Esmé Finlay, MD, Fellow, Division of Hematology/Oncology, Hospital of the University of Pennsylvania, Philadelphia, PA, USA.
Joseph B. Straton, MD, MSCE, Chief Medical Director, Wissahickon Hospice; Assistant Professor, Family Medicine and Community Health; Assistant Professor, Anesthesiology and Critical Care, Hospital of the University of Pennsylvania, Philadelphia, PA, USA.
Jonathan R. Gavrin, MD, Director, Symptom Management and Palliative Care; Clinical Associate Professor, Anesthesiology and Critical Care; Clinical Associate Professor, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA, USA.

Nausea and emesis are distressing symptoms that can contribute to malnutrition, dehydration, and decreased quality of life in older patients. Dopaminergic, cholinergic, histaminergic, serotonergic, and neurokinin receptor mechanisms play roles in the causation of nausea. Pharmacologic therapy targeted at these and other mechanisms is necessary to effectively treat the symptoms of nausea and vomiting. Multidrug regimens that target multiple mechanisms are often needed to control persistent symptoms. However, caution is advised when prescribing these medications in older patients, as many of the effective medications can cause sedation, confusion, or delirium. This article describes the mechanisms of nausea and vomiting and reviews effective treatment regimens.
Key words: nausea, vomiting, emesis, antiemetics, older adults.

Karen L. Smith, MSc, Kunin Lunenfeld Applied Research Unit, Baycrest and Department of Nutritional Sciences, University of Toronto, Toronto, ON.
Carol Greenwood, PhD, Kunin Lunenfeld Applied Research Unit, Baycrest and Department of Nutritional Sciences, University of Toronto, Toronto, ON.
Helene Payette, PhD, Director, Research Center on Aging, Health & Social Services Centre - University Institute of Geriatrics of Sherbrooke, Faculty of Medicine and Health Sciences, University of Sherbrooke, Sherbrooke, QC.
Shabbir M.H. Alibhai, MD, MSc, Division of General Internal Medicine & Clinical Epidemiology, University Health Network; Geriatric Program, Toronto Rehabilitation Institute; Departments of Medicine and Health Policy, Management and Evaluation, University of Toronto, Toronto, ON.

Unintentional weight loss is common among older adults and is associated with significant adverse health outcomes, increased mortality, and progressive disability. The diagnosis is often associated with an underlying illness; however, in as many as one in four older adults with unintentional weight loss, no obvious medical cause can be identified. A variety of nonpharmacologic interventions may improve energy intake and lead to weight gain. The most common approach to the treatment of weight loss among older adults is consumption of high-energy/protein oral supplements between meals as a means of increasing daily energy intake. Involving other health professionals, including a dietitian, may be helpful in the assessment and management plan. In addition, a number of pharmacologic treatments have been investigated, but the potential benefit of these treatments remains unclear.
Key words: weight loss, older adults, malnutrition, oral nutritional supplementation, megestrol.

Richard Saad, MD, Lecturer, Division of Gastroenterology, Department of Medicine, University of Michigan Medical Center, Ann Arbor, MI, USA.
William D. Chey, MD, AGAF, FACG, FACP, Associate Professor of Internal Medicine; Director, GI Physiology Laboratory, University of Michigan Medical Center, Ann Arbor, MI, USA.

Irritable bowel syndrome (IBS) is traditionally considered a disorder of young adulthood; however, it affects adults of all ages, including older adults. As the older population increases so will the impact of IBS in this age group. Irritable bowel syndrome with constipation (IBS-C) is believed to be particularly significant given the prevalence of constipation among the aged. At present, the evaluation and management of this disorder has been largely driven by data obtained from younger adults. However, there are numerous aspects of the underlying pathophysiology, evaluation, and treatment of IBS-C that remain unique to older adults, of which the clinician should be cognizant.
Key words: irritable bowel syndrome, constipation, older adults, functional bowel disorder.

