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aging

Importance and Management of Low Levels of High-density Lipoprotein Cholesterol in Older Adults - Part I: Role and Mechanism

Importance and Management of Low Levels of High-density Lipoprotein Cholesterol in Older Adults - Part I: Role and Mechanism

Teaser: 

Gustavo A. Cardenas, MD, Carl J. Lavie, MD and Richard V. Milani, MD, Department of Cardiology, Ochsner Medical Institutions, New Orleans, LA, USA.

There is growing evidence that risk factors, which predict cardiovascular disease in younger people, are also predictive in older adults. Given the huge burden of cardiovascular disease in this latter population, older adults should not be excluded from primary or secondary prevention strategies, such as management of dyslipidemia. Low levels of high- density lipoprotein cholesterol (HDL-C) have a stronger association with cardiovascular disease than do high levels of low-density lipoprotein cholesterol (LDL-C). This article focuses on the importance of HDL-C as a risk factor for older patients, the evidence that exists supporting this association, the factors associated with low levels of HDL-C, and the mechanisms by which low HDL-C is related to an increased risk of cardiovascular diseases.
Key words: high-density lipoprotein cholesterol, aging, older adults, dyslipidemia, lipoprotein, atherosclerosis, cardiovascular disease.

Age-related Cardiorenal Changes and Predisposition to Congestive Heart Failure

Age-related Cardiorenal Changes and Predisposition to Congestive Heart Failure

Teaser: 

Michihisa Jougasaki, MD, PhD, Institute for Clinical Research, National Hospital Kyushu Cardiovascular Center, Kagoshima, Japan.

Congestive heart failure (CHF) has become an increasingly important health care issue in the older population. The prevalence of cardiovascular diseases such as hypertension, coronary artery disease and valvular heart disease increase with advancing age. In addition, age-related structural and functional changes in the cardiovascular system, such as impaired ventricular diastolic relaxation, altered energy metabolism, decreased sympathetic nervous activities and increased systemic vascular resistance, predispose older people to the development of CHF. Renal function decreases in older people, and the adequacy of renal function is important in delaying progression of CHF. Renal condition should be carefully monitored to prevent adverse effects in the treatment of CHF in older patients.

Key words: heart failure, renal function, aging, heart, kidney.

Appropriate Management of Temporomandibular Disorders in the Elderly

Appropriate Management of Temporomandibular Disorders in the Elderly

Teaser: 

Benjamin R. Davis, BSc, DDS, FRCD(C), Department of Oral and Maxillofacial Surgery, Queen Elizabeth II Health Sciences Centre, Halifax, NS.

Temporomandibular disorders (TMDs) are common and can be divided into either muscular or intra-joint conditions. With advancing age, the craniomandibular complex undergoes changes that are similar to other musculoskeletal structures. Many of these changes may explain the decrease in incidence of TMDs seen in the older population. Conservative treatment is usually effective at decreasing TMD pain and improving function. A small percentage of patients will benefit from surgery when appropriate conservative measures have failed, and an intra-joint etiology has been definitively established.
Key words: temporomandibular disorders, aging, facial pain, temporomandibular joint surgery.

The Morphology of the Aging Heart

The Morphology of the Aging Heart

Teaser: 

Jagdish Butany, MBBS, MS, FRCPC and Manmeet S. Ahluwalia, MBBS, Department of Pathology, Toronto General Hospital, University Health Network, Toronto, ON.

With advancing age, the cardiovascular system undergoes subtle but progressive changes that result in altered function. The endocardium becomes thicker and opaque, left ventricular (LV) wall thickness increases and there is increased interstitial fibrosis in the myocardium. Although myocyte size increases, the number of myocytes decreases, as does the number of cells in the conduction system. The decrease in the filling rate of LV in early diastole is accompanied by a greater rate of filling in late diastole augmented by atrial contraction. Maximum achievable heart rate and ejection fraction (with exercise) decreases. All these changes make increasing age a significant independent risk factor for heart failure, the most common reason for hospitalisation in patients older than 65 years.
Key words: aging, cardiovascular disease, myocardium, fibrosis, heart failure.

Vitamin B12 Deficiency in the Elderly

Vitamin B12 Deficiency in the Elderly

Teaser: 

12 Deficiency in the Elderly

Sudeep S. Gill, MD, FRCP(C), Research Fellow, Division of Geriatric Medicine, University of Toronto and Kunin-Lunenfeld Applied Research Unit, Baycrest Centre for Geriatric Care, Toronto, ON.
Shabbir M.H. Alibhai, MD, MSc, FRCP(C), Staff Physician, Department of Medicine, University Health Network, Toronto, ON.

Vitamin B12 deficiency is a common disorder in older adults, but its diagnostic work-up and management can be complex. In this article, we review the metabolic pathways involving vitamin B12 and the various pathologies that can interfere with these pathways. This discussion provides a framework to understand the following section, which outlines an approach to the clinical examination, laboratory evaluation and treatment of subjects with suspected vitamin B12 deficiency.
Key words: vitamin B12, folic acid, deficiency diseases, dementia, aging.

