Svante Östling, MD, PhD, Sahlgrenska Academy at Göteborg University, Institute of Clinical Neuroscience and Physiology, Psychiatry Section, Mölndal, Sweden.

The growing proportion of older adults in the population has increased the interest in psychiatric symptoms and disorders that seriously compromise the quality of life in this age group. Psychotic symptoms are common among both demented and nondemented older adults and demand resources from the social and health care systems. There are different etiologies of these symptoms, and different possible underlying medical contributing illnessess, concomitant medications, dementia, delirium, and psychiatric comorbidities should be identified before a specific antipsychotic treatment is considered.
Key words: psychosis, hallucinations, delusions, paranoid older adults.

Sonal Singh, MD, Department of Medicine, Wake Forest University School of Medicine, Winston-Salem, NC, USA.
Yoon K. Loke, MBBS, MD, University of East Anglia, School of Medicine, Health Policy and Practice, Norwich, UK.

Cardiovascular disease is the leading cause of mortality among older adults with type II diabetes. The thiazolidinediones (rosiglitazone and pioglitazone) lower blood sugar levels among individuals with type II diabetes. The thiazolidinediones have favourable effects on surrogate markers of cardiovascular disease such as microalbuminuria, carotid intimal thickness, and blood pressure. Emerging evidence from recent randomized clinical trials has confirmed both that thiazolidinediones increase the risk of heart failure, and that rosiglitazone increases the risk of myocardial infarction among those with type II diabetes. Clinicians should avoid thiazolidinediones for older individuals with type II diabetes who are at risk for cardiovascular events as the negative cardiovascular effects of the thiazolidinediones outweigh any potential benefits on surrogate markers.
Key words: thiazolidinediones, pioglitazone, rosiglitazone, heart failure, myocardial infarctions.

Mario Masellis, MSc, MD, FRCPC, Clinical Associate & Research Fellow, L.C. Campbell Cognitive Neurology Research Unit, Division of Neurology, Department of Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON.
Sandra E. Black, MD, FRCPC, Brill Professor of Neurology, L.C. Campbell Cognitive Neurology Research Unit, Division of Neurology, Department of Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON.

Cognitive impairment occurs along a continuum from mild subjective memory complaints occurring during the normal aging process to severe memory and other cognitive deficits due to dementia, the most common subtype being mixed Alzheimer’s disease and vascular dementia. Due to the significant growth of the older adult population, the incidence of dementia is on the rise and is posing significant challenges for health care systems worldwide. Primary care practitioners are on the front lines of this battle against dementia and will play an increasingly important role in the early identification of disease. Cognitive screening tests are helpful in detecting people in the early stages of dementia and facilitate further clinical and diagnostic evaluations. Primary care practitioners should aggressively treat known cardiovascular risk factors for dementia and institute early symptomatic therapy when appropriate.
Key words: dementia, cognitive screening test, cognitive reserve, neuroimaging, biomarkers.

Nicholas J. Giacomini, BS, Research Assistant, University of California, San Francisco, School of Nursing, Department of Community Health Systems, San Francisco, CA, USA.
Roberta K. Oka, RN, ANP, DNSc, Associate Professor, University of California, San Francisco, School of Nursing, Department of Community Health Systems, San Francisco, CA, USA.

Peripheral arterial disease (PAD) is a common but frequently undetected and undertreated condition among older adults. Untreated PAD and cardiovascular disease (CVD) risk factors results in functional impairment, poor quality of life and increased risk for cardiovascular disease morbidity and mortality. The increased risk for CVD events associated with PAD necessitates raising public awareness of PAD and the potential impact on health, and placing greater emphasis by providers on detection and management of PAD to maximize survival and life quality. This article briefly describes the detection and medical management of PAD, with greater emphasis on lifestyle modification among older adults with PAD.
Key words: vascular disease, cardiovascular disease, risk factor reduction, lifestyle modification.

Keri-Leigh Cassidy, MD, Department of Psychiatry, Dalhousie University, Halifax, NS; Department of Psychiatry, University of Toronto, Toronto, ON.
Neil A. Rector, PhD, Department of Psychiatry, University of Toronto, Toronto, ON.

Late-life anxiety can often be “silent”--missed or difficult to diagnose as older adults tend to somatize psychiatric problems; have multiple psychiatric, medical, and medication issues; and present anxiety differently than do younger patients. Yet late-life anxiety disorders are a “geriatric giant,” being twice as prevalent as dementia among older adults, and four to eight times more prevalent than major depressive disorders, causing significant impact on the quality of life, morbidity, and mortality of older adults. Treatment of late-life anxiety is a challenge given concerns about medication side effects in older, frail, or medically ill patients. Antidepressants are recommended but not always tolerated, and benzodiazepines are generally to be avoided in this population. Effective psychotherapies such as cognitive behavioural therapy (CBT) are of particular interest for the older adult population, and the combination of CBT and medication is often needed to optimize treatment.
Key words: anxiety, late life, management, cognitive behavioural therapy.

