Roger Y. Wong, BMSc, MD, FRCPC, Division of Geriatric Medicine, University of British Columbia, Vancouver Hospital & Health Sciences Centre, Vancouver, BC.

Palpitations are common in ambulatory older people and have a variety of causes. The correlation of palpitations and cardiac arrhythmias is poor. Basic assessment, which includes history taking, physical examination, 12-lead electrocardiogram (ECG), and laboratory data, is necessary but may not be sufficient to diagnose the underlying problem. Ambulatory ECG monitoring can be helpful, depending on the frequency of the palpitations. Continuous-loop event monitors are cost-effective in diagnosing palpitations, and the optimal duration of monitoring is two weeks. The overall clinical outcomes of patients with palpitations are favourable, with low mortality but high recurrence risk.

Key words: palpitations, arrhythmias, assessment, cardiac, older adults.

Anna T. Monias, MD, Erickson Retirement Communities, Oak Crest Village, Parkville, MD.

Kenneth S. Boockvar, MD, MS, Assistant Professor, Brookdale Department of Geriatrics and Adult Development, Mount Sinai School of Medicine; Investigator, Program of Research on Serious Physical and Mental Illness, Bronx Veterans Affairs Medical Center, Geriatric Research, Education, and Clinical Center, New York, NY.

Acute illness often presents atypically in long-term care patients. Atypical presentation refers to the lack of one or more symptoms or signs that usually indicate acute illness. Due to underlying medical illness, nursing home patients with acute infection, metabolic disorders, and even surgical emergencies frequently present with delirium, malaise, or weakness. Nursing assistants are often the first to recognize these non-specific indicators. It is imperative that researchers include assessments by nursing assistants when developing and validating tools to recognize early but atypical indicators of disease.

Key words: long-term care facility, atypical presentation, delirium, nursing assistants, non-specific symptoms.

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.htm

Peter Pommerville, BA, MD, FRCS(C), Director of Research, Can-med Clinical Research, Inc.; Consulting Urologist, Vancouver Island Health Authority,
Vancouver, BC.

Abstract:Sildenafil was introduced in Canada in 1998 as the first effective oral therapy for erectile dysfunction (ED). Since its release, sidenafil has been proven to be an effective and safe treatment for ED in older patients with multiple medical problems. In the last year, two new PDE5 inhibitors have been approved for ED treatment: vardenafil and tadalafil. There are subtle differences between the three phosphodiesterase type 5 (PDE5) inhibitors with respect to efficacy, dosing instructions, and adverse event profiles. All three PDE5 inhibitors have exhibited efficacy and safety in the cardiac patient as long as he is not reliant upon the regular use of nitroglycerine. This article reviews the similarities and differences between the three PDE5 inhibitors, and refers to patient attitudes in Canada towards sexual activity and its treatment with these agents, as discussed in the Canadian Sexual Satisfaction Survey (CSSS).

Key words: Erectile dysfunction, phosphodiesterase inhibitor, sildenafil, vardenafil, tadalafil

Introduction
Physicians in Canada are treating an increasingly aging population, and coupled with this is an increase in the incidence of specific diseases that may arise as a result of the breakdown of biological mechanisms (e.

David F. Mobley, MD, Department of Urology, Memorial City Hospital, Houston, TX, USA.
Neil Baum, MD, Associate Clinical Professor of Urology, Tulane Medical School, New Orleans, LA, USA.

Abstract
Benign Prostatic Hyperplasia (BPH) is a pervasive condition associated with the aging process. Causes of BPH include stimulation of the alpha receptors located in the prostate gland and bladder neck, or an increase in epithelial cell proliferation, resulting in enlargement of the prostate gland and subsequent passive compression of the urethra. Medical treatment consists of alpha-blockers or 5-alpha-reductase inhibition. This article will review the evaluation and the medical treatment for patients with mild to moderate BPH and provide suggestions for urologic referral.

Key words: BPH, prostate, alpha blockers, 5-alpha-reductase inhibitors, PSA.

Ian K. Tsang, MB, FRCPC, Clinical Professor, Division of Rheumatology, Faculty of Medicine, University of British Columbia, Vancouver, BC.

