Dr. Carol Townsley, Clinical Research Fellow, Princess Margaret Hospital,
University Health Network, Toronto, ON.
Dr. David Hedley, Staff Medical Oncologist, Princess Margaret Hospital,
University Health Network, Toronto, ON.

Pancreatic cancer is the fourth leading cause of cancer-related death for both men and women in North America (following lung, colon and prostate/breast), and is responsible for 5% of all cancer-related deaths. At two to three percent, pancreatic adenocarcinoma has the worst overall five-year survival rate of any cancer. Due to the extreme difficulty in diagnosing pancreatic cancer when it is still surgically resectable, and because of the lack of effective systemic therapies, incidence rates are, unfortunately, virtually equal to mortality rates. Although the overall survival is quite poor, there is a subgroup of patients with slow growing tumours who may survive for several years with good symptom control.

Epidemiology and Risk Factors
An increased incidence of pancreatic cancer is seen in patients of male gender, advanced age and black race. The risk of developing pancreatic cancer is low in the first three to four decades of life but increases sharply after the age of 50 years, with most patients being between the ages of 60 and 80 at the time of diagnosis. Although exact risk factors for pancreatic cancer are not well defined, there appears to be a clear association with smoking and possibly with chronic pancreatitis.

At the time of the writing of this editorial, there is a 'high profile' inquest going on in Toronto concerning driving and the elderly. Two years ago, an elderly woman making a right hand turn struck and killed a young woman. The young woman was then dragged under the car for almost a kilometre with the driver apparently unaware. There was no suggestion that the elderly driver had any physical or cognitive impairment that affected her driving. However, despite the absence of cognitive impairment, this was felt to be a case that could raise the profile of cognitive impairment and the aging driver. The inquest has not concluded, but fortunately initial testimony has stressed that most elderly drivers are competent to drive.

The same day that my testimony at this inquest was reported in the papers, another story was reported, more gruesome than the first. A 25-year-old Texas woman struck a homeless man, impaled him on her windshield, and then locked him and the car in the garage while he slowly bled to death over two or three days. She and her friends then removed the body and 'dumped' it in a garbage bin. For some reason, the first case has sparked an intense interest in whether or not the elderly should drive, but I have not read or heard any musing about restricting the driving privileges of 25-year-olds. Perhaps all young people should have random drug testing to maintain their driving privileges (a presumed factor in the Texas incident)!

Clearly, the difference in the two cases from a geriatrician's perspective is as follows: The incident with the elderly driver is immediately generalized to reflect all the elderly, whereas the incident with the young driver is a reflection of her actions, and her actions alone. In the first case, the trial judge last year pronounced that the woman's ability to drive was 'impaired by age.' I have yet to identify any evidence that shows age is an independent risk factor for driving. Rather, it is the morbidity that accompanies aging that impairs driving. I suspect that any slowing of reaction time and reflexes in the elderly is more than compensated by better judgment and increased caution. Even though we know that a large number of the over 80 population has cognitive impairment, we do not have accurate information on how many still drive, vital information to have if any screening endeavours are considered.

This issue focuses on cancer and the elderly and, as I have discussed in the past, the presumption is often made that the elderly should be treated less aggressively than should younger patients, even though comorbidity is a more important factor than age alone. The lesson, brought home once again by this inquest, is that management must be tailored to the individual and based on comprehensive assessment, not just a single factor such as age.

Fortunately, in this issue we feature articles by experts who do not fall prey to age bias. Dr. Townsley and Dr. Hedley discuss pancreatic cancer in the elderly, and other articles address the issues of cardiac tumours (Desai and Butany), ovarian cancer (Gould and McMeekin), male breast cancer (Glück and Friedenreich), and screening for colorectal cancer (Rossos and Yeung). As well, we have our usual assortment of other articles, including a special piece on estrogen and the aging brain by Elise Levinoff and Dr. Howard Chertkow, one of Canada's leading investigators in the field of cognitive impairment.

Enjoy this issue.

Dr. Clarfield, MD, FRCSC, is the Chief of Academic Affairs at the Herzog Hospital in Jerusalem, Director of Geriatrics in the Ministry of Health, and on staff in the Division of Geriatric Medicine, Sir Mortimer B. Davis-Jewish General Hospital, McGill University, Montreal, PQ.

Geriatrics, the medical specialty which deals with the old, is still relatively young. Although not all Canadian medical schools offer a comprehensive approach to teaching this subject, progress has been made especially in the last two decades. There are now more clinical units, more research is being carried out, and certainly more attention is being paid to the subject of the elderly than ever before.

