Andrea Sotirakopoulos, BSc

Atrial fibrillation (AF) is one of the most common sustained arrhythmias encountered by clinicians. Its incidence increases with age and the presence of structural heart disease, although it may also be present in patients without identifiable heart disease. When healthy, the atria contract at a rate that is coordinated with the contractions in the ventricles. In AF instead of beating effectively, the atria produce numerous chaotic electrical impulses that result in a non-organized, quivering movement of the heart muscle called fibrillation. As a result, the ventricles then beat too quickly, generating a rapid pulse rate and possibly allowing the blood to pool and clot. If a piece of the blood clot in the atria becomes lodged in an artery in the brain, a stroke occurs. A rapid or irregular heart rate during AF can cause symptoms such as palpitations, exertional breathlessness, fatigue, or hypotension. AF may be classified as Paroxysmal, defined as recurrent episodes reverting spontaneously or following treatment to sinus rhythm or Chronic, referring to persistent arrhythmia.

Treatment of AF should be of special interest to doctors treating the elderly. The prevalence of AF is 0.5% for the group aged 50 to 59 years and rises to 8.8% in the group aged 80 to 89 years.

Barry J. Goldlist MD, FRCPC, FACP

The first five international conferences on Alzheimer's Disease were meant for scientists, as there was essentially nothing available for clinical use. This year's meeting was quite different. The recent licensing of donepezil in Canada and the United States will soon be followed by numerous new drugs, many of which will have novel modes of action. The importance of Canadian research in this field was highlighted by the active participation in the program of Howard Feldman (Vancouver), Serge Gauthier (Montreal) and Ken Rockwood (Halifax). One of the keynote presentations was by Peter St. George Hyslop, Director of the Centre for Research in Neurodegenerative Disorders at the University of Toronto.

The meeting still emphasized basic science, particularly in the area of molecular genetics and molecular biology, but there were more than enough sessions for clinicians and clinical investigators. One interesting symposium concerned itself with the design of clinical trials for demonstrating disease course-altering effects (rather than just symptomatic improvement). It seems that for the immediate future, staggered start and withdrawal design will be the standard. The theory is that if a drug truly alters the disease course, patients starting the active drug later (i.e. placebo changed to active drug) will never achieve the same benefit as the group started on active drug (i.e. active drug to active drug). Similarly, early withdrawal patients (i.e. active drug changed to placebo) would have a better end result than patients never on active drug (placebo to placebo). Preliminary evidence was presented that suggested a new drug, propentofylline, might have such an effect. This drug is not a cholinesterase inhibitor such as donepezil, but rather is felt to be a microglial cell modulator, and thus inhibits some of the inflammatory response seen in various dementias.

Farther from clinical applicability, but still exciting was a round table discussion entitled "Beyond Cholinesterase Inhibitors: Toward the Next Generation of AD Therapeutics." Presentations on possible therapeutic interventions, such as modulating b-amyloidogenesis, inhibiting neurofibrillary degeneration or using muscarinic agonists. It seems quite likely that the 7th International Symposium in the year 2000 will be even more exciting for clinicians.

Lilia Malkin, BSc

Contrary to popular belief, heart disease is not predominantly a "male" illness: according to Health Canada, nearly 20,000 Canadian women, compared to approximately 24,000 men, died of causes related to ischemic heart disease in 1995.

As awareness of women's vulnerability to cardiovascular disease increases, so does the number of clinical studies that address potential differences between men and women in coronary heart disease (CHD) presentation, course, and treatment. Notably, Dr. Beth Abramson, Director of Women's Cardiovascular Health in the Division of Cardiology at St. Michael's Hospital in Toronto emphasized that there are many issues in cardiology where treatment is irrespective of gender. However, recent research shows that several cardiac health issues may be specific to women, such as risk perception, heart disease presentation, use of diagnostic and treatment procedures, as well as some unique risk factors.

Unfortunately, many North American women do not perceive cardiovascular disease as a considerable health risk and focus their attention predominantly on illnesses affecting reproductive organs, as well as breast cancer. However, CHD is the leading cause of death in Canadian women, especially older women. It is estimated that 1 in 3 North American women will die of heart disease, while 1 in 25 will succumb to breast cancer.

Kim Wilson BSc, MSc and Geriatrics & Aging Staff

A myocardial infarction (MI) is generally caused by a thrombus obstructing a coronary artery, resulting in death of heart muscle. Thrombi are usually caused by rupture of an atherosclerotic plaque on the wall of the coronary artery. About 50% of patients hospitalized for an acute myocardial infarction are elderly.¹ The majority of patients who develop complications (such as congestive heart failure) or die from their first MI are also over the age of 65. Clearly coronary artery disease is a significant cause of morbidity and mortality in seniors.

Primary prevention refers to risk factor modification to prevent a first MI, and includes education, lifestyle changes, and possibly pharmacological therapy in both younger and older men and women.

Rhonda Witte, BSc

Many alterations occur within the cardiovascular system with age. Structural changes can be noted through the pathological examination of aged hearts. The identification of such changes has helped us better understand the aging process. Research is also being conducted to reveal the changes in the aging heart at the cellular level.

Young adult heart (left) with the aging heart (right)

Growth and Structural Changes

Dr. Jagdish Butany of the Department of Laboratory Medicine and Pathobiology at The Toronto Hospital, General Division, outlined findings about age-related growth and structural changes associated with hearts of otherwise healthy, physically inactive persons over 65 years of age. In an interview, Dr. Butany stated that there does not appear to be any age-related changes at the ultrastructural level. Age-related changes can, however, be noted at the microscopic level.

Cardiac Valves

As one ages, changes in the valves are noticeable, particularly those concerning the aortic and mitral valves. An increase in the thickness of the aortic and mitral valves can be seen from decade to decade.

