Amitabh Gupta, MD, Clinical Fellow, Movement Disorders Centre, Toronto Western Hospital, University of Toronto, ON.
Susan Fox, MD, Assistant Professor, Movement Disorders Centre, Toronto Western Hospital, University of Toronto, ON.

Progressive supranuclear palsy (PSP) is a rare, fatal neurodegenerative disease with limited treatment options that is characterized by gait and postural instability and a classical vertical supranuclear gaze palsy. Initially often misdiagnosed as idiopathic Parkinson’s disease (IPD), proper patient care in PSP may be delayed until late into the disease course, after dopaminergic medication fails to improve symptoms. Here, we review the diagnostic criteria that help to separate PSP from IPD and rarer forms of parkinsonian diseases to help clinicians with earlier recognition. We discuss current treatment concepts as well as ongoing experimental approaches that are derived from an emerging pathological understanding.
Key words: progressive supranuclear palsy, clinical diagnosis, imaging, differential diagnosis, management.

Jackie Gardner-Nix, MB BS, PhD, MRCP(UK), Assistant Professor, University of Toronto; Chronic Pain Consultant, Department of Anesthesia, St Michael’s Hospital; and Pain Management Programme, Sunnybrook Health Sciences Centre, Toronto, ON.

The management of neuropathic pain at any age is aimed at the relief of suffering rather than focusing on decreasing pain scores, and it should involve even simple measures that affect pain and coping. Addressing physical stressors—poor diet, hydration, and sleep quality and quantity—is particularly relevant in older adults. Medications relieving neuropathic pain may be adjunctive to initial interventions and need to be carefully assessed for efficacy and side effects to ensure they relieve, rather than add to, suffering.
Key words: neuropathic pain, analgesics, older adults, mindfulness, psychological interventions.

Eric Widera, MD, Division of Geriatrics, University of California at San Francisco; San Francisco Veterans Affairs Medical Center, San Francisco, CA, USA.
Alex Smith, MD, Division of Geriatrics, University of California at San Francisco; San Francisco Veterans Affairs Medical Center, San Francisco, CA, USA.

This article highlights the complex challenges seen when managing pain in patients with moderate or advanced dementia. Recent evidence demonstrates that pain is often poorly recognized and treated in patients with cognitive impairment. The progressive decline in cognitive function often leads to difficulties in expressing and recalling painful experiences. Making pain assessments routine and combining patient reports, caregiver reports, and direct observation may help alleviate this poor recognition of pain. Once pain is confirmed, a comprehensive history and physical examination are central in determining the underlying cause of pain and in choosing the best modality to treat the pain.
Key words: dementia, cognitive impairment, pain, opioids, assessment.

M. Faisal Jhandir, MD, RVT, Clinical Assistant Professor of Medicine, Co-Chair Vascular Risk Reduction Program, University of Calgary, Calgary, AB.
Robert J. Herman, MD, FRCPC, Professor of Medicine, Head, Division of General Internal Medicine, University of Calgary, Calgary, AB.
Norm R.C. Campbell, MD, FRCPC, Professor of Medicine, Physiology and Pharmacology and Community Health Sciences, University of Calgary and Libin Cardiovascular Institute, Calgary, AB.

The World Health Organization has named hypertension the leading risk for death globally in adults. Antihypertensive therapy reduces the risks of major cardiovascular complications. As blood pressure increases with increasing age, frequent screening for hypertension is advisable in older adults. The risk of developing hypertension is about 90% even in normotensive 65 year olds. Until recently, data supporting antihypertensive therapy in the very old had been inconclusive. However, the HYVET trial published in 2008 shows a clear reduction in cardiovascular events and mortality. Based on this study the Canadian Hypertension Education Program recommends treating hypertension regardless of age. Attention should also be given to reducing overall cardiovascular risk.
Key words: hypertension, high blood pressure, older adults, recommendations, HYVET study.

Carrie Lynde, MD, Dermatology PGY-1, University of Toronto, Toronto, ON.
John Kraft, MD, Dermatology PGY-4, University of Toronto, Toronto, ON.
Charles Lynde, MD, FRCPC, Assistant Professor, Division of Dermatology, University of Toronto; Dermatology consultant for Metropolitan Homes for the Aged, Toronto; Markham Stouffville Hospital; Scarborough Grace Hospital, Toronto, ON.

Psoriasis is a chronic relapsing skin disease. Age of onset is bimodal with a peak in second to third decades and the sixth decade. Individuals affected by psoriasis usually complain of lower self-esteem. Choice of therapy depends on many factors, including areas affected, extent of disease, patient’s lifestyle, other health problems, and medications. Many effective therapies exist, including topicals, phototherapy, systemics, and biologicals.
Key words: psoriasis, comorbidities, topical steroids, phototherapy, biologics.

