Elderly Step into False Security

Marked crosswalks are designed with the well-meaning intention of assisting pedestrians safely across a busy intersection. Yet University of Washington researchers have recently found that more elderly people are hit by a vehicle at these very intersections that traffic engineers thought so wise. Is it possible that crosswalk markings actually make our vulnerable journey across a busy street more risky?

During the 10-year period between 1988 and 1997, pedestrian fatalities in Canada averaged 486 per year and there was an average of 15,358 pedestrians injured. Of the female and male pedestrian fatalities, a respective 25% and 38% involved people 65 years and older. Furthermore, 85% of the fatalities within this older age group occurred in urban areas. Clearly, older pedestrians in cities are at a higher risk, often due to their slower pace, misguided judgements and loss of agility to avoid danger. Thus, this group of investigators was prompted to determine whether crosswalk markings at urban intersections influence the risk of injury to older pedestrians.

Collaborating with traffic authorities in six cities in Washington and California, the researchers identified 282 episodes between 1995 and 1999 of a pedestrian aged 65 years or older who had been struck by a vehicle while crossing an intersection. Trained fieldworkers collected information on these and 564 case-matched intersection sites. At each site on the same day of the week and time of day when the case event had occurred, the fieldworkers compiled data on environmental characteristics, such as the presence of a traffic signal or stop sign, as well as vehicular traffic flow and speed and pedestrian use.

After adjusting for pedestrian and vehicle flow, crossing length and signalization, the risk of a pedestrian-vehicle collision was 2.1-fold greater at sites with a marked crosswalk. However, nearly all of this excess risk was due to the 3.6-fold higher risk associated with marked crosswalks at sites with neither stop signs nor traffic signals. In fact, there was almost no association between risk of collision and presence of a crosswalk marking at sites with traffic signals or stop signs.

These results clearly show that more crosswalks are not necessarily better when there are no other traffic signs present to direct the attention of drivers. The researchers hope that traffic engineers will use this information to assess the safety of crosswalks at intersections with future planning. The message to elderly pedestrians should be that a marked crosswalk isn't necessarily a safe place to cross, and when possible, they should use intersections with either a traffic signal or sign.

Sources

1. Koepsell T, McCloskey L, Wolf M, et al. Crosswalk markings and the risk of pedestrian-motor vehicle collisions in older pedestrians. JAMA 2002;288:2136-43.
2. Transport Canada. Pedestrian fatalities and injuries 1988-1997: Fact sheet #RS2001-1. February 2001.

What can We Learn from Poor, Old Confused Mr. L

Typical or atypical? It depends on your point of view

Dr. Clarfield is the Chief of Geriatrics, Soroka Hospital Centre, Professor, Faculty of Medicine, Ben Gurion University of the Negev, Beersheva, Israel, and Professor (Adjunct), Division of Geriatric Medicine, McGill University and Jewish General Hospital, Montreal, QC., Canada.

Mr. CL, an 84-year-old gentleman, had coped reasonably well with his Parkinson's disease for several years. One Saturday evening he began to act strangely: muttering to himself, wandering aimlessly throughout the house, and from time to time uncharacteristically swearing at his wife. Mrs. L was surprised and distressed by her husband's behaviour since he had never before acted in this manner.

That Saturday night was difficult for Mrs. L, but eventually Mr. L fell asleep. The next morning he seemed somewhat improved, but as the afternoon wore on he once more began to act in the bizarre manner of the previous day. Sunday night was a repeat of the previous night and Mr. L's elderly wife was exhausted and at her wits end by Monday morning.

On that afternoon, Mrs. L phoned her husband's neurologist. He prescribed thioridazine 25mg b.i.d. to be added to the usual regimen of carbidopa/levodopa. The physician hurriedly mentioned something about patients with Parkinson's disease eventually developing dementia. Though horrified by this grave news, Mrs. L dutifully complied, providing the medication, as prescribed, to her husband.

