Ehab A. Elzayat, MD, Urology Fellow, Dalhousie University, Halifax, NS.
Ali Alzahrani, MD, Urology Fellow, Dalhousie University, Halifax, NS.
Jerzy B. Gajewski, MD, FRCSC, Professor of Urology and Pharmacology, Department of Urology, Dalhousie University, Halifax, NS.

Urinary incontinence is a common symptom among older adults that is often marginalized and not properly addressed. It is, however, often associated with potentially treatable conditions. Concurrent chronic medical problems add more challenges in this patient population. Comprehensive assessments and evaluations are necessary because of the multifactorial underlying pathology. The selection of the best treatment option is challenging. This article reviews the effect of age on lower urinary tract symptoms, mainly incontinence, and describes the evaluation and management of urinary incontinence in older men.
Key words: urinary incontinence, aging male, older adults, men’s health.

Kannayiram Alagiakrishnan, MD, MPH, FRCP(C), Associate Professor, Division of Geriatric Medicine, Department of Medicine, University of Alberta, Edmonton, AB.
Cheryl A. Sadowski, BSc(Pharm), PharmD, Associate Professor, Faculty of Pharmacy and Pharmaceutical Sciences, University of Alberta, Edmonton, AB.

Cholinergic deficits are seen in the brains of individuals with non-Alzheimer’s dementia. Antidementia drugs such as cholinesterase inhibitors and memantine have showed some cognitive and behavioural benefits in non-Alzheimer’s dementia trials, but more evidence is needed to define their role.
Key words: mixed dementia, cholinesterase inhibitors, Lewy body dementia, Parkinson disease dementia, vascular dementia.

Bejoy C. Thomas, PhD, Department of Psychosocial Resources, Tom Baker Cancer Centre, Alberta Cancer Board; Department of Oncology, University of Calgary, Calgary, AB.
Barry D. Bultz, PhD, Department of Psychosocial Resources, Tom Baker Cancer Centre, Alberta Cancer Board; Department of Oncology, University of Calgary, Calgary, AB.

Geriatric care is undoubtedly complex. A cancer diagnosis in itself creates significant concerns, irrespective of age, for the patient, and these concerns may be compounded by stresses related to moving into later life. Despite the scarce literature on geriatric oncology, the numerous challenges are acknowledged. Substantial evidence is offered on the benefits to the patient as well as the treating institution (cost off-sets, for example) on the benefits of psychosocial care. However, psychosocial care does not necessarily begin only at the cancer centre. Screening for the sixth vital sign, emotional distress, should begin at the primary care physician’s office. This not only benefits the primary care practice but also enables the tertiary referral centre to streamline resources to the specific needs of the patient, thereby ultimately improving the patient experience across the disease trajectory.
Key words: geriatric, chronic disease, emotional distress, screening, sixth vital sign.

Edzard Ernst, MD, PhD, FRCP, FRCPEd, Complementary Medicine, Peninsula Medical School, Universities of Exeter and Plymouth, Exeter, UK.

Many patients use herbal medicines, often without telling their physicians. In order for doctors to advise their patients responsibly, they should know the basics of efficacy, safety, and quality of herbal medicines. As one herbal medicine is different from another, there can be no generalizations.
Key words: herbal medicine, efficacy, safety, quality, evidence.

Gayatri Gupta, MD, Assistant Professor of Medicine, Department of Medicine, Division of Geriatrics, New York Medical College, Valhalla, NY, USA.
Wilbert S. Aronow, MD, AGSF, FGSA, Clinical Professor of Medicine, Department of Medicine, Divisions of Geriatrics, Cardiology, and Pulmonary/Critical Care, New York Medical College, Valhalla, NY, USA.

Of 2,780 persons admitted to a long-term care (LTC) facility in the first half of 1993 and followed up in the facility through the end of 1994, 435 (16%) had advance directives and 805 (29%) had do not resuscitate orders either at admission to or subsequently while in the LTC facility. In contrast, 50 of 57 LTC residents (88%) in six Maryland community LTC facilities had either completed an advance directive or had another person complete one on their behalf. The physicians caring for the residents in an academic LTC facility affiliated with Westchester Medical Center/New York Medical College are members of the Geriatric faculty at New York Medical College and have been taught on numerous occasions to obtain advance directives for all residents admitted to the LTC facility. This article reports the prevalence of the use of advance directives among all residents currently residing in an academic LTC facility.
Key words: advance directives, long-term care facility, do not resuscitate orders, health care proxy, legal guardian.

