Børge Sivertsen, PhD, Department of Clinical Psychology, University of Bergen, Bergen, Norway.

Chronic primary insomnia is a sleep disorder with no known secondary etiology, and the prevalence increases with advancing age. Insomnia is associated with a range of adverse consequences, both on an individual and societal level. While pharmacotherapy is still the most common form of treatment of late-life insomnia, it is associated with a number of side effects, and recent evidence shows cognitive-behavioural therapy (CBT) to be more effective in managing chronic primary insomnia. This article will discuss the development, consequences, assessment and treatment of chronic primary insomnia among older adults.
Key words: sleep initiation and maintenance disorders, aged, morbidity, treatment, insomnia.

Kerstin Stieber Roger, PhD, Assistant Professor, Department of Family Social Sciences, Faculty of Human Ecology, University of Manitoba, Winnipeg, MB.

This article discusses current research in the social sciences on end-of-life care and people living with dementia. Given the projected increase within the next twenty years of older adults living with dementia, end-of-life care for this demographic will become more relevant than ever before. The main themes emerging in the literature are discussed in this article: personhood, decision-making, counselling and spirituality, pain management, training for professionals, and settings of primary care. Recommendations for further research are offered.
Keywords: care, dementia, end-of-life, family, personhood.

Oren K. Steinmetz, MDCM, FRCSC, Associate Professor of Surgery, McGill University; Chief, Division of Vascular Surgery, McGill University Health Centre, Montreal, QC.
Peter I. Midgley, MD, FRCSC, Vascular Surgery Fellow, McGill University, Montreal QC.

Abdominal aortic aneurysms are a common cause of death among older adults in North America. Most commonly they are asymptomatic until they rupture. Rupture of an abdominal aortic aneurysm is usually lethal, so effective treatment to prevent rupture depends on accurate diagnosis on physical exam or one of various imaging modalities such as ultrasound, CT scan, or magnetic resonance imaging. Once the diagnosis is made, choice of treatment will depend on several factors including patient age and comorbidity, and aneurysm diameter. If elective treatment is contemplated there are currently two main options available to most patients: open surgical repair and endovascular repair. The fundamental differences between these two treatment options are outlined in this review.
Key words: abdominal aortic aneurysm, open surgical repair, endovascular aneurysm repair, older adults, aortic rupture.

Philippe Voyer, RN, PhD, Associate Professor, Faculty of Nursing, Laval University; Researcher, Laval University Geriatric Research Unit,St-Sacrement Hospital, Quebec, QC.
Michel Préville, MD, Associate Professor, Faculty of Medicine, Université de Sherbrooke; Researcher, Research Centre on Aging, Sherbrooke Geriatric University Institute, Sherbrooke, QC.
and Researchers of the Étude sur la santé des aînés team.

Sleep complaints by older adults constitute a very common situation faced by health care providers. However, not all professionals respond to the complaint the same way. Some will briefly assess the complaint and resort rather quickly to medication while others will assess the complaint carefully in order to exclude the diagnosis of primary insomnia and prescribe alternative interventions to improve sleep. When medicine is prescribed, the type of compound often selected is benzodiazepine. However, benzodiazepine carries a significant risk of adverse reaction, including drug dependency, both of which are clinical problems that should not be underrated, especially when treating a subjective complaint and not a specific diagnosis.
Key words: insomnia, benzodiazepine, dependency, addiction, older adults.

Victoria A. Walker, MD, Department of Internal Medicine, Division of Geriatric Medicine, Duke University Medical Center, Durham, North Carolina, USA.
Heather E. Whitson, MD, Department of Internal Medicine, Division of Geriatric Medicine, Duke University Medical Center, Durham, North Carolina, USA.

Smoking is the leading cause of preventable death worldwide. Though older adults are the segment of the population least likely to smoke, they incur significant morbidity and mortality from tobacco use and can benefit from quitting. Older smokers have beliefs regarding smoking and motivating factors for cessation that differ from younger adults. Clinicians should understand these unique factors and can then use strategies to assist the older adult in smoking cessation.
Key words: smoking cessation, tobacco, epidemiology, older adults, prevention.

Katherine R. Schlaerth, MD, Fellow, American Academy of Pediatrics; Fellow, American Academy of Family Practice; Fellow, Pediatric Infectious Disease Society; Associate Professor, Department of Family Medicine, Loma Linda University School of Medicine, Loma Linda, California; Associate Professor Emeritus, Departments of Family Practice and Pediatrics, University of Southern California School of Medicine, Los Angeles, California, USA.

