Lawrence J. Papoff

As Canadians age, they are becoming concerned with the infirmities that aging can bring. And one of those infirmities is Alzheimer's Disease (AD). It is the specter of the Alzheimer patient, unable to fend for herself or himself, suffering a prolonged period of dying, incapable of communicating a decision to end life-sustaining treatment, that has popularized the use of the living will.

Geriatrician Dr. Barbara Clive says she sees an increasing number of living wills in use among her patients, one-third of whom suffer from some form of dementia, most often AD. More and more patients are filling out the paperwork and having discussions with their families about end of life decisions.

A living will, or advance directive, is a written document that contains the will maker's wishes regarding medical treatment and personal care. Taking effect only when the maker is incapable of understanding and appreciating what medical treatment or care is required, it instructs a representative, called an attorney, to decide what treatment should be used, and when it should be terminated. The document may also give decision-making ability to a number of attorneys and provide for resolution of disagreements among them.

Olya Lechky

A new multi-national clinical trial of donepezil (Aricept) confirms and augments the encouraging findings from previous multi-centre studies that the drug significantly improves cognition and global functioning in patients with mild to moderate Alzheimer's Disease (AD).

Presented by Dr. Serge Gauthier and colleagues at the McGill Centre for Studies in Aging in Montreal, the new trial provided the international (including Canadian) data showing efficacy and safety. Following HPB approval of donepezil last August, Canadian physicians for the first time have a highly specific, effective, non-toxic and well-tolerated drug with which to treat the rapidly growing number of older people affected by this progressive and ultimately fatal disease.

According to Dr. Gauthier, the large multi-centre trial published in Neurology (January 1998) showed that donepezil improved memory, orientation and the use of language in addition to the performance of daily functions such as bathing, dressing and eating. The new trial, reported at the 5th International Geneva/Springfield Symposium on Advances in Alzheimer Therapy in April in Geneva, Switzerland, confirmed these findings.

Michele Kohli, BSc

Cardiopulmonary bypass (CPB) machines, which oxygenate and pump blood, allow surgeons to stop the heart during cardiac surgery. Complicated surgeries are technically easier to perform on a non-beating heart. However, CPB can damage blood cells and increase the risk of complications including damage to the lung, excessive bleeding, low output syndrome, renal failure and perioperative myocardial infarction.¹ Also, bringing the patient on and off the CPB pump increases the overall operating time, which in turn increases the risk of complications. The other major causes of morbidity and mortality in cardiac surgery include the sternotomy and manipulation of the aorta.^2,3,4 In a recent survey of cardiac surgeons at a forum in Montreal, 81% identified CPB as the most common cause of complication, while 19% cited sternotomy.⁵

Recently, work in minimally invasive abdominal and general thoracic techniques has provoked interest in utilizing these techniques for cardiac surgery.⁴ Also, surgeons in South America such as Benetti and Buffolo reported that coronary artery bypasses performed on a beating heart, had mortality rates similar to conventional procedures with CPB. ^3,4

In the past few years, interest in a variety of techniques that eliminate use of CPB, sternotomy and aortic manipulation has grown.

Thomas Tsirakis, BA

Alzheimer Disease (AD) is the leading cause of dementia in Canada, affecting 8% of the general population over 60 years of age, and more than 35% of those over 80 years of age. The current number of Canadians affected with the disease is estimated to be 160,000 with approximately 10,000 dying of AD and related dementias every year.

The normal progression of AD typically follows a gradual 7- to 10-year decline in cognitive abilities. All brain functions are eventually affected, but disturbances in judgment, memory, and language appear early on in the disease, with motor function, and bowel and bladder control being maintained during this time period. The progressive and slow decline of an individual's cognitive abilities in AD has been compared to observing the process of normal human development in a reverse order.

Since there is currently no definitive clinical test available for establishing the presence of AD, it is imperative that the clinician utilize standardized diagnostic criteria and formal testing in order to rule out the possibility of any reversible forms of dementia. Individuals presenting with cognitive deficits of a rapid onset should be suspected of having some underlying etiology other than AD.