Zena Moore, RGN, MSc, FFNMRCSI, Health Research Board of Ireland, Clinical Nursing and Midwifery Research Fellow, Royal College of Surgeons in Ireland, Dublin, Ireland.
Seamus Cowman, PhD, MSc, FFNMRCSI, P.G Cert Ed (Adults), Dip N (London), RNT, RGN, RPN, Professor and Head of Department, Faculty of Nursing and Midwifery, Royal College of Surgeons in Ireland, Dublin, Ireland.

Pressure ulcers are common, costly, and adversely affect quality of life. Nutritional status is one risk factor that predisposes individuals to the development of a pressure ulcer. The impact of nutritional supplementation is reflected in the reduced incidence of pressure ulcers; however, the evidence is limited. The precise role of nutritional supplementation in pressure ulcer healing is less clear, yet a trend towards healing has been suggested. Patients should have their nutritional status monitored carefully. If difficulties arise, these should be detected early, and if it is not possible to increase the intake of normal food and fluids, then advice should be sought from the dietitian.
Key words: pressure ulcers, risk, prevention, treatment, nutrition.

Muhammad Firdaus, MD, FACP, Section of Endocrinology, Department of Medicine, University of Oklahoma Health Sciences Center; Veterans Affairs Medical Center, Oklahoma City, OK, USA.
Timothy J Lyons, MD, FRCP, Section of Endocrinology, Department of Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA.

The metabolic syndrome, though controversial due to lack of a uniform pathophysiological mechanism, is a useful clinical tool for identifying persons at risk for diabetes and cardiovascular disease. It indicates the cumulative cardiometabolic risk exerted by abdominal obesity, hyperglycemia, high triglyceride, low high density lipoprotein cholesterol (HDL-C), and high blood pressure. Lifestyle factors, high calorie intake, and less physical activity have been implicated in the causation of the metabolic syndrome, and thus older adults are at particular risk for the development of this syndrome. Current evidence indicates that the components of the metabolic syndrome can be targeted with lifestyle interventions to prevent the complications of diabetes and cardiovascular disease. This paper reviews various diagnostic criteria, etiological factors, and lifestyle interventions to combat the metabolic syndrome in order to prevent diabetes and cardiovascular disease in older adults.
Key words: metabolic syndrome, prevention, lifestyle modification, diet, physical activity.

Guido Falcone, MD, Department of Neurology, Raul Carrea Institute for Neurological Research (FLENI), Buenos Aires, Argentina.
Ji Y. Chong, MD, Assistant Professor of Neurology, Columbia University, New York, NY, U.S.A.

Stroke is a common disease in the older population. Many gender differences are seen in the epidemiology, outcomes, and treatment of geriatric stroke. Although these differences are not fully understood, recognition of gender differences may help with appropriate treatment and improve outcomes.
Key words: stroke, gender, outcomes, prevention, treatment.

Victoria A. Walker, MD, Department of Internal Medicine, Division of Geriatric Medicine, Duke University Medical Center, Durham, North Carolina, USA.
Heather E. Whitson, MD, Department of Internal Medicine, Division of Geriatric Medicine, Duke University Medical Center, Durham, North Carolina, USA.

Smoking is the leading cause of preventable death worldwide. Though older adults are the segment of the population least likely to smoke, they incur significant morbidity and mortality from tobacco use and can benefit from quitting. Older smokers have beliefs regarding smoking and motivating factors for cessation that differ from younger adults. Clinicians should understand these unique factors and can then use strategies to assist the older adult in smoking cessation.
Key words: smoking cessation, tobacco, epidemiology, older adults, prevention.

Sudeep S. Gill, MD, MSc, FRCPC, Assistant Professor, Division of Geriatric Medicine, Queen’s University, Kingston, ON.

