Summer is almost here as I write this editorial. After a long winter in Canada, one of the real pleasures of spring and summer is getting out of the house and walking. It is a wonderful time to see neighbours again and to see the gardens blooming. However, these simple pleasures of life are difficult to enjoy if one’s mobility is limited and, unfortunately, this is often the case as we age. Arthritis is the number one condition impairing the quality of life of community-dwelling older people, but we physicians often do not take it seriously enough. That is why Geriatrics & Aging regularly has theme issues on musculoskeletal problems: we try to remind clinicians of the importance of mobility in maintaining quality of life.

We have all had muscle cramps at one time or another, but are the cramps older adults get different? It will be easy to find out, just read the article “Muscle Cramps in Older Adults” by Dr. David Guay. Modern imaging has made the diagnosis of spinal stenosis much easier to ascertain but has raised many questions about proper management. The article “Management of Spinal Stenosis” by Drs. Maria Frazer and John Markman is an attempt to answer some of these difficult questions. The article “Intra-articular Corticosteroids in Osteoarthritis” by Dr. Sunita Paudyal and Dr. Stephen Campbell will help the primary care physician utilize this treatment modality in a rational manner.

We also have our usual potpourri of articles on various topics. Our cardiovascular column “Orthostatic Hypotension Screening in Older Adults Taking Antihypertensive Agents” is by Dr. Kenneth Madden, who is also the new associate editor of the Canadian Journal of Geriatrics. Our dementia column addresses a difficult and eternal issue in geriatric medicine, “Adherence to Medication in Patients with Dementia: Problems and Solutions,” and is written by Dr. Dan Brauner. Our caregiving column addresses the topic of “Caregiver Stress: The Physician’s Role” and is by Dr. Abisola Famakinwa. Our technology in medicine column this month is relatively low tech but very important to older adults, namely “Canes & Walkers: A Practical Guide to Prescribing” by Dr. Robert Lam and Alison Wong.

Enjoy this month’s issue,
Barry Goldlist

David R.P. Guay, PharmD, College of Pharmacy, University of Minnesota; HealthPartners Geriatrics, Minneapolis, MN, USA.

Symptomatic muscle cramps in older adults can be extremely painful and seriously compromise health-related quality of life. Although numerous etiologies exist for muscle cramps, the majority in older adults are benign in nature (also called ordinary) and of unknown etiology. Serious systemic disorders associated with cramping illness can usually be readily ruled out by obtaining a thorough medical history and performing a targeted physical examination. Active or passive muscle stretching is the treatment of choice for acute ordinary muscle cramps. To prevent recurrent ordinary muscle cramps, drug therapy with quinine has been advocated for many years. However, a critical review of its efficacy and tolerability reveals a compound of questionable efficacy with substantial toxicity risks. Selected muscle relaxants, gabapentin, and verapamil may be preferable to use as initial therapy, but the use of these agents is also not supported by rigorous research data. Modestly effective treatments have been identified for cramps caused by hemodialysis, cirrhosis, and some neurological disorders.
Key words: muscle cramps, cramp syndrome, muscle contraction syndrome, quinine, quality of life.

Pascal Jean-Pierre, PhD, Department of Radiation Oncology, Department of Family Medicine, University of Rochester Medical Center, Rochester, New York, USA.
Gary Morrow, PhD, MS, Department of Radiation Oncology, Department of Psychiatry, University of Rochester Medical Center, Rochester, New York, USA.

Fatigue due to cancer and its treatments is a highly prevalent and debilitating symptom experienced by many patients. This symptom is often present prior to a pathologically confirmed diagnosis of cancer and can be experienced both during and for considerable periods after treatment. Oncology professionals are becoming more cognizant of the impact of cancer-related fatigue on key aspects of patients’ psychosocial performance, cognitive functioning, and overall quality of life. This paper discusses the importance of cancer-related fatigue, the challenges involved in assessing this debilitating symptom among cancer patients, and the influence of researchers’ conceptualization of this symptom on the characteristics of the measures developed to assess it. Strategies to facilitate differential diagnosis of cancer-related fatigue are also presented and discussed.
Key words: cancer-related fatigue, assessment, measurement dimension, older adults, quality of life.

