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.

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.