Kimby N. Barton, MSc
Associate Editor,
Geriatrics & Aging.

If you have ever known anyone with any degree of heart trouble you may be aware of the options available for the treatment of heart disease. We have medications that treat hypertension, medications that lower lipids and medications to prevent clotting. We can use diet and exercise to keep our arteries clear and our heart muscle healthy. But can we repair a heart once cells have been lost? Coronary heart disease accounts for 50% of all cardiovascular deaths and nearly 40% of the incidence of heart failure. Heart attacks lead to the death of vital cardiac myocytes and impair cardiac performance. The cells that survive an MI are unable to reconstitute the tissue that is lost, and eventually the heart begins to deteriorate. The victims of heart attack and their caregivers are well aware of the slow progression from heart attack to heart failure, and the lack of available therapies to stop this progression.

What if there was a way to re-vitalize the damaged cell population or to replace the cells that are lost? Unfortunately, in order to form a functional cardiac unit, the replacement cells must be able to survive, mature, electromechanically couple with pre-existing heart cells and have a beneficial effect on the function of the damaged heart.

Injury to a target organ is sensed by distant stem cells; these cells migrate to the site of damage and then differentiate, promoting structural and functional repair.

Bob Chaudhuri, MD
Resident in Psychiatry,
Department of Psychiatry,
University of Toronto.

In 1990, three million members of the US population were 85 years of age or older. By the year 2050, it is expected that the numbers of these very elderly people will reach 20 million. However, the percentage of older people in the US is less than that in most European nations. If one considers developing nations, 250 million Chinese will be over the age of 60 by the year 2020, and the number of people in developing nations over the age of 60 will be greater than that number in all the countries in Europe. Importantly, the number of people over the age of 80 continues to grow in proportion to the nation's population.¹ Given these demographic numbers,² the sequella of aging is relevant to psychiatry in general and geriatric psychiatry specifically. There is no specific Canadian data on this subpopulation.

Dementia is primarily a disease of later life, affecting approximately 5% of people over the age of 65, and in some populations studied, almost 50% of those over the age of 85. The essential features of dementia include the development of multiple cognitive deficits including, memory impairment, disturbance in executive functioning, and at least one of aphasia, apraxia or agnosia.

Eileen P. Sloan, PhD, MD
Resident in Psychiatry,
Department of Psychiatry,
University of Toronto.

Introduction
Agitation is an aspect of dementia that can have serious emotional, medical and health-care system consequences. It results in decreased quality of life for both patient and caregiver and is often cited as the reason for the patient being admitted to a long-term care facility. Within the nursing home setting, agitation may often result in increased use of physical and/or chemical restraints, with concomitant problems such as physical injury and falls. Medical care of the agitated patient can be compromised and nursing staff is required to spend greater amounts of time caring for the agitated patient.

Definition and Prevalence
Allen (1999) points out that "agitation" is not a diagnosis but refers to a constellation of symptoms.¹ Cohen-Mansfield and Billing (1986)² define agitation as "inappropriate verbal, vocal or motor activity unexplained by apparent needs or confusion." These authors divide the symptoms of agitation into three: aggressive behaviours (hitting, kicking, verbal aggression, spitting); inappropriate physically non-aggressive behaviours (pacing, repetitious mannerisms, robing and disrobing); and inappropriate verbal agitated behaviours (screaming, complaining, constant demands for attention).

A. Mark Clarfield

The fact that dementia is finally beginning to receive the attention that it deserves is evidenced by the editors of Geriatrics & Aging wisely deciding to devote most of this issue to the subject. Dementia is primarily associated with memory loss; this means, unfortunately, that professionals often pay far less attention to the other symptoms that can accompany the syndrome. In fact, caregivers tell us that their loved one's problem with memory is usually far less burdensome than are the behavioural symptoms. Two of these symptoms are featured in this issue: agitation, by Dr. Elizabeth Sloan (a resident in Psychiatry at the U of T); and wandering, written by Dr. Bob Chaudhari, of the same department.

Dr. Sloan reminds us that agitation--sometimes accompanied by other symptoms such as screaming and aggression--is not a diagnosis per se but rather consists of a "constellation of symptoms." In geriatric care we are not afraid of such terminology, even if the terms are not always easily found in the index of Harrison's Textbook of Medicine. The same, of course, would hold for falls or incontinence.

