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.

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.