Aleksandra Klimkowicz-Mrowiec, PhD, Department of Neurology, University Hospital Cracow, Poland.

Stroke and dementia are major health problems affecting older people. Cerebrovascular disease is the second-leading cause of dementia after Alzheimer’s disease, the third- leading cause of death, and one of 10 leading causes of physical disability. In parallel with the increased prevalence of stroke in aging populations and the decline in mortality from stroke, the rate of diagnosed poststroke dementia has increased, causing a growing financial burden for health care systems. This article discusses the epidemiology, etiology, and determinants of poststroke dementia and outlines the search for a suitable treatment.
Key words: dementia, stroke, cognition, risk factors, cognitive impairment.

Wilbert S. Aronow, MD, FACC, FAHA, AGSF, Department of Medicine, Cardiology Division, New York Medical College, Valhalla, NY, USA.

Numerous double-blind, randomized, placebo-controlled studies have documented that antihypertensive drug therapy reduces cardiovascular events in older adults. In the Hypertension in the Very Elderly Trial, individuals 80 years of age and older treated with antihypertensive drug therapy had, at 1.8-year follow-up, a 30% reduction in fatal or nonfatal stroke, a 39% reduction in fatal stroke, a 21% reduction in all-cause mortality (p=0.02), a 23% reduction in death from cardiovascular causes, and a 64% reduction in heart failure. The goal of treatment of hypertension in older adults is to reduce the blood pressure to <140/90 mmHg and to <130/80 mmHg in older persons with diabetes or chronic renal insufficiency. Older adults with diastolic hypertension should have their diastolic blood pressure reduced to 80-85 mmHg. Diuretics should be used as initial therapy in persons with no associated medical conditions. The selection of antihypertensive drug therapy in persons with associated medical conditions depends on their medical conditions. If the blood pressure is >20/10 mmHg above the goal blood pressure, drug therapy should be initiated with two antihypertensive drugs, one of which should be a thiazide-type diuretic. Other coronary risk factors must be treated.
Key words: hypertension, older adults, antihypertensive drug therapy, angiotensin-converting enzyme inhibitors, beta-blockers.

R.N. Martinez-Gallino, MD, Department of Orthopaedic Surgery, University of British Columbia, Vancouver, BC.
L.K. Burke, BScN, BHSc, Department of Orthopaedic Surgery, University of British Columbia, Vancouver, BC.
R.G. McCormack, MD, FRCSC, Department of Orthopaedic Surgery, University of British Columbia, Vancouver, BC.

Frozen shoulder, or adhesive capsulitis, is a frustrating condition for both patients and physicians. The protracted course of frozen shoulder in combination with the pain and limited range of motion significantly impacts patients’ quality of life. Controversy over the best course of treatment for this chronic condition has proved to be a major challenge for physicians. The goal of this article is to present an organized review of the assessment and management of a frozen shoulder. The emphasis is placed on treatment options. Special considerations for the older adult are highlighted.
Key words: frozen shoulder, adhesive capsulitis, diabetes, glenohumeral joint, pain.

Cornelia M. Borkhoff, PhD, Postdoctoral Research Fellow, Centre for Global Health, University of Ottawa, Ottawa, ON; Canadian Osteoarthritis Research Program, Women’s College Hospital, Toronto, ON.
Gillian A. Hawker, MD, MSc, FRCPC, Chief of Medicine, Women’s College Hospital;
F.M. Hill Chair in Academic Women’s Medicine, University of Toronto; Arthritis Society of Canada Senior Distinguished Rheumatology Investigator, Toronto, ON.

Although total joint arthroplasty (TJA) is a highly effective treatment for individuals with moderate to severe osteoarthritis who have not responded to medical therapy, disparities in TJA utilization based on gender, race/ethnicity, and socioeconomic status are well documented. These disparities may be due in part to patient-level factors such as perceptions of, and willingness to consider, TJA. Another possible explanation is that subtle or overt biases may inappropriately influence physicians’ treatment recommendations regarding this procedure. Because of the potential for an increased quality of life among TJA recipients, disparity in rates of use of TJA among individuals with an identified need represents inadequate care. In this article, we make recommendations about how to make sure your patient gets the best care.
Key words: quality of care, osteoarthritis, joint arthroplasty, disparities.

Simon H.K. Huang, MD, FRCPC, Clinical Associate Professor, Division of Rheumatology, Faculty of Medicine, University of British Columbia, Vancouver, BC.
Ian K. Tsang, MB, FRCPC, Clinical Professor Emeritus, Division of Rheumatology, Faculty of Medicine, University of British Columbia, Vancouver, BC.

