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.

Goran Eryavec, MD, FRCP, Medical Director, Geriatric Psychiatry and Memory Clinic, North York General Hospital; Assistant Professor, Department of Psychiatry, University of Toronto, Toronto, ON.
Gabriel Chan, MD, FRCP, Medical Director, Geriatric Medicine, North York General Hospital; Assistant Professor, Department of Medicine, University of Toronto, Toronto, ON.
Brian Hoffman, MD, FRCP, Chief of Psychiatry, North York General Hospital; Associate Professor, Department of Psychiatry, University of Toronto, Toronto, ON.

Discussing a diagnosis of cancer and obtaining consent to treat older patients can be difficult and challenging. Older cancer patients are often frail, and may have depression or cognitive impairment that brings into question their ability to cope with the diagnosis and their capacity to consent to treatment. Family members may be distressed and fearful of how the patient will cope with the cancer diagnosis. Physicians can be pressured to withhold the diagnosis. The evolution of informed consent, informed decision making, and shared decision making is reviewed along with consent and capacity to consent or refuse treatment legislation in Ontario. We present a case study illustrating these issues and discuss how physicians can cope with the complex clinical, legal, and ethical issues involved.
Key words: informed consent, capacity, older adult, cancer.

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

Christine B. Brezden-Masley, MD, PhD, Staff Physician, Department of Medicine, St. Michael’s Hospital; Assistant Professor, Department of Medicine, University of Toronto, Toronto, ON.
Maureen Trudeau, BSc, MA, MD, Acting Regional Vice President, Cancer Services--Clinical; Head, Division of Medical Oncology/Hematology, Sunnybrook & Women’s College Hospital Sunnybrook Campus; Head, Systemic Therapy Program, Toronto Sunnybrook Regional Cancer Centre; Associate Professor, Department of Medicine, University of Toronto, Toronto, ON.

Breast cancer is the most common cause of cancer mortality in women over 65 years of age. Older women with breast cancer are usually understaged and undertreated as a result of factors such as significant patient comorbidities, patient preferences, age-biases, and poor cognition. Furthermore, women over the age of 70 have been excluded from many breast cancer clinical trials, making treatment conclusions difficult. Patients’ characteristics (including age and comorbidities) should be considered when deciding on the final treatment, a decision ideally made by both the treating physician and the patient. This review will discuss current treatment strategies for breast cancer patients, with a focus on the older population.
Key words: breast cancer, older adults, staging, systemic chemotherapy, radiotherapy.

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

Hsiupei Chen, MD, Carolina Pain Consultants and Critical Health Systems, Raleigh, North Carolina, USA.
Randall P. Brewer, MD, The Spine Institute, Willis Knighton Health System, Shreveport, Louisiana, USA.

Neuropathic pain (NP) results from injury or dysfunction in the processing of sensory information in the nervous system. It occurs in a wide array of disease processes and may involve complex management strategies. A comprehensive approach utilizing proven pharmacologic and nonpharmacologic therapies can be used to return function and improve quality of life that has been lost because of pain. In the older population, age-related physiologic and pharmacodynamic alterations, coexisting diseases, and the prevalence of polypharmacy must be considered when selecting therapies for neuropathic pain.
Key words: neuropathic pain, older adults, neuropathy, pain, analgesics.

Tessa L. Lewis, MD, General Practitioner, Carreg Wen Surgery, Church Road, Blaenavon, Torfaen, UK.

The NO TEARS structure can aid efficient medication review within a 10-minute consultation. It is a flexible system that can be tailored to the individual practitioner’s consultation style:
Need/indication
Open questions
Tests
Evidence
Adverse effects
Risk reduction
Simplification/switches

Key words: medication review, NO TEARS, primary care, older adults, polypharmacy.

A. Mark Clarfield, MD,FRCPC, Chief of Geriatrics, Soroka Hospital, Beer-sheva, Israel; Sidonie Hecht Professor of Geriatrics, Ben-Gurion University of the Negev, Beer-sheva, Israel; Staff Geriatrician of the Division of Geriatric Medicine, Sir Mortimer B. Davis Jewish General Hospital, McGill University, Montreal, QC.