D'Arcy L. Little, MD
Chief Resident, Family Medicine, Sunnybrook Health Science Centre, North York, Ontario.

The proportion of the population over the age of 65 is growing rapidly. Currently over 12% of the population is in this age category, and by the year 2016 this proportion will increase to almost 16% (Statistics Canada). The incidence of coronary heart disease increases with age and is the leading cause of death among the elderly. In addition, elderly patients have on average a fourfold greater mortality from first and subsequent acute myocardial infarctions (AMI) than do younger patients. As summarized by Milzman in "An Introduction to Resuscitating the Ages" (Emergency Medicine Clinics of North America, February 1996) and Rich in "Therapy for Acute Myocardial Infarction" (Clinics in Geriatric Medicine, February 1996), some of this mortality can be attributed to age, as it is an independent negative predictive factor, and to various co-morbid illnesses which often accompany age. However, recent studies indicate that much of the increase in morbidity and mortality incurred by the elderly patient experiencing an AMI may be related to under-aggressive resuscitation and management.

ABCs

The presentation of AMI in the elderly is influenced by age-related changes and pre-existing disease.

The Canadian Society of Geriatric Medicine (CSGM) now has a homepage, which can be viewed at www.canger.org. The homepage has links to several hundred other internet sites specific to geriatric clinical care and research. Educational materials and cases, geared to physicians in geriatric practice are provided, as is a listing of recent job postings for geriatricians in Canada. A bibliography of all recent peer-reviewed publications by CSGM members is posted, as is the GAIN (Geriatric Assessment and Intervention Network) database.

GAIN is a clinical trials network for members of the CSGM. It is meant to facilitate and coordinate multisite clinical geriatric research in Canada by geriatrics trained physicians, residents and fellows in geriatric medicine, recognizing that most geriatric centres have at least some assessment and research infrastructure in place. Apart from individual projects, such as the Canadian Study of Health and Aging, collaborative geriatric research in Canada has been limited to date.

GAIN is NOT meant to focus geriatric research in particular areas, but instead to facilitate geriatric research that may currently be limited by lack of funding, insufficient sample size, lack of local interest, etc.

How GAIN Works

The CSGM website allows access to GAIN. The CSGM website will promote the exchange of information, scientific skills and research ideas across the country. Research ideas and research protocols can be securely posted at the website. Research ideas can be considered 'fishing expeditions', to attract additional help with developing a research protocol, or to determine general interest in a particular project by other CSGM members. For example, CSGM members interested in a particular project would communicate by e-mail to further develop protocols and compile results.

Access to posted GAIN research ideas and protocols is limited to CSGM members, as is access to the csgm membership and the e-mail addressbook.

Membership costs $50/year and is open to Phds and physicians whose primary focus is research and/or care of the elderly.

Contact Dr. Gary Naglie, at gary.naglie@utoronto.ca, CSGM secretary treasurer to join.

Teaching cases or educational materials, monthly columns, evidence based reviews of geriatric literature and other relevant material can be posted directly on the home page, or by contacting Dr. John Puxty at puxtyj@pccc.kari.net, Dr. Mike Newnham at miken@biostats.uwo.ca, or Gaetane Blom glblom@brktel.on.ca.

Please visit the CSGM home page at www.canger.org for more details.

The United Nations General Assembly decided to observe the International Year of Older Persons "in recognition of humanity's demographic coming of age" and the promise that holds for "maturing attitudes and capabilities in social, economic, cultural and spiritual undertakings" (General Assembly resolution 47/5, 1992).

For more information, visit the United Nations website at:

www.un.org/dpcsd/dspd/iyop.htm

The following are some quotes taken from the website:

Situation of older persons

"...the transition to a positive, active and developmentally oriented view of ageing may well result from action by elderly people themselves, through the sheer force of their growing numbers and influence. The collective consciousness of being elderly, as a socially unifying concept, can in that way become a positive factor" (International Plan of Action on Ageing, 1/para. 32).

Life-long individual development

"Ageing is a life-long process and should be recognized as such. Preparation of the entire population for the later stages of life should be an integral part of social policies and encompass physical, psychological, cultural, religious, spiritual, economic, health and other factors" (International Plan of Action on Ageing, para. 25 (i)).

Multi-generational relationships

"The respect and care for the elderly, which has been one of the few constants in human culture everywhere, reflects a basic interplay between self-preserving and society-preserving impulses which has conditioned the survival and progress of the human race" (International Plan of Action on Ageing, para. 27).

Development and the ageing of populations

"Countries should recognize and take into account their demographic trends and changes in the structure of their populations in order to optimize their development" (International Plan of Action on Ageing, para.13).

Michael J. Borrie, BSc, MB, ChB, FRCPC
Chair, Division of Geriatric Medicine, The University of Western Ontario

Prevalence studies of urinary incontinence in the elderly report widely-varying rates from 4.5-44% in healthy, elderly women to 4.6-24% in healthy, elderly men. The prevalence in institutionalized people ranges from 22-90%.¹

Choice of definition, wording of the questionnaire and study population contribute to this variability. The International Continence Society has defined incontinence as a condition in which involuntary loss of urine is a social or hygienic problem and is objectively demonstrated.² Based on the symptom complex, urinary incontinence is characterized as urge, stress, mixed, overflow, functional, or iatrogenic.

Urgency urinary incontinence is the most common type and is divided into sensory or motor urgency. Ambulatory or longer-term urodynamic studies have demonstrated involuntary detrusor contractions and calls into question the notion of sensory urgency. A new classification of overactive bladders has been proposed but has not yet been resolved.³ Detrusor instability is commonly associated with neurologic conditions such as stroke or Parkinson's Disease. It can also accompany prostatic obstruction.