Pamela Katz, MD, Department of Endocrinology and Metabolism, University of Toronto, Toronto, ON.
Jeremy Gilbert, MD, FRCPC, Staff Endocrinologist, Toronto General Hospital, University Health Network, Toronto, ON.

The global prevalence of diabetes has increased substantially in recent years, attributable to an increase in new cases and declining mortality. Aging is associated with changes in beta cell function and insulin resistance that predispose to diabetes. Cardiovascular disease is the leading cause of death among older adults with diabetes. In order to reduce the excessive risk of cardiovascular disease, all coronary risk factors must be addressed and treated aggressively. This article will focus on the importance of blood pressure and glycemic control and lipid lowering with statin therapy. Specific considerations in this patient population include high rates of comorbid disease, shorter life expectancy, polypharmacy and falls risk. These factors may alter the therapeutic goals. Treatment should therefore be individualized with consideration given to patient preference and quality of life.
Key words: diabetes, cardiovascular disease, older adults, metabolic syndrome.

As I rapidly advance towards the geriatric age group, fears of cancer, in my case colon cancer because of a positive family history, start to increase. As a result, the unpleasantness of a recent colonoscopy was greatly alleviated later on by learning that I had no polyps or tumours. I am not alone in my concern about cancer, and the increasing prevalence of cancer as our population ages (and as age-corrected cardiovascular mortality declines) make these concerns quite legitimate. This high prevalence of cancer means that nearly all physicians--specialists as well as family physicians--who cares for adult patients will be caring for individuals with cancer in their practice. This issue’s focus on cancer in older adults allows us to address some of the learning needs of physicians caring for older adults with cancer.

Before her untimely death from breast cancer, a colleague of mine at the University Health Network wrote poignantly about the fatigue she experienced with her cancer. This taught me that as important as relieving pain is in cancer, many other symptoms are equally distressing for the patient. Our continuing education article this month is on some of these symptoms, and is titled “Fatigue, Pain, and Depression among Older Adults with Cancer: Still Underrecognized and Undertreated” by Dr. Manmeet Aluwhalia. An overview for supportive care of patients with cancer is addressed in the article ”Psychosocial Oncology for Older Adults in the Primary Care Physician’s Office” by Dr. Bejoy Thomas and Dr. Barry Bultz. Finally, in the same vein, is the article “Palliative Care in the Primary Care Setting” by Dr. Sandy Buchman, Dr. Anthony Hung, and Dr. Hershl Berman.

Our Cardiovascular Disease column this month is on “Diabetes and Cardiovascular Disease among Older Adults: An Update on the Evidence” by Dr. Pamela Katz and Dr. Jeremy Gilbert. Our Dementia column is on “Managing Non-Alzheimer’s Dementia with Drugs” by Dr. Kannayiram Alagiakrishnan and Dr. Cheryl Sadowski. One of the most important problems facing older adults, “Age-Related Hearing Loss,” is addressed by Dr. Christopher Hilton and Dr. Tina Huang. Urinary incontinence is usually considered a concern for older women; however, men are not exempt. Our Men’s Health column this month is on “Urinary Incontinence among Aging Men,” and is written by Dr. Ehab A. Elzayat, Dr. Ali Alzahran, and Dr. Jerzy Gajewski, who is a member of our partner association, the Canadian Society for the Study of the Aging Male. Dr. Gayatri Gupta and one of our international advisers, Dr. Wilbert S. Aronow, contribute an important article on "Prevalence of the Use of Advance Directives among Residents of a Long-term Care Facility" this month. Finally, it is imperative that physicians acknowledge the increasing prevalence of herbal medication use, which can lead to adverse drug interactions among their older patients. Dr. Edzard Ernst reviews this this topic in "What Physicians Should Know about Herbal Medicines.

Enjoy this issue.
Barry Goldlist

Michel Carmel, MD, FRCSC, Professor, Sherbrooke University; Chair, Division of Urology, CHUS, Sherbrooke, QC.