Christopher Hilton, MD, Instructor, Department of Otolaryngology, University of Minnesota, Minneapolis, MN, USA.
Tina Huang, MD, Assistant Professor, Department of Otolaryngology, University of Minnesota, Minneapolis, MN, USA.

Age-related hearing loss (ARHL) is the most common neurosensory deficit associated with aging. It presents with a predictable pattern of sensorineural hearing loss, causing problems with communication that have been associated with depression and social isolation. Recent studies have improved our understanding of the etiology of ARHL on a molecular level. While treatment options exist with hearing aids and cochlear implants, prevention by identification and avoidance of key risk factors remains the best strategy for dealing with this disease.
Key words: presbycusis, age-related hearing loss, deafness, hearing aids, aging.

Pamela Katz, MD, Department of Endocrinology and Metabolism, University of Toronto, Toronto, ON.
Jeremy Gilbert, MD, FRCPC, Staff Endocrinologist, Toronto General Hospital, University Health Network, Toronto, ON.

The global prevalence of diabetes has increased substantially in recent years, attributable to an increase in new cases and declining mortality. Aging is associated with changes in beta cell function and insulin resistance that predispose to diabetes. Cardiovascular disease is the leading cause of death among older adults with diabetes. In order to reduce the excessive risk of cardiovascular disease, all coronary risk factors must be addressed and treated aggressively. This article will focus on the importance of blood pressure and glycemic control and lipid lowering with statin therapy. Specific considerations in this patient population include high rates of comorbid disease, shorter life expectancy, polypharmacy and falls risk. These factors may alter the therapeutic goals. Treatment should therefore be individualized with consideration given to patient preference and quality of life.
Key words: diabetes, cardiovascular disease, older adults, metabolic syndrome.

Sandy Buchman, MD, CCFP, FCFP, Assistant Professor, Department of Family and Community Medicine, University of Toronto, Toronto, ON; and McMaster University, Hamilton,ON; Palliative Care Physician, The Temmy Latner Centre for Palliative Care and The Baycrest Geriatric Health System, Toronto, ON.
Anthony Hung, MD, FRCPC, Fellow in Palliative Care, 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, Toronto, ON; Associated Medical Services Fellow in End of Life Care Education, University of Toronto, Toronto, ON.

The principle of “cradle-to-grave” care is fundamental to the discipline of family medicine. This includes palliative care. However, many physicians are not comfortable providing care at the end of life. Challenges include logistical support and proficiency and comfort in the specific skills required, such as pain and other symptom management. The following case presents an example of successful palliative care, provided in the primary care setting, from diagnosis of a life-threatening illness to death in a palliative care unit.
Key words: palliative care, end of life, primary care, family medicine, longitudinal care.

Antonio Terracciano, PhD, Laboratory of Personality and Cognition, National Institute on Aging (NIA), National Institutes of Health (NIH), U.S. Department of Health and Human Services (DHHS), Baltimore, MD, USA.
Robert R. McCrae, PhD, Laboratory of Personality and Cognition, NIA, NIH, DHHS, Baltimore, MD, USA.
Paul T. Costa Jr., PhD, Laboratory of Personality and Cognition, NIA, NIH, DHHS, Baltimore, MD, USA.

Individual differences in personality traits are generally stable during adulthood; where there are changes, they are generally in the direction of greater maturity. The trends are similar for men and women and across cultures. With advancing age, people generally become more emotionally stable, agreeable, and conscientious, with better impulse control, but less active and less open to new actions and values than younger individuals. Those trajectories provide several insights into adult development, challenging some negative stereotypes about older adults and serving as a reminder that enduring individual differences are more important than age in understanding personality.
Key words: personality traits, aging, cross-cultural, depression, Alzheimer’s disease.

Michel Carmel, MD, FRCSC, Professor, Sherbrooke University; Chair, Division of Urology, CHUS, Sherbrooke, QC.

Prostate cancer is the highest in incidence in Canada, ahead of lung and colon cancers. This is largely due to prostate-specific antigen (PSA) screening. Choosing among management options, including watchful waiting, active surveillance, and surgery, seems more difficult than ever for the patient and his physician as new treatments are emerging, often presented as accepted alternatives, while long-term efficacy and toxicity results are not yet available.
Key words: cancer, prostate, older adults, prostate-specific antigen, screening.