Canadian Association on Gerontology’s 31st Annual Scientific and Educational Meeting: Wrap-up of Events

This year's Canadian Association of Gerontology meeting (October 24-26) offered over 300 presentations--including plenary sessions, concurrent sessions, poster presentations and workshops--that embraced the theme "Aging and Society: Taking Charge of the Future". Hosted at the Hotel Bonaventure Hilton in Montreal, QC., opening ceremonies set the tone for the conference with a keynote session by Dr. Xavier Gaullier, an expert in the study of "managing ages" in the workplace and in society.

Symposia focusing on integrated service delivery networks for the frail elderly followed, with speakers including Dr. Pierre Durand, a geriatrician and community health specialist from Laval University, and Dr. Michel Tousignant from the Institut Universitaire de Geriatrie de Sherbrooke. Concurrently, paper sessions covered themes ranging from issues in long-term care facilities and psychosocial aspects of health to assessment issues in dementia. The day concluded with symposia on the challenge of mild cognitive disorders as well as a roundtable discussion on the challenges of aging communities and their effects on seniors' services.

Dr. Thomas Perls, an associate professor in medicine at Boston University School of Medicine and a geriatrician at the Boston Medical Center, introduced the second day of the CAG meeting with a review of the New England Centenarian Study, which he has directed for the past eight years. The study has documented that centenarians have a history of aging relatively slowly and have either markedly delayed or are entirely free of diseases normally associated with aging, such as Alzheimer disease, cancer, stroke and heart disease. Morning sessions followed with a focus on resilience and adaptation in later life, with many appearances of Dr. Norm O'Rourke from the Gerontology Research Centre at Simon Fraser University, as well as many presentations addressing addictions, abuse, neglect and mistreatment.

Ideas on how to improve the care of seniors in the emergency department were presented at the same time as a nutrition symposium, at which the prevention of weight loss in dementia patients was discussed as well as interventions to promote health and quality of life of vulnerable seniors. Finally, a workshop on assisting the visually challenged elderly and a roundtable discussion on lifelong learning in older adults helped conclude the CAG's goal of creating a better old age for all.

Geriatrics & Aging followed this year's CAG events in Montreal and would like to thank all those who visited our exhibit and who offered their support and encouragement for our ongoing efforts at providing continuing medical education for primary care practitioners specializing in geriatrics.

“Prehabilitation” Program May Prevent Functional Decline in the Elderly

The potential benefits of home-based programs to prevent functional decline in the elderly remain equivocal, although most of the literature to date has focused on the restoration of function in disabled elderly following an acute medical event. Few attempts have been made to evaluate so-called "prehabilitation" strategies aimed at preventing functional decline in elderly persons who have suffered neither acute illness nor injury, but who are physically frail nonetheless. In a randomized clinical trial, Gill et al. sought to explore the effect of a home-based intervention program on the functional decline of physically frail, elderly individuals.

The need for longer than 10 seconds to complete a rapid-gait test, or the inability to rise free-handed from a seated position in a hardback chair were used as the defining criteria for recruiting physically frail persons. A total of 188 participants 75 years and older who met one or both of these criteria were randomly assigned to the intervention or control group. The physical frailty and cognitive status of patients were assessed, as well as the self-reported abilities of patients (on a scale from one to 16) to walk, bathe, dress, rise from a chair, use the toilet, eat and groom. Data were collected at baseline, and then at three, seven and 12 months.

Participants in the intervention group were visited at home by a physical therapist 16 times, on average, over six months. Recommended intervention included the completion of supervised resistance exercises using elastic bands, instruction on safe techniques for facilitating various levels of activity, removal of potentially hazardous obstacles in the home, placement of nonskid mats in the bathroom and kitchen, lighting improvement and repair of walking surfaces, stairwells and railings. The control patients received six home visits by a health educator, during which the promotion of good health was reviewed.

