Tarek Rajji, MD, Geriatric Mental Health Program, Centre for Addiction and Mental Health; Department of Psychiatry, University of Toronto, Toronto, ON.
Benoit H. Mulsant, MD, MSc, FRCPC, Western Psychiatric Institute and Clinic and Department of Psychiatry, University of Pittsburgh, Pittsburgh, USA; Geriatric Mental Health Program, Centre for Addiction and Mental Health; Department of Psychiatry, University of Toronto, Toronto, ON.
Hiroyuki Uchida, MD, PhD, PET Centre, Centre for Addiction and Mental Health, Toronto, ON.
David Mamo, MD, MSc, FRCPC, PET Centre and Geriatric Mental Health Program, Centre for Addiction and Mental Health; Department of Psychiatry, University of Toronto; Centre for Addiction and Mental Health, Toronto, ON.

Antipsychotics are increasingly being prescribed to older patients for the management of a variety of neuropsychiatric conditions. Available evidence supports the use of second-generation antipsychotics (SGAs) when treating these conditions. However, given their modest clinical effect for certain conditions (e.g., behavioural and psychological symptoms of dementia), their adverse effects, and their safety profile, a careful analysis of their risks and benefits is needed before initiating treatment with an SGA for an older patient. Among SGAs, choice of medication should be guided by their respective clinical indications and adverse effect profile, with use of lower initial and target doses (compared to younger adults) and periodic reviews of whether or not their continued use is warranted.
Key words: antipsychotics, older adults, dementia, delirium, schizophrenia.

Kati Juva, MD, PhD, Department of Psychiatry, Helsinki University Central Hospital, Helsinki, Finland.
Sari Rastas, MD, PhD, Department of Neuroscience and Neurology, University of Kuopio, Kuopio, Finland; Kauniala Disabled War Veterans’ Hospital, Espoo, Finland.
Tuula Pirttilä, PhD, Professor, Department of Neuroscience and Neurology, University of Kuopio and Kuopio University Hospital, Kuopio, Finland.

The harmful effects of high blood pressure on cardiovascular morbidity and mortality are well established. However, hypertension in the very old is an extremely complex issue. Current epidemiological data suggest that high blood pressure may be a marker of survival in the very old, and lowering blood pressure may lead to an increase in total mortality. In this review we will summarize the evidence on the association between blood pressure and mortality and discuss the implications of the data.
Key words: older adults, hypertension, survival, very old, blood pressure.

Naven Duggal, MD, FRCSC, Department of Orthopaedic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA.

Diabetes mellitus is a major cause of nontraumatic lower extremity amputation in Canada and the United States. This multisystemic disease is most effectively managed by a team approach. Structural abnormalities and the resultant plantar ulcers will increase the risk of amputation among older adults with diabetes. Effective management of the diabetic foot begins with education and prevention.
Key words: diabetic foot, amputation, diabetic ulcers, Charcot arthropathy.

Muhammad Firdaus, MD, FACP, Section of Endocrinology, Department of Medicine, University of Oklahoma Health Sciences Center; Veterans Affairs Medical Center, Oklahoma City, OK, USA.
Timothy J Lyons, MD, FRCP, Section of Endocrinology, Department of Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA.

The metabolic syndrome, though controversial due to lack of a uniform pathophysiological mechanism, is a useful clinical tool for identifying persons at risk for diabetes and cardiovascular disease. It indicates the cumulative cardiometabolic risk exerted by abdominal obesity, hyperglycemia, high triglyceride, low high density lipoprotein cholesterol (HDL-C), and high blood pressure. Lifestyle factors, high calorie intake, and less physical activity have been implicated in the causation of the metabolic syndrome, and thus older adults are at particular risk for the development of this syndrome. Current evidence indicates that the components of the metabolic syndrome can be targeted with lifestyle interventions to prevent the complications of diabetes and cardiovascular disease. This paper reviews various diagnostic criteria, etiological factors, and lifestyle interventions to combat the metabolic syndrome in order to prevent diabetes and cardiovascular disease in older adults.
Key words: metabolic syndrome, prevention, lifestyle modification, diet, physical activity.

Jeremy Gilbert, MD, FRCPC, Staff Endocrinologist, Toronto General Hospital, Toronto, ON.

Diabetes is a very common condition, especially among older adults. There are numerous benefits associated with improved glycemic control. However, achieving glycemic targets can be challenging, particularly for older adults with comorbidities. In recent years more oral antihyperglycemic agents have become available to better manage diabetes, and there are many pharmacological therapies currently in development. In order to select the most appropriate agent to use as monotherapy or in combination for an individual patient, it is important to be familiar with the mechanism, efficacy, safety, and cost of the various antihyperglycemic agents.
Key words: diabetes, older adults, oral antihyperglycemic agents, monotherapy, combination therapy.

Maitreyi Raman, MD, FRCPC, Assistant Professor, Department of Medicine, Division of Gastroenterology, University of Calgary, Calgary, AB.
Elaheh Aghdassi, PhD, Scientific Associate, University of Toronto, Toronto, ON.
Johane P. Allard, PhD, Associate Professor, Division of Gastroenterology, Department of Medicine, University of Toronto, Toronto, ON.

