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.

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

Psychotic symptoms, hallucinations, and delusions, arising de novo in older adults, represent a major risk factor for the development of dementia, illness, delirium, functional impairment and death. These symptoms and associated behavioural manifestations overlap with depressive disorders and may be signs of cognitive impairment or dementia. Symptoms may be vague or legitimized so that the psychosis is unrecognized by family and physicians. Specific queries regarding the nature of the symptoms and the impact on function will provide diagnostic clues. Several brief assessment tools can be used in primary care, specifically the NPI-Q and Blessed Dementia Scale.
Key words: psychosis, hallucinations, delusions, dementia, depression.

Wilbert S. Aronow, MD, Department of Medicine, Cardiology, Geriatrics, and Pulmonary/Critical Care Divisions, New York Medical College, Valhalla, NY, USA.

Randomized, double-blind, placebo-controlled studies and observational studies have demonstrated that statins reduce mortality and major cardiovascular events among high-risk older adults with hypercholesterolemia. The Heart Protection Study showed that statins reduced mortality and major cardiovascular events in high-risk persons regardless of the initial level of serum lipids, age, or gender. The updated National Cholesterol Education Program (NCEP) III guidelines state that among very high-risk patients a serum LDL cholesterol level of less than 70 mg/dl (1.8 mmol/l) is a reasonable clinical strategy, regardless of age. When a high-risk person has hypertriglyceridemia or low serum HDL cholesterol, consideration can be given to combining a fibrate or nicotinic acid with an LDL cholesterol-lowering drug. For moderately high-risk persons (having two or more risk factors and a 10-year risk for CHD of 10-20%) the serum LDL cholesterol should be reduced to less than 100 mg/dl (2.6 mmol/l). When LDL cholesterol-lowering drug therapy is used to treat high-risk persons or moderately high-risk persons, the serum LDL cholesterol should be reduced at least 30-40%.
Key words: lipids, statins, lipid-lowering drugs, coronary heart disease, atherosclerotic vascular disease, low-density lipoprotein cholesterol, high-density lipoprotein cholesterol, triglycerides.

Shailaja Shah, MD, Clinical Assistant Professor, Assistant Director Geriatric Psychiatry Fellowship, Robert Wood Johnson Medical School, University of Medicine and Dentistry of New Jersey, Piscataway, NJ, USA.
Gautam Rohatgi, DO, Geriatric Psychiatry Fellow, Robert Wood Johnson Medical School, University of Medicine and Dentistry of New Jersey, Piscataway, NJ, USA.
Daniela Ganescu, MD, Geriatric Psychiatry Fellow, Robert Wood Johnson Medical School, University of Medicine and Dentistry of New Jersey, Piscataway, NJ, USA.

Alzheimer’s disease (AD) is the most common cause of dementia, affecting nearly 18 million people around the world. Alzheimer’s disease is characterized by cognitive, functional, and behavioural decline. As the condition progresses the affected individual becomes increasingly dependent on others for assistance in performing all activities of daily living. Neuropsychiatric symptoms (NPS) such as agitation, psychosis, and apathy are very common in dementia and especially in AD. Agitation and apathy contribute to a tremendous amount of caregiver distress. Treatment guidelines recommend utilizing nonpharmacologic behavioural approaches in all instances. When behavioural interventions fail or when the behaviour is severe, medications are recommended. At present, no psychotropic agent presently available within the United States is FDA-approved for use in dementia complicated with behaviour disturbance.
Key words: agitation, apathy, behaviour interventions, atypical antipsychotics, dementia.

Chris MacKnight, MD, MSc, FRCPC, Associate Professor, Department of Medicine, Dalhousie University, Halifax, NS.

Three cholinesterase inhibitors are available in Canada for the treatment of mild and moderate Alzheimer’s disease. As the three agents differ in their pharmacology, switching among them does sometimes make sense. Switching may be necessary because of intolerance, lack of response, and occasionally loss of response. This article will describe how and when to switch cholinesterase inhibitor.
Key words: Alzheimer’s disease, treatment response, cholinesterase inhibitors, switching, dementia.

David F. Tang-Wai, MDCM, FRCPC, Assistant Professor, University of Toronto; Division of Neurology, University Health Network Memory Clinic, Toronto Western Hospital, Toronto, ON.

Alzheimer’s disease is the most common cause of dementia among older adults. After a century of research, there have been significant scientific advances in the understanding of this disorder. Over the past 15 years, treatment for Alzheimer’s disease exists but it is symptomatic and its effects are modest at best. Currently, newer disease-modifying treatments are being investigated that have the potential of slowing the progression of the disease.
Key words: Alzheimer’s disease, disease-modifying agents, amyloid, tau, neuroprotection.

Esmé Finlay, MD, Fellow, Division of Hematology/Oncology, Hospital of the University of Pennsylvania, Philadelphia, PA, USA.
Joseph B. Straton, MD, MSCE, Chief Medical Director, Wissahickon Hospice; Assistant Professor, Family Medicine and Community Health; Assistant Professor, Anesthesiology and Critical Care, Hospital of the University of Pennsylvania, Philadelphia, PA, USA.
Jonathan R. Gavrin, MD, Director, Symptom Management and Palliative Care; Clinical Associate Professor, Anesthesiology and Critical Care; Clinical Associate Professor, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA, USA.

Nausea and emesis are distressing symptoms that can contribute to malnutrition, dehydration, and decreased quality of life in older patients. Dopaminergic, cholinergic, histaminergic, serotonergic, and neurokinin receptor mechanisms play roles in the causation of nausea. Pharmacologic therapy targeted at these and other mechanisms is necessary to effectively treat the symptoms of nausea and vomiting. Multidrug regimens that target multiple mechanisms are often needed to control persistent symptoms. However, caution is advised when prescribing these medications in older patients, as many of the effective medications can cause sedation, confusion, or delirium. This article describes the mechanisms of nausea and vomiting and reviews effective treatment regimens.
Key words: nausea, vomiting, emesis, antiemetics, older adults.