Prostate cancer is the highest in incidence in Canada, ahead of lung and colon cancers. This is largely due to prostate-specific antigen (PSA) screening. Choosing among management options, including watchful waiting, active surveillance, and surgery, seems more difficult than ever for the patient and his physician as new treatments are emerging, often presented as accepted alternatives, while long-term efficacy and toxicity results are not yet available.
Key words: cancer, prostate, older adults, prostate-specific antigen, screening.

Wilbert S. Aronow, MD, FACC, FAHA, AGSF, Department of Medicine, Cardiology Division, New York Medical College, Valhalla, NY, USA.

Numerous double-blind, randomized, placebo-controlled studies have documented that antihypertensive drug therapy reduces cardiovascular events in older adults. In the Hypertension in the Very Elderly Trial, individuals 80 years of age and older treated with antihypertensive drug therapy had, at 1.8-year follow-up, a 30% reduction in fatal or nonfatal stroke, a 39% reduction in fatal stroke, a 21% reduction in all-cause mortality (p=0.02), a 23% reduction in death from cardiovascular causes, and a 64% reduction in heart failure. The goal of treatment of hypertension in older adults is to reduce the blood pressure to <140/90 mmHg and to <130/80 mmHg in older persons with diabetes or chronic renal insufficiency. Older adults with diastolic hypertension should have their diastolic blood pressure reduced to 80-85 mmHg. Diuretics should be used as initial therapy in persons with no associated medical conditions. The selection of antihypertensive drug therapy in persons with associated medical conditions depends on their medical conditions. If the blood pressure is >20/10 mmHg above the goal blood pressure, drug therapy should be initiated with two antihypertensive drugs, one of which should be a thiazide-type diuretic. Other coronary risk factors must be treated.
Key words: hypertension, older adults, antihypertensive drug therapy, angiotensin-converting enzyme inhibitors, beta-blockers.

M. Bachir Tazkarji, MD, CCFP, CAQ Geriatric Medicine, Lecturer, Family Medicine Department, University of Toronto; Toronto Rehabilitation Institute, Toronto, ON.

As the population is aging, physicians from all specialties are expected to see more older adults at their outpatient practices and in the acute settings. Abdominal pain remains one of the most common and potentially serious complaints that emergency physicians encounter. Vascular pathology should be considered early in the diagnostic course of all older adults who have abdominal pain because the time for intervention is critical.
Key words: abdominal pain, older adults, management of acute abdominal pain.

Bailus Walker Jr., PhD, MPH, Department of Community and Family Medicine, College of Medicine, Howard University, Washington, DC, USA.
Charles Mouton, MD, MS, Department of Community and Family Medicine, College of Medicine, Howard University, Washington, DC, USA.

In the late 1990s, it became increasingly clear that air pollution, even at the lower ambient concentrations prevalent in many urban areas, is associated with increased mortality and other serious health effects. More recently, considerable research has focused on particulate air pollution as studies have linked a growing number of health effects to fine particles. Hundreds of studies now indicate that breathing fine particles discharged by vehicles, factories, and power plants can trigger a cardiac event and exacerbate respiratory disease in vulnerable populations. Older adults are one subgroup considered more susceptible to the effects of airborne particles. This sensitivity can be attributed to a number of factors including loss of pulmonary functional reserve and compensation due to age or disease. Although a number of mechanisms have been proposed to explain the adverse impact of particles on cardiovascular health, many questions remain. Their answers will require further transdisciplinary research.
Key words: heart disease, air pollution, smog, particulates, older adults.

Victoria J. Scott, PhD, RN, Clinical Assistant Professor, School of Population and Public Health; Senior Advisor, Falls & Injury Prevention, BC Injury Research & Prevention Unit and Ministry of Healthy Living and Sport, Victoria, BC.
S. Johnson, PhD, Professor, Faculty of Kinesiology and Health Studies, University of Regina, SK.
J.F. Kozak, PhD, Assistant Professor, School of Population and Public Health, University of British Columbia; Director of Research Centre for Healthy Aging, Providence Health, Vancouver, BC.
Elaine M. Gallagher, PhD, RN, Professor, School of Nursing; Director, Centre on Aging,
University of Victoria, Victoria, BC.

