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.

Ruwaida Dhala, BSc, MSc

Vaccination has one of the greatest impacts on disease prevention. Most vaccines generate protective immune responses against a pathogen, preventing disease initiation. Often the immunity generated by vaccines to specific pathogens is lifelong. Preventative vaccines are not effective in cancer prevention, however, mostly because cancer antigens elicit poor immune responses. For this reason many cancers evade the immune system. Cancer vaccine strategy focuses on eliciting anti-tumour responses in patients that are already afflicted with cancer. These vaccines will presumably prevent cancer progression and reoccurrence rather than prevent cancer initiation.

In order for the body to mount an immune response, the invading pathogen, or components of it, must be exposed to the immune system. There are two major components of the immune system, humoral and cellular. Humoral immunity is involved in the generation of antibody responses. These antibodies are usually directed against extracellular pathogens such as bacteria. Most preventative vaccines rely on this arm of the immune system.

Cancer and Nutrition: Be Cautious When Making Dietary Recommendations

Eleanor Brownridge,
Registered Dietitian

While a number of major dietary components--including fat, total energy, salt, red meat and alcohol--have been implicated as contributing to specific cancers, current case-control and cohort studies do not support some of the predominant hypotheses that are influencing Canadian eating habits. A major reason for the current level of certainty is the challenges inherent in nutrition epidemiology.

Diets are extremely complex. Nutrients are found in a multitude of foods, and their absorption and activity is influenced by other dietary components eaten at the same time. People change their eating habits over time and we have no idea as to the relevant latency period for various diet-related effects.

If the thought of packing into a crowded banquet hall this summer to get those CME credits does not excite you, then you may want to consider "studying" at The Arthritis University. Produced by McNeil Consumer Healthcare, in consultation with Canadian Rheumatologists, GPs and The Arthritis Society, the newly launched CD-ROM is designed to support doctors in refining their diagnosis and treatment of musculoskeletal conditions. MAINPRO-M2 accreditation is available.

"With the prevalence of arthritis growing at such a rapid pace, and newer treatments for the disease being developed all the time, we saw a need to provide some context on the critical issues of diagnosis and management," said Dr. J Carter Thorne, Rheumatologist, Medical Coordinator of The Arthritis Program (TAP) at York County Hospital, and chairman of the Teaching Faculty of The Arthritis University. "And when we considered the time constraints that physicians face, we decided to take advantage of the available technology."

The virtual campus has three larger buildings: a lecture hall, where expert faculty provide key insights into arthritis and discuss epidemiology, diagnosis, treatment and patient issues; a library which is filled with practice management tools such as treatment matrices and algorithms, as well as web links and an arthritis prevalence calculator; and a clinic/laboratory where users can access six patient case studies with accompanying video and commentary.

The CD-ROM also in-cludes a campus building for The Arthritis Society outlining its programs and services as well as downloadable patient information, and the McNeil building , which offers physicians an osteoarthritis CME toolkit complete with downloadable slides. "Clearly, one of the benefits of learning via CD-ROM is that it allows physicians to learn at their own pace, and to revisit areas of particular interest," said Dr. Thorne.

According to Dr. Thorne, one of the primary focuses of the CD-ROM is diagnosis, which emphasizes the need for a thorough case history. "Correctly diagnosing patients leads to more appropriate treatment plans. The pain experienced in mild to moderate osteoarthritis, for example, is primarily related to the mechanical nature of the disease as opposed to the presence of inflammation. In these situations, it may be more appropriate to prescribe a simple analgesic."

According to Denis Morrice, President of the Arthritis Society, The Arthritis University is a valuable tool for sorting through the huge volume of information on the disease. "Ongoing research has enabled us to gain a vast amount of knowledge about arthritis. The key now is to ensure that all of this information filters down to the people who need it most…"

To obtain a free copy of The Arthritis University, please call McNeil Consumer Healthcare at 1 800 265-7323.

Michelle Durkin, BSc

The most common form of cancer today is skin cancer. Approximately half of all new cancers diagnosed are one of three defined types: basal cell carcinoma (BCC) , squamous cell carcinoma (SCC), or malignant melanoma (MM). Although the age of diagnosis is decreasing, most skin cancers do not appear until after the age of fifty, making this disease a serious threat to the elderly population. Fortunately it is also a disease which is successfully treated if detected early.

Epidemiology
The incidence of nonmelanoma (BCC and SCC) and MM skin cancers has increased so significantly over the past few decades it may have reached epidemic proportions, particularly in the United States and Canada. It has been projected by the National Cancer Institute along with the Center for Disease Control that in 1999 alone, skin cancer (all types combined) will claim the lives of nearly 9,200 people in the United States. Besides increasing annual incidence, more women are getting skin cancer and people are getting skin cancer at younger ages.

Individual types of skin cancer follow different morbidity and mortality distributions. About 80% of skin cancers are BCC, 16% SCC, and 4% MM. The mortality rate for nonmelanoma skin cancer is decreasing and that of melanoma is increasing.

Lilia Malkin, BSc

Breast cancer has the dubious distinction of being the most frequently diagnosed neoplasm and the second leading cause of cancer deaths in Canadian women today. Since the incidence of breast cancer increases with age, its appropriate diagnosis, management, and prevention are highly important in the geriatric population.

Epidemiology
A widely quoted statistic is that one in nine Canadian women will develop breast cancer in her lifetime, while one in twenty-five will die from it. The National Cancer Institute of Canada (NCIC) estimates that 18,700 Canadian women will be diagnosed with breast cancer and that 5,400 will succumb to it in 1999. In Ontario alone, more than 7,000 new cases are reported and approximately 2,000 women die each year. Although breast cancer affects men as well as women, male patients make up less than one percent of all cases. In 1994, when nearly 16,000 Canadians were diagnosed with breast cancer, only 97 of them were male.

Breast cancer remains a significant contributor to morbidity and mortality in the female geriatric population. More than 50% of breast cancer patients are older than 65 at diagnosis. According to NCIC's 1999 estimates, 6,000 of the new breast cancer cases will occur in Canadian women aged 70 and over.