Siamak Moayedi, MD, Assistant Professor, Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD, USA.
Mercedes Torres, MD, Instructor, Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD, USA.

Dyspnea is among the most frequent complaints among older adults. The prevalence of comorbid medical conditions combined with physiological changes of aging present significant challenges to the diagnosis. The initial approach to the older adult with dyspnea mandates consideration of a broad range of diagnoses. Failure to consider life-threatening medical conditions presenting with dyspnea, such as pulmonary embolism, acute coronary syndromes, congestive heart failure, asthma, obstructive pulmonary disease, pneumothorax, and pneumonia, can lead to significant morbidity and mortality. This review focuses on the rapid assessment and approach to the older adult with acute dyspnea.
Key words: dyspnea, shortness of breath, approach, geriatric, older adults.

Mark A. Lutterbie, MD, Fellow in Family Medicine, University of Virginia, Department of Family Medicine, Charlottesville, VA, USA.
Daniel F. McCarter, MD, Vice-Chair and Associate Professor of Family Medicine, University of Virginia, Department of Family Medicine, Charlottesville, VA, USA.

Cerumen, or earwax, is the product of the sebaceous and ceruminous glands combined with débrided epithelial cells and hair from the external auditory canal. Cerumen is usually extruded by a combination of jaw movements from chewing and speech, and natural epithelial migration. However, cerumen may become impacted, especially among older adults and individuals with mental retardation. Cerumen impaction may cause hearing loss, otitis externa, vertigo, tinnitus, or cough. There are multiple methods for removing earwax, with limited evidence to support any of the current practices. Irrigation or manual disimpaction using a curette have long been the accepted earwax removal methods, yet neither has been subjected to comparative trials with other methods. Irrigation alone is effective in up to 70% of cases of impacted cerumen. Ceruminolytics or eardrops are effective in up to 40% of cases without irrigation, and when combined with irrigation can be effective up to 97%. Cotton ear buds and ear candling should be avoided.
Key words: cerumen, earwax, irrigation, ceruminolytic, impaction.

Chris Hudson, PhD, MCOptom, FAAO, Professor, School of Optometry, University of Waterloo, Waterloo, ON; Associate Professor, Department of Ophthalmology and Vision Sciences, University of Toronto, Toronto, ON; Director of Retinal Research, University Health Network, Toronto, ON; scientist, Toronto Western Research Institute, Toronto, ON.

Diabetic retinopathy (DR) remains the leading cause of vision loss and blindness in people of working age, in spite of the fact that current treatments are effective. Vision loss occurs in DR due to the development of maculopathy, especially diabetic macular edema, and due to proliferative diabetic retinopathy. Vision loss due to DR is preventable with the appropriate monitoring and timely treatment. Improved patient and health professional, education to encourage tight control of blood glucose and other systemic factors, and the establishment of readily available and appropriately timed eye examinations are necessary steps to further reduce visual impairment of people with diabetes.
Key words: diabetic retinopathy, vision loss, macular edema, neovascularization, laser photocoagulation.

Lorne Bellan, MD, Chairman, Department of Ophthalmology, University of Manitoba, Winnipeg, MB.

Cataract surgery is the most common refractive surgical procedure performed on aging individuals. Major advancements in surgical and lens technology have led to enormous increases in surgical volume because of the improved safety profile and outcomes. Current research holds the potential for restoring full vision, including accommodation, without the need for glasses in the near future.
Key words: cataract, lens, refractive, vision, phacoemulsification.

Robert E. Coffee, MD, MPH, Clinical Instructor, Jules Stein Eye Institute, David Geffen School of Medicine, University of California, Los Angeles, USA.
Tara A. Young, MD, PhD, Assistant Professor, Jules Stein Eye Institute, David Geffen School
of Medicine, University of California, Los Angeles, USA.

Age-related macular degeneration (AMD) is the leading cause of blindness among older adults in North America. This article reviews the clinical spectrum, risk factors, pathophysiology, and potential therapeutic options for this disease. Despite significant advances in the treatment of certain forms of AMD, there is currently no cure for this degenerative condition. The substantial personal, social, and economic burden of AMD requires that those who provide care to older adults have a general understanding of this cause of blindness. It is important for the ophthalmologist and primary care physician to address modifiable risk factors for the progression of AMD such as poor cardiovascular status and smoking, which may worsen visual loss. In addition, educating patients and their families regarding risk factors and potential treatment options may greatly benefit those affected by AMD.
Key words: blindness, geriatric, age-related macular degeneration, choroidal neovascularization, ranibizumab, bevacizumab.

Jeffrey Schiff, MD, FRCP(C), Instructor, Division of Medicine, University of Toronto; Division of Nephrology and Multi-Organ Transplant Program, Toronto General Hospital, Toronto, ON.

