Jennifer L. Martin, PhD, Assistant Research Professor, University of California, Los Angeles; Department of Medicine and Research Health Scientist, VA Greater Los Angeles Healthcare System, Geriatric Research, Education and Clinical Center, Los Angeles, California, USA.

Caregivers often report sleep disturbances in persons with dementia. Older adults with dementia have more nighttime awakenings, less deep sleep, more daytime sleepiness and napping, and experience changing in the timing of sleep. Sleep disorders such as sleep disordered breathing, restless legs syndrome, periodic limb movement disorder, and REM behaviour disorder are more common among individuals with some types of dementia. Sleep problems are associated with difficulties in caregiving and quality of life. As a result, sleep problems should be evaluated and treated. Treatment should always consider nighttime environmental and daytime lifestyle factors.
Key words: sleep, dementia, Alzheimer’s disease, circadian rhythms, sleep disorders.

Kannayiram Alagiakrishnan, MD, MPH, FRCPC, ABIM, Associate Professor, Division of Geriatric Medicine, Department of Medicine, University of Alberta, Edmonton, AB.

Postural and postprandial hypotension are common conditions among older adults. They are causes of dizziness, syncope, and falls in older people. These conditions may result in significant morbidity, a decrease in function, and mortality. Dysregulation of blood pressure in older adults can result in postural and postprandial hypotension. Routine screening for these conditions is easy to perform and helps to diagnose and manage them appropriately. Management includes a combination of nonpharmacological and pharmacological interventions.
Key words: postural hypotension, postprandial hypotension, management, blood pressure, older adults.

Pascal Jean-Pierre, PhD, Department of Radiation Oncology, Department of Family Medicine, University of Rochester Medical Center, Rochester, New York, USA.
Gary Morrow, PhD, MS, Department of Radiation Oncology, Department of Psychiatry, University of Rochester Medical Center, Rochester, New York, USA.

Fatigue due to cancer and its treatments is a highly prevalent and debilitating symptom experienced by many patients. This symptom is often present prior to a pathologically confirmed diagnosis of cancer and can be experienced both during and for considerable periods after treatment. Oncology professionals are becoming more cognizant of the impact of cancer-related fatigue on key aspects of patients’ psychosocial performance, cognitive functioning, and overall quality of life. This paper discusses the importance of cancer-related fatigue, the challenges involved in assessing this debilitating symptom among cancer patients, and the influence of researchers’ conceptualization of this symptom on the characteristics of the measures developed to assess it. Strategies to facilitate differential diagnosis of cancer-related fatigue are also presented and discussed.
Key words: cancer-related fatigue, assessment, measurement dimension, older adults, quality of life.

Scott M. Sellick, PhD, CPsych, Associate Research Scientist & Director of Supportive Care, Thunder Bay Regional Health Sciences Centre, Thunder Bay, ON.

Approximately 25% of persons with cancer report symptoms that meet the diagnostic criteria for the most prevalent mood disorders, including major depression, dysthymic minor depression, and adjustment disorder with depressed mood. This is two to four times the incidence found among the general population. To simply consider depression as “normal” precludes the possibility that some very good things can happen when patients are properly diagnosed and referred to a psychosocial program to be seen by a psychiatrist, psychologist, or social worker. Asking about a patient’s general mood or spirits needs to become as routine as asking about pain. While screening instruments can be very helpful, single questions are equally useful for identifying patients with this unmet need. Otherwise, patients remain feeling helpless or that their condition is hopeless, and this can easily spiral into despair and significantly worsened depression.
Key words: cancer, depression, psychosocial, supportive care, coping.

Deepali Kumar MD, MSc, FRCP(C), Consultant, Infectious Diseases, Immunocompromised Host Service, University Health Network; Assistant Professor, University of Toronto, Toronto, ON.

The incidence of cancer continues to increase, and many persons receiving treatment for cancer are older adults. Fever in older adults with cancer can be an emergency. Any patient with fever and neutropenia should be given antibiotics as soon as possible. In addition to the immune senescence associated with aging, individuals with cancer have immunodeficiencies specific to their underlying malignancy, and these predispose them to specific infections. Older adults are also at higher risk of the complications of chemotherapy, including infections. Prompt evaluation and judicious management of the febrile cancer patient can reduce morbidity and mortality. The following review considers an approach to the etiologies and evaluation of fever in cancer including the infectious and noninfectious causes.
Key words: fever, cancer, older adults, antibiotics, neutropenia.

David R. Staskin, MD, Department of Urology, New York Presbyterian Hospital, Weill-Cornell Medical College, New York, NY, USA.
Edward Zoltan, MD, Division of Urology, Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA.
Alan J. Wein, MD, Division of Urology, Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA.

