Mary A. Corcoran, OTR, PhD, Professor of Clinical Research and Leadership, The George Washington University, School of Medicine and Health Sciences, Washington, DC, USA.

There is an average delay of 20 months between the first recognition of symptoms of Alzheimer’s disease or a related disorder (ADRD) and the seeking of physician help. One reason for this delay is tendency for families to miss early symptoms until the onset of behavioural disturbances. Families may provide more timely accounts with prompted questions. It is important to diagnose cognitive impairment early since there are potential benefits to early treatment. The purpose of this article is to help guide caregivers in identifying a list of symptoms that reflect first indicators of ADRD, based on a study of 68 spouse caregivers of patients with ADRD.
Key words: Alzheimer’s disease, dementia, caregivers, diagnosis, primary care.

Susan B. Jaglal, PhD, Toronto Rehabilitation Institute Chair, Associate Professor, Faculty of Medicine, Department of Physical Therapy, University of Toronto, Toronto, ON.

A wrist fracture is associated with an increased risk of another fracture and should prompt investigation for osteoporosis in both men and women. If the fracture was caused by low trauma (a fall from a standing height or less), a bone density test should be ordered. If the T score is <–1.5, pharmacological treatment with a bisphosphonate and calcium (1,500 mg/d) and vitamin D3 (≥800 IU/d) is recommended. Management should also include balance, posture, and muscle-strengthening exercises and walking, as well as a review of fall-prevention strategies.
Key words: wrist fracture, osteoporosis, diagnosis, treatment, exercise, falls.

Mohammed O. Rahman, BHSc student, McMaster University, Hamilton, ON.
Aliya Khan, MD, FRCPC, FACP, FACE, Professor of Clinical Medicine, McMaster University, Hamilton, ON, Director, Calcium Disorders Clinic, St. Joseph’s Healthcare, Hamilton; Director, Oakville Bone Center, Oakville, ON.

Osteoporosis is a skeletal disease characterized by impaired bone strength and an increased risk of fragility fracture. Effective screening should be aimed at evaluating risk factors for osteoporosis with identification of individuals at risk, allowing for intervention prior to fragility fracture. This article presents an overview of the risk factors for fracture in men and women and the integration of these factors in various models, enabling an assessment of the 10-year fracture risk. Through effective screening, early identification, and early intervention with pharmacological therapy of osteoporosis, significant impact can be made on reducing fragility fracture incidence, thereby alleviating the economic and clinical costs to our health care system.
Key words: osteoporosis, screening, risk factors, diagnosis, FRAX.

John R. Wherrett, MD, FRCP(C), PhD, Professor Emeritus, Division of Neurology, University of Toronto; consultant in Neurology, Toronto Western Hospital and Toronto Rehabilitation Institute; member, Memory Clinic, Toronto Western Hospital, Toronto, ON.

Nonneurologist practitioners faced with the diagnosis of dementia cannot be expected to conduct the detailed assessments for which neurologists are trained. Nonetheless, they should be able to diagnose the most common forms of neurodegenerative dementia and identify individuals that require more detailed neurologic workup. A neurologic examination algorithm is described that allows the practitioner, in a stepwise and efficient manner, to elicit findings that distinguish the main categories of neurodegenerative and vascular dementia, namely, Alzheimer’s disease, dementia with Lewy bodies, vascular dementia, and frontotemporal lobar degenerations. Patients are assessed for gait, frontal signs, signs of parkinsonism, signs of focal or lateralized lesions, neuro-ophthalmologic signs, and signs characteristic of frontotemporal lobar degeneration.
Key words: neurologic, examination, neurodegenerative, dementia, diagnosis, gait, frontal dysfunction, cognitive impairment.

Bhaskar Ghosh, MD, DNB, DM, MNAMS, Movement Disorders Program, Department of Clinical Neurosciences, University of Calgary, Calgary, AB.
Oksana Suchowersky, MD, FRCPC, FCCMG, Movement Disorders Program, Department of Clinical Neurosciences; Department of Medical Genetics, Faculty of Medicine, University of Calgary, Calgary, AB.

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.

The burden of heart failure is rapidly rising. Heart failure is associated with substantial mortality, morbidity, and economic cost, which disproportionately affect older adults. Heart failure among older individuals is frequently complicated by geriatric syndromes, including frailty, functional decline, cognitive impairment, and atypical clinical presentations. Understanding the nature of these geriatric syndromes and their impact on the assessment and management of heart failure is a critical component to diagnosing and delivering appropriate care to these patients. In this article we review the geriatric aspects of heart failure.
Key words: geriatric syndrome, heart failure, older adults, diagnosis, frailty.

