Sheldon Singh, BSc

Hypothyroidism (thyroid hormone deficiency) can affect all body systems; the degree of severity can range from mild and unrecognized to a state of striking myxedema. In the elderly, hypothyroidism is not unusual. However, it may go unrecognized for a variety of reasons including mistaking the non-specific signs and symptoms as a part of the "normal aging" process or other medical conditions that may exist in the elderly. This article will discuss normal thyroid physiology, changes to the thyroid as a result of the aging process, etiology of hypothyroidism as well as diagnosis, management and screening for hypothyroidism.

Physiology of the Thyroid
A review of the physiology of the normal feedback loop of the hypothalamic-pituitary-thyroid axis is quite useful in aiding clinicians in interpreting thyroid function tests and subsequently diagnosing thyroid dysfunction (see figures 1 and 2). Thyrotropin-releasing hormone (TRH) is produced by the hypothalamus. This hormone stimulates thyrotroph cells in the anterior pituitary to secrete thyrotropin (TSH). This hormone then stimulates the thyroid follicular cells to release tri-iodothyronine (T3) and thyroxine (T4). The release of T3 and T4 suppress the release of TSH and TRH; this completes the feedback loop. Although T3 differs from T4 by one iodide molecule (see figure 1 on page 18), this difference results in a significant increase in receptor affinity and activation.

Margaret C Gibson, PhD, CPsych
Psychologist
Veterans Care Program
Parkwood Hospital Site
St. Joseph's Health Centre
London, Ontario

Sexual health is defined by the World Health Organization as the integration of the physical, emotional, intellectual and social aspects of sexual being in ways that are positively enriching and that enhance personality, communication and love.¹ Sexual health includes elements that are sensory, cognitive, emotional, physical, spiritual, functional, relational, social, cultural and historical. It reflects our basic concepts of ourselves as male, female, man, woman, child, mother, father, partner, lover and friend. Sexual health includes overt sexual behaviours, but is about much more than behaviours alone. It is about who we are, about our connections to others with whom we share both basic evolutionary drives and the capacity for profound interpersonal bonds. Sexual health involves having a sense of comfort with the life course of one's own sexuality. It is an integral part of overall psychological well-being and quality of life.

Eleanor Brownridge

Until recently, many general practitioners have been hesitant to diagnose Alzheimer's Disease (AD), especially at the mild and moderate stages. They believe that patients and their families don't want to hear this bad news and therefore don't push the issue.

"We have to work hard to change the attitudes of physicians," says Dr. Ron Keren, geriatric psychiatrist with the University Health Network, Toronto General Hospital. "We have to move away from stigmatizing Alzheimer's and start approaching it as any other serious disease. We need to talk frankly, openly and honestly with our patients." Research from the United States has shown that 80 percent of seniors want to know if they have dementia. Dr. Keren, who also practices at the Toronto Rehabilitation Institute and the Whitby Health Centre, says that in over seven years he has never had a patient who didn't want to know the state of his disease. "If you can't talk about it, how can you treat it?"

With the recent decisions of Ontario and Manitoba to reimburse donepezil (Aricept) in those provinces, physicians now have a treatment for mild to moderate dementia of the Alzheimer's type that can bring hope to all patients and their families, not just those who can afford it.

Donepezil inhibits the activity of acetylcholinesterase, thereby increasing levels of acetylcholine in the brain.

No More Splitting Pills! Study Calls for Low Dose Pills for Seniors

An Ontario study is calling for pharmaceutical companies to make low dose tablets of commonly prescribed drugs for seniors.

The population-based study, conducted by Baycrest Centre for Geriatric Care, was published in the August issue of the Journal of the American Geriatrics Society. It is the first comprehensive look at low dose prescribing in a large population of seniors.

Using the Ontario Drug Benefit Plan database, investigators at Baycrest identified over 133,000 adults aged 65 and older who were prescribed either thiazide diuretics or beta blockers over a one-year period from 1995 to 1996.

The study found that of the 120,000 seniors in Ontario who were repeat users of thiazide diuretics, more than a quarter (26%) were dispensed a dose lower than the standard pills produced by pharmaceutical companies.

The "mismatch" between dosage prescribing and dosage formulations means doctors rely on patients and pharmacists to split standard dose tablets. Splitting pills, particularly when done by older patients who may have impaired vision or motor skills, may increase drug error or lead to frustration and non-compliance.

