Michele Kohli, BSc, MSc

The Osteoporosis Society of Canada estimates that 1.4 million Canadians have osteoporosis (OP). As discussed in the Clinical Practice Guidelines for the diagnosis and management of osteoporosis,¹ the Society recommends several treatments to improve bone mineral density (BMD) and decrease an individual's risk of fracture.¹ Since BMD loss occurs in all people as they age, the challenge is to decide which individuals have a low enough BMD to warrant preventive treatment. The Osteoporosis Society of Canada endorses using the World Health Organization definition of OP to decide whether or not BMD loss is significant enough to increase the risk of fracture. This definition utilizes the spectrum, or distribution, of BMDs found in young adults. Any individual whose BMD is at least 2.5 standard deviations below the mean for this distribution is said to have OP.¹

Several risk factors for OP and OP-related fractures have been identified, including: older age, female gender, low body weight, cigarette smoking, family history of fracture, history of fragility fractures, loss in height, hyperthyroidism, immobility/ inactivity, calcium or vitamin D deficiency, use of certain pharmaceutical agents (benzodiazepines, anticonvulsants, corticosteroids, heparin) and alcoholism. These risk factors only account for about one third of the risk of having an OP-related fracture.

Rhonda Witte, BSc

Our body's framework is subjected to continual use throughout our daily rituals. Whether we are walking, lifting, exercising or even rolling over in bed while we sleep, we depend on our skeletal system to function adequately. Amazingly, it handles a lot of use and is incredibly reliable. With age, however, our framework becomes less capable of withstanding the "wear and tear" of every day life. Research provides insight into the mechanisms behind the "normal" aging of the skeletal system. With this knowledge, we are gradually learning ways to counteract the effects of aging bone.

Lawrence Papoff

Warfarin is an important tool in the prevention of thromboembolisms. Prescribing the drug to the elderly, and monitoring their progress while on the drug, however, are becoming increasingly complex matters, requiring careful attention to patient's blood levels, as measured by International Normalized Ratios (INRs) and in-depth knowledge of the patient.

Michele Kohli, BSc

Congestive heart failure (CHF), a clinical syndrome caused by failure of the left or right ventricle, is a leading cause of chronic illness in older persons. In the United States, CHF is the most common cause of hospitalization among those aged 65 years and above. Each year, approximately 400,000 Americans are diagnosed with CHF. Few statistics regarding CHF in Canada have been compiled, but the Heart and Stroke Foundation estimates that 200,000 to 300,000 Canadians have the syndrome. The incidence of CHF appears to be increasing in both Canada and the United States.

An individual's risk of developing CHF increases exponentially as a person ages (See Figure 1), due to age-related changes in the heart structure and function. Physiological and pathological alterations affecting heart rate, preload, afterload and contractile states of the heart reduce cardiac output (See More Fat, Less Specialized Cells in Old Heart). Concurrent changes in the kidney, respiratory and nervous systems may further impair the function of the heart. Congestive heart failure is a syndrome with multiple etiologies.

Early diagnosis of CHF greatly improves the success of treatment.

Sonya Lytwynec, RegN, BScN
Nurse Clinician, Southwestern Ontario Regional Geriatric Program: Continence Outreach

Stress urinary incontinence (SUI) is one of five types of incontinence.¹ The assessment and therapeutic interventions associated with stress incontinence will be reviewed in this second article of a five-part series on Urinary Incontinence.

SUI is defined as urine loss coincident with an increase in intra-abdominal pressure in the absence of a detrusor muscle contraction or an over-distended bladder.² SUI is a term used in reference to symptoms, physical findings or conditions. Coughing, sneezing, laughing, lifting, or bending over along with simultaneous urine loss often indicates SUI. However, in complex or unresolved cases, urodynamic testing may be beneficial to differentiate between SUI and other types such as urge incontinence.

Prevalence studies report variable results according to definition and design. Subjective reports of SUI in community-dwelling elderly women (65 years of age or older) ranged between 12% and 17%, while urodynamic studies at a urological clinic estimated prevalence rates of SUI at 16% for females and 2% for males.³

SUI in males is commonly the result of intrinsic sphincter deficiency (ISD) post prostatectomy.

Paul WM Fedak, MD

Myocardial revascularization is a scarce resource where demand exceeds supply. Waiting lists for these procedures are increasingly lengthy and the growing elderly population with advanced coronary artery disease (CAD) challenges physicians to consider the appropriateness of our contemporary revascularization procedures. Despite the current period of accelerating resource demands, resource allocation decisions regarding myocardial revascularization should not be made on the basis of age alone. Available evidence suggests that definitive revascularization strategies significantly benefit appropriately selected elderly patients but have been underused. Guidelines in the management of the elderly patient with CAD will help to ensure that resources are rationed fairly and that interventions are directed at prolonging life with an improved state of health. The ultimate goal of revascularization in CAD is to optimize symptom-free survival at a reasonable cost and with minimal morbidity.

