Wey Leong, MSc, MD, Department of Surgical Oncology, Princess Margaret Hospital, University Health Network, University of Toronto, ON.
Alexandra M. Easson, MSc, MD, Department of Surgical Oncology, Princess Margaret Hospital and Mount Sinai Hospital, University of Toronto, ON.
Michael Reedijk, PhD, MD, Department of Surgical Oncology, Princess Margaret Hospital, University Health Network, University of Toronto, ON.

Melanoma must be considered in the differential diagnosis of any skin lesion in older adults. With the incidence of melanoma increasing in general and even more so among older people, more older adults are being diagnosed with melanoma than in the past. Among older adults, melanomas display more aggressive histological features with worse prognosis and treatment outcomes than among younger individuals. Furthermore, older individuals have fewer surgical and medical treatment options because of age-associated comorbidities. This article reviews the epidemiology and management of melanoma with emphasis on the older adult population.
Key words: older adults, melanoma, aged, cancer, skin neoplasm.

Kristen Davidge, MD, Plastic Surgery Resident; Candidate, Master of Surgical Science, Department of Surgery, University of Toronto, ON.
Joel Fish, MD, MSc, FRCS(C), Burn Surgeon, Ross Tilley Burn Unit, Sunnybrook Health Sciences Centre; Chief Medical Officer, St. Johns Rehab Hospital; Associate Professor, Department of Surgery, University of Toronto; Director of Research, Division of Plastic Surgery, University of Toronto, Toronto, ON.

Burn injury among older adults will result in significant morbidity and mortality despite the many advances in burn treatment. Many adult burn units in North America admit and treat a significant number of older adults so understanding the issues and problems specific to this age group is important. Older adults experience specific problems with wound care, and if the injury is large, they will require critical care interventions during the course of treatment. Despite the advances in wound care and critical care that have occurred, the mortality rates of older adults with burn injuries remain quite high. This article reviews the literature on specific issues for older adults that need to be considered when treating older adults with burn injury.
Key words: burn injury, burn depth, older adults, geriatric, mortality.

The neurological exam is arguably the highest yield examination in all of medicine. It certainly is the most elegant part of the physical examination, and watching an experienced neurologist perform an examination can be a thing of beauty. Despite this, my long experience as a teacher suggests that for internists and family physicians the neurological exam is the most feared and probably most poorly executed aspect of the physical examination. I think there are many reasons for this, including the fact that in training we spend less time learning about neurology than, for example, cardiology. As well, an informed neurological exam depends on having a reasonable knowledge of neuroanatomy. For many of us that knowledge seems to steadily erode over the years. In a generalist practice, we almost always examine the lungs and heart of sick patients, but not always the neurological system, so there is less practice. As well, older patients often have multiple neurological findings, and it is hard to separate the background conditions from the important findings.

This is my long-winded explanation of why periodic updates in neurology are of value for most practitioners, and we hope that you will find this primer on neurology helpful. When I mentioned that watching a neurological exam can be a thing of beauty, I was particularly thinking of the author of this month’s CME article, “The Role of the Neurologic Examination in the Diagnosis and Categorization of Dementia.” Dr. John Wherrett is one of Canada’s most accomplished neurologists, and has excelled at one point or another in every area of neurology. New information on the significance and prognosis of essential tremor has recently become available, so the article on “Approach to Tremor in Older Adults” by Dr. Joel Hurwitz is of particular importance. Parkinson’s disease is extremely common among older adults, making the article “An Update on the Management of Parkinson’s Disease” by Drs. Shen-Yang Lim and Susan Fox particularly helpful to those of us who care for older adults. Our Dementia column fits in well with our focus this month, namely “Mild Cognitive Impairment: What Is It and Where Does It Lead?” by Lesley J. Ritchie and Dr. Holly Tuokko.

