Frank J. Molnar, MSc, MDCM, FRCPC, Canadian Institutes of Health Research (CIHR) CanDRIVE Research Team, Clinical Epidemiology Program, University of Ottawa Health Research Institute; Division of Geriatric Medicine, Department of Internal Medicine, University of Ottawa; Division of Geriatric Medicine, the Ottawa Hospital; REVTAR Research Group and CT Lamont Centre for Primary Care Research, Élisabeth-Bruyère Research Institute, Ottawa, ON.
Anna M. Byszewski, MD, FRCPC, CIHR CanDRIVE Research Team; Division of Geriatric Medicine, Department of Internal Medicine, University of Ottawa; Division of Geriatric Medicine, the Ottawa Hospital, Ottawa, ON.
Mark Rapoport, MD, FRCPC, CIHR CanDRIVE Research Team; Department of Psychiatry,
University of Toronto; Sunnybrook Health Sciences Centre, Toronto, ON.
William B. Dalziel, MD, FRCPC, Division of Geriatric Medicine, Department of Internal Medicine, University of Ottawa; Division of Geriatric Medicine, the Ottawa Hospital; the Regional Geriatric Program of Eastern Ontario, Ottawa, ON.

There may be up to 1.5 million persons with dementia who are driving in North America. In many jurisdictions, physicians are mandated to assess and report fitness to drive in such patients. Lack of knowledge of patients’ driving status does not protect physicians from lawsuits. There is a paucity of research to aid physicians in the assessment of fitness to drive in persons with dementia. Guidelines recommend the Mini-Mental State Examination, the clock-drawing test, and Trails A and B but lack evidence-based instructions regarding how to interpret such tests. This article provides experience-based approaches to the assessment of fitness to drive in dementia as well as an approach to disclosure of the findings to patients.
Key words: dementia, Alzheimer, driving, family physicians, cognitive testing.

Jason Strauss, MD, Departments of Psychiatry and Medicine, Division of Gerontology, Harvard Medical School; Beth Israel Deaconess Medical Center, Boston, MA; Hebrew Rehabilitation Center, Roslindale, MA; Cambridge Health Alliance, Cambridge, MA, USA.

Sleep disturbances are frequently seen among older adults with dementia, leading to significant distress for both patients and their caregivers. It is likely that neuronal loss in key areas of the brain contributes to sleep disturbances in this population. When evaluating older adults with dementia and insomnia, try to obtain information regarding all details of their sleep, and determine whether medical, psychiatric, or environmental factors may be contributors. In treating sleep disturbances in older adults with dementia, behavioural interventions should first be used to improve sleep hygiene. At the present time, there are not enough data to standardize recommendations for pharmacological treatment of insomnia in this population, so treatment should be guided by attempting to minimize potential side effects and interactions with other medications.
Key words: sleep, dementia, older adults, sleep hygiene, pharmacological treatment of insomnia.

Jiska Cohen-Mansfield, PhD, ABPP, Department of Health Promotion, School of Public Health and Herczeg Center on Aging, Tel-Aviv University, Tel-Aviv, Israel, and Department of Health Care Sciences and of Prevention and Community Health, George Washington University Medical Center, Washington, DC, USA.

Approximately 20% of older people with dementia manifest visual or auditory hallucinations. In order to effectively diagnose and treat these individuals, the etiology of hallucinations must be addressed; however, there has been very limited research in this area. There is an association between vision loss and hallucinations, and analyses of case studies suggest other potential etiologies. Accordingly, hallucinations can occur when the person with dementia either misinterprets reality, experiences sensory deprivation, is exposed to inappropriate sensory stimulation, has delirium/medical problems, or when his/her behaviour is misinterpreted due to cultural differences with caregivers. Understanding the etiology of hallucinations will assist in developing an appropriate nonpharmacological treatment, which may improve quality of life.
Key words: hallucinations, dementia, etiology, nonpharmacological, treatment.

Irwin W. Kuzmarov, MD, FRCSC, Assistant Professor, Department of Surgery (Urology), McGill University; Director of Professional and Hospital Services, Santa Cabrini Hospital, Montreal, QC; Past President, Canadian Society for the Study of the Aging Male.
Jerald Bain, BScPhm, MD, MSc, FRCPC, CertEndo, BA, Professor Emeritus, Department of Medicine, Division of Endocrinology and Metabolism, Mount Sinai Hospital; University of Toronto, Toronto, ON; Past President, Canadian Society for the Study of the Aging Male.

Sexual desire and activity continue well into later life, and advanced age alone is not a deterrent to a happy and healthy sex life; however, clinicians should be aware that the normal sexual response of men and women may change with aging. When sexual dysfunction occurs, studies show that men and women tend to view sexual dysfunction differently. Part I addressed sexual function and dysfunction with age in females. Part II of this two-part article series addresses sexuality and sexual dysfunction in aging men. For the emotional well-being of their patients, it is crucial that family doctors be aware of sexuality in the aging couple, and be able to evaluate and manage problems that may arise.
Key words: aging, sexual activity, sexual dysfunction, men, testosterone therapy.

Marc Ginsburg, RN, MScN, NP, Medical Student, University of Sint Eustatius School of Medicine, Sint Eustatius, Netherlands-Antilles.
Shawna Silver, MD, PEng, Resident, Department of Pediatrics, Hospital for Sick Children, University of Toronto, Toronto, ON.
Hershl Berman, MD, FRCPC, Assistant Professor, Faculty of Medicine, University of Toronto; Staff Physician, Department of Medicine, University Health Network; Associated Medical Services Fellow in End-of-Life Care Education, University of Toronto; Centre for Innovation In Complex Care, University Health Network, Toronto, ON.

