David F. Tang-Wai, MDCM, FRCPC, Assistant Professor, Department of Medicine, University of Toronto; University Health Network Memory Clinic, University of Toronto, Toronto, ON.
Naida L. Graham, PhD, Research Associate, Department of Speech-Language Pathology, University of Toronto; University Health Network Memory Clinic, University of Toronto; Toronto Rehabilitation Institute, Toronto, ON.

Impairment in language is a common finding among individuals with dementia and can be a presenting symptom, particularly in Alzheimer’s dementia and primary progressive aphasia. Early recognition of language dysfunction can help with an accurate diagnosis, management, and prognosis. There are numerous established and validated language evaluation protocols. This article provides a simple means for the primary care physician to identify and evaluate language disorders in dementia, but it is not meant to replace established protocols.
Key words: aphasia, dementia, primary progressive aphasia, semantic dementia, Alzheimer’s disease.

Marc Schermerhorn, MD, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, MA, USA.
Kristina Giles, MD, Beth Israel Deaconess Medical Center, Boston, MA, USA.

Peripheral arterial disease (PAD) is a common disorder among older adults. Recognition of the signs and symptoms and appropriate referral of patients to a vascular surgeon can improve functional outcomes and limb salvage. Behavioural, medical, and percutaneous endovascular or open surgical therapies may all be used, depending upon the severity of symptoms and likelihood of limb loss. Cardiovascular comorbidities are common with PAD, and appropriate treatment to minimize cardiovascular mortality is important.
Key words: peripheral arterial disease, claudication, critical limb ischemia, endovascular treatment, lower extremity bypass.

Linda M. Rapson, MD, CAFCI, Rapson Pain and Acupuncture Clinic, Toronto; Consultant, Acupuncture Program, Toronto Rehabilitation Institute Lyndhurst Centre, Toronto, ON.
Robert Banner, MD, CCFP, FRCP(C), Dip AAPM/CAPM, Department of Anesthesia and Perioperative Medicine, University of Western Ontario, London, ON.

Acupuncture, an ancient form of medicine that originated in China several thousand years ago, has been used by Canadian physicians since the 1970s. Research on the neurophysiology of acupuncture analgesia supports the theory that it is mediated primarily via the selective release in the central nervous system of neuropeptides. Evidence of its anti-inflammatory effects is emerging. Meta-analyses of randomized controlled trials provide evidence for acupuncture’s effectiveness in treating back pain, neck pain, and osteoarthritis. Applications of electroacupuncture using transcutaneous electrical nerve stimulation can provide good pain relief via home treatment and make management of cancer pain using acupuncture knowledge realistic.
Key words: acupuncture, pain, TENS, endorphin, anti-inflammation.

Mary Xiumei Wu, MD, TCM (China), MSc, Dipl OM, RAc, President, Toronto School of Traditional Chinese Medicine, Toronto, ON.

Traditional Chinese medicine (TCM) is a distinct and comprehensive medical system deeply rooted in Chinese philosophy. It is composed of fundamental theory, unique diagnostic methods, and a variety of treatment modalities primarily including acupuncture, Chinese herbal medicine, tuina massage, and taiji qigong. Traditional Chinese medicine has a wide range of clinical applications encompassing health promotion, disease prevention, and treatment and may be used for pain management either as an alternative or complement to allopathic medicine. An advantage of TCM is that it improves the patient’s general health in addition to controlling pain; therefore, it usually provides long-lasting effects and results in the relief of other accompanying symptoms such as fatigue, poor circulation, anxiety, depression, and insomnia, which are common comorbidities of pain in older adults.
Key words: traditional Chinese medicine (TCM), acupuncture, herbal medicine, tuina massage, taiji qigong, chronic pain.

Grant Chen, MD, FRCPC, Clinical Associate, Division of Gastroenterology, Sunnybrook Health Sciences Centre, Toronto, ON.

Chronic abdominal pain is a common problem that is frustrating for both the patient and the physician. This article provides a general approach to chronic abdominal pain, including diagnostic considerations (both organic and functional) as well as important features for diagnosis and management of the common chronic functional abdominal pain syndromes.
Key words: chronic abdominal pain, functional abdominal pain, irritable bowel syndrome, functional dyspepsia.

Neeraj Bhala, MBChB, MRCP, Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Clinical Medicine, Oxford, UK.
Angel Lanas, MD, PhD, Service of Gastroenterology, Instituto Aragones de Ciencias de la Salud, University Hospital, CIBERehd. Zaragoza, Spain.

