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

For the diabetic patient, hypertension more than doubles the risk of myocardial infarction, stroke and cardiovascular death, and is central in the development of diabetic nephropathy. Control of hypertension is an important vascular protective measure. However, the thresholds and goals of antihypertensive treatment have fallen as trials have shown improved outcomes with blood pressures reduced to 120/80mmHg or less. Although reducing blood pressure to the lower target levels must be the primary goal of treatment, the use of diuretics and angiotensin-converting enzyme inhibitors should be considered as first-line therapy in the diabetic patient. Both agents have been demonstrated to improve a wide range of cardiovascular outcomes compared to other antihypertensive medications.
Key words: diabetes, hypertension, nephropathy, blood pressure control.

Xiumei Feng, MD, MSc and Norm R.C. Campbell, MD, Division of General Internal Medicine, University of Calgary, Calgary, AB.

Normal blood pressure is less common than "hypertension" in the elderly, and most hypertension is primary, or essential. Nevertheless, secondary hypertension in the elderly should be considered in patients with suggestive features, as the prevalence of secondary hypertension increases with age. The most common causes of secondary hypertension in the elderly are renal parenchyma diseases, primary aldosteronism, renal vascular stenosis and drug induced. Timely recognition and treatment of secondary hypertension will reduce the morbidity and mortality associated with uncontrolled hypertension.
Key words: hypertension, high blood pressure, elderly, secondary causes.

Sheldon Tobe, MD, FRCP(C), Assistant Professor of Medicine, Nephrology, University of Toronto; Division Director Nephrology, Sunnybrook & Women's College Health Sciences Centre, Toronto, ON.
Sudha Cherukuri, MD, DNB(Nephrology), Clinical Fellow, University of Toronto, Toronto, ON.

Isolated systolic hypertension (ISH) is a common disorder in the elderly. Several studies have shown a constant positive and graded association between the level of systolic blood pressure and subsequent mortality from cardiovascular disease and stroke. ISH is defined as an elevated systolic pressure above 160mmHg and a diastolic pressure below 90mmHg. Arterial stiffening is the main cause of increasing systolic pressure in the elderly. The finding of high systolic blood pressure with diastolic below 90mmHg is a marker of higher cardiovascular risk and an indication to follow this patient more closely. The placebo-controlled SHEP and Syst-Eur trials have demonstrated that the treatment of ISH with diuretics or long-acting calcium channel blockers results in a marked reduction in cardiovascular events and stroke.
Key words: hypertension, isolated systolic hypertension, clinical trials, drug therapy, elderly.

Robert J. Petrella, MD, PhD, President, Canadian Coalition for High Blood Pressure Prevention and Control; Associate Professor and Medical Director, Canadian Centre for Activity and Aging, University of Western Ontario, London, ON.

Hypertension is the leading reason for office visits to primary care physicians and is also the leading chronic disease of aging. Given the aging demographic in Canada, its burden on the health care system will grow, making prevention and treatment of hypertension a priority. Solid evidence regarding effective pharmacological therapies in hypertension is available, yet diagnosis and treatment rates remain poor. Likewise, solid evidence regarding the effect of non-pharmacological or lifestyle interventions also is available for clinicians. Furthermore, lifestyle interventions may potentiate the effects of pharmacological therapies due to their inherent modification of positive chronic disease behaviour, resulting in improved maintenance of treatment interventions. With pressure to see many patients in the busy primary care practice, clinicians should resist the "quick-fix" approach to treating hypertension solely by pharmacological means. Consideration of lifestyle modification is worth the time in terms of obtaining sustained control of a growing population at risk.
Key words: hypertension, lifestyle interventions, behaviour change.

Kelly B. Zarnke, MD, MSc, Departments of Medicine, Epidemiology & Biostatistics, University of Western Ontario, London, ON, and on behalf of the Canadian Hypertension Education Program (CHEP).

Poor blood pressure control, particularly among the older Canadian population, remains an important cause of preventable cardiovascular morbidity and mortality. It behooves Canadian health care workers to identify, treat and control hypertension. Recent trials, including ALLHAT and LIFE, add to the information clinicians need to achieve these targets. ALLHAT establishes the central role of thiazide-like diuretics for many hypertensive patients. ALLHAT demonstrates that good blood pressure control can be achieved in the majority of hypertensive patients if a systematic effort is maintained. LIFE adds important information regarding angiotensin receptor blockers as an effective alternative to the other commonly used classes of antihypertensive drugs, particularly among patients with diabetes or isolated systolic hypertension. Finally, the Canadian Hypertension Education Program will continue to produce and disseminate annually updated systematic reviews and recommendations related to the assessment and management of hypertension.
Key words: hypertension, recent clinical trials, clinical practice guidelines.

