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.

Guido Falcone, MD, Department of Neurology, Raul Carrea Institute for Neurological Research (FLENI), Buenos Aires, Argentina.
Ji Y. Chong, MD, Assistant Professor of Neurology, Columbia University, New York, NY, U.S.A.

Stroke is a common disease in the older population. Many gender differences are seen in the epidemiology, outcomes, and treatment of geriatric stroke. Although these differences are not fully understood, recognition of gender differences may help with appropriate treatment and improve outcomes.
Key words: stroke, gender, outcomes, prevention, treatment.

Elizabeth A. Johnson, RN, PhD(c), Board Certified Geriatric Clinical Nurse Specialist, Doctoral Candidate, Indiana University School of Nursing; Department of Adult Health, Indiana University School of Nursing, Indianapolis, IN, USA.
Tamilyn Bakas, RN, DNS, FAHA, Associate Professor, Department of Adult Health, Indiana University School of Nursing, Indianapolis, IN, USA.
Linda S. Williams, MD, Chief of Neurology, Roudebush Veterans Administration Medical Center; Research Coordinator, VA Stroke QUERI; Associate Professor of Neurology, Indiana University School of Medicine; Research Scientist, Regenstrief Institute, Indianapolis, IN, USA.

Depression, the most frequent neuropsychological problem after stroke, is greatly influenced by the complex relationships between the neurobiological and psychological changes that occur after stroke. Post-stroke depression leads to negative rehabilitation outcomes including less participation in therapy, extended recovery time, significantly decreased quality of life, and increased utilization of health care resources. Because of the high prevalence of post-stroke depression, all stroke survivors should be screened early in the rehabilitation process. Use of a biopsychosocial framework acknowledges the multifactorial etiology of post-stroke depression and contributes to effective, evidence-based treatment. Attention to the needs of the family caregivers further promotes successful post-stroke rehabilitation.
Key words: stroke, depression, risk factors, recovery, treatment.

Nikolai Steffenhagen MD, Calgary Stroke Program, University of Calgary, Calgary, AB.
Michael D. Hill, MD, MSc, FRCPC, Calgary Stroke Program, University of Calgary, Calgary, AB.

The majority of strokes occur among the older adult population. Typically, ischemic stroke can be classified by mechanism, and this is the most practical way to think about stroke since it has a direct bearing on the approach to prevention. It is not enough to simply consider that a past stroke implies a need for antiplatelet therapy or anticoagulant therapy without consideration of cause. In this article, we discuss the use of preventive strategies within the context of antithrombotics and according to stroke mechanism.
Key Words: stroke prevention, geriatric, octogenerian, vascular risk factors, carotid stenosis, atrial fibrillation.

Weerasak Muangpaisan, MD, FRCPT, Assistant Professor, Department of Preventive and Social Medicine, Faculty of Medicine, Siriraj Hospital, Mahidol University, Thailand; visiting fellow, Harris Manchester College, University of Oxford, Oxford, U.K.

Cases of dementia are increasing due to longer life expectancy of the world population. Physicians should be able to recognize common dementia syndromes. After excluding reversible causes of dementia, there are four common dementia syndromes, which are Alzheimer’s disease, vascular dementia, dementia with Lewy body, and frontotemporal dementia. The key points of clinical differences of these dementia syndromes are summarized in this article.
Key words: Alzheimer’s disease, vascular dementia, dementia with Lewy body, frontotemporal dementia, Parkinson’s disease.

Mary Anne Huggins, MD, CCFP, DABHPC, Palliative Care Services, Toronto General Hospital, University Health Network; Assistant Professor, Department of Family and Community Medicine, University of Toronto, Toronto, ON.
Laura Brooks, BScN, MScN, ACNP, Palliative Care Services, Toronto General Hospital, University Health Network, Toronto, ON.

Discussing end-of-life care with older patients is very important, as it ensures their preferences are known and they retain control over their care decisions even when they may no longer be actively involved in them. Unfortunately, these discussions do not always occur, and when they do occur, they are not always done well. There are patient and physician barriers to advanced care planning. Physicians may lack the skills necessary to accomplish the task of making decisions for future care. In this article we discuss advanced care planning, its importance as well as related challenges and barriers. We then outline a practical approach to advanced care planning for older adults.
Key words: end-of-life care, advance directives, advanced care planning, living wills, substitute decision-maker.

Alberto Matteelli, MD, Institute of Infectious and Tropical Diseases, University of Brescia, Brescia, Italy.
Anna Cristina Carvalho, MD, Institute of Infectious and Tropical Diseases, University of Brescia, Brescia, Italy.
Veronica Dal Punta, MD, Institute of Infectious and Tropical Diseases, University of Brescia, Brescia, Italy.

The number of international travellers is steadily increasing, paralleled by the number of persons with travel-related diseases. Fever in the returning traveller should always raise suspicion of severe and potentially life-threatening infections. Therefore, physicians should be familiar with the most common syndromes, relevant diagnostic procedures, optimal treatment regimens, and referral criteria. This review gives a general overview of the pathogens causing fever in the returning traveller, their clinical presentation, and standard management procedures.
Key words: fever, travel, older adults, tropical diseases, vaccination.