Gail A. Eskes, PhD
Department of Psychology,
Queen Elizabeth II Health Sciences Centre Assistant Professor,
Psychiatry and Medicine (Neurology),
Adjunct Professor, Psychology,
Dalhousie University, Halifax, NS.

Beverly C. Butler, BSc
Department of Psychology,
Dalhousie University, Halifax, NS.

Introduction
Unilateral neglect is a cognitive and behavioural syndrome after brain damage that can have serious consequences for patient recovery, rehabilitation success and long-term reintegration to independent living. Outcome studies commonly identify neglect and related sequelae as significant predictors of poor outcome in stroke patients in terms of increased need for assistance in self-care activities and decreased quality of life.

Definition and Clinical Presentation
Unilateral neglect is most commonly defined as a failure to orient, report or respond to stimuli located in the space or body contralateral to a brain lesion (often due to stroke or brain injury), despite adequate sensorimotor ability to do so.¹ The neglect syndrome is fundamentally different from, although sometimes confused with, hemianopia, hemisensory loss or hemiplegia.

Madhuri Reddy, MD, FRCPC
Associate Editor,
Geriatrics & Aging,
Toronto, ON.

Introduction
It is well documented that, throughout North America, a large percentage of elderly clients (10-52%) do not have the medical need or are not sufficiently disabled to justify placement in high level of care settings such as a nursing home (NH).^1,2,3,4

The placement of low-care clients in NH is often assumed to indicate inappropriate and inefficient use of NH resources.⁵ In addition, it is well established that disabled clients prefer home or community-based care rather than receiving care in NHs.⁶ So why do clients continue to be placed in high levels of care that they do not need?

Subjective Placement Criteria
The process of client placement does not always explore the possibility that the client may best be cared for outside of a long-term care (LTC) institution. In addition, even when clients truly do need NH care, the definitions of the various levels of care are often vague; thus, adherence by placement committees is often inconsistent. This lack of objective criteria regarding the level of care required by a particular patient leads to subjective decision-making by a placement panel; this can result in patients who require the same level of care being placed in different levels depending on who makes the decision.

Professor Michael S Roberts, DSc
Julie Stokes, BPharm, PG
Dip Clin Hosp Pharm.
Department of Medicine,
University of Queensland,
Ipswich Road,
Buranda, Qld, Australia.

Introduction
One of the most professionally satisfying scenes we have observed while working in nursing homes is an older person regaining his or her dignity and independence after unnecessary drugs have been ceased. It is often easy to add medications to the drug regimen of older people¹ to treat "new" conditions, some of which may in fact be the adverse effects of medications already prescribed. Drugs can cause subclinical diminution in function or their adverse effects can mimic almost any clinical syndrome.² It has been shown that the risk and frequency of adverse drug outcomes increase with the number of drugs prescribed--some residents may be on up to 22 medicines at a given time³ and not all of these are needed. Some classes of medications, most notably psychoactive drugs, are of particular concern in nursing homes.⁴ In a prospective cohort study of 1106 nursing beds in 12 nursing homes in Los Angeles, Beers et al.5 suggested that 40% of the residents received at least one inappropriate medication order, 10% received two or more inappropriate medication orders concurrently, and 7% of all medications were inappropriate. A similar finding has been reported for the UK.

Harold Parker, BSW, MSW, RSW
Social Worker, Outreach Team,
Southwestern Ontario Regional Geriatric Program,
London, ON.

Laura Diachun, BASc, MD, FRCP(C)
Geriatrician,
Southwestern Ontario Regional Geriatric Program,
London, ON.

As an Outreach Team that provides service to the frail elderly for the Southwestern Ontario Region (10 counties), our ongoing challenge is how to respond to the needs of cognitively-impaired older persons living at some degree of risk. The perception and assessment of risk vary depending upon the lens through which we are looking. A living situation that may be perceived as risky by some may be quite unproblematic to others. Caring family members can often rationalize paternalism toward their elderly loved one so as to err on the side of safety--a value that can often take precedence over issues of quality of life and self-determination. A lifetime of responsible decision-making is no guarantee of the continued exercise of free will at the latter end of the life cycle. The 'assailants' to independence can be many, including paternalism and the presence of disease beyond normal aging, which can affect both function and cognition. It is often unclear where to draw the line between granting the individual the freedom to make poor lifestyle decisions and deeming that someone is exceeding family/community standards of acceptable lifestyle choices.

Morris D. Kerstein, MD
Professor and Vice-Chairman,
Director of Research and Education,
Department of Surgery, Mount Sinai School of Medicine,
New York, NY, USA.

Ernane D. Reis, MD
Assistant Professor
Department of Surgery,
Mount Sinai School of Medicine,
New York, NY, USA.

Venous leg ulcers influence the physical, financial and psychological well-being of patients, and result in an estimated two million workdays lost, annually. Despite a variety of therapeutic options, venous leg ulcers remain a substantial management challenge to the health-care professional. Some form of lower extremity venous disease is present in nearly 30% of the American adult population. Venous leg ulcers are often debilitating sequelae of venous insufficiency, and account for 80-90% of leg ulcers reported. A quality-of-life study reported that 65% of chronic-leg-ulcer patients had severe pain, 81% experienced reduced mobility, and nearly 100% reported a negative impact of their disease on work capacity.

Manifestations of venous insufficiency may include dilated superficial veins, with or without dilated tributaries of the deep vein system, swelling, leg pain, heaviness and changes in the skin (hyperpigmentation, venous dermatitis, eczema with dryness and itching). Ultimately, the adverse effects of venous disease appear as skin ulceration of lipodermatosclerosis.

