Sander Veldhuyzen van Zanten, MD, PhD, Division of Gastroenterology, Department of Medicine, University of Alberta, Edmonton, AB.

Dyspepsia is defined as an epigastric pain or discomfort thought to originate in the upper gastrointestinal (GI) tract. There is discussion, especially in uninvestigated patients, about whether gastroesophageal reflux disease (GERD) can be separated from dyspepsia. If heartburn and regurgitation are the dominant symptoms, GERD is the likely diagnosis. Among older adults, more severe esophagitis is often seen, while at the same time patients report less severe symptoms. The use of nonsteroidal anti-inflammatory drugs (NSAIDs), acetylsalicylic acid (ASA), and cyclo-oxygenase 2 selected inhibitors is associated with an increased frequency of dyspepsia and, more importantly, ulcers and upper GI bleeding. In new-onset dyspepsia among older adults, endoscopy should be considered given the increased risk of an upper GI malignancy. Among individuals taking NSAIDs, the medication should ideally be discontinued if it is thought to be the cause of dyspepsia. For NSAID prophylaxis, there is evidence that use of a once-daily proton pump inhibitor or misoprostol 200 µg two to four times per day decreases the risk of upper GI ulcers. NSAID prophylaxis is underused among older adults taking non-ASA NSAIDs, and the reasons for this and its consequences require further study.
Key words: dyspepsia, gastroesophageal reflux disease, NSAIDs, ASA, H. pylori.

Alissa R. Segal, PharmD, CDE, Associate Professor, Massachusetts College of Pharmacy and Health Sciences; Clinical pharmacist, Joslin Diabetes Center, Boston, Massachusetts, U.S.A.
Medha N. Munshi, MD, Assistant Professor, Harvard Medical School; Director of Joslin
Geriatric Diabetes Program, Joslin Diabetes Center; Division of Gerontology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, U.S.A.

The aging of the population and increasing prevalence of diabetes are worldwide phenomena that require a better focus on challenges of diabetes management in older adults. We now understand the benefits of tight glycemic control and have an armament of agents to achieve such a feat. However, in an aging population, balance must be sought between the goals of glycemic control and those of overall health status, including quality of life. Insulin therapy, in particular, requires significant self-care abilities. Insulin therapy can be used safely and effectively if diabetes management plans are formulated with consideration of the clinical, functional, and psychosocial contexts of an older adult.
Key words: diabetes, older adults, insulin therapy, geriatrics, glycemic control.

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.