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.

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.