Athanasios Katsarkas, MD, MSc, FRCS(C), Professor of Medicine, McGill University; Director, Dizziness Clinic, Royal Victoria Hospital, Montreal, QC.

Dizziness is a frequent complaint in aging. Although a number of circumstances in everyday life may cause falls and injuries, such events are often due to dizziness induced by pathology. Dizziness as a consequence of more than one organic syndrome is not uncommon in the elderly. In addition, medication may further complicate the clinical picture. Such combinations may pose diagnostic challenges. This paper deals briefly with postural and gaze control in health and disease, how to take the history in dizziness, some peculiarities of the clinical examination, and the most common syndromes of brain stem or inner ear diseases that cause dizziness in general and, more specifically, in aging.
Key words: dizziness, vertigo, falls, vestibular dysfunction, brain stem disease.

Anahita Deboo, MD, Assistant Professor of Neurology, Drexel University College of Medicine, Philadelphia, PA, USA.

The evaluation of numbness and paresthesias in geriatric patients can present a particular challenge to the primary care physician. Careful sensory examination, in combination with recognition of motor and reflex involvement, will suggest a pattern that aids in neuroanatomic localisation. This article reviews the common patterns seen in polyneuropathies, focal neuropathies, plexopathies and radiculopathies. Central nervous system etiologies also are mentioned. The differential diagnosis and further evaluation of sensory disturbances in the elderly population are discussed.
Key words: paresthesias, numbness, neuropathy, radiculopathy, plexopathy.

Philippe L. Bedard, B.Arts, Sc, Fourth Year Medical Student.
Feisal A. Adatia, MSc, Fourth Year Medical Student.

Increasingly, physicians are turning to handheld computers for a variety of applications in their medical practices. For physicians interested in purchasing their first handheld computer or upgrading their existing model, this brief article introduces some important considerations.

Operating System
Although there are many different manufacturers of handheld computers, most handheld devices run on two operating systems (OS): Palm OS or Microsoft Pocket PC (formerly Windows CE). To determine which OS is most suitable, you should take into account which platform your colleagues are using to facilitate information exchange. The Palm OS is the current industry leader. Recently, Pocket PC has made significant market inroads with the release of more inexpensive models. In the medical arena, there are far more medical software titles designed for the Palm OS; however, many new medical programs are compatible with the Pocket PC as well.

The Pocket PC interfaces with MS Word and Excel out of the box. Files created in Microsoft applications on a desktop computer can easily be transferred back and forth with a Pocket PC. Most Palm OS devices come bundled with Documents to Go, a software program that allows you to work with Word and Excel files without the loss of fonts. Both platforms synchronise with Outlook for the popular functions of scheduling, contacts and to-do-lists.

Processor Speed, Memory and Expansion Support
The speed of the processor determines how quickly a handheld is able to retrieve information. Only recently have Palm OS handhelds started to use the faster processors that power Pocket PC devices. The fastest Palm OS devices run OS version 5.0. A handheld computer's internal RAM memory is akin to the hard drive of a personal computer. Palm OS handhelds offer either 8 or 16MB of internal RAM memory. Generally, this amount of memory is sufficient to support all of the personal information management programs on Palm OS devices, including calendar, to-do-list and datebook, along with one or two more space-intensive medical reference tools, such as pharmacopoeias and electronic textbooks. Newer models of Pocket PCs feature 32 or 64 MB of internal RAM. It is difficult to compare processor speeds and memory across these two platforms because the Pocket PC platform is more resource-hungry.

Many newer handheld models allow users to increase the storage capacity through expansion memory cards. Expandable Palm OS devices offer expansion slots that allow users to add an additional 8-256MB of expansion memory to their devices. However, of the current Palm OS devices, only select high-end Sony CLIE devices have dual expansion slots. There are several Pocket PC models that offer dual expandability, such as the inexpensive Dell Axim and various Toshiba models. Both Palm OS and Pocket PC handhelds are compatible with many peripheral add-on devices through their expansion slots, including digital cameras and full-size keyboards.

