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).

Dr. Clarfield is the Chief of Geriatrics, Soroka Hospital Centre, Professor, Faculty of Medicine, Ben Gurion University of the Negev, Beersheva, Israel. Professor (Adjunct), Division of Geriatric Medicine, McGill University and Jewish General Hospital, Montreal, QC, Canada.

Have you ever heard of the wonderful one-hoss shay.
That was built in such a logical way.
It ran a hundred years to a day.
And then, of a sudden, it-ah, but stay.
I'll tell you what happened without delay.
Scaring the parson into fits.
Frightening people out of their wits,
Have you ever heard of that, I say?
Oliver Wendell Holmes

My own grandfather died when he was over 100 years old. Why? We don't know because, for religious reasons, no autopsy was performed. Even if it had been, what might it have shown? Possibly a Whitmore stage A or B carcinoma of the prostate, maybe a tumour in the cecum, perhaps the scars of previous myocardial infarcts, but very likely nothing that a pathologist could confidently have labeled as the cause of death.

So why do old people die? Is aging a disease or is it simply a normal life stage? Or, as Crapo and Fries have so elegantly described in their book "Vitality and Aging" (from which the above quote was lifted), is it simply the final disintegration of the old buggy?

In order to come to some understanding as to what aging actually comprises, it might be helpful to examine what pertains in other mammalian species.

Dr. Gabriel Chan, MBBS(HK), FHKAM, MRCP(UK), ABIM, FRCP(C), FRCP(EDIN),
Director of Geriatric Medical Services and Program Medical Director of Long-Term Care, North York General Hospital, Lecturer of Medicine, University of Toronto, Toronto, ON.

Frances Simone, BSc, MHA, Director, Geriatric Ambulatory Care Services, North York General Hospital, Toronto, ON.

The POWER (Promoting Osteoporosis Wellness through Education, Exercise and Resources) program is a collaborative, multi-site initiative designed to empower older adults with osteoporosis to improve their quality of life and prevent falls. POWER consists of a seven-week, culturally sensitive education, exercise and nutrition program developed by North York General Hospital, Baycrest Centre for Geriatric Care, Toronto Public Health and Yee Hong Centre for Geriatric Care. POWER is an effective health promotion model for osteoporosis management and falls prevention that can be replicated in other communities across the country.

Health promotion and disease prevention are very important concepts that support our collective goal for a healthy society. Currently, there is a need to develop models that fully integrate health promotion activities into our 'illness treatment' oriented health system. Without such models, we will face significant challenges as our population ages and our health system attempts to cope with the impact of chronic diseases.

Kathryn M. Yorkston, Ph.D., BC-NCD, Department of Rehabilitation Medicine, University of Washington, Seattle, WA.
David Beukelman, Ph.D., Department of Special Education and Communication Disorders, University of Nebraska, Lincoln, Munroe-Meyer Institute for Genetics and Rehabilitation, University of Nebraska, Omaha, NE.
Laura Ball, Ph.D., Munroe-Meyer Institute for Genetics and Rehabilitation, University of Nebraska, Omaha, NE.

Summary
This article describes intervention for dysarthria associated with amyotrophic lateral sclerosis (ALS). Five critical periods are presented including a stage with normal speech, detectable speech disturbance, behavioural intervention, use of augmentative communication, and loss of useful speech. Intervention strategies at each of these stages are outlined with the goal of maintaining functional communication regardless of the severity of dysarthria.

ALS is a rapidly progressive degenerative disease of unknown etiology involving the motor neurons of both the brain and spinal cord.¹ The symptoms characteristic of ALS are generally classified by site of involvement (that is, upper motor neuron versus lower motor neuron) and by whether spinal nerves (those innervating the arms and legs) or bulbar nerves (those innervating the muscles of speech and swallowing) are involved.