D'Arcy Little, MD, CCFP
York Community Services,
Toronto, and
Department of Family Medicine
Sunnybrook Campus of
Sunnybrook and Women's
College Health Sciences Centre,
Toronto, Ontario

Chronic Obstructive Pulmonary Disease (COPD) is a general term for a group of conditions characterized by some or all of the following features: a chronic cough, increased sputum production, shortness of breath, airflow obstruction, and impaired gas exchange. Unlike asthma, which is usually episodic and reversible, the major characteristics of COPD are that it is chronically progressive and irreversible. Under the umbrella of COPD, there are two major disease categories: chronic bronchitis and emphysema. Chronic bronchitis is clinically characterized by a productive cough, lasting three months of the year for at least two consecutive years. Pathologically, chronic bronchitis is characterized by mucus gland and airway smooth muscle hypertrophy. Emphysema is clinically characterized by dyspnea, although the other features mentioned above may also be present in various degrees. Technically, emphysema is a pathological diagnosis characterized by destruction of the air spaces distal to the terminal bronchioles (respiratory bronchioles, alveolar ducts and alveoli). It is worthwhile to note that it may not be clinically important, or useful, to categorize a patient as having either chronic bronchitis or emphysema.

Lilia Malkin, BSc

The myriad of human physiological systems undergo change as the body grows older, and the respiratory system is no exception. For a more detailed look at the aging lungs, please see the Biology of Aging article, Age-related Changes to the Respiratory System Will Not Affect Healthy Elderly. It is worth noting, however, that the evaluation of the geriatric patient presenting to the physician's office with respiratory symptoms such as cough and shortness of breath is quite similar to that of a younger adult. The following is a two-part review of diagnostic and treatment approaches to the geriatric patient presenting to the primary care physician for the first time with symptoms of dyspnea and cough, respectively.

Part I. Dyspnea
Dyspnea may be defined as "abnormal or uncomfortable breathing in the context of what is normal for a person according to his or her level of fitness and exertional threshold for breathlessness."¹ However, upon presenting to the physician, patients will usually refer to the alarming feeling of "shortness of breath," or "difficulty breathing." The complaint is fairly common, owing to the plethora of conditions that give rise to this symptom.

Sharron Ladd, BSc
Managing Editor

"It is clear that the study of back pain has been overlooked in the geriatric community, perhaps relegated to second-class status behind health conditions like diabetes, heart disease and cognitive impairment," says Dr. Hart Bressler, the primary author of the landmark study entitled "The Prevalence of Low Back Pain in the Elderly." The study, co-authored by Dr. Warren Keyes, Dr. Paula Rochon and Dr. Elizabeth Badley appeared in the September 1st issue of the journal Spine. Several reasons are cited for the under-representation of elderly in back pain studies. One of the main reasons is the economic burden of maintaining worker's compensation programs; these programs are necessarily directed at the younger working population. Other reasons are listed in Table 1.

Using the key words low back pain, back pain, elderly, geriatrics and aged for their literature analysis, the researchers found only twelve studies on low back pain in the elderly, between 1966 and the present, that met their final selection criteria! The methodologies underlying some of these studies are dubious. "Many studies have grouped younger and older patients together, such as a 40 year old with an 82 year old.

Thomas Tsirakis, BA

Social isolation is common amongst the elderly. Socially isolated individuals display significantly higher suicide rates, a greater number of physical and cognitive impairments, and a lower life expectancy rate when compared to those who are socially active. European studies have shown that even minor interventions to break social isolation, such as friendly visitors or routine volunteer phone calls, improve survival in the socially isolated elderly. The Baycrest Centre for Geriatric Care in Toronto, Ontario offers a wide range of innovative programs that specifically address problems with withdrawal and social isolation.

Studies show that the elderly population in general feels that their contributions to society are deemed to be insignificant by younger generations. Being able to contribute to the lives of others is important for building self-worth, and ultimately increases the value placed on life itself. For many older persons, various physical ailments (such as osteoporosis, and reduced level of vision and hearing) can cause a reduction in mobility and communication with others, ultimately causing social withdrawal. If the person's withdrawal becomes prolonged, it can become increasingly difficult to break free of this isolation.

Nariman Malik, BSc

The word bronchiectasis is derived from the Greek words bronchos, meaning windpipe, and ektasis, which means extension or stretching.¹ Bronchiectasis is defined as the abnormal and persistent dilatation of bronchi due to destructive changes in the elastic and muscular layers of the bronchial wall.² It is a condition that can affect airways of all sizes but tends to mainly affect medium-sized airways. It can be either focal, affecting the air supply to a limited region of lung parenchyma, or diffuse in nature. Bronchiectasis most often is a consequence of chronic or recurrent infections and the associated secretions that pool in these airways.³

In North America, fewer and fewer patients present with gross disease.⁴ The advent of antibiotics has lead to a dramatic decrease in severe respiratory infections and the subsequent development of bronchiectasis. However, because its incidence has decreased in developed countries, it is now believed that low clinical suspicion is a factor in the underdiagnosis of bronchiectasis.⁵ Bronchiectasis is characterized by the production of large amounts of sputum, which is also a defining trait of chronic bronchitis. As such, patients who are producing copious amounts of sputum and who smoke are likely to be misdiagnosed with chronic bronchitis.