Low-dose acetylsalicylic acid (ASA) is widely used in the prevention of cardiovascular events but can be associated with upper gastrointestinal (GI) complications, including ulcers. In this article, the range of effects of GI toxicity and the epidemiology of ASA-associated events are discussed, as well as risk factors, such as increasing age, that predict bleeding. Strategies to minimize upper GI events in older adults include the use of mucosal protectants such as proton pump inhibitors. The use of alternative antiplatelet agents including clopidogrel or Helicobacter pylori infection eradication may not provide sufficient protection in at-risk individuals who need low-dose ASA.
Key words: low-dose ASA, upper gastrointestinal events, older adults, gastroprotection, proton pump inhibitor.

Bhaskar Ghosh, MD, DNB, DM, MNAMS, Movement Disorders Program, Department of Clinical Neurosciences, University of Calgary, Calgary, AB.
Oksana Suchowersky, MD, FRCPC, FCCMG, Movement Disorders Program, Department of Clinical Neurosciences; Department of Medical Genetics, Faculty of Medicine, University of Calgary, Calgary, AB.

Chorea is a hyperkinetic movement disorder characterized by nonsustained, rapid, and random contractions that may affect all body parts. Chorea is hypothesized to be due to an imbalance between the direct and indirect pathways in the basal ganglia circuitry. Important causes of chorea among older adults include medications, stroke, and toxic-metabolic, infective, immune-mediated, and genetic causes. The history and clinical examination guide appropriate investigations and help determine an accurate diagnosis. In secondary causes, removal of the precipitating cause is the mainstay of treatment. If the chorea is persistent or progressive, drug therapy may be instituted. Genetic counselling is important in hereditary chorea.
Key words: movement disorders, chorea, older adults, diagnosis, treatment.

Emily Saks, MD, Fellow, Division of Urogynecology and Female Reproductive Surgery, Department of Obstetrics and Gynecology, University of Pennsylvania, Philadelphia, PA, USA.
Lily Arya, MD, Assistant Professor and Program Director, Division of Urogynecology and
Female Reproductive Surgery, Department of Obstetrics and Gynecology, University of Pennsylvania, Philadelphia, PA, USA.

Pelvic organ prolapse is a common condition among women, and its prevalence increases with age. Pelvic organ prolapse is multifactorial in etiology but ultimately results from a disruption in the pelvic floor muscles and their attachments. Patients may be asymptomatic or may report a variety of pelvic floor symptoms. Prolapse can be easily diagnosed through clinical examination. Treatment involves simple observation, pessary, or surgery.
Key words: pelvic organ prolapse, older women, pessary, vaginal surgery.

Ali Ahmed, MD, MPH, FACC, FAHA, FESC, associate professor, Division of Gerontology, Geriatric Medicine, and Palliative Care, Department of Medicine, School of Medicine and Department of Epidemiology, School of Public Health, University of Alabama at Birmingham; director, Geriatric Heart Failure Clinics, Veterans Affairs Medical Center, Birmingham, AB, USA.

Heart failure (HF) is the leading cause of hospitalization among older adults. Digoxin has been shown to reduce hospitalization due to worsening HF. However, at the commonly prescribed dose of 0.25 mg/day, digoxin does not reduce mortality. New data suggest that at low doses (0.125 mg/day or lower) digoxin not only reduces hospitalization due to HF, but may also reduce mortality. Further, at lower doses, it also reduces the risk of digoxin toxicity and obviates the need for routine serum digoxin level testing. Digoxin in low doses should be prescribed to older adults with symptomatic HF.
Key words: chronic heart failure, older adults, treatment, digoxin, update.

Eran Metzger, MD, Associate Director of Geropsychiatry, Hebrew SeniorLife, Boston; Assistant Professor of Psychiatry, Harvard Medical School, Boston, MA, USA.

The management of depression among individuals with dementia can be one of the more challenging problems in geriatric practice. Depression in dementia is common regardless of the type of dementia and compounds the impairment of the underlying dementing illness. Some symptoms of dementia, including apathy, impaired concentration, and decreased food intake, may be difficult to distinguish from similar symptoms of depression. This article presents background information on the epidemiology and pathophysiology of depression in dementia followed by recommendations for a systematic approach to diagnosis. Treatment modalities including psychotherapy, pharmacotherapy, and electroconvulsive therapy are reviewed.
Key words: dementia, depression, Alzheimer’s disease, psychotherapy, psychopharmacology.