Most practitioners assume that the use of illegal or “street” drugs is confined to the young. However, a recent phenomenon has been the use of such drugs by individuals above the age of 50. Social trends play a part: many older addicts began using in the 1960s. Others share the use of illegal drugs with other family members as a mode of family recreation. The latter trend is probably more common in inner cities where drugs are more easily obtained. Older men are twice as likely to use illegal drugs as are older women, though the latter outnumber the former demographically. Many illegal drugs, especially cocaine, methamphetamines, and even marijuana have cardiovascular effects that are especially dangerous when they occur in older individuals who may already have underlying cardiovascular disease. Practitioners must be vigilant about querying patients about their use of illegal drugs, no matter what their age, and especially if cardiovascular illness is involved.
Key words: older adults, illegal drugs, cardiovascular disease, cocaine, methamphetamines.

Ann Schmidt Luggen, PhD, GNP, Professor Emeritus, Northern Kentucky University, Highland Heights, Kentucky, USA.

The number of older adults who drink to excess is not known, partly because primary health practitioners seldom screen for this problem. The signs of alcohol abuse are vague prior to late-stage liver failure and many of them are attributed to normal aging. Two types of alcohol dependence are commonly seen in older adults: type I is a late-onset alcohol dependence in which depression, chronic illness, or life changes such as retirement precipitate drinking, while type II is mainly genetic and reflects lifelong drinking that has not been previously identified by health professionals. Pharmacologic agents such as naltrexone and acamprosate have been shown in a number of clinical trials to be useful in care. A great many others are still in testing phases. Nonpharmacologic management is also effective, especially when teamed with drug therapy. Some of these are cognitive behavioural therapy, motivational enhancement therapy, and counselling that the primary care physician can do in the office, also known as the brief intervention approach. There is much that can be done if alcohol dependence is recognized.
Key words: alcohol, aging, older adults, dependence, liver disease.

A.M. Johnson, PhD, Assistant Professor, Faculty of Health Sciences, University of Western Ontario, London, ON.
Q.J. Almeida, PhD, Director, Movement Disorders Research & Rehabilitation Centre, Wilfrid Laurier University, Waterloo, ON.

Although medication therapy is generally effective in the clinical management of Parkinson’s disease (PD), additional improvement of some gross motor symptoms may be achieved through the use of nonpharmacological treatments, such as physical therapy and exercise rehabilitation. Despite the fact that PD is a neurological disorder, successful rehabilitation has been demonstrated with treatments that combine cognitive and physical approaches. While the exact mechanism through which these therapies obtain successful outcomes is still largely unknown, it is worthwhile to explore these adjunctive approaches to treating the motor output symptoms of PD.
Key words: Parkinson’s disease, movement disorders, exercise rehabilitation, physical therapy, motor control.

Miguel G. Madariaga, MD, Assistant Professor of Medicine, Section of Infectious Diseases, University of Nebraska Medical Center, Omaha, NE, USA.
Philip W. Smith, MD, Professor of Medicine and Division Chief, Section of Infectious Diseases, University of Nebraska Medical Center, Omaha, NE, USA.

Tuberculosis is a re-emerging public health threat. This article discusses the particular characteristics of tuberculosis among older adults and the use of the tuberculin skin test as a tool for diagnosis of tuberculosis infection with emphasis in long-term care facility residents. An overview of new diagnostic tests based on gamma interferon release is also included.
Key words: tuberculosis, tuberculin skin test, long-term care facilities, purified protein derivative.

Christopher Frank, MD, CCFP, Department of Medicine, Division of Geriatrics, Queen’s University, Kingston, ON.

Skin ulcers are common among older adults, especially those in hospital or in long-term care facilities. Prevention of ulcers is important in all clinical settings. Clarifying the cause(s) and exacerbating factors is the first step in management. Pressure and venous insufficiency are the most common causes among older adults. Poor nutrition, edema, arterial insufficiency, and anemia may impair wound healing. Adequate debridement and cleaning is important to decrease infection risk and to promote healing. The choice of dressings depends on the needs of the individual wound but should emphasize the provision of a moist wound environment. Options for dressings are summarized.
Key words: skin ulcers, treatment, wound healing, older adults, pressure ulcers.