John Granton, MD, Assistant Professor of Medicine, University of Toronto; Pulmonary Arterial Hypertension Programme, University Health Network, Toronto, ON.
Moiz Zafar, MD, Resident, Respiratory Medicine, McMaster University, Hamilton, ON; Pulmonary Arterial Hypertension Programme, University Health Network, Toronto, ON.

Introduction
On first glance, a review of pulmonary arterial hypertension (PAH) in a journal that focuses on the health of the elderly may seem out of place. PAH is typically envisioned as a progressively disabling disease in young females. However, PAH is not a disease restricted to the young. Indeed, 20% of the patients followed in our pulmonary hypertension clinic are over the age of 65. Although information regarding the natural course of PAH has been described in a report of the National Registry for Primary Pulmonary Hypertension, this information is not representative of the elderly population.¹ In particular, given the greater prevalence of comorbid conditions in the elderly, one must be particularly vigilant in searching for an underlying secondary cause of PAH. Owing to a paucity of information in this population, most of our comments derive from our own observations of PAH in the elderly and from inferences made from their younger counterparts.

Definition
PAH is defined as an elevation in pulmonary arterial pressure greater than 25mmHg at rest or 30mmHg with exercise.

Yaron Shargall, MD and Michael R. Johnston, MD, FRCSC, Division of Thoracic Surgery, Department of Surgery, University of Toronto; Division of Thoracic Surgery and Department of Surgical Oncology, Toronto General and Princess Margaret Hospitals, Toronto, ON.

Introduction
Lung cancer is the leading cause of cancer death in Canada and the Western world. In the year 2001, it is estimated that 21,200 people in Canada will be diagnosed with lung cancer, and approximately 18,500 people will die as a result.¹ Despite extensive research and clinical efforts, the survival rate has not changed appreciably over the past 30 years and remains poor, with an overall five-year survival of about 13%.² Lung cancer is predominantly a disease of the elderly, since more than 60% of all lung cancer cases occur in people older than 60 years.³ There is overwhelming experimental and epidemiological data to support the contention that cigarette smoking is the primary risk factor for the development of lung cancer. Of all lung cancers in Canada, 85% are directly attributable to smoking, and another 3% may be caused by second-hand smoking.⁴ In this article, we summarize the current status of lung cancer screening and treatment, with special emphasis on the elderly population.

Screening for Lung Cancer
Lung cancer screening studies have not clearly demonstrated a reduction in mortality.

Dr. Robert Hyland, MD, FRCPC, Physician-in-Chief, St. Michael's Hospital, Professor of Medicine, University of Toronto, Toronto, ON.

Introduction
Before considering the impact of chronic obstructive pulmonary disease (COPD) in the elderly, the normal physiological changes that take place in the lungs with aging should be reviewed¹ (Table 1). In general terms, the lungs lose elastic recoil properties and alveolar surface area. This results in a mild decline in expiratory flow rates, and an increase in trapped air (residual volume) along with a decrease in resting arterial partial pressure of oxygen (PaO2). Airway closure occurs progressively in dependent portions of the lung in the supine position beginning in the mid-40s, and the sitting position in the mid-60s. This airway obstruction results in some shunting and further hypoxemia. Muscle strength--particularly diaphragmatic--declines and the chest wall becomes stiffer, contributing to decreased exercise tolerance. Neural reflexes to hypoxia and hypercapnia as well as the perception of changes in lung stiffness and air flow obstruction are blunted in elderly patients, decreasing their awareness of acute problems. Despite all these changes, it is probably fair to say that lung aging is not limiting unless affected by disease. However, elderly patients also have a less effective cough, are prone to aspiration and have less effective lung defenses, thereby increasing the risk of infection.