Due to the excellent outcomes of renal transplantation, there is an increasing number of people surviving with, or receiving a transplant, at an older age. While the transplant centre usually manages the immunosuppression and renal problems, these individuals also require primary care. This article will review the common health issues that primary care physicians encounter routinely among these patients. Common problems include managing cardiovascular risk factors, screening for malignancy, vaccinations, treatment of uncomplicated infections, and bone disease. Important drug interactions will be reviewed. Communication between the primary care physician and the transplant centre will also improve care of these patients.
Key words: renal transplantation, primary care, cardiovascular disease, drug interactions, chronic kidney disease.

Zena Moore, RGN, MSc, FFNMRCSI, Health Research Board of Ireland, Clinical Nursing and Midwifery Research Fellow, Royal College of Surgeons in Ireland, Dublin, Ireland.
Seamus Cowman, PhD, MSc, FFNMRCSI, P.G Cert Ed (Adults), Dip N (London), RNT, RGN, RPN, Professor and Head of Department, Faculty of Nursing and Midwifery, Royal College of Surgeons in Ireland, Dublin, Ireland.

Pressure ulcers are common, costly, and adversely affect quality of life. Nutritional status is one risk factor that predisposes individuals to the development of a pressure ulcer. The impact of nutritional supplementation is reflected in the reduced incidence of pressure ulcers; however, the evidence is limited. The precise role of nutritional supplementation in pressure ulcer healing is less clear, yet a trend towards healing has been suggested. Patients should have their nutritional status monitored carefully. If difficulties arise, these should be detected early, and if it is not possible to increase the intake of normal food and fluids, then advice should be sought from the dietitian.
Key words: pressure ulcers, risk, prevention, treatment, nutrition.

Wey Leong, MSc, MD, Department of Surgical Oncology, Princess Margaret Hospital, University Health Network, University of Toronto, ON.
Alexandra M. Easson, MSc, MD, Department of Surgical Oncology, Princess Margaret Hospital and Mount Sinai Hospital, University of Toronto, ON.
Michael Reedijk, PhD, MD, Department of Surgical Oncology, Princess Margaret Hospital, University Health Network, University of Toronto, ON.

Melanoma must be considered in the differential diagnosis of any skin lesion in older adults. With the incidence of melanoma increasing in general and even more so among older people, more older adults are being diagnosed with melanoma than in the past. Among older adults, melanomas display more aggressive histological features with worse prognosis and treatment outcomes than among younger individuals. Furthermore, older individuals have fewer surgical and medical treatment options because of age-associated comorbidities. This article reviews the epidemiology and management of melanoma with emphasis on the older adult population.
Key words: older adults, melanoma, aged, cancer, skin neoplasm.

Jenny Rogers, MD, Psychiatry Department, Postgraduate Education, University of British Columbia, Vancouver, BC.
Bonnie S. Wiese, MD, Psychiatry Department, Postgraduate Education, University of British Columbia, Vancouver, BC.
Kiran Rabheru, MD, CCFP, FRCP, Clinical Associate professor, Psychiatry Department, University of British Columbia, Vancouver, BC.

Alcohol, recreational drugs, over-the-counter, and prescription medications may cause a range of cognitive impairments from confusion to delirium, and may even mimic dementia. Moderate to high alcohol consumption is one of the often overlooked risk factors for development of dementia and cognitive impairment among older adults. Substances such as opioids, benzodiazepines, and anticholinergics pose a particular risk of cognitive impaiment and the risk increases when these are combined with multiple medications, as polypharmacy is common in patients over 65. A substance-induced dementia may have a better prognosis compared to other types of dementia, as once the instigating factor is gone, the cognition often improves.
Key words: Alcohol related dementia, geriatric substance abuse and dependence, polypharmacy, anticholinergic adverse effects, cognitive impairment.

Robert J. Hinchliffe, MD, MRCS, Clinical Lecturer in Vascular Surgery, St George’s Regional Vascular Institute, St George’s Hospital and St George’s University of London, London, UK.
William Jeffcoate, FRCP, Professor, Foot Ulcer Trials Unit, Department of Diabetes and Endocrinology, Nottingham University Hospitals, City Hospital Campus, Nottingham, UK.

Individuals with ulceration of the foot should be identified and referred urgently to a specialist. Unfortunately there is little formal health care education in diabetic foot ulceration and often no specialist referral pathway. We discuss the common modes of presentation of patients with diabetes and foot ulcer. The clinical implications of a range of symptoms and signs will be explained, including the most common diagnostic pitfalls in everyday primary care practice.
Key words: diabetes, peripheral vascular disease, ulcer, vascular surgery, peripheral arterial disease, diabetic foot.