The Impact of Aging on the Liver

The Impact of Aging on the Liver

Teaser: 

David Stell, PhD, FRCS(Gen) and William J. Wall, MD, FRCS(C), Department of Surgery and Multi-Organ Transplant Program, London Health Sciences Centre, London, ON.

The process of aging does not produce changes in the liver that can be described as pathological. The major age-related alterations are a reduction in liver mass and a reduction in total blood flow, neither of which interferes with the liver's normal homeostatic functions. In spite of the liver's resilience, however, the aged liver is more vulnerable to injury from toxins, viruses and ischemia, and its capacity to regenerate is slowed. There also is a decline in liver enzymes with aging that affects metabolic clearance of drugs, a finding that has implications for drug dosing in the elderly.
Key words: liver, aging, function, metabolism, injury.

Aging and the Male Gonads

Aging and the Male Gonads

Teaser: 

 

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.

The Neurological Examination in Aging, Dementia and Cerebrovascular Disease Part 2: Motor Examination

The Neurological Examination in Aging, Dementia and Cerebrovascular Disease Part 2: Motor Examination

Teaser: 

Part 2: Motor Examination

David J. Gladstone, BSc, MD, Fellow, Cognitive Neurology and Stroke Research Unit, Sunnybrook and Women's College Health Sciences Centre, 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 (featured in the September issue of Geriatrics & Aging) began with an approach to the neurological examination in normal aging and in disease, and reviewed components of the general physical, head and neck, neurovascular and cranial nerve examinations relevant to aging and dementia. Part 2, featured here, covers the motor examination with an emphasis on upper motor neuron signs and movement disorders.

The Neurological Examination in Aging, Dementia and Cerebrovascular Disease

The Neurological Examination in Aging, Dementia and Cerebrovascular Disease

Teaser: 


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.

The Aging Skin

The Aging Skin

Teaser: 

The weekend prior to my writing this editorial, skin was featured prominently in the Sunday New York Times magazine. However, the articles were more like a commentary on society than a treatise on skin care. One article concentrated on plastic surgeons and how their major interventions were now nonsurgical and focused on skin. Botox (botulinum toxin) injections, collagen injections and dermabrasion procedures were reported as being more commonly performed by plastic surgeons than their previous mainstays: breast augmentation and liposuction. One surgeon commented on how advances in science had improved the field of cosmetic surgery, such that face-lifts, in particular, were no longer required. Several seemed inordinately proud of the recent publication (as yet unverified) that stem cells could be isolated from fat cells harvested by liposuction. The second article talked about the New York dermatologist who helped popularize Botox injections. It mentioned her indulgent life style, by extension making her procedure seem indulgent as well.

However, skin is not just a cosmetic organ. As our largest organ, it is vital to our health, and serious diseases of the skin are not uncommon. The elderly are particularly prone to these diseases and accurate diagnosis and management are important. Dr. Lester discusses Bullous Pemphigoid, a serious blistering disease that is almost exclusively seen in the elderly. Recent studies have expanded the treatment options for this condition. Skin cancer is also more common in the elderly, at least partially because of longer exposure to the sun. Dr. John Adam of Ottawa discusses this topic in detail. Dr. Scott Murray tackles the ubiquitous, but challenging, problem of dry skin in the elderly. Skin manifestations of systemic illness are also very common in the elderly, and the dynamic duo of Dr. Gary Sibbald and Dr. Madhuri Reddy address the topics of pressure ulcers and diabetic foot ulcers.

Also in this issue is an article by Cynthia Westerhout and Eric Boersma, from the Department of Cardiology at the University Hospital Rotterdam and the University of Alberta on glycoprotein IIb/IIIa in percutaneous coronary intervention. This is one of those areas where basic science investigations (in this case, on platelet function) rapidly led to important therapeutic advances.

When I saw Dr. Chris MacKnight's article on acetylcholinesterase inhibitors in the treatment of Dementia with Lewy Bodies, I thought of a chart review I had just completed on a patient (not mine) who had died in hospital. When looking at the entire chart, it was obvious that the patient's confusion with fluctuating course, Parkinsonism and falls were likely secondary to this disorder, but the diagnosis was not made. There is now solid evidence that this disorder is common and can be diagnosed reasonably accurately (e.g. data from Bristol, UK). Unfortunately, there is also evidence that in most places the diagnosis is not made accurately (neither specific nor sensitive). As therapy for this disorder evolves, accurate diagnosis will be vital to ensure that our patients benefit.

Finally, Dr. Rory Fisher, Director of the Regional Geriatric Program of Metropolitan Toronto, has contributed an excellent article on the role of specialized geriatric services in acute hospitals.

In response to last year's readership survey, the next issue will focus on Nutrition in the elderly. We'll also announce the prize winners from this year's survey. Remember to look for your name!

Enjoy this issue.