As is the case with many of the non-specific ("atypical") presentations of disease in the elderly, Sloan points out, an underlying medical illness must never be overlooked as a possible causal factor. As I like to teach my medical students, "Take a history before prescribing haldol." (Unfortunately, now that the older anti-psychotic medications are increasingly being replaced by less toxic molecules, I'll have to figure out a new alliteration to go with, for example, risperidone--now what starts with an "r"? "rectum", no; "respiratory system"--doesn't ring true.) But I digress.

Dr. Sloan goes on to offer a great deal of good advice and the interested reader is advised to consult the references in her comprehensive bibliography.

Dr. Chaudhuri tackles the related problem of wandering, where he offers an interesting tri-partite classification which I admit that I have not seen before: volitional (depressive), motivational (anxious) and repetitive behavioural (irritable) wandering. Perhaps as a geriatrician, I am used to a more "medical" classification; but the author, not surprisingly as he is a psychiatrist, offers a more psychodynamic approach.

Like Sloan, Dr. Chaudhuri points out that management must take into account the patient's environment. Appropriately, he does not spend much time on a pharmacological approach, which is not usually an effective method unless, of course, your aim is to drug the patient into a stupor.

My own experience is that the wandering (pacing) patient with dementia must be allowed his/her own space. Obviously, as is also the case at the other end of the age spectrum with the toddler, wanderers must be protected against the obvious dangers involved. However, when all is said and done, the milieu extérieur seems to me to be of more importance than the milieu intérieur.

Dr. Clarfield is the Chief of Academic Affairs at the Herzog Hospital in Jerusalem, Director of Geriatrics in the Ministry of Health, and on staff in the Division of Geriatric Medicine, Sir Mortimer B. Davis-Jewish General Hospital, McGill University, Montreal.

Clinical and Ethical Perspectives

Michael Gordon, MD, MSc, FRCPC
Vice President of Medical Services,
Baycrest Centre for Geriatric Care,
Professor of Medicine,
University of Toronto,
Toronto, ON.

David Goldstein, PhD
Director, Centre for Knowledge Transfer,
Baycrest Centre for Geriatric Care,
Professor of Psychology,
University of Toronto,
Toronto, ON.

The daughter told me (MG) that Dr. L. was prescribing Donepezil to her 87-year-old mother. "Do you agree with her decision?" she queried, then added, "We won't use the "A" word will we?" This recent exchange reflects the anxiety and fear that accompanies the communication of a diagnosis of Alzheimer's disease. It presents many complex clinical, legal and ethical problems, which may be challenging to many physicians.

Physicians are generally expected to communicate honestly and directly with their patients on matters of clinical significance. For patients suffering from Alzheimer's and other dementias, such straightforward communication may not always be appropriate. The patient may not be aware of his or her own cognitive changes and family members may balk at the idea of communicating such a devastating diagnosis. The physician may be left with a clinical and ethical conundrum: the desire to communicate honestly with the patient may conflict with the compelling desire to concur with the wishes of the patient's family.

Since I have my pen in hand, I hope that you will indulge me if I make a couple of personal remarks in response to our Editor-in-Chief's kind words about me.

It is true that Barry and I trained together but he is senior to me by a year or two. And, as those of us who have worked with and were trained by him can attest, he is no slouch himself! Physician, teacher, administrator and editor--each role acted out with his usual calm and panache. But perhaps the highest compliment that I can pay the good doctor is to recount a short anecdote. When I was an intern, and Barry a medical resident, I brought my father--who was suffering from chest pain--into the ER of Toronto's Mt. Sinai Hospital, where Barry and I were both in training. As my mother and I waited anxiously in the anteroom for word of his fate, I was scared to death that my dad would die.

To my great relief and good fortune, who should rush past but Dr. Goldlist, who had been called in by the ER staff to have a look at my father. As Dr. Goldlist walked through the ER doors on his way to examine my father, I turned to my mother and said, "Don't worry, Mom, one of the hospital's best doctors is going to be taking care of Dad. We've got nothing to worry about."

And so it was. Almost 30 years later--there Barry, it's out--my father is still hale and hearty.

By coincidence, another important influence on my professional life and career choice is also well represented in this issue. The prolific and dynamic Dr. Michael Gordon, Medical Director of the world-renowned Baycrest Hospital, was a couple of years senior to both Barry and me and, as Barry points out, in his role as chief medical resident at Mt. Sinai, he had a powerful effect on all of us. It would be safe to say that no one had more influence on my decision to enter the field than did Michael, and all of us continue to enjoy his special blend of qualities.

I encourage the readers to read Dr. Gordon's articles and the rest of the informative articles in this special issue of Geriatrics & Aging. Thanks again to the editors for allowing me to blather on and, above all, for the opportunity to contribute to this important issue.

