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.

Samuel N. Markowitz, MD, FRCS(C), Associate Professor of Ophthalmology, Faculty of Medicine, University of Toronto; Director, Low Vision Rehabilitation Program, Department of Ophthalmology, University of Toronto; Staff, Toronto Western Hospital, University Health Network, Toronto, ON.

Low vision can result from loss of macular function, with loss of peripheral vision or from loss of hemi-fields of vision such as in cases with stroke. Low vision rehabilitation (LVR) is the continuation of care after all other means for restoration of vision were used and failed. Modern LVR is a multidisciplinary endeavour responsible for providing assessment, prescribing devices, and conducting training sessions for individuals with low vision. Ontario recognizes the diverse needs of individuals requiring LVR interventions, covers LVR assessments and LVR training sessions, and provides financial subsidies for the purchase of low vision devices.
Key words: low vision rehabilitation, low vision, age-related macular degeneration, assistive devices, vision therapy.

Kenneth R. Melvin, MD, FRCPC, Associate Professor, Department of Medicine, Cardiology, University Health Network, University of Toronto, Toronto, ON.
Lindsay J. Melvin, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON.

The increasing average age of natural survival and effective therapies for many previously fatal illnesses have increased the older adult population. Thus, there is a concomitant increase in long-term treatment requirements for many conditions, including chronic angina pectoris. Advances in nonsurgical interventions include angioplasty and stent technology. The medical treatment of angina should be individualized to the patient and usually involves multiple-drug regimens. Mainstays of therapy include acetylsalicylic acid and nitroglycerin 0.4 mg spray with combinations of long-acting nitrates, beta-blockers, calcium channel blockers, and the ancillary use of angiotensin-converting enzyme inhibitors and statins. Risk reduction involves controlling modifiable factors, including smoking, weight control, hypertension, and hyperlipidemia; this will reduce disease progression and cardiac event occurrences. Older adults should be monitored for drug interactions and sensitivity to medication in the presence of associated medical problems and other therapies. Cardiac rehabilitation programs are a useful addition to comprehensive medical treatments for chronic stable angina.
Key words: angina, antianginal drug therapy, risk reduction, cardiac rehabilitation, percutaneous coronary intervention, PCI.

Sameer Satija, MD, Clinical Fellow, Division of Cardiology, Emory University School of Medicine, Atlanta, GA, USA.
Nanette K. Wenger, MD, Professor of Medicine (Cardiology), Emory University School of Medicine, Atlanta; Chief of Cardiology, Grady Memorial Hospital, Atlanta, GA, USA.

Chronic angina is a common problem among older adults. The burden of coronary heart disease in patients over age 75 is high. Coronary angiography, percutaneous coronary intervention with or without stenting, and coronary artery bypass graft surgery all entail higher risk in the older population. Nevertheless, patients older than 75 also may accrue a greater benefit, given their increased risk for overall cardiac mortality. We suggest a measured approach to revascularization in older adults with chronic angina, considering their severity of symptoms, the adequacy of treatment of angina, their left ventricular ejection fraction, patient preference, other comorbidities, and ischemic burden identified by noninvasive testing.
Key words: angina, revascularization, older adults, coronary disease, coronary angiography.

Nastaran Ostad, BScPharm, PharmD Candidate, Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON.
Glen J. Pearson, BSc, BScPharm, PharmD, FCSHP, Associate Professor of Medicine, Division of Cardiology, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB.

Dual antiplatelet therapy (DAT) with acetylsalicylic acid and a thienopyridine agent (clopidogrel) as secondary prevention for patients with atherosclerotic coronary artery disease has been proven effective in those with unstable angina or acute coronary syndromes and following a percutaneous coronary intervention. At present, detailed guidelines provide specific guidance to clinicians regarding which patients to treat, the specific safe and effective combination regimen to use, and the appropriate duration of DAT. This evidence applies to the prevention of cardiovascular events in older adults; however, special considerations should be undertaken when using DAT in older adults due to their overall increased propensity for bleeding complications and potential concomitant medication use for comorbid conditions. This article provides an overview of the evidence for DAT, with a focus on treating older adults.
Key words: cardiovascular protection, clopidogrel, acetylsalicylic acid, acute coronary syndromes, coronary stenting.