Jennifer Pike, PhD, Neuropsychiatric Institute, Department of Psychiatry and Biobehavioral Sciences, University of California, Los Angeles (UCLA), CA, USA.

Michael Irwin, MD, Cousins Center for Psychoneuroimmunology, Neuropsychiatric Institute,
Department of Psychiatry and Biobehavioral Sciences, University of California, Los Angeles (UCLA), CA, USA.

Introduction
Depressive disorders are common in the geriatric primary care setting,¹ and are associated with considerable costs and human suffering.^2-4 In 1990, depression was ranked as the fourth leading cause of disability worldwide,⁵ with annual health care costs estimated at $44 billion in the United States alone. Much of this cost is a reflection of higher health care utilization rates in depressed individuals, irrespective of medical comorbidity and mental health visits.³

The prevalence of depressive disorders, defined by the DSM-IV-TR (Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision; Table 1), in the elderly is high and ranges from 6.5-17% in the primary care setting.^1,6 The rates for dysthymia, minor depression or subsyndromal depressions are roughly double those for major depression. The functional impairments and medical burden of these minor depressed geriatric patients are comparable to those of younger patients with major depression.

Arthur Bookman, MD, FRCPC, Senior Staff Physician, University Health Centre, Coordinator, Core Residency Rheumatology Program, University of Toronto, Toronto, ON.

Rheumatoid arthritis (RA), traditionally, has been a difficult and discouraging condition for medical practitioners to treat. In general, physicians have been taxed to contend with the overwhelming physical destruction, as well as the sometimes devastating medical complications, seen in the disease. Our medical schools do not provide sufficient preparation, giving us inadequate tools for recognition of joint disease in general and few tools for following and monitoring disease progression.

Only 10 years ago, the treatment plan for RA was a leisurely-paced pyramid of medications. It began with non-steroidal anti-inflammatory agents (NSAIDs), and flowed through empirical remedies such as gold salts and chloroquine, into newer empirical remedies co-opted from cancer treatment or transplantation, such as methotrexate or imuran in recent years.

Over the last five to 10 years, modern studies have contributed to an evolving understanding of the disease. It is now evident that the diagnosis of RA amounts to a prediction of joint inflammation that will inevitably evolve to joint damage, leading to X-ray evidence of erosion and joint space narrowing. Furthermore, these X-ray changes are markers for loss of function and disability. The evolution of X-ray change over time is constant (Figure 1).

Daniel HS Silverman, MD, PhD, Ahmanson Biological Imaging Center, Division Nuclear Medicine, Department of Molecular and Medical Pharmacology, School of Medicine, University of California, Los Angeles, CA.

Introduction
Early-stage dementia is often unrecognized or misdiagnosed.¹ This can be particularly problematic for dementias due to neurodegenerative disease, like Alzheimer's, where the most can be gained from effective therapies that intervene as early as possible in the course of progressive, irreversible damage to brain tissue. Conventional methods for evaluation are often inaccurate for making a diagnosis or prognosis in the early stages of dementia. However, over the past several years it has become increasingly evident that certain neuroimaging methods--making use of low levels of radioactive compounds to noninvasively elucidate brain function--can be used to sensitively identify such disease at the time of a patient's first presentation of symptoms.

Neuronuclear Imaging in Dementia Assessment
Over the last two decades, clinicians and researchers have gained substantial experience in using the three-dimensional imaging capabilities of positron emission tomography (PET) and single photon emission computed tomography (SPECT) for the identification and differential diagnosis of dementia.

Ali Ahmed, MD, MPH, FACP, Assistant Professor, Division of Gerontology and Geriatric Medicine, Department of Medicine, School of Medicine and Department of Epidemiology and International Health, School of Public Health, Scientist, Center for Aging and Center for Outcomes and Effectiveness Research and Education, University of Alabama at Birmingham; Staff Physician, Heart Failure Clinic and Section of Geriatrics, Veterans Affairs Medical Center; Member, Heart Failure Project, Alabama Quality Assurance Foundation, Birmingham, AL, USA.

