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.

Pippa Tyrrell, FRCP, Salford Royal Foundation Trust and University of Manchester; UK NICE Guidelines Development Group, Acute Stroke and TIA, London, UK.
Sharon Swain,PhD, National Coordinating Centre for Chronic Conditions, Royal College of Physicians; UK NICE Guidelines Development Group, Acute Stroke and TIA, London, UK.
Anthony Rudd, FRCP, St Thomas’s Hospital London; UK NICE Guidelines Development Group, Acute Stroke and TIA, London, UK.

The investigation and management of stroke has changed beyond recognition in the last two decades. The management of frail older patients with stroke represents a particular clinical challenge. Recognition of symptoms in people with significant comorbidities may be difficult and while intensive investigation may be inappropriate for a very frail aging patient, older people can gain a great deal from expert treatment and secondary prevention following stroke.
Key words: stroke, frail older adults, ischemic stroke, intracerebral hemorrhage.

Hsu-Ko Kuo, MD, MPH, Department of Geriatrics and Gerontology, National Taiwan University; Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan.
Yau-Hua Yu, DDS, DMSc, Department of Medical Research, Veterans General Hospital, Taipei, Taiwan.
Shin-Yu Lien, BS, School of Nursing, Chang Gung University, Taoyuan, Taiwan.
Yi-Der Jiang, MD, PhD, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan.

There has been a substantial increase in total cases of diabetes mellitus in industrialized countries among older adults. Diabetes mellitus has been increasingly recognized as a risk factor for cognitive impairment and dementia. This article discusses the epidemiological evidence for diabetes to predict Alzheimer’s disease, vascular dementia, and decline in various domains of cognition. We also address the features of diabetes-related executive dysfunction and its importance in the clinical care of diabetic older adults.
Key words: diabetes mellitus, cognition, Alzheimer’s disease, vascular dementia, frontal executive dysfunction.

Carla Miller, PhD, RD, Associate Professor, Department of Human Nutrition, Ohio State University, Columbus, OH, USA.

The translation of effective treatments for obesity and diabetes management into clinical care has been slow. However, self-management education and counselling regarding diet and physical activity can improve weight, blood glucose, and lipid levels, and blood pressure control among older adults with type 2 diabetes. A collaborative approach to counselling is more effective than simply lecturing in promoting and sustaining behaviour change. The five A’s to behavioural counselling—assess, advise, agree, assist, and arrange—provide a model for care. A key component of the five A’s for counselling is the development of an action plan that specifies goals and implementation intentions for behaviour change.
Key words: type 2 diabetes mellitus, older adults, behavioural research, patient education, behavioural therapy.

Mae Sheikh-Ali, MD, Assistant Professor of Medicine, University of Florida College of Medicine, Division of Endocrinology Diabetes and Metabolism, Department of Medicine, University of Florida College of Medicine, Jacksonville, FL, USA.
Joe M. Chehade, MD, Associate Professor of Medicine, University of Florida College of Medicine, Division of Endocrinology Diabetes and Metabolism, Department of Medicine, University of Florida College of Medicine, Jacksonville, FL, USA.

Over the past decade, eight classes of drugs have been used to treat diabetes; however, insulin remains the most effective and least costly treatment for older adults. The American Diabetes Association has recommended that the approach to drug therapy of diabetes consider insulin a first-tier therapy. Nevertheless, there is a general reluctance among physicians and patients alike to accept insulin. The initiation of insulin therapy is especially challenging in older adults, who often have multiple comorbidities and physical limitations. In this article, we present a case-based approach to the initiation of insulin therapy in older adults.
Key words: diabetes, older adults, insulin therapy, glycemic goals, antihyperglycemic agents.

Ajay Sood, MD, Division of Clinical and Molecular Endocrinology, Case Western Reserve University School of Medicine; Louis Stokes Cleveland Veterans Affairs (VA) Medical Center, Cleveland, OH, USA.
David C. Aron, MD, MS, Division of Clinical and Molecular Endocrinology, Case Western Reserve University School of Medicine; VA Network 10 Geriatric Research, Education, and Clinical Centers, VA Health Services Research and Development Quality Enhancement Research Initiative Diabetes Clinical Coordinating Center; Louis Stokes Cleveland VA Medical Center, Cleveland, OH, USA.

Glycemic goals and the decision to intensify glycemic control among older adults with diabetes must be individualized based on comorbid conditions and the risks associated with treatment. The duration of diabetes mellitus, baseline glycosylated hemoglobin value, prior history of cardiovascular disease, and history of severe hypoglycemia are important factors to consider. This article reviews how the management of diabetes mellitus in this subgroup is changing in view of three recently reported randomized trials of intensive glycemic control.
Key words: diabetes, older adults, glycemic control, cardiovascular disease, glycemic goal.

Ali A. Rizvi, MD, Professor of Medicine, Division of Endocrinology, Diabetes, and Metabolism, University of South Carolina School of Medicine, Columbia, South Carolina, USA.

Recent therapeutic advances have seen the emergence of several oral agents for type 2 diabetes, providing an opportunity for better management of the disease. Older adults may pose a special challenge because of altered drug kinetics, the presence of other medical conditions, an increased propensity to adverse reactions, and a lack of evidence-based information for clinical decision making. Consideration should be given to treatment satisfaction, side effects, and the overall risk-benefit ratio of oral medications. It is important for providers to become familiar with the medication profiles and follow a rational initiation and titration regimen tailored to the individual patient.
Key words: diabetes, older adults, hyperglycemia, oral medications, combination therapy.