Alexander I. Aspinall, MD, PhD and Jon B. Meddings, MD, FRCPC, Division of Gastroenterology, Faculty of Medicine, University of Calgary, Calgary, AB.

The inflammatory bowel diseases (IBD)--Crohn's disease (CD) and ulcerative colitis (UC)--have a second peak of onset after the age of 60. Discerning IBD from alternate diagnoses is a great challenge in the geriatric population, as other diseases commonly encountered in the elderly can mimic IBD. The possibilities include ischemic colitis, diverticulitis and infectious colitis. Diagnosing and treating IBD should involve consultation with a gastroenterologist, but the approaches do not vary significantly from the strategies used in younger patients. Therapeutic modalities used in younger age groups are also applicable to the geriatric population, but great attention needs to be given to side effects and drug interactions.
Key words: inflammatory bowel, crohn's disease, ulcerative colitis, differential diagnosis

Epidemiology and Pathophysiology
The inflammatory bowel diseases--Crohn's disease (CD) and ulcerative colitis (UC)--are illnesses of unknown cause.

Jerald Bain, BScPhm, MD, MSc, FRCPC, CertEndo, BA, Professor of Medicine and Obstetrics and Gynecology, University of Toronto; Staff Physician, Division of Endocrinology and Metabolism, Mount Sinai Hospital; President, Canadian Andropause Society, Toronto, ON.

The time has come to put to rest the barbs and criticisms of the naysayers who either question or outright deny that the andropause exists. It is also time to put to rest the hesitation and discomfort some may have with the terminology, andropause. Andropause exists and andropause is its name, and many of yesterday's naysayers are among today's converts.

The Four "Pauses"
Perhaps the easiest way to envisage andropause is to view it as one of the four major "--pauses" in the endocrinology of aging.¹ There are many theories as to why we age and many studies trying to understand the molecular basis of aging. Yet whatever the underlying mechanisms finally turn out to be, there are at least four significant alterations of endocrine function, each of which has been designated the suffix "pause". Whether or not this is an appropriate designation or the most descriptive of each of these endocrine changes is a moot point. The names transmit concepts that we can recognize and study, and that we can influence, if needed, with therapeutic strategies.

The most well known of the four "pauses" is menopause. Menopause is the culmination of a process that occurs over several years.

David Jewell, MSW, MHSc, Irene Turpie, MB, ChB, MSc, FRCP(C),
Christopher Patterson, MD, FRCP(C), David Lewis, PhD, Julia Baxter, BScHK,
affiliated with the Regional Geriatric Program Central Ontario.

Objective: To determine the top learning needs of local specialized geriatrics services staff.
Participants: Health care professionals within the Regional Geriatric Program central area.
Methodology: A snowball sample (n=67) ranked five of 20 possible learning needs (derived from a literature review) by priority.
Analysis: Responses were sorted by those listing a particular subject in any priority, those making it the top priority, and Q-sort.
Results: The top three learning needs--scoring highest on all techniques--were management of dementia, risk and discharge from hospital to community.
Conclusion: This appears to be a viable method of appraising needs for education planning.
Key words: geriatrics, continuing education, survey, needs assessment, Q-sort

Nina M. Silverstein, PhD, Associate Professor, Gerontology, University of Massachusetts Boston, College of Public & Community Service, Boston, MA.
Gerald Flaherty, Director of Special Projects & Safe Return Alzheimer's Association, Massachusetts Chapter, Boston, MA.

Nearly half of all residents in long-term care settings suffer from some type of dementing illness, with Alzheimer disease by far the most common type. People with dementia should be presumed at high risk for wandering due to their cognitive deficits and unpredictable behaviour. Recommendations are shared to minimize attempts to wander and actual wandering episodes by promoting a more therapeutic environment both through the physical structure and through staff training. In addition, effective strategies to follow in situations when a resident is, in fact, missing are presented.
Key words: dementia, wandering, long-term care, environment.

A.D. Baines, MD, PhD, FRCPC, Professor, Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON.

This article presents a summary of recent recommendations for the diagnosis and treatment of Type 2 diabetes in the elderly. Onset of nephropathy, neuropathy and retinopathy can be slowed by treatment designed to reach realistic target values for fasting plasma glucose and HbA1c. Therapy also should minimize the dangers of hypoglycemia. Hepatic and renal function must be monitored when selecting drugs and dosages. Significant reductions in renal function may be associated with serum creatinine within the normal reference range. A stepwise approach to therapy beginning with diet and exercise and proceeding to single and multidrug treatment is outlined. The mode of action, advantages, disadvantages and contraindications for five groups of hypoglycemic agents are summarized.
Key words: Type 2 diabetes, diagnosis, stepped treatment, oral drugs, elderly.