Recent research has shown that close to 10% of the older population have at least one potentially inappropriate prescription, placing them at risk of acute hospitalization due to overdose or harmful drug interactions. The problem of polypharmacy in the aged is growing. Primary care physicians are obliged to take responsibility for coordinating the patient’s care and must be aware of various aspects of medication use such as cumulative drug exposure, chronic comorbidities, changing pharmacokinetics, and prescribing habits of consultants.

Key words: polypharmacy, older adult, adverse drug reaction, compliance.

Dale A. Lund, PhD, Professor of Gerontology & Sociology, University of Utah Center on Aging, Salt Lake City, UT, USA.
Scott D. Wright, PhD, Associate Professor of Gerontology, University of Utah Center on Aging, Salt Lake City, UT, USA.
Michael S. Caserta, PhD, Associate Professor of Gerontology, University of Utah Center on Aging, Salt Lake City, UT, USA.

Obtaining respite, defined as having time away from performing caregiving tasks and meeting various responsibilities, has been found to be the single most desired and needed service by family caregivers to older adults. Although respite has the potential to enhance the quality of life for most caregivers, far too many caregivers wait too long to use the services, do not use them often or regularly enough, or spend their respite time unwisely (thus not deriving the maximum benefit). Also, many caregivers feel guilty and reluctant to use the services even when they are available. This article helps document the value of using respite services, describes the various forms in which they are available, and offers suggestions on how to make the most out of these promising services.

Key words: respite, caregiving, older adults, quality of life.

Joseph M. Blondeau, Department of Clinical Microbiology, Royal University Hospital; Department of Microbiology, Department of Immunology and Pathology, University of Saskatchewan, Saskatoon, SK.
Glenn S. Tillotson, Oscient Pharmaceuticals, Waltham, MA; Public Health Research Laboratory, Newark, NJ, USA.

Antimicrobial agents are essential for the treatment of patients with bacterial infectious diseases. Unfortunately, the global escalation of antibiotic resistant pathogens in both the community and hospital settings have compromised the use of some compounds for treating both common and uncommon infections. Over the past three to four years, several new or modified compounds have been approved and may have applicability in treating a wide range of infections in older patients. Some brief characteristics of these compounds and their appropriate indications are summarized.

Key words: older adult, antimicrobial agents, antibiotics, fluoroquino-lones, ketolides.

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

Diabetes mellitus (DM) is a very common condition in the older population. The disease may interact with other medical conditions that increase the degree of frailty in aging adults. Nonpharmacological and pharmacological interventions are the usual steps in managing of DM. In this article, a stepwise treatment strategy will be suggested after a review of the pertinent literature.

Key words: diabetes mellitus, older adult, diet, exercise, pharmacotherapy.

Daniel Tessier MD, MSc, Head of Geriatric Services, Sherbrooke Geriatric University Institute, Sherbrooke, QC.

D’Arcy Little, MD, CCFP, Lecturer, Department of Family and Community Medicine, University of Toronto; Director of CME, Geriatrics & Aging, Toronto, ON.

The Baycrest Centre for Geriatric Care and the Department of Psychiatry at the University of Toronto held “Psychogeriatrics Update 2004” at the Wagman Centre on the grounds of Baycrest on November 19, 2004. The morning consisted of a plenary session of particular interest to geriatric psychiatrists, community psychiatrists, geriatricians, primary care physicians, and other paramedical personnel working with older patients. This was followed by an afternoon of supplementary small group workshops. The following are some highlights from the plenary session.

Key words: psychogeriatric, bipolar, depression, older adult.

The symposium opened with Dr. Kenneth Shulman’s review of late-life bipolar disorder. Dr. Shulman reminded the audience that bipolar disorder in older adults, while not a major public health problem, represents a paradigm for psychiatry in old age. This particular illness represents a complex mix of genetic, environmental, and biological factors. In addition, the treatment of the illness is often challenging because of the coexistence of other medical problems in older patients, as well as the potential for adverse drug interactions with medications such as lithium.

According to Dr. Shulman, the clinical manifestations of mania in old age are similar to those seen in patients of other ages. However, the symptoms are often not as intense as in younger patients. Furthermore, there is a higher prevalence of cognitive impairment in older adults with mania. Dr. Shulman reviewed data showing that 57% of older patients with a first episode of mania had other neurological disorders.¹

Central nervous system lesions associated with secondary mania in the aging consist primarily of right-sided lesions, especially in the orbitofrontal cortex, and are often vascular in nature. The lesions are often silent cerebral infarctions picked up as hyperintensities on CT scanning. This right-hemispheric predominance is in contradistinction to late-life depressive disorders that have been shown to have an association with left-hemispheric lesions (Figure 1).²

Dr. Shulman then reviewed the practical application of this data. The prevalence of vascular lesions in late-onset mania suggests important components of treatment. The initial workup of late-onset mania should include a detailed neurological exam as well as neuroimaging to detect the presence of associated neurological lesions. An important aspect of management is to optimize the treatment of other medical illnesses and to aggressively treat vascular risk factors.

