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.

Michael A. Drebot, PhD, Chief, Viral Zoonoses, Zoonotic Diseases and Special Pathogens, National Microbiology Laboratory, Public Health Agency of Canada, Winnipeg, Manitoba, Canada.
Harvey Artsob, PhD, Director, Zoonotic Diseases and Special Pathogens, National Microbiology Laboratory, Public Health Agency of Canada, Winnipeg, Manitoba, Canada.

Since its introduction into North America in 1999, West Nile virus (WNV) has rapidly expanded its range across the continent. There is evidence that it has moved into the Caribbean and South and Central America. The virus has significantly affected public health, causing more than 20,000 cases of associated illness and resulting in the largest WNV epidemic ever recorded. Although neuroinvasive disease occurs in less than 1% of infections, the risk for encephalitis and other neurological illnesses increases with age. Currently there is no specific therapy for the treatment of WNV-associated disease and a vaccine is not yet available. Decreasing the risk of virus exposure requires seasonal preventative and control measures.
Key Words: West Nile virus, epidemiology, diagnosis, neurological illness, disease prevention.

Felix Geser, MD, PhD, Clinical Department of Neurology, Innsbruck Medical University, Innsbruck, Austria.
Gregor K. Wenning, MD, PhD, Clinical Department of Neurology, Innsbruck Medical University, Innsbruck, Austria.

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.

Those of you who are regular readers of this journal, and my column, know that I am especially interested in the cognitive changes that occur with aging, particularly the various neurodegenerative disorders. While cardiovascular disorders and cancer are the top two killers in old age, neither robs its victims so completely of their identity. To see loved ones die with Alzheimer’s disease or another dementing disorder is like seeing them die twice; once when their personality and memory are so impaired that they are but a shadow of their former selves, and a second time when their heart stops beating. Sometimes only after the physical death has occurred can the relatives and friends allow themselves to remember their loved ones as they were, rather than what they became.

We have just entered the era when medical care for patients with dementia can make a difference. This means that accurate diagnosis of dementia, including the type of dementia, will become ever more important in clinical practice. Gone are the days when we could simply call the patient “senile.” Unfortunately, the diagnosis is not always easy to make, and Dr. Lonn Myronuk addresses this problem in his article “Pitfalls in the Diagnosis of Dementia.” As well, Dr. Ging-Yuek Robin Hsiung reviews the “Current Pharmacological Management of Alzheimer’s Disease and Vascular Dementia.” Dr. Ron Keren, the chair of the 3rd Canadian Colloquium on Dementia (CCD), keeps us up to date with the newest information on dementia by reviewing the highlights from the Colloquium, which was held in October 2005 in Ottawa. This conference, held every other year, has become the leading conference on dementia for Canadian clinicians and clinician researchers, and has a global impact. The 4th CCD, scheduled for the fall of 2007, will be held in Vancouver. The innovative format of the meeting ensures that everybody can benefit, whether specialist, researcher, or primary care physician.

Many of our regular columns this month also touch on the topic of dementia. Dr. John Wherrett’s Biology of Aging column, “Morphological and Cellular Aspects of the Aging Brain,” provides important baseline information for those of us who try to understand the clinical pathological changes of the various dementias. Keeping with the theme, our Caregiving column this month is on “Reporting on Quality of Long-Term Care Homes in Ontario” by Jennifer Gold, Tamara Shulman, and Dr. Paula Rochon. The topic of our Dementia column this month is “Nonpharmaceutical Management of Hypokinetic Dysarthria in Parkinson’s Disease” by Drs A. M. Johnson and S.G. Adams. Even our book review this month touches on dementia. Hazel Sebastian, a renowned geriatric social worker, reviews the book “Parenting Your Parents, 2nd Edition” by Bart Mindszenthy and Dr. Michael Gordon.

This month’s Cardiovascular Disease column is on that most common of arrhythmias in the elderly: atrial fibrillation. Finally, Drs. Rajneesh Calton, Vijay Chauhan, and Kumaraswamy Nanthakumar review a critical controversy in the management of atrial fibrillation in their discussion of “Rate vs. Rhythm Control and Anticoagulation.”

Enjoy this issue,
Barry Goldlist

Rowena Ridout, MD, FRCPC, Toronto Western Hospital, Toronto, ON.

Osteoporosis is a significant cause of morbidity and mortality in the older population. Bone density testing is recommended for all men and women 65 or older. In postmenopausal women, and in men over the age of 50, testing is recommended for those at high risk for osteoporosis. Effective therapy is available for those at risk for fracture. Bone density testing combined with clinical risk factors, including age and fracture history, can be used to assess fracture risk and identify those individuals most likely to benefit from drug therapy.
Key words: osteoporosis, bone density, fracture, diagnosis.

