When I started out in medicine, differentiating between the various causes of hepatobiliary disease was extraordinarily difficult. It is not easy now (what in medicine ever is?), but modern imaging techniques have certainly helped us dramatically. As well, new discoveries have made more disorders treatable, which is wonderful news for our patients. However, for clinicians that means learning more about liver disease so that we can effectively manage our patients’ conditions. The University of Toronto, my home base, has long been a leader in the study of liver disease. One of my clinical teachers, Victor Feinman, was a leader in the field of liver disease and in particular the study of hepatitis B. One of my contemporaries, Jenny Heathcote, is a world leader in the study of primary biliary cirrhosis. Thus I feel I have a personal tie to this issue’s focus on hepatobiliary disease.

At times it seems like almost all of our older patients have gallstones. Which ones require treatment, and which can be managed conservatively? Our continuing medical education article, “Gallstone Diseases in the Older Adult” by Dr. Simon Yang and Dr. Calvin Law should help us tackle how to manage these patients. With so many routine blood tests being performed these days, it is inevitable that we will all come across patients who have abnormal liver tests. The article “Managing Abnormal Liver Blood Tests in Older People” by Drs. James Frith and Julia Newton should help us with this common problem. For those of us in internal medicine, an expanding belly is much more likely to signify ascites than pregnancy (especially for us geriatricians!). Diagnosis is usually much easier than management, so one of our focus articles is on this topic. I am sure you will find the article “Management of Patients with Ascites” by Dr. Karen Krok and Dr. Andrés Cardénas very useful. Our Biology of Aging column this month is related to our focus theme as well, namely “The Aging Liver” by Dr. David le Couteur, Dr. Arthur Everitt, and Dr. Michel Lebel.

Of course, we have our usual collection of excellent articles on varied topics. Our Cardiovascular Disease column is on “Functional Gains for Stroke Survivors in Response to Functional Electrical Stimulation” by Dr. Janis Daly. The issue of behavioural disturbances in demential is so prevalent, so concerning, and so difficult to manage that we like to revisit the topic on a regular basis, and our Dementia column this month is entitled “Approach to the Management of Dementia-Related Behavioural Problems” by Dr. Michael Passmore. Our Caregiving column this month is on the “Clinician’s Role in the Documentation of Elder Mistreatment” by Dr. Elizabeth Pham and Dr. Solomon Liao. I serve on a committee with some police officers who are experts in elder mistreatment, and their stories are very frightening. Our final article on Technology in Medicine is very patient-focused, namely “Information Communication Technology–Enabled Health Care for Older Adults at Home” by Dr. Simon Brownsell, Dr. Elaine Biddiss, and Dr. Mark Hawley.

Enjoy this issue,
Barry Goldlist

Ann Schmidt Luggen, PhD, GNP, Professor Emeritus, Northern Kentucky University, Highland Heights, Kentucky, USA.

The number of older adults who drink to excess is not known, partly because primary health practitioners seldom screen for this problem. The signs of alcohol abuse are vague prior to late-stage liver failure and many of them are attributed to normal aging. Two types of alcohol dependence are commonly seen in older adults: type I is a late-onset alcohol dependence in which depression, chronic illness, or life changes such as retirement precipitate drinking, while type II is mainly genetic and reflects lifelong drinking that has not been previously identified by health professionals. Pharmacologic agents such as naltrexone and acamprosate have been shown in a number of clinical trials to be useful in care. A great many others are still in testing phases. Nonpharmacologic management is also effective, especially when teamed with drug therapy. Some of these are cognitive behavioural therapy, motivational enhancement therapy, and counselling that the primary care physician can do in the office, also known as the brief intervention approach. There is much that can be done if alcohol dependence is recognized.
Key words: alcohol, aging, older adults, dependence, liver disease.

Don Rodgers, National Director of Communications, Canadian Liver Foundation.

What few laypeople realize is that the liver plays a crucial role in maintaining overall health. It performs numerous vital functions including the processing of dietary nutrients and vitamins, maintaining blood sugar levels, activating or detoxifying medications and manufacturing proteins. People may also be surprised to learn that liver disease is the fourth leading cause of death by disease in Canada. More than two million Canadians, regardless of age, sex, ethnic origin or lifestyle, will be affected by a liver or biliary tract disease in their lifetime. With improvements in diagnostic testing and a growing awareness of risk factors, more Canadians are finding out they have liver disease. Many liver diseases can be prevented, quite a few can be treated and early diagnosis is very important. The outlook is hopeful and research is continuing to improve the lives of people living with these disorders.

