Vikas Kuriachan, MD, FRCP(C), Fellow, Cardiac Arrhythmia, Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, AB.
Robert Sheldon, MD, PhD, FRCP(C), Professor, Cardiac Sciences, and Associate Dean of
Clinical Research, Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, AB.

The implantable cardioverter defibrillator (ICD) plays an important role in primary and secondary preventions of sudden cardiac death. Several trials conducted in the past few years have shown the superiority of ICDs over drug therapy. Cardiac resynchronization therapy (CRT) is also emerging as an adjunctive treatment for heart failure, with some survival benefits as well. This article reviews the major recent clinical trials of ICD and CRT devices and summarizes their importance in contemporary cardiology.
Key words: cardioverter defibrillator, cardiac resynchronization, older adults, sudden cardiac death, cardiology.

Jagdish Butany, MBBS, MS, FRCPC, Department of Pathology, Toronto General Hospital, University Health Network; Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON.
Gursharan S. Soor, BSc, Department of Pathology, Toronto General Hospital, University Health Network, Toronto, ON.
Adriana Luk, BSc, Department of Pathology, Toronto General Hospital, University Health Network, Toronto, ON.
Anna Woo, MD, FRCPC, FACC, Hypertrophic Cardiomyopathy Program, Division of Cardiology, Toronto General Hospital; Department of Medicine, University of Toronto,Toronto, ON.
Anthony Ralph-Edwards, MD, FRCSC, Division of Surgery, Toronto General Hospital, University of Toronto, Toronto, ON.
Heather Ross, MD, FRCPC, Department of Medicine, Division of Cardiology, University of Toronto, Toronto General Hospital, Toronto, ON.

Hypertrophic cardiomyopathy (HCM) is an uncommon disease with significant consequences. Since the 1950s, major strides in understanding its etiology and pathogenesis have led to improved management and patient survival. Hypertrophic cardiomyopathy is associated with various mutations in several cardiac sarcomeric genes. Due to the complications of HCM, such as left ventricular outflow tract obstruction, diastolic dysfunction, arrhythmias, increased risk of stroke, infective endocarditis, and, most importantly, sudden cardiac death, appropriate and timely diagnosis is critical. This review summarizes current knowledge about HCM and the most appropriate investigations for persons suspected of having HCM. Treatment strategies for the disease and its complications are presented briefly.
Key words: hypertrophic cardiomyopathy, cardiomyopathy, sudden cardiac death, older adults.

The burden of heart failure is rapidly rising. Heart failure is associated with substantial mortality, morbidity, and economic cost, which disproportionately affect older adults. Heart failure among older individuals is frequently complicated by geriatric syndromes, including frailty, functional decline, cognitive impairment, and atypical clinical presentations. Understanding the nature of these geriatric syndromes and their impact on the assessment and management of heart failure is a critical component to diagnosing and delivering appropriate care to these patients. In this article we review the geriatric aspects of heart failure.
Key words: geriatric syndrome, heart failure, older adults, diagnosis, frailty.

Fatemeh Akbarian, MD, Dermatologist, Clinical Research Fellow, University of Toronto, Toronto, ON.
Vahid Ghafarian, MD, MPH, BSc.PT, Physiotherapist, Northpark Physiotherapy and Annex Retirement Residence, Toronto, ON.
Mohammad Ali Shafiee, MD, FRCPC, General Internist, Nephrologist, Department of Medicine, Toronto General Hospital, University Health Network; Clinician Teacher, University of Toronto, Toronto, ON.

Treatment-resistant hypertension (TRHTN) is a common challenge in geriatric practice and a significant cause of mortality and morbidity among older adults. In this overview, we will use a case-based approach to define the magnitude of the problem, identify characteristics of individuals with TRHTN, and explore the causes of uncontrolled hypertension including technical issues, patient-related and physician-related factors, and secondary causes of hypertension. We will then provide a simple approach to the problem, illustrating straightforward diagnostic workup and therapeutic options. In our approach most of the emphasis has been given to detailed history-taking and a targeted physical examination.
Key words: resistant hypertension, hyperaldosteronism, obstructive sleep apnea, older adults.

Hershl Berman, MD, FRCPC, Assistant Professor, University of Toronto Faculty of Medicine, Department of Medicine, University Health Network, Toronto, ON.
Laura Brooks, RegN, MscN, APN, Advanced Practice Nurse in Palliative Care, Department of Psychosocial Oncology and Palliative Care, University Health Network, Toronto, ON.
Shawna Silver, MD, PEng, Hospital for Sick Children; University of Toronto, Toronto, ON.

Constipation is a common complaint, especially in older adults. It results in millions of physician visits per year, with hundreds of millions of dollars spent on laxatives. Untreated it can lead to serious morbidity and can be a contributing factor in mortality. A rational approach to the patient presenting with constipation includes a detailed history, general and focused physical examination, specific investigations, and appropriate therapy. Treatment should aim to address the underlying cause, as should the choice of laxative. In general, it is best to clear out hard stool in the distal bowel before using an aggressive oral regimen.
Key words: constipation, laxatives, older adults, opioids.