The two most common forms of crystal-induced arthritis among older adults are gout and calcium pyrophosphate dihydrate (CPPD) deposition disease. Gout in older adults has unique clinical features. The new case incidence is the same in males and females over age 60. Upper limb and polyarticular involvement are not unusual. CPPD deposition disease may present as asymptomatic chondrocalcinosis on radiographs and symptomatically as pseudogout, pseudo–rheumatoid arthritis, or pseudo-osteoarthritis. Other crystals may cause periarthritis or arthritis. Management of crystal-induced arthritis among older adults requires special considerations due to comorbid conditions and concomitant medications. Nonsteroidal anti-inflammatory drugs may be contraindicated. Steroids taken either orally or intra-articularly are often an alternative.
Key words: gout, chondrocalcinosis, pseudogout, pseudo–rheumatoid arthritis, pseudo-osteoarthritis.

Arthur Bookman, MD, FRCPC, Division of Rheumatology, Toronto Western Hospital/University Health Network, Toronto, ON.

Rheumatoid arthritis (RA) in older adults has a lower female-to-male ratio, and presents as either a rheumatoid factor positive typical case of RA, or an acute seronegative syndrome consisting of myalgia, fever, weight loss, and fatigue. Differentiating among systemic lupus erythematosus, polymyalgia rheumatica, and rheumatoid arthritis may initially be very difficult in older patients. Rheumatoid arthritis beginning in younger people can lead to earlier death, accelerated atherosclerosis, complicated polypharmaceutical management, debilitating deformity, osteoporosis, and more frequent infection as these patients enter their geriatric years.
Key words: rheumatoid arthritis, geriatrics, polypharmacy, chronic disease, inflammatory arthritis.

Michael Gordon, MD, MSc, FRCPC, FRCP Edin, Medical Program Director, Palliative Care Baycrest Geriatric Health Care System; Professor of Medicine, University of Toronto, Toronto, ON.
Kayi Li, BHSc, medical student, University of Toronto, Toronto, ON.

Osteoporosis is a systemic disease resulting in bone fragility and increased risk of fractures. For optimal prevention, the literature increasingly supports the combined use of education on nutrition, lifestyle, and exercise. Currently, multidisciplinary, multimodal initiatives are rarely implemented in the community. The POWER (Promoting Osteoporosis Wellness through Education, Exercise and Resources) program in Toronto, Ontario, strives to empower individuals with osteoporosis with diverse cultural backgrounds to sustain healthy behaviours for self-management of their condition. This article provides a description of the POWER program philosophy, as well as a preliminary evaluation to assess its benefits and potential for further expansion and adaptation.
Key words: osteoporosis, management program, cultural differences, education, health beliefs.

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

As the population is aging, physicians from all specialties are expected to see more older adults at their outpatient practices and in the acute settings. Abdominal pain remains one of the most common and potentially serious complaints that emergency physicians encounter. Vascular pathology should be considered early in the diagnostic course of all older adults who have abdominal pain because the time for intervention is critical.
Key words: abdominal pain, older adults, management of acute abdominal pain.

Ellen Grober, PhD, Department of Neurology, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, NY, USA.

We have developed and validated a cost-effective case finding tool for early dementia in primary care that consists of two stages: a rapid dementia screening test administered to all patients over the age of 65 and a second stage to identify memory impairment administered to patients who fail the first stage. The Alzheimer’s Disease Screen for Primary Care (ADS-PC) had high sensitivity and specificity for early dementia and higher sensitivity for AD, and distinguished AD from non-AD dementias. The ADS-PC outperformed the MMSE and worked equally well in African-American and Caucasian primary care patients and in patients that differed in educational level.
Key words: Alzheimer’s disease, early dementia, mass screening, primary health care, neuropsychological tests.

Bailus Walker Jr., PhD, MPH, Department of Community and Family Medicine, College of Medicine, Howard University, Washington, DC, USA.
Charles Mouton, MD, MS, Department of Community and Family Medicine, College of Medicine, Howard University, Washington, DC, USA.

In the late 1990s, it became increasingly clear that air pollution, even at the lower ambient concentrations prevalent in many urban areas, is associated with increased mortality and other serious health effects. More recently, considerable research has focused on particulate air pollution as studies have linked a growing number of health effects to fine particles. Hundreds of studies now indicate that breathing fine particles discharged by vehicles, factories, and power plants can trigger a cardiac event and exacerbate respiratory disease in vulnerable populations. Older adults are one subgroup considered more susceptible to the effects of airborne particles. This sensitivity can be attributed to a number of factors including loss of pulmonary functional reserve and compensation due to age or disease. Although a number of mechanisms have been proposed to explain the adverse impact of particles on cardiovascular health, many questions remain. Their answers will require further transdisciplinary research.
Key words: heart disease, air pollution, smog, particulates, older adults.