Gout is more prevalent in older adults than middle-age adults, and it affects women almost as commonly as men. An important clinical consideration regarding gout is that while hyperuricemia is commonly associated with gouty arthritis, a diagnosis of asymptomatic hyperuricemia does not generally require treatment. In addition, the clinical presentation and course of gout in older patients differ from the typical cases of middle-aged patients. Moreover, older gout patients present a challenge for physicians who manage them because of the high incidence of comorbid conditions and the likely occurrence of reduced renal function among this age group. This article reviews the diagnosis and management of asymptomatic hyperuricemia and gout in the older adult.
Key words: gout, hyperuricemia, NSAID, allopurinol, arthritis.

Dale A. Lund, PhD, Professor of Gerontology & Sociology, University of Utah, Salt Lake City, UT, USA.
Michael S. Caserta, PhD, Associate Professor of Gerontology & Health Promotion & Education, University of Utah, Salt Lake City, UT, USA.

Although men are less likely than women to outlive their spouses, 27% of men age 65 and over in Canada are widowed and in the U.S., 43% of men over age 85 are widowed. Rather than relying on cultural stereotypes about how men cope with widowhood and bereavement, research findings can be used to provide a more accurate description of their process of adjustment, identify their most common difficulties, and offer valuable suggestions for effective ways to maintain and restore a high quality of daily life.
Key words: widowhood, widowers, grief, bereavement, coping.

Wojciech P.Olszynski, MD, PhD, FRCPC, Clinical Professor of Medicine,University of Saskatchewan, Director, Saskatoon Osteoporosis Centre, Saskatoon, SK.

Though osteoporosis occurs less frequently in men than in women, it is nonetheless a significant medical problem. Osteoporotic vertebral fractures in particular are as common for men as for women, and about one-third of all hip fractures occur in men. As a consequence of fragility fractures, the associated morbidity and mortality are higher in men than women, particularly after fracture of the hip. Idiopathic osteoporosis is common; however, secondary causes are found in about 50% of cases. Bone density measurements should be advised for every man over 65 years of age and for younger men in the presence of osteoporosis risk factors. For practical purposes, the use of T-score <= 2.5 for men over age 65 should be used for the diagnosis of osteoporosis.

Key words: osteoporosis, men, fracture, diagnosis, treatment

Epidemiology
Osteoporosis is a skeletal disorder characterized by compromised bone strength predisposing a person to an increased risk of fracture.

D’Arcy Little, MD, CCFP, lecturer and Academic Fellow, Department of Family and Community Medicine, University of Toronto; Director of Medical Education, York Community Services; 2002 Royal Canadian Legion Scholar in Care of the Elderly, Toronto, ON.

Part II of this series briefly reviews the literature on the success of family therapy in families with dementia. A case from the author’s practice (with significant details modified to conserve privacy) is then presented with a view toward applying family therapy. Finally, as the author has an interest in medical education, a proposal on how to integrate family therapy for families with dementia into an educational program is briefly described. The author welcomes comments and suggestions at darcy.little@geriatricsandaging.ca.
Key words: dementia, Alzheimer’s disease, family therapy, family, Systems Theory.

David Fitchett, MD, FRCP(C), St Michael's Hospital, University of Toronto, Toronto, ON.

The incidence of coronary heart disease increases with advancing age. Although older patients may develop classical symptoms of ischemic heart disease, other symptoms such as dyspnea, syncope, and fatigue are often the dominant presenting features of angina and myocardial infarction. The present discussion aims to heighten awareness of the atypical nature of myocardial ischemic symptoms in the older adult and to suggest a structured approach to facilitate achieving a more accurate diagnosis.
Key words: chest pain, myocardial ischemia, dyspnea, coronary artery disease, infarction.

Muammer Kendirci, MD, Tulane University, School of Medicine, Department of Urology, Section of Andrology and Male Infertility, New Orleans, LA, USA.
Wayne J. G. Hellstrom, MD, FACS, Tulane University, School of Medicine, Department of Urology, Section of Andrology and Male Infertility, New Orleans, LA, USA.

Sexual dysfunction in the older man is common and has a significant impact on quality of life. In the aging man, erectile dysfunction (ED) has been encountered frequently due not only to associated comorbidities such as heart disease, hypertension, medications, diabetes, smoking, and depression, but also as a result of the aging process itself. Aging may impair molecular and structural components of erectile function. The introduction of effective oral erectogenic drugs has led to increased awareness of sexual issues and advancement in the methods used by clinicians to diagnose ED. Over the last twenty years, the approach for identification and evaluation of ED has transformed from invasive techniques to patient self-reporting and minimally invasive office procedures.

Key words: erectile dysfunction, aging, diagnosis, evaluation.