Dimitri M. Drekonja, MD, MS, Staff Physician, Minneapolis Veterans Affairs Medical Center; Assistant Professor of Medicine, University of Minnesota Medical School, Minneapolis, MN, USA.

Urinary tract infections (UTIs) are a frequent diagnosis in older adults, leading to substantial antimicrobial use. Increased antimicrobial use is associated with higher rates of resistance, making future infections more difficult to treat. Unfortunately, many UTIs actually represent asymptomatic bacteriuria, which should not be treated in most cases. Adhering to clinical guidelines (based on high-quality evidence from randomized trials) would likely result in fewer UTI diagnoses, less antimicrobial use, and decreased antimicrobial resistance. Knowing when treatment for asymptomatic bacteriuria is recommended, and limiting therapy to these well defined circumstances is vital to appropriately managing a patient with a positive urine culture.
Key words: urinary tract infection, asymptomatic bacteriuria, catheter-associated bacteriuria, antimicrobial management.

Natasha Bagdasarian, MD, Department of Internal Medicine, Divisions of Infectious Diseases, University of Michigan Health System, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, MI, USA.
Preeti N. Malani, MD, Department of Internal Medicine, Divisions of Infectious Diseases and Geriatric Medicine, University of Michigan Health System, Veterans Affairs Ann Arbor Healthcare System; Geriatric Research Education and Clinical Center, Ann Arbor, MI, USA.

The treatment and prevention of Clostridium difficile infection (CDI) in the long-term care (LTC) setting presents unique challenges. In this review, we offer an overview of CDI treatment along with a brief discussion of infection control strategies in the LTC setting. The approach to recurrent CDI is also addressed.
Key words: Clostridium difficile, aging, metronidazole, vancomycin, long-term care.

D.F. Gilpin, PhD, Research Fellow, School of Pharmacy, Queen’s University, Belfast, Northern Ireland.
M.M. Tunney, PhD, Senior Lecturer, School of Pharmacy, Queen’s University, Belfast, Northern Ireland.
N. Baldwin, PhD, Research Fellow, School of Pharmacy, Queen’s University, Belfast, Northern Ireland.
C.M. Hughes, PhD, Professor, School of Pharmacy, Queen’s University, Belfast, Northern Ireland.

Methicillin-resistant Staphlyococcus aureus (MRSA) and vancomycin-resistant Enterococci (VRE) are responsible for substantial morbidity and mortality in acute care settings. Older residents in long-term care (LTC) facilities possess many of the risk factors for colonization with these antibiotic resistant bacteria, and the potential exists for both transmission, via transiently colonized staff, within LTC, and subsequent reintroduction into hospitals. Infection control policies in LTC are primarily based on those used in acute care and may not be appropriate for this unique environment. Studies to determine which infection control procedures are effective at reducing the prevalence and transmission of MRSA and VRE in LTC are required.
Key words: long-term care, MRSA, VRE, colonization, infection control.

Emmanuel Andrès, MD, Professor of Internal Medicine, Strasbourg University; Head of the Department of Internal Medicine, Diabetes and Metabolic Diseases, Hôpitaux Universitaires de Strasbourg, Strasbourg, France.
Mustapha Mecili, MD, Clinical Specialist, Department of Internal Medicine, Diabetes and Metabolic Diseases, Hôpitaux Universitaires de Strasbourg, Strasbourg, France.
Helen Fothergill, MD, Clinical Specialist, Department of Internal Medicine, Diabetes and Metabolic Diseases, Hôpitaux Universitaires de Strasbourg, Strasbourg, France.
Thomas Vogel, MD, Clinical Specialist, Department of Internal Medicine and Geriatrics, Hôpitaux Universitaires de Strasbourg, Strasbourg, France.
Laure Federici, MD,Clinical Specialist, Department of Medicine, Hôpitaux de Colmar, Colmar, France.
Jacques Zimmer, MD PhD, Clinical Researcher, Laboratoire d’Immunogénétique-Allergologie, Centre de Recherche Public de la Santé (CRP-Santé) de Luxembourg, Luxembourg.

Cobalamin (vitamin B12) deficiency is particularly common in among older adults, although it is frequently undiagnosed as the clinical presentations may be subtle. However, serious complications do occur, in particular neuropsychiatric and hematological disorders. In older adults, the main causes of cobalamin deficiency are food-cobalamin malabsorption (50–60%) and pernicious anemia (30–40%). Food-cobalamin malabsorption syndrome is a disorder characterized by the inability to release cobalamin from food or its binding proteins. This syndrome is frequently associated with atrophic gastritis, which may be a result of Helicobacter pylori infection, and long-term ingestion of antacids and biguanides. The management of cobalamin deficiency with cobalamin injections is currently well documented, however new routes of cobalamin administration (including via oral and nasal passages) are being studied. Oral cobalamin therapy is of particular interest in the management of food-cobalamin malabsorption syndrome.
Key words: cobalamin, vitamin B12, cobalamin deficiency, food-cobalamin malabsorption, oral cobalamin therapy.

Michel Silberfeld, MD, FRCP, Department of Psychiatry, University of Toronto, Toronto, ON.

The requests for mental capacity assessments are increasing in number and variety. It is incumbent upon those who perform these assessments to ensure that they properly understand mental capacity. Mental capacity has a legal policy framework and is linked to specific legal criteria for capacity. Doing mental capacity assessments means understanding both the framework in which those assessments are carried out and the task of coming to a legally meaningful opinion.
Key words: mental capacity, allocation of rights, human potential, autonomy, adversarial process.

