form of cerebral vascular disease, is caused by the reduction of blood supply to the nervous tissue of the brain. The result is often a rapid onset of focal neurological deficit or global impairment; this is commonly referred to as a stroke or cerebral vascular accident (CVA).¹ Despite similar presentations, the etiology of ischemic strokes vary considerably, and must be differentiated rapidly in order to provide appropriate care.

Despite new diagnostic and treatment modalities, stroke continues to be the third largest cause of mortality in Canada and the leading cause of disability.^2,3 Currently, approximately 50,000 new cases of strokes emerge annually, leading to an overall prevalence of 200,000 cases.³ Furthermore, strokes continue to be a leading cause of hospital admissions, even higher than acute myocardial infarctions, costing the Canadian health care system $2.