Anne-Sophie Rigaud, Hôpital Broca, CHU Cochin-Port-Royal, Paris, France.
Bernard Forette, Centre Claude Bernard de Gérontologie, Hôpital Sainte Périne, Paris, France.

Abstract
Diastolic blood pressure is considered an important risk factor for the development of cerebrovascular disease, congestive heart failure and coronary heart disease. However, it is now clear that isolated systolic hypertension and elevated pulse pressure play an important role in the development of these diseases, which are the major causes of cardiovascular morbidity and mortality among subjects aged 65 years and older. The benefit of antihypertensive therapy in reducing the incidence of cardiovascular and cerebrovascular complications has been shown for systolic and systolo-diastolic hypertension in all age groups. Because of the higher risk of cardiovascular disease in the elderly, the effect of antihypertensive treatment appears greater in patients over 60 or 65 years when expressed as an absolute risk reduction.

Definition
Essential (i.e. primary) hypertension is the main cause of hypertension in the elderly population. However, secondary, especially renovascular hypertension is more common in older than in younger adults. The incidence of hypertension in the elderly is high. In an ambulatory population aged 65-74, the overall prevalence is 49.6 % for stage 1 hypertension (140-159/90-99 mmHg), 18.2% for stage 2 (160-179/100-109 mmHg), and 6.

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

Introduction/Epidemiology
Osteoporosis is a common, serious disease in older adults. Until recently, osteoporosis research and treatment have focussed on postmenopausal women. Recently, however, the epidemiology of this condition in elderly men has become clearer and it is evident that osteoporosis is also prevalent in this population. In fact, men over the age of 50 years have a 19-25% lifetime risk of an osteoporotic fracture, as compared to women who have a 50% lifetime risk. In addition, it is estimated that 30% of hip fractures that occur worldwide occur in men, and lead to significant mortality and loss of independence. Indeed, post-hip fracture, men have a higher mortality rate than do women.^1,2,3,4 The role of androgens in bone physiology has suggested that testosterone may be one arm in the treatment regimen. The following article will review the place of testosterone in the management of osteoporosis in males.

Bone Physiology and Pathophysiology
Osteoporosis is a "disease characterized by low bone mass and microarchitectural deterioration of bone tissue leading to enhanced bone fragility and a consequent increase in fracture incidence."⁵ The origin of idiopathic osteoporosis lies in the aging process and normal bone physiology.

Jan Bruder, MD, Assistant Professor and Director of Osteoporosis Metabolic Bone Clinic, Division of Endocrinology, University of Texas Health Science Center, Department of Medicine, San Antonio, TX, USA.

Introduction
Osteoporosis is a disease characterized by low bone mass and bone strength, resulting in an increase in bone fragility and susceptibility to fractures.¹ It is asymptomatic prior to fractures, which most commonly occur in the vertebral body, hip and forearm.

Dual energy x-ray absorptiometry is the technology used to measure bone mineral density at the sites of interest. This technology has revolutionized our approach to this disease. In 1994, the World Health Organization (WHO) published diagnostic guidelines for osteoporosis, which are based on an individual's bone mineral density (BMD) according to a T-score.² The T-score is defined as the number of standard deviations (SD) above or below the mean BMD at peak bone mass at age 30 years. A T-score of -2.5 or lower defines osteoporosis. At risk individuals can now be diagnosed early, thereby allowing the use of highly effective interventional strategies which prevent further bone loss and potentially debilitating fractures. Unfortunately, currently once significant bone mass has been lost, there are no commercially available therapies that are proven to increase bone density. This will likely change in the next few years.

Sophie Jamal, MD, FRCPC, Osteoporosis Research Fellow, Sunnybrook and Women's College Health Sciences Centre, Toronto, ON.

Osteoporosis, defined as a reduction in bone mass leading to an increased susceptibility to fracture with minimal trauma, affects 1.4 million Canadians.¹ Osteoporotic hip and vertebral fractures are major causes of disability and premature death. For example, the average length of stay in an acute care hospital after a hip fracture is three weeks, and one in four patients must remain in long-term care institutions for at least one year. Furthermore, patients with hip and vertebral fractures face a 20% increased risk of mortality.² Osteoporosis is also costly--in Canada, in 1993, the total expenditure for fractures was estimated to be 1.3 billion dollars.³ As the population of Canada ages, the impact of osteoporosis will increase. As such, health care providers should be aware of techniques to prevent fractures due to osteoporosis.

