Christina S. McCrae, PhD, Assistant Professor, Center for Gerontological Studies, Institute on Aging, and Department of Psychology, University of Florida, Gainesville, FL, USA.

Candece Glauser, MA, Department of Psychology and Institute on Aging, University of Florida, Gainesville, FL, USA.

A variety of patient and environmental factors make nursing home residents particularly vulnerable to insomnia or poor sleep. Although precise estimates are not available, research suggests that up to 75% of institutionalized older adults suffer from disturbed sleep.^1-3 Identifying the contributory factors and intervening to resolve or limit their impact on sleep is the key to effective management. Frequently, these factors can be difficult to control, and as a result, standard sleep evaluation and treatment practices may need to be modified for use in long-term care settings.

Evaluation
Insomnia may be present if an individual has more than 30 minutes of unwanted awake time on six or more days during a two-week period. Evaluation involves having patients record various aspects of their sleep habits, such as bed and wake times, in a sleep diary, daily for two weeks. Polysomnographic (PSG) evaluation is not necessary to diagnose insomnia; however, it may be necessary in some cases in order to rule out other sleep disorders such as sleep apnea.

Dr. Marie-Josée Filteau, MSc, MD, FRCPC, Clinical Professor, Department of Psychiatry, Laval University, Clinical Researcher, Laval University-Robert-Giffard Research Centre, and Director, Clinique Marie Fitzbach, Quebec City, QC.

Patricia Gravel, BA, Department of Psychiatry, Laval University, Quebec City, QC.

Although depression is a highly prevalent psychiatric disorder and the focus of much research and discussion, it remains underdiagnosed and undertreated in the primary care setting. One of the key reasons for the underdiagnosis of depression is the tendency among physicians to focus on the emotional and psychological symptoms of the disorder at the expense of its physical symptoms. Although elderly patients with depression are more likely than their younger counterparts to present with physical rather than psychological symptoms, little emphasis is placed on physical symptoms in diagnostic tools and rating scales. Additionally, the understanding of the role and etiology of physical symptoms in depression remains poor.

Diagnosis can be especially challenging in the elderly population, since both patients and health care professionals often perceive depression to be a normal consequence of age-associated changes, such as physical illness or social or economic difficulties.

Dr. Scott B. Patten, MD, PhD, Associate Professor, Departments of Community Health Sciences and Psychiatry, Faculty of Medicine, University of Calgary, Calgary, AB.

Introduction
The term depression can refer either to an emotion, such as sadness, or to a set of depressive disorders. As an emotion, depression is a universal experience, which likely explains why people naturally understand feelings of depression, on an intuitive level, as a reaction to undesirable life events. However, intuition tends not to be clinically useful for depressive disorders, and can even act as a barrier to effective communication and clinical decision-making. Of course, when depression really does represent a non-pathological reaction to a negative life event, empathic and intuitive understanding is completely appropriate, but a mental disorder should not be diagnosed in these circumstances. It is critical to be able to distinguish normal emotional reactions from the potentially dangerous and usually destructive manifestations of depressive disorders. This distinction is particularly important in the elderly, who may experience a variety of losses such as financial security, health and loved ones. Bereavement in relation to such losses may be normal and adaptive, whereas the emergence of a mood disorder--even if triggered by such events--is typically destructive and can be dangerous.

It is often difficult for patients and physicians to understand the distinction between normal or adaptive forms of depression and depressive disorders.

Jennifer Pike, PhD, Neuropsychiatric Institute, Department of Psychiatry and Biobehavioral Sciences, University of California, Los Angeles (UCLA), CA, USA.

Michael Irwin, MD, Cousins Center for Psychoneuroimmunology, Neuropsychiatric Institute,
Department of Psychiatry and Biobehavioral Sciences, University of California, Los Angeles (UCLA), CA, USA.

