Nabeel AlAteeqi MD, FRCPC and Johane Allard MD, FRCPC
University of Toronto, Toronto, ON.

Introduction
Zinc is one of the essential micronutrients, and plays an important role in human nutrition and health. In 1961, Prasad first recognized zinc deficiency as the cause of dwarfism and hypogonadism among iron-deficient adolescent Iranian village boys.^1,2

Zinc deficiency occurs in individuals and populations with diets low in sources of readily bioavailable zinc, such as red meat, and high in unrefined cereals that are rich in phytate. The elderly population is potentially vulnerable to zinc deficiency because of decreased intake of food energy, protein, vitamins and minerals, and increased intake of carbohydrates.^3,4

In this review, we discuss the importance of zinc to humans, as well as the causes, clinical features and management of zinc deficiency in the elderly population.

Importance of Zinc
Zinc is an essential mineral, present in most systems of the human body, and plays a role in stabilization of cell membranes, tissue regeneration and protein synthesis. It also serves as a structural component of at least 70 metalloenzymes. Examples of zinc metalloenzymes are carbonic anhydrase, alkaline phosphatase, alcohol dehydrogenase and zinc-copper superoxide dismutase.

In addition, zinc is needed for growth, normal development, DNA synthesis, RNA conformation, immunity, neurosensory function and other important cellular processes.

Jenny F.S. Basran, BSc, MD, and David B. Hogan MD, FACP, FRCPC
Division of Geriatric Medicine, University of Calgary, Calgary, AB.

Introduction
Recently, there has been growing interest in the use of vitamins for the treatment of various health conditions. One study has estimated that 35-54% of older Canadians take some form of vitamin or mineral supplement.¹ Oxidative stress has been theorized to be an important contributor to select conditions, particularly those involving the cardiovascular and central nervous systems. Vitamin E is the only fat-soluble, chain-breaking antioxidant found in biological membranes⁴ and, therefore, has been investigated for its use in the treatment of ischemic cardiovascular disease in recent landmark studies such as the Heart Outcome Evaluation Study (HOPE)² and Heart Protection Study (HPS).³

How Does Vitamin E Work?
Vitamin E is a generic term for chemical derivatives of tocopherol and tocotrienol.⁵ There are eight naturally occurring forms, but only a-tocopherol is found in human plasma, has the highest bioactivity and is the form used for medicinal purposes. a-tocopherol is found naturally in vegetable oils, almonds, sunflower seeds, walnuts, sweet potato, liver, wheat germ and egg yolk.⁶ Synthetic forms are available as vitamin capsules and in fortified foods.

Rory Fisher, MB, FRCP(Ed)(C), Director, Regional Geriatric Program of Toronto and Interdepartmental Division of Geriatrics, Faculty of Medicine, University of Toronto, Toronto, ON.

In Canada, the sustainability of the health care system is a major issue. Two commissions have been established to address the future of health care.^1,2 Improvements in technology and changes in the delivery of health care have led to major restructuring of the system. Acute hospital beds and the length of hospital stays have decreased with the concomitant expansion of ambulatory services. The aging population, which is increasing dramatically in Canada, particularly with regard to the oldest old, is a major priority policy issue in these discussions.³ However, the current management of the elderly in acute hospitals is of concern. In the United Kingdom, an enquiry into the care of older people in acute wards in general hospitals entitled "Not because they are old" found that problems existed with older patient and relatives' dissatisfaction with the care, numerous deficiencies in physical environments, clear evidence of staff shortages and concerns about nutrition.⁴ Problems were also identified with preserving dignity, interactions with staff, insufficient training, discharge planning and the accessibility of services in the community. In addition, a recent study by Health Canada on unmet needs for health care reported, an estimated 7% of Canadians, or about 1.