MC Faes, MD, MSc, Department of Geriatric Medicine, University Medical Centre Nijmegen, The Netherlands.
MG Spigt, PhD, Department of General Practice/Research Institute CAPHRI, University of Maastricht, The Netherlands.
MGM Olde Rikkert MD, PhD, Department of Geriatric Medicine, University Medical Centre Nijmegen, The Netherlands.

Homeostasis of fluid balance is an important prerequisite for healthy aging. The high prevalence of disturbances of fluid balance among older adult patients has triggered clinical research on age- and disease-related changes in water homeostasis. Empirical findings on risk factors of dehydration and on diagnostic and therapeutic strategies are reviewed in this paper. No single measure has proved to be the gold standard in the diagnosis of dehydration. Diagnosing dehydration and monitoring fluid balance requires repeated measurements of weight, creatinine, and physical signs such as tongue hydration. Rehydration and prevention requires fluid on prescription (> 1.5 litre/day), and the route of fluid administration depends on the acuteness and severity of clinical signs.
Keywords: older adults, dehydration, fluid therapy, risk factors, diagnosis.

Lana S. Rothenburg, BSc(Hons), Neuropsychopharmacology Research Program, Department of Pharmaceutical Sciences, University of Toronto, Toronto, ON.
Nathan Herrmann, MD FRCP(C), Neuropsychopharmacology Research Program; Department of Psychiatry, Sunnybrook Health Sciences Centre; Department of Psychiatry, University of Toronto, Toronto, ON.
Krista L. Lanctôt, PhD, Neuropsychopharmacology Research Program; Department of Psychiatry, Sunnybrook Health Sciences Centre; Departments of Psychiatry and Pharmacology, University of Toronto, Toronto, ON.

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.

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

Andrew McIvor MD, MSc, FRCP, Professor of Medicine, McMaster University; Firestone Institute for Respiratory Health, St Joseph’s Healthcare, Hamilton, ON.

At present, some 750,000 Canadians are known to have chronic obstructive pulmonary disease (COPD). This number is believed to represent the tip of the iceberg, as COPD is often only diagnosed in the advanced stage. Respiratory symptoms or a previous smoking history are common among older adults yet they seldom trigger further assessment for COPD. Objective demonstration of airflow obstruction by spirometry is a simple procedure, even in older adults, and is the gold standard for diagnosis of COPD. Early intervention with routine nonpharmacological management includes partnering with the patient and family, providing education, smoking cessation, vaccination, collaborative self-management, and advice on exercise and pulmonary rehabilitation. Anticholinergic inhalers remain the gold standard for optimal bronchodilation and dyspnea relief in COPD, and new long-acting agents have underpinned new treatment algorithms, improving quality of life and exercise capacity as well as reducing exacerbations. For those with advanced disease, recent trials have reported further benefits with the addition of combination inhalers (inhaled corticosteroid and long-acting B2-agonist) to core anticholinergic treatment. Physicians and patients can expect a promising future for COPD treatment as significant advances in management and improved outcomes in COPD are now being made.
Key words: chronic obstructive pulmonary disease, older adults, spirometry, diagnosis, management.

Karen L. Smith, MSc, Kunin Lunenfeld Applied Research Unit, Baycrest and Department of Nutritional Sciences, University of Toronto, Toronto, ON.
Carol Greenwood, PhD, Kunin Lunenfeld Applied Research Unit, Baycrest and Department of Nutritional Sciences, University of Toronto, Toronto, ON.
Helene Payette, PhD, Research Center on Aging, Health & Social Services Center - University Institute of Geriatrics of Sherbrooke, Faculty of Medicine and Health Sciences, University of Sherbrooke, Sherbrooke, QC.
Shabbir M.H. Alibhai, MD, MSc, Division of General Internal Medicine & Clinical Epidemiology, University Health Network; Geriatric Program, Toronto Rehabilitation Institute; Departments of Medicine and Health Policy, Management and Evaluation, University of Toronto, Toronto, ON.

Unintentional weight loss is a common problem among community-dwelling older adults. Although a slight decline in body weight is considered a normal part of the aging process, clinically significant weight loss (>5% of usual body weight) has harmful consequences on functional status and quality of life, and is associated with excess mortality over a three- to twelve-month period. A variety of physical and psychological conditions, along with age-related changes, can lead to weight loss. In up to one-quarter of patients, there is no identifiable cause. A rational approach to clinical investigation of these patients can facilitate arriving at a diagnosis and minimize unnecessary diagnostic procedures.
Key words: weight loss, older adults, mortality, epidemiology, diagnosis.