Raj C. Shah, MD, Rush Alzheimer’s Disease Center; Department of Family Medicine, Rush University Medical Center, Chicago, IL, USA.
David A. Bennett, MD, Rush Alzheimer’s Disease Center; Department of Neurological Sciences, Rush University Medical Center, Chicago, IL, USA.

Mild cognitive impairment (MCI), the presence of cognitive difficulties without having dementia, is viewed as a preclinical state for Alzheimer’s disease (AD) or another dementing illness. With the burden of AD expected to increase, research efforts have focused on interventions to delay the progression of MCI to AD. In this review, we first discuss the current conceptual understanding of MCI. Then, we outline a simplified approach to help clinicians diagnose MCI. Finally, we provide an overview of how to address the clinical needs of individuals with MCI.
Key words: mild cognitive impairment, Alzheimer’s disease, diagnosis, prognosis, treatment.

Tony Lo, MD, Resident, Department of Psychiatry, University of Calgary, Calgary, AB.
Nadeem H. Bhanji, BSc(Pharm), MD, FRCP(C), Assistant Professor, University of Calgary; Staff Psychiatrist, Carewest Glenmore Rehabilitation Hospital; Elderly Psychiatrist, Department of Psychiatry, Peter Lougheed Centre; Assistant Professor, University of Calgary, Calgary, AB.

Major depression and subsyndromal depression are common in older persons. Unrecognized depression results in increased morbidity and mortality. Recognition of depression is challenging due to patient- and clinician-related factors. Diagnosis in the older person is confounded by medical comorbidities as well as normal changes. Depression in older adults manifests differently: somatic complaints, nonspecific symptoms, and cognitive difficulties are common, as are behavioural changes, including apathy and irritability. Anhedonia better reflects depression, since depressed mood is often denied by the older person. Depression is likely to be missed if only typical symptoms are sought. Appropriate recognition can lead to improved treatment and outcomes.
Key words: depression, older adult, diagnosis, recognition, management.

Maurice H. Miller, PhD, Department of Speech-Language Pathology & Audiology/Steinhardt School of Education, New York University, New York, NY, USA.
Jerome D. Schein, PhD, Professor Emeritus, New York University, New York, NY, USA; Adjunct Professor, University of Alberta, Edmonton, AB.

Hearing loss that occurs instantaneously or over a period of a few days without immediately apparent cause is called Idiopathic Sudden Sensorineural Hearing Loss (ISSNHL). In part 1 of this series, the diagnosis and initial treatment of this condition are described in relation to most patients’ demands for active and aggressive intervention. Part 2 (to follow in the next issue) will address rehabilitation.
Key words: audiology, deafness, diagnosis, hearing aids, idiopathic, otology, rehabilitation, unilateral and bilateral hearing loss, sensorineural.

Linda Boise, PhD, MPH, Director, Education/Information Transfer Core, Layton Aging & Alzheimer Disease Research Center, Oregon Health & Science University, Portland, OR, USA.
Cathleen M Connell, PhD, Professor, Department of Health Behavior and Health Education, School of Public Health; Director, Education/Information Transfer Core, Michigan Alzheimer’s Disease Research Center, University of Michigan, Ann Arbor, MI, USA.

The high prevalence of dementia and the increased availability of treatments for Alzheimer’s disease and related dementias have increased the need to find optimal approaches to disclosing the diagnosis of dementia. In this article, relevant research is reviewed on physician practices and perspectives, and on older patients’ and family members’ preferences. Research suggests that, in general, patients and families want an accurate and clearly explained diagnosis, and that they desire guidance from the physician in understanding the course of the illness over time as well as resources that will help them to cope. Considerations in disclosing a dementia diagnosis and recommendations on how to disclose a dementia diagnosis are offered.

Key words: dementia, Alzheimer’s disease, disclosure, physicians, diagnosis.

Jayna M. Holroyd-Leduc, MD, FRCPC, Assistant Professor, Department of Medicine, University of Toronto; Clinician-Investigator, University Health Network, Toronto, ON.
Cara Tannenbaum, MD, FRCPC, MSc, Assistant Professor, Department of Medicine, University of Montreal; Director, Geriatric Incontinence Clinic, McGill University Health Centre; Director, Institut Universitaire de Geriatrie de Montreal, Montreal, QC.

Urinary incontinence is a prevalent condition among long-term care residents, particularly those with dementia. The costs and morbidity associated with urinary incontinence are significant. Urinary incontinence can be easily assessed within the long-term care setting. Several modifiable risk factors should be identified and addressed. Effective behavioural treatment options for incontinence exist and several treatment strategies can be used successfully for patients with dementia.

Key words: urinary incontinence, dementia, long-term care, diagnosis, management.