The roots of geriatrics can be traced back to the beginning of this century, and two of its pioneers hail from opposite sides of the Atlantic: Dr. Ignatz Nascher, an American whose medical career began at the end of the 19th century;¹ and an English physician, Dr. Marjory Warren, who reached the zenith of her influence in the 1940s.²

Dr. Nascher was born in Vienna in 1863 and was brought up in New York. In 1882, aged 19, he graduated in pharmacy and several years later completed his MD and began private practice. Little is known about his early years, but Dr. Nascher's first paper on geriatrics ("Longevity & Rejuvenesence," New York Medical Journal, 1909) was to have a profound influence on the discipline simply by giving us its name.

Jane Oshinowo, RNEC, Primary health care Nurse Practitioner,
York Community Services, Toronto, ON.

Introduction
Pain is more than the perception of a nociceptive stimulus in the peripheral or central nervous system. It is "what the person says it is."¹ Ferrell1 developed a conceptual model that identifies four dimensions of pain and their impact on a person's quality of life (Figure 1). This model can be used to enhance the caregiver's understanding of the patient's experience of pain. Pain can be acute, chronic or chronic malignant in nature. In the elderly, illness tends to be chronic and the pain is often related to a degenerative condition. However, the elderly do experience acute pain. Whether acute or chronic, pain is more difficult to assess in the cognitively impaired elder. Despite our recognition of the global impact of pain on the individual, and the morbidity and mortality associated with inadequately managed pain, 25-50% of community dwelling elders are living in pain.²

Chronic pain management today is multidimensional. Analgesics tend to be the mainstay of therapy. However, non-pharmacological therapies are currently under investigation and in practice as complementary or alternative therapies to medications. This field is very large and continues to expand. For the purposes of this article, only the more commonly used and better-researched therapies will be discussed.

Madhuri Reddy , MD, FRCPC,
Associate Editor, Geriatrics & Aging.

As the Canadian population ages, policy makers must begin to make predictions regarding the needs of long-term care (LTC) clients. This is confounded by a number of variables that make long-term predictions difficult. In the following article, different schools of thought and theories on the variables that will influence the needs of the LTC sector in the next several decades are reviewed.

Numbers of Clients that Require LTC
The Expansion of Morbidity Hypothesis
The expansion of morbidity hypothesis suggests that the numbers of clients requiring institutional LTC will increase, leading to an increased burden of disability and dependency.^1,2 With advances in medical, social and economic conditions, active-life expectancy has increased³ and the age of onset of terminal dependency has been postponed; however, some believe that the duration of terminal dependency will eventually increase.¹ There has been an increase in both the hospital length-of-stay of elderly clients and the proportion of the lifespan spent in long-term hospital care. The number of very old people, including centenarians, has also steadily risen. There is evidence that both disability and dependency have also increased. In Canada, up to 80% of the gain in life expectancy consists of increased years of disability.

Michael J. Borrie, BSc, MB, ChB, FRCPC, Chair, Division of Geriatric Medicine, University of Western Ontario, London, ON.

Acute urinary retention (AUR) occurs predominantly in men and the incidence increases with age. The most common cause of urinary retention is benign prostatic hypertrophy (BPH). For men in their 40s who have no or mild obstructive symptoms (American Urologic Association Symptom Score 7 or less), the incidence of acute urinary retention is 2.6/1000 person years and 3.0/1000 person years in people with moderate to severe symptoms. In contrast, men in their 70's with mild to moderate symptoms have an incidence of AUR of 9.3/1000 person years and this rises to 34.7/1000 person years in those with moderate to severe symptoms.¹ Over five years, the risk of AUR for men in their 70s is 10% and for men in their 80s it is almost 30%.¹ These findings are based on a cohort of over 2,000 men 40-79, followed over four years and is one of the few longitudinal epidemiologic studies in the area.

Definition
Acute urinary retention has been defined as painful inability to void with a urine volume on catheterization of less than 800 ml.^2,3 Chronic retention has been defined as the presence of the post-void residual urine volume greater than 500 mls (estimated on bladder ultrasound scan) with or without upper tract dilatation on ultrasound and/or uremia occurring in a patient who is still able to void spontaneously.