The primary outcome was measured as the change between the baseline score and that at each subsequent assessment session. As a whole, participants in the intervention group experienced less disability than those in the control group. This result was especially true in the moderately frail participants (mean score of 2.7 in the intervention group versus 4.2 in the control group), whereas less discrepancy was manifested in those who were severely frail (5.0 versus 6.3). During the 12-month follow-up period, 14% of the intervention group required admittance to a nursing home, compared to 19% in the control group. The average cost per participant in the intervention group was $1,998 (U.S.). The frequency of adverse events in the intervention group was not greater than that in the control group, indicating the safety of the home-based intervention program.

The data indicate the benefit of home-based "prehabilitation" over educational programs, as demonstrated by a marked reduction in self-reported disability after seven and 12 months. The reason for failure of the severely frail participants to benefit significantly from intervention is unclear. While the cost of the program is relatively moderate, the time investment required of physical therapists is greater than that covered by Medicare in the United States. Conducting a Canadian study would be useful firstly to determine whether home-intervention is of similar benefit in Canada, and secondly, to assess whether this benefit is sufficiently large to warrant the extra burden put on Canadian health care professionals.

Source

1. Gill TM, Baker DI, Gottschalk M, et al. A program to prevent functional decline in physically frail, elderly persons who live at home. N Engl J Med 2002;347:1068-74.

Forget Vitamin E for Immune Boost

It is well known that aging is often associated with a poor immune response and a vulnerability to respiratory tract infections. It is also well recognised that nutritional status plays an important role in immune impairment, especially in the elderly. Vitamin and nutrient supplementation is thus often encouraged in the elderly under the assumption that it can only boost health, including their immune response. However, supplementing the diet with vitamin E may actually have an adverse effect on the severity of respiratory tract infections in the elderly, according to a recent Dutch study.

The investigators randomized 652 well-nourished, noninstitutionalized individuals from the Netherlands, 60 years or older, to physiological doses of either multivitamin-minerals, 200mg of vitamin E, both or placebo. The incidence and severity of self-reported acute respiratory tract infections were assessed by telephone with a nurse, home visits and microbiological and serological testing at 15 months.

Those participants taking the multivitamin-mineral supplements reported no increased rate or severity of infection. The vitamin E-users also did not report a greater incidence of infections, but they did suffer from greater severity compared to those who were not taking vitamin E. Among those randomized to vitamin E, illness duration was extended by five days and the number of symptoms experienced was six compared to four in non-users. Furthermore, 36.7% suffered from fever and 52.3% had their daily activities restricted, compared to only 25.2% and 41.1% of participants who did not take vitamin E respectively.

The study group concluded that neither daily multivitamin-mineral supplementation at physiological doses nor 200mg of vitamin E showed favourable effects on incidence and severity of acute respiratory tract infections in this group of elderly. Rather, they observed several adverse effects of vitamin E on illness severity. They suggested that further investigation of the effect of multivitamins and minerals in older persons with suboptimal plasma concentration of vitamins would be valuable. In the meantime, perhaps elderly people who are already well nourished should take caution when supplementing their diets with vitamin E.

Source

1. Graat JM, Schouten EG, Kok FJ. Effect of daily vitamin E and multivitamin- mineral supplementation on acute respiratory tract infections in elderly persons. JAMA 2002;288:715-21.

…and Ginkgo for Memory Enhancement

There have been many claims that the herb ginkgo, available as an over-the-counter dietary supplement, can improve memory, attention and other mental functions in as little as four weeks. Although the herb is marketed towards both those with and without significant cognitive impairments, these claims have thus far only been supported by studies of cognitively impaired clinical populations, such as patients with Alzheimer disease. A recent randomized, controlled, double-blind study now challenges earlier notions that ginkgo facilitates performance on learning, memory, attention and concentration in healthy elderly adults.

