Geriatrics & Aging 2005;9,October 2005,51-54.

Dear Editor,

I very much enjoyed Dr. Jerrilynn Prior’s article entitled “Symptomatic Menopause--What Are the Safe and Effective Options?” in the October 2005 edition of your journal. I have three questions.

Question 1-Does Dr. Prior recommend the addition of a progestin for women with an intact uterus using vaginal estrogens for dryness/dysparunia?

Question 2-In figure 1, she suggests that women with disturbing hot flushes combined with osteoporosis take transdermal estradiol along with daily micronized progesterone at a dose of 300 mg. In the text of her article, she states that this dose of OMP is equivalent to 10 mg of MPA. This seems like a higher dose of MPA than most would use for daily dosing. Is this correct?

Question 3-Is there evidence to assure us that unopposed progestin therapy (as she suggests as treatment for severe vasomotor symptoms without osteoporosis) is safe?

Again, thanks very much for the informative article.

Sincerely,

A. Lewis
Family Medicine
Calgary, AB

Deborah Radcliffe-Branch, PhD, University of Montreal, Centre de Recherche, Institut universitaire de gériatrie de Montréal, Montréal, QC.
Cara Tannenbaum, MDCM, MSc, Assistant Professor, Department of Medicine, Division of Geriatrics, University of Montreal, Centre de Recherche, Institut universitaire de gériatrie de Montréal, Montréal, QC.

Older women are one of the most rapidly growing segments of the Canadian population. This growth necessitates an evaluation of the quality and breadth of care women receive to promote successful aging in later life. Older women’s perceptions of health priorities being addressed by the current health care system and those for which improvements are required are reviewed. Recommendations include screening for memory loss, falls, muscle weakness, depression, and urinary incontinence. Guidelines for assessment and prevention as well as the adoption of a patient-centred approach to care are suggested to address the broader context of promoting physical, emotional, and social well-being for older women.
Key words: older women’s health, health priorities, patient-centred care, screening guidelines, primary care.

Wendy Duggleby, DSN, RN, AOCN, Associate Professor, College of Nursing, University of Saskatchewan, Saskatoon, SK.
David Popkin, BSc, MD, CM, FRCSC, FSOGC, FACOG, Executive Director, Saskatoon Cancer Center; Head, Division of Oncology, College of Medicine, University of Saskatchewan; Head, Department of Oncology, Saskatoon Health Region, Saskatoon, SK.

What is it that patients at the end of life want to know? What is the best way to provide the information? A review of the scientific literature was conducted to answer these two questions. The findings suggested that, regardless of age or culture, patients at the end of life wanted information about their illness and prognosis. The expertise of the physician, his/her relationship with the patient, and the use of hopeful communication styles were important factors in how patients understood the information provided. Honest and factual communication fostered hope and quality of life at the end of life.
Key words: physician-patient communication, end of life, literature review, palliative care.

Peter Pommerville, BA, MD, FRCS(C), Director of Research, Can-Med Clinical Research, Inc.; Clinical Instructor, University of British Columbia; Clinical Instructor, University of Victoria; Consulting Urologist, Vancouver Island Health Authority, Vancouver, BC.

It is estimated that 50% of men between 40 and 70 have erectile dysfunction (ED). The number of men with ED rises to 65% or greater over age 70. Despite the fact that men in this age range have significant medical comorbidities causing their ED, they have often cared for a spouse with a terminal illness. In search of companionship, they become acquainted with a woman who has just been through a similar circumstance. Therefore, it’s usual for men to have performance anxiety contributing to their ED. Proper diagnosis and assessment to determine the etiology of ED is usually done by the primary care physician, with possible follow-up by an urologist or psychiatrist if the main cause is deemed to be organic or psychological, respectively. In some cases, there is overlap as medications such as antidepressants may interfere with sexual function.
Primary care physicians, geriatricians, and allied health care professionals charged with the management of these older men should be empathetic towards their sexual health. Safe and effective treatments for ED are available to permit these couples to enjoy a healthy sexual experience in their elder years.
Key words: erectile dysfunction, diabetes, vardenafil, sildenafil, tadalafil.

Karin H. Humphries, MBA, DSC, Division of Cardiology, Department of Medicine, University of British Columbia, Vancouver, BC.
Janet McElhaney, MD, Department of Geriatrics, University of British Columbia, Vancouver, BC.

The growth in information about hormone replacement therapy (HRT) over the past few years has been impressive. This review summarizes the latest information on HRT and cardiovascular disease, osteoporotic fractures, and cognitive function. The risks of HRT (e.g., stroke, breast cancer, and venous thromboembolism) clearly outweigh the benefits (e.g., reduction in osteoporotic fractures). The use of HRT for primary or secondary prevention of coronary heart disease or to decrease the risk of cognitive dysfunction is also not supported. While the evidence in older adults is substantial, there is some controversy regarding the effectiveness of HRT initiated in women at the start of menopause.
Key words: hormone replacement therapy, cardiovascular disease, osteoporosis, cognitive function, dementia.

