Mohammed E. Hussain, Department of Medicine, Mount Sinai Hospital, Toronto, ON.
Dominick Amato, Department of Medicine, Mount Sinai Hospital; Department of Medicine, University of Toronto, Toronto, ON.

Thrombocytopenia, whether symptomatic or not, is a relatively common finding in clinical medicine. The causes of thrombocytopenia are many, and all of these may be found at all ages. However, just as the frequencies of these causes vary between pediatric and adult age-groups, so too is there variation between younger adults and older individuals. Also, the pathophysiological approach to thrombocytopenia (decreased production, increased destruction, sequestration, dilution) remains just as valid to the seasoned hematologist as to the neophyte. In this article, we provide a suggested approach to the patient with thrombocytopenia, with emphasis on the more common causes in older adults.
Key words: thrombocytopenia, platelets, bleeding disorders, primary hemostasis, older adults.

I am someone who believes fervently in screening for colon cancer, and have had two colonoscopies (separated by 5 years). Even those at normal risk seem to benefit from some form of screening, and I have been particularly concerned because I have had close relatives afflicted by the disease. However, it is clear that many people who should know better refuse to be screened. Even simple screening tests such as fecal occult blood testing require people to endure relatively unpleasant activities, and colonoscopy prep is hardly fun.

Independent of my views, it is obvious that the rising prevalence of cancer of all types in Canada is a result of the aging of our population and the relative decline in cardiovascular mortality. Many of today’s cancer patients are relatively frail, or become so while getting treatment, and attention to geriatric medicine principles in these patients is important. Most oncology training programs in the United States incorporate a geriatric module to cover these issues. We are lagging a bit behind in Canada in this respect, but I am proud to say that one of the nation’s outstanding leaders in the field of geriatric oncology is our own senior editor, Dr. Shabbir Alibhai. The focus of this month’s edition is how cancer management is altered in older adults.

Our continuing education article, “Management of Primary Colon Cancer in Older Adults,” is by Dr. Robin McLeod, Selina Schmocker, and Dr. Erin Kennedy. Obviously, I hope never to have to worry about this because I have a commitment to screening! The very common ( and currently in the press) topic of “Multiple Myeloma in Older Adults: An Update” is written by Dr. Madappa N. Kundranda and Dr. Joseph Mikhael. The commonest cancer in older individuals is addressed in the article “Basal Cell Carcinoma” by Dr. Christian A. Murray and Dr. Erin Dahlke.

As well, we have our usual collection of articles on varied topics. Our Cardiovascular column is an “Update on the Management of Atrial Fibrillation in Older Adults” by Dr. Hatim Al Lawati, Dr. Fatemeh Akbarian, and Dr. Mohammad Ali Shafiee. Our Dementia article is on a common and difficult topic, “Withholding and Withdrawing Life-Sustaining Treatment in Advanced Dementia: How and When to Make These Difficult Decisions,” by Dr. Dylan Harris. In the area of nutrition, we have the article “Nutrition Guidelines for Cancer Prevention: More Than Just Food for Thought” by Kristen Currie, Sheri Stillman, Susan Haines, and Dr. John Trachtenberg. This is a natural extension from our focus this month. Our Community Care article is “Community-Based Health Care for Frail Seniors: Development and Evaluation of a Program” by Dr. Douglas C. Duke and Teresa Genge. Finally we feature one of Canada’s most prominent physicians in our “I Am a Geriatrician” column, namely Dr. Howard Bergman.

Enjoy this issue,
Barry Goldlist

Hatim Al Lawati, MD, FRCPC, Cardiology Resident, Division of Cardiology, Faculty of Medicine, University of Toronto, Toronto, ON.
Fatemeh Akbarian, MD, Dermatologist, Research Fellow, University of Toronto, Toronto, ON.
Mohammad Ali Shafiee, MD, FRCPC, General Internist, Nephrologist, Department of Medicine, Toronto General Hospital, University Health Network; Clinician Teacher, University of Toronto, Toronto, ON.

Atrial fibrillation (AF) is by the far the most common cardiac rhythm disturbance encountered in clinical practice. It is associated with significant morbidity and mortality and has potentially lifelong implications in terms of therapy and complications. This disease is more commonly seen now given the increased life expectancy and the remarkable advances made in health care. The already at-risk older adult population is particularly vulnerable to complications from AF, especially embolic cerebrovascular events. This article reviews the evidence-based management of AF with a particular focus on the older adult population.
Key words: atrial fibrillation, older adults, stroke, rate control, rhythm control, stroke prophylaxis, anticoagulation.

Madappa N. Kundranda, MD, PhD, Department of Hematology/Oncology, Mayo Clinic, Scottsdale, AZ, USA.
Joseph Mikhael, MD, Department of Hematology/Oncology, Mayo Clinic, Scottsdale, AZ, USA.

Multiple myeloma (MM) is an uncommon malignant plasma cell disorder that often presents in older adults. An accurate diagnosis is critical as a spectrum of plasma cell disorders have been defined, including monoclonal gammopathy of undetermined significance, smouldering/asymptomatic multiple myeloma, multiple myeloma, and plasma cell leukemia. Although multiple myeloma is incurable disease, survival over 7 years is possible, during which patients can enjoy a good quality of life. Many therapeutic options now exist for individuals with MM who are ineligible for autologous stem cell transplantation; these include adding thalidomide, bortezomib, and lenalidomide to the current standard of melphalan and prednisone.
Key words: multiple myeloma, MGUS, older adults, plasma cell leukemia, supportive care.