Heart Failure: A Geriatric Syndrome
Heart failure (HF) is a "geriatric syndrome" as much as it is a "cardiac syndrome." The prevalence of HF in Canada is over 350,000 and between 25% and 40% of patients are dead within one year of diagnosis.¹ Most HF patients are 65 years of age and older,² and both the incidence and prevalence of HF increase with age.³ Over 90% of all HF-related deaths occur in persons 65 years of age and older.⁴ HF is the number one hospital discharge diagnosis for this group of patients.5 Diagnosis and management of HF in older adults is complicated by functional impairment, multiple comorbidities, polypharmacy and left ventricular systolic dysfunction (LVSD).^6,7

Historic Role of Digitalis in Heart Failure
Digitalis glycosides are present in the leaves of the foxglove, Digitalis purpurea (digitoxin) or Digitalis lanata (digoxin), or in the seeds of Strophanthus gratus (ouabain).

Scott A. Farrell, BA, BEd, MD, FRCSC, Iwk Health Centre, Halifax, NS.

Introduction
Adult women who enjoy urogenital health are usually sublimely unaware of their pelvic organs. It is not until urogenital organ dysfunction occurs that attention is focused upon factors that are essential to the maintenance of a healthy urogenital tract. Maintenance of urogenital health is largely dependent upon healthy lifestyle habits and, to a lesser extent, a woman's hormonal milieu. This article will briefly discuss the following relevant topics: normal anatomy and function, the effect of lifestyle and hormones on normal functioning of the urogenital organs, and common problems encountered with aging.

Normal Anatomy and Function of the Urogenital Tract
The urogenital tract is composed of three organ groups which lie in close proximity within the pelvic cavity: the bladder and urethra; the genital organs (uterus, fallopian tubes, ovaries, vagina and vulva); and the rectum and anal canal. These organs share a common embryologic origin and all possess estrogen receptors.^1,2 They rest upon a common support structure--the pelvic diaphragm or levator muscles³--which not only invests each organ with supportive fibres, but also contributes to the mechanisms that maintain urinary and anal continence and close the introitus of the vagina. The urethral and anal continence mechanisms are dependent upon the normal functioning of both smooth and striated muscle sphincters.

Part 1: Introduction, Head and Neck, and Cranial Nerves

David J. Gladstone, BSc, MD, Fellow, Cognitive Neurology and Stroke Research Unit, Sunnybrook and Women's College Health Sciences Centre and 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 begins with an approach to the neurological examination in normal aging and in disease, and reviews components of the general physical, head and neck, neurovascular and cranial nerve examinations relevant to aging and dementia. Part 2 covers the motor examination with an emphasis on upper motor neuron signs and movement disorders. Part 3 reviews the assessment of coordination, balance and gait. Part 4 discusses the muscle stretch reflexes, pathological and primitive reflexes, sensory examination and concluding remarks.

Roland R. Tremblay, DSc, MD, PhD, Professor Emeritus of Medicine, Laval University, Quebec City, QC.

Introduction
In both sexes, aging is associated with a progressive reduction in skeletal muscle mass and strength, although this may be masked by increases in subcutaneous fat or abdominal obesity that give the impression of stable body weight. Progressive frailty, however, occurs on a more global level with seniors "affected by multiple chronic diseases which cause physical and functional limitations."¹ These comorbid diseases may cause a systemic stress, which by itself (excess cortisol secretion), or by virtue of its suppressive action on the pituitary-gonadal axis, leads to a decline in androgen production. While the tendency to associate andropause and androgens has become increasingly common, the causal link between male hormone deficiency and the clinical disorder andropause still remains a weak one. A medical anthropologist is certainly likely to qualify the association as a reductionist vision of the frailty syndrome. In a sense, this vision serves the interests of both patients and physicians: it facilitates the diagnostic approach and the treatment strategies in an aged population, estimated at 20%, that seeks medical attention because of frailty, low mental and physical energy, depression-like symptoms and sexual hypofunction.

