Janis J. Daly, PhD, MS, Director, Cognitive and Motor Learning Laboratory; Associate Director, FES Center of Excellence, Louis Stokes Cleveland Department of Veterans Affairs Medical Center; Research Career Scientist, DVA, Washington, DC; Associate Professor, Department of Neurology, Case Western Reserve University School of Medicine, Cleveland, OH, USA.

For those with persistent gait and upper limb deficits after stroke, it is difficult to obtain recovery of motor control and functional capability in response to standard care methods. Functional electrical stimulation (FES) is a promising intervention. Surface FES for wrist and hand muscles can result in improved impairment sufficient to produce important gains in functional capability. In addition, an FES gait training system with multiple channels and implanted electrodes has shown a statistically significant additive advantage for the recovery of coordinated gait components versus a comparable comprehensive gait training treatment without FES. Results were sufficiently robust to show important gains in quality of life.
Key words: stroke, functional electrical stimulation, neuromuscular electrical stimulation, functional neuromuscular stimulation, functional recovery, rehabilitation.

James Frith, MB ChB, MRCP, Clinical Research Associate, Biomedical Research Centre in Ageing—Liver Theme and Institute for Ageing and Health, Newcastle University, Newcastle, UK.
Julia L. Newton PhD, FRCP, Professor, Biomedical Research Centre in Ageing—Liver Theme and Institute for Ageing and Health, Newcastle University, Newcastle, UK.

The prevalence of chronic liver disease is increasing in older people. The presentation of these diseases is often asymptomatic or nonspecific, so they easily go undiagnosed. Investigating the older person who has abnormal liver function is important in primary care, and the same vigilance should be applied to an older person as to a young person, even with mild abnormalities. Referral for specialist opinion in appropriate older people provides important diagnostic and prognostic information. Treatment options are similar for all age groups. Morbidity and age-adjusted mortality are often more severe in older people; therefore, early diagnosis and intervention are important.
Key words: chronic liver disease, aging, liver function tests.

Simon Yang, MD, Division of General Surgery, University of Toronto, Toronto, ON.
Calvin Law, MD, MPH, FRCS, Division of General Surgery, University of Toronto; Sunnybrook Health Sciences Centre, Toronto, ON.

The prevalence of gallstones has been increasing among the aging population. Common sequelae of cholelithiasis include asymptomatic gallstones, biliary colic, acute cholecystitis, choledocholithiasis, cholangitis, and gallstone pancreatitis. Among individuals over age 65, gallstone diseases represent an important cause of recurrent abdominal symptoms and surgical admissions. As advanced age is correlated with increased mortality and morbidity in complicated gallstone disease, timely diagnosis and appropriate management are essential to improving disease outcomes.
Key words: older adults, gallstones, cholecystitis, choledocholithiasis.

Abisola Famakinwa, MD, Instructor in Medicine, Harvard Medical School; Staff Physician, Edith Nourse Rogers Memorial Hospital, Bedford, MA, USA.

Increases in life expectancy and the aging of the baby boomer generation has resulted in unprecedented high numbers of older adults in the U.S. and Canada and, thus, a rising number of frail older adults with chronic medical conditions. Informal caregivers, primarily family members, have traditionally provided a large proportion of care at home, and their contribution is expected to be of even greater significance. Informal caregivers provide care at great expense to themselves, because caregiving can result in emotional, physical, and financial stresses. This article discusses the role physicians play in identifying and alleviating caregiver stress.
Key words: family caregivers, informal caregivers, caregiver stress, physician, older adults.

Robert Lam, MD, CCFP (Care of the Elderly), Attending Physician, Geriatric Rehabilitation Program, Toronto Rehabilitation Institute, Toronto, ON.
Alison Wong, MPT, Physiotherapist, Geriatric Rehabilitation Program, Toronto Rehabilitation Institute, Toronto, ON.

Primary care physicians often see older adults using gait aids during office visits. Gait aids can provide increased independence with functional mobility but, if used incorrectly, can lead to injury. Unfortunately, gait aids are often purchased without professional advice. Gait aid prescription requires consideration of multiple factors. This article outlines general tips primary care physicians can use to help decide which gait aid might be most appropriate for a patient. Primary care physicians should examine an older patient’s gait aid as physical mobility needs change, and consider referring the patient to a physiotherapist for a complete assessment and gait training.
Key words: gait aid, cane, walker, older adults, ambulation.

Daniel J. Brauner, MD, Department of Medicine/Geriatrics, University of Chicago, Chicago, IL, USA.

Lack of adherence is a major reason for the failure of medical therapies and is an especially important and sometimes underappreciated issue for the growing number of people with dementia. The factors that tend to affect adherence in persons with dementia have begun to be appreciated and have implications for patients more generally. Strategies for improving adherence in patients with dementia based on their cognitive problems are discussed. Increased awareness of adherence will encourage physicians to create more reasonable and simplified medical regimes and promote the use of aids for improving adherence, which can also be used with cognitively intact patients.
Key words: dementia, adherence, medication management capacity.

Kenneth M. Madden, MSc, MD, FRCP, VITALITY (Vancouver Initiative to Add Life To Years) Group, Department of Medicine, University of British Columbia, Vancouver, BC.

Orthostatic hypotension (OH), while not itself a disease, is an important physical finding in the setting of unexplained syncope or falls. All antihypertensive medications directly interfere with the normal cardiovascular responses (increased venous return, tachycardia, and vasoconstriction) to orthostatic stress. Regular screening for this condition in older adults with hypertension, as well as careful titration of antihypertensive medications, can greatly improve both mortality and quality of life in this vulnerable population.
Keywords: orthostatic hypotension, postural vitals, antihypertensives, syncope, geriatric medicine.

Sunita Paudyal, MD, Department of Medical Education, Providence Portland Medical Center, Portland, OR, USA.
Stephen M. Campbell, MD, Department of Medical Education, Providence Portland Medical Center, Portland, OR, USA.

Osteoarthritis is a major cause of disability among older adults. Treatment of the symptoms involves multiple modalities, including exercise, physical measures such as braces or canes, analgesics, and sometimes surgery. Many studies have demonstrated the utility of intra-articular corticosteroids in the knee, but data on their use in other joints are lacking. Intra-articular corticosteroids alleviate pain in the short term but have little effect on long-term function. Overall, they are quite safe, with relatively few contraindications or complications. Intra-articular corticosteroids are a temporizing measure rather than definitive therapy and are most useful in the treatment of acute exacerbations of osteoarthritis pain, to alleviate symptoms as other therapies are instituted, and to tide patients over as they await surgery.
Key words: osteoarthritis, corticosteroids, intra-articular, injections, therapy.

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.

David B. Hogan, MD, FRCPC, Professor and Brenda Strafford Foundation Chair in Geriatric Medicine, University of Calgary, Calgary, AB.

Cholinesterase inhibitors are a treatment option for most people with Alzheimer’s disease of mild to moderate severity. This article offers an approach to their use, based on the recommendations of the Third Canadian Consensus Conference on the Diagnosis and Treatment of Dementia. Treatment decisions must be individualized. Monitoring includes evaluating both safety and effectiveness, which entails more than just assessing cognition. Treatment is clinically beneficial when there is evidence of improvement, stabilization, or a slowing of the rate of decline seen prior to the start of treatment without unacceptable side effects.
Key words: dementia, Alzheimer’s disease, cholinesterase inhibitors, safety, effectiveness.