Delirium is common among hospitalized older adults and is associated with significant morbidity and excess mortality. Despite its prevalence and consequences, delirium is often underrecognized and undertreated. Antipsychotic drugs are commonly used to manage symptoms of delirium, but few controlled trials exist to support their efficacy and safety in this setting. Several recent studies have focussed on preventing delirium in high-risk populations. Clinical trials have demonstrated benefits with multifaceted nonpharmacological interventions, but widespread implementation of these interventions has not yet occurred. Two recent drug trials evaluated an antipsychotic and a cholinesterase inhibitor to prevent delirium, but neither trial demonstrated a reduction in incident delirium. At present, the most promising approach involves targeted, multifactorial interventions that focus on preventing delirium in high-risk patient groups. More work is needed to facilitate the implementation of these evidence-based strategies.
Key words: delirium, prevention, treatment, antipsychotic drugs, cholinesterase inhibitors.

Joseph F. Coffey, BSc, MD, PGY4 Dermatology, University of Alberta, Edmonton, AB.
Gordon E. Searles, OD, MD, MSc, FRCPC, Assistant Clinical Professor; Program Director, University of Alberta, Edmonton, AB.

As the population ages, the corresponding rise in incidence of skin cancer and photodamaged skin necessitate skin assessments of older patients in the dermatology clinic. Sallowness, wrinkles, solar lentigos, and other benign conditions reflect extensive ultraviolet damage to the skin, and provide a background of mutagenesis for skin cancer formation. Some treatments available for photodamaged skin are cosmetic and only available in a dermatology or plastic surgery office setting. However, there are many treatments that improve sun-damaged skin as well as prevent progression to skin cancer formation; these tools are available in the primary care physician’s office. This article addresses ablative and nonablative treatment options for sun-damaged skin and encourages the promotion of sun-safe behaviours, including use of protective clothing and sunscreen.
Key words: photoaging, therapy, prevention, cosmetic, nonablative, ablative.

Barbara Brillhart, RN, PhD, CRRN, FNP-C, Arizona State University, College of Nursing, Tempe, Arizona, USA.

Prevention of and assessment for pressure ulcers and skin tears are the responsibilities of the client, family, caregivers, and the health care team. Prevention will avoid discomfort, disfigurement and decreased quality of life, and decrease health care expenses. Assessment includes use of the Braden, Gosnell, Norton, or Waterlow Scales for pressure ulcers and the Payne-Martin classification for skin tears. Factors to prevent pressure ulcers are pressure relief, prevention of shearing and friction, skin cleansing, plus adequate nutrition and hydration. Variables to prevent skin tears include nonbinding clothing, careful transfers, environmental protection, adequate nutrition and hydration, and individualized skin care.
Key words: pressure ulcers, skin tears, assessment, prevention.

Geriatrics & Aging’s mandate is to provide education about the health concerns of older adults to doctors in Canada and throughout the world (although other health care practitioners also find the journal useful). However, we all learn in different ways, and G&A has long acknowledged this by having an innovative web site and, more recently, by incorporating accredited continuing medical education modules in our journal and website.

I was thrilled to be part of yet another new educational endeavour sponsored by Geriatrics & Aging on the evening of February 8, 2006. This was a live, interactive, web-based educational event. The topics of discussion were the use of cholinesterase inhibitors (starting and switching) and the controversies surrounding atypical antipsychotic use in older patients with dementia (please access recording by logging on to http://cme.geriatricsandaging.ca/p45673593/). I moderated, and we had an all-star panel. Morris Freedman is a behavioural neurologist, and is the head of behavioural neurology at the University of Toronto and the head of neurology at Baycrest Centre for Geriatric Care. Sandra Black, a renowned scientist and clinician also in the field of behavioural neurology, is the head of neurology at Sunnybrook & Women’s in Toronto. David Conn is the head of geriatric psychiatry at Baycrest and one of the driving forces in the national coalition for senior’s mental health. Despite this awesome assemblage of clinical knowledge on the panel, the true stars of the evening were the audience who challenged the panel with difficult questions and even provided some of the answers! Particular thanks to the G&A staff for making this happen: James Schultz, Regina Starr, Mark Varnovitski, and Gennady Kucheruk. Thanks as well to our publisher, Michael Yasny, for his tremendous support.

