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.

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.