Emerging drug therapies for dementia are increasingly chosen to tackle molecular targets important in Alzheimer’s disease (AD) pathobiology. Amyloid oligomers, amyloid deposits, and neurofibrillary tangles (NFTs) are characteristic findings in AD. Hence, drugs that interfere with these proteinaceous aggregates are receiving the most attention: a) alpha, beta, and gamma secretase modulators, b) inhibitors of amyloid beta (Ab) aggregation, and c) anti-Ab immunologic strategies. Oxidative stress and inflammatory reactions appear part of a loop of neurotoxicity with the proteinacous aggregates. Antioxidants and anti-inflammatory compounds have thus received much attention. Finally, other compounds may work by a variety of other mechanisms.
Key words: Alzheimer’s disease, amyloid, secretase inhibitors, antioxidants, anti-inflammatory agents.

Sarah E. Wilson, MSc, MD, PGY1, Internal Medicine, University of Toronto, Toronto, ON.
Mark A. Crowther, MD, MSc, Associate Professor of Medicine, Department of Medicine, McMaster University, Hamilton, ON.

Warfarin reduces the risk of thrombotic complications in a wide range of patients and appears to be particularly effective in older adults. Warfarin initiation should be undertaken with care in the older adults because they are likely to require smaller maintenance doses to achieve the same target international normalized ratio (INR). Inappropriate prescribing of medications among older adults increases the risk of drug interactions that may alter warfarin anticoagulation. Such interactions should be anticipated and monitored to ensure that over- or under-anticoagulation do not persist. A range of strategies are available to follow warfarin therapy in the outpatient setting to ensure safe and effective anticoagulation.
Key words: warfarin, anticoagulation, vitamin K, atrial fibrillation.

Michael A. Borger, MD, PhD, Division of Cardiovascular Surgery, Toronto General Hospital and Department of Surgery, University of Toronto, Toronto, ON.
Tirone E. David, MD, Division of Cardiovascular Surgery, Toronto General Hospital and Department of Surgery, University of Toronto, Toronto, ON.

Systolic murmurs in older adults require investigation with echocardiography. The most common cause is aortic sclerosis, which does not require therapy, followed by aortic stenosis. Surgery is indicated for aortic stenosis in patients with symptoms (fatigue, shortness of breath, angina and/or syncope) and in asymptomatic patients with left ventricular dysfunction or marked hypertrophy. Older aortic stenosis patients can undergo surgery with minimal increased risk, excellent long-term outcomes, and marked improvements in quality of life. Such patients may be referred directly to cardiac surgeons in order to limit age discrimination that may be present within the medical community.
Key words: aortic stenosis, congestive heart failure, aortic valve replacement, quality of life, outcomes.

Molly Thangaroopan, MD, FRCPC, Senior Fellow, Cardiology (Echocardiography), University Health Network, Toronto, ON.
Anusha Jegatheeswaran, MD, Resident, Cardiac Surgery, University of Toronto, University Health Network, Toronto, ON.
Vivek Rao, MD, FRCPC, Staff Surgeon and Associate Professor, University of Toronto, University Health Network, Toronto, ON.
Jagdish Butany, MBBS, MS, FRCPC, Staff Pathologist, University Health Network, Professor, University of Toronto, Toronto, ON.

Deaths from cardiovascular diseases have been declining in many countries; however, the incidence and prevalence of heart failure continues to increase in most countries. This is related, at least in part, to the increasing proportion of older people, a fact that is emphasized by the nearly three-fold increase in the incidence of heart failure in women. Good medical treatments are now available, and for refractory cases there are increasing numbers of surgical interventions available and new ones being devised. The morbidity and mortality associated with heart failure are higher than those associated with any other chronic condition. This article addresses the basis of heart failure, its appropriate management, and some of the newer treatments available.
Key words: heart failure, therapy, surgical treatment, ventricular assist devices.

The accredited CME learning activity based on this article is offered under the auspices of the CE department of the University of Toronto. Participating physicians are entitled to one (1) MAINPRO-M1 credit by completing this program, found online at www.geriatricsandaging.ca/cme

Kenneth M. Madden, MSc, MD, FRCP(C), Assistant Professor, Division of Geriatric Medicine, Department of Medicine, University of British Columbia, Vancouver, BC.

Syncope is a common presenting complaint in the older adult population. Unfortunately, cognitive issues and the fact that most falls are not witnessed in older adults can make the separation of falling and syncope quite difficult. In fact, about one third of older adults will have amnesia for faints, even if they are cognitively normal. A systemic approach can help separate cardiac from neurocardiovascular causes and avoid future mortality and morbidity.
Key words: syncope, aging, neurocardiovascular instability, Holter monitoring, tilt table testing.