A. Mark Clarfield

Margaret MacAdam, PhD
Senior Vice President and Vice President,
Community Services,
Baycrest Centre for Geriatric Care,
Toronto, ON.

Two of the biggest problems facing patients with cognitive impairment and their families are access to a safe and appropriate physical environment, and access to supportive services throughout the course of the patient's disease. These problems arise because it may become increasingly difficult for the patient to obtain an appropriate level of care in his or her original residence. The options that are currently available to these patients vary widely from province to province but include staying at home, moving to one of the supportive housing projects that are becoming available in many communities, or moving to a long-term care facility. To determine which of these options is most appropriate, one must take into account the needs of the individual patient, his or her prognosis and the resources that are available to the family for maintaining their relative in the community. Because of the progressive nature of many forms of cognitive impairment, housing and care decisions are subject to change during the patient's life span.

The first step in deciding what type of housing is most appropriate is to make an assessment of the individual's needs.

Michael Gordon, MD, MSc, FRCPC
Vice President of Medical Services,
Baycrest Centre for Geriatric Care,
Professor of Medicine,
University of Toronto,
Toronto, ON.

The husband looked to his wife when he was asked if he would allow me to refer him to participate in a research trial. He admitted that he had some "memory" problems but was not really aware of the degree of his cognitive decline. His wife said she would consider it and discuss it with her husband and their children. She was distraught about the diagnosis of Alzheimer's disease and the future implications for his function and the requirements for his care. She wanted to know if the trial might help him. I explained the principles of a double-blind randomized drug trial and suggested that she discuss her concerns with the researcher conducting it.

Without research there is no progress in Medicine. Most people support the concepts of, and need for, medical research. Throughout history, some form of medical research has occurred. As an outcome of the horrific experiments done on involuntary subjects during the Nazi regime, and the more contemporary American studies on poor black syphilis victims in the Tuskegee experiment and the Willowbrook hepatitis study, a more rigorous and protective approach to human research has been developed.

Contemporary medical researchers are expected to understand the basic ethical principles that govern clinical research.

Chris MacKnight, MD, MSc, FRCPC
Division of Geriatric Medicine,
Dalhousie University,
Halifax, NS.

Dementia and hypertension are two of the most common conditions affecting older adults. A number of recent studies suggest that dementia is one of the long-term complications of hypertension. Studies also suggest that the treatment of hypertension may prevent dementia. This brief review will focus on the relationship between hypertension and dementia in older adults.

Epidemiology of Dementia
Eight percent of Canadians who are over the age of 65 suffer from dementia, with Alzheimer's disease being the most common cause (approximately 60% of cases).¹ Dementia is age-related, with the prevalence increasing from 2.4% of those from 65-74 years of age, to 34.5% of those 85 and older. Sixty thousand new cases occur each year in Canada.² The cost of providing care to these patients is substantial, at 3.9 billion dollars/year, in 1991 dollars.³ Vascular dementia is the second most common cause of dementia in Canada, accounting for 20% of cases. When discussing vascular dementia, it is important to recognize that the classic pattern of multiple infarcts is found only in approximately 1/3 of the cases. The other cases consist of patients who have changes in their white matter (likely on the basis of small vessel ischemia) with or without lacunar infarcts, or, rarely, single strategic strokes.

Dr. Bernard Isaacs, one of the great men of modern British geriatrics, died several years ago in Jerusalem. In order to commemorate this physician, A. Mark Clarfield has written the following piece.

Prof. Isaacs' untimely death, six years ago this month, robbed us all of a great man. First and foremost, he was a first-rate geriatrician, truly one of the "giants" in the field. In addition, he had a golden hand and was a beautiful writer. Finally, to me and to many others, he was a great friend. We will miss him.

In order to commemorate my beloved colleague, I will concentrate on bringing to you some of Bernard's words of wisdom and wit. I shall try to do so via judicious quotations from his third and final book, "The Challenge of Geriatrics Medicine" (Oxford University Press, 1992). In fact, Bernard had intended to call the book, "The Giants of Geriatrics", after his now famous formulation. He listed the giants via four "I's"-- namely immobility, instability, incontinence, and intellectual impairment. Unfortunately, the publisher, in its limited wisdom, thought otherwise and gave the book the less interesting title.

Bernard's published works included scores of articles, as well as three books. Merely perusing the titles of some of his works will testify to his humour and wit. For example, Bernard wrote a series of articles for Nursing mirror.