Our Cardiovascular Disease column this month by Dr. Christian Werner and Dr. Michael Böhm asks a very topical question: “Is Dual Blockade Most Effective for CHF? When to Use ARB and ACE Inhibitors Together”. Our Nutrition column will be of benefit for those who counsel both younger and older patients on diet. It is entitled “Nutritional Guidelines in Canada and the US: Differences between Younger and Older Adults” by Joan Pleuss. And this month’s Case Study is on the topic of “Dysphagia among Older Adults” by Dr. Amira Rana, Anselmo Mendez, and Dr. Shabbir Alibhai.

Enjoy this issue,
Barry Goldlist

Muzumel A. Chaudhary, MD, Psychiatry Resident, University of British Columbia, Vancouver, BC.
Kiran Rabheru, MD, CCFP, FRCP, ABPN, Clinical Associate Professor, Department of Psychiatry, University of British Columbia; Geriatric Psychiatrist, Vancouver General, University of British Columbia, and Riverview Hospitals, Vancouver, BC.

New-onset paranoid symptoms are common among older individuals. They can signify an acute mental status change owing to medical illness, correspond to behavioural and psychological symptoms of dementia, or equate to an underlying affective or primary psychotic mental disorder. The implications of paranoid symptoms are considerable and affect patients, families, and caregivers alike. Accurate identification, diagnosis, and treatment of late-life paranoid symptoms present a unique clinical challenge as issues of morbidity and mortality are inherent both to the illness state and available treatment approaches.
Key words: paranoia, delusions, etiology, older adults, atypical antipsychotic.

The focus of this month’s journal is Older Adults and Mental Health. This area is one of paramount importance to those who care for older adults, and the greatest challenge lies in managing Alzheimer’s disease and its complications. Our CME article this month, “Paranoid Symptoms among Older Adults” by Dr. Muzumel Chaudhary and Dr. Kiran Rabheru, is on a common syndrome with numerous underlying causes. Dr. Svante Östling contributes an article on “Presentation of Psychosis,” an issue that may not come to mind automatically for the nonpsychiatrist assessing an older adult. Dr. Keri-Leigh Cassidy and Dr. Neil Rector provide an intriguing article “The Silent Geriatric Giant: Anxiety Disorders in Late Life.” This article should force all of us to pause before writing our next prescription for benzodiazepines. We all complain about our memory at times, but Dr. Mario Masellis and Dr. Sandra Black advise us on what to do when our patients similarly complain in their article “Assessing Patients Complaining of Memory Impairment.”

Rounding off this issue we have an article on “Management of Cardiovascular Disease Risk Factors among Older Adults with Peripheral Arterial Disease” by Nicholas Giacomini and Dr. Roberta Oka, and one on a recent pharmacological controversy, “Thiazolidinediones and Cardiovascular Disease: Balancing Benefit and Harm” by Dr. Sonal Singh and Dr. Yoon Loke.

Our journal has consistently focused on practical articles that physicians can immediately use to help their older patients. However, an esteemed colleague of mine (and regular reader of Geriatrics & Aging) recently commented to me that physicians face their own challenges as they age. I am currently trying to find someone with expertise to write an article on the problems that older physicians (myself included) experience. I would appreciate any comments, anecdotes, and experiences that you, our readers, might contribute to this topic. If you have anything you would like to share, please contact our Managing Editor Andrea Németh by email (anemeth@geriatricsandaging.ca), by fax (416-480-9449), or by regular mail (162 Cumberland Street, ste. 300, Toronto, Ontario, M5R 3N5).

Enjoy this month’s articles,
Barry Goldlist

Steve Iliffe, FRCGP, Professor of Primary Care for Older People, Research Department of Primary Care, University College London, UK.

Long-term benzodiazepine use in older adults with sleep disorders is potentially hazardous, but it is also becoming easier to manage as approaches to withdrawal become feasible in primary care, without adverse consequences. This article reviews the evidence and describes practical approaches to reducing consumption of benzodiazepine hypnotics.
Key words: benzodiazepines, insomnia, older adults, primary care, hypnotics.

