Tarek Rajji, MD, Geriatric Mental Health Program, Centre for Addiction and Mental Health; Department of Psychiatry, University of Toronto, Toronto, ON.
Benoit H. Mulsant, MD, MSc, FRCPC, Western Psychiatric Institute and Clinic and Department of Psychiatry, University of Pittsburgh, Pittsburgh, USA; Geriatric Mental Health Program, Centre for Addiction and Mental Health; Department of Psychiatry, University of Toronto, Toronto, ON.
Hiroyuki Uchida, MD, PhD, PET Centre, Centre for Addiction and Mental Health, Toronto, ON.
David Mamo, MD, MSc, FRCPC, PET Centre and Geriatric Mental Health Program, Centre for Addiction and Mental Health; Department of Psychiatry, University of Toronto; Centre for Addiction and Mental Health, Toronto, ON.

Antipsychotics are increasingly being prescribed to older patients for the management of a variety of neuropsychiatric conditions. Available evidence supports the use of second-generation antipsychotics (SGAs) when treating these conditions. However, given their modest clinical effect for certain conditions (e.g., behavioural and psychological symptoms of dementia), their adverse effects, and their safety profile, a careful analysis of their risks and benefits is needed before initiating treatment with an SGA for an older patient. Among SGAs, choice of medication should be guided by their respective clinical indications and adverse effect profile, with use of lower initial and target doses (compared to younger adults) and periodic reviews of whether or not their continued use is warranted.
Key words: antipsychotics, older adults, dementia, delirium, schizophrenia.

Kati Juva, MD, PhD, Department of Psychiatry, Helsinki University Central Hospital, Helsinki, Finland.
Sari Rastas, MD, PhD, Department of Neuroscience and Neurology, University of Kuopio, Kuopio, Finland; Kauniala Disabled War Veterans’ Hospital, Espoo, Finland.
Tuula Pirttilä, PhD, Professor, Department of Neuroscience and Neurology, University of Kuopio and Kuopio University Hospital, Kuopio, Finland.

The harmful effects of high blood pressure on cardiovascular morbidity and mortality are well established. However, hypertension in the very old is an extremely complex issue. Current epidemiological data suggest that high blood pressure may be a marker of survival in the very old, and lowering blood pressure may lead to an increase in total mortality. In this review we will summarize the evidence on the association between blood pressure and mortality and discuss the implications of the data.
Key words: older adults, hypertension, survival, very old, blood pressure.

Jeremy Gilbert, MD, FRCPC, Staff Endocrinologist, Toronto General Hospital, Toronto, ON.

Diabetes is a very common condition, especially among older adults. There are numerous benefits associated with improved glycemic control. However, achieving glycemic targets can be challenging, particularly for older adults with comorbidities. In recent years more oral antihyperglycemic agents have become available to better manage diabetes, and there are many pharmacological therapies currently in development. In order to select the most appropriate agent to use as monotherapy or in combination for an individual patient, it is important to be familiar with the mechanism, efficacy, safety, and cost of the various antihyperglycemic agents.
Key words: diabetes, older adults, oral antihyperglycemic agents, monotherapy, combination therapy.

Maitreyi Raman, MD, FRCPC, Assistant Professor, Department of Medicine, Division of Gastroenterology, University of Calgary, Calgary, AB.
Elaheh Aghdassi, PhD, Scientific Associate, University of Toronto, Toronto, ON.
Johane P. Allard, PhD, Associate Professor, Division of Gastroenterology, Department of Medicine, University of Toronto, Toronto, ON.

Zinc is one of the essential micronutrients and has an important role in the maintenance of human health. Older adults are particularly vulnerable to zinc deficiency due to poor intake of zinc-rich foods. Zinc deficiency may result from poor intake due to alterations in both olfactory and gustatory sensations in addition to difficulty in mastication from poor dentition, or due to inadequate absorption resulting from excess consumption of phytate-containing products that inhibit the absorption of zinc. This review focuses on the clinical consequences associated with zinc deficiency among older adults.
Key words: zinc, deficiency, older adults, clinical manifestations.

Alberto Matteelli, MD, Institute of Infectious and Tropical Diseases, University of Brescia, Brescia, Italy.
Anna Cristina Carvalho, MD, Institute of Infectious and Tropical Diseases, University of Brescia, Brescia, Italy.
Veronica Dal Punta, MD, Institute of Infectious and Tropical Diseases, University of Brescia, Brescia, Italy.

The number of international travellers is steadily increasing, paralleled by the number of persons with travel-related diseases. Fever in the returning traveller should always raise suspicion of severe and potentially life-threatening infections. Therefore, physicians should be familiar with the most common syndromes, relevant diagnostic procedures, optimal treatment regimens, and referral criteria. This review gives a general overview of the pathogens causing fever in the returning traveller, their clinical presentation, and standard management procedures.
Key words: fever, travel, older adults, tropical diseases, vaccination.

Indranil Dasgupta, MD, MPh, MBA, Clinical Assistant Professor of Medicine, Division of Cardiology, Department of Medicine, Jefferson Medical College, Thomas Jefferson University, Philadelphia, PA.
Marc A. Tecce, MD, Clinical Assistant Professor of Medicine, Division of Cardiology, Department of Medicine, Jefferson Medical College, Thomas Jefferson University, Philadelphia, PA.
Bernard L. Segal, MD, Professor of Medicine and Director, Division of Cardiology, Department of Medicine, Jefferson Medical College, Thomas Jefferson University, Philadelphia, PA.

