Wojciech P.Olszynski, MD, PhD, FRCPC, Clinical Professor of Medicine,University of Saskatchewan, Director, Saskatoon Osteoporosis Centre, Saskatoon, SK.

Though osteoporosis occurs less frequently in men than in women, it is nonetheless a significant medical problem. Osteoporotic vertebral fractures in particular are as common for men as for women, and about one-third of all hip fractures occur in men. As a consequence of fragility fractures, the associated morbidity and mortality are higher in men than women, particularly after fracture of the hip. Idiopathic osteoporosis is common; however, secondary causes are found in about 50% of cases. Bone density measurements should be advised for every man over 65 years of age and for younger men in the presence of osteoporosis risk factors. For practical purposes, the use of T-score <= 2.5 for men over age 65 should be used for the diagnosis of osteoporosis.

Key words: osteoporosis, men, fracture, diagnosis, treatment

Epidemiology
Osteoporosis is a skeletal disorder characterized by compromised bone strength predisposing a person to an increased risk of fracture.

D’Arcy Little, MD, CCFP, lecturer and Academic Fellow, Department of Family and Community Medicine, University of Toronto; Director of Medical Education, York Community Services; 2002 Royal Canadian Legion Scholar in Care of the Elderly, Toronto, ON.

Part II of this series briefly reviews the literature on the success of family therapy in families with dementia. A case from the author’s practice (with significant details modified to conserve privacy) is then presented with a view toward applying family therapy. Finally, as the author has an interest in medical education, a proposal on how to integrate family therapy for families with dementia into an educational program is briefly described. The author welcomes comments and suggestions at darcy.little@geriatricsandaging.ca.
Key words: dementia, Alzheimer’s disease, family therapy, family, Systems Theory.

David Fitchett, MD, FRCP(C), St Michael's Hospital, University of Toronto, Toronto, ON.

The incidence of coronary heart disease increases with advancing age. Although older patients may develop classical symptoms of ischemic heart disease, other symptoms such as dyspnea, syncope, and fatigue are often the dominant presenting features of angina and myocardial infarction. The present discussion aims to heighten awareness of the atypical nature of myocardial ischemic symptoms in the older adult and to suggest a structured approach to facilitate achieving a more accurate diagnosis.
Key words: chest pain, myocardial ischemia, dyspnea, coronary artery disease, infarction.

Muammer Kendirci, MD, Tulane University, School of Medicine, Department of Urology, Section of Andrology and Male Infertility, New Orleans, LA, USA.
Wayne J. G. Hellstrom, MD, FACS, Tulane University, School of Medicine, Department of Urology, Section of Andrology and Male Infertility, New Orleans, LA, USA.

Sexual dysfunction in the older man is common and has a significant impact on quality of life. In the aging man, erectile dysfunction (ED) has been encountered frequently due not only to associated comorbidities such as heart disease, hypertension, medications, diabetes, smoking, and depression, but also as a result of the aging process itself. Aging may impair molecular and structural components of erectile function. The introduction of effective oral erectogenic drugs has led to increased awareness of sexual issues and advancement in the methods used by clinicians to diagnose ED. Over the last twenty years, the approach for identification and evaluation of ED has transformed from invasive techniques to patient self-reporting and minimally invasive office procedures.

Key words: erectile dysfunction, aging, diagnosis, evaluation.

Colin A. Barry, MD, FRCPC and Marino Labinaz, MD, FRCPC, University of Ottawa Heart Institute, Ottawa, ON.

Cardiovascular disease remains the number one cause of mortality in Canada. Persons over 65 represent the most rapidly growing demographic group in Canada. These factors will result in a significant increase in the total number of cardiovascular cases in the next several decades. Coronary revascularization procedures such as coronary artery bypass grafting and percutaneous coronary interventions have steadily increased over the past decade and will continue to do so as the population ages. Several studies have demonstrated that older patients derive significant benefit in terms of reduced morbidity and mortality, but these procedures are often underutilized in this patient group.

Key words: coronary artery bypass grafting, percutaneous coronary intervention, cardiovascular disease

Introduction
Cardiovascular disease remains the number one cause of mortality in Canada, representing 36% of all deaths in Canada (1999) with death from coronary artery disease accounting for 19.

Gordon E. Searles, OD, MD, MSc, FRCPC, FACP, Internal Medicine and Dermatology, Western Canada Dermatology Institute, Edmonton, AB.