Size and Weight
Generally, Palm OS handhelds tend to be thinner and lighter than Pocket PCs. Some of the new and more popular Palm OS devices, such as the Sony T series and the Palm's Tungsten T, are small and light enough to fit comfortably into a shirt pocket. However, some multimedia Palm OS devices which also house built-in digital cameras, are larger. The new HP iPac H1910 is the smallest of the Pocket PC family.

Screen
Palm handhelds feature either a monochrome or colour screen. However, not all monochrome screens are identical; some offer much sharper resolution that makes for easier reading of text. Similarly, like digital cameras, colour handhelds differ in the number of colours that are supported and the screen resolution. Currently, Palm OS handheld screens range from 160X160 pixels to 320x480 pixels. All Pocket PC devices feature a colour screen with resolution of 320x240 pixels. If you plan to use your handheld to read a lot of text or to view graphics, it may be worthwhile to invest in a higher-end resolution model.

Input Methods and Convergence Features
Handspring's Treo and the Sony CLIE TG50 and N series are Palm OS devices with built-in thumb-boards which are an alternative to stylus-driven data input. High-end Palm handhelds offer MP3 playback and voice recording features that are standard on all Pocket PCs. Phone-hybrids, Internet and e-mail functions and digital cameras also are available on some models of Palm OS and Pocket PC devices.

In summary, a clear understanding of your handheld needs should guide your decision-making. If all that you require is quick and simple calendaring, reminders and contact management, then an inexpensive Palm OS handheld should suffice. If you foresee your handheld as a medical information resource at the point of care, look to an expandable Palm OS device or a low-end Pocket PC. Finally, if you have greater multimedia demands, desire a colour screen, and would like to play MP3s, watch video clips or edit digital pictures, then consider Palm OS 5 devices or a new Pocket PC.

Dr. Clarfield is the Chief of Geriatrics, Soroka Hospital Centre, Professor, Faculty of Medicine, Ben Gurion University of the Negev, Beersheva, Israel, and Professor (Adjunct), Division of Geriatric Medicine, McGill University, and Jewish General Hospital, Montreal, QC.

The other day, I was consulted on a 75-year-old lady who was (supposedly) ingesting 12 different medications: ranging across the daylight hours and in all the colours of the spectrum, exhibiting various shapes and sizes. Some were to be taken before, others after, and the remainder with meals. The total number of tablets that was theoretically being consumed by this lady was 62. Individually, all of these medications could have caused adverse drug reactions (ADR), and many of them are also known to interact in various ways with each other. My patient exhibited a typical "final common pathway" of the results of basic research, drug trials, pharmaceutical marketing, physician prescribing practices and pharmacist dispensing behaviour. Unfortunately for the patient in question, the option of noncompliance was not available since her husband tried his best to help her ingest this immense pharmacological load.

This lady represents an extreme example of the kind of medication problems that elderly patients can face in Canada. Yet, it must also be pointed out that the modern pharmaceutical armamentarium is more extensive and far superior to that available 30 years ago.

Robert H. Binstock, PhD, Professor of Aging, Health, and Society, Eric T. Juengst, PhD, Associate Professor of Bioethics, Maxwell J. Mehlman, JD, Professor of Law, and Stephen G. Post, PhD, Professor of Bioethics; Case Western Reserve University, Cleveland, OH, USA.

An international group of more than 50 biogerontologists--scientists who conduct research on the biology of aging--have launched a war on a burgeoning anti-aging medicine movement. They seek to discredit what they regard as the pseudoscience of practitioners and entrepreneurs that purvey hormone injections, special mineral waters and other services and products purported to combat the effects of aging. Yet, an unintended consequence of the biogerontologists' campaign against anti-aging medicine is that they are diverting attention from the potentially radical societal implications of their own anti-aging efforts--implications that should be widely discussed in nations throughout the world.
Key words: anti-aging, biology of aging, life extension, research funding, science policy.

Marian McLeod, MEd (Counselling), Manager/Supervisor, Hearing Care Counselling Program, The Canadian Hearing Society, Kingston Regional Office, Kingston, ON.

