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.

Wilbert S. Aronow, MD, CMD, Clinical Professor of Medicine, Department of Medicine, Divisions of Cardiology and Geriatrics, New York Medical College, Valhalla, NY.

Serum High-Density Lipoprotein Cholesterol
A low serum, high-density lipoprotein (HDL) cholesterol is a risk factor for the development of new coronary events in older men and women.^1-6 In the Framingham Heart Study,¹ in the Established Population for Epidemiologic Studies of the Elderly Study,⁴ and in 2,152 older men and women,³ a low serum HDL cholesterol was a more powerful predictor of new coronary events than was serum total cholesterol. In 1,793 older men and women, mean age 81 years, a decrease of 10 mg/dL (0.26 mmol/L) of serum HDL cholesterol significantly increased by 2.56 times, the probability of having coronary artery disease after controlling for other prognostic variables.² At 48-month follow-up of 1,488 older women, mean age 82 years, and at 40-month follow-up of 664 older men, mean age 80 years, a decrease of 10 mg/dL (0.26 mmol/L) of serum HDL cholesterol significantly increased the relative risk of developing new coronary events by 1.95 times in women and by 1.7 times in men, after controlling for other prognostic variables.

Ernane D. Reis, MD, Assistant Professor, Department of Surgery, Mount Sinai School of Medicine, New York, NY.
Osvaldo J. Yano, MD, Attending Vascular & Endovascular Surgeon, Saint Francis Hospital, Roslyn, NY.

Introduction
Peripheral vascular [arterial] disease (PVD) of the lower extremities is a result of generalized atherosclerosis, and has the same risk factors as do stroke and myocardial infarction.¹ PVD is associated with increased mortality even in asymptomatic patients,² and is an important cause of complications and death after successful coronary revascularization.^3,4 Twenty-five percent of patients with limb-threatening ischemia die within one year of diagnosis.² In patients older than 60 years, the prevalence of clinically detectable PVD is approximately 15%, and claudication occurs in up to 5%.² PVD also reduces ambulatory capacity and quality of life and, therefore, represents an enormous human and financial burden to individual patients and society.⁵

During the last decade, management of arterial disease of the lower extremities has undergone remarkable changes. A true medical revolution is ongoing, as a consequence of the successful introduction of new technologies that can be used alone or in conjunction with established surgical and radiological methods.

Results from the Multicentre Randomized Arterial Revascularization Therapy Study

V. Legrand¹ MD, PhD, FESC,
P. Serruys² MD, PhD, FACC, FESC,
WK Lindeboom³ PhD,
M. Vrolix⁴ MD,
G. Fransen⁴ MD,
P. Materne⁵ MD,
G. Dekoster⁵ MD,
R. Seabra-Gomes⁶ MD,FESC,
J. Queiroz E Melo⁶ MD

¹CHU Liege Belgium.
²Thoraxcenter, Rotterdam, The Netherlands.
³Cardialysis, Rotterdam, The Netherlands.
⁴St Jansziekenhuis, Genk, Belgium.
⁵CHR Citadelle, Liege, Belgium.
⁶Hosp Santa Cruz, Carnaxide, Portugal.

Key words : coronary angioplasty, stent, coronary bypass surgery, elderly.

Introduction
As the population ages, an increasing number of elderly patients are presenting with symptomatic multivessel coronary artery disease requiring revascularization. However, the most appropriate myocardial revascularization procedure for older patients with multivessel disease is still controversial. Indeed, it is well recognized that the procedure-related morbidity associated with either percutaneous coronary intervention (PCI) or coronary artery bypass graft (CABG) increases dramatically with age.

Paul B. Miller, BA, MA, MPhil, is a JD/PhD candidate in law and philosophy at the University of Toronto, and a Junior Fellow of Massey College in Toronto, Toronto, ON.
Trudo Lemmens, Lic Iur, LLM, is Assistant Professor in the Faculty of Law at the University of Toronto, Toronto, ON.

Lucrative Research
A pharmaceutical company invites Dr. B, a primary care physician, to assist with a placebo-controlled randomized clinical trial (RCT) of a new cholinesterase inhibitor for the treatment of dementia. The study will include patients who have been diagnosed with early-onset dementia. Dr B will receive $3,500 for each patient who ultimately agrees to enrol in the study. In the protocol, this fee is explained as payment of the administrative costs associated with Dr B's participation in the trial (in particular, as payment of "costs of obtaining informed consent, accumulating data, secretarial support, and consultation with each subject").

This hypothetical case illustrates an increasingly common phenomenon--offers of "finder's fees" and other "administrative" fees by pharmaceutical companies or Contract Research Organizations (CROs) to primary care physicians for conducting research involving their patients. Finder's fees are offers of money to physicians in reward for referral of patients eligible for research participation. They can be distinguished from payments made to cover costs of research participation.

Jerilynn C. Prior MD, FRCPC, Professor of Endocrinology/Metabolism, Department of Medicine, University of British Columbia and Vancouver Hospital, Vancouver,

Abstract
Estrogen and progesterone (so-called "hormone replacement") therapy was formerly considered essential for menopausal women. The purpose of this paper is to outline the shifts in concepts related to estrogen and progesterone therapy and to describe situations in which it remains a practical, effective therapy for older women.

Estrogen and progesterone are useful for women >65 years old who have osteoporosis diagnosed by bone mineral density or vasomotor symptoms (VMS) disturbing sleep, especially if either are combined with recurrent urinary tract infections or severe dysparunia. If a woman has had a fragility fracture (in a fall from a standing height or less), hormone therapy should be combined with a bisphosphonate such as etidronate for optimal fracture prevention.

Optimal hormone therapy for older women, ideally, is transdermal (patch or gel), rather than oral, to decrease thromboembolic risks. Several lines of evidence suggest that low estrogen doses (such as 25 µg Estraderm®‚ patch, one pump Estragel®) are adequate. Oral micronized progesterone (Prometrium®), given daily, avoids flow, is effective for VMS and increases bone formation. Optimal therapy is daily full or moderate dose progesterone (200 to 300 mg or 5-10 mg medroxyprogesterone).