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.

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

Insomnia is very common among older adults and may have serious consequences. The assessment of insomnia can be challenging, given the number of possible causes and the fact that insomnia is often not a presenting complaint. Inquiring about patients’ sleep and performing a thorough evaluation of any concerns will allow a rational and targeted approach to treatment.

Key words: insomnia, sleep, older adults, aging, diagnosis.

Wojciech P.Olszynski, MD, PhD, FRCPC, Clinical Professor of Medicine,University of Saskatchewan, Director, Saskatoon Osteoporosis Centre, Saskatoon, SK.

Though osteoporosis occurs less frequently in men than in women, it is nonetheless a significant medical problem. Osteoporotic vertebral fractures in particular are as common for men as for women, and about one-third of all hip fractures occur in men. As a consequence of fragility fractures, the associated morbidity and mortality are higher in men than women, particularly after fracture of the hip. Idiopathic osteoporosis is common; however, secondary causes are found in about 50% of cases. Bone density measurements should be advised for every man over 65 years of age and for younger men in the presence of osteoporosis risk factors. For practical purposes, the use of T-score <= 2.5 for men over age 65 should be used for the diagnosis of osteoporosis.

Key words: osteoporosis, men, fracture, diagnosis, treatment

Epidemiology
Osteoporosis is a skeletal disorder characterized by compromised bone strength predisposing a person to an increased risk of fracture.

Muammer Kendirci, MD, Tulane University, School of Medicine, Department of Urology, Section of Andrology and Male Infertility, New Orleans, LA, USA.
Wayne J. G. Hellstrom, MD, FACS, Tulane University, School of Medicine, Department of Urology, Section of Andrology and Male Infertility, New Orleans, LA, USA.

Sexual dysfunction in the older man is common and has a significant impact on quality of life. In the aging man, erectile dysfunction (ED) has been encountered frequently due not only to associated comorbidities such as heart disease, hypertension, medications, diabetes, smoking, and depression, but also as a result of the aging process itself. Aging may impair molecular and structural components of erectile function. The introduction of effective oral erectogenic drugs has led to increased awareness of sexual issues and advancement in the methods used by clinicians to diagnose ED. Over the last twenty years, the approach for identification and evaluation of ED has transformed from invasive techniques to patient self-reporting and minimally invasive office procedures.

Key words: erectile dysfunction, aging, diagnosis, evaluation.

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

Lianne Tile MD, FRCPC, M Ed, Staff Physician, Osteoporosis
Program and Division of General Internal Medicine, University Health Network, Toronto, ON

Osteoporosis and fractures are a common cause of morbidity in postmenopausal women. Women age 65 and older, and those with risk factors for bone loss, should be screened by DEXA. When osteoporosis is diagnosed, secondary causes need to be considered. Fracture risk is determined by bone mineral density, age, prior fracture, and family history of osteoporosis. Adequate calcium and vitamin D intake and regular exercise are essential for the prevention and treatment of osteoporosis. Pharmacologic therapy should be used based on fracture risk. Patient preferences and side effect profile must be considered in choosing among several effective treatment options.
Key words: osteoporosis, treatment, postmenopausal, diagnosis, guidelines

Definition and Epidemiology
Osteoporosis is a skeletal disorder characterized by compromised bone strength predisposing to an increased risk of fracture.

G.A.E. Wong, MBChB, MRCP (UK); N.H. Shear, MD, FRCP(C), Divisions of Dermatology and Clinical Pharmacology, Sunnybrook & Women’s College Health Sciences Centre, University of Toronto, Toronto, ON.

Cutaneous adverse drug reactions (ADR) are a common problem affecting ambulatory and hospitalized patients. Older patients may be more predisposed to ADR due to inappropriate prescribing of medications, age-associated changes in pharmacokinetics and pharmacodynamics, altered homeostatic mechanisms, multiple medical pathology and use of drugs with a narrow therapeutic margin. In this first of two articles, a practical approach to the assessment and diagnosis of patients with suspected drug-induced rashes will be described. A subsequent article will discuss the management of patients with cutaneous ADR.
Key words: adverse drug reaction, skin, rash, cutaneous, diagnosis, assessment.

