The accredited CME learning activity based on this article is offered under the auspices of the CE department of the University of Toronto. Participating physicians are entitled to one (1) MAINPRO-M1 credit by completing this program, found online at www.geriatricsandaging.ca/cme

David B. Hogan MD, FACP, FRCPC, Professor and Brenda Strafford Chair in Geriatric Medicine, University of Calgary, Calgary, AB.

A number of agents are available for treatment of Alzheimer’s disease (AD). They include drugs with a specific indication for AD, nutritional supplements, herbal preparations, and drugs approved for other conditions. Cholinesterase inhibitors (ChEIs) such as donepezil, galantamine, and rivastigmine are modestly effective for mild to moderate stages of AD. Memantine has a slight, beneficial effect on moderate to severe stages of AD. As ChEIs and memantine have different mechanisms of action, they can be used together. Antioxidants, B vitamins, anti-inflammatories, HMG-CoA reductase enzyme inhibitors, and sex steroids can not be recommended for the treatment of AD at the present time.
Key words: Alzheimer’s disease, drug therapy, cholinesterase inhibitors, memantine, dementia.

Anita W. Asgar, MD, FRCPC, Interventional Cardiology Fellow, Montreal Heart Institute, Montreal, QC.
Renee L. Schiff, MD, FRCPC, Echocardiography Fellow, Montreal Heart Institute, Montreal, QC.
Reda Ibrahim, MD, CSPQ, FRCPC, Interventional Cardiologist, Montreal Heart Institute, Associate Professor of Medicine, Universite de Montreal, Montreal, QC.

Hypertension is a common health concern among older adults and constitutes an important risk factor for cardiovascular disease. Despite its prevalence, it is a constant management challenge. We review four aspects of hypertension management that have been of interest over the past year.
Key words: hypertension, diabetes, drug therapy, gender differences, resistant hypertension.

Alan D. Bell, MD, Department of Family and Community Medicine, Humber River Regional Hospital, Toronto, ON.

Douglas C. Conaway, MD, Section of Rheumatology, Carolina Health Specialists, Myrtle Beach, SC, USA.

Recent disclosures of cardiovascular safety issues with medications that have become mainstays of osteoarthritis management have compelled clinicians to reconsider treatment approaches. This new information must be taken into account along with the well-known risk of gastrointestinal complications associated with nonsteroidal anti-inflammatory drugs. Consequently, clinical management of osteoarthritis pain in older patients requires careful evaluation and consideration of the individual patient’s risk factors. Co-therapy with proton pump inhibitors has demonstrated reductions in endoscopic gastropathy, but clinical outcome trials are lacking. For all treatment decisions, monitoring of patients’ responses to therapy is crucial for optimizing long-term safety and efficacy outcomes.

Key words: osteoarthritis, drug therapy, nonsteroidal anti-inflammatory drugs, cyclo-oxygenase-2 inhibitors.

Amit Morris, BSc, School of Medicine, Queen’s University, Kingston, ON; Department of Psychiatry, Sleep and Alertness Clinic, Toronto Western Hospital, University of Toronto, Toronto, ON.

Henry J. Moller, MD, FRCP(C), DABSM, Department of Psychiatry, Sleep and Alertness Clinic, Toronto Western Hospital, University of Toronto, Toronto, ON.

Colin M. Shapiro, MBBCh, PhD, FRCP(C), Department of Psychiatry, Sleep and Alertness Clinic, Toronto Western Hospital, University of Toronto, Toronto, ON.

Chronic insomnia is common among older adults and has significant negative consequences for health and well being. A comprehensive approach to treatment begins with identification and management of any underlying conditions. Treatment of insomnia includes both non-pharmacologic and pharmacologic options. Non-pharmacologic approaches form the foundation of treatment; hypnotic medications can also be effective but may be associated with adverse drug effects. Zopiclone and zaleplon appear to be associated with fewer side effects than benzodiazepines.

Key words: insomnia, older adults, drug therapy, behavioural therapy, hypnotics.

Sheldon Tobe, MD, FRCP(C), Assistant Professor of Medicine, Nephrology, University of Toronto; Division Director Nephrology, Sunnybrook & Women's College Health Sciences Centre, Toronto, ON.
Sudha Cherukuri, MD, DNB(Nephrology), Clinical Fellow, University of Toronto, Toronto, ON.

Isolated systolic hypertension (ISH) is a common disorder in the elderly. Several studies have shown a constant positive and graded association between the level of systolic blood pressure and subsequent mortality from cardiovascular disease and stroke. ISH is defined as an elevated systolic pressure above 160mmHg and a diastolic pressure below 90mmHg. Arterial stiffening is the main cause of increasing systolic pressure in the elderly. The finding of high systolic blood pressure with diastolic below 90mmHg is a marker of higher cardiovascular risk and an indication to follow this patient more closely. The placebo-controlled SHEP and Syst-Eur trials have demonstrated that the treatment of ISH with diuretics or long-acting calcium channel blockers results in a marked reduction in cardiovascular events and stroke.
Key words: hypertension, isolated systolic hypertension, clinical trials, drug therapy, elderly.

Julie Dergal, MSc,
Baycrest Centre for Geriatric Care

Paula A. Rochon, MD, MPH, FRCPC
Baycrest Centre for Geriatric Care,
Assistant Professor of Medicine,
University of Toronto

Introduction
Older people often have multiple health conditions that require drug therapy. In Ontario in 1998, drug expenditure by people aged >65 years of age was estimated at 1.03 billion dollars, accounting for 74% of total drug costs to the Ontario Drug Benefit (ODB) Program. Prescribing drug therapy for older people presents a challenge to many physicians. Inappropriate prescribing such as the excessive and unnecessary use of drug therapy or the under prescribing of proven beneficial therapy, appears to be a common problem. Several factors place older people at risk for serious drug complications including advanced age, frailty, and increased drug use. Long-term care residents are a particularly vulnerable population, as they are primarily, older, frail women, who take an average of eight medications. Drug-related problems, including reaction to medication, are estimated to account for as many as 28% of hospital admissions.¹ With an increase in the aged population, and the associated increasing drug costs, it is imperative that older people receive optimal pharmacotherapy. Reducing drug related morbidity and mortality is, therefore, important both to improve the quality of life of older people, and to reduce health care costs.

Shechar Dworski, MSc

Aspirin has been the traditional drug of choice for preventing cardiovascular events in cerebrovascular, cardiovascular, and peripheral vascular disease. However, many recent studies comparing aspirin to ticlopidine and clopidogrel in terms of efficacy and side effects, have produced results which favor these new antiplatelet drugs. Clopidogrel is the newer of the two drugs, and consequently, fewer studies have been done with it. Still, clopidogrel has shown promise as an alternative to ticlopidine; it is safer and has similar efficacy. However, studies are lacking to show that clopidogrel works equally well in all possible clinical situations, whereas ticlopidine's effectiveness has been proven in settings such as post-coronary stent insertion. Nevertheless, studies done with clopidogrel have shown it to be useful in many instances, such as secondary prevention after an initial cerebrovascular (TIA/ stroke) event. Most studies compare the two drugs against aspirin, but not directly against each other. Even so, it has become clear that clopidogrel produces fewer side effects, and is safer than ticlopidine. This article will present some of the information available about these two drugs to help the reader decide which antiplatelet agent to use.