Julie Lemieux, MD, MSc, FRCPC, Adjunct Professor, Department of Medicine, Université Laval, Centre des maladies du sein Deschênes-Fabia, Centre d’hématologie et d’immunologie clinique, Unité de recherche en santé des populations, Hôpital St-Sacrement du Centre Hospitalier affilié de l’Université Laval, Québec, QC.
Louise Provencher, MD, MA, FRCSC, Associate professor, Department of Surgery, Université Laval, Centre des maladies du sein Deschênes-Fabia, Unité de recherche en santé des populations, Hôpital St-Sacrement du Centre Hospitalier affilié de l’Université Laval, Québec, QC.

A large proportion of breast cancers in older women have positive hormone receptors. Therefore, these women are eligible to receive adjuvant endocrine therapy to decrease their chance of cancer recurrence. Over the last few years, a new class of endocrine therapy, aromatase inhibitors (AIs), has challenged the place of tamoxifen as the gold standard adjuvant endocrine agent. We will discuss randomized clinical trials comparing tamoxifen to AIs in terms of efficacy and side effects.
Key words: breast cancer, tamoxifen, aromatase inhibitors, side effects, quality of life.

Michael A. Borger, MD, PhD, Division of Cardiovascular Surgery, Toronto General Hospital and Department of Surgery, University of Toronto, Toronto, ON.
Tirone E. David, MD, Division of Cardiovascular Surgery, Toronto General Hospital and Department of Surgery, University of Toronto, Toronto, ON.

Systolic murmurs in older adults require investigation with echocardiography. The most common cause is aortic sclerosis, which does not require therapy, followed by aortic stenosis. Surgery is indicated for aortic stenosis in patients with symptoms (fatigue, shortness of breath, angina and/or syncope) and in asymptomatic patients with left ventricular dysfunction or marked hypertrophy. Older aortic stenosis patients can undergo surgery with minimal increased risk, excellent long-term outcomes, and marked improvements in quality of life. Such patients may be referred directly to cardiac surgeons in order to limit age discrimination that may be present within the medical community.
Key words: aortic stenosis, congestive heart failure, aortic valve replacement, quality of life, outcomes.

Dale A. Lund, PhD, Professor of Gerontology & Sociology, University of Utah Center on Aging, Salt Lake City, UT, USA.
Scott D. Wright, PhD, Associate Professor of Gerontology, University of Utah Center on Aging, Salt Lake City, UT, USA.
Michael S. Caserta, PhD, Associate Professor of Gerontology, University of Utah Center on Aging, Salt Lake City, UT, USA.

Obtaining respite, defined as having time away from performing caregiving tasks and meeting various responsibilities, has been found to be the single most desired and needed service by family caregivers to older adults. Although respite has the potential to enhance the quality of life for most caregivers, far too many caregivers wait too long to use the services, do not use them often or regularly enough, or spend their respite time unwisely (thus not deriving the maximum benefit). Also, many caregivers feel guilty and reluctant to use the services even when they are available. This article helps document the value of using respite services, describes the various forms in which they are available, and offers suggestions on how to make the most out of these promising services.

Key words: respite, caregiving, older adults, quality of life.

Jane Oshinowo, RN(EC), BScN, PNC, Primary Health Care Nurse Practitioner, York Community Services, Staff Nurse, St. Michael’s Hospital, Toronto, ON.

Heart failure is a serious illness characterized by impaired quality of life, decreased survival and frequent hospitalization, which mainly affects older adults. As the population ages, there is concern that congestive heart failure-related costs will place an undue strain on the health care system unless more cost-effective management is implemented. Various multidisciplinary strategies researched have demonstrated improved quality of life, reduced hospitalization, a trend towards decreased mortality, and a potential for cost savings.
Key words: heart failure, quality of life, cardiac nurse, disease management, cost.