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.

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

Depression is the most common psychiatric disease in the elderly. Over 30% of community-dwelling elderly suffer from subsyndromal depression and over 10% of hospitalized elderly have syndromal major depressive disorder (MDD). Depression is frequently a persistent and recurrent disorder leading to increased morbidity and mortality, as well as poor quality of life.

Early antidepressant medications, tricyclic antidepressants (TCAs) and monoamine oxidase inhibitors (MAOIs) were discovered through astute clinical observations. These first-generation medications are effective because they enhance serotonergic and/or noradrenergic function. Unfortunately, the TCAs also block histaminic, cholinergic and alpha-1 adrenergic receptor sites, causing unwanted side effects such as weight gain, dry mouth, constipation, urinary retention, confusion, drowsiness and dizziness. MAOIs interact with tyramine to cause potentially lethal hypertension and cause dangerous interactions with a number of prescribed and over-the-counter medications.¹

A major goal of antidepressant development is to improve on preceding drug classes for greater specificity, fewer unwanted side effects and more rapid onset of action.

Daniel Foley, MS, National Institute on Aging, National Institutes of Health, Bethesda, MD.

Introduction
It is well known that sleep disturbances can occur secondary to the onset and progression of Alzheimer disease (AD) and related dementias in many patients.¹ In the community setting, sleep disturbances in AD patients can disrupt the sleep of caregivers and other family members and increase the risk of institutionalization.² In the institutional setting, sleep disturbances and other behavioural features known generally as "the sundown syndrome" present management problems for nurses and other attending staff in the late evening and at night.³

In contrast, few studies have reported on the possible neuropsychological deficits that may arise from disrupted sleep. However, because sleep complaints are common among elderly persons, clinical and epidemiological studies are now beginning to address the association between sleep disorders and cognitive function.⁴ Prevalence data show that a majority of older adults without dementia have one or more complaints, including difficulty initiating sleep, early morning awakening, daytime sleepiness and feeling unrested in the morning. These complaints may be attributable to underlying medical conditions that are common in old age such as hypertension, diabetes, depression and arthritis, or they may stem directly from the effects of common primary sleep disorders such as sleep-disordered breathing and restless leg syndrome.

Christina S. McCrae, PhD, Assistant Professor, Center for Gerontological Studies, Institute on Aging, and Department of Psychology, University of Florida, Gainesville, FL, USA.

Candece Glauser, MA, Department of Psychology and Institute on Aging, University of Florida, Gainesville, FL, USA.

A variety of patient and environmental factors make nursing home residents particularly vulnerable to insomnia or poor sleep. Although precise estimates are not available, research suggests that up to 75% of institutionalized older adults suffer from disturbed sleep.^1-3 Identifying the contributory factors and intervening to resolve or limit their impact on sleep is the key to effective management. Frequently, these factors can be difficult to control, and as a result, standard sleep evaluation and treatment practices may need to be modified for use in long-term care settings.

Evaluation
Insomnia may be present if an individual has more than 30 minutes of unwanted awake time on six or more days during a two-week period. Evaluation involves having patients record various aspects of their sleep habits, such as bed and wake times, in a sleep diary, daily for two weeks. Polysomnographic (PSG) evaluation is not necessary to diagnose insomnia; however, it may be necessary in some cases in order to rule out other sleep disorders such as sleep apnea.

Dr. Marie-Josée Filteau, MSc, MD, FRCPC, Clinical Professor, Department of Psychiatry, Laval University, Clinical Researcher, Laval University-Robert-Giffard Research Centre, and Director, Clinique Marie Fitzbach, Quebec City, QC.

Patricia Gravel, BA, Department of Psychiatry, Laval University, Quebec City, QC.

Although depression is a highly prevalent psychiatric disorder and the focus of much research and discussion, it remains underdiagnosed and undertreated in the primary care setting. One of the key reasons for the underdiagnosis of depression is the tendency among physicians to focus on the emotional and psychological symptoms of the disorder at the expense of its physical symptoms. Although elderly patients with depression are more likely than their younger counterparts to present with physical rather than psychological symptoms, little emphasis is placed on physical symptoms in diagnostic tools and rating scales. Additionally, the understanding of the role and etiology of physical symptoms in depression remains poor.

Diagnosis can be especially challenging in the elderly population, since both patients and health care professionals often perceive depression to be a normal consequence of age-associated changes, such as physical illness or social or economic difficulties.

Dr. Scott B. Patten, MD, PhD, Associate Professor, Departments of Community Health Sciences and Psychiatry, Faculty of Medicine, University of Calgary, Calgary, AB.

Introduction
The term depression can refer either to an emotion, such as sadness, or to a set of depressive disorders. As an emotion, depression is a universal experience, which likely explains why people naturally understand feelings of depression, on an intuitive level, as a reaction to undesirable life events. However, intuition tends not to be clinically useful for depressive disorders, and can even act as a barrier to effective communication and clinical decision-making. Of course, when depression really does represent a non-pathological reaction to a negative life event, empathic and intuitive understanding is completely appropriate, but a mental disorder should not be diagnosed in these circumstances. It is critical to be able to distinguish normal emotional reactions from the potentially dangerous and usually destructive manifestations of depressive disorders. This distinction is particularly important in the elderly, who may experience a variety of losses such as financial security, health and loved ones. Bereavement in relation to such losses may be normal and adaptive, whereas the emergence of a mood disorder--even if triggered by such events--is typically destructive and can be dangerous.

It is often difficult for patients and physicians to understand the distinction between normal or adaptive forms of depression and depressive disorders.