We also have a great educational issue for you this month, focussed on prevention. Our CME focus is on “Cancer Screening” by our senior editor Shabbir Alibhai, who is fast becoming an international authority on the topic of cancer in older adults. “Screening for and Prescribing Exercise for Older Adults” by Drs. Barbara Resnick, Marcia G. Ory, Michael E. Rogers, Phillip Page, Roseann M. Lyle, Cody Sipe, Wojtek Chodzko-Zajko, and Terry L. Bazzarre addresses one of the most important issues our society faces. The closely related article “Yoga as a Complementary Therapy” is contributed by Dr. Marian Garfinkel. Falls are one of the most important issues facing older adults and the topic of “Ophthalmic Interventions to Help Prevent Falls” is written by Drs. John G. Buckley and David B. Elliott. Our final screening/prevention article, “Should Older People Be Regularly Screened for Vision and Hearing by Primary Health Care Providers?” is by Drs. Jie Jin Wang, Jennifer L. Smith, and Stephen R. Leeder.

We also have our usual collection of articles on other diverse topics. There is “Multiple System Atrophy: An Update” by Drs. Felix Geser and Gregor K. Wenning, and a critically important drug article, “Medication Review for Older Adults,” by Drs. Richard Holland and David Wright. There are numerous drugs that are started for appropriate reasons that are continued even if not effective or when circumstances change. I am particularly pleased to see the article on “Cardiac Rehabilitation in the Older Population” by Dr. Terence Kavanagh. Dr. Kavanagh virtually invented the field of cardiac rehabilitation and is one of Canada’s most distinguished medical practitioners.

Enjoy this issue.
Barry Goldlist

Kevin L. Billups, MD, Urologist & Medical Director, The EpiCenter for Sexual Health & Medicine, Edina; Adjunct Assistant Professor, Laboratory Medicine & Pathology, University of Minnesota, Minneapolis, MN, USA.

Erectile dysfunction (ED) is a prevalent vascular disorder that, like cardiovascular disease, is now believed to cause endothelial dysfunction. In fact, a growing body of literature now suggests that ED may be an early marker for atherosclerosis, increased cardiovascular risk, and subclinical vascular disease. The emerging awareness of ED as a barometer of overall cardiovascular health represents a unique opportunity for primary prevention of vascular disease in all men. Although the implications of this relationship for primary and secondary prevention of cardiovascular disease are not yet fully appreciated, the available literature makes a strong argument for the role of erectile dysfunction as an early marker for the development of significant cardiovascular risk factors and cardiovascular disease. Early detection of erectile dysfunction could play a major role in improving male cardiovascular health.
Key words: erectile dysfunction, cardiovascular disease, atherosclerosis, endothelium, prevention.

Anne-Chantal Braud, Institut Paoli Calmettes, Marseille, France,
Martine Extermann, MD, H. Lee Moffitt Cancer Center and Research Institute and the University of South Florida, Tampa, FL,USA.

Half of breast cancers occur in patients older than 65 and 25% in patients aged 75 or older. Prevention and early diagnosis are a societal but also an individual issue in this population. Good guidelines for screening and prevention are available for patients up to 70, but few data are available for older patients. The present article reviews these data in an effort to provide some guidance to geriatricians and primary physicians about screening and prevention of breast cancer in their older patients. Age alone should not be used to determine when to screen; rather, life expectancy estimates can help decision-making. Patients with a life expectancy of 10 years or more are likely to benefit from mammography screening. Very few data are available for tamoxifen prevention in women older than 70. There is a need for further randomized controlled trials to clarify a host of outstanding issues in improving the prevention and the care of breast cancer in older people.
Key words: older women, breast cancer, mammography, prevention.