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.

Kristen L. Currie, MA, CCRP, Department of Surgical Oncology, Division of Urology, Princess Margaret Hospital, University Health Network (UHN), Toronto, ON.
Sheri Stillman, RD, Clinical Nutrition, Allied Health, Princess Margaret Hospital, UHN, Toronto, ON.
Susan Haines, RD, Clinical Nutrition, Allied Health, Princess Margaret Hospital, UHN, Toronto, ON.
John Trachtenberg, MD, FRCSC, FACS, Department of Surgical Oncology, Division of Urology, Princess Margaret Hospital, UHN, Toronto, ON.

Older adults represent the highest percentage of new cancer diagnoses each year. This, combined with the increasing age of the population, underscores the importance of identifying methods for risk reduction. The World Cancer Research Fund, together with the American Institute for Cancer Research, has published recommendations for cancer prevention through diet and physical activity. These guidelines should be considered when counselling patients in cancer prevention. In this article, colorectal, breast, and prostate cancers are highlighted, and nutritional recommendations for these cancers are presented.
Key words: nutrition, prevention, colorectal cancer, breast cancer, prostate cancer.

Dylan Harris, MBBCh(Hons), MRCP, DipPallMed, Specialist Registrar in Palliative Medicine, Princess of Wales Hospital, Bridgend, UK.

Dementia is a progressive incurable illness. In the advanced stages of the disease, decisions need to be made whether to withhold or withdraw life-sustaining treatment. This article reviews the principles of deciding a patient’s best interests when he or she lacks mental capacity, the role of advance statements, and principles for the practising physician to consider in common withholding/withdrawing treatment scenarios that arise in clinical practice, such as artificial feeding, cardiopulmonary resuscitation, and antibiotics for pneumonia.
Key words: dementia, palliative care, withholding and withdrawing treatment, artificial feeding, resuscitation, antibiotics.

Hatim Al Lawati, MD, FRCPC, Cardiology Resident, Division of Cardiology, Faculty of Medicine, University of Toronto, Toronto, ON.
Fatemeh Akbarian, MD, Dermatologist, Research Fellow, University of Toronto, Toronto, ON.
Mohammad Ali Shafiee, MD, FRCPC, General Internist, Nephrologist, Department of Medicine, Toronto General Hospital, University Health Network; Clinician Teacher, University of Toronto, Toronto, ON.

Atrial fibrillation (AF) is by the far the most common cardiac rhythm disturbance encountered in clinical practice. It is associated with significant morbidity and mortality and has potentially lifelong implications in terms of therapy and complications. This disease is more commonly seen now given the increased life expectancy and the remarkable advances made in health care. The already at-risk older adult population is particularly vulnerable to complications from AF, especially embolic cerebrovascular events. This article reviews the evidence-based management of AF with a particular focus on the older adult population.
Key words: atrial fibrillation, older adults, stroke, rate control, rhythm control, stroke prophylaxis, anticoagulation.

Erin Dahlke, MD, Dermatology Resident, University of Toronto, Toronto, ON.
Christian A. Murray, MD, FRCPC, Assistant Professor of Medicine and Dermatology, University of Toronto; Co-director of Dermatologic Surgery, Women’s College Hospital, Toronto, ON.

Basal cell carcinoma (BCC) is a common, slow-growing malignant skin tumour that only very rarely metastasizes. The main subtypes of BCC are nodular, superficial, and sclerosing. The most important risk factors for the development of BCC include fair skin, extensive sun exposure as a child, past personal history of skin cancer, and advanced age. Basal cell carcinoma is the most common human malignancy, and its incidence is increasing worldwide. There are a number of different treatm ent modalities for BCC including topical therapies, cryotherapy, electrodesiccation and curettage, surgical excision, radiotherapy, and Mohs’ micrographic surgery. Treatment should be tailored to the individual situation, and advanced age does not typically alter the management choice or reduce the expectation of an excellent outcome, including cure.
Key words: basal cell carcinoma, nonmelanoma skin cancer, risk factors, epidemiology, treatment.