The focus of this issue is Altered Mood and Behaviour in the Older Adult. Although the most common diseases producing changes in mood or behaviour are depression and dementia, altered behaviour may also be the first indication of delirium. Whenever an older adult’s behaviour changes abruptly, delirium should be the first thought that comes to the clinician’s mind. I served as an expert witness several years ago at a coroner’s inquest for an older woman who died in long-term care. The nurse had meticulously detailed changes in behaviour that were classic signs of delirium, but did not understand the significance of these changes and so did not inform the attending physician of them. When the doctor arrived on her usual day to round on her patients, she immediately recognized the gravity of the situation and sent the patient to hospital, where she died shortly thereafter of sepsis and hyperglycemia. A totally preventable death would have been avoided had the staff understood the significance of the change in the patient’s behaviour. The Registered Nurses’ Association of Ontario has been very active in developing educational modules to help nurses distinguish delirium, dementia, and depression, to the great benefit of hospitalized patients.

Over the last few years, our understanding of vascular dementia has expanded beyond the mere presence of strokes in an individual with dementia, and we are now appreciating the more subtle manifestations of the disease. One of the most common behavioural issues that geriatricians see, “Post-Stroke Depression” is discussed by Drs. Lana Rothenburg, Nathan Herrmann, and Krista Lanctôt in their article, which serves as the basis for our CME module. The next piece, “Behavioural Disorders in Vascular Dementia” is by Drs. Rita Moretti, Paola Torre, and Rodolfo M. Antonello. For those of us particularly interested in the differential diagnosis of the type of dementia our patient has, the article “Clinical Differences among Four Common Dementia Syndromes” by Dr. Weerasak Muangpaisan will be especially helpful. Our regular column on dementia this month is “Behavioural Interventions Can Minimize Functional Decline in Mild Cognitive Impairment and Dementia” by Drs. Angela Troyer and Kelly Murphy.

We also have our usual collection of interesting articles on diverse topics. Our CVD article this month is “Diagnosis and Management of Mitral Valve Disease in Older Adults” by Drs. Indranil Dasgupta, Marc Tecce, and Bernard Segal. Dr. Mary Anne Huggins and Laura Brooks have provided the article “Discussing End-of-Life Care with Older Patients: What Are You Waiting For?” Our last two articles are particularly intriguing. Older adults today are often much wealthier than previous generations, and extensive travel is often common during retirement, making the article “Fever in the Returning Traveller” by Dr. Alberto Matelli, Dr. Anna Cristina Carvalho, and Dr. Veronica Dal Punta particularly relevant. Finally we are reminded that social and economic factors result in quite different experiences of aging in the article “Aging in Africa” by Dr. Irene Turpie and Leigh Hunsinger.

Enjoy this issue,
Barry Goldlist

K. C. Giede, MD, FRCP, Clinical Fellow in Gynecologic Oncology, Princess Margaret Hospital, University Health Network, University of Toronto, Toronto, ON; Associate Professor of Gynecology and Obstetrics, University of Saskatchewan, Saskatoon, SK.
A. M. Oza, MD, FRCP, Co-Director, Drug Development Program; Co-Chair, NCIC Clinical Trials Group, Princess Margaret Hospital, University Health Network, University of Toronto, Toronto, ON.

The purpose of this article is to review the incidence, prognosis, and management of metastatic cervical cancer in older patients. A literature review was conducted using the key words cervical cancer, elderly, and metastatic disease. There were no studies found specific to metastatic cervical cancer in older patients. The incidence of cervical cancer over the age of 65 remained significant with a greater proportion of older patients presenting with metastatic disease. We found good phase III data on the use of chemotherapy for metastatic cervical cancer. We reviewed data supporting the safe use of chemotherapy and radiotherapy in older patients.
We conclude that older patients are more likely to present with metastatic cervical cancer then their younger counterparts. Standard therapies should not be withheld on the basis of age, though management should focus on palliation.

Key words: cervical cancer, older patients, metastatic.

David Fitchett, MD FRCP(C), St Michael’s Hospital, University of Toronto, Toronto, ON.

As a response to recent clinical trials of low-density lipoprotein (LDL) lowering, the Adult Treatment Panel III (ATP III) has proposed new thresholds and targets for treatment. In addition, the population that is considered to benefit from LDL lowering has been extended to include the diabetic and the older patient. This article reviews the clinical trial evidence, and the new recommendations, and provides commentary with special reference to management of the older person.

Key words: cardiovascular disease, LDL cholesterol, statin therapy, older patients, diabetes.