Lynn McNicoll, MD, FRCPC, Department of Internal Medicine, Brown University School of Medicine, Providence, RI.

Delirium in older hospitalized persons in non-critical care settings is associated with higher morbidity, mortality, and worse long-term outcomes. Delirium in critically ill persons is a growing field of research. This article presents recent research indicating a high frequency of delirium in critical care. Several studies have shown that delirium in critical care is associated with poor short-term as well as long-term outcomes, including increased length of stay, persistent cognitive deficits, and hospital and one-year mortality. Further research on strategies to prevent delirium in critical care may improve short- and long-term outcomes.

Key words: delirium, critical care, aging, outcomes, older adults.

Chanaka Wijeratne, MD, MB, BS, FRANZCP, Conjoint Senior Lecturer in Psychiatry, University of New South Wales, Sydney, AUS.

Somatic presentations such as fatigue, headache, and abdominal and joint pain are common in primary care, although investigation may not readily identify an underlying cause. Such “functional somatic syndromes” are best conceptualized within a multifactorial, inclusive illness model rather than as diagnoses of exclusion (that is, of medical pathology). For instance, the syndrome of fatigue occurs in up to 25% of older people and is predicted by factors as diverse as female gender, more severe medical illness, and concurrent anxiety and depression. Although the management of functional somatic syndromes is frustrating to the clinician, the importance of a multimodal management model is emphasized.

Key words: functional somatic syndromes, older adults, primary care.

Robert W. Teasell, MD, FRCPC, Physical Medicine and Rehabilitation, Lawson Health Research Institute, University of Western Ontario, London, ON.
Jeffrey W. Jutai, PhD, Cpsych, Physical Medicine and Rehabilitation, Lawson Health Research Institute, University of Western Ontario, London, ON.

Stroke rehabilitation is best provided by a specialized interdisciplinary team, and the benefits of such a program in improving functional outcomes and reducing disability have been well established in multiple randomized controlled trials (RCTs). There is also evidence that the intensity of therapy is important. The risk of not providing stroke rehabilitation, established in one RCT, is a marked increase in death and dependency for moderate to severe stroke patients. Rehabilitation is best provided early to take advantage of post-stroke brain plasticity. Increasing age has an impact on stroke recovery, and very old patients respond better to a slower, less intensive approach to rehabilitation. Insufficient attention is often given to the importance of assistive devices.

Key words: stroke rehabilitation, interdisciplinary stroke rehabilitation unit, older adult, assistive devices.

Christopher B. Johnson, MD, FRCPC, University of Ottawa Heart Institute, Ottawa, ON.

Older patients have a high prevalence of heart valve disease and prosthetic heart valves, and are therefore at particularly high risk for endocarditis. Streptococcus viridans and Staphylococcus aureus are the most common pathogens in older patients with endocarditis. While antibiotics may cure endocarditis, surgery is required on occasion to treat complications of endocarditis such as heart failure due to valvular regurgitation, systemic and cerebral emboli, and persistent bacteremia. Endocarditis can be accurately diagnosed in aging patients using clinical, microbiological, and echocardiographic criteria. Early diagnosis and prompt institution of antibiotic therapy can result in excellent outcome among older patients with endocarditis.

Key words: endocarditis, older adults, echo, heart valve, bacteria.

George P. Chandy, MD, MSc, Department of Medicine, University of Ottawa, Ottawa, ON.
Shawn D. Aaron, MD, MSc, Department of Medicine and the Ottawa Health ResearchInstitute, University of Ottawa, Ottawa, ON.

Chronic Obstructive Pulmonary Disease (COPD) has been increasing in prevalence over the past several decades. The impact of COPD on the health status of Canadians will continue to be a major issue, despite declining rates of smoking, as physiologic manifestations of COPD may only be evident decades after the initiation of smoking. Given the delay between the initiation of smoking and the development of significant disease, COPD is primarily a disease of the older population. While a cure for COPD is not available, a number of medications have been noted to have a significant impact on symptoms, exercise tolerance, and quality of life.

Key words: COPD, treatment, management, older adults.

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.

Roger Y. Wong, BMSc, MD, FRCPC, Division of Geriatric Medicine, University of British Columbia, Vancouver Hospital & Health Sciences Centre, Vancouver, BC.

Palpitations are common in ambulatory older people and have a variety of causes. The correlation of palpitations and cardiac arrhythmias is poor. Basic assessment, which includes history taking, physical examination, 12-lead electrocardiogram (ECG), and laboratory data, is necessary but may not be sufficient to diagnose the underlying problem. Ambulatory ECG monitoring can be helpful, depending on the frequency of the palpitations. Continuous-loop event monitors are cost-effective in diagnosing palpitations, and the optimal duration of monitoring is two weeks. The overall clinical outcomes of patients with palpitations are favourable, with low mortality but high recurrence risk.

Key words: palpitations, arrhythmias, assessment, cardiac, older adults.

Heather H. Keller, RD, PhD, Associate Professor, Dept. Family Relations and Applied Nutrition, University of Guelph, Guelph, ON.

Although the prevalence of malnutrition and, specifically, undernutrition are unknown among Canadian seniors, nutritional risk has been identified as a common problem. As nutritional risk can lead to malnutrition and all of its sequelae, efforts are needed to identify nutrition problems early in their course to improve the quality of life of seniors. The following article provides a variety of approaches for identifying nutritional problems, from simple indicators to a simplified and standardized nutritional assessment. Suggestions also are provided on how the practitioner can seek assistance with intervening and helping the senior to overcome these problems.
Key words: nutrition, older adults, screening, intervention, risk, weight.

Gustavo A. Cardenas, MD, Carl J. Lavie, MD and Richard V. Milani, MD, Department of Cardiology, Ochsner Medical Institutions, New Orleans, LA, USA.

There is growing evidence that risk factors, which predict cardiovascular disease in younger people, are also predictive in older adults. Given the huge burden of cardiovascular disease in this latter population, older adults should not be excluded from primary or secondary prevention strategies, such as management of dyslipidemia. Low levels of high- density lipoprotein cholesterol (HDL-C) have a stronger association with cardiovascular disease than do high levels of low-density lipoprotein cholesterol (LDL-C). This article focuses on the importance of HDL-C as a risk factor for older patients, the evidence that exists supporting this association, the factors associated with low levels of HDL-C, and the mechanisms by which low HDL-C is related to an increased risk of cardiovascular diseases.
Key words: high-density lipoprotein cholesterol, aging, older adults, dyslipidemia, lipoprotein, atherosclerosis, cardiovascular disease.

Jacqueline Gardner-Nix, MBBS, PhD, MRCP(UK), Assistant Professor, Department of Anaesthesia, University of Toronto; Chronic Pain Consultant, Sunnybrook & Women’s College Health Sciences Centre; St. Michael’s Hospital Pain Clinic, Department of Anaesthesia, Toronto, ON.

Older adults pose additional challenges in pain management when noncancer pain has become chronic. Health care professionals are increasingly aware of the effect of past and current life stressors on the pain experience, and the roles of gender, genetics and culture. Reduced activity as individuals age often amplifies the disabling effects of pain. Pain medications are more problematic in this age group due to many factors, including polypharmacy, comorbidities and reduced renal function. However, judicious use of opioid analgesics in a subset of the population may allow increased function and access to activities, which become part of their pain management.
Key words: older adults, opioids, pain management, noncancer pain, holistic.