Chorea is a hyperkinetic movement disorder characterized by nonsustained, rapid, and random contractions that may affect all body parts. Chorea is hypothesized to be due to an imbalance between the direct and indirect pathways in the basal ganglia circuitry. Important causes of chorea among older adults include medications, stroke, and toxic-metabolic, infective, immune-mediated, and genetic causes. The history and clinical examination guide appropriate investigations and help determine an accurate diagnosis. In secondary causes, removal of the precipitating cause is the mainstay of treatment. If the chorea is persistent or progressive, drug therapy may be instituted. Genetic counselling is important in hereditary chorea.
Key words: movement disorders, chorea, older adults, diagnosis, treatment.
Heart failure (HF) is the leading cause of hospitalization among older adults. Digoxin has been shown to reduce hospitalization due to worsening HF. However, at the commonly prescribed dose of 0.25 mg/day, digoxin does not reduce mortality. New data suggest that at low doses (0.125 mg/day or lower) digoxin not only reduces hospitalization due to HF, but may also reduce mortality. Further, at lower doses, it also reduces the risk of digoxin toxicity and obviates the need for routine serum digoxin level testing. Digoxin in low doses should be prescribed to older adults with symptomatic HF.
Key words: chronic heart failure, older adults, treatment, digoxin, update.
Stroke is a common disease in the older population. Many gender differences are seen in the epidemiology, outcomes, and treatment of geriatric stroke. Although these differences are not fully understood, recognition of gender differences may help with appropriate treatment and improve outcomes.
Key words: stroke, gender, outcomes, prevention, treatment.
Depression is a common sequela of stroke, occurring in approximately 33% of all patients. Post-stroke depression (PSD) is associated with greater cognitive and functional impairments, excess mortality, and increased health care costs, although symptoms are often mild. Diagnosis of PSD can be made using standard clinical criteria, despite the potential overlap with the somatic and vegetative symptoms of stroke. Post-stroke depression responds to standard antidepressant pharmacotherapies, but use of tricyclic antidepressants may result in increased cardiac adverse events. Given the high prevalence and major negative impact of PSD, active screening of all stroke patients for depression and aggressive treatment is recommended.
Key words: stroke, depression, diagnosis, risk factors, treatment.
Chronic primary insomnia is a sleep disorder with no known secondary etiology, and the prevalence increases with advancing age. Insomnia is associated with a range of adverse consequences, both on an individual and societal level. While pharmacotherapy is still the most common form of treatment of late-life insomnia, it is associated with a number of side effects, and recent evidence shows cognitive-behavioural therapy (CBT) to be more effective in managing chronic primary insomnia. This article will discuss the development, consequences, assessment and treatment of chronic primary insomnia among older adults.
Key words: sleep initiation and maintenance disorders, aged, morbidity, treatment, insomnia.
Skin ulcers are common among older adults, especially those in hospital or in long-term care facilities. Prevention of ulcers is important in all clinical settings. Clarifying the cause(s) and exacerbating factors is the first step in management. Pressure and venous insufficiency are the most common causes among older adults. Poor nutrition, edema, arterial insufficiency, and anemia may impair wound healing. Adequate debridement and cleaning is important to decrease infection risk and to promote healing. The choice of dressings depends on the needs of the individual wound but should emphasize the provision of a moist wound environment. Options for dressings are summarized.
Key words: skin ulcers, treatment, wound healing, older adults, pressure ulcers.
Multiple system atrophy (MSA) is a sporadic neurodegenerative disorder characterized clinically by various combinations of parkinsonian, autonomic, cerebellar, or pyramidal signs and pathologically by cell loss, gliosis, and a-synuclein-positive glial cytoplasmic inclusions in several brain and spinal cord structures. The clinical recognition of MSA has improved, and the recent consensus diagnostic criteria have been widely established in the research community as well as in movement disorders clinics. Although the diagnosis of this condition is largely based on clinical expertise, several investigations have been proposed in the last decade to assist in early differential diagnosis. Symptomatic therapeutic strategies are still limited.
Key words: multiple system atrophy, clinical presentation, diagnosis, treatment.
Mild Cognitive Impairment (MCI) describes a state of abnormal cognitive functioning that is insufficient to warrant a diagnosis of dementia. While dementia requires that activities of daily functioning be compromised due to cognitive symptomology, the diagnosis of MCI can be made earlier, in the absence of such functional impairment. In MCI, the patient must present with cognitive complaints (or someone who knows the patient well must present them on the patient's behalf), and these complaints must be corroborated by abnormalities on standardized cognitive testing. The diagnosis of MCI alerts the clinician to a higher risk of future development of dementia and provides an ideal target population that may benefit the most from “disease-modifying” cognitive therapies currently in development.
Key words: mild cognitive impairment, MCI, Alzheimer’s disease, dementia, early diagnosis, treatment.
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