Jocalyn P. Clark, MSc

The link between hyperlipidemia (elevated cholesterol levels) and coronary artery disease (CAD) is well established in adult populations, for which there are a variety of preventative and treatment strategies. Research has not typically included older patients in large numbers, therefore extrapolation of evidence to the care of older people can be difficult. Controversy exists about both diet and drug options for cholesterol treatment in the elderly, especially among those 75 years and older, suggesting that careful consideration and caution is required in determining 'whom' and 'how' to treat. Since the majority of cardiovascular disease occurs above the age of 65, especially in women, treatment of hyperlipidemia in the elderly is an important challenge.

In considering treatment options for hyperlipidemia in elderly patients, a recent review in Drugs and Aging suggests that target low density lipoprotein cholesterol (LDL-C) levels should be <3.2 mmol/L, with total cholesterol levels aiming to be <5.2 mmol/L.

Thomas Tsirakis, BA

Attempting a home visit on a paranoid patient often presents the clinician with a number of difficult challenges. These include: gaining and maintaining the patient's trust, addressing the patient's concerns without reinforcing their suspicions or delusions, attempting to physically examine the patient, the avoidance of becoming incorporated into a patient's delusion(s) and avoiding personal injury when confronted with a potentially violent patient.

The term paranoid describes those individuals who display "fixed suspicions, delusions of reference, jealousy, or persecution, dominant ideas or grandiose trends, which are logically elaborated with due regard for reality once a false premise has been accepted." It is important to remember that paranoia is only a symptom of an underlying pathology and is not a diagnosis. Thus, if the patient is unknown to the clinician, it is important to determine (via family or the patient's physician) whether the paranoia is of acute onset or chronic in nature and whether it has already been medically addressed.

There are a number of factors (some reversible) which may generate paranoid reactions in the elderly, and should be completely ruled out (see Table 1).

The Alzheimer Society announced August 18th a commitment of over $1.2 million to further the cause of Alzheimer research in Canada. Since 1989, the Society has funded both biomedical and psychosocial research in an effort to find a cause and cure for the disease and find improved methods of caregiving and delivering services to people affected by Alzheimer Disease (AD).

Dr. Marilyn Miller of McGill University in Montreal is one of the 20 researchers across Canada receiving funding. Dr. Miller is investigating the role that estrogen plays in AD. Alzheimer Disease affects more women than men and affected women score lower than men in performance scores. Previous research has indicated that women given estrogen replacement therapy showed improved cognitive function. Dr. Miller seeks to determine why this occurs and whether estrogen could be used as a treatment for the disease.

In an effort to enhance care for those with AD, Dr. Marian Campbell of the University of Manitoba in Winnipeg will use her grant to research eating and feeding issues of people with AD. Those with the disease are at risk of malnutrition and weight loss because of under consumption of food and liquids. Eating-related difficulties contribute to these problems and can make meals difficult and emotionally taxing for both the caregiver and the person with the disease. Dr. Campbell's research will examine the challenges encountered and strategies used by caregivers in the home to determine how food preparation, environmental adaptations and the promotion of independence in eating can enhance the eating experience of people with AD.

Other projects the Society is funding include research on the role of anti-inflammatory drugs, amyloid-beta protein, managing challenging behaviours and reducing vehicle crash injuries.

While the Society's $1 million commitment to research is significant, Alzheimer research in general remains severely underfunded. "There is such potential for Alzheimer research in this country; Canadians are leaders in Alzheimer research", says Dr. Peter Scholefield, Chair of the Research Policy Committee of the Alzheimer Society of Canada. "Unfortunately, funding is not keeping up with the need. Especially with the aging baby boom population, there is an urgent and immediate need for more Alzheimer research funding."

Funding for the Joint Alzheimer Society Research Program includes contributions from provincial and local Alzheimer Societies across Canada, individuals, and corporations including key leadership gifts from Bayer Healthcare, Extendicare Health Services and the Royal Bank of Canada Charitable Foundation.

For a complete listing of the 1998-1999 research grants and awards, look under "Research", then "Research Program" on the Alzheimer Society of Canada Web site: www.alzheimer.ca or call Debbie Krulicki at (416) 488-8772 ext. 232.

Roger Y.M. Wong, BMSc, MD, FRCPC
Division of Geriatric Medicine, Department of Medicine, University of British Columbia, Vancouver, BC

Together with history taking, physical examination plays an integral part in formulating clinical diagnoses in the elderly patient. While the task of conducting a detailed and proper physical examination in a patient aged 65 years or above may appear daunting at first glance, we should remember that the technical aspects of the physical examination are almost identical to those used in the adult patient. The real challenge comes when we have to interpret the clinical meaning of physical findings identified in the elderly, especially when we have to differentiate between age-related changes and disease-specific changes of different organ systems. This article will highlight the common changes observed in the examination of the cardiovascular system in the elderly patient. As always, every patient encounter is a unique experience, and the relevant physical findings should be interpreted within the clinical context of the patient.

Before we begin to examine the cardiovascular system in the elderly, we must first ensure that the patient is comfortable. Good bedside manner, such as proper draping, is just as important in those above 65 years old as in their younger counterparts.