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.

Diagnosis and Management in the Elderly

Deirdre A. Jenkins, MD
Richard C. Woodman, MD
Division of Hematology and Hematological Malignancies,
University of Calgary and Tom Baker Cancer Centre, Calgary, AB.

Introduction
Chronic lymphocytic leukemia (CLL) is a monoclonal disorder of long-lived, mature lymphocytes. It is the most common leukemia in North America with an incidence of 2.7 cases per 100,000. CLL is primarily a disease of the elderly, with a median age of 70 at diagnosis and a slight male predominance. In patients older than 85 years, the incidence rises to 30.6 per 100,000.¹ There are no clear hereditary patterns; however, increased incidence is noted in families with other lymphoproliferative disorders. The etiology is unknown, and typical risk factors for other cancers (like viruses, radiation and chemicals) have no clear role in CLL. The importance of understanding the diagnosis and treatment of this disorder lies in the chronic nature of the disease, as patients may live years to decades after diagnosis. Knowing your treatment goals, and anticipating complications are fundamental for managing patients with CLL.

Diagnosis
While there has been a growing number of patients serendipitously diagnosed on routine blood tests, the majority of patients will present with symptoms referable to their disease (Table 1).

Lucia Gagliese, PhD
Assistant Professor, School of Kinesiology and Health Science, York University,
Staff Scientist, Department of Anaesthesia, University Health Network, and
Assistant Professor, Department of Anaesthesia, University of Toronto.

Brenda Kraetschmer, RN, BScN
Clinical Research Coordinator,
Department of Anaesthesia, Mount Sinai Hospital and
University Health Network, Toronto, ON.

As the population ages, health care workers will increasingly be called upon to provide effective pain assessment and management to elderly patients. Fortunately, information regarding age-related patterns of pain, disability and psychological distress has become more readily available over the past decade. However, this area of study remains in its infancy and further research is urgently needed. In this article, we present a brief overview of some of the most recent data about the epidemiology, assessment and management of chronic pain in elderly people.

Epidemiological Studies
There is no clear-cut pattern of age differences in the prevalence of pain. Results vary depending on the population and type of pain studied.¹ Epidemiological studies conducted in community settings have found that the prevalence of many pain complaints, including headache, migraine and low back pain, peaks in middle-age and decreases thereafter.

Gail A. Eskes, PhD
Department of Psychology,
Queen Elizabeth II Health Sciences Centre Assistant Professor,
Psychiatry and Medicine (Neurology),
Adjunct Professor, Psychology,
Dalhousie University, Halifax, NS.

Beverly C. Butler, BSc
Department of Psychology,
Dalhousie University, Halifax, NS.

Introduction
Unilateral neglect is a cognitive and behavioural syndrome after brain damage that can have serious consequences for patient recovery, rehabilitation success and long-term reintegration to independent living. Outcome studies commonly identify neglect and related sequelae as significant predictors of poor outcome in stroke patients in terms of increased need for assistance in self-care activities and decreased quality of life.

Definition and Clinical Presentation
Unilateral neglect is most commonly defined as a failure to orient, report or respond to stimuli located in the space or body contralateral to a brain lesion (often due to stroke or brain injury), despite adequate sensorimotor ability to do so.¹ The neglect syndrome is fundamentally different from, although sometimes confused with, hemianopia, hemisensory loss or hemiplegia.

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

Introduction
It is well documented that, throughout North America, a large percentage of elderly clients (10-52%) do not have the medical need or are not sufficiently disabled to justify placement in high level of care settings such as a nursing home (NH).^1,2,3,4

The placement of low-care clients in NH is often assumed to indicate inappropriate and inefficient use of NH resources.⁵ In addition, it is well established that disabled clients prefer home or community-based care rather than receiving care in NHs.⁶ So why do clients continue to be placed in high levels of care that they do not need?