Isao Shimokawa, MD, PhD
Pathology & Gerontology,
Department of Respiratory and Digestive Medicine,
Nagasaki University School of Medicine,
Nagasaki, Japan.

Introduction
Caloric restriction (CR)--the restriction of food intake while maintaining adequate supplies of essential nutrients (i.e. not malnutrition)--is widely recognized as the most powerful intervention for the extension of lifespan in organisms. CR slows the aging process, prevents or retards age-related diseases and extends the mean and maximum lifespan in laboratory organisms.^1,2 In the 66 years since the seminal report of McCay,³ many studies have confirmed its life-extending effects. These effects do not depend on the restriction of specific nutrients or food contaminants.4 Despite numerous efforts, our knowledge of the mechanisms underlying the effects of CR is not yet complete. The present article focuses on several possible mechanisms. Other historic and recent research can be found in more comprehensive reviews^1,2 and a recent update.⁴

An Evolutionary Perspective
It has been suggested that the anti-aging effects of CR might derive from adaptive responses that evolved to maximize organism survival during periods of food shortage. In order to avoid extinction, organisms have evolved neuroendocrine and metabolic response systems to enhance survival during natural periods of food shortage.

D'Arcy Little, MD, CCFP
Director of Medical Education,
York Community Services, Toronto, ON.

Introduction
Thrombocytopenia is a common hematologic problem in the elderly.¹ A classic survey indicated that over 50% of patients with thrombocytopenia were over 50 years of age, and 25% were over 70 years of age.² The elderly patient with thrombocytopenia presents the clinician with both diagnostic and management challenges. Because the disorders and mechanisms that lead to decreased numbers of platelets in the circulation are varied, the spectrum of differential diagnoses is broad and includes decreased platelet production and accelerated destruction.³ In addition, the clinical implications of thrombocytopenia fall into a wide spectrum, from a benign condition picked up incidentally in an asymptomatic patient to a life-threatening disorder.⁴ The following article will present an approach to the evaluation of thrombocytopenia in the elderly patient (Figure 1).

Definition and Clinical Significance
Thrombocytopenia is a condition in which there is a deficient number of circulating platelets. The cutoff for diagnosis is 150 x 10⁹/L of blood, which represents the platelet count two standard deviations below the mean obtained when sampling a large number of persons from the general population.

Jeffrey Zonder, MD
Ulka Vaishampayan, MD
Division of Hematology/Oncology,
Department of Medicine
Wayne State University School of Medicine/Barbara Ann Karmanos Cancer Institute
Detroit, MI, USA.

Introduction
The incidence of hematologic malignancies, especially lymphoma, is steadily rising in the elderly. These diseases and their complications pose specific problems for older patients. Factors that contribute to increased toxicity in the elderly include diminished marrow reserve, impaired renal and hepatic metabolism and, perhaps most importantly, poor performance status as a result of comorbidities.¹ This article will focus on the management of common complications of hematologic malignancies, particularly as they pertain to older patients.

Febrile Neutropenia

Risk of Neutropenia in the Elderly
The incidence of life-threatening neutropenia (absolute neutrophil count, ANC, <0.5x 10⁹/L) in elderly patients following chemotherapy for hematologic malignancies is 40% or higher.² The risk of infection is affected by the duration and severity of neutropenia with a steep rise in infection incidence at a neutrophil count of less than 0.5x 10⁹/L.

Wendy S. Meschino, MD, CCFP, FRCPC, FCCMG
Clinical Geneticist,
North York General Hospital,
Toronto, ON.

"My mother has Alzheimer disease. Can I be tested to see if I carry the gene?" Such questions from patients are likely to be a familiar refrain to many physicians. While there is a great deal of discussion regarding the potential hereditary aspects of Alzheimer disease (AD), genetic testing is not appropriate for the vast majority of patients or their unaffected relatives. Genetic testing is possible only in selected situations where there is a significant family history of early-onset disease. In this article, we will explore how to take a family history of Alzheimer disease, how to recognize when genetic testing is appropriate, the critical issues to be discussed in genetic counselling and a brief review of the genes identified to date which are associated with familial Alzheimer disease (FAD).

In taking a family history, it is important to inquire about affected and unaffected relatives on both sides of the family. Details of the family history may be recorded in pictorial form as a pedigree (Figure 1). A minimum of three generations should be noted including siblings, parents, aunts, uncles, cousins and grandparents.

Jennifer M. Jones, PhD
Research Scientist,
Psychosocial Oncology Program,
Princess Margaret Hospital, University Health Network,
Toronto, ON.

Gary Rodin, MD, FRCP(C)
Head, Psychosocial Oncology,
Princess Margaret Hospital & Psychiatrist-in-Chief,
University Health Network,
Toronto, ON.

Psychological Response to Illness: Coping with a Diagnosis of Cancer
The diagnosis of cancer is inevitably experienced as a traumatic event, although the individual response to it depends upon the nature and stage of the disease, the associated disability, the life stage of the individual affected, its personal meaning and the sociocultural context in which the individual is situated. In the elderly, who commonly experience concerns about self-sufficiency, the onset of a serious medical illness such as cancer may trigger intolerable feelings of helplessness and dependence.

Most patients experience shock when they first learn of their diagnosis of cancer. In some cases, there may be profound anxiety with symptoms of hyperarousal and vigilance arousal, and an oscillation between intrusive thoughts of the cancer and avoidance of the frightening reality. These symptoms represent a stress response syndrome, which may be reactivated following a recurrence of the cancer, which can be even more traumatic than the original diagnosis.