Anna Liachenko, BSc, MSc

A large body of observational evidence suggested that estrogen replacement therapy (ERT) after menopause decreases a women's lifetime risk of death from myocardial infarction by 35 to 50 percent and increases life expectancy by 2 to 3 years. However, a recent major clinical trial concluded that estrogen plus progestin therapy did not decrease the overall risk of myocardial infarction and coronary death among postmenopausal women with previous heart disease. The main question raised by the results of the trial is whether doctors should change their prescribing patterns and which patient populations will be affected. While there is no simple answer, it is important to consider the issues involved such as, How serious were the limitations of the observational research? Did the trial look at the right group of patients? How far can we extrapolate the results? And what are the future implications?

The Heart and Estrogen/progestin Replacement Study (HERS) trial was a randomized, blinded, placebo-controlled trial designed to test the efficacy and safety of hormone replacement therapy (HRT, estrogen plus progestin) on secondary prevention of heart disease. The trial involved 2763 postmenopausal women with established coronary artery disease. In the HRT group, the rate of coronary events increased by 50% in the first year of the trial and subsequently decreased by 40% in the forth and fifth years, yielding no significant effect overall.

Rhonda L. Witte, BSc

Skin--we clean it, shave it, cream it and tan it, all with a common goal--to preserve our youthful image. Not only does it help our general appearance, but it also feeds our self-image, making us "feel" younger. In a society where younger parallels attractiveness, we find ourselves constantly in search of new remedies to prevent our skin from aging . On the other hand, aging is a sign of wisdom and the more signs we have, the better we look. Can't we just age without looking older? And is what we consider to be aging of the skin really due to the aging process itself?

Cutaneous aging is a result of both intrinsic and extrinsic events. Intrinsic aging, also referred to as chronological aging, occurs independently of environmental influences. The changes seen with intrinsic aging occur in sun-protected areas. It is this characteristic that sets it apart from extrinsic aging which occurs as a result of environmental effects on the skin, the most important of which is exposure to sunlight.^1,2 The term "photoaging" refers to the age-related cutaneous changes resulting from exposure to sunlight and accounts for the majority of changes generally associated with appearance.

Michele Kohli, BSc, MSc

The persistence of influenza in the North American population has not been completely explained by epidemiologists.¹ During the last influenza season (1997-98), there were 5,148 laboratory confirmed cases of influenza in Canada (see Table 1).² The elderly population, those aged 65 years and above, are particularly susceptible to this disease. Over 95% of the deaths caused by influenza occur in this age group, in part, because of the higher prevalence of congestive heart failure and lung disease.¹ Last year, the occurrence of influenza peaked between January and March.² When the prevalence of influenza is high in a population, patients presenting with a febrile respiratory illness along with symptoms such as myalgia, headache, sore throat and cough are often diagnosed as having influenza.¹ However, the gold standard for diagnosis is laboratory detection of the virus in nasopharyngeal swabs.¹ The genes of the influenza virus mutate frequently, causing the antigenic molecules of the virus to change, resulting in the emergence of new viral sub-types. This process is known as antigenic drift. When human and swine or avian strains of influenza A recombine, the resulting new subtypes can cause pandemics.

Michelle Durkin, BSc

The skin is the largest organ of the body and the most visible. Ironically its importance in health promotion can be easily overlooked, especially in elderly patients. Because the skin is the first line of defense against infection, disease, and injury, proper skin care is always important. As the skin ages, however, the importance of its care increases, because structural changes occur which are responsible for compromised skin functioning (see Table 1) and a transformation in appearance (see related article on the aging skin: Wrinkles, Age-spots and Spider Veins Primary Aesthetic Concerns).

D'Arcy L. Little, MD*
Anu Kumar, MD**
*Chief Resident, Family Medicine. Sunnybrook Health Science Centre, North York, Ontario
**Radiology Resident, Mount Sinai Hospital, Toronto, Ontario

As our society ages, dementia increases in prevalence. Although uncommon before age fifty, it is estimated that 10% of those over age 65 years, and up to 40% of those over age 85 years suffer from a type of dementia. Although there are over 70 different causes of dementia, Alzheimer's Disease (AD) is the most common type (See Table 1) . Some conditions that cause dementia can be treated and this can alleviate or occasionally resolve the dementia. As a result, patients with cognitive impairment should undergo appropriate investigation to assess any potential for reversibility.

Alzheimer's Disease is a progressive neurodegenerative disease with characteristic clinical and pathological features. A definitive diagnosis of AD requires the analysis of brain tissue, usually at autopsy, looking for the classic features of cortical atrophy, synaptic and neuronal loss, amyloid angiopathy, neuritic plaques with an amyloid core, neurofibrillary tangles with paired helical filaments, and localized inflammatory reaction. However, the combination of clinical features, and appropriate laboratory and/or radiologic techniques results in a diagnostic accuracy of approximately 80 percent.

Sharron Ladd, BSc

The Baycrest Centre for Geriatric Care hosted the Dr. Ira Pollock Clinic Day entitled "Issues in Geriatric Medicine," on November 27th. The morning session was comprised of short lectures followed by afternoon workshops. The event, chaired by Dr. Michael Gordon, proved to be both a humorous and sobering experience.

"It used to be common practice to recommend patients stop taking anticoagulants if they are going to the dentist," began Dr. John A. Blakely, director of the Anticoagulation Clinic at Sunnybrook Hospital in Toronto, in his lecture on anticoagulation. A recent study concluded that there were no serious bleeding problems in patients remaining on anticoagulants while receiving dental care (Arch Int Med 1998;158(15):1596-608). Patients should remain on anticoagulants if going for dental work.

Blakely concluded his talk advising that atrial fibrillation (AF) must be treated with warfarin, not aspirin. He admitted that anticoagulants are difficult to prescribe. There are a lot of tests involved, numerous telephone calls, collecting of patient information and discussions with family, for only $9 a month. Conversely, aspirin is easy to prescribe. Despite difficulties, warfarin is the drug of choice for AF!

In a section on fall prevention and assessment, Dr.

Lilia Malkin, BSc

A fracture is often the first clinical sign of osteoporosis (OP), the silent disease of skeletal fragility characterized by decreased bone mass and deterioration of bone tissue that results in an increased vulnerability to fractures.

The bone mineral density (BMD) criterion frequently used to define osteoporosis was set in 1994 by the World Health Organization (WHO) as more than 2.5 standard deviations below the "young adult mean." An estimated 1.4 million Canadians suffer from OP. In the population aged 50 and over, approximately one in four women and one in eight men are affected. The incidence of the disease increases with age: 70 percent of women have osteoporosis by the age of 80. Predictably, the fracture risk rises with age, with women at higher risk due to both more extensive bone loss and longer average life span. Osteoporotic fractures make a significant contribution to morbidity and mortality in the geriatric population. For instance, the mortality rates within one year of hip fracture are estimated at between 12 and 37 percent, while the average death rate in octogenarians is 2.6 percent per year.

Unfortunately, OP is often asymptomatic prior to the occurrence of a fragility fracture, a break that occurs in the absence of major trauma to the affected bone. The best predictor of fracture risk is low bone density.