To evaluate ginkgo's potential as a memory enhancer, 230 healthy volunteers aged 60 to 82 years were randomly assigned to receive either 40mg of ginkgo or placebo three times daily with meals for six weeks. One day before randomization, and six weeks later, participants underwent neuropsychological evaluation, including tests of memory, learning, attention and concentration, and expressive language. Volunteers also provided a self-assessment of their own memory, and each of them had a close companion evaluate their overall change in memory.

After six weeks, data showed that ginkgo did not enhance performance on standard neuropsychological tests of learning, memory, naming and verbal fluency, or attention and concentration. Moreover, there were no differences between the gingko group and those taking placebo on the subjective self-reports of memory function or on the global ratings made by their companions. Both groups showed improved performance at six weeks, most likely because they became more familiar with the evaluations the second time around.

Marketers of gingko for the enhancement of memory promise positive results in four weeks. Although it is possible that the memory-boosting powers of ginkgo take longer than the six-week period used in this study, it can be concluded that healthy, elderly adults will not benefit from this supplement if they take it according to the manufacturer's suggestions.

Source

1. Solomon PR, Adams F, Silver A, et al. Ginkgo for memory enhancement: A randomized controlled trial. JAMA 2002;288:835-40.

Hope for Home Care

Hope for Home Care

To meet Ann Keane is to recognize one's self-imposed limitations. How daunting a task to leave a life behind, kiss children goodbye, and decide, one small woman, to run across Canada? Across Canada, no less?! How many of us would be willing to make that sacrifice?

Incredibly, this woman found the courage, and is currently in the middle of an epic journey, in an effort to raise awareness and funds for home care and long-term care in Canada. She is also running to publicize the Hope Foundation of Alberta, a non-profit organization that is dedicated to understanding the role that hope plays in human life.

Ann began her journey on April 19th in Newfoundland. So far she has logged over 5000 km, passing through the Maritimes, Quebec, Ontario and Manitoba, and is now on her way through Saskatchewan. She hopes to be in British Columbia by late September.

Has it been difficult? You betcha! In her online diary, Ann has described her pitting edema, excruciating fatigue, black toenails, miserable blisters, the heat and constant battles with her arch nemeses, mosquitoes, or as she calls them, 'squiters.'

Why has she chosen to do it, and why has she chosen to raise funds for home care? Ann is a nurse with over twenty years experience in long-term care and home care. She is the former director of a home care program in Alberta, ran a 200 bed auxiliary hospital, and until the beginning of this run, was a member of provincial and national health care boards. She is also a woman frustrated and angered by the token government attention and funding to this important area. In her own words: "I was tired of being a warrior, and nothing ever changing."

Credit Greg Laychak

According to a VHA Home Health care survey published in 2001, in Ontario 82% of the population is concerned about having access to home health care support as they age. Eighty-three percent of respondents to the same survey, with parents who were not currently receiving home care or institutional elder care services, fear a shortage of professional home care workers as the baby boom population retires.¹

As a recent Census report shows, they have plenty to fear. Currently, over 13% of the population is 65 years of age or older, and the fastest-growing segment of the population is that aged 80 or older. The over 80 age group has increased by 41.2% between 1991 and 2001.²

In a 1988 US survey, older adults with long-term care needs stated a clear preference for home health care.³ However, currently only 4% of the national health care budget is spent on home care. Moreover, poor morale and recruitment problems are contributing to a shortage of home care workers, who are paid on average 30% less than are their colleagues who work in more formal facilities. They also face strict limitations with their time. How is one to preserve the dignity of an elderly client, when forced to enter an apartment, bathe the client and exit, all in the space of half an hour?

Does Ann believe in her cause? Absolutely. She is completely committed to the challenge, and is determined to make this journey count. That is not to say that she has not been discouraged or disappointed. She has periodically faced an upsetting lack of media interest in her cause. For better or worse, apparently there are many people biking or blading across the country to raise money or awareness for their chosen plight. While it is heartening that so many are willing to make these sacrifices, it makes it more difficult to raise funds for such an important cause. Especially when raising those funds involves running between 50 and 80 kilometres a day!