Seniors with long-term hearing loss find it progressively more difficult to understand conversation and remain involved in society. When hearing impairment combines with other disabilities, the result is to multiply, rather than only add to, the negative consequences.¹ Poor vision, arthritis and other illnesses complicate the management of hearing loss. No hearing loss should be considered unimportant.

Acquired hearing loss in seniors is a hidden disability, yet is one of the most common chronic disabilities associated with aging. Acquired hearing loss in seniors may occur for a variety of reasons, including illness, head trauma, presbycusis, ototoxic medications, heredity, wax build-up in the ear canals or prolonged noise exposure. Hearing loss may be sensorineural or conductive. Presbycusis initially affects hearing of the high frequency range and eventually the low frequency range. Thus, at first it may be difficult to understand speech in a noisy room, but the disability can progress to the point where communication is difficult in all situations.

Regardless of cause, hearing loss in seniors profoundly affects every dimension of their lives as well as their significant others.

André Tanguay, MD, Chief Physician, Pavillon Hubert-Maisonneuve, CHSLD Drapeau-Deschambault, Rosemère, QC.

A common theme in dementia is misunderstanding--patients with dementia are confused in their thoughts, about the people around them, and by their environment. Furthermore, the patient's family should not be astounded by the seemingly different viewpoints of professionals. In dementia, understanding is of the utmost importance between professionals and family caregivers, and delivering the facts in a clear manner is essential. Striving for this goal, the training tool presented in this article allows the factual understanding of the natural progression of Alzheimer disease. Clinical data and 13 grades are charted within a single table to allow optimal understanding of this disease.
Key words: Alzheimer disease, caregivers, GDS-FAST, training table, MMSE.

Jagdish Butany, MBBS, MS, FRCPC and Manmeet S. Ahluwalia, MBBS, Department of Pathology, Toronto General Hospital, University Health Network, Toronto, ON.

With advancing age, the cardiovascular system undergoes subtle but progressive changes that result in altered function. The endocardium becomes thicker and opaque, left ventricular (LV) wall thickness increases and there is increased interstitial fibrosis in the myocardium. Although myocyte size increases, the number of myocytes decreases, as does the number of cells in the conduction system. The decrease in the filling rate of LV in early diastole is accompanied by a greater rate of filling in late diastole augmented by atrial contraction. Maximum achievable heart rate and ejection fraction (with exercise) decreases. All these changes make increasing age a significant independent risk factor for heart failure, the most common reason for hospitalisation in patients older than 65 years.
Key words: aging, cardiovascular disease, myocardium, fibrosis, heart failure.

Kiran Rabheru, MD, CCFP, FRCP, ABPN, Physician Leader, Geriatric Psychiatry Program, Regional Mental Health Care; Chair, Division of Geriatric Psychiatry, University of Western Ontario, London, ON.

Electroconvulsive therapy (ECT) is an effective and relatively safe procedure for treating severe, treatment-refractory mood disorders in special populations, particularly in the elderly. The frail elderly are especially good candidates for ECT because they are often unresponsive to, or intolerant of, psychotropic medications. The central nervous, cardiovascular and respiratory systems require special attention during the course of ECT. With modern anesthesia techniques and careful medical management of each high-risk patient, most elderly can successfully complete a course of ECT. Obtaining informed consent for ECT from incapable patients is a challenging issue with few concrete guidelines.
Key words: electroconvulsive therapy, elderly, depression, special patient population.

Christopher J. Danner, MD, Fellow Otology/Neurotology/Skull Base Surgery and Jeffery P. Harris, MD, PhD, Departmental Chairman, Department of Otolaryngology, Head and Neck Surgery, University of California--San Diego, San Diego, CA, USA.

Multiple factors lead to the cause and progression of presbycusis or hearing loss secondary to increased age. Noise trauma, genetic predisposition and oxidative damage all have been implicated in its development. Tinnitus, a frequent side effect of hearing loss, often has its origin within the central auditory system. A classification scheme for hearing loss and treatment options for tinnitus are discussed.
Key words: hearing loss, presbycusis, tinnitus, free radicals, central auditory system.