Barry D. Bultz, PhD, Director, Department of Psychosocial Resources, Tom Baker Cancer Centre, Alberta Cancer Board; Department of Oncology, University of Calgary, Calgary, AB.
Bejoy C. Thomas, PhD, Department of Psychosocial Resources, Tom Baker Cancer Centre, Alberta Cancer Board, Calgary, AB.
Douglas A. Stewart, MD, FRCPC, Divisions of Medical Oncology and Hematology, Departments of Oncology and Medicine, Tom Baker Cancer Centre and University of Calgary, Calgary, AB.
Linda E. Carlson, PhD, Department of Psychosocial Resources, Tom Baker Cancer Centre, Alberta Cancer Board; Department of Oncology, University of Calgary, Calgary, Alberta, Canada

Cancer is perceived as an illness that most frequently affects the older adult population, yet there is a dearth of research on the psychosocial aspects of cancer affecting this cohort. The effect of chemotherapy on the psychosocial sequelae in this group is moderately researched. This article discusses emotional distress across the trajectory of cancer care in the older adult population. It also identifies key milestones, times when distress is likely to peak, and the psychological, physiological, and social symptoms of distress. The benefits of psychosocial interventions are also discussed.
Key words: older adult, cancer, chemotherapy, emotional distress, 6th vital sign.

Andrew Liu, BSc Hon, BScPhm, RPh, Clinical Pharmacist, Thrombosis Service, Toronto East General Hospital, Toronto, ON.
Carmine Stumpo, BScPhm, PharmD, RPh, Director, Pharmacy and Emergency Services, Toronto East General Hospital, Toronto, ON.

Warfarin-drug interactions are often encountered in the care of older adults. Interactions may be classified as pharmacokinetic, resulting in changes in serum warfarin concentrations, or pharmacodynamic, resulting in changes in hemostasis or platelet function. Knowledge of these mechanisms of warfarin-drug interactions may help identify warfarin interactions, facilitate prescribing decisions, and assist with appropriate monitoring.
Key words: warfarin, drug interactions, anticoagulants, cytochrome P-450 enzyme system, older adults.

Madhav V. Rao, MD1, Department of Medicine, Section of Nephrology, University of Chicago, Chicago, IL, USA.
Vijaykumar M. Rao, MD, FACP, FASN, President, Associates in Nephrology, Chicago, IL, USA.

Alterations in potassium balance occur frequently in all patient populations, but in particular, among older adults. Physicians commonly encounter such disorders when taking care of patients in the clinic or in the hospital. Most often the etiology of such disturbances is due to prescribed medications, but a number of clinical conditions exist which predispose people to both hyperkalemia and hypokalemia. These conditions can have grave consequences if not addressed quickly. Furthermore, the approach to definitive treatment depends on the underlying physiology that often occurs at the tubular level within the kidney.
Key words: potassium balance, hyperkalemia, hypokalemia, older adults.

Gemini Tanna, MD, FRCPC, Division of Nephrology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
Sarbjit Vanita Jassal, MB, BCh, MD, Division of Nephrology, University Health Network, University of Toronto, Toronto, Ontario, Canada

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Chronic kidney disease (CKD) is increasingly common among older adults. In the older individual, the presence of CKD is predictive of cardiovascular death, increased all- cause mortality, and progression to end-stage renal disease and the need for dialysis. Early identification of these high-risk individuals may prevent or delay such adverse outcomes. The Canadian Society of Nephrology (CSN) released a position statement in September 2006 suggesting that screening be limited to those at high risk. We recommend that clinicians follow the CSN algorithm for screening for CKD among older adults.
Key words: chronic kidney disease, estimated glomerular filtration rate, older adults, renal function, screening.

MC Faes, MD, MSc, Department of Geriatric Medicine, University Medical Centre Nijmegen, The Netherlands.
MG Spigt, PhD, Department of General Practice/Research Institute CAPHRI, University of Maastricht, The Netherlands.
MGM Olde Rikkert MD, PhD, Department of Geriatric Medicine, University Medical Centre Nijmegen, The Netherlands.

Homeostasis of fluid balance is an important prerequisite for healthy aging. The high prevalence of disturbances of fluid balance among older adult patients has triggered clinical research on age- and disease-related changes in water homeostasis. Empirical findings on risk factors of dehydration and on diagnostic and therapeutic strategies are reviewed in this paper. No single measure has proved to be the gold standard in the diagnosis of dehydration. Diagnosing dehydration and monitoring fluid balance requires repeated measurements of weight, creatinine, and physical signs such as tongue hydration. Rehydration and prevention requires fluid on prescription (> 1.5 litre/day), and the route of fluid administration depends on the acuteness and severity of clinical signs.
Keywords: older adults, dehydration, fluid therapy, risk factors, diagnosis.