• Office-based risk factor evaluation is mandatory in people with diabetes, and aggressive risk factor modification should be based on those results.
• The metabolic syndrome commonly precedes the onset of diabetes by several years. Insulin resistance apparently predates the risk factors associated with metabolic syndrome, thus detection of insulin resistance relatively early in life offers the opportunity to identify, at an early stage, those people likely to develop blood fat abnormalities, high blood pressure (HBP) and, ultimately, diabetes.
• A person with diabetes who smokes is at double the risk for cardiovascular disease (CVD). Therefore, every effort must be made to convince the patient to stop smoking.
• HBP increases a diabetic patient's risk of coronary heart disease (CHD), stroke, kidney failure and heart failure. Treatment of HBP in people with diabetes should be intensive enough to reach blood pressure goals.
• The common drugs to treat high blood pressure--diuretics, beta-blockers, angiotensin converting enzyme (ACE) inhibitors and calcium channel blockers--are generally effective in treating patients with diabetes.
• Assiduous treatment of high blood pressure in people with diabetes can delay the progression of diabetic nephropathy and retinopathy, as well as CVD.

James Brown, MD, Minimally Invasive Urologic Oncology Fellow
Department of Urology, Thomas Jefferson University, Assistant Professor of Urology
Medical College of Georgia, Augusta, GA, USA.

Leonard G. Gomella, MD, Bernard Godwin Associate Professor of Prostate Cancer
Director of Urologic Oncology, Department of Urology, Kimmel Cancer Center,
Thomas Jefferson University, Philadelphia, PA, USA.

Abstract
The treatment options for localized prostate cancer are extensive and highly controversial. Although there is general agreement that symptomatic metastatic disease should be treated by hormonal ablation, there is no consensus on how to treat patients with localized disease. While an argument can be made not to screen any patient for prostate cancer, many organizations, including the American Urological Association, support both screening and the treatment of prostate cancer in men with a life expectancy of greater than 10 years. In the asymptomatic, older man with localized, low-risk disease, characterized by a low Gleason score, low PSA and low clinical stage, observation may be the treatment of choice. However, in the older man with localized prostate cancer and high-risk features such as a high Gleason score, aggressive treatment is warranted since many of these men will progress and ultimately die of prostate cancer.

Cynthia M. Westerhout, MSc and Eric Boersma, PhD
From the Department of Cardiology, Erasmus Medical Centre,
Rotterdam, The Netherlands and the University of Alberta, Edmonton, AB, Canada.

Introduction
The introduction of balloon angioplasty in the early 1980s and stents in the mid-1990s has revolutionized mechanical reperfusion therapy in patients with stenotic coronary arteries.^1,2 In fact, percutaneous coronary interventions (PCI) are one of most frequently performed procedures, with more than 1.3 million performed worldwide in 1999.³ However, an important limitation of PCI is the risk of inducing platelet aggregation. As a result of the disruption of the culprit plaque and injury to the coronary vessel during the procedure, the periprocedural risk of reocclusion of the vessel and myocardial infarction (MI) is high, and there is a 20-40% incidence of restenosis at 6-12 months after the index procedure.³

In an attempt to reduce the risk of these complications, several new strategies have been explored. Glycoprotein IIb/IIIa receptor inhibitors (GPIs), for example, have been enthusiastically tested in over 25,000 patients undergoing PCI over the last decade (Table 1). Gp IIb/IIIa receptors are found in great abundance on the surface of platelets and blocking these receptors obstructs the final common pathway leading to platelet aggregation.

Chris MacKnight, MD, MSc, FRCPC, Assistant Professor, Division of Geriatric Medicine, Dalhousie University, Halifax, NS.

Introduction
Lewy body disease is one of the many conditions causing dementia. As it is relatively common, and has an effective management distinct from that of Alzheimer disease,¹ all physicians who see older adults should have some familiarity with Lewy body disease.

Diagnosis
Lewy body disease is underdiagnosed.² It should be suspected in an older adult who presents with cognitive impairment (even if quite mild) in addition to hallucinations or parkinsonism. Clinical criteria are presented in Table 1.^3,4 The criteria of fluctuation have proven difficult to apply at the bedside, but clinical tools are now available.⁵ The parkinsonism is often mild and subtle, and is more often rigidity than tremor. An important feature is neuroleptic sensitivity. Up to 80% of these patients can, even with low doses, develop reactions to neuroleptics or atypical agents, which are often severe.⁶ Extrapyramidal symptoms and cognitive decline are the most common manifestations. The decline can be permanent, and neuroleptic malignant syndrome can occur. This likelihood of reaction to neuroleptics is one of the chief reasons to be familiar with the disorder and to have a low threshold to at least suspect its presence.