Regardless, she runs on. Ann is nothing if not persistent, and she clearly believes deeply in her cause. If nothing else, she knows that with this run she has given absolutely everything she can and has held nothing in reserve. She hopes that this will be enough to effect a change. Let us hope that she is right!

Ann Keane can be reached at her website at www.powerofpeoplerun.com. If you are interested in donating to her cause, you can click on the donation button on the website or phone or email her Donation Manager, John Duke at (780) 469-5094 or johnduke@telusplanet.net.

Sources

1. VHA Home Healthcare. Ontarians worried about inadequate home care for seniors [Press release]. VHA Home Healthcare, April 2001, www.vha.ca/news/press.htm.
2. Statistics Canada. Census Report. www.statcan.ca/english/IPS/Data/97F0024XIE2001001.htm
3. National Survey of Caregivers: Summary of Findings. National Opinion Research Center Chicago, IL: October 1988.

A Simple Test of Leg Function

Peripheral vascular disease (PVD) of the lower extremities, also known as peripheral arterial disease (PAD), is a result of generalized atherosclerosis, and is associated with increased mortality, even in asymptomatic patients. In patients over the age of 60, the prevalence of PAD is estimated at 15% and claudication occurs in up to 5%.

A recent study suggests that a relatively simple test, the ankle brachial index (ABI), is more closely associated with leg function in patients with PAD than is intermittent claudication or other leg symptoms.

The study involved 740 men and women, 460 with PAD. Leg function was determined using accelerometer-measured physical activity over seven days, 4-metre walking velocity, standing balance and ABI. Of the 460 people with PAD, only 33% had intermittent claudication. However, compared with an ABI of 1.1 to 1.5, an ABI of less than 0.50 was associated with a shorter distance walked in six minutes, less physical activity, slower 4-metre walking velocity and less likelihood of maintaining a tandem stand for 10 minutes. The associations between leg function and ABI were stronger than were associations between leg symptoms and function.

Unfortunately, the ABI is not 100% accurate in detected PAD. In addition, in this study, many of the patients with PAD were recruited from specialized centres where they are referred for suspected PAD--people with unrecognized PAD may have different findings than do those specifically referred for diagnostic evaluation of PAD.

Nonetheless, the evidence suggests that the ABI, a simple and inexpensive procedure, is more closely associated with leg function in persons with PAD than is either intermittent claudication or leg symptoms.

Source

1. McDermott M, Greenland P, Liu K et al. The ankle brachial index is associated with leg function and physical activity: The Walking and Leg Circulation study. Ann Internal Med 2002; 136:873-83.

Targeting Human Amyloidosis

Amyloidosis is a disorder of protein folding, in which a normal soluble protein is deposited in extracellular tissue spaces. Amyloidosis has been proposed as a pathogenic mechanism associated with neurodegeneration in Alzheimer disease, with islet failure in type 2 diabetes and is also a common complication of hemodialysis for end-stage renal failure.

Although there is still no definitive evidence that accumulation of amyloid is causal for these diseases, it is believed that removal of amyloid may have a clinical effect.

Recently, a compound has been identified that may allow for breakdown of amyloid deposits. A series of experiments were designed to investigate the role of a serum amyloid P component, or SAP, protein in amyloid deposition, and to determine whether removal of SAP could facilitate amyloid breakdown. SAP is universally present in amyloid deposits, is highly resistant to proteolysis, and binding of SAP to amyloid fibrils has been demonstrated to protect them from degradation.^1,2 Plasma levels of SAP are related to amyloidogenesis, and mice with targeted deletion of the SAP gene show retarded and reduced induction of amyloidosis. Based on this evidence, the authors decided to test whether removal of SAP from amyloid could lead to the breakdown of amyloid deposits.³

