Joan Pleuss, RD, MS, CDE, CD, Director, Bionutrion & Body Composition Units, Clinical & Translational Research Institute, Medical College of Wisconsin, Milwaukee, WI.

The requirement for some nutrients changes as adults age. The Dietary Reference Intakes, the 2007 Canada Food Guide, and the 2005 Dietary Guidelines for Americans (MyPyramid.gov) provide guidance for the consumer and the professional for nutritional needs throughout the life span. The Guidelines provide recommendations in user-friendly messages. MyPyramid.gov and the Food Guide allow the public to access information on the internet that is individualized for age, gender, and physical activity. The Dietary Reference Intakes provide the health professional with nutrition requirements for gender and specific age groupings through the entire lifespan. This article will address those nutrients whose requirements significantly change with adult aging.
Key words: Dietary Reference Intakes, Canada Food Guide, Dietary Guidelines of America, MyPyramid, aging, nutrition.

Lesley J. Ritchie, MSc, Department of Psychology, Centre on Aging, University of Victoria, Victoria, BC.
Holly Tuokko, PhD, Department of Psychology, Centre on Aging, University of Victoria, Victoria, BC.

Mild cognitive impairment (MCI) is an intermediary stage in the cognitive continuum from normal aging to dementia. Six to 48% of individuals with MCI are estimated to develop dementia.1 As such, the conceptualization and operationalization of MCI present unique opportunities for the development and implementation of strategies to prevent or delay the conversion to dementia. Despite the lack of a “gold standard” case definition for MCI, information gathered from neuropsychological assessment may inform a diagnosis of MCI based on clinical judgment, as impaired performance on several neuropsychological measures is predictive of conversion to dementia for persons exhibiting cognitive decline but who are not demented.
Key words: mild cognitive impairment, dementia, conversion, neuropsychology, predictors of dementia.

Joel S. Hurwitz, MB, FRCPC, FRCP (London), Associate Professor, Department of Medicine (Division of Geriatric Medicine), University of Western Ontario, London, ON.

This article will assist the clinician in defining and categorizing tremor, also suggesting key questions and physical examination techniques to facilitate a probable diagnosis in an older adult. The role of many drugs in the causation and exacerbation of tremor is discussed and the treatment of several specific tremor disorders is reviewed.
Key words: essential tremor, postural tremor, kinetic tremor, enhanced physiological tremor, parkinsonism.

John R. Wherrett, MD, FRCP(C), PhD, Professor Emeritus, Division of Neurology, University of Toronto; consultant in Neurology, Toronto Western Hospital and Toronto Rehabilitation Institute; member, Memory Clinic, Toronto Western Hospital, Toronto, ON.

Nonneurologist practitioners faced with the diagnosis of dementia cannot be expected to conduct the detailed assessments for which neurologists are trained. Nonetheless, they should be able to diagnose the most common forms of neurodegenerative dementia and identify individuals that require more detailed neurologic workup. A neurologic examination algorithm is described that allows the practitioner, in a stepwise and efficient manner, to elicit findings that distinguish the main categories of neurodegenerative and vascular dementia, namely, Alzheimer’s disease, dementia with Lewy bodies, vascular dementia, and frontotemporal lobar degenerations. Patients are assessed for gait, frontal signs, signs of parkinsonism, signs of focal or lateralized lesions, neuro-ophthalmologic signs, and signs characteristic of frontotemporal lobar degeneration.
Key words: neurologic, examination, neurodegenerative, dementia, diagnosis, gait, frontal dysfunction, cognitive impairment.

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.