William Lear, MD, FRCPC, FAAD, Dermatologist, Silver Falls Dermatology PC, Salem, OR, USA.
Jennifer Akeroyd, RN, PhD student, Oregon Health & Science University, Portland, OR, USA.

In this article, we discuss skin findings affecting older adults, with a focus on pruritus, flushing, dermatitis, and ulcers, and consider related internal diseases. Our goal is to make this information readily transferable to the clinical setting for the non-dermatologist.
Key words: dermatology, skin manifestations, older adults, pruritus, flushing, dermatitis, ulcers.

Elizabeth Pham, MD, Resident Physician, Department of Medicine, University of California, Irvine Medical Center, Orange, CA, USA.
Solomon Liao, MD, Associate Clinical Professor, Department of Medicine, University of California, Irvine Medical Center, Orange, CA, USA.

As the population ages, elder mistreatment is a growing concern in North America, and it includes physical and financial abuse and neglect. Careful documentation of the history, physical examination, and diagnostic data help achieve a clinical assessment that may be crucial to the outcome of a legal case and the protection of a patient. Good medical documentation ultimately saves clinicians time and demonstrates competency. This article discusses the items clinicians need to document in suspected cases of elder mistreatment. The emphasis is on issues that are above or beyond those performed in a routine clinical encounter.
Key words: elder mistreatment, elder neglect, elder abuse, financial exploitation, forensic documentation.

Karen L. Krok, MD, Assistant Professor of Medicine, Division of Gastroenterology, Hospital of the University of Pennsylvania, Philadelphia, PA, USA.
Andrés Cárdenas, MD, MMSc, Institut de Malalties Digestives i Metaboliques, Hospital Clinic, Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain.

Ascites is the accumulation of free fluid in the peritoneal cavity. In over 80% of cases, it is a result of cirrhosis. Ascites develops in 60% of patients with cirrhosis within 10 years of the diagnosis of cirrhosis, and its development marks a turning point in the natural history of the disease. The mainstays of treatment are twofold: sodium restriction and diuretics. The development of spontaneous bacterial peritonitis is another ominous sign that requires indefinite antibiotic prophylaxis to prevent future infections. A referral to a transplant centre is essential once ascites or spontaneous bacterial peritonitis develop.
Key words: ascites, portal hypertension, cirrhosis, spontaneous bacterial peritonitis, paracentesis, albumin infusion.

Simon Brownsell, PhD, Research Fellow, School of Health and Related Research, University of Sheffield, UK.
Elaine Biddiss, PhD, Scientist, Bloorview Research Institute, Bloorview Kids Rehab; Assistant Professor, Institute of Biomaterials and Biomedical Engineering, University of Toronto, ON.
Mark Hawley, PhD, Professor, School of Health and Related Research, University of Sheffield, UK.

The delivery of health care to people at home using information and communication technologies, often termed telecare, telehealth, or telehomecare, is set for rapid expansion. This article provides a brief overview of the applications and the evidence supporting its implementation. Relevant national policies in England and Canada are discussed, along with prominent examples of services and deployments. Finally, the links between research evidence, government policies, and service changes in primary care in the two countries are discussed.
Key words: telecare, telehealth, eHealth, telehomecare.

David G. Le Couteur, MD, PhD, Professor of Geriatric Medicine, Centre for Education and Research on Ageing and ANZAC Research Institute, University of Sydney and Concord RG Hospital, Sydney, Australia.
Arthur Everitt, PhD, Associate Professor, Centre for Education and Research on Ageing, and Department of Physiology, University of Sydney, Sydney, Australia.
Michel Lebel, PhD, Associate Professor, Centre de Recherche en Cancérologie de l’Université Laval, Hôpital Hôtel-Dieu de Québec, Québec, PQ.

The liver undergoes substantial changes in structure and function in old age. There are age-related changes in liver mass, blood flow, and hepatocyte and sinusoidal cell morphology. These changes are associated with a significant impairment of many hepatic metabolic and detoxification activities, with implications for systemic aging and age-related disease. For example, the age-related impairment of the hepatic metabolism of lipoproteins predisposes to cardiovascular disease. The age-related decline in the hepatic clearance of most medications causes an increased risk of adverse drug reactions. Many of the beneficial effects of caloric restriction and caloric restriction mimetics such as resveratrol are mediated by their effects on the liver. Increasingly, the liver is seen as having a key role in aging.
Key words: liver, aging, hepatocyte, liver sinusoid, drug metabolism.