Initially, researchers identified a substance, R-1-[6-[R-2-carboxy-pyrrolidin-1-yl]-6-oxohexanoyl] pyrrolidine-2-carboxylic acid (CPHPC), which inhibits SAP binding to amyloid fibres. CPHPC was found to cross-link pairs of pentameric human SAP molecules. The metabolism and excretion of CPHPC was determined and its function was tested in mouse models of amyloidosis. Continuous infusion of CPHPC over five days accelerated whole-body clearance of radiolabelled human SAP tracer, with which the amyloid deposits had previously been loaded, and removed all endogenous mouse SAP from the deposits. In addition, CPHPC provided in the drinking water to mice transgenic for a human SAP, led to significant reduction of amyloid in the treatment relative to a control group.

CPHPC was then administered for 48h by IV infusion to seven patients with systemic amyloidosis. Circulating SAP levels were rapidly and consistently depleted in all subjects. Direct evidence for depletion of SAP from amyloid was obtained by whole-body scintigraphy using 123I-labelled SAP as a tracer.

Finally, in an open-label study, CPHPC was infused intravenously into 19 patients with sytemic amyloidosis for a period of 1.2-9.5 months. Throughout treatment, plasma SAP values were reduced to 5% of pre-treatment levels in all patients, and there were no adverse clinical effects locally or systemically.

The binding of SAP stabilizes amyloid fibrils in vivo and protects them from proteolytic degradation. It is hoped that the removal of SAP will retard new amyloid deposition, reduce stability of current deposits and promote their regression. Currently, the authors are testing this hypothesis by long-term treatment of systemic amyloidosis in patients with CPHPC. It is hoped that CPHPC may be readily used not only for systemic amyloidosis, but also for diseases in which local amyloid deposits are implicated in pathogenesis.

Sources

1. Pepys MB et al. Amyloid P component. A critical review. Int J Exp Clin Invest 1997; 4:274-95.
2. Tennent GA, Lovat LB and Pepys MB. Serum amyloid P component prevents proteolysis of the amyloid fibrils of Alzheimer's disease and systemic amyloidosis. Proc Natl Acad Sci 1995; 92:4299-303.
3. Pepys MB, Herbert J, Hutchinson WL et al. Targeted pharmacological depletion of serum amyloid P component for treatment of human amyloidosis. Nature 2002; 417: 254-9.

‘Of a Certain Age': Wisdom Through the Eyes of Some Fascinating Old People

A Mark Clarfield, MD, FCFP, FRCPC

As a geriatrician, I was initially put off by the idea of a book full of interviews with famous people&emdash;just because they had attained "a certain age."

But I was wrong.

"Of a Certain Age" by Naim Attallah (Quartet Books, 1992) is well worth the read. The 14 people featured all have had fascinating pasts. They are now quite old (average age 70) and are just as--perhaps more--interesting for having aged so well.

Mostly Bruits, they represent primarily the English uppercrust--a group once described by a wag as "a bunch of crumbs held together by dough."

And some are indeed crumbs--Clause von Bulow and Lady Diana Mosely are two excellent examples. Many are wealthy, but all are worth the listen. There are professors, judges, writers, publishers and sophisticated hangers-on--all expertly interviewed by the British writer and publisher Naim Attallah.

I am not the kind of Jewish reader who divides up members of humanity depending on their attitudes towards my ethnic group. However, in this book it is difficult not to be struck by how these old grandees self-differentiate so clearly into two groups: anti- and philo-Semitic.

At one end of the spectrum stands Diana Mosely, one of the celebrated Mitford girls and the wife of Oswald Mosely, leader of the wartime British Union of Fascists. Today, she lives a quiet, unrepentant life in southern France. Her interview really is a bit awe-inspiring. In it, Lady Diana speaks in such a matter-of-fact manner about her close relations with things Nazi.

For example, relating to her friendship with Hitler. "Unity (Diana's sister) loved and adored him, thought him utter perfection. I never felt like that about him but I did admire him very much for what he had done."