David J. Gladstone, BSc, MD, FRCPC; Lorne Zinman, MD, FRCPC; Jodie Burton, MD; Leanne Casaubon, MD; David Chan, MD; Neil Cashman, MD, FRCPC; Sandra E. Black, MD, FRCPC; Morris Freedman, MD, FRCPC.
From the Division of Neurology, University of Toronto, Toronto, ON.

At the Third Annual University of Toronto (U of T) Behavioural Neurology Clinic Day for residents, fellows and other trainees, presentations were given by faculty members from the U of T Department of Medicine (Divisions of Neurology and Geriatric Medicine) and the Department of Psychiatry. Highlights of this educational event are summarized herein by residents in the neurology training program.
Key words: dementia, diagnosis, fronto-temporal dementia, dementia with Lewy bodies, Creutzfeld-Jakob disease, vascular dementia.

Arthur Bookman, MD, FRCPC, Senior Staff Physician, University Health Centre, Coordinator, Core Residency Rheumatology Program, University of Toronto, Toronto, ON.

Pain in the older adult is of diagnostic significance. The pattern of distribution reflects the dermatome of the same spinal root that supplies the irritated deep structure. The timing helps differentiate inflammatory and infiltrative from mechanical pathology. Certain diseases of the musculoskeletal system are seen in the older adult. These include osteoarthritis, pseudogout, gout, spontaneous osteonecrosis of the knee and polymyalgia rheumatica. Diagnosis is key to effective treatment. Although the patients in this age group are often “boxed in” by a series of relative contraindications to treatment, with care and perseverence, it is often possible to break open the box and find an effective therapeutic regimen.
Key words: musculoskeletal pain, arthritis, diagnosis, spinal disease, older adults.

William J. Kostuk MD, FRCPC, FACC, FACP, Professor of Medicine, University of Western Ontario; Cardiologist, University Campus London Health Sciences Centre, London, ON.

Heart failure is the most rapidly rising cardiovascular condition in Canada. At times, the clinical presentation of heart failure may not make the diagnosis obvious. The diagnosis of heart failure should be considered when an older individual presents with complaints of exertional dyspnea or fatigue. In such individuals, the physician should not assume the symptoms are merely the result of age, obesity or chest disease. Physical examination and a few simple investigations,reviewed here, can be extremely helpful and may delay or even prevent the progression to symptomatic disease.
Key words: heart failure, diagnosis, dyspnea, fatigue, evaluation in older adults.

A.D. Baines, MD, PhD, FRCPC, Professor, Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON.

This article presents a summary of recent recommendations for the diagnosis and treatment of Type 2 diabetes in the elderly. Onset of nephropathy, neuropathy and retinopathy can be slowed by treatment designed to reach realistic target values for fasting plasma glucose and HbA1c. Therapy also should minimize the dangers of hypoglycemia. Hepatic and renal function must be monitored when selecting drugs and dosages. Significant reductions in renal function may be associated with serum creatinine within the normal reference range. A stepwise approach to therapy beginning with diet and exercise and proceeding to single and multidrug treatment is outlined. The mode of action, advantages, disadvantages and contraindications for five groups of hypoglycemic agents are summarized.
Key words: Type 2 diabetes, diagnosis, stepped treatment, oral drugs, elderly.

David C.W. Lau, MD, PhD, FRCPC, Professor of Medicine, Biochemistry and Molecular Biology; Director, Julia McFarlane Diabetes Research Centre, University of Calgary, Calgary, AB.

As the population ages, the diagnosis of Type 2 diabetes is expected to skyrocket over the next two decades. Diabetes is diagnosed by a fasting venous plasma glucose level of equal to or greater than 7mmol/L or, in the presence of classic symptoms of hyperglycemia, a casual plasma glucose value greater than 11.1mmol/L. Early diagnosis, screening and prevention of diabetes in the elderly will greatly reduce the burden of this serious chronic disease that is associated with increased morbidity and mortality.
Key words: impaired glucose tolerance, diagnosis, screening, prevention, Type 2 diabetes

The Diabetes Epidemic
Diabetes is now reaching epidemic proportions in Canada and the U.