Feedback from Our Readers

In the July/August 2002 issue of Geriatrics & Aging (Volume 5, Number 6), the article "Dietary Measures to Prevent Prostate Cancer" (pages 18-20) suggested that dairy foods are strongly linked to prostate cancer, and that the higher the intake of dairy foods, the higher the risk of cancer. Mr. Thomas Anderson, PhD from Summerland, B.C., wrote G&A to point out that only defatted dairy products are known to have this effect (e.g., skim milk and fat-free yogurt), whereas unaltered dairy foods do not, and in fact appear to actually protect against prostate, breast and several other types of cancer. References provided by Mr. Anderson include:

1. Ip C, Scimeca JA, Thompson HJ. Conjugated linoleic acid: powerful anticarcinogen from animal fat sources. Cancer 1994;74:1050-4.
2. Jonnalagadda SS, Mustad VA, Yu S, et al. Effects of individual fatty acids on chronic diseases. Nutrition Today 1996;31:90-106.
3. Knekt P, Jarvinen R, Seppanen R, et al. Intake of dairy products and the risk of breast cancer. British Journal of Cancer 1996;73:687-91.
4. Veierod MB, Leake P, Thelle DS. Dietary fat intake and risk of prostate cancer: a prospective study of 25,708 Norwegian men. Int J Cancer 1997;73:634-8.
5. Schuuman AG, Van den Brandt PA, Dorrant E, et al. Animal products, calcium and protein and prostate cancer in the Netherlands Cohort Study. Br J Cancer 1999;80:1107-13.

We thank Mr. Anderson for his feedback and encourage our readers to send their comments.

Geriatrics & Aging, 20 Eglinton Ave. West, Suite 1109, Toronto, ON M4R 1K8 Fax: 416-480-2740 or Email: info@geriatricsandaging.ca.

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 Fellow in Care of Elderly at Baycrest Centre, Toronto, ON.

Prevalence of Smoking in the Elderly
Smoking is one of the major causes of morbidity and mortality in Canada. In fact, it has been called the leading preventable cause of death in North America.¹ This is because smoking is a known risk factor for four of the leading causes of death in the industrialized world--coronary heart disease, cancer, lung disease and stroke--and because it contributes to many other causes of morbidity.² While the current prevalence of smoking in Canadians aged 15 years and older declined by 10.3% between 1985 and 1999, the numbers remain high for both men and women (26.8% and 22.9%, respectively, in 1999).³ In those aged 65 and older, current smoking prevalence decreased by 8.9% over the same time period. However, it is estimated that 11.6% of seniors continue to smoke. The prevalence of smoking is highest in the Atlantic provinces and Quebec, and lowest in Saskatchewan and Ontario.⁴

Impact of Smoking on Health of the Elderly

Mortality
The health-related impact of smoking in the elderly is manifold. The increase in mortality has already been mentioned.

Dr. Lynn Stothers, MD, MHSc, FRCSC, Assistant Professor of Surgery/Urology, Associate Member, Department of Health Care and Epidemiology, University of British Columbia, Vancouver, BC.

Dr. Howard Fenster, MD, FRCSC, Clinical Professor, Department of Surgery, Division of Urology, University of British Columbia, Vancouver, BC.

Definitions and Epidemiology
Urinary incontinence (UI), the involuntary loss of urine, is a common medical condition in the elderly. Over 1.5 million Canadians are currently afflicted with the condition, and the number is expected to increase significantly over the next 20 years as the baby boom population ages.¹ Chronic UI has far-reaching consequences for both the individuals affected and their caregivers. Physical complications include renal failure, urinary tract sepsis, renal calculi, hematuria, skin disease, falls and fractures and death relating to renal failure/urosepsis. Psychosocial impact can range from embarrassment and social isolation to depression and suicidal ideation. Less than 50% of those affected seek help for the condition, often due to embarrassment.

Classification
UI can be categorized according to the simple clinical classification presented in Table 1.

David K. Conn, MB, FRCPC, Psychiatrist-in-Chief, Baycrest Centre for Geriatric Care; Associate Professor, Department of Psychiatry, University of Toronto, Toronto, ON; President, Canadian Academy of Geriatric Psychiatry; Co-Chair, Canadian Coalition for Seniors' Mental Health.

Shelly Haber, BA, MHSc, Project Director, Canadian Coalition for Seniors' Mental Health.

Ken LeClair, MD, FRCPC, Professor and Chair, Division of Geriatric Psychiatry, Department of Psychiatry, Queen's University, Kingston, ON.; Co-Chair, Canadian Coalition for Seniors' Mental Health.