Older adults have a high prevalence of urinary incontinence. Among the older adult population, many nonurinary pathological, anatomical, physiological, and pharmacological factors may serve as comorbidities in the development of incontinence. The treating physician must appreciate potentially reversible pathologies. Older adults frequently are prescribed several drugs; therefore, it is important to consider drug-drug metabolic interactions. Age-associated changes may affect pharmacological actions of the drug. Antimuscarinic therapy has been proven efficacious and represents the first line of pharmacologic therapy for overactive bladder (OAB). The selection of an antimuscarinic agent for the management of an older individual presenting with OAB is limited by the natural condition of the aging body and by the side effects associated with antimuscarinics as a class and the specific agents themselves.
Key words: urinary incontinence, antimuscarinics, older adult, frail older adult, geriatrics.

Pooja Viswanathan, BMath, MSc Candidate, Department of Computer Science, University of British Columbia, Vancouver, BC.
Jennifer Boger, MASc, Research Manager, Intelligent Assistive Technology and Systems Lab, Department of Occupational Science and Occupational Therapy, University of Toronto; Toronto Rehabilitation Institute, Toronto, ON.
Jesse Hoey, PhD, Lecturer, School of Computing, University of Dundee, Dundee, Scotland; Toronto Rehabilitation Institute, Toronto, ON.
Pantelis Elinas, MSc, PhD Candidate, Department of Computer Science, University of British Columbia, Vancouver, BC.
Alex Mihailidis, PhD, PEng, Assistant Professor and Head of Intelligent Assistive Technology and Systems Lab, Department of Occupational Science and Occupational Therapy, University of Toronto; Toronto Rehabilitation Institute, Toronto, ON.

Mobility and independence are essential components of a high quality of life. Although they lack the strength to operate manual wheelchairs, most physically disabled older adults with cognitive impairment are also not permitted to use powered wheelchairs due to concerns about their safety. The resulting restriction of mobility often leads to frustration and depression. To address this need, the authors are developing an intelligent powered wheelchair to enable safe navigation and encourage interaction between the driver and his/her environment. The assistive technology described in this article is intended to increase independent mobility, thereby improving the quality of life of older adults with cognitive impairments.
Key words: mobility, artificial intelligence, assistive technology, wheelchairs, cognitive impairment.

Abi Rayner, MD, MPH, Buller Medical Service, Westport, New Zealand.

Hallucinations and delusions increase the risk of developing dementia, delirium, functional impairment, and of death. The differential diagnosis includes isolated hallucinations, delirium, depression with psychotic symptoms, late-onset schizophrenia, and unrecognized dementing disorder, including Lewy Body disease and frontotemporal dementia. Optimum management requires diagnosis, assessment of the goals of treatment, and understanding the risks and benefits associated with psychoactive medications. Atypical neuroleptics are appropriate first-line agents for most patients with dementia and psychotic symptoms. Response to medications is modest and a second agent (including acetylcholinesterase inhibitors, antidepressants, and anticonvulsants) may be necessary to reduce behaviour to acceptable levels. In addition, decline in cognitive status and increased risk of cerebrovascular events and death are associated with the use of antipsychotic medications. Change in functional status and time alter the impact of behavioural symptoms. Periodic reassessment and reduction of medication dosage over time appears safe, usually without re-emergence of symptoms.
Key words: psychotic symptoms, older adult, dementia, antipsychotics, behavioural disturbance.

Maxime Lamarre-Cliche, MD, FRCPC, MSc, Institut de Recherches Cliniques de Montréal, Université de Montréal, Montréal, QC.

Syncope is a frequent cause for emergency consultation and hospital admission; it is also an indicator of reduced survival rate among older adults. The differential diagnosis may be large, but bradyarrhythmias, neurocardiogenic syncope, carotid hypersensitivity syndrome, and orthostatic hypotension are the more frequent causes. Good history-taking and physical examination usually orient the diagnosis and testing strategy. In working with older patients, great care must be taken in assessing comorbidities and concomitant medications as they can exacerbate syncopal symptoms. A multidisciplinary and dedicated approach to syncope increases the diagnostic yield and rapid management of patients.
Key words: syncope, orthostatic hypotension, arrhythmia, neurally mediated syncope.

Suzanne Bridge, MD, Internal Medicine Program, University of Toronto, Toronto, ON.
John Granton, MD, FRCPC, Associate Professor of Medicine, Faculty of Medicine, University of Toronto; Director, Pulmonary Hypertension Program, Toronto General Hospital, Toronto, ON.

Pulmonary arterial hypertension is a rare but incurable disease characterized by a progressive increase in pulmonary vascular resistance and ultimately dysfunction of the right ventricle. Clinically, the reduction in right ventricular output and ensuing right ventricular failure causes severe physical limitation, reduced quality of life, and increased mortality. With the present use of directed therapies such as prostanoids, prognosis is slowly improving. Currently, unique challenges in both clinical assessment and management arise as the population of patients with pulmonary arterial hypertension ages and we better recognize the spectrum of this disease in older adults.
Key words: Pulmonary arterial hypertension, echocardiogram, dyspnea, bone morphogenic protein receptor type-2, prostanoids, endothelin.