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.

Mohammed Al Houqani, MBBS, Department of Medicine, University of Toronto, Toronto, ON.
Theodore K. Marras, MD, FRCPC, Attending Staff, Division of Respirology, Department of Medicine, University Health Network and Mount Sinai Hospital; Assistant Professor of Medicine, University of Toronto, Toronto, ON.

Long-term care-acquired pneumonia is a clinical syndrome of pneumonia that develops in a resident of a long-term care facility who has not been recently hospitalized. It is one of the leading causes of mortality and morbidity among the residents of long-term care facilities. Streptococcus pneumonia, Haemophils influenza, and Moraxella catarrhalis are the most frequently identified bacterial causative. Poor oral hygiene increases the risk of long-term care-acquired pneumonia. In this review, we discuss the risk factors, pathogenesis, etiology, management, and the preventive measures for long-term care-acquired pneumonia.
Key words: Long-term care, nursing home, health care facilities, pneumonia, fluoroquinolones.

The accredited CME learning activity based on this article is offered under the auspices of the CE department of the University of Toronto. Participating physicians are entitled to one (1) MAINPRO-M1 credit by completing this program, found online at www.geriatricsandaging.ca/cme

Andrew McIvor MD, MSc, FRCP, Professor of Medicine, McMaster University; Firestone Institute for Respiratory Health, St Joseph’s Healthcare, Hamilton, ON.

At present, some 750,000 Canadians are known to have chronic obstructive pulmonary disease (COPD). This number is believed to represent the tip of the iceberg, as COPD is often only diagnosed in the advanced stage. Respiratory symptoms or a previous smoking history are common among older adults yet they seldom trigger further assessment for COPD. Objective demonstration of airflow obstruction by spirometry is a simple procedure, even in older adults, and is the gold standard for diagnosis of COPD. Early intervention with routine nonpharmacological management includes partnering with the patient and family, providing education, smoking cessation, vaccination, collaborative self-management, and advice on exercise and pulmonary rehabilitation. Anticholinergic inhalers remain the gold standard for optimal bronchodilation and dyspnea relief in COPD, and new long-acting agents have underpinned new treatment algorithms, improving quality of life and exercise capacity as well as reducing exacerbations. For those with advanced disease, recent trials have reported further benefits with the addition of combination inhalers (inhaled corticosteroid and long-acting B2-agonist) to core anticholinergic treatment. Physicians and patients can expect a promising future for COPD treatment as significant advances in management and improved outcomes in COPD are now being made.
Key words: chronic obstructive pulmonary disease, older adults, spirometry, diagnosis, management.

The accredited CME learning activity based on this article is offered under the auspices of the CE department of the University of Toronto. Participating physicians are entitled to one (1) MAINPRO-M1 credit by completing this program, found online at www.geriatricsandaging.ca/cme

David B. Hogan MD, FACP, FRCPC, Professor and Brenda Strafford Chair in Geriatric Medicine, University of Calgary, Calgary, AB.

A number of agents are available for treatment of Alzheimer’s disease (AD). They include drugs with a specific indication for AD, nutritional supplements, herbal preparations, and drugs approved for other conditions. Cholinesterase inhibitors (ChEIs) such as donepezil, galantamine, and rivastigmine are modestly effective for mild to moderate stages of AD. Memantine has a slight, beneficial effect on moderate to severe stages of AD. As ChEIs and memantine have different mechanisms of action, they can be used together. Antioxidants, B vitamins, anti-inflammatories, HMG-CoA reductase enzyme inhibitors, and sex steroids can not be recommended for the treatment of AD at the present time.
Key words: Alzheimer’s disease, drug therapy, cholinesterase inhibitors, memantine, dementia.

Holly A. Tuokko, PhD, RPsych, CIHR Institute of Aging Senior Investigator; Professor, University of Victoria, Victoria, BC.

Impairments in cognition and everyday activities are primary risk factors for increases in need for care. Even before cognitive impairment is of sufficient severity to be considered dementia, complex, high-level, everyday activities may be notably impaired. As cognitive impairment increases, so too does the type and magnitude of difficulties in performing everyday tasks. When the severity of cognitive impairment and level of dependency for everyday tasks exceeds that which can be provided at home in the community, long-term care facility admission may need to be considered.
Key words: mild cognitive impairment, dementia, everyday functioning, long-term care facility admission.

Timothy O. Lipman, MD, Chief, GI-Hepatology-Nutrition Section, Washington D.C. Veterans Affairs Medical Center; Professor of Medicine, Georgetown University School of Medicine, Washington, D.C., USA.

Herbal therapy (botanical products) and probiotics are two forms of complementary and alternative medicine (CAM). Primary care providers and geriatricians should know about CAM therapies as their patients may well be using it--an estimated 50% or more of the Western population take some form of supplement. Herbals and probiotics are often used for both functional and organic gastrointestinal diseases, with some limited evidence by randomized controlled trials demonstrating occasional efficacy. Issues of toxicity and lack of regulation are major limitations surrounding herbal and probiotic therapies.
Key words: complementary and alternative medicine, herbal therapy, probiotics, herbal toxicity, randomized controlled trials.

Bridget K. Gorman, PhD, Assistant Professor, Department of Sociology, Rice University, Houston, TX, USA.
Jen’nan Ghazal Read, PhD, Assistant Professor, Department of Sociology and Center for Health Policy Research, University of California, Irvine, CA, USA.

Men have shorter life expectancies than women in most nations around the world. The gender gap in mortality is particularly striking in high-income industrialized nations such as the United States, where women were expected to live 5.3 years longer than men in 2003 (80.1 years compared to 74.8 years). However, in recent decades this gap has been steadily shrinking in many nations. This review examines the mortality gap, primarily in the U.S. context, by providing an overview of the gender pattern in mortality, an explanation of its existence, and an assessment of how and why it has changed over time.
Key words: mortality, life expectancy, gender, smoking, cigarettes.