In addition to encouraging physical activity and ensuring adequate calcium and vitamin D intake, several medications can be used to prevent osteoporotic fractures. These drugs, which have been studied predominantly in postmenopausal women, include bisphosphonates, estrogen, selective estrogen receptor modulators and calcitonin. The evidence that supports the use of these agents to prevent bone loss and fractures in postmenopausal women is reviewed below.

Keith B.J. Franklin, PhD
Professor, Department of Psychology, McGill University, Montreal, QC.

Frances V. Abbott, PhD
Professor, Department of Psychiatry, McGill University, Montreal, QC.

Chronic pain afflicts a majority of persons over the age of 60 and a large proportion of those afflicted receives little or no treatment. Many of the long-term conditions that limit activity involve pain, although recognition of pain in primary care settings is complicated by the fact that stoicism tends to increase with age, and older people tend to focus on acute pain and under-report chronic complaints.¹ Activity limitation, as a health indicator, has improved over the past twenty years for non-institutionalized Canadians in the 45-64 and 65-74 age groups (from 19 to 16% and 33 to 22%, respectively). In contrast, the prevalence of activity limitation in those over 75 has remained stable at around 35%. The most significant painful conditions that limit activity, arthritis and rheumatism, have remained stable over the past 20 years with an incidence of about 50% for women and just over 30% for men aged 65 and over.²

In light of the prevalence of pain in the elderly, it is surprising how little is known about the influence of age on the neurology and pharmacology of pain.

Bill McCarberg, MD
Director of Pain Services, Board of Directors, American Pain Society
Department of Family Medicine, Kaiser Permanente Medical Center, San Diego, CA, USA.

As humans age, they invariably become more susceptible to disease, which can impair function and enjoyment of life and pose significant challenges to the health care system. Osteoarthritis, the most common joint disease, affects over 18% of adults in Ontario.¹ Pain has also been associated with a three- to seven-fold increased prevalence of inability to perform daily tasks in the non-institutionalized elderly in Canada.²

More than half of elderly persons in the US are estimated to experience pain daily,³ and recent initiatives in the US have focused attention on the need to treat pain. The Joint Commission on Accreditation of Healthcare Organizations recently introduced new pain management standards to require better pain medicine in hospitals and other institutions as part of their accreditation process.

Non-pharmacologic Therapy
Although medications are commonly required to manage pain and maintain function in elderly patients, non-pharmacologic therapy remains a cornerstone of treatment. It should be started prior to the initiation of pharmacologic therapy, when possible, and be maintained throughout the pain management process.

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

Introduction and Epidemiology
While symptom complaints tend to increase as the population ages due to age and comorbid conditions, the prevalence of headaches actually decreases in the elderly compared to their younger counterparts.^1,2,3 However, headache is still very common in this age group and causes significant morbidity. It is the 10th most common reported symptom in women, and the 14th most common symptom in men over the age of 65 living in the community.^1,2,3 A large cohort study found that 11% of women over the age of 65 years and 5% of men over this age reported frequent headaches.¹

While most (two-thirds of) headaches in the elderly result from benign causes such as tension-type, migraines and cluster headaches, one-third of headaches in this age group arise secondary to systemic disease and primary intracranial lesions.^2,4 This is significantly different from the situation in younger patients, where only 10% of headaches are caused by such significant conditions (Table 1).^2,4 Another difference in headaches between the young and old is the fact that even benign dysfunctional headaches (e.g. migraine, tension-type, cluster) can have an atypical presentation in the elderly.

Ailsa KR Cook, BSc
Research Fellow, Centre for Social Research on Dementia,
Department of Applied Social Science, University of Stirling, Stirling, UK.

