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.

Anna Liachenko, BSc, MSc

While non-pharmacological approaches are clearly beneficial for prevention of osteoporosis (OP), for many women these measures are not enough and a pharmacological treatment is required. Until early this decade, this meant one choice, hormone replacement therapy. Now, non-hormonal bisphosphonate treatments are also available. Both approaches are comparably efficient in preventing bone loss, at least on repeat bone mineral density testing. Some experts are also advocating slow-release fluoride, and combination therapy is also increasing. However, treatment choice is a complex decision which should only be made after careful consideration of the risks and benefits of each treatment, by the patient and her physician.

Before reviewing particular classes of drugs, physicians need to remember that all patients at risk for OP or with proven OP should be taking calcium and vitamin D in appropriate doses (see Fracture Prevention Part 1).

Sonya Lytwynec, RegN, BScN,
Michael Borrie, BSc, MB, ChB, FRCPC
Southwestern Ontario Regional Geriatric Program: Continence Outreach

Urge urinary incontinence is one of five types of incontinence.¹ The assessment and therapeutic interventions associated with urge incontinence will be reviewed in this third article of a five-part series on urinary incontinence. The first article in this series provided an overview of the prevalence, types and treatment of incontinence in the frail elderly; the second discussed stress urinary incontinence.

Urge incontinence is defined as the involuntary loss of urine associated with the urgency to void. It is the most common type of incontinence in those individuals over the age of 60. Several studies report that urge incontinence occurs predominantly in men (73.3%), followed by mixed incontinence (19.1%), and stress incontinence (7.6%). The prevalence of urge incontinence in women is reported at 22%, and mixed incontinence at 29%.² Older women often experience combined symptoms of stress and urge incontinence called mixed incontinence. Patients with urge incontinence often suffer severe emotional distress, social embarrassment and isolation.

The severity of urge incontinence symptoms vary from occasional urine losses on the way to the bathroom to sudden, uncontrollable "flooding" without warning.

Thomas Tsirakis, BA

Late Onset Schizophrenia (LOS) is a rare disorder with a prevalence rate of less than 1 percent within the general population. LOS applies to those individuals who develop schizophrenia after the age of 40. The existence of LOS as a disorder separate from schizophrenia has been wrought with controversy, due mostly to a lack of consensus between European and North American medical standards. The general lack of agreement between the world's medical communities, as well as the overlapping of clinical features between LOS and other psychiatric disorders, has often resulted in misdiagnosis and confusion. In North America, LOS was completely eliminated from the third revised edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IIIR) of the American Psychiatric Association after the release of DSM-IV in 1994, and is now classified utilizing the same criteria as schizophrenia. The European medical community, however, still considers it to be a separate, yet related entity, with its own distinct symptomatology, and continues to define it utilizing DSM-IIIR criteria.

SMH Alibhai, MD, FRCPC

As any physician knows, stroke is a common cause of morbidity and mortality in older patients. Strokes can be divided into three major aetiological groups--haemorrhagic, thromboembolic, and lacunar. Practically speaking, if neuroimaging does not show evidence of haemorrhage, physicians will generally treat patients who present with an acute stroke (or a transient ischaemic attack (TIA), for that matter) with either antiplatelet or anticoagulant therapy. For patients with a well-documented embolic source (e.g. atrial fibrillation), warfarin is the treatment of choice. For all other patients with non-haemorrhagic stroke, the treatment is traditionally antiplatelet therapy.

However, there are several options within antiplatelet therapy. The standard drug has been acetylsalicylic acid (ASA), or aspirin. At least four large randomized controlled trials revealed Ticlopidine to be slightly more effective in reducing the incidence of strokes and TIAs than aspirin, although it was more costly and more toxic.¹ However, a later meta-analysis of 145 studies suggested ticlopidine was probably as equally effective as aspirin.² Although newer antiplatelet agents are on the horizon (e.g.