Shabbir M.H. Alibhai, MD, MSc, FRCP(C), Staff Physician, University Health Network, Toronto, ON, Canada, Assistant Professor, Departments of Medicine and Health Policy, Management, and Evaluation, University of Toronto, Research Scientist, Canadian Cancer Society

Abstract
More than one-half of new cancers and over 70% of cancer deaths occur in adults age 65 or older. Systematic screening has been associated with reductions in cancer- related mortality for a variety of cancers, including breast, cervical, and colorectal cancer. Prostate cancer screening remains more controversial despite the recent publication of two large randomized trials of screening. Although guidelines are beginning to address cancer screening specifically among the growing group of seniors age 70 or older, there is virtually no guidance on estimating remaining life expectancy or considering competing causes of mortality (e.g. comorbid medical illness) in this age group. In this article, I review evidence-based guidelines for cancer screening in adults and discuss the limitations of screening studies with respect to older adults. I have also highlighted new evidence and substantive updates to guidelines since the last publication on cancer screening in Geriatrics & Aging five years ago.

Keywords: cancer screening, aged, mass screening.

Wey Leong, MSc, MD, Department of Surgical Oncology, Princess Margaret Hospital, University Health Network, University of Toronto, ON.
Alexandra M. Easson, MSc, MD, Department of Surgical Oncology, Princess Margaret Hospital and Mount Sinai Hospital, University of Toronto, ON.
Michael Reedijk, PhD, MD, Department of Surgical Oncology, Princess Margaret Hospital, University Health Network, University of Toronto, ON.

Melanoma must be considered in the differential diagnosis of any skin lesion in older adults. With the incidence of melanoma increasing in general and even more so among older people, more older adults are being diagnosed with melanoma than in the past. Among older adults, melanomas display more aggressive histological features with worse prognosis and treatment outcomes than among younger individuals. Furthermore, older individuals have fewer surgical and medical treatment options because of age-associated comorbidities. This article reviews the epidemiology and management of melanoma with emphasis on the older adult population.
Key words: older adults, melanoma, aged, cancer, skin neoplasm.

Børge Sivertsen, PhD, Department of Clinical Psychology, University of Bergen, Bergen, Norway.

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.

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

Shabbir M.H. Alibhai, MD, MSc, FRCPC, Department of Medicine, University Health Network; Department of Medicine and Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON.

More than one-half of new cancers and over 70% of cancer deaths in industrialized nations occur in adults age 65 or older. Systematic screening has been associated with reductions in cancer-related mortality for a variety of cancers, including breast, cervical, and colorectal cancer. While increasing numbers of older adults are living beyond 70, few guidelines address cancer screening in this group of older adults. In this article, evidence-based guidelines are reviewed for cancer screening in adults and limitations of screening studies with respect to older adults are discussed. A framework for deciding when to stop cancer screening in older adults is presented based on estimating remaining life expectancy, which incorporates age, comorbidity, and functional status.
Key words: cancer screening, aged, mass screening, overdiagnosis, cancer mortality.

Conan Kornetsky, PhD, Professor of Psychiatry and Pharmacology, Boston University School of Medicine, Boston, MA, USA.

There is a common belief, supported by considerable experimental reports, that the aged have higher pain thresholds than the young and are more responsive to the analgesic actions of opiate drugs. To a considerable degree this belief shapes pain treatment in aged adults. This article reviews the evidence for this belief and discusses why there is often a disparity between the reported alleviation of pain in older adults and the widely held belief that these individuals receive inadequate pain management. Among the issues discussed is the amount of control the patient really has in patient-controlled analgesia.

Key words: pain, aged, analgesia, pain measurement, morphine.

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.htm

Lonn Myronuk, MD, FRCPC, Member of the Canadian Academy of Geriatric Psychiatry, President, GeriPsych
Medical Services, Inc., Parksville, BC.

Depressive symptoms in older adults are common and are associated with subjective distress, increased rates of functional impairment, and death. The natural history of depression in the aged appears to differ from that of the younger population, such that conventional criteria for diagnosis of a major depressive episode may not be met by the older patient. Yet, these subsyndromally depressed patients have equivalent levels of disability and risk of morbidity and mortality. Current thinking advises the inclusion of subsyndromal patients in treatment for depression, in contrast to earlier recommendations.

Key words: aged, depressive disorders, morbidity, mortality.