Introduction
Depressive disorders are common in the geriatric primary care setting,¹ and are associated with considerable costs and human suffering.^2-4 In 1990, depression was ranked as the fourth leading cause of disability worldwide,⁵ with annual health care costs estimated at $44 billion in the United States alone. Much of this cost is a reflection of higher health care utilization rates in depressed individuals, irrespective of medical comorbidity and mental health visits.³

The prevalence of depressive disorders, defined by the DSM-IV-TR (Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision; Table 1), in the elderly is high and ranges from 6.5-17% in the primary care setting.^1,6 The rates for dysthymia, minor depression or subsyndromal depressions are roughly double those for major depression. The functional impairments and medical burden of these minor depressed geriatric patients are comparable to those of younger patients with major depression.

Arthur Bookman, MD, FRCPC, Senior Staff Physician, University Health Centre, Coordinator, Core Residency Rheumatology Program, University of Toronto, Toronto, ON.

Rheumatoid arthritis (RA), traditionally, has been a difficult and discouraging condition for medical practitioners to treat. In general, physicians have been taxed to contend with the overwhelming physical destruction, as well as the sometimes devastating medical complications, seen in the disease. Our medical schools do not provide sufficient preparation, giving us inadequate tools for recognition of joint disease in general and few tools for following and monitoring disease progression.

Only 10 years ago, the treatment plan for RA was a leisurely-paced pyramid of medications. It began with non-steroidal anti-inflammatory agents (NSAIDs), and flowed through empirical remedies such as gold salts and chloroquine, into newer empirical remedies co-opted from cancer treatment or transplantation, such as methotrexate or imuran in recent years.

Over the last five to 10 years, modern studies have contributed to an evolving understanding of the disease. It is now evident that the diagnosis of RA amounts to a prediction of joint inflammation that will inevitably evolve to joint damage, leading to X-ray evidence of erosion and joint space narrowing. Furthermore, these X-ray changes are markers for loss of function and disability. The evolution of X-ray change over time is constant (Figure 1).

Daniel HS Silverman, MD, PhD, Ahmanson Biological Imaging Center, Division Nuclear Medicine, Department of Molecular and Medical Pharmacology, School of Medicine, University of California, Los Angeles, CA.

Introduction
Early-stage dementia is often unrecognized or misdiagnosed.¹ This can be particularly problematic for dementias due to neurodegenerative disease, like Alzheimer's, where the most can be gained from effective therapies that intervene as early as possible in the course of progressive, irreversible damage to brain tissue. Conventional methods for evaluation are often inaccurate for making a diagnosis or prognosis in the early stages of dementia. However, over the past several years it has become increasingly evident that certain neuroimaging methods--making use of low levels of radioactive compounds to noninvasively elucidate brain function--can be used to sensitively identify such disease at the time of a patient's first presentation of symptoms.

Neuronuclear Imaging in Dementia Assessment
Over the last two decades, clinicians and researchers have gained substantial experience in using the three-dimensional imaging capabilities of positron emission tomography (PET) and single photon emission computed tomography (SPECT) for the identification and differential diagnosis of dementia.

Ali Ahmed, MD, MPH, FACP, Assistant Professor, Division of Gerontology and Geriatric Medicine, Department of Medicine, School of Medicine and Department of Epidemiology and International Health, School of Public Health, Scientist, Center for Aging and Center for Outcomes and Effectiveness Research and Education, University of Alabama at Birmingham; Staff Physician, Heart Failure Clinic and Section of Geriatrics, Veterans Affairs Medical Center; Member, Heart Failure Project, Alabama Quality Assurance Foundation, Birmingham, AL, USA.

Heart Failure: A Geriatric Syndrome
Heart failure (HF) is a "geriatric syndrome" as much as it is a "cardiac syndrome." The prevalence of HF in Canada is over 350,000 and between 25% and 40% of patients are dead within one year of diagnosis.¹ Most HF patients are 65 years of age and older,² and both the incidence and prevalence of HF increase with age.³ Over 90% of all HF-related deaths occur in persons 65 years of age and older.⁴ HF is the number one hospital discharge diagnosis for this group of patients.5 Diagnosis and management of HF in older adults is complicated by functional impairment, multiple comorbidities, polypharmacy and left ventricular systolic dysfunction (LVSD).^6,7

Historic Role of Digitalis in Heart Failure
Digitalis glycosides are present in the leaves of the foxglove, Digitalis purpurea (digitoxin) or Digitalis lanata (digoxin), or in the seeds of Strophanthus gratus (ouabain).

