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.

Karen E. Hall, MD, PhD, Department of Internal Medicine, Division of Geriatric Medicine, University of Michigan Healthcare System; Geriatric Research, Education, and Care Center, Veterans Affairs Medical Center, Ann Arbor, MI, USA.

An understanding of the changes in gastrointestinal function that occur with aging can assist physicians in making patient care decisions. Aging affects many aspects of gastrointestinal function; however, swallowing and colonic function are particularly vulnerable to age-related changes. This explains the high prevalence of swallowing disorders and lower GI tract problems such as constipation and fecal incontinence seen by gastroenterologists and primary care physicians among the older adults they treat. Common comorbid conditions in the geriatric population, such as impairment in cognition and mobility, can affect the treatment of older adults with GI disease. This article highlights important changes in gastrointestinal function that occur with aging.
Key words: dysphagia, constipation, diarrhea, gastrointestinal immunity, gastric function.

Sylvia Davidson, MSc, BSc, Dip Ger, OT Reg.(Ont.), Psychogeriatric Resource Consultant, Toronto Rehabilitation Institute, Toronto, ON.

Caregivers frequently struggle to manage challenging behaviours associated with dementia, often without a good understanding of why these behaviours occur. This article presents a simple framework to help build understanding as well as a systematic approach to dealing with resistance to care.
Key words: dementia, caregiver, systematic approach, understanding behaviour, resisting care.

Anita W. Asgar, MD, FRCPC, Interventional Cardiology Fellow, Montreal Heart Institute, Montreal, QC.
Renee L. Schiff, MD, FRCPC, Echocardiography Fellow, Montreal Heart Institute, Montreal, QC.
Reda Ibrahim, MD, CSPQ, FRCPC, Interventional Cardiologist, Montreal Heart Institute, Associate Professor of Medicine, Universite de Montreal, Montreal, QC.

Hypertension is a common health concern among older adults and constitutes an important risk factor for cardiovascular disease. Despite its prevalence, it is a constant management challenge. We review four aspects of hypertension management that have been of interest over the past year.
Key words: hypertension, diabetes, drug therapy, gender differences, resistant hypertension.

Karen L. Smith, MSc, Kunin Lunenfeld Applied Research Unit, Baycrest and Department of Nutritional Sciences, University of Toronto, Toronto, ON.
Carol Greenwood, PhD, Kunin Lunenfeld Applied Research Unit, Baycrest and Department of Nutritional Sciences, University of Toronto, Toronto, ON.
Helene Payette, PhD, Director, Research Center on Aging, Health & Social Services Centre - University Institute of Geriatrics of Sherbrooke, Faculty of Medicine and Health Sciences, University of Sherbrooke, Sherbrooke, QC.
Shabbir M.H. Alibhai, MD, MSc, Division of General Internal Medicine & Clinical Epidemiology, University Health Network; Geriatric Program, Toronto Rehabilitation Institute; Departments of Medicine and Health Policy, Management and Evaluation, University of Toronto, Toronto, ON.

Unintentional weight loss is common among older adults and is associated with significant adverse health outcomes, increased mortality, and progressive disability. The diagnosis is often associated with an underlying illness; however, in as many as one in four older adults with unintentional weight loss, no obvious medical cause can be identified. A variety of nonpharmacologic interventions may improve energy intake and lead to weight gain. The most common approach to the treatment of weight loss among older adults is consumption of high-energy/protein oral supplements between meals as a means of increasing daily energy intake. Involving other health professionals, including a dietitian, may be helpful in the assessment and management plan. In addition, a number of pharmacologic treatments have been investigated, but the potential benefit of these treatments remains unclear.
Key words: weight loss, older adults, malnutrition, oral nutritional supplementation, megestrol.