Dr. Shulman then reviewed the important role of lithium carbonate in the management of bipolar disorder in the aging. This drug has the best evidence as a mood stabilizer in the older patient.³ However, its use declined with the introduction of divalproex in 1993, despite the lack of efficacy or effectiveness data in older adults. Of course, there are special considerations for the use of lithium in older patients. These include drug interactions with medications commonly used in older patients, such as thiazide diuretics, loop diuretics, angiotensin-converting enzyme inhibitors, and non-steroidal anti-inflammatory drugs. Other important considerations include altered pharmacokinetics and the possibility of altered kidney function in the older patient; in light of this, a narrower therapeutic range for lithium in the older population has been advocated, with a target serum lithium level in this population of 0.4-0.8mEq/L.

Dr. Alastair Flint reviewed an approach to treatment-resistant depression in the older adult. He defined treatment resistance as the “failure to adequately improve with an adequate dose [of treatment] given for an adequate duration.” He explicated this concept by stating that treatment-resistant depression can be defined as the failure to adequately improve after two trials of two different antidepressants from two different classes with or without augmentation. Using this definition, a significant number of patients will not undergo remission. He referred to the recognition of this problem as a significant paradigm shift in psychiatry, and urged clinicians to be thinking ahead with respect to each patient with depression and their next therapeutic step(s) should remission not be achieved.
The first steps in treatment-resistant depression are to ensure that the diagnosis is correct, the patient has indeed received an adequate treatment, and that there are not coexistent medical or psychiatric disorders that are interfering with the response to treatment.
In older adults, two important coexistent disorders that need to be considered are dementia (especially frontotemporal dementia) and psychosis. For instance, an early subcortical or frontal lobe dementia can present with significant apathy and loss of motivation that can be confused with depression. In addition, the presence of psychosis is often missed and can present with profound psychomotor retardation that can be confused with severe depression. In cases of profound psychomotor retardation, Dr. Flint encouraged clinicians to consider the diagnosis of psychosis until proven otherwise. This is important because psychotic depression in older adults has been shown to be responsive to electroconvulsive therapy (ECT), but much more resistant to tricyclic antidepressants or a combination of tricyclic antidepressants and antipsychotics.

Other disorders that can coexist with depression and render it less likely to respond to medication include other medical diseases such as cerebrovascular disease, dementia, and other psychiatric illnesses such as anxiety, substance abuse, and personality disorders.
Once other disorders are ruled out, a variety of strategies exist for treatment-resistant depression, including:

1. Optimizing existing treatment
2. Augmenting the antidepressant
3. Combining antidepressants
4. Substituting another antidepressant
5. Considering ECT

Optimizing existing treatment can take the form of increasing the dose of medication and/or the duration of treatment to optimize the effect. Augmentation includes using other agents to enhance the success of antidepressant treatment. This can be accomplished by adding agents such as lithium (to a serum level of 0.5-1.0mmol/L), triiodothyronine (25-50µg/day), anticonvulsants, antipsychotics, stimulants (such as methylphenidate hydrochloride), or tryptophan. Lithium augmentation has the most compelling data in augmentation.

Dr. Flint reminded the audience that electroconvulsive therapy is the most efficacious treatment for depression, especially treatment-resistant depression. Important considerations here include the need to taper the ECT after a response and to start pharmacotherapy during the ECT to maintain the response.

1. Tohen M, Shulman KI, Satlin A. First-episode mania in late life. Am J Psych 1994;151:130-2.
2. Braun CM, Larocque C, Daigneault S, et al. Mania, pseudomania, depression, and pseudodepression resulting from focal unilateral cortical lesions. Neuropsychiatry Neuropsychol Behav Neurol 1999;12:35-51.
3. Bauer MS, Mitchner L. What is a “mood stabilizer”? An evidence-based response. Am J Psych 2004;161:3-18.