Christopher Patterson, MD, FRCPC
Division of Geriatric Medicine
McMaster University
Hamilton, ON

• What do you do when an older man complains that his wife is more forgetful than one year ago?
• Can you distinguish depression from dementia in an older women who is having difficulty looking after herself?
• How do you manage an individual with dementia who resides in a nursing home and becomes aggressive?

Approaches to these and other clinical situations are addressed in the recently published conclusions from the Canadian Consensus Conference on Dementia.¹ This work built upon the earlier recommendations of the Canadian Consensus Conference on the Assessment of Dementia which was published in 1991.² For the recent con- ference, a more comprehensive view of dementing conditions was undertaken. A panel of Canadian experts in the areas of Geriatric Medicine, Geriatric Psychiatry, Neurology, Family Medicine and other disciplines undertook an evidence-based approach to the recognition, assessment and management of dementing disorders. Recommendations are targeted towards primary care physicians in Canada.

Joyce So, BSc

Despite growing concerns about air pollution, environmental tobacco smoke, and actions taken to reduce them, the incidence of asthma in North America has continued to rise since the 1970s.^1,2 It is estimated that about 4 to 5% of the general population suffers from asthma.¹ Asthma is a chronic inflammatory disease of the airways triggered by allergens and other stimuli, which lead to episodes of bronchial hyper-responsiveness and obstruction of airflow. Common signs and symptoms of asthma include recurrent wheezing, coughing, difficulty breathing and chest tightness. These symptoms often occur or worsen at night, during exercise, or in the presence of viral infection and common allergens such as dust, pets, pollen and smoke.

In the elderly, studies have shown that advanced age, male gender, parental history of chronic airway disease or hay fever, history of childhood respiratory illness, and environmental tobacco smoke exposure are all risk factors for developing asthma.1 In addition, various studies have established a clear association between bronchospasmic exacerbation and air pollution, with increased incidence of obstructed airways and hospital emergency department admissions for asthma in polluted, urban regions.

David Heath, MB, ChB, FRCPC
Geriatric Psychiatrist
Program for Older Adults
Homewood Health Centre
Guelph, ON

You receive a call from Mrs. Roberts' daughter and she tells you, "They want to give mum shock treatment for her depression. I didn't think they still did that. What do you think doctor? Mum says she doesn't want to sign the consent form without first talking to you." Some physicians might feel put on the spot after such a conversation and are unsure how to respond. They may not have learned much about electroconvulsive therapy (ECT) in medical school and much of what they hear about it in the media is negative and often sensationalised. So, what are the facts about this widely misunderstood treatment?

ECT's voodoo image is not helped by the fact that its mechanism of action is still unknown. The induction of a seizure is universally accepted as necessary for its effectiveness, however, and its origins are quite scientifically respectable. Convulsion, induced by camphor, has been known to "cure insanity" since 1764. Von Meduna started treating schizophrenic patients this way using camphor and then Metrazol in the 1930's. In 1938, Cerletti used electrical stimulation as a less unpleasant convulsant.

Neil Fam, BSc, MSc

Pneumonia is a common and serious condition that claims over 6,000 lives in Canada annually. The elderly are particularly at risk, with individuals over 65 accounting for 50% of all pneumonia cases and 90% of deaths due to lower respiratory tract infection.¹ Indeed, elderly patients with pneumonia have a mortality rate 3-5 times that of young adults. A combination of factors contribute to the increased incidence of pneumonia in the elderly, including the presence of comorbid illness and the effects of aging on the lungs and immune system (see Age-related Changes to the Respiratory System Will Not Affect Healthy Elderly). Recent advances in our understanding of pneumonia have led to a re-evaluation of traditional approaches to the disease. This review outlines disease presentation, common pathogens and current diagnostic, treatment and preventive options in the care of elderly patients with pneumonia.

Donepezil (Aricept), is now being reimbursed to eligible Ontario patients by the Ontario Drug Benefit Program. Donepezil received Health Protection Branch (HPB) approval in August 1997. Until now, however, donepezil has not been reimbursed by any provincial health plan, including Ontario's public drug program which covers senior citizens and those on social assistance. People wanting donepezil have had to pay for it themselves or have it reimbursed by private insurance.

Effective June 1, 1999, eligible ODBP beneficiaries will have the cost of donepezil reimbursed. There are two categories of coverage. Those who have already been on donepezil treatment for more than 60 days, have a confirmed diagnosis of mild to moderate AD and meet the ODBP program criteria will be eligible for reimbursement of donepezil by the ODBP.

Others with a confirmed diagnosis and who meet the ODBP and program criteria but who have never taken donepezil (or have taken it for less than 60 days) will be enrolled in a 12-week trial prescription program, with the medication provided free of charge by Pfizer. The trial prescription program is administered by an independent pharmacy and healthcare company, Caremark Ltd., based in Mississauga, Ontario.

The patient and caregiver also will receive a Pfizer-sponsored program of educational material about AD, including a video, called TriAD and a patient diary. The physician will continue to be supplied with diagnostic and other support tools to help him or her evaluate and track the patient's progress.

At the end of the 12-week trial prescription program, those patients who have benefited from the treatment will be eligible for continuing treatment reimbursed by the Ontario government. All patients receiving reimbursement will be reviewed annually to ensure they are still benefiting from the treatment and thus remain eligible for reimbursement.