Muzumel A. Chaudhary, MD, Psychiatry Resident, University of British Columbia, Vancouver, BC.
Kiran Rabheru, MD, CCFP, FRCP, ABPN, Clinical Associate Professor, Department of Psychiatry, University of British Columbia; Geriatric Psychiatrist, Vancouver General, University of British Columbia, and Riverview Hospitals, Vancouver, BC.

New-onset paranoid symptoms are common among older individuals. They can signify an acute mental status change owing to medical illness, correspond to behavioural and psychological symptoms of dementia, or equate to an underlying affective or primary psychotic mental disorder. The implications of paranoid symptoms are considerable and affect patients, families, and caregivers alike. Accurate identification, diagnosis, and treatment of late-life paranoid symptoms present a unique clinical challenge as issues of morbidity and mortality are inherent both to the illness state and available treatment approaches.
Key words: paranoia, delusions, etiology, older adults, atypical antipsychotic.

John T. Schousboe, MD, MS, Park Nicollet Osteoporosis Center, Park Nicollet Health Services, Division of Health Policy and Management, School of Public Health, University of Minnesota, Minneapolis, MN, USA.

Fractures related to osteoporosis are increasingly recognized as a serious public health problem among older men. As in women, bone densitometry has substantial utility to aid in the identification of older men at high risk of fracture and for whom fracture prevention therapies are indicated. This article briefly reviews the epidemiology of osteoporosis and associated fractures in men, the association of bone mineral density with fractures in men, indications for bone densitometry among older men, and the interpretation of bone mineral density test results in men.
Key words: osteoporosis, bone mineral density, densitometry, men, fractures.

Sanjeev Rastogi, MD, CAc, Consulting Physician, Department of Holistic Medicine,BMCRC, Vatsala Hospital,Tulsi Das Marg, Lucknow, UP, India.
Rajeev Rastogi, MSc, BNYS, Assistant Director (Naturopathy), Central Council for Research in Yoga and Naturopathy, Department of AYUSH, Ministry of Health, Government of India, New Delhi, India.
Ranjana Rastogi, MD, Head, Department of Obstetrics and Gynecology, State Ayurvedic College and Hospital, Lucknow, India.

The shoulder is one of the most versatile but also most unstable and vulnerable joints of the body. It is vulnerable to a variety of injuries, of which rotator cuff injuries predominate. These require specific tissue-targeted therapy to heal the point injuries. Conventional physiotherapy has been found to be limited in its efficacy as it offers superficial physical measures that cannot reach the traumatized tissue. Acupuncture, by virtue of its mode of application, can reach deeper in the traumatized tissue and offer substantial pain relief along with rapid healing of the trauma through ways that are yet to be fully understood. Acupuncture therapy for the management of rotator cuff injury seems to be the most productive way to reduce the intervention time and improve the net outcome, as observed in the case studied.
Key words: acupuncture, rotator cuff, macrotrauma, tendon sheath.

Steve Iliffe, FRCGP, Professor of Primary Care for Older People, Research Department of Primary Care, University College London, UK.

Long-term benzodiazepine use in older adults with sleep disorders is potentially hazardous, but it is also becoming easier to manage as approaches to withdrawal become feasible in primary care, without adverse consequences. This article reviews the evidence and describes practical approaches to reducing consumption of benzodiazepine hypnotics.
Key words: benzodiazepines, insomnia, older adults, primary care, hypnotics.

R.A. Harrison, MD, FRCPC, Department of Internal Medicine and Division of Infectious Diseases, University of Alberta, Edmonton, AB.
T.J. Marrie, MD, FRCPC, Department of Internal Medicine and Division of Infectious Diseases, University of Alberta, Edmonton, AB.

Among older adults, aspiration pneumonia is associated with higher rates of morbidity and mortality than community-acquired pneumonia. Individuals admitted to acute care from continuing care facilities are at increased risk for aspiration pneumonia. Risk factor assessment forms a cornerstone in diagnosing aspiration pneumonia syndromes. Monitoring for timely clinical response to therapy and for potential complications is an important step in the care of patients with aspiration pneumonia. Further high-quality research is needed to better delineate the effects of risk factor modification on the incidence of aspiration pneumonia. Aiming to prevent aspiration pneumonia poses health care providers with an opportunity for ongoing development, study, and implementation of preventive strategies for older adults.
Key words: aspiration, pneumonia, older adults, geriatric, risk factor.