Disorders of the mitral valve such as mitral valve prolapse (MVP), mitral regurgitation, and, to a lesser degree, mitral stenosis are relatively common forms of heart disease. According to the Women’s Heart Foundation, MVP is the most common condition of the heart valves, and while it is more frequently diagnosed in young women, data from the Framingham study suggest that, overall, MVP affects equal numbers of men and women. These conditions often progress over years, frequently causing symptoms among affected older adults. Understanding the etiology, diagnosis, management, and treatment of mitral valve disease is vital for this population. Medical advances and other factors have allowed the general population to live longer, making mitral valve disease significantly more prevalent. An understanding of the details of the physical exam, ECG changes seen in these disorders, x-ray findings, and echocardiographic and catheterization data are critical to providing the necessary standard of care for older adults.
Key words: mitral regurgitation, mitral stenosis, mitral valve prolapse, older adults, heart failure.

Lili Liu, PhD, Associate Professor and Associate Chair, Department of Occupational Therapy, Faculty of Rehabilitation Medicine, University of Alberta, Edmonton, AB.
Alison Barnfather, MSc, Co-Director, Social Support Research Program, University of Alberta, Edmonton, AB.
Miriam Stewart, PhD, Scientific Director, Institute of Gender and Health, Canadian Institutes of Health Research; Professor, Faculties of Nursing, Medicine and Dentistry, and School of Public Health; Principal Investigator, Social Support Research Program. University of Alberta, Edmonton, AB.

In Canada, older adults are the most likely of all age groups to experience chronic health conditions. Most Canadians living with disabilities or chronic conditions and most older adults are supported by family members or close friends. Caregivers frequently describe the emotional, physical, and financial burdens associated with the caregiver role. Accessible support programs can improve health outcomes for family/friend caregivers of older adults with chronic conditions. Practitioners can use the strategies presented to help caregivers access timely and accessible support resources.
Key words: family caregivers, caregiver support, older adults, home care, chronic conditions.

Susan L. Eldred, RN, BScN, MBA, PhD candidate, University of Ottawa, Ottawa, ON.
Wendy A. Gifford, RN, PhD candidate, University of Ottawa, Ottawa, ON.

HIV/AIDS is rapidly increasing among adults age 50 and older. However, limited research has been conducted to understand the issues associated with HIV/AIDS in advancing age. This paper describes issues related to the transmission and contraction of HIV/AIDS among older adults, their complex clinical picture, and management of antiretroviral therapy, as well as social considerations. Cognizance of polypharmacy and comorbidities common with advanced age as well as the double stigmatization of age and HIV/AIDS is essential. Further research is needed to better understand the interactions between HIV/AIDS and age, and to determine effective, safe treatments and appropriate highly active antiretroviral therapy dosing in older adults.
Key words: HIV, AIDS, sexually transmitted diseases, older adults, highly active antiretroviral therapy.

Oren K. Steinmetz, MDCM, FRCSC, Associate Professor of Surgery, McGill University; Chief, Division of Vascular Surgery, McGill University Health Centre, Montreal, QC.
Peter I. Midgley, MD, FRCSC, Vascular Surgery Fellow, McGill University, Montreal QC.

Abdominal aortic aneurysms are a common cause of death among older adults in North America. Most commonly they are asymptomatic until they rupture. Rupture of an abdominal aortic aneurysm is usually lethal, so effective treatment to prevent rupture depends on accurate diagnosis on physical exam or one of various imaging modalities such as ultrasound, CT scan, or magnetic resonance imaging. Once the diagnosis is made, choice of treatment will depend on several factors including patient age and comorbidity, and aneurysm diameter. If elective treatment is contemplated there are currently two main options available to most patients: open surgical repair and endovascular repair. The fundamental differences between these two treatment options are outlined in this review.
Key words: abdominal aortic aneurysm, open surgical repair, endovascular aneurysm repair, older adults, aortic rupture.

Philippe Voyer, RN, PhD, Associate Professor, Faculty of Nursing, Laval University; Researcher, Laval University Geriatric Research Unit,St-Sacrement Hospital, Quebec, QC.
Michel Préville, MD, Associate Professor, Faculty of Medicine, Université de Sherbrooke; Researcher, Research Centre on Aging, Sherbrooke Geriatric University Institute, Sherbrooke, QC.
and Researchers of the Étude sur la santé des aînés team.

Sleep complaints by older adults constitute a very common situation faced by health care providers. However, not all professionals respond to the complaint the same way. Some will briefly assess the complaint and resort rather quickly to medication while others will assess the complaint carefully in order to exclude the diagnosis of primary insomnia and prescribe alternative interventions to improve sleep. When medicine is prescribed, the type of compound often selected is benzodiazepine. However, benzodiazepine carries a significant risk of adverse reaction, including drug dependency, both of which are clinical problems that should not be underrated, especially when treating a subjective complaint and not a specific diagnosis.
Key words: insomnia, benzodiazepine, dependency, addiction, older adults.