Marie-Hélène Mayrand, MD, MSc, FRCSC, Departments of Oncology and Epidemiology, McGill University, Montreal, PQ.
Eduardo L. Franco, PhD, Professor of Epidemiology and Oncology, Director, Division of Cancer Epidemiology, McGill University, Montreal, PQ.

Introduction
The Canadian population is growing older, and women represent an ever higher proportion among the elderly: 57% of Canadians over 65 years of age are female, and in the "over 85" age group, this proportion reaches 70%.¹ We can expect that specific health care issues that pertain to this segment of the population will receive renewed attention. Understandably, there has been a special interest in identifying preventive health care measures that can effectively prevent disability or premature death in women over age 65.

With the sole exception of cervical cancer, there is no evidence that screening women for urogenital neoplasms, such as endometrial, ovarian and bladder cancers, reduces mortality from these cancers, regardless of age.² Therefore, the focus of this article will be on reviewing the basis for practice recommendations concerning screening for cervical cancer. Although essentially preventable, cancer of the uterine cervix continues to be a significant health problem, particularly in older women. In Canada, older women have the highest incidence and mortality rates from cervical cancer when compared to younger age groups.

Céline Chayer MD, FRCPC, Behavioural Neurology, Hôpital Maisonneuve Rosemont, Montreal, PQ.

Introduction
The prevalence of dementia in Canada has been estimated at 8%, after the age of 65 years.¹ Alzheimer disease (AD) accounts for approximately 60% of cases, while other conditions accounting for the remaining 40% include, among others, vascular dementia, dementia with Lewy bodies (DLB) and frontotemporal lobar degeneration (FTLD). Differences in prognosis and symptomatic treatment, as well as eventually disease-modifying therapy underline the importance of the differential diagnosis of dementia. The use of clinical criteria for diagnosis of degenerative and vascular dementias can increase the level of clinical diagnosis accuracy² and should, therefore, be known by physicians dealing with dementia. Advances in the understanding of FTLD have been made over the past 15 years. We will review the clinical manifestations of FTLD and highlight the differences with AD.

Pick's disease, fronto-temporal lobar degeneration and Pick complex
In 1892, Arnold Pick described patients with predominant language impairment in whom focal atrophy of the frontal and temporal lobes was found.³ Later, Alois Alzheimer described, in Pick's original patients, ballooned cortical neurons containing cytoplasmic inclusions that were subsequently called Pick bodies. Pick's disease became synonymous with frontotemporal dementia.

Kiran Rabheru, MD, CCFP, FRCPC, Active Staff, Geriatrics Psychiatry,London Psychiatric Hospital, London, ON.

Depression is the most common psychiatric disease in the elderly, and is a problem of major public health importance; however, it is underrecognized and undertreated, particularly in primary care and long-term care settings.¹ Major depression may affect up to 20% of hospitalized elderly while up to 30% of older persons in the community suffer from milder forms of depression. In many, the symptoms are persistent or recurrent, resulting in increased disability, worsening of symptoms caused by other medical illness, greater health care utilization, and higher mortality from suicide as well as other medical causes such as vascular diseases.

Antidepressant medication, although not adequate or sufficient on its own, is often an essential part of the treatment plan for an older person who suffers from a significant burden of depressive symptoms. A dysregulation of the central neurotransmitters, norepinephrine (NE), serotonin (5-HT) and dopamine (DA), has been suggested to be part of the underlying mechanism in major depression.

In recent years, newer compounds have been introduced that have similar efficacy but far fewer side effects than do tricyclic antidepressants (TCA).

D'Arcy Little, MD, CCFP, Academic Fellow, Department of Family and Community Medicine, University of Toronto, and Director of Medical Education, York Community Services, Toronto, ON.

Introduction
Congestive heart failure (CHF) is a serious common, condition. It qualifies as one of the most important contributors to cardiovascular morbidity and mortality in the developed world. Due to the burgeoning elderly population, as well as to new treatments for acute myocardial infarction which are allowing more patients to survive with impaired ventricular function, the incidence of CHF will continue to increase dramatically.¹ While significant improvements in CHF therapy have been made in the last few decades with the development of angiotensin-converting enzyme inhibitors (ACE inhibitors), as well as a clarification of the role of beta-blockers in therapy, additional strategies are still needed to further reduce progression of disease and consequent morbidity and mortality.^1,2 Angiotensin receptor blockers (ARB) may represent an additional approach to the treatment of CHF with the possibility for improved outcomes. Despite physiological explanations that would make such an assertion sound, significant supporting clinical data are currently lacking.