David R. Thomas, MD, FACP, FAGS
John E. Morley, MB, ChB
Division of Geriatric Medicine
Saint Louis University Health Sciences Center and
GRECC, Veterans Administration Center
Saint Louis, MO, USA.

Abstract
Unintentional weight loss is a common problem among older adults, especially those in institutional settings. Physicians respond by prescribing increased oral calories, prescribing nutritional supplements or by considering enteral feeding. The response of patients to these interventions is often poor. For this reason, pharmacological agents that stimulate appetite or produce weight gain have attracted considerable attention. Should these agents be used? This review focuses on the benefits and risks of these orexigenic agents.

Introduction
Malnutrition is a major problem among residents in long-term care facilities.^1-4 The prevalence of protein-energy malnutrition in nursing home residents ranges from 23-85%.5,6 By comparison, the prevalence of protein-energy malnutrition ranges from 32-50% in acutely hospitalized patients.^7,8 The high prevalence of malnutrition in nursing homes may reflect a unique problem in elderly persons, the presence of chronic conditions, failure to address specific nutritional problems in this setting, or transfer of malnourished patients from acute care hospitals to long-term care facilities following an acute illness.

Peter Uhlenberg, PhD
Jenifer Hamil-Luker, MA
Department of Sociology,
University of North Carolina,
Chapel Hill, NC, USA.

Towards the end of life, many older people experience physical decline that forces them to depend upon others for care. This loss of independence, never an easy life transition, is often made more difficult by the limited opportunities that those in long-term care (LTC) have for interacting with other people. Yet, as all sensitive medical professionals know, older adults in LTC, like people at every other stage of life, need meaningful social relationships in order to thrive. Thus, it is unfortunate that long-term care institutions tend to be highly age-segregated, providing few chances for older residents to develop and enjoy friendships with children and young people. It is not necessary, however, that social isolation and age segregation be the common experience of those in LTC. This article reports on efforts to promote intergenerational relationships in LTC, the potential benefits of greater age integration, and research findings of what conditions facilitate positive outcomes from exchanges between children and older adults in LTC.

Benefits of Age Integration
Nursing homes, assisted living facilities and day care providers are increasingly bringing the young and old together on a regular, formally planned basis to build enduring, mutually beneficial relationships.

Jean Chouinard, MD
Medical Director,
Complex Continuing Care Program,
SCO Health Service,
Ottawa, ON.

Background
The likelihood of admission to a nursing home (NH) is very much age-related. Roughly 5% of patients over the age of 65 live in institutions; this proportion rises to 50% for people aged 90 and up. With cutbacks in health spending, and the rising demand for this type of care, the NH populations are becoming increasingly frail and often have multiple coexisting active health problems on a background of precarious homeostatic reserve. Currently, over 50% of our inpatients are totally dependent on help for their care. Only 15% of these inpatients can ambulate independently. Such patients are also at much higher risk of complications. In our facilities, the yearly incidence rate of pneumonia is 200% (!), with a case fatality rate of 30%. Between 5 and 10% of patients admitted to Ontario Chronic Care Facilities will develop a pressure sore every quarter. Annual mortality rates in institutions range from 15 to 30%.¹

Some definitions--in much abridged version²
A care process is a series of sequential or parallel interactions among clinicians and between clinicians and patients aimed at a given outcome.

Potential Herb-Drug Interactions in Older People

Julie Dergal, MSc
Kunin-Lunenfeld Applied Research Unit,
Baycrest Centre for Geriatric Care,
Toronto, ON.

Paula A. Rochon, MD, MPH, FRCPC
Baycrest Centre for Geriatric Care,
Assistant Professor of Medicine,
University of Toronto, Toronto, ON.

Introduction
The use of herbal medicines has recently gained a great deal of acceptance in North America. In 1996 in the United States, an estimated two billion dollars was spent on herbs, tablets, extracts, capsules, and teas, in health food stores.¹ In 1997, Eisenberg conducted a telephone survey of 2055 people and found that 12% used herbal medicines, a 4-fold increase from 1991.² Despite the widespread use of herbal medicines in North America, little research has examined the safety of these alternative medicines, particularly when taken in conjunction with conventional medicines. A common misconception about alternative medicines is that they are "natural" and are, therefore, safe. However, herbal medicines are marketed as dietary supplements and, as such, are not subject to the rigorous standards established for conventional drug therapies. This means that the quality and content of herbal medicines are largely unregulated and uncontrolled.

Nizar N. Mahomed, MD, ScD, FRCSC
Toronto Western Hospital,
University Health Network,
Assistant Professor, Department of Surgery, University of Toronto,
Toronto, ON.

Gillian Hawker, MD, MSc, FRCSC
Sunnybrook and Women's
College Health Sciences Centre,
Associate Professor,
Department of Medicine,
University of Toronto,
Toronto, ON.

Arthritis is the number one cause of disability in any age group. It is estimated that over half of those over the age of 75 suffer from this condition.^1,2 The prevalence of arthritis increases with age; current estimates indicate that the number of people with arthritis-related disability will double by the year 2020.³ Pain and the loss of physical function result in a reduction in quality of life and a loss of independence for these patients. This in turn causes a significant burden to society in terms of lost productivity and the utilization of health care resources.^4,5 Studies have shown long-term improvement in joint pain, physical functioning and quality of life in patients following total hip and knee replacement.^6,7 Total joint replacement (TJR) is cost-effective and, in some cases, even cost saving.⁸ Currently there are over 35,000 hip and knee replacements performed annually in Canada.

Findings of a Provocative New Meta-Analysis

Jason M. Burstein, MD
Internal Medicine Resident,
University of Toronto,
Toronto, ON.