A national symposium entitled Canadian Invitational Symposium on Gaps in Mental Health Services for Seniors in Long-Term Care Facilities was held on April 28-29, 2002 in Toronto. The participants, who represented more than 65 organizations from across Canada, included national and provincial associations, policymakers, consumers, service providers, educators, researchers and representatives from private industry. The main outcome of the symposium was overwhelming support for the establishment of the Canadian Coalition for Seniors' Mental Health, the purpose of which is to improve the mental health of seniors through a coordinated national strategy. The Coalition's first priority will focus on the needs of seniors living in long-term care facilities.

Dr. Shafiq Qaadri, MD, Family Physician and CME Lecturer, Toronto, ON.

Introduction
With the demographic shift in Canada--the "greying" of its population--arthritis is a growing health concern. A leading cause of long-term disability in Canada, arthritis and other musculoskeletal diseases result in $17.8 billion in lost productivity annually.¹ Currently, four million Canadians are affected by arthritis, and the number of people afflicted is expected to double in the next 20 years.² Already, 33% of Canada's seniors have osteoarthritis,2 the most common form of arthritis in older adults.

Effective osteoarthritis care requires a spectrum of approaches on the biopsychosocial model including: advice on carrying out daily activities (coping with fatigue, protecting joints, using orthotics); controlling pain through approaches such as relaxation therapy, massage therapy, hydrotherapy or acupuncture; using walking/assistive devices; and learning more about arthritis from organizations or websites. Self-help groups are a particularly valuable resource for arthritis patients.

Many patients ask about alternative remedies such as glucosamine or chondroitin, which have shown some effectiveness in studies. A full discussion of complementary therapies for arthritis is presented on the Arthritis Society website at www.arthritis.ca.

Medication remains the mainstay for controlling arthritis pain of all types.

Part 2: Motor Examination

David J. Gladstone, BSc, MD, Fellow, Cognitive Neurology and Stroke Research Unit, Sunnybrook and Women's College Health Sciences Centre, Division of Neurology, University of Toronto, Toronto, ON.

Sandra E. Black, MD, FRCPC, Professor of Medicine (Neurology), University of Toronto; Head, Division of Neurology and Director, Cognitive Neurology Unit, Sunnybrook and Women's College Health Sciences Centre, Toronto, ON.

Abstract
This four-part series of articles provides an overview of the neurological examination of the elderly patient, particularly as it applies to patients with cognitive impairment, dementia or cerebrovascular disease. The focus is on the method and interpretation of the bedside physical examination; the mental state and cognitive examinations are not covered in this review. Part 1 (featured in the September issue of Geriatrics & Aging) began with an approach to the neurological examination in normal aging and in disease, and reviewed components of the general physical, head and neck, neurovascular and cranial nerve examinations relevant to aging and dementia. Part 2, featured here, covers the motor examination with an emphasis on upper motor neuron signs and movement disorders.

Mercè Roqué, MD, Cardiovascular Institute, Hospital Clínic de Barcelona, Spain.

Ernane D. Reis, MD, Department of Surgery, Mount Sinai School of Medicine, New York, U.S.A.

Introduction
Tricuspid valve disease is rarely an isolated condition. Most cases are associated with other valvular or myocardial disease, pulmonary hypertension or systemic disorders. The tricuspid valve is located in the outflow tract of the right ventricle, and is the largest heart valve with an area of approximately 11cm². The valvular apparatus includes the fibrous annulus, the leaflets (anterior, septal and posterior), the tendinae chordae and the papillary muscles. Given that the tricuspid valve's main function is to regulate inflow to the right ventricle, conditions affecting the tricuspid valve generally have an impact on the right atrium and the venous circulation. Similarly, disorders affecting the left or right ventricle or the pulmonary arterial system can impair tricuspid valve function.

This review focuses on the most common causes of tricuspid stenosis (TS) and regurgitation (TR) in older adults. In these patients, functional tricuspid regurgitation is by far the most frequent tricuspid disorder. In the evaluation of tricuspid valve disorders, a thorough physical examination is essential to provide information for a correct diagnosis. An overview of the most useful ancillary tests and treatment options is also presented.