Zinc is one of the essential micronutrients and has an important role in the maintenance of human health. Older adults are particularly vulnerable to zinc deficiency due to poor intake of zinc-rich foods. Zinc deficiency may result from poor intake due to alterations in both olfactory and gustatory sensations in addition to difficulty in mastication from poor dentition, or due to inadequate absorption resulting from excess consumption of phytate-containing products that inhibit the absorption of zinc. This review focuses on the clinical consequences associated with zinc deficiency among older adults.
Key words: zinc, deficiency, older adults, clinical manifestations.

Evelyn Hutt, MD, Associate Professor of Medicine, University of Colorado at Denver and Health Sciences Center; Director, Colorado Research in Care Coordination, VA Eastern Colorado HCS, Denver, CO, USA.
Martha D. Buffum, DNSc, APRN, BC, CS, Associate Chief Nurse for Research, VA Medical Center, San Francisco; Associate Clinical Professor, School of Nursing, University of California, San Francisco, CA, USA.
Regina Fink, RN, PhD, FAAN, Research Nurse Scientist, University of Colorado Hospital, Aurora, CO, USA.
Katherine R. Jones, RN, PhD, FAAN, Sarah Cole Hirsh Professor and Associate Dean for Evidence-Based Practice, Frances Payne Bolton School of Nursing, Case Western Reserve University, Cleveland, OH, USA.
Ginette A. Pepper, PhD, RN, FAAN, Professor and Helen Lowe Bamberger Colby Endowed Chair in Gerontological Nursing Associate Dean for Research and PhD Program, University of Utah College of Nursing, Salt Lake City, UT, USA.

Pain is common among long-term care residents and is often undertreated. A high prevalence of dementia, sensory impairment, and disability, as well as structural issues such as staffing patterns and turnover in long-term care facilities make assessment and management of pain challenging. An overview of the evidence regarding the assessment and treatment of pain in individual residents, and recommendations for improving the overall quality of pain management in the long-term care setting, is presented.
Key words: pain, dementia, long-term care, pain assessment, pain management.

Sheri L. Koshman, BScPharm, ACPR, PharmD, Assistant Professor of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB.
Glen J. Pearson, BSc, BScPhm, PharmD, FCSHP, Associate Professor of Medicine; Division of Cardiology, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB.

Antiplatelet agents are the cornerstone of secondary prevention for patients who present with an ischemic stroke or transient ischemic attack (TIA). At present, monotherapy with acetylsalicylic acid (ASA) or clopidogrel or the combination regimen of ASA plus extended-release dipyridamole are recommended as first-line options in the stroke prevention guidelines. The combination of ASA and clopidogrel is not routinely recommended for secondary stroke prevention, since it has been shown to offer no therapeutic advantage and an increased risk of bleeding. The clear answer as to whether one or two antiplatelet agents are better for the secondary prevention of ischemic stroke events in older adults depends upon the combination of agents, as well as the monotherapy comparator.
Key words: stroke prevention, clopidogrel, acetylsalicylic acid, dipyridamole, antiplatelet agents.

Ashok Devasenapathy, MD, Assistant Professor of Medicine and Neurology, Penn State University, Milton S. Hershey Medical Center, Hershey, PA, USA.
Rathna Muthukumaran, MD, Graduate Student, Faculty of Psychology, Penn State University, Harrisburg, PA, USA.
Vladimir Hachinski, MD, Distinguished Professor Emeritus, Professor of Neurology, Clinical Neurosciences, University of Western Ontario, London, ON.

The term “vascular dementia” should be considered obsolete, a reflection of the 20th century concept that dementia does not respond to preventive measures, is always a neuro-degenerative disease, is not reversible, and has no treatment. A new approach necessitates the redefinition of vascular dementia as vascular cognitive impairment (VCI), with “dementia” as the terminal manifestation of a treatable process. Vascular cognitive impairment encompasses the vascular component of all dementias and is hence the only treatable element of a disease that has a highly significant impact on the health of older adults at risk for both strokes and coronary artery disease (cardiovascular disease).
The principal aim of this article is to illustrate the relationship between cognitive loss among older adults with vascular risk factors, stroke, and cardiovascular disease. Such an approach should help in understanding the basis for VCI, its prevention, and treatment.
Key words: vascular cognitive impairment, preventable senility, brain at risk, dementia, stroke.

Daniel Tascona, MD, Nephrology Fellow, Queen’s University, Kingston, ON.
Karen Yeates, MD, FRCPC, Nephrologist, Kingston General Hospital, Assistant Professor of Medicine, Queen’s University, Kingston, ON.

Leg edema is a common condition among older adults. It increases the risk of ulcers and cellulitis. Edema may be broadly classified as either venous edema or lymphedema. Many conditions associated with leg edema show a substantial increase in prevalence with age. Chronic venous insufficiency (CVI) is the most common cause of chronic leg edema among older adults. Causes of leg edema can be subdivided as acute (<72 h) or chronic and unilateral or bilateral. The acute onset of unilateral leg edema is always suspicious for a deep vein thrombosis (DVT), whereas a more chronic onset would suggest CVI. A careful clinical history can be very helpful and will often suggest the likely etiology. Treatment should be guided by the suspected etiology and can be either pharmacologic, nonpharmacologic, or both.
Key words: edema, chronic venous insufficiency, lymphedema, deep venous thrombosis.