The use of opioid medications and converting among them in the older adult population can often be challenging. Physiological changes in older adults may affect metabolism and cognitive abilities. Due to renally cleared metabolites, some opioids, such as morphine, should be used with caution among older adults. Others, such as meperidine, should never be used at all. When prescribing or changing opioids, the choice of the correct formulation, appropriate counselling, and close follow-up are essential for optimal pain management and in order to prevent adverse outcomes.
Key words: opioids, pain management, older adults, analgesia, opioid conversion.

Aileen Burford-Mason, PhD, President, Holistic Health Research Foundation of Canada, Toronto, ON.

Accumulated research evidence suggests that vitamin D deficiency or insufficiency has profound implications for health and well-being, compromising immune responses and increasing the risk for osteoporosis, arthritis, diabetes, depression, cancer, and cardiovascular disease. Older adults, especially those who are housebound, are at increased risk for vitamin D deficiency. In addition to sun avoidance and the use of sunscreen, age, ethnicity, and obesity are risk factors for vitamin D deficiency. This article discusses the use of serum 25-hydroxyvitamin D to assess vitamin D needs and outlines current recommendations on appropriate interventions to improve vitamin D status in older adults.
Key words: vitamin D, older adults, supplements, UVB exposure, immunity.

Ann Kolanowski, PhD, RN, FAAN, Elouise Ross Eberly Professor of Nursing, The Pennsylvania State University, University Park, PA, USA.
Donna M. Fick, PhD, RN, GCNS-BC, Associate Professor of Nursing, The Pennsylvania State University, University Park, PA, USA.
Linda Buettner, PhD, LRT, CTRS, Professor of Recreation Therapy/Gerontology, Department of Recreation, Tourism, Hospitality Management, University of North Carolina, Greensboro, NC, USA.

Few clinicians have an educational grounding in the use of nonpharmacological therapies for people with dementia. In this article, we explore the utility of recreational activities as one nonpharmacological intervention that has demonstrated effectiveness for reducing the behavioural symptoms of dementia. The implementation of effective recreational activities involves three components: understanding the evidence for this approach; acknowledging the need to reduce medications that have the potential to interfere with activity effectiveness; and individualizing activities so that the maximum benefit from the intervention is obtained.
Key words: dementia, activities, nonpharmacological interventions, potentially inappropriate medications, individualized care.

Jason Andrade, MD, Division of Cardiology, University of British Columbia, Department of Medicine, Vancouver, BC.
Aneez Mohamed, MD, Division of Cardiology, University of British Columbia, Department of Medicine, Vancouver, BC.
Chris Rauscher, MD, Division of Geriatric Medicine, University of British Columbia, Department of Medicine, Vancouver, BC.

Infective endocarditis (IE) is a rare but potentially devastating clinical entity with a well-delineated pathogenesis. While previously thought to be a disorder of younger individuals, older adults now represent one of the highest risk groups for the acquisition of and adverse outcomes related to IE. Prior to focusing on the updated recommendations for IE prophylaxis and the rationale behind them, we briefly review the clinical aspects of IE in the general population, as well as special considerations for older adults.
Key words: endocarditis, prophylaxis, older adults, cardiovascular disease, antibiotics.

Susan B. Jaglal, PhD, Toronto Rehabilitation Institute Chair, Associate Professor, Faculty of Medicine, Department of Physical Therapy, University of Toronto, Toronto, ON.

A wrist fracture is associated with an increased risk of another fracture and should prompt investigation for osteoporosis in both men and women. If the fracture was caused by low trauma (a fall from a standing height or less), a bone density test should be ordered. If the T score is <–1.5, pharmacological treatment with a bisphosphonate and calcium (1,500 mg/d) and vitamin D3 (≥800 IU/d) is recommended. Management should also include balance, posture, and muscle-strengthening exercises and walking, as well as a review of fall-prevention strategies.
Key words: wrist fracture, osteoporosis, diagnosis, treatment, exercise, falls.

Alison Mudge, MBBS, FRACP, Physician, Department of Internal Medicine and Aged Care, Royal Brisbane and Women’s Hospital, Herston, Queensland, Australia.
Robert Mullins, MAppSci (Clin Ex Sci), Clinical Exercise Physiologist, Heart Failure Service, Royal Brisbane and Women’s Hospital, Herston, Queensland, Australia.
Julie Adsett, BPhty (Hons), Physiotherapist, Heart Failure Service, Royal Brisbane and Women’s Hospital, Herston, Queensland, Australia.

Exercise offers significant health benefits to older people, but may also carry risks of injury and cardiovascular events. These can be minimized with appropriate screening, prescription, and monitoring of an exercise program. Tailored exercise prescription is developed in consultation with the participant, taking into account identified risks, functional limitations, and individual goals. Exercise professionals can provide valuable assistance with screening, prescription, and supervision of an exercise program, but limited access to experienced staff and supervised programs remains a significant barrier to exercise participation. Innovative models of care are required to investigate optimal participant targeting, long-term exercise adherence, and cost-effectiveness.
Key words: exercise therapy, physical fitness health services for older adults, risk assessment, patient compliance.