Joyce So, BSc

Benign prostatic hyperplasia (BPH) is a non-malignant condition of nodular but symmetrical enlargement of the prostate in the peri-urethral region, likely due to androgen imbalances associated with aging. It is common in men over the age of 40, regardless of ethnic background. The incidence of BPH can be as high as 50% by the age of 60, and 90% by age 85.¹ This makes BPH a condition of increasing importance as the population ages.

Because of its proximity to the urogenital tract, prostatic enlargement most commonly presents as obstructive lower urinary tract symptoms, although some are asymptomatic (see Figure 1). Bladder outlet obstruction, causing incomplete emptying and subsequent rapid filling, results in urgency, frequency, and nocturia as the primary presenting complaints. The weak and reduced urinary stream in BPH produces hesitancy, intermittency and post-void dribbling. Urinary retention and stasis predispose BPH patients to infection, which can cause bladder and upper urinary tract inflammation, as well as calculus formation. In severe, prolonged obstruction, there is a risk of hydronephrosis and progressive renal failure and azotemia.

Figure 1. Location of the prostate gland in relations to the urogenital tract

Anna Liachenko, BSc, MSc

Despite potentially serious side effects, non-steroidal anti-inflammatory drugs (NSAIDs) are currently one of the very few options available for alleviating chronic pain and inflammation. Over the past 30 years, scientists searched for safer NSAIDs and managed to create the 20 different drugs and 40 dosing options currently available in Canada. While some of the newer drugs turned out to be safer than others, their design was based largely on trial-and-error. A recent major breakthrough in the understanding of the molecular mechanisms of NSAID action allowed researchers to methodically design a new class of NSAIDs. These new drugs, the Cox-2 Inhibitors or C-2SIs, are not only comparable to the older NSAIDs in efficacy but are also (at least in theory) devoid of some of the most serious side effects. One of these drugs, celecoxib (Celebrex) has just become available in the US and Canada. Another, rofecoxib (Vioxx) is under review by the Food and Drug Administration (FDA) in the US and the Health Protection Branch (HPB) in Canada. Moreover, increased safety of some of the previously approved NSAIDs is now thought to be attributed to the same molecular mechanism. Newly arriving NSAIDs as well as the best NSAID options currently available in Canada are discussed below.

Lilia Malkin, BSc

Heart disease is a major cause of morbidity and mortality in the geriatric population. According to Health Canada, myocardial infarction (MI) and ischemic heart disease (IHD) accounted for over one-third of deaths in men and women aged 65 and older in 1995, once again firmly establishing coronary artery disease (CAD) as the leading cause of mortality in Canada. In Ontario, 23 percent of patients die within one year of experiencing MI and one-third of congestive heart failure (CHF) patients succumb within one year of being hospitalized for CHF. Importantly, as Dr. David Naylor, co-editor of the 1999 Institute for Clinical Evaluative Sciences (ICES) Cardiovascular Atlas points out, the Canadian demographic profile is shifting toward a larger geriatric population, potentially greatly increasing the number of Canadians vulnerable to heart disease. Therefore, it is imperative that both primary and secondary prevention methods be used as extensively as possible to reduce the morbidity and mortality due to CAD.

Rhonda L Witte, BSc

The immune system is an elegant example of nature's work. When functioning properly, it protects us against what is "foreign" and does not attack the "self". Throughout an individual's life, changes occur within the immune system which make defense mechanisms less effective. Immunogerontology--the study of the aging immune system--is an up and coming field of research that will help build our knowledge, not only about the aging immune system, but also about the immune system in general.

The Immune System

Our immune system can be broken down into two interacting components: innate (natural) immunity and acquired (specific) immunity.¹ Innate and acquired immunity differ regarding the effector cells and molecules that carry out their specific and essential functions. Natural immunity is composed of defense systems that are present before exposure to foreign macromolecules and infectious microbes. Physical barriers (i.e. the skin) phagocytic cells and eosinophils, a specific class of lymphocytes called natural killer cells, and a range of blood-borne molecules (i.e. soluble proteins of the complement cascade) make up the natural immune system.² Acquired immunity requires stimulation by exposure to foreign molecules and includes sub-types of lymphocytes (e.g. B- and T-cells), cutaneous and mucosal immune responses and antibodies which circulate to find their target.

Thomas Tsirakis, BA

Bipolar disorder is a recurrent and potentially incapacitating illness affecting a person's mood and behaviour, which manifests itself in different ways throughout its course (Table 1). The first episode of bipolar disorder may be manic, hypomanic (milder form of mania with elevated mood), mixed (both mania and depression), or depressive. Due to the extremely variable nature of the illness, it may present itself differently from patient to patient in terms of the severity and duration of episodes. Often, the type of episode an individual experiences may also follow a seasonal pattern (e.g. hypomanic in the summer and depressed in the winter.) With proper intervention, some people recover completely between episodes and may experience years of symptom-free relief, while others may experience continuous low-grade depression and mild mood swings throughout the course of their lives.

