A novel brain mapping technique has provided the first quantitative, dynamic visualization of the spreading wave of cortical atrophy in the brains of living patients with Alzheimer disease (J Neurosci 2003;23:994-1005).

Using this unique mapping method, Australian neuroscientists were able to visualize dynamic patterns of atrophy in 52 high-resolution MRI scans of 12 patients with AD and 14 elderly matched controls. Based on these scans, dramatic time-lapse videos were created, showing sequential loss of gray matter in four dimensions as it spread over time from temporal and limbic cortices into frontal and occipital brain regions, while sparing sensori-motor areas. The visualized patterns of cortical atrophy correlated with the AD patients' progressively declining cognitive ability and mirrored the sequence of neurofibrillary tangle accumulation observed at autopsy. AD patients were found to lose an average of 5.3% grey matter per year compared to a loss of only 0.9% in the healthy volunteers.

In the future, such images may offer researchers a potent tool for assessing the impact of therapies on dementia as well as for evaluating the spread of the disease.

Is it possible that virtual reality--the stuff of Matrix movies and futuristic fantasy--helps elderly stroke survivors along the road to recovery? Researchers from the University of Toronto think it's a question worth investigating, and have already begun a pilot study of stroke survivors 60 years and older to explore the possible benefits of this immersive, interactive, 3-D computer experience.

Theoretically, the researchers explain, virtual reality can encourage competence, expression and pleasure in leisure activities in older stroke survivors. They believe that virtual reality has the potential to offer people with disabilities greater control over events in their environment, thereby contributing to a sense of competence and satisfaction with life.

How might this be possible? The Mandala® Gesture Xtreme virtual reality system uses a video camera as a capturing and tracking device to give the user the sense of being immersed in the virtual environment. The user sees herself on a television screen while the virtual reality system responds to her movements. The user does not have to wear, touch or hold anything, making this system especially ideal for the disabled elderly. By means of the system's video gesture capability, the user's movements (reaching, bending) trigger visible or invisible icons to score points and manipulate animations, such as playing a virtual drum kit.

One concept the investigators use to illustrate how disabled elderly interact with and may benefit from virtual environments is entexturing--the awareness of the body with respect to a variety of sensory stimuli (space, light, colour, sound) and the regulation of activity surrounding the body in order to produce a finely articulated and satisfying whole. In the virtual environment shown here, the user was required to reach out to the sides and across her body to hit the various drums placed around her. By hitting the drums, the user is executing an activity by responding to auditory and visual stimuli, creating a rhythm and expressing creativity.

The use of virtual reality, according to the investigators, can be a positive addition to the lives of people recovering from stroke. Although they will be focusing on the social and psychological benefits of virtual reality, the potential physical gains, such as improved balance and range of motion, merit exploration as well.

Margda Wærn, MD, PhD, Institute of Clinical Neuroscience, Sahlgrenska University Hospital, Göteborg, Sweden.

Seniors who commit suicide often consult their doctors a short time before they take their lives, but few communicate their suicide intent. Rather, they may focus on somatic complaints. This paper reviews the literature on the connection between physical illness and suicide. Recent research shows that over half of those who commit suicide late in life suffer from serious physical illness or impairment. The association between physical illness and suicide may be stronger in men than in women. Since most physically ill persons who commit suicide suffer from depression, depression should be treated aggressively in seniors with concomitant physical disorders.
Key words: suicide, suicide attempts, physical illness, depression, elderly.

Ron Keren, MD, FRCPC, Clinical Director, University Health Network and Whitby Mental Health Centre Memory Clinics; Assistant Professor, University of Toronto, Toronto, ON.

In recent years, a number of observational studies have shown that when consumed in moderation, alcohol may contribute to healthy living, reducing the risks of both coronary artery disease and dementia. While the ill effects of excessive drinking on cognition have been extensively described, there are no clinical or pathological consensus criteria defining alcohol-induced dementia. In fact, its existence as a distinct entity is controversial. More research on the effects of alcohol on the brain is needed in order to advise patients on the potential risks and benefits of alcohol consumption.
Key words: alcohol consumption, dementia, prevention, cognition, Wernicke-Korsakoff.

Rory H. Fisher, MB, FRCP(Ed)(C), Director, The Regional Geriatric Program of Toronto and Interdepartmental Division of Geriatrics, Faculty of Medicine, University of Toronto, Toronto, ON.

The impact of the Romanow Report on the elderly is reviewed here. Recommendations for a Health Council, modernization of the Canada Health Act, improved home care and a National Drug Agency would benefit all elderly Canadians. However, the current unmet needs of the elderly, the value of specialized geriatric services and the developments in other jurisdictions are not recognized. The Romanow Commission fails senior citizens by ignoring their current unmet needs.
Key words: Romanow Report, recommendations, elderly.