Standing in stark contrast is the Irish politician, writer and editor, Conor Cruise O'Brien.

He is so unabashedly on the side of the Jews: "...[My] degree of sympathy for Israel is based on the realization that Israel is the result of horrendously extreme conditions ... it's an emotional issue with me."

A more "balanced" view is noted by many of those interviewed.

For example, Lord Deedes, an eminent Member of Parliament and publisher, in describing his father's views:

"He had what you might call the Edwardian, old Eton conscience, and I look back on him as a very respected Christian socialist. He was left of centre for what might be described as inner reasons rather than ideology.

"There was one period, for example, when he bought every book he could lay his hands on about Mussolini. There was an endearing enthusiasm about my father's political beliefs and in the early stages he even thought Hitler might do Germany a bit of good."

Another experience, which so many of these famous oldsters seem to have in common, was that of an unhappy childhood and/or a fearful disdain for their parents. Return for a moment to Lady Mosely, not unlike many children of her time and class: "In a way, the person who meant most to me ... was my nanny. I loved her far more than I did my parents.."

[Far more bizarre experiences seemed to have "dogged" young Diana. In answer to a question relating to her father who on occasion would chase the children with the family canine: "I don't think that he was nearly as eccentric as people imagine. You see, he had a bloodhound, and it was rather fun to hunt with him. And we children were there, available…"

She goes on to reassure us that "he didn't hunt us very often... and in any case the bloodhound died."]

A less bizarre, but equally characteristic description of the childhood suffered by so many of the upper class comes from Lord Deedes. He is ashamed "to this day" that his relationship with his own son did not differ significantly from the cold and distant rapport Lord Deedes had with his own father.

"Frankly I was neglectful and I treated my children as my father treated me." And so typical of his generation and class: "...of course, there were nurses and governesses to look after them."

The oh-so-Anglo temperament of these old-timers is much in evidence. Their command of the Queen's English is one of the delights of the book. (And keep in mind that these are merely interviews.) For example, take Lord Deedes once again. In describing a pessimistic view of mankind, he characterizes our species as "being born to trouble as the sparks fly upwards."

There are also many examples of the classic British use of understatement. One of those interviewed, by any estimate a brilliant and supremely accomplished man, is asked a question about his weaknesses. The response: "Every now and again, I get mildly alarmed at the extent to which someone of my rather limited intellectual capacity has succeeded in doing certain things."

The interviewees in the book are all old people and surprisingly, a few have some interesting things to say about aging. One elderly lady talks about a fear greater than that of dying itself: her concerns relating to the manner of her death.

"I'd like to be somebody with a weak heart and then I could simply have a heart attack. But alas, it won't be like that."

Publisher John Murray is asked if he is more or less certain of his opinions as he ages. He responds, "Less sure" and goes on to offer a beautiful quote by Goethe on the subject:

"To be uncertain is uncomfortable, to be certain is ridiculous."

He offers another tasty little quote on the subject of aging: "Man is not old when his teeth decay. Man is not old when his hair turns grey. But man is approaching his last long sleep when his mind makes appointments his body cannot keep."

On the question of the possibility of an afterlife, one that I am sure becomes more pressing with age, Lord Shawcross (chief British prosecutor at the Nuremberg trials) offers the following delightful response:

"It may be that as I get nearer the end [he was 90 at the time of the interview], I become more hopeful that the end will not be final, that there might be something beyond it. But it doesn't absorb much of my thinking even now. All I can say is that I have a little hope that I may meet 'round the corner' those who have preceded me."

The same Lord Shawcross goes on to confirm my non-clinical impression that mourning for a beloved spouse often goes on much longer than is commonly supposed, even among those who are well adjusted:

"My enthusiasm for life did rather come to an end with the death of my second wife, which did come as a terrible shock to me."