Pain Assessment in Patients with Dementia
Pain is an important consideration when caring for patients with dementia. Being in pain leads to cognitive (e.g. poor concentration) and behavioural (e.g. apathy) symptoms, which if left untreated, exacerbate the effects of the existing cognitive impairment.^1,2 Pain is also associated with increased depression amongst people with dementia, as well as increases in other behavioural disorders, such as calling out and aggression.^3,4,5,6

Despite its significant negative impact, research has shown that many older people with dementia experience untreated pain.^7,8,9,10 A survey of 13,625 older cancer patients living in nursing homes revealed that 26% of those with daily pain received no analgesics, and a disproportionate number of this group were cognitively impaired.⁷ Similarly, a review of analgesic use in nursing homes found that residents with dementia were prescribed and administered fewer analgesics than were their cognitively intact counterparts.⁸

If pain management in this population is to improve, it is essential that health care professionals pay more attention to the assessment of pain in patients with dementia.

This month we are very pleased to make several major announcements concerning Geriatrics & Aging for the year 2002. Over the past year, we have invested a great deal of time and energy in assessing your needs and in providing you with information that is of practical importance to your day-to-day practice. In the same vein, we have been working towards establishing affiliations with recognized programs and institutions in order to ensure that we continue to publish high quality educational material. We are pleased to announce that Geriatrics & Aging is now working with the Regional Geriatric Programs of Ontario to provide you with current information on best-practice medicine and on important programs and services for the elderly.

The RGPs were established in the mid-80s, as part of a strategic plan to provide a comprehensive system of health services for the elderly. The RGPs are set up as a network of independently operating programs that exist at each of the five academic health science centres in Ontario: Ottawa, Kingston, Toronto, Hamilton and London. They provide a variety of services ranging from consultation and education to the development of treatment and rehabilitation programs. We are very pleased to have been chosen as a vehicle for disseminating information for the RGPs and look forward to working closely together. Keep your eyes open for the RGPs' supplements that will appear regularly in 2002. For further information on the Regional Geriatric Programs, please visit their website at www.rgps.on.ca.

Secondly, I would like to welcome some new members to the Geriatrics & Aging team. We are delighted to announce the addition of three new physicians to our advisory board: Dr. Christopher MacKnight (Dalhousie University), Dr. David Gladstone (Sunnybrook and Women's College) and Dr. Wilbert Aronow (Mount Sinai School of Medicine). Drs. MacKnight and Gladstone are rising stars in the fields of dementia and stroke research and we look forward to having them keep us current on exciting developments in these fields. Both have contributed outstanding articles to recent issues of Geriatrics & Aging on the Management of Vascular Dementia (April 2001) and New Frontiers in Stroke Recovery (September 2001), respectively. Dr. Aronow is an internationally renowned geriatric cardiologist with over 400 publications, who joins us from the Department of Geriatrics and Adult Development at the Mount Sinai School of Medicine in New York. I am sure that all three will be excellent additions to our team.

Our final announcement concerns the format of our publication. Our readership survey, conducted earlier this year, indicated that many of our readers have difficulty archiving information from the publication in its current format. In response to readers' requests and in order to meet the needs of our partners, we are pleased to announce that, as of January 2002, Geriatrics & Aging will be published in a journal format. We are determined to maintain our high production quality, innovative illustrations and dynamic layout, but aim to combine this with a format that will be more reader-friendly. We hope that you will support us in our efforts and we look forward to receiving feedback. Don't miss our 'flagship issue' in the mail in early February.

Rodrigo B. Cavalcanti, MD, FRCP(C)
Clinical Assistant, Internal Medicine, University Health Network.

Shabbir M.H. Alibhai, MD, MSc, FRCP(C)
Staff Physician, Internal Medicine and Geriatrics,
University Health Network, Lecturer, Dept. of Medicine,
University of Toronto, Toronto, ON.

Introduction
Syncope is defined as a transient loss of consciousness accompanied by a loss of postural tone, followed by complete, spontaneous recovery.¹ Population-based studies, such as the Framingham study, indicate that the overall incidence of syncope is 3% per year for men and 3.5% per year for women.² Moreover, syncopal events become more frequent with age, with the incidence rising to 6% per year in persons over 75 years of age.²

It is important to note that syncope is fundamentally a symptom, rather than a disease process, with multiple conditions giving rise to this symptom. The common step in most etiologies is a transitory compromise in cerebral blood flow. Impairment in blood flow to the reticular activating system in the brainstem results in loss of consciousness, while lack of perfusion to the corticospinal pathways impairs motor tone.

Currently, it is estimated that between 2-6% of all hospital admissions are for evaluation of syncope or treatment of associated falls, 80% of which are in persons aged 65 years or older.