Subjective Placement Criteria
The process of client placement does not always explore the possibility that the client may best be cared for outside of a long-term care (LTC) institution. In addition, even when clients truly do need NH care, the definitions of the various levels of care are often vague; thus, adherence by placement committees is often inconsistent. This lack of objective criteria regarding the level of care required by a particular patient leads to subjective decision-making by a placement panel; this can result in patients who require the same level of care being placed in different levels depending on who makes the decision.

Professor Michael S Roberts, DSc
Julie Stokes, BPharm, PG
Dip Clin Hosp Pharm.
Department of Medicine,
University of Queensland,
Ipswich Road,
Buranda, Qld, Australia.

Introduction
One of the most professionally satisfying scenes we have observed while working in nursing homes is an older person regaining his or her dignity and independence after unnecessary drugs have been ceased. It is often easy to add medications to the drug regimen of older people¹ to treat "new" conditions, some of which may in fact be the adverse effects of medications already prescribed. Drugs can cause subclinical diminution in function or their adverse effects can mimic almost any clinical syndrome.² It has been shown that the risk and frequency of adverse drug outcomes increase with the number of drugs prescribed--some residents may be on up to 22 medicines at a given time³ and not all of these are needed. Some classes of medications, most notably psychoactive drugs, are of particular concern in nursing homes.⁴ In a prospective cohort study of 1106 nursing beds in 12 nursing homes in Los Angeles, Beers et al.5 suggested that 40% of the residents received at least one inappropriate medication order, 10% received two or more inappropriate medication orders concurrently, and 7% of all medications were inappropriate. A similar finding has been reported for the UK.

Harold Parker, BSW, MSW, RSW
Social Worker, Outreach Team,
Southwestern Ontario Regional Geriatric Program,
London, ON.

Laura Diachun, BASc, MD, FRCP(C)
Geriatrician,
Southwestern Ontario Regional Geriatric Program,
London, ON.

As an Outreach Team that provides service to the frail elderly for the Southwestern Ontario Region (10 counties), our ongoing challenge is how to respond to the needs of cognitively-impaired older persons living at some degree of risk. The perception and assessment of risk vary depending upon the lens through which we are looking. A living situation that may be perceived as risky by some may be quite unproblematic to others. Caring family members can often rationalize paternalism toward their elderly loved one so as to err on the side of safety--a value that can often take precedence over issues of quality of life and self-determination. A lifetime of responsible decision-making is no guarantee of the continued exercise of free will at the latter end of the life cycle. The 'assailants' to independence can be many, including paternalism and the presence of disease beyond normal aging, which can affect both function and cognition. It is often unclear where to draw the line between granting the individual the freedom to make poor lifestyle decisions and deeming that someone is exceeding family/community standards of acceptable lifestyle choices.

Morris D. Kerstein, MD
Professor and Vice-Chairman,
Director of Research and Education,
Department of Surgery, Mount Sinai School of Medicine,
New York, NY, USA.

Ernane D. Reis, MD
Assistant Professor
Department of Surgery,
Mount Sinai School of Medicine,
New York, NY, USA.

Venous leg ulcers influence the physical, financial and psychological well-being of patients, and result in an estimated two million workdays lost, annually. Despite a variety of therapeutic options, venous leg ulcers remain a substantial management challenge to the health-care professional. Some form of lower extremity venous disease is present in nearly 30% of the American adult population. Venous leg ulcers are often debilitating sequelae of venous insufficiency, and account for 80-90% of leg ulcers reported. A quality-of-life study reported that 65% of chronic-leg-ulcer patients had severe pain, 81% experienced reduced mobility, and nearly 100% reported a negative impact of their disease on work capacity.

Manifestations of venous insufficiency may include dilated superficial veins, with or without dilated tributaries of the deep vein system, swelling, leg pain, heaviness and changes in the skin (hyperpigmentation, venous dermatitis, eczema with dryness and itching). Ultimately, the adverse effects of venous disease appear as skin ulceration of lipodermatosclerosis.