James W. Cooper, RPh, PhD, BCPS, CGP, FASCP, FASHP, Emeritus Professor and Consultant Pharmacist, College of Pharmacy, University of Georgia, Athens, and Assistant Clinical Professor of Family Medicine, Medical College of Georgia, Augusta, GA, USA.
Allison H. Burfield, RN, PhD, Assistant Professor, School of Nursing, College of Health and Human Services, University of North Carolina-Charlotte, Charlotte, NC, USA.

The high incidence of falls among older adults leads to increased health care costs and decrements in functional status. Psychoactive medications consumed by older adults are often implicated in falls. This article briefly reviews the associations between falls and psychoactive medications, with a focus on the long-term care setting, and offers an assessment method and strategies to reduce the risk of certain classes of medications known to contribute to fall risk.
Key words: falls, medications, psychoactive load, interventions, older adults.

Gregory An, DDS, MPH, Director, Geriatric Dentistry Fellowship Program, Harvard School of Dental Medicine, Harvard University, Cambridge, MA, USA.

The rate of edentulism (being toothless) is declining in older adults. Thanks to more effective community-based prevention programs , reliable treatment methods, and improved dental technology, people are retaining more of their natural teeth. Since it has been only recently that people have lived as long and retained so much of their teeth, research done in the area of normal and abnormal aging of the teeth is limited. This article reviews some of the current knowledge regarding normal aging of the different structures of teeth and clinical manifestations of advancing age. More specifically, age-related changes in tooth enamel, dentin, pulp, and cementum are reviewed.
Key words: aging, dental, teeth, older, adults.

Mary A. Corcoran, OTR, PhD, Professor of Clinical Research and Leadership, The George Washington University, School of Medicine and Health Sciences, Washington, DC, USA.

There is an average delay of 20 months between the first recognition of symptoms of Alzheimer’s disease or a related disorder (ADRD) and the seeking of physician help. One reason for this delay is tendency for families to miss early symptoms until the onset of behavioural disturbances. Families may provide more timely accounts with prompted questions. It is important to diagnose cognitive impairment early since there are potential benefits to early treatment. The purpose of this article is to help guide caregivers in identifying a list of symptoms that reflect first indicators of ADRD, based on a study of 68 spouse caregivers of patients with ADRD.
Key words: Alzheimer’s disease, dementia, caregivers, diagnosis, primary care.

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

Low bone mineral density (BMD) is associated with obstructive coronary artery disease (CAD); this article reviews several recent studies that have demonstrated the association. In one study, for every 1-unit reduction in femoral neck T score, a 0.23 minute decrease in treadmill exercise duration was found after values were adjusted for age and other patient characteristics (95% confidence interval [CI], 0.11–0.35, p<0.001). For every 1-unit reduction in femoral neck T score, there was a 22% increased risk of myocardial ischemia after values were adjusted for age and other patient characteristics (95% CI, 1.06–1.41, p = 0.004). Overall after adjustments, patients with a low BMD who were referred for exercise echocardiographic stress testing had a 43% greater risk of myocardial ischemia than did patients with normal BMD referred for exercise echocardiographic stress testing (95% CI, 1.06–1.94, p = 0.02). Reduced physical activity may contribute to both low BMD and CAD through the development of atherosclerotic vascular disease.
In a second study, stress test-induced myocardial ischemia developed in 95 of 254 patients (37%) with osteoporosis, in 81 of 260 patients (31%) with osteopenia, and in 62 of 251 patients (25%) with normal BMD (p= 0.009) (p= 0.002 comparing osteoporosis with normal BMD; p=0.007 comparing osteoporosis or osteopenia with normal BMD). Patients with osteoporosis or osteopenia had a 1.7 times higher chance of stress test-induced myocardial ischemia than those with normal BMD after controlling the confounding effects of systemic hypertension, diabetes mellitus, body mass index, and age.
Key words: osteoporosis, osteopenia, bone mineral density, coronary artery disease, myocardial ischemia.

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.