Constantine A. Soulellis, MD, FRCP(C), GI Fellow, McGill University; Division of Gastroenterology, McGill University Health Centre, Montreal, QC.
Carlo A. Fallone, MD, FRCP(C), AGA(F), Associate Professor, McGill University; Director, GI Services, Royal Victoria Site of the McGill University Health Centre, Montreal, QC.

Peptic ulcer disease (PUD) is a prevalent medical problem among older adults. Several issues unique to older adults impart variability and complexity to PUD, making this entity difficult to diagnose and treat. Age-related gastrointestinal physiological changes, increasing prevalence of Helicobacter pylori, comorbidities, and polypharmacy (especially nonsteroidal anti-inflammatory drug [NSAID] use) are factors that potentiate ulcer formation. Older adults may present with few or none of the usual features of PUD, often delaying diagnosis and therapy. The cornerstones of therapy include cessation of NSAIDs, proton pump inhibition, and eradication of H. pylori if present.
Key words: peptic ulcer, older adults, NSAIDs, Helicobacter pylori.

Nahid Azad, MD, Associate Professor, Faculty of Medicine, University of Ottawa, Ottawa, ON.
Arlene S. Bierman, MD, MS, FRCPC, Ontario Women’s Health Council Chair in Women’s Health, Centre for Research on Inner City Health, St. Michael’s Hospital; Faculties of Medicine and Nursing, University of Toronto, Toronto, ON.

Cardiovascular disease (CVD) is a leading cause of morbidity and mortality for both men and women. Among individuals with coronary heart disease (CHD), there are gender differences in clinical epidemiology, prevalence of risk factors, clinical presentation, and quality and outcomes of care. Older adults and older women in particular are at risk for underdiagnosis and suboptimal management of CHD and its risk factors. Adherence to clinical practice guidelines for diagnosis and management of CHD can improve outcomes of care for older men and women with CHD and narrow gender disparities in clinical outcomes.
Key words: cardiovascular disease, gender, older adults, quality of care, women’s health, coronary heart disease.

Jagdish Butany, MBBS, MSc, FRCPC, Department of Pathology, Toronto General Hospital, University Health Network; Departments of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON.
Nasir A. Khan, BSc, Department of Pathology, Toronto General Hospital, University Health Network, Toronto, ON.
Sarah A. Erlich, BSc, Department of Pathology, Toronto General Hospital, University Health Network, Toronto, ON.
Anusha Jegatheeswaran, MD, Department of Cardiac Surgery, Toronto General Hospital, University Health Network, Toronto, ON.
Frances Budden, MD, FRCPC, Department of Geriatric Medicine, St. Joseph’s Health Centre, Toronto, ON.
Vivek Rao, MD, PhD, Department of Cardiac Surgery, Toronto General Hospital, University Health Network, Toronto; Department of Surgery, University of Toronto, Toronto, ON.

The incidence of valvular heart disease continues to increase, and the majority of individuals undergoing heart valve replacement today are older adults. Good postoperative management of these patients is critical and should include a complete history and thorough physical examination along with regular testing (typically including chest x-ray, echocardiogram, and blood tests) to carefully monitor heart function. Older adults are particularly at risk of bleeding and thromboembolic complications and, as such, compliance with anticoagulation and other medication should be closely monitored. Judicious attention to these issues will help minimize potential complications and improve survival in this patient population. This review discusses the postoperative management of older adults with a mechanical or a biological prosthetic heart valve.
Key words: heart valve replacement, prosthetic heart valves, older adults, anticoagulation, prosthetic valve endocarditis.

Shakaib U. Rehman, MD, Primary Care Service Line, Ralph H. Johnson V.A. Medical Center; Department of Medicine, Medical University of South Carolina, Charleston, SC, USA.
Jan N. Basile, MD, Director, Primary Care Service Line, Ralph H. Johnson VA Medical Center; Professor of Medicine, Medical University of South Carolina, Charleston, SC, USA.
Florence N. Hutchison, MD, Chief of Staff, Ralph H. Johnson V.A. Medical Center; Department of Medicine, Medical University of South Carolina, Charleston, SC, USA.