Scott A. Farrell, BA, BEd, MD, FRCSC, Iwk Health Centre, Halifax, NS.

Introduction
Adult women who enjoy urogenital health are usually sublimely unaware of their pelvic organs. It is not until urogenital organ dysfunction occurs that attention is focused upon factors that are essential to the maintenance of a healthy urogenital tract. Maintenance of urogenital health is largely dependent upon healthy lifestyle habits and, to a lesser extent, a woman's hormonal milieu. This article will briefly discuss the following relevant topics: normal anatomy and function, the effect of lifestyle and hormones on normal functioning of the urogenital organs, and common problems encountered with aging.

Normal Anatomy and Function of the Urogenital Tract
The urogenital tract is composed of three organ groups which lie in close proximity within the pelvic cavity: the bladder and urethra; the genital organs (uterus, fallopian tubes, ovaries, vagina and vulva); and the rectum and anal canal. These organs share a common embryologic origin and all possess estrogen receptors.^1,2 They rest upon a common support structure--the pelvic diaphragm or levator muscles³--which not only invests each organ with supportive fibres, but also contributes to the mechanisms that maintain urinary and anal continence and close the introitus of the vagina. The urethral and anal continence mechanisms are dependent upon the normal functioning of both smooth and striated muscle sphincters.

Part 1: Introduction, Head and Neck, and Cranial Nerves

David J. Gladstone, BSc, MD, Fellow, Cognitive Neurology and Stroke Research Unit, Sunnybrook and Women's College Health Sciences Centre and Division of Neurology, University of Toronto, Toronto, ON.

Sandra E. Black, MD, FRCPC, Professor of Medicine (Neurology), University of Toronto; Head, Division of Neurology and Director, Cognitive Neurology Unit, Sunnybrook and Women's College Health Sciences Centre, Toronto, ON.

Abstract
This four-part series of articles provides an overview of the neurological examination of the elderly patient, particularly as it applies to patients with cognitive impairment, dementia or cerebrovascular disease. The focus is on the method and interpretation of the bedside physical examination; the mental state and cognitive examinations are not covered in this review. Part 1 begins with an approach to the neurological examination in normal aging and in disease, and reviews components of the general physical, head and neck, neurovascular and cranial nerve examinations relevant to aging and dementia. Part 2 covers the motor examination with an emphasis on upper motor neuron signs and movement disorders. Part 3 reviews the assessment of coordination, balance and gait. Part 4 discusses the muscle stretch reflexes, pathological and primitive reflexes, sensory examination and concluding remarks.

Roland R. Tremblay, DSc, MD, PhD, Professor Emeritus of Medicine, Laval University, Quebec City, QC.

Introduction
In both sexes, aging is associated with a progressive reduction in skeletal muscle mass and strength, although this may be masked by increases in subcutaneous fat or abdominal obesity that give the impression of stable body weight. Progressive frailty, however, occurs on a more global level with seniors "affected by multiple chronic diseases which cause physical and functional limitations."¹ These comorbid diseases may cause a systemic stress, which by itself (excess cortisol secretion), or by virtue of its suppressive action on the pituitary-gonadal axis, leads to a decline in androgen production. While the tendency to associate andropause and androgens has become increasingly common, the causal link between male hormone deficiency and the clinical disorder andropause still remains a weak one. A medical anthropologist is certainly likely to qualify the association as a reductionist vision of the frailty syndrome. In a sense, this vision serves the interests of both patients and physicians: it facilitates the diagnostic approach and the treatment strategies in an aged population, estimated at 20%, that seeks medical attention because of frailty, low mental and physical energy, depression-like symptoms and sexual hypofunction.