When a person is diagnosed with a liver disease, it can be a very stressful time for all concerned--patients, families and friends. Unanswered questions create anxiety, and doctors and other health care providers often are too busy to discuss every detail. Pamphlets and websites can provide a wealth of information but cannot possibly answer all of a patient's questions. Hence the role of the Canadian Liver Foundation's Living with Liver Disease Program, which provides a wide range of information about all aspects of liver disease, as well as a forum in which people can ask questions about their individual concerns.

The program provides emotional and social support through the participants' interaction with others in the same situation. Facilitated group sessions feature qualified speakers who cover issues such as nutrition, exercise, diagnosis, treatment, liver transplantation and social assistance. During each session, patients can hear valuable information from a physician or another knowledgeable health care provider caring for liver disease patients. In the course of the session, patients will have the opportunity to ask questions and chat with other people who are experiencing the same or similar challenges. The Canadian Liver Foundation offers Living with Liver Disease Programs in communities across the country. Depending upon local needs, sessions may cover one topic per month or may be compacted into an all-day seminar format.

The Canadian Liver Foundation's National 1-800 Help Line offers a confidential bilingual service to all people affected by liver disease. When people are first diagnosed with liver disease, they have many questions about their prognosis, how it will impact their lifestyle and what treatments or other interventions might be available to them. The Foundation's National 1-800 Help Line gives patients and their family members somewhere to turn for answers. For more information about a program in your area, please call the National Help Line at 1-800-563-5483 or visit our website at www.liver.ca.

The liver is seemingly an organ without any facility for "self promotion". Unlike the large bowel, it lacks an orifice that allows for early presentation of disease and dysfunction. Instead, like the kidney, a massive loss of function is required before symptoms of liver disease develop, and those symptoms are typically non-specific. Unlike the kidney, however, for which simple blood tests often give an indication of overall renal function, most so-called "liver function tests" do not measure function at all. This combination of factors results in liver disease often going undiagnosed until late in its course. In particular, infectious hepatitis can be contracted early in life, but may have its major deleterious effects only once the individual is much older.

The liver also gets little respect from geriatricians. We are continuously concerned about renal changes with aging and how to prescribe medications properly to accommodate those changes. However, the effects of an aging liver on drug disposition are less predictable, so we tend to ignore them, except in the presence of overt liver dysfunction. I certainly have had patients presenting with "drug-induced falls" who really had occult but severe liver disease with abnormal drug metabolism as the cause of their problems.

Hence, I think an issue with a focus on liver disease in the elderly is timely. From Drs. David Stell and William Wall, we have an excellent article in our Biology of Aging series on the impact of aging on the liver, which will help us understand the cumulative effects of aging on disease presentation. Dr. Robert Fingerote discusses primary biliary cirrhosis, another disease in which major, serious manifestations present after many years of disease progression. This issue presents articles on acute viral hepatitis by Dr. D'Arcy Little, portal hypertension and its complications in elderly patients with liver cirrhosis by Drs. Faisal Sanai and Cameron Ghent, and the diagnosis and management of gallstones in the elderly by Drs. Bao Tang and David Urbach. As the field of organ transplantation matures, an increasing number of elderly patients are being transplanted, and Drs. Douglas Thorburn and Paul Marotta review the indications and outcomes of liver transplantation in the elderly. To cap off this topic, our For Your Patient column comes from the Canadian Liver Foundation.

In other articles, Dr. Ron Keren discusses the relationships between alcohol and dementia, Drs. Ernane Reis and Nicholas Morrissey review the diagnosis of peripheral arterial disease in the elderly, Drs. Simpson and Ulanski II examine ocular malignancies, while Dr. Margda Wærn writes about physical illness and suicide. In a special article, one of Canada's most eminent and respected geriatricians and Program Director of the Regional Geriatric Program of Toronto, Professor Rory Fisher, reviews the implications of the Romanow Report for health care of the elderly.

Enjoy this issue.