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 the Elderly at Baycrest Centre, Toronto, ON.

Introduction
I was recently given the difficult task of creating a paper on the application of developmental theory to the human condition of dementia. Given the complexity of that endeavor, this article will address both content and process issues involved. I will start with a consideration of the relevant developmental stage as conceptualized by Erikson, and then demonstrate that the biomedical model of dementia is actually insufficient to allow a discussion of dementia in a developmental context. This will be followed by an introduction to a paradigm shift from the biomedical model to the social-environmental model whereby developmental issues in dementia can be more fully explored. The prominence of spirituality as a means to resolve Erikson's final crisis of integrity versus despair will be discussed with reference to both personal reflection as well as recent arguments by clinical ethicists and psychologists working in this field and a prominent patient with dementia. Finally, connections to a different developmental model will serve to confirm the views put forth here.

Erikson's Life Cycle: Application to Dementia
According to Erikson, the dominant antithesis in old age is "integrity versus despair".

Part 3: Coordination, Balance and Gait

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 in the October issue) covered the motor examination with an emphasis on upper motor neuron signs and movement disorders.

J. George Fodor, MD, PhD, FRCPC, FAHA, Professor of Medicine, Head of Research, University of Ottawa Heart Institute Prevention and Rehabilitation Centre, Ottawa, ON.

It is worthwhile to review the issue of hypertension in the elderly not only because it will become an ever-increasing problem with our aging population, but also because of the robust database currently at our disposal concerning improved risk assessment and efficacious therapy.

The Epidemiology
Generally, the elderly are considered those above 65 years of age. Dealing with hypertension in this age group, we quickly realize that this disease is a major epidemic with far-reaching consequences for both the health status of this segment of the population as well as our health care system.

The Canadian Heart Health Survey ascertained that among people in the age group 65-74 years, 56% of males and 58% of females were hypertensive.¹ This survey defined hypertension as systolic blood pressure (SBP) > 140mmHg or diastolic blood pressure (DBP) > 90mmHg, or current treatment with a prescription antihypertension medication or non-pharmacological treatment of blood pressure (weight control or sodium/salt restriction). The problem of hypertension in the elderly will continue to increase steadily in importance.

Theodore K. Marras, MD, FRCPC, Division of Pulmonary and Critical Care Medicine, University of California, San Francisco, California, USA; Postdoctoral Fellow, Department of Medicine, University of Toronto, Toronto, ON.

Abstract
Community-acquired pneumonia (CAP) is a common disease in the older adult with significant mortality. The following review focuses on the antibiotic management of CAP, with specific reference to the older adult. Common etiologic organisms and organism-specific risk factors that tend to be associated with increasing age are presented. The rationale behind initial empiric antibiotic therapy is discussed and recent guidelines for the selection of empiric antibiotic therapy are compared. A synthesis of guidelines for antibiotic selection and recommendations regarding the switch from parenteral to oral therapy are presented.

Introduction
Community-acquired pneumonia (CAP) is a common infectious disease, the incidence of which is consistently associated with increasing age. The overall incidence of CAP has been reported at 10 to 14 per 1,000 patients per year,^1,2 and 30 per 1,000 among those older than 75 years.^2,3 Compared with people 60-69 years of age, those 70 years or older had a relative risk of developing CAP of 1.5,⁴ independent of the additional risk conferred by heart disease and institutionalization.

Benjamin Chiam, MD, Department of Medicine, Pulmonary Division, University of Alberta, Edmonton, AB.
Don D. Sin, MD, FRCP(C), Department of Medicine, Pulmonary Division, University of Alberta, and The Institute of Health Economics, Edmonton, AB.

Introduction
Respiratory conditions are among the leading causes of morbidity and mortality worldwide. Although they are currently listed as the fifth leading cause of death in Canada, respiratory diseases are predicted to be the third leading cause of mortality by the year 2020, following ischemic heart disease and stroke.¹ Furthermore, since the prevalence of these conditions increases with age, the adverse impact of respiratory illnesses on the Canadian health care system will grow enormously over the next few decades as the overall population ages² and treatments for other common conditions, such as ischemic heart disease, stroke and diabetes, improve. A good understanding of the aging process of the respiratory system is clearly needed to formulate better strategies to prevent, diagnose and manage respiratory conditions in Canada.

Why are Respiratory Diseases so Prevalent in the Elderly?
The lungs of elderly persons are subject to a lifetime of exposure to known and unknown harmful agents. Decades may pass before the physical manifestations of cigarette smoke, pollution and other noxious environmental agents become clinically apparent.

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.