Shabbir M.H. Alibhai, MD, MSc, FRCP(C)
Clinical Assistant, Internal
Medicine & Geriatrics,
University Health Network, Toronto, ON.

Introduction
Atrial fibrillation is a common cardiac condition that challenges many physicians, including primary care and emergency doctors, general internists, geriatricians and cardiologists. One of the best-understood and most studied complications is cardio-embolic stroke. While management of atrial fibrillation may seem straightforward, it is interesting to note that there are still large variations in practice patterns, and a recent meta-analysis was contradictory to many previous studies and guidelines. This paper will focus on the epidemiology and treatment of atrial fibrillation in the older population and will examine both the reasons for variations in practice pattern and the conflicting evidence in major medical journals.

Epidemiology and Causes of Atrial Fibrillation
Age is perhaps the most important influence on the incidence and prevalence of disease. The prevalence rate of atrial fibrillation is 2-3% at age 60 to 65 and 8-10% at age 80. Up to 70% of all affected patients are at least 65 years old. The incidence of atrial fibrillation before age 50 is 0.

D'Arcy Little, MD, CCFP
Director of Medical Education,
York Community Services,
Toronto, ON.

Introduction and Historical Background
Although first described in 1888 as "senile rheumatic gout," it wasn't until the 1950s when more cases were described in the literature that Barber coined the term "Polymyalgia rheumatica" to describe a syndrome of myalgias, stiffness of the shoulder and pelvic girdle muscles, and concomitant constitutional symptoms. A case of Temporal arteritis was first described by Thomas Hutchinson in 1890 when an 80-year-old man presented with a painful, inflamed temporal artery. In 1932, Horton first described the typical histological features of temporal artery from biopsies in patients with this condition, and the term "Giant cell arteritis" was first used.^1,2,3

Giant cell arteritis (GCA) and polymyalgia rheumatica (PMR) are closely related conditions that are almost always seen in patients over the age of 50 years. These conditions are relatively common and may represent a continuum of disease.^3,4 The following review will provide a framework for consideration of these diagnoses, as well as a review of their treatments.

Epidemiology
Once considered uncommon, PMR and GCA are among the most common, chronic inflammatory illnesses affecting the elderly, primarily as a result of raised awareness of the conditions.⁴ PMR has an incidence in North America of 52.

Glucosamine and Chondroitin in Osteoarthritis

Gerlie C. de los Reyes, BSc, MSc
Department of Pharmaceutical
Sciences, University of Southern California, Los Angeles, CA, U.S.A.

Robert T. Koda, PharmD
Department of Pharmaceutical
Sciences, University of Southern California, Los Angeles, CA, U.S.A.

Eric J. Lien, PhD
Department of Pharmaceutical
Sciences, University of Southern California, Los Angeles, CA, U.S.A.

"Medicine provides the means to treat diseases. Knowledge is the foundation of good health." E. J. Lien

Osteoarthritis (OA) is a chronic joint disease that is estimated to affect almost 5 million Canadians (16% of the population) by the year 2016.¹ This degenerative disorder is one of the primary causes of pain and long-term disability in the elderly. The disease is characterized by the progressive deterioration of the articular cartilage, the protective "cushion" at the articulating surfaces of bones. This degenerative process is caused primarily by a defect in the metabolism of the component macromolecules including proteoglycans (aggrecans) and type II collagen.

The non-steroidal anti-inflammatory drugs (NSAIDs) like aspirin, ibuprofen, indomethacin and piroxicam are the most widely used medications for the treatment of patients with symptomatic OA.

Dr. Angela G. Juby, MBChB, Cert Geriatrics
Associate Clinical Professor, Division of Geriatrics,
Department of Medicine, University of Alberta, Edmonton, AB.

Dr. Paul Davis, MBChB, FRCP, FRCPC
Associate Dean, Faculty of Medicine, University of Alberta,
Professor, Division of Rheumatology,
Department of Medicine, University of Alberta, Edmonton, AB

Introduction
Rheumatoid arthritis most commonly presents in the 3rd and 4th decades of life; elderly patients with initial presentation and patients whose disease persists into the later decades of life can present interesting challenges. In particular, the differences in clinical presentations of rheumatoid disease in the elderly when compared to younger patients may lead to difficulty in making a definitive diagnosis. There may be diagnostic challenges related to the interpretation of laboratory findings, particularly serological tests. Elderly patients often have comorbidities; therefore, pharmacologic management of rheumatoid disease must be undertaken with caution to reduce interference with the stability of other organ system therapies, and the potential for drug-disease and drug-drug interaction and polypharmacy must be addressed. Finally, it is important to dispel the attitude that "arthritis" is a process associated with "normal aging.

Seniors Benefit from Being Online

David Patrick Ryan, PhD, C.Psych
Director of Education, Regional
Geriatric Program of Toronto,
Faculty of Medicine,
University of Toronto, Toronto, ON.

There is an interesting paradox at the heart of Internet use by seniors which is: Although seniors are under-represented among Internet users, when they do get online, they become its most frequent users. Only 16% of seniors use the Internet, compared to the national average of 44%. Yet, once online, Canadian seniors use the Internet, on average, for 12 hours weekly. This is more than the average for teenagers (7 hours) and 80 minutes more than for any other age group. Given the emerging realization that the Internet expands the world of seniors, particularly disabled seniors, at a time when it would otherwise be contracting, and the developing evidence that computers and the Internet can be powerful tools for maintaining health and well-being, it is imperative that an attempt be made to reduce the digital divide amongst seniors.¹

The Obstacles to Internet Use for Seniors
What are the obstacles to seniors' use of the Internet? Anxiety is one obstacle.