R.A. Harrison, MD, FRCPC, Department of Internal Medicine and Division of Infectious Diseases, University of Alberta, Edmonton, AB.
T.J. Marrie, MD, FRCPC, Department of Internal Medicine and Division of Infectious Diseases, University of Alberta, Edmonton, AB.

Among older adults, aspiration pneumonia is associated with higher rates of morbidity and mortality than community-acquired pneumonia. Individuals admitted to acute care from continuing care facilities are at increased risk for aspiration pneumonia. Risk factor assessment forms a cornerstone in diagnosing aspiration pneumonia syndromes. Monitoring for timely clinical response to therapy and for potential complications is an important step in the care of patients with aspiration pneumonia. Further high-quality research is needed to better delineate the effects of risk factor modification on the incidence of aspiration pneumonia. Aiming to prevent aspiration pneumonia poses health care providers with an opportunity for ongoing development, study, and implementation of preventive strategies for older adults.
Key words: aspiration, pneumonia, older adults, geriatric, risk factor.

Neeraj Bhala, MBChB, MRCP, Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Clinical Medicine, Oxford, UK.
Angel Lanas, MD, PhD, Service of Gastroenterology, Instituto Aragones de Ciencias de la Salud, University Hospital, CIBERehd. Zaragoza, Spain.

Low-dose acetylsalicylic acid (ASA) is widely used in the prevention of cardiovascular events but can be associated with upper gastrointestinal (GI) complications, including ulcers. In this article, the range of effects of GI toxicity and the epidemiology of ASA-associated events are discussed, as well as risk factors, such as increasing age, that predict bleeding. Strategies to minimize upper GI events in older adults include the use of mucosal protectants such as proton pump inhibitors. The use of alternative antiplatelet agents including clopidogrel or Helicobacter pylori infection eradication may not provide sufficient protection in at-risk individuals who need low-dose ASA.
Key words: low-dose ASA, upper gastrointestinal events, older adults, gastroprotection, proton pump inhibitor.

Bhaskar Ghosh, MD, DNB, DM, MNAMS, Movement Disorders Program, Department of Clinical Neurosciences, University of Calgary, Calgary, AB.
Oksana Suchowersky, MD, FRCPC, FCCMG, Movement Disorders Program, Department of Clinical Neurosciences; Department of Medical Genetics, Faculty of Medicine, University of Calgary, Calgary, AB.

Chorea is a hyperkinetic movement disorder characterized by nonsustained, rapid, and random contractions that may affect all body parts. Chorea is hypothesized to be due to an imbalance between the direct and indirect pathways in the basal ganglia circuitry. Important causes of chorea among older adults include medications, stroke, and toxic-metabolic, infective, immune-mediated, and genetic causes. The history and clinical examination guide appropriate investigations and help determine an accurate diagnosis. In secondary causes, removal of the precipitating cause is the mainstay of treatment. If the chorea is persistent or progressive, drug therapy may be instituted. Genetic counselling is important in hereditary chorea.
Key words: movement disorders, chorea, older adults, diagnosis, treatment.

Ali Ahmed, MD, MPH, FACC, FAHA, FESC, associate professor, Division of Gerontology, Geriatric Medicine, and Palliative Care, Department of Medicine, School of Medicine and Department of Epidemiology, School of Public Health, University of Alabama at Birmingham; director, Geriatric Heart Failure Clinics, Veterans Affairs Medical Center, Birmingham, AB, USA.

Heart failure (HF) is the leading cause of hospitalization among older adults. Digoxin has been shown to reduce hospitalization due to worsening HF. However, at the commonly prescribed dose of 0.25 mg/day, digoxin does not reduce mortality. New data suggest that at low doses (0.125 mg/day or lower) digoxin not only reduces hospitalization due to HF, but may also reduce mortality. Further, at lower doses, it also reduces the risk of digoxin toxicity and obviates the need for routine serum digoxin level testing. Digoxin in low doses should be prescribed to older adults with symptomatic HF.
Key words: chronic heart failure, older adults, treatment, digoxin, update.