Ellen Costello, PT, PhD, Assistant Professor of Physical Therapy, The George Washington University, School of Medicine and Health Sciences, Washington, DC, USA.
Mary A. Corcoran, OTR, PhD, Professor of Clinical Research and Leadership, The George Washington University, School of Medicine and Health Sciences, Washington, DC, USA.

Bathing individuals with dementia has been reported as one of the most difficult activities of daily living and often results in unwanted behaviours. A review of the literature on bathing practices for those with dementia resulted in few empirically tested bathing techniques. Based on this review and the authors’ clinical experience, the following guidelines are presented: (1) consider a towel/bed bath in lieu of a shower/tub bath—be flexible; (2) educate the caregiver (improved outcomes are noted)—communication is key; and (3) optimize the environment to meet the needs of the individual and to maintain safety.
Key words: dementia, Alzheimer’s disease, bathing, caregiver, hygiene.

Wilbert S. Aronow, MD, FACC, FAHA, AGSF, Department of Medicine, Divisions of Cardiology, Geriatrics, and Pulmonary/Critical Care, New York Medical College, Valhalla, NY, USA.

Randomized, double-blind, placebo-controlled studies and observational studies have documented that statins reduce mortality and major cardiovascular events in high-risk persons with hypercholesterolemia. The Heart Protection Study showed that statins reduced mortality and major cardiovascular events in high-risk persons regardless of the initial level of serum lipids, age, or gender. The updated National Cholesterol Education Program (NCEP) III guidelines state that in very-high-risk patients, a serum low-density lipoprotein (LDL) cholesterol level of <1.81 mmol/L (<70 mg/dL) correct is a reasonable clinical strategy, regardless of age. When a high-risk person has hypertriglyceridemia or low serum high-density lipoprotein cholesterol, consideration can be given to combining a fibrate or nicotinic acid with an LDL cholesterol–lowering drug. For moderately high-risk persons, the serum LDL cholesterol should be reduced to <2.59 mmol/L 2.59 (<100 mg/dL). When LDL cholesterol–lowering drug therapy is used to treat high-risk persons or moderately high-risk persons, the serum LDL cholesterol should be reduced by at least 30–40%. High-risk older persons should be treated with lipid-lowering drug therapy according to NCEP III updated guidelines to reduce cardiovascular morbidity and mortality. The LDL cholesterol should be reduced to <4.14 mmol/L (<160 mg/dL)correct in persons at low risk for cardiovascular disease.
Key words: lipids, statins, lipid-lowering drugs, atherosclerotic vascular disease.

Lisa Chodirker, MD, FRCPC, Clinical Fellow, Division of Hematology/Oncology, Odette Cancer Centre*, Sunnybrook Health Sciences Centre, Toronto, ON.
Rena Buckstein, MD, FRCPC, Co-director of MDS research programs, Division of Hematology/Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON.

Myelodysplastic syndromes (MDS) are among the most common hematological malignancies in Western countries, with a median age at diagnosis of 74. They are a stem cell disorder characterized by cellular dysplasia, cytopenias, and an increased risk of transformation to acute myeloid leukemia. Disease trajectory is commonly determined by the international and world prognostic scoring systems (International Prognostic Scoring System and the World Health Organization [WHO] classification–based prognostic scoring system) and the WHO classification. Some patients have an indolent disease course, while others experience a rapid deterioration and short overall survival. For many years, the mainstay of therapy was supportive care with blood transfusions and hematopoietic growth factors. Fortunately, novel effective agents including lenalidomide, hypomethylating agents, and oral iron chelators have emerged over the past 5–10 years that improve transfusion dependence and may alter the natural history of the disease. These new therapeutic options offer new hope for individuals with MDS and bolster the role for the investigation of unexplained cytopenias in the older patient.
Key words: myelodysplastic syndrome, erythropoietin, anemia, red blood cell transfusions, stem cell disorder.

Mohammed E. Hussain, Department of Medicine, Mount Sinai Hospital, Toronto, ON.
Dominick Amato, Department of Medicine, Mount Sinai Hospital; Department of Medicine, University of Toronto, Toronto, ON.

Thrombocytopenia, whether symptomatic or not, is a relatively common finding in clinical medicine. The causes of thrombocytopenia are many, and all of these may be found at all ages. However, just as the frequencies of these causes vary between pediatric and adult age-groups, so too is there variation between younger adults and older individuals. Also, the pathophysiological approach to thrombocytopenia (decreased production, increased destruction, sequestration, dilution) remains just as valid to the seasoned hematologist as to the neophyte. In this article, we provide a suggested approach to the patient with thrombocytopenia, with emphasis on the more common causes in older adults.
Key words: thrombocytopenia, platelets, bleeding disorders, primary hemostasis, older adults.

Douglas C. Duke, MD, CCFP, Seniors Health, Northeast Community Health Centre, Edmonton, AB.
Teresa Genge, MN, Nurse Practitioner, Seniors Health, Northeast Community Health Centre, Edmonton, AB.

The delivery of relevant and coordinated health care to community-dwelling frail older adults is challenging. The community-based program described in this article applies a collaborative and flexible approach to the management and coordination of care of frail older adults. Although a feature of the program is its small size, its connection with professionals and services within a comprehensive health care system creates a much larger “virtual team.” Effectiveness of care is maintained through ongoing communication with care providers and the development of connections within the larger team.
Key words: frail older adults, geriatric evaluation and management, community-based care.