Older patients with hyperthyroidism present with atypical symptoms such as difficulty concentrating. This is in contrast to younger patients, who present with classic symptoms such as heat intolerance, tremor, and tachycardia. Hyperthyroidism in older adults is most often caused by toxic multinodular goiter and Graves’ disease. Thyroid hormones and thyroid-stimulating hormone assays can establish the diagnosis quickly. Antithyroid medication can be used in medically unstable older hyperthyroid patients to quickly suppress the hormones. When the patient is stable, definitive therapies such as radioactive iodine or surgery should be considered. Radioactive iodine therapy is well tolerated and effective. Surgery is indicated in patients who fail to respond to radioactive iodine therapy and patients with multinodular goiter.
Key words: thyrotoxicosis, older adults, hyperthyroidism, Graves’ disease, T3 toxicosis.

Mary Beth Jennings, PhD, Reg. CASLPO, Aud(C), FAAA, Audiologist, Assistant Professor, National Centre for Audiology, Faculty of Health Sciences, University of Western Ontario, London, ON.
Frances Richert, MSc, Reg. CASLPO, Audiologist, H.A. Leeper Speech and Hearing Clinic, School of Communication Sciences and Disorders; National Centre for Audiology, Faculty of Health Sciences, University of Western Ontario, London, ON.

Older adults are the fastest-growing age group in Canada. Hearing loss is highly prevalent among this population. Of those persons who would benefit from the use of hearing aids, only a small number actually own and use them. Digital hearing aids now constitute the majority of hearing aids on the market. Technological advances in hearing aids and hearing assistive technologies have expanded the range of options available to improve the success of device use. Matching the needs and optimizing performance of older adults with the broad range of devices available requires appropriate assessment, selection, verification, and follow-up by the audiologist.
Key words: hearing aids, hearing assistive technologies (HATS), rehabilitation services, older adults.

Clodagh M. Ryan, MD MRCPI, Assistant Professor of Medicine, Division of Respirology, University Health Network / University of Toronto, Toronto, ON.

Chronic cough is defined as a cough that persists longer than eight weeks. It is one of the most frequent complaints of patients attending physicians’ outpatient clinics. Contrary to popular belief, the diagnosis and treatment of the majority of patients can be achieved by following an empiric, integrative approach. As chronic cough may be responsible for significant deterioration in quality of life, successful management and treatment is important for individual patients. Unfortunately, failure to adequately manage chronic cough is usually due to physician ignorance of the current diagnostic algorithms, which pertain as much to older as to younger adults.
Key words: chronic cough, older adults, upper airway cough syndrome, reflux disease, asthma.

Karen L. Smith, MSc, Kunin Lunenfeld Applied Research Unit, Baycrest and Department of Nutritional Sciences, University of Toronto, Toronto, ON.
Carol Greenwood, PhD, Kunin Lunenfeld Applied Research Unit, Baycrest and Department of Nutritional Sciences, University of Toronto, Toronto, ON.
Helene Payette, PhD, Research Center on Aging, Health & Social Services Center - University Institute of Geriatrics of Sherbrooke, Faculty of Medicine and Health Sciences, University of Sherbrooke, Sherbrooke, QC.
Shabbir M.H. Alibhai, MD, MSc, Division of General Internal Medicine & Clinical Epidemiology, University Health Network; Geriatric Program, Toronto Rehabilitation Institute; Departments of Medicine and Health Policy, Management and Evaluation, University of Toronto, Toronto, ON.

Unintentional weight loss is a common problem among community-dwelling older adults. Although a slight decline in body weight is considered a normal part of the aging process, clinically significant weight loss (>5% of usual body weight) has harmful consequences on functional status and quality of life, and is associated with excess mortality over a three- to twelve-month period. A variety of physical and psychological conditions, along with age-related changes, can lead to weight loss. In up to one-quarter of patients, there is no identifiable cause. A rational approach to clinical investigation of these patients can facilitate arriving at a diagnosis and minimize unnecessary diagnostic procedures.
Key words: weight loss, older adults, mortality, epidemiology, diagnosis.