Ernane D. Reis, MD, Assistant Professor, Department of Surgery, Mount Sinai School of Medicine, New York, NY.
Nicholas Morrissey, MD, Assistant Professor, Department of Surgery, Mount Sinai School of Medicine, New York, NY.

Prevalence of peripheral arterial disease (PAD) increases with age. PAD is not only associated with disability (e.g., claudication, limb loss), but also with increased mortality from cardiac and cerebrovascular events. A thorough assessment of symptoms, risk factors and physical signs--including ankle-brachial indices--can be sufficient to determine whether PAD is present. Further testing--such as Duplex examination, magnetic resonance imaging and conventional arteriography--is often required to determine progression and accurate localization of lesions, as well as to direct therapeutic intervention. Early detection of PAD can help prevent functional impairment and death in the elderly.
Key words: atherosclerosis, peripheral arterial disease, ankle-brachial index, diabetes, claudication.

E. Rand Simpson, MD, Associate Professor of Ophthalmology, University of Toronto; Director, Ocular Oncology, Princess Margaret Hospital, Toronto, ON.
Larry Ulanski II, MD, Ocular Oncology Fellow, University of Toronto, Princess Margaret Hospital, Toronto, ON.

Ocular malignancies in the elderly are often difficult to diagnose and manage. The five main cancers found in association with the eye are basal, squamous and sebaceous cell carcinomas, uveal melanoma and malignant cancers to the orbit. These include malignancies from breast, lung, GI, prostate and myelogenous proliferations. This article briefly reviews the most common forms of ocular cancer and brings the general practitioner up to date on the most current data from the Collaborative Ocular Melanoma Study (COMS). We use clinical photos to demonstrate specific clinical signs of cancerous disease. By maintaining a high level of suspicion when treating patients with acute visual symptoms, unnecessary morbidity and mortality may be avoided.
Key words: ophthalmology, cancer, radiotherapy, malignancy.

David Stell, PhD, FRCS(Gen) and William J. Wall, MD, FRCS(C), Department of Surgery and Multi-Organ Transplant Program, London Health Sciences Centre, London, ON.

The process of aging does not produce changes in the liver that can be described as pathological. The major age-related alterations are a reduction in liver mass and a reduction in total blood flow, neither of which interferes with the liver's normal homeostatic functions. In spite of the liver's resilience, however, the aged liver is more vulnerable to injury from toxins, viruses and ischemia, and its capacity to regenerate is slowed. There also is a decline in liver enzymes with aging that affects metabolic clearance of drugs, a finding that has implications for drug dosing in the elderly.
Key words: liver, aging, function, metabolism, injury.

Dr. Faisal M. Sanai, MD, ABIM, Hepatology Fellow, London Health Sciences Centre, University of Western Ontario, London, ON.
Dr. Cameron N. Ghent, MD, FRCP(C), Consultant Hepatologist, Adjunct Professor, University of Western Ontario, London Health Sciences Centre, London, ON.

Cirrhosis of the liver is highlighted essentially by its portal hypertensive complications. The incidence of these complications in elderly cirrhotic individuals has been rising due to better management of this disease in the younger population. Moreover, improved diagnostic techniques have further contributed to this rising incidence. Early recognition of the cirrhotic complications coupled with aggressive intervention has led to reductions in mortality. Special consideration is given to elderly patients in view of the higher incidence of comorbidity and the variability in disease presentation. We present here a review of cirrhosis and its sequelae in this distinct population group with emphasis on recent trends towards diagnosis and management.
Key words: cirrhosis, portal hypertension, ascites, liver.

Douglas Thorburn, MD, MRCP and Paul J. Marotta, MD, FRCPC, Multi-Organ Transplant Unit, London Health Sciences Centre, University of Western Ontario, London, ON.

Liver transplantation improves survival for selected patients with chronic liver disease, fulminant hepatic failure and hepatocellular carcinoma. There is no absolute upper age limit for liver transplantation and the proportion of patients undergoing liver transplantation who are older than 60 years is increasing. Although the indications for liver transplantation in elderly patients do not differ from those in younger patients, the prevalence of comorbidities that are contraindications to liver transplantation are higher among the elderly. Outcomes after transplantation for selected patients over 60 years of age with Child-Pugh class B cirrhosis who are well nourished and at home are comparable to those for younger patients.
Key words: liver transplantation, fulminant hepatic failure, hepatocellular carcinoma, indications.