And, in response to whether he believes he will ever see her again: "I hope I may. I carry in my pocketbook, even today, something that one sees quoted much more often in memorial services: 'Death is nothing at all. I have only slipped away into the next room. I am I and you are you. What we were to each other we are still. Call me by my familiar name.'

Not surprisingly, given the age of those interviewed, some will have had some interesting childhood memories of people long dead, and places inexorably changed. A particularly evocative example relates to John Murray (the sixth in a line of namesake publishers).

His grandfather (John Murray IV) was ill and young John was a schoolboy home on holiday. Grandad mentioned that a distinguished author was coming to visit.

John IV to John VI: "I think Sir Arthur Conan Doyle is calling today. Will you be kind to him? I hope he may be bringing another typescript."

Conan Doyle did, in fact, come that day, to deliver the very last volume of the Sherlock Holmes stories, and, "I was so staggered by this distinguished man's courtesy to a young whippersnapper like me that I thought: if this is an author, let me spend my life with authors."

And he did.

Also on the issue of aging, we read one of the funniest lines in the book. Lord Soper is quoted as stating that the continued existence of the House of Lords has, among other things, reaffirmed his belief in life after death.

The question for Canadian readers, of course, is whether milord's comments are relevant to our own Upper House.

One of the most poignant expressions, also by Lord Soper, happens to be contained in the last two sentences of the book. In answer to whether he had any regrets, his Lordship responds: "An infinite number. At my age one's sense of failure in the past is an interesting and solemnizing experience. You haven't much time in which to put things right. Which makes me say better prayers than I used to."

This book is a lovely read. Especially if you are interested in the wisdom (and sometimes cant) of an extraordinary stable of old people who aged along with the past century.

Dr. Clarfield, MD, FRCSC, is the Chief of Geriatrics, Soroka Hospital Centre, a Professor and Sidonie Hecht Chair of Gerontology, Faculty of Health Sciences at Ben Gurion University of the Negev in Beersheva, Israel , and an Adjunct Professor in the Division of Geriatric Medicine, McGill University and Jewish General Hospital, Montreal, QC.

Geriatrics and Aging Readership Survey Results 2002

It has been an exciting year at Geriatrics & Aging, with the formation of new alliances and major changes to the publication, including the move to a journal size format and the new indexing on the AgeLine database.

Last year, we conducted our first ever readership survey to determine how you felt about the quality and content of the publication. Thanks to last year's respondents, we were able to make big improvements to the publication for the current year.

This year, we asked how you felt about the changes that have been made. I am happy to report that the feedback was very positive, with many people particularly pleased with the change to a more 'user-friendly' journal size format. We were also excited to see that the majority of respondents regularly use our publication for making clinical decisions and consider the quality of the content as Very Good or Excellent. Feedback like this makes our jobs that much easier!

However, we were disappointed to find out that many of you were not aware that all of our clinical content is available on our website at www.geriatricsandaging.ca. Articles are indexed by topic, author and keyword, and content goes back to our first year of publication. We have also recently added a new Message Boards section, where visitors can ask questions, or participate in discussions. Drop by the site and take a look!

As promised, all respondents to the survey were entered into a draw for prizes and the winners have been selected. Insert drum-roll here please! The lucky Grand-prize winner of $1000 for the 2002 Geriatrics & Aging Reader's Survey is Dr. Roger Bunn, of Brampton, Ontario. Dr. Bunn's administrative professional Irene Theodoropolous will also walk away with $100. In close second is Dr. Jeff Tschirhart of Simcoe, Ontario, who wins $500, with $100 in prize money going to Vicki McKnight. Last, but certainly not least, is Dr. Christena Côté of Halifax, Nova Scotia and her administrative professional Marilyn Healey, who win $200 and $100, respectively. Congratulations to all of our winners!

We would also like to take this opportunity to thank everyone who participated in the readership survey. We also encourage you to contact us on a regular basis with any comments or suggestions you may have. To those of you who responded but didn't win …don't despair, you'll have another shot at the big money next year!