It seems that regardless of the focus of our issue, I have just had a patient or occurrence that makes the theme resonate even more. This issue’s focus is on hematology in older adults, and just yesterday I had the honour of examining a colleague’s 92-year-old mother regarding her hematological disorder. Her major complaint was weakness and fatigue (she lives in her own apartment with little professional help), and she had been diagnosed years ago as having chronic lymphocytic leukemia. Her current problems are likely related to the tremendous increase in her white cells over the last two months. Diagnosis is easy in this case, but the judgment issue of if and how treatment will progress is very difficult. This is one of the challenges of geriatric practice: no simple algorithm is available for making these difficult decisions. That is also one of the great joys as well, in that individual assessment and planning make a huge difference.

I have always enjoyed hematology, perhaps because of the opportunity to see the beautiful slides that the hematologists review on a regular basis. Our CME article is on a topic that is quite important and common in geriatric practice, namely the “Approach to Thrombocytopenia in Older Adults” by Dr. Mohammed E. Hussain and Dr. Dominic Amato. We often order vitamin B12 levels in clinical practice, and the article “Cobalamin Deficiency in Older Adults” by Dr. Emmanuel Andrès, Dr. Mustapha Mecili, Dr. Helen Fothergill, Dr. Thomas Vogel, Dr. Laure Federici, and Dr. Jacques Zimmer will aid us in using the information we obtain in a rational manner. One of the common, and often poorly understood, causes of anemia in older people is addressed in the article “Myelodysplastic Syndromes in Older Adults” by Dr. Lisa Chodirker and Dr. Rena Buckstein.

Of course, we have our usual collection of useful articles on various geriatric topics. “Management of Hypercholesterolemia” is addressed by our frequent and brilliant contributor Dr. Wilbert S. Aronow. We often are concerned about the choices our patients make and wonder if they are capable in making those decisions. These issues are addressed in the article “Overview of Mental Capacity Assessments” by Dr. Michel Silberfeld. For caregivers of patients with dementia, the common day-to-day tasks are often what give the most problems. One of these tasks is addressed in the article “How to Bathe A Person with Dementia: An Evidence-Based Guide” by Dr. Ellen Costello and Dr. Mary Corcoran. Finally, in our geriatrician column we profile Dr. Ken Madden, the co-editor of the Canadian Journal of Geriatrics.

Enjoy this issue,
Barry Goldlist

D'Arcy Little, MD, CCFP
Director of Medical Education,
York Community Services, Toronto, ON.

Introduction
Thrombocytopenia is a common hematologic problem in the elderly.¹ A classic survey indicated that over 50% of patients with thrombocytopenia were over 50 years of age, and 25% were over 70 years of age.² The elderly patient with thrombocytopenia presents the clinician with both diagnostic and management challenges. Because the disorders and mechanisms that lead to decreased numbers of platelets in the circulation are varied, the spectrum of differential diagnoses is broad and includes decreased platelet production and accelerated destruction.³ In addition, the clinical implications of thrombocytopenia fall into a wide spectrum, from a benign condition picked up incidentally in an asymptomatic patient to a life-threatening disorder.⁴ The following article will present an approach to the evaluation of thrombocytopenia in the elderly patient (Figure 1).

Definition and Clinical Significance
Thrombocytopenia is a condition in which there is a deficient number of circulating platelets. The cutoff for diagnosis is 150 x 10⁹/L of blood, which represents the platelet count two standard deviations below the mean obtained when sampling a large number of persons from the general population.