Jackie Gardner-Nix, MB BS, PhD, MRCP(UK), Assistant Professor, University of Toronto; Chronic Pain Consultant, Department of Anesthesia, St Michael’s Hospital; and Pain Management Programme, Sunnybrook Health Sciences Centre, Toronto, ON.

The management of neuropathic pain at any age is aimed at the relief of suffering rather than focusing on decreasing pain scores, and it should involve even simple measures that affect pain and coping. Addressing physical stressors—poor diet, hydration, and sleep quality and quantity—is particularly relevant in older adults. Medications relieving neuropathic pain may be adjunctive to initial interventions and need to be carefully assessed for efficacy and side effects to ensure they relieve, rather than add to, suffering.
Key words: neuropathic pain, analgesics, older adults, mindfulness, psychological interventions.

M. Faisal Jhandir, MD, RVT, Clinical Assistant Professor of Medicine, Co-Chair Vascular Risk Reduction Program, University of Calgary, Calgary, AB.
Robert J. Herman, MD, FRCPC, Professor of Medicine, Head, Division of General Internal Medicine, University of Calgary, Calgary, AB.
Norm R.C. Campbell, MD, FRCPC, Professor of Medicine, Physiology and Pharmacology and Community Health Sciences, University of Calgary and Libin Cardiovascular Institute, Calgary, AB.

The World Health Organization has named hypertension the leading risk for death globally in adults. Antihypertensive therapy reduces the risks of major cardiovascular complications. As blood pressure increases with increasing age, frequent screening for hypertension is advisable in older adults. The risk of developing hypertension is about 90% even in normotensive 65 year olds. Until recently, data supporting antihypertensive therapy in the very old had been inconclusive. However, the HYVET trial published in 2008 shows a clear reduction in cardiovascular events and mortality. Based on this study the Canadian Hypertension Education Program recommends treating hypertension regardless of age. Attention should also be given to reducing overall cardiovascular risk.
Key words: hypertension, high blood pressure, older adults, recommendations, HYVET study.

William Lear, MD, FRCPC, FAAD, Dermatologist, Silver Falls Dermatology PC, Salem, OR, USA.
Jennifer Akeroyd, RN, PhD student, Oregon Health & Science University, Portland, OR, USA.

In this article, we discuss skin findings affecting older adults, with a focus on pruritus, flushing, dermatitis, and ulcers, and consider related internal diseases. Our goal is to make this information readily transferable to the clinical setting for the non-dermatologist.
Key words: dermatology, skin manifestations, older adults, pruritus, flushing, dermatitis, ulcers.

Simon Yang, MD, Division of General Surgery, University of Toronto, Toronto, ON.
Calvin Law, MD, MPH, FRCS, Division of General Surgery, University of Toronto; Sunnybrook Health Sciences Centre, Toronto, ON.

The prevalence of gallstones has been increasing among the aging population. Common sequelae of cholelithiasis include asymptomatic gallstones, biliary colic, acute cholecystitis, choledocholithiasis, cholangitis, and gallstone pancreatitis. Among individuals over age 65, gallstone diseases represent an important cause of recurrent abdominal symptoms and surgical admissions. As advanced age is correlated with increased mortality and morbidity in complicated gallstone disease, timely diagnosis and appropriate management are essential to improving disease outcomes.
Key words: older adults, gallstones, cholecystitis, choledocholithiasis.

Abisola Famakinwa, MD, Instructor in Medicine, Harvard Medical School; Staff Physician, Edith Nourse Rogers Memorial Hospital, Bedford, MA, USA.

Increases in life expectancy and the aging of the baby boomer generation has resulted in unprecedented high numbers of older adults in the U.S. and Canada and, thus, a rising number of frail older adults with chronic medical conditions. Informal caregivers, primarily family members, have traditionally provided a large proportion of care at home, and their contribution is expected to be of even greater significance. Informal caregivers provide care at great expense to themselves, because caregiving can result in emotional, physical, and financial stresses. This article discusses the role physicians play in identifying and alleviating caregiver stress.
Key words: family caregivers, informal caregivers, caregiver stress, physician, older adults.

Robert Lam, MD, CCFP (Care of the Elderly), Attending Physician, Geriatric Rehabilitation Program, Toronto Rehabilitation Institute, Toronto, ON.
Alison Wong, MPT, Physiotherapist, Geriatric Rehabilitation Program, Toronto Rehabilitation Institute, Toronto, ON.

Primary care physicians often see older adults using gait aids during office visits. Gait aids can provide increased independence with functional mobility but, if used incorrectly, can lead to injury. Unfortunately, gait aids are often purchased without professional advice. Gait aid prescription requires consideration of multiple factors. This article outlines general tips primary care physicians can use to help decide which gait aid might be most appropriate for a patient. Primary care physicians should examine an older patient’s gait aid as physical mobility needs change, and consider referring the patient to a physiotherapist for a complete assessment and gait training.
Key words: gait aid, cane, walker, older adults, ambulation.