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.

G.A.E. Wong, MBChB, MRCP(UK), and N.H. Shear, MD, FRCP(C), Divisions of Dermatology and Clinical Pharmacology, Sunnybrook & Women’s College Health Sciences Centre, University of Toronto, Toronto, ON.

Cutaneous adverse drug reactions are a common problem affecting ambulatory and hospitalized patients. Older patients may be predisposed to adverse drug reactions due to inappropriate medication prescription, age-associated changes in pharmacokinetics and pharmacodynamics, altered homeostatic mechanisms, multiple medical pathologies, and use of drugs with a narrow therapeutic margin. In this second of two articles, the management of cutaneous adverse drug reactions
is reviewed.

Key words: adverse drug reaction, skin, cutaneous, rash, drug eruption, treatment, management.

Michelle A. Ghert, MD, Clinical Fellow in Musculoskeletal Oncology, University of Toronto, ON, Mount Sinai Hospital, Toronto, ON. and Peter C. Ferguson, MD, MSc, FRCSC, Assistant Professor of Surgery, University of Toronto, Division of Orthopaedic Surgery, Mount Sinai Hospital, Department of Surgical Oncology, Princess Margaret
Hospital, Toronto, ON.

Primary bone and soft tissue tumours are rare in the general population. While bone malignancies in the geriatric age group are most often due to metastases or multiple myeloma, primary tumours can occur. These are treated with surgical resection and occasionally chemotherapy. Soft tissue sarcomas are more common and are usually treated with a combination of radiation and surgery. The outcome of treatment for bone sarcomas is poorer in the geriatric age group, but this is not true of soft tissue sarcomas. Patients with both primary bone and soft tissue malignancies should be referred to regional cancer centres for management.

Key words: sarcoma, surgery, radiotherapy, chemotherapy, cancer

Introduction
Musculoskeletal complaints are common in the geriatric population, but rarely are these complaints attributable to malignancies.

Sue O’Hara, RN, MScN, ACNP, GNC(C), Nurse Practitioner/Clinical Nurse Specialist, Specialized Geriatric Services, St. Josephs Health Care London, Parkwood Hospital, London, ON.; Michael J. Borrie, BSc, MB, ChB, FRCPC, Professor, Department of Medicine, Division of Geriatric Medicine, The University of Western Ontario, London, ON.

Urinary incontinence is a significant problem in older women. Prevalence rates vary from 4.5–44% in healthy older women and increase to 22–90% in patients in long-term care facilities. Canadian Continence Guidelines have recently been developed to assist patients and health care professionals in assessment, treatment and follow-up of urinary incontinence. Urinary incontinence can be treated successfully, improved or better managed in most patients. Treatment falls into four major categories: behavioural, pharmacologic, surgical and supportive measures. Education, the key to effectively addressing the needs of women with incontinence, is aimed at the patient and/or their caregiver, as well as health care professionals.
Key words: urinary incontinence, older women, assessment, treatment, Canadian Continence Guidelines.

The accredited CME learning activity based on this article is offered under the auspices of the CE department of the University of Toronto. Participating physicians are entitled to one (1) MAINPRO-M1 credit by completing this program, found online at www.geriatricsandaging.ca/cme.htm

Lianne Tile MD, FRCPC, M Ed, Staff Physician, Osteoporosis
Program and Division of General Internal Medicine, University Health Network, Toronto, ON

Osteoporosis and fractures are a common cause of morbidity in postmenopausal women. Women age 65 and older, and those with risk factors for bone loss, should be screened by DEXA. When osteoporosis is diagnosed, secondary causes need to be considered. Fracture risk is determined by bone mineral density, age, prior fracture, and family history of osteoporosis. Adequate calcium and vitamin D intake and regular exercise are essential for the prevention and treatment of osteoporosis. Pharmacologic therapy should be used based on fracture risk. Patient preferences and side effect profile must be considered in choosing among several effective treatment options.
Key words: osteoporosis, treatment, postmenopausal, diagnosis, guidelines

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