Peter J. Pommerville, BA, MD, FRCS(C), Consultant Urologist, Vancouver Island Health Authority, Victoria, BC; Principal Investigator, Can-Med Clinical Research Inc., Victoria, BC.

Introduction
Erectile Dysfunction is a significant and common medical problem. The National Institutes of Health has defined erectile dysfunction as "the persistent inability to achieve or maintain an erection sufficient for satisfactory sexual performance."¹ The nature of sexual dysfunction is more precisely defined by the term erectile dysfunction (ED) than by the term impotence.¹

ED is a clearly defined problem that the medical practitioner must differentiate from premature ejaculation, orgasmic dysfunction and Peyronie's disease.

Prevalence of Erectile Dysfunction
According to the NIH Consensus Development Panel, ED may affect as many as 30 million males in the U.S.¹ Data collected by Statistics Canada indicate that as many as three million Canadian men may suffer from ED. However, it is estimated that fewer than 20% seek treatment.²

Epidemiological studies conducted in the U.S. provide the most extensive information on the prevalence of ED. One such study that is often referred to is the Massachusetts Male Aging Study (MMAS).³ This study demonstrated a combined prevalence of minimal, moderate and severe ED in 52% of non-institutionalized men aged 40 to 70 (Figure 1). Of these, 10% reported complete ED, 25% reported moderate ED and 17% minimal ED.

Stephen Holzapfel, MD, CCFP, FCFP, Medical Director, Sexual Medicine Counselling Unit,
Sunnybrook and Women's College Health Sciences Centre;
Associate Professor, Department of Family and Community Medicine,
University of Toronto, Toronto, ON.

Sexual function and self-perception is integral to our sense of self and well-being. Yet we live in a society that desexualizes older people, especially women. Aging women experience changes in their sexuality that are often associated with negative effects on mood. Can we help women who are distressed by these changes?

Mood and Sexuality Changes Associated with Menopause
Most women make the transition through menopause with few long-term negative effects on their sexuality. Two-thirds of women in relationships are still sexually active in their 60s, with a gradual decline to about 25% of couples in their 80s. While many are comfortable with these changes, some are distressed by the loss of physical intimacy. The absence of a partner due to death, divorce or partner illness curtails women's sexual lives more often than do their own medical issues. Aging men face increasing erectile dysfunction, with one in seven men experiencing complete impotence by age 70.¹ Given that North American women marry men who are on average four years older than themselves, and that men die six years sooner, most women face up to a decade of widowhood.

Laumann et al.

Shawna L. Johnston, MD, FRCSC, Assistant Professor, Department of Obstetrics and Gynecology, Queen's University, Kingston, ON.

Abstract
The population of postmenopausal women in Canada is growing rapidly. It is now estimated that there are more than four million women in Canada over the age of 50. Menopause, hormone replacement and the sequelae of estrogen deprivation will become important foci for health care in this century.

Urogenital aging occurs as a result of estrogen deprivation in menopause and of tissue aging itself. Problems originate from the lower urinary tract (urethra and bladder) and from the vagina. Vaginal complaints include dryness, dyspareunia, discharge and/or bleeding. Estimates of prevalence suggest that 40-50% of postmenopausal women are affected. These symptoms, while not life-threatening, can be extremely uncomfortable and limiting, and can negatively impact on quality of life.

Estrogen replacement therapy has long been the mainstay of treatment for vaginal atrophy. Both oral and vaginal estrogen are effective, though the vaginal route is often chosen because it avoids the enterohepatic circulation and can therefore be given in much lower doses. Estrogen can be administered vaginally as a cream. Newer methods of delivery include estradiol vaginal tablets and sustained release intravaginal estradiol rings. Effective nonhormonal alternatives include the vaginal moisturizer, polycarbophil.