Bipolar disorder is classified according to the symptoms that an individual experiences. In Bipolar I Disorder, an individual will have one or more manic episodes, or mixed episodes, lasting at least one week. Many also experience at least one major depressive episode. In Bipolar II Disorder, a person will have one or more major depressive episodes accompanied by at least one hypomanic episode but no manic episodes.

Eleanor Brownridge

Since access to assistive devices is not a federally-mandated program, financial assistance for canes, wheel chairs and braces for patients with arthritis varies considerably from province to province. In fact, the majority of provincial health plans cover none of these aids.

The Ontario Ministry of Health does have an Assistive Devices Program (ADP) which covers a portion of the cost of manual and power wheelchairs, scooters and walkers, back supports, and specialized canes for people with long-term disabilities. ADP pays up to 75 percent of a predetermined price, with the patient paying the remaining 25 percent directly to the vendor at the time of purchase. For those on social assistance, the program will cover 100 percent of the cost. "To access this program, your patient must have a valid Health Card and the device must be authorized by a physiotherapist or occupational therapist registered with the program," says Robert Jankowski, a public information officer with ADP. There are currently over 5,000 registered authorizers working in hospitals, home care agencies or private practice. Physicians or patients can call 1-800-268-6021 to obtain the name of local health professionals authorized to access this program or speak with the local CCAC/Home Care Coordinator for further information.

Hand deformity typical of rtheumatoid arthiritis

Novel Biological Therapy for Rheumatoid Arthritis Looks Promising

Ruwaida Dhala, BSc, MSc

Rheumatoid arthritis (RA) is the most common autoimmune disease worldwide. RA primarily affects joints of the extremities, particularly the fingers. The disease is characterized by chronic inflammation of the synovial joints resulting in joint destruction and deformity. RA occurs both in children and adults. The peak incidence of RA is between the ages of 30 and 50 and occurs more frequently in women than in men.¹ The clinical manifestations of the disease include peri-articular soft tissue swelling, joint pain and joint stiffness. Like most autoimmune diseases, there is a genetic susceptibility to RA (see related article on Unravelling the Genetic Mystery of Arthritis). T cells appear to be important in disease initiation whereas monocytes are implicated in disease progression.

Naushad Hirani, BSc, MD*

The seronegative arthritides, also commonly referred to as the spondylo-arthropathies because of their predilection for involving the spine, are inflammatory diseases that can be distinguished from the more common rheumatoid arthritis and osteoarthritis based on several general characteristics. In addition to being, by definition (with rare exceptions), rheumatoid factor negative (as opposed to rheumatoid arthritis), they also have distinct patterns of articular and extra-articular involvement, and most exhibit an association with the HLA-B27 gene.

The main conditions encompassed by this classification include Psoriatic arthritis (PSA), Reactive arthritis or Reiter's syndrome, and Inflammatory bowel disease-associated arthritis, although Ankylosing spondylitis⁼ (AS) is the prototypical seronegative disease. The key features of each of the seronegative arthritides are summarized in Table 1. From a geriatric standpoint, most of these conditions are not diagnostic challenges, as they are generally diseases that present in young or middle-aged people. However, an understanding of the group of diseases is helpful for the management of patients in the chronic state, and particularly in the case of distinguishing PSA from rheumatoid arthritis. Many of the features of the seronegative arthritides can be illustrated by first considering AS.

Extracts from the leaves of the Ginko biloba tree and Vitamin E are just two of the therapies being investigated for the treatment of Alzheimer's Disease

Try Combining Donepezil and Vitamin E for Alzheimer's

Neil Fam, BSc, MSc

Alzheimer's Disease (AD) is a chronic neurodegenerative disorder characterized clinically by a gradual onset of progressive memory loss with deterioration in patients' social and occupational function. Changes in mood, behaviour and perception are also problematic aspects of the disease. Neuropathologically, AD is associated with the formation of amyloid plaques and neurofibrillary tangles, with impaired synaptic function and neuronal cell death. In particular, patients with AD suffer the loss of cholinergic, noradrenergic and dopaminergic neurons. Loss of acetylcholine neurotransmission in brain areas involved in learning and memory is thought to underlie many of the cognitive symptoms of AD. This concept forms the basis of current therapeutic strategies which aim to increase available acetylcholine levels in the brain by inhibition of acetylcholinesterase.

Dr. A. Mark Clarfield is the Chief of Academic Affairs at the Sarah Herzog Hospital in Jerusalem and a staff geriatrician of the Division of Geriatric Medicine, Sir Mortimer B. Davis-Jewish General Hospital, McGill University, Montreal. We regret that Dr. Clarfield's articles are not available on-line.