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.

Fritz Francois, MD, Gerald A. Villanueva, MD, Edmund J. Bini, MD, FACP, FACG, Division of Gastroenterology, VA New York Harbor Healthcare System, Bellevue Hospital, and NYU School of Medicine, New York, NY.

Iron deficiency anemia is the most common cause of anemia encountered in clinical practice. In elderly patients, iron deficiency anemia is most commonly due to gastrointestinal blood loss, but also can be caused by poor iron intake or malabsorption of iron. Therefore, a careful evaluation of the gastrointestinal tract is warranted in all elderly patients with iron deficiency anemia. Upper endoscopy and colonoscopy can detect clinically important lesions in up to 44-84% of patients. In those who do not have a cause of iron deficiency anemia identified by endoscopy, the prognosis is excellent. Treatment includes iron supplementation and careful monitoring of hemoglobin levels.
Key words: iron deficiency, anemia, endoscopy, gastrointestinal bleeding, iron malabsorption.

Khaleeq ur Rehman, MBBS, MS(Urol), Department of Urology, McGill University, Montreal, QC.
Serge Carrier, MD, FRCS(C), Department of Urology, McGill University, Montreal, QC.

The increase in male life expectancy has raised concerns about the impact of aging on the male reproductive system. Male testicular function declines gradually with advancing age. In general, testicular perfusion is reduced, aging pigment is accumulated, and the tunica albuginea of the testes and basal membrane of the seminiferous tubules are thickened. The function of Sertoli cells and Leydig cells declines. Among the semen parameters, semen volume, sperm motility and sperm morphology are decreased. The hypothalamic-pituitary-gonadal axis is affected at all levels. In some aging men, the reduction of testosterone levels leads to sexual dysfunction and "andropause". Children born to older fathers carry a higher risk of genetic diseases. This review focuses on the effect of aging on the male gonads.
Key words: aging, gonads, fertility, testosterone.

Marla Shapiro, CCFP, MHSc, FRCPC, FCFP, Assistant Professor, University of Toronto, Department of Family Medicine; Medical Consultant, CTV, Toronto, ON.

Whether women are taking hormone replacement therapy for the prevention of heart disease, osteoporosis or the symptoms of menopause, results from the Women's Health Initiative (WHI) study have brought to the forefront many concerns. Results from this as well as the HOPE study are reviewed, followed by the ensuing responses and recommendations from medical societies. Assessing and tailoring hormone replacement therapy for every woman individually is what can be recommended clearly until further studies are published.
Key words: menopause, hormone replacement therapy, current controversies

With a life expectancy of 81.

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 Elderly, Toronto, ON.

Diabetes is a common disease in the elderly. While pharmacological management is important, the need for and benefits of non-phamacological therapy should not be underestimated in this population. Such therapy includes nutrition therapy, physical activity, smoking cessation and diabetic education. This article reviews, in detail, current recommendations for nutrition therapy and physical activity in elderly patients with Type 2 diabetes, including specific recommendations for all types of food groups and specific recommendations for pre-exercise evaluation.
Key words: elderly, diabetes mellitus Type 2, nutrition therapy, diet, physical activity, exercise.

Jay Lee, MD, FRCS(C), Urologist, Division of Urology, Rockyview General Hospital, Calgary, AB.

"Andropause" is currently a controversial clinical diagnosis. However, more information is being garnered due to physician and patient interest. Declines in testosterone are known to have a multitude of systemic effects. Replacement in those who are truly androgen deplete has been demonstrated to be beneficial. This article reviews the diagnosis of andropause and its treatment and related side effects with testosterone replacement therapy.
Key words: androgen, andropause, hormone deficiency, testosterone replacement.

Jeremy L. Freeman, MD, FRCSC, FACS, Professor of Otolaryngology, University of Toronto; Temmy Latner/Dynacare Chair in Head and Neck Oncology, Otolaryngologist-in-Chief, Mount Sinai Hospital, Toronto, ON.

Carsten E. Palme, MB BS, FRACS, Fellow, Head and Neck Oncology, Department of Otolaryngology, University of Toronto, Toronto, ON.

The management of thyroid nodules in the elderly patient involves paying specific attention to risk factors for malignancy. Certainly, patients over 45 years of age have a higher risk of harbouring a malignancy than younger patients. When a decision is made for intervention, one must keep in mind comorbidity issues balanced against the risk of surgery for a potential malignant tumour of low biological activity.
Key words: thyroid, risk factors, comorbidity, malignant tumour.