The major instrument used to measure eligibility and effectiveness will be the Mini Mental Status Exam (MMSE). A score of 30 represents full cognitive ability; persons with impairment caused by AD score lower and their scores diminish over time as the disease takes its toll on cognitive function.

To be eligible for coverage, persons with mild to moderate AD will have to have and maintain an MMSE score between 10 and 26. A score that drops below 10 is indicative of advanced cognitive impairment of the later stages of AD, for which treatment with donepezil would not be appropriate.

Patients, caregivers or healthcare professionals seeking more information about reimbursement for donepezil can call toll-free to 1-800-510-6141.

Warren T Blume, MD, FRCP(C)
Professor, Department of Clinical Neurological Sciences, Director, EEG Laboratory,
London Health Sciences Centre, London, Ontario

Presented with an elderly patient exhibiting apparent cognitive decline, the physician must address three questions: (1) Does the decrease in apparent intellectual performance represent true dementia or pseudo-dementia? (2) Is there a treatable etiology? and (3) What is the prognosis? Of the diagnostic tests that society can afford, a well performed EEG can answer these questions as well as any test--after a thorough functional enquiry and physical examination.

Diffuse, persistent, excess delta (1-3 Hz) activity in this awake 75 year old man with cognitive decline.

Alzheimer's disease, a principal cause of dementia in the elderly, can produce several EEG abnormalities: a slowing of background rhythms, the appearance of diffuse slow-waves, triphasic waves, and a lack of clear EEG distinction between wakefulness, drowsiness, and light sleep. Rae-Grant et al. found a true dementing illness in 38 of 39 elderly subjects when such features appeared persistently in the recording and in 31 of 39 in whom they appeared intermittently.

Roger Wong, BMSc, MD, FRCPC

Division of Geriatric Medicine, Department of Medicine,
University of British Columbia, Vancouver, BC

Palpitations refer to the subjective sensation of a person's own heart beat. These are common complaints in adults 65 years or older, and are often described as uncomfortable. Synonyms of palpitations include "skipped heart beats," "rapid heart beats," "a racing heart," "extra heart beats" and "fibrillation." The exact prevalence of palpitations among older adults remains unclear. Previous studies reported prevalence data between 8.3% and 16%.^1,2 The uncertainty is partly due to a lack of uniform diagnostic criteria for palpitations. It should also be noted that the sensitivity of the symptom of palpitations in predicting cardiac arrhythmias is relatively poor. For instance, in the same study where the prevalence of palpitations among individuals age 60 to 94 years was reported as 8.3%, more individuals (12.6%) actually demonstrated cardiac arrhythmias by 12-lead electrocardiography.¹ Palpitations are also non-specific. Many physiologic reasons may produce palpitations, such as exercise, anxiety and anger.

Etiologies

Palpitations in older adults may result from a variety of causes (see Table 1). As in the management of other geriatric clinical syndromes, the precipitating causes of palpitations may be multiple.

Nariman Malik, BSc

Gynaecologic cancers remain a leading cause of cancer-related deaths in Canadian women. The three malignancies focussed on in this article, endometrial cancer, ovarian cancer and cervical cancer, have good prognoses if they are detected in their early stages. As such, it is of utmost importance that primary health care physicians be aware of Canadian guidelines for detecting these conditions and their limitations.

Endometrial Cancer

When diagnosed early, endometrial cancer is highly treatable and has a high survival rate. Stage I, grade I endometrial cancer has a five-year survival rate of 98%. This type of cancer most often presents as post-menopausal vaginal bleeding early in the course of the disease. Any woman who presents with unexplained post-menopausal bleeding should undergo endometrial assessment which can lead to early detection and improve the chances for a cure.

Detection

To identify women at risk of developing endometrial cancer, the progesterone challenge test can be used. In the United States, it had been recommended that all post-menopausal women should undergo this test at each annual examination. There are currently no Canadian recommendations regarding this test.

Expect One to Two Cases of Depression for Every Day of Office Practice

D'Arcy L Little, MD
Chief Resident, Department of Family Medicine,
Sunnybrook Campus of Sunnybrook and
Women's College Health Sciences Centre,
North York, Ontario

Depression is one of the most common illnesses seen by primary care doctors. The lifetime prevalence of this disease lies between 15 and 30%. It is estimated that one in 20 Canadians are suffering from depression at any given point in time, therefore the average family physician should expect to see one to two cases of significant depression for every day of office practice. Besides being common, depression causes significant morbidity in terms of suffering, disability, and cost to society, as well as a 15% mortality rate from suicide.

There is evidence that the recognition of depression and its early treatment improves outcome by decreasing suffering and improving function, quality of life and somatic symptoms. It is estimated, however, that between 35 and 50% of cases go undiagnosed. There can be numerous barriers to the diagnosis of this illness, for instance, only half of depressed people seek help specifically for this problem. However, the Ontario Health Survey [1990&endash;91] estimated that approximately 80% of depressed people did visit their family physician one or more times during the period of their illness for other reasons.

Legend:

1. Parietal Cells of stomach lining
2. Mucus
3. Neutralized Acid
4. Drug

Neil Fam, BSc, MSc

Helicobacter pylori was first isolated from human gastric mucosa in 1983. Since that time, recognition of its role as a major etiological agent in the pathogenesis of peptic ulcer disease has revolutionized the approach to diagnosis and treatment of this common condition. Approximately 90% of patients with duodenal ulcers and 80% with gastric ulcers not associated with non-steroidal anti-inflammatory drugs (NSAIDs) are infected with H. pylori.