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.

Daniel Tessier, MD, FRCPC, Professor, Head of Geriatric Service, Sherbrooke Geriatric University Institute, Sherbrooke University, Sherbrooke, QC.

The concept of insulin resistance is a major field of interest in the medical literature. The basic science research has significantly increased our knowledge of this phenomenon, which has become a silent killer in our society. The main factors involved in insulin resistance are obesity (mainly abdominal), lack of physical activity, loss of muscle mass and secondary diminution in insulin action followed by diabetes mellitus. The changes in lifestyle and diet observed in many older subjects increases the risk of insulin resistance and diabetes. This paper will underline the main elements for primary and secondary prevention of insulin resistance in older adults.
Key words: insulin resistance, older adults, diabetes mellitus, obesity, free fatty acid, pharmacotherapy.

Ellie Chuang, MD and Mark E. Molitch, MD, Division of Endocrinology, Metabolism and Molecular Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.

The worldwide prevalence of diabetes is expected to double to 300 million people by 2025, and nearly 40% of those currently diabetic are older than 65 years. In those who are at high risk for diabetes, including older adults, intervention with diet and exercise has been shown to markedly reduce the development of diabetes. Medications such as metformin, acarbose, troglitazone, pravastatin, ramipril, losartan and estrogen/progestin also have been shown to be effective, although benefits in older patients have not always been demonstrated. Implementation of lifestyle changes in people of all ages could dramatically reduce the size of the developing diabetes epidemic.
Key words: diabetes, primary prevention, impaired glucose tolerance, impaired fasting glucose, older adults.

Dr. Lindsay E. Nicolle, MD, FRCPC, Department of Internal Medicine and Medical Microbiology, University of Manitoba, Winnipeg, MB.

The prevalence of asymptomatic bacteriuria increases with advancing age in community populations, and approaches 50% in the functionally impaired, institutionalized elderly. Asymptomatic bacteriuria is usually associated with pyuria, but has not been shown to contribute to any short- or long-term negative clinical outcomes in the older population. Treatment of asymptomatic bacteriuria is not recommended. Clinical trials evaluating antimicrobial therapy have found no improved outcomes, and therapy is usually followed by recurrence of bacteriuria. Antimicrobial treatment also is associated with increasing antimicrobial resistance and adverse drug effects. Due to the high prevalence of positive urine cultures, bacteriuria is not a useful diagnostic test for symptomatic urinary tract infection. However, a negative urine culture may exclude the urinary tract as a potential source of infection.
Key words: urinary tract infection, bacteriuria, older adults, long-term care.

Gina Bravo, PhD
Head, Department of Community
Health Sciences,
University of Sherbrooke
Researcher, Research Centre,
Sherbrooke University
Geriatric Institute,
Sherbrooke, QC.

Introduction
Over the past 30 years, as in all provinces across Canada, the population has aged rapidly in Quebec. From 1901 to 1971, a span of 70 years, the proportion of people aged 65 and over increased by only 2.1%: from 4.8%-6.9%. By comparison, it will rise by 21% in the next 70 years. In fact, according to recent projections, 28% of the people living in Quebec will be over 65 by the year 2041.¹

While a majority of older adults consider themselves to be in good health, a significant proportion suffers from impairments that require long-term care. The Canadian Health and Activity Limitations Survey established the prevalence of physical impairments among people aged 65-74 years old at 31%; it is 55% in those over 75. While most elderly individuals live with family members, partially compensating for their impairment, many live alone or with a spouse who also suffers from impairment.²

A Historical Perspective

Introduction of new services
In response to the increasing health care requirements of an aging society, provincial health authorities developed a broad range of services adapted to the needs of the aged.

David R. Thomas, MD, FACP, FAGS
John E. Morley, MB, ChB
Division of Geriatric Medicine
Saint Louis University Health Sciences Center and
GRECC, Veterans Administration Center
Saint Louis, MO, USA.

Abstract
Unintentional weight loss is a common problem among older adults, especially those in institutional settings. Physicians respond by prescribing increased oral calories, prescribing nutritional supplements or by considering enteral feeding. The response of patients to these interventions is often poor. For this reason, pharmacological agents that stimulate appetite or produce weight gain have attracted considerable attention. Should these agents be used? This review focuses on the benefits and risks of these orexigenic agents.

Introduction
Malnutrition is a major problem among residents in long-term care facilities.^1-4 The prevalence of protein-energy malnutrition in nursing home residents ranges from 23-85%.5,6 By comparison, the prevalence of protein-energy malnutrition ranges from 32-50% in acutely hospitalized patients.^7,8 The high prevalence of malnutrition in nursing homes may reflect a unique problem in elderly persons, the presence of chronic conditions, failure to address specific nutritional problems in this setting, or transfer of malnourished patients from acute care hospitals to long-term care facilities following an acute illness.