Practitioners are commonly asked about issues of skin and skin disorders. While many skin lesions are benign, it is becoming increasingly important for clinicians to be able to distinguish benign lesions from premalignant or malignant lesions. The goal of this article is to describe the most common forms of benign lesions in older patients and suggest various treatment strategies.

Key words: melanoma, pigmentary, macules, keratosis, ephelides.

Mohammed Al-Omran, MD, MSc, and Yaron Sternbach, MD, Division of Vascular Surgery, Toronto General Hospital and the University of Toronto.

Arterial occlusive disease of the lower extremities is an important cause of disability in older adults and those with risk factors for atherosclerosis. The process may be asymptomatic or manifest as a progression from claudication to ulceration. Identification of patients at risk is vital to careful surveillance and early intervention. Revascularization remains the mainstay of therapy for critically ischemic limbs. Catheter-based techniques such as angioplasty are useful for focal disease. Conventional bypass surgery remains the mainstay of therapy for more extensive disease with ulceration and may be supplemented by adjunctive plastic surgery procedures for soft tissue coverage and limb salvage. Amputation is performed when reconstruction is not feasible or in the setting of severe progressive infection. The current article provides a more detailed review of lower extremity ischemia.

Key words: Peripheral arterial occlusive disease (PAOD), atherosclerosis risk factors, bypass, angioplasty, patency rates.

D’Arcy Little, MD, CCFP, Lecturer and Academic Fellow, Department of Family and Community Medicine, University of Toronto, Toronto, ON.

Dermatophytes are fungi that require keratin for growth and thus are restricted to the hair, nails and superficial skin.1 Dermatophytoses are referred to as “tinea” infections and are also named for the site of the body affected. Such infections can be spread by direct person-to-person contact (anthropophilic organisms), by contact with animals (zoophilic organisms) or with the soil (geophilic organisms). Onychomycosis, fungal infections of the nails, accounts for one-third of fungal skin and nail infections.2 The purpose of this article is to briefly review the diagnosis and management of common fungal infections of the skin and nails.

Key words: Dermatophytes, Tinea corporis, Tinea pedis, Tinea cruris, Tinea unguium.

Serge Gauthier, MD, FRCPC, McGill Centre for Studies in Aging, Montréal, QC.

Functional disability is an important component of Alzheimer’s disease. A number of scales are available to measure activities of daily living (ADL) throughout the course of disease, including instrumental as well as self-care activities. A randomized clinical study comparing donepezil to a placebo in moderate-to-severe stages of AD showed a stabilization of ADL decline over six months for patients on donepezil. Less time for ADL care was required by caregivers of patients on donepezil compared to those on placebos.

Key words: Alzheimer, therapy, activities of daily living, donepezil, caregiving time

Introduction
The importance of decline in activities of daily living (ADL) in older adults with dementia has been recognized in the condition’s diagnostic criteria, described as “significant impairment in social or occupational functioning” in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV).

Scott R.A. Walsh PhD, MD, Division of Dermatology, Department of Medicine, Sunnybrook & Women’s College Health Sciences Centre, University of Toronto Medical School, Toronto, Ontario.

Dermatitis herpetiformis (DH) is a pruritic and chronic autoimmune blistering skin disease associated with varying degrees of gluten-induced enteropathy. Associated symptomatic celiac disease (CD) occurs in a minority of patients, but the pathogenesis of both diseases shares several features. In addition to some features of enteropathy, patients with DH also form specific antibodies to epidermal transglutaminase not typically found in patients with only CD. Although incidence is highest in middle age, because it is a life-long condition its prevalence is highest in the older population. Chronic complications of DH, including gastrointestinal lymphomas, are more likely to present in the geriatric group. Similarly, common comorbid disease associations including pernicious anemia, splenic atrophy and thyroid disease should be routinely assessed in this population. Long-term treatment of DH requires strict adherence to a gluten-free diet. Symptomatic treatment of this skin disease commonly uses dapsone to inhibit neutrophil accumulation and disease expression. Older patients may be more susceptible to toxic side effects of dapsone metabolites, and both careful patient selection and close monitoring should be undertaken with dapsone treatment.

Key words: dermatitis herpetiformis, autoimmunity, anemia, comorbidities, dapsone.