Approximately one in two older adults living in long-term care (LTC) settings sustains a fall every year, resulting in significant human suffering and treatment costs. The complex set of factors that contribute to fall risk among this population demands a multidisciplinary approach to this problem, with physicians playing a pivotal role in risk assessment, prevention, and management. We describe a study where facility personnel from five LTC sites were trained in the use of a standardized surveillance tool to track falls, fall injuries, and contributing factors over 16-months. Using a pre-/post-test design, interventions included a multidisciplinary, evidence-based approach to fall risk assessment and monitoring, environmental modifications, exercise, and education strategies. Interventions by a multidisciplinary team, including physicians, were successful in reducing fall-related injuries and relatively successful in reducing the rate of falls among LTC residents. Further study is needed over a longer period of time, using a randomized control trial, to determine the effectiveness of specific interventions and to generalize findings to the larger population of LTC residents.
Key words: fall prevention, long-term care, multidisciplinary approach, older adults.

Mazen S. Bader, MD, FRCPC, MPH, Department of Medicine, Division of Infectious Diseases, Memorial University of Newfoundland and Labrador, St. John’s, NL.
Daniel Hinthorn, MD, FACP, Department of Medicine, Division of Infectious Diseases, University of Kansas Medical Center, Kansas City, KS, USA.

Preventive health interventions are key to maintaining the health and good function of older adults. Despite being safe and a highly effective method of preventing certain infectious diseases, vaccination rates among older adults continue to lag behind national goals. Vaccines for older adults can be divided into three categories: those that are required for all older adults, those that may be required for special circumstances, and those that are required for travel. Physicians should be familiar with the indications, contraindications, and adverse effects of commonly used vaccines among older adults. This article will focus only on the vaccines required for all older adults.
Key words: vaccines, older adults, influenza, pneumococcal vaccine, herpes zoster, tetanus.

Alissa R. Segal, PharmD, CDE, Associate Professor, Massachusetts College of Pharmacy and Health Sciences; Clinical pharmacist, Joslin Diabetes Center, Boston, Massachusetts, U.S.A.
Medha N. Munshi, MD, Assistant Professor, Harvard Medical School; Director of Joslin
Geriatric Diabetes Program, Joslin Diabetes Center; Division of Gerontology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, U.S.A.

The aging of the population and increasing prevalence of diabetes are worldwide phenomena that require a better focus on challenges of diabetes management in older adults. We now understand the benefits of tight glycemic control and have an armament of agents to achieve such a feat. However, in an aging population, balance must be sought between the goals of glycemic control and those of overall health status, including quality of life. Insulin therapy, in particular, requires significant self-care abilities. Insulin therapy can be used safely and effectively if diabetes management plans are formulated with consideration of the clinical, functional, and psychosocial contexts of an older adult.
Key words: diabetes, older adults, insulin therapy, geriatrics, glycemic control.

Siamak Moayedi, MD, Assistant Professor, Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD, USA.
Mercedes Torres, MD, Instructor, Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD, USA.

Dyspnea is among the most frequent complaints among older adults. The prevalence of comorbid medical conditions combined with physiological changes of aging present significant challenges to the diagnosis. The initial approach to the older adult with dyspnea mandates consideration of a broad range of diagnoses. Failure to consider life-threatening medical conditions presenting with dyspnea, such as pulmonary embolism, acute coronary syndromes, congestive heart failure, asthma, obstructive pulmonary disease, pneumothorax, and pneumonia, can lead to significant morbidity and mortality. This review focuses on the rapid assessment and approach to the older adult with acute dyspnea.
Key words: dyspnea, shortness of breath, approach, geriatric, older adults.