M. Bachir Tazkarji, MD, CCFP, CAQ Geriatric Medicine, Lecturer, Family Medicine Department, University of Toronto, Toronto, ON; Toronto Rehabilitation Institute, Toronto; Family Physician, Summerville Family Health Team, Mississauga, ON.

Arterial hypertension is one of the most important and preventable causes of death worldwide; therefore, adequate treatment of high blood pressure should be mandatory for patients with hypertension. Hypertension is defined on the basis of systolic and diastolic blood pressure levels and classified into stages on the basis of the degree of elevation. Normal blood pressure is widely considered as being less than 120/80 mm Hg. The presence of risk factors such as elevated blood cholesterol, smoking, diabetes, and obesity greatly increases the risk for hypertension-related morbid events.
Cardiovascular disease and stroke disproportionately affect older adults. Blood pressure is a potent modifiable target for reducing the risk for stroke and cardiovascular morbidity and mortality in older adults. In clinical trials, the number needed to treat to prevent one cardiovascular death was 79, one fatal or nonfatal stroke was 48, and one fatal or nonfatal coronary event was 64.
Key words: blood pressure, myocardial infarction, CVA, cardiovascular risk, older adults.

Mohammed O. Rahman, BHSc student, McMaster University, Hamilton, ON.
Aliya Khan, MD, FRCPC, FACP, FACE, Professor of Clinical Medicine, McMaster University, Hamilton, ON, Director, Calcium Disorders Clinic, St. Joseph’s Healthcare, Hamilton; Director, Oakville Bone Center, Oakville, ON.

Osteoporosis is a skeletal disease characterized by impaired bone strength and an increased risk of fragility fracture. Effective screening should be aimed at evaluating risk factors for osteoporosis with identification of individuals at risk, allowing for intervention prior to fragility fracture. This article presents an overview of the risk factors for fracture in men and women and the integration of these factors in various models, enabling an assessment of the 10-year fracture risk. Through effective screening, early identification, and early intervention with pharmacological therapy of osteoporosis, significant impact can be made on reducing fragility fracture incidence, thereby alleviating the economic and clinical costs to our health care system.
Key words: osteoporosis, screening, risk factors, diagnosis, FRAX.

Cathy R. Kessenich, DSN, ARNP, Professor of Nursing, University of Tampa, Tampa, FL, USA.
Darlene A. Higgs, RN, BSN, Nurse Practitioner Student, University of Tampa, Tampa, FL, USA.

Osteoporosis is a major cause of health problems in residents of long-term care facilities. It often results in bone fracture, causing poor quality of life and a national financial burden. As the population ages, the incidence of osteoporosis and its consequences increase. It is essential to employ fracture-prevention strategies that have proven most beneficial in long-term care settings and those tailored to promote adherence among older adults. This article reviews osteoporotic treatment appropriate for individuals in long-term care, including treatment through pharmacology, nutritional support, fall prevention, and hip fracture prevention.
Key words: osteoporosis, long-term care, hip protectors, fall prevention, vitamin D.

Angela G. Juby, MD, Associate Professor, Department of Medicine, Division of Geriatrics, University of Alberta, Edmonton, AB.
David A. Hanley, MD, Professor, Department of Medicine, Division of Endocrinology and Metabolism, University of Calgary, Calgary, AB.

Low bone density is major risk for osteoporotic fracture. In older adults special precautions apply in interpreting bone mineral density measurements (either by central dual energy X-ray absorptiometry [DXA] or peripherally with calcaneal ultrasonography). Clinical assessment for vertebral fractures is an important part of the management. Therapeutic regimes for osteoporosis treatment are complicated and require repeated reinforcement to ensure long term compliance. Adequate compliance (80%) is required for optimal therapeutic benefit.
Key words: calcaneal ultrasonography, central dual energy x-ray absorptiometry (DXA), bone mineral density (BMD), older adult, special precautions.

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.