It can sometimes be difficult to distinguish Lewy body disease from Alzheimer disease, Parkinson's disease or delirium.

Madhuri Reddy, MD, Dermatology Day Care (Wound Healing Clinic), Sunnybrook and Women's College Health Care Centre, Toronto, ON, Associate Editor, Geriatrics & Aging.

R. Gary Sibbald, BSc, MD, FRCPC (Med), FRCPC (Derm), MACP, DABD, Associate Professor and Director of Continuing Education, Department of Medicine, University of Toronto, Toronto, ON.

Introduction
Pressure ulcers are areas of localized damage to the skin and underlying tissue caused by pressure, shear, friction, excess moisture, incontinence or abrasion. They usually occur over bony prominences such as the sacrum, heels, hips and elbows (Figure 1).

Pressure ulcers are associated with a significant burden of illness in the elderly and a significant financial burden to the health care system. In a recent study of a geriatric unit in Glasgow, the prevalence of pressure ulcers was 41%.¹ The incidence in acute care² has been estimated at 10%, and up to 60% of patients develop ulcers while in acute care hospitals.³ In one study, the prevalence of stage I-IV pressure ulcers in 1,960 acute care facilities in Canada from 1995-1998 was 11.2%.⁴ The incidence rate for home care is 15.4%.⁵ Approximately 45% of all pressure ulcers are probably preventable.

Annually, 1.7 million patients in the U.

Easy and Inexpensive Management

Dr. Scott Murray, MD, FRCPC, Dermatology, Assistant Professor Dermatology, Dalhousie University, Halifax, NS.

As you observe the geriatric patient, a variety of visual cues--posture, body habits, energy level and hair colour--can provide the observer with clues to the patient's age. However, in many ways it is the skin that is the first giveaway of the effects of aging. The skin is the most accessible organ for treatment and can be considered the parameter of aging most easily affected by intervention--at least cosmetically. As a result, there is huge interest in remedies to reverse age-associated skin changes. This has led to the development of an immense industry, both in medicine and in cosmetics, to defy these effects.

Skin Aging
Some changes to aging skin occur as a result of intrinsic effects such as genetics and racial types. There is little we can do to control these variables.¹ For instance, the variable ability of skin to deal with sun exposure is predetermined to some extent in this way. Some visual changes of the skin also result from sagging of underlying muscles (sagging) and repetitive motion (grooves or "laugh lines"). These lines add to the lines on the skin that we visually identify with advancing years.

Extrinsic factors such as ultraviolet light, nutrition, underlying illness, smoking and stress can also contribute to skin aging.

Marvin Lester, BA, MD, FRCPC, The Fitness Institute, Mississauga, ON.

Bullous Pemphigoid (BP) is essentially a disease of the elderly with the average age of onset usually in the sixties to seventies. However, this is not a hard and fast rule and it can occur in other ages, including children, although rarely.

BP is thought to be an autoimmune reaction, with circulating basement membrane zone (BMZ) and antibodies of the IgG class present in the majority of cases.

BP has occasionally been reported to be associated with other diseases including Ulcerative Colitis, Dermatomyositis, Diabetes Mellitus, Rheumatoid Arthritis and multiple autoimmune diseases involving organs other than the skin. Drugs have also been reported as possible causes for this condition and include medications such as Furosemide, Enalapril, Captopril, Penicillin and Sulfasalazine.

Clinical Features
The disease is characterized by large, tense, very firm, fluid-filled bullae as opposed to the more flaccid lesions that are seen in bullous diseases such as Pemphigus Vulgaris. In Pemphigus Vulgaris these may be widespread over the skin surface or may be localized to one part of the body including the groin, axillae and flexural surfaces of the forearms. Oral involvement has been reported and varies anywhere from 10-40%; usually an average of about 20% is quoted. Involvement of other mucosal surface such as the throat, nose, vulva, urethra and eye are not common.