Richard Saad, MD, Lecturer, Division of Gastroenterology, Department of Medicine, University of Michigan Medical Center, Ann Arbor, MI, USA.
William D. Chey, MD, AGAF, FACG, FACP, Associate Professor of Internal Medicine; Director, GI Physiology Laboratory, University of Michigan Medical Center, Ann Arbor, MI, USA.

Irritable bowel syndrome (IBS) is traditionally considered a disorder of young adulthood; however, it affects adults of all ages, including older adults. As the older population increases so will the impact of IBS in this age group. Irritable bowel syndrome with constipation (IBS-C) is believed to be particularly significant given the prevalence of constipation among the aged. At present, the evaluation and management of this disorder has been largely driven by data obtained from younger adults. However, there are numerous aspects of the underlying pathophysiology, evaluation, and treatment of IBS-C that remain unique to older adults, of which the clinician should be cognizant.
Key words: irritable bowel syndrome, constipation, older adults, functional bowel disorder.

Constantine A. Soulellis, MD, FRCP(C), GI Fellow, McGill University; Division of Gastroenterology, McGill University Health Centre, Montreal, QC.
Carlo A. Fallone, MD, FRCP(C), AGA(F), Associate Professor, McGill University; Director, GI Services, Royal Victoria Site of the McGill University Health Centre, Montreal, QC.

Peptic ulcer disease (PUD) is a prevalent medical problem among older adults. Several issues unique to older adults impart variability and complexity to PUD, making this entity difficult to diagnose and treat. Age-related gastrointestinal physiological changes, increasing prevalence of Helicobacter pylori, comorbidities, and polypharmacy (especially nonsteroidal anti-inflammatory drug [NSAID] use) are factors that potentiate ulcer formation. Older adults may present with few or none of the usual features of PUD, often delaying diagnosis and therapy. The cornerstones of therapy include cessation of NSAIDs, proton pump inhibition, and eradication of H. pylori if present.
Key words: peptic ulcer, older adults, NSAIDs, Helicobacter pylori.

Nahid Azad, MD, Associate Professor, Faculty of Medicine, University of Ottawa, Ottawa, ON.
Arlene S. Bierman, MD, MS, FRCPC, Ontario Women’s Health Council Chair in Women’s Health, Centre for Research on Inner City Health, St. Michael’s Hospital; Faculties of Medicine and Nursing, University of Toronto, Toronto, ON.

Cardiovascular disease (CVD) is a leading cause of morbidity and mortality for both men and women. Among individuals with coronary heart disease (CHD), there are gender differences in clinical epidemiology, prevalence of risk factors, clinical presentation, and quality and outcomes of care. Older adults and older women in particular are at risk for underdiagnosis and suboptimal management of CHD and its risk factors. Adherence to clinical practice guidelines for diagnosis and management of CHD can improve outcomes of care for older men and women with CHD and narrow gender disparities in clinical outcomes.
Key words: cardiovascular disease, gender, older adults, quality of care, women’s health, coronary heart disease.

Cinzia Maraldi, MD, Department of Clinicial and Experimental Medicine, Division of Internal Medicine, Gerontology, and Geriatrics, University of Ferrara, Ferrrara, Italy; Department of Aging and Geriatric Research, College of Medicine, Institute on Aging, University of Florida, Gainesville, FL, USA.
Marco Pahor, MD, Department of Aging and Geriatric Research, College of Medicine, Institute on Aging, University of Florida; Geriatric Research, Education and Clinical Center (GRECC), Malcolm Randall Veteran’s Affairs Medical Center, Gainesville, FL, USA.

Maintaining independence is one of the major goals in geriatric care, and identification of modifiable conditions that may promote the onset and progression of disability is of paramount importance in the clinical approach to the older patient. Anemia is key among those factors that may affect physical function in older adults. It is a common condition that appears to predict the onset of functional decline and disability in older adults. Early diagnosis of anemia and identification of its underlying causes is important not only in order to prevent the condition from worsening but also to prevent its associated poor health outcomes.
Key words: anemia, aging, disability, hemoglobin, functional decline.

Julie Lemieux, MD, MSc, FRCPC, Adjunct Professor, Department of Medicine, Université Laval, Centre des maladies du sein Deschênes-Fabia, Centre d’hématologie et d’immunologie clinique, Unité de recherche en santé des populations, Hôpital St-Sacrement du Centre Hospitalier affilié de l’Université Laval, Québec, QC.
Louise Provencher, MD, MA, FRCSC, Associate professor, Department of Surgery, Université Laval, Centre des maladies du sein Deschênes-Fabia, Unité de recherche en santé des populations, Hôpital St-Sacrement du Centre Hospitalier affilié de l’Université Laval, Québec, QC.

A large proportion of breast cancers in older women have positive hormone receptors. Therefore, these women are eligible to receive adjuvant endocrine therapy to decrease their chance of cancer recurrence. Over the last few years, a new class of endocrine therapy, aromatase inhibitors (AIs), has challenged the place of tamoxifen as the gold standard adjuvant endocrine agent. We will discuss randomized clinical trials comparing tamoxifen to AIs in terms of efficacy and side effects.
Key words: breast cancer, tamoxifen, aromatase inhibitors, side effects, quality of life.

Elise J. Levinoff, MSc, BSc, University of Ottawa, Faculty of Medicine, Ottawa, ON.

Dementia is a neurological disease that is associated with aging. The incidence and prevalence of dementia is increasing as the population continues to age. The two most common forms of dementia are Alzheimer’s disease (AD) and vascular dementia (VaD). Although these two forms of dementia represent different pathologies and different clinical presentations, they share similar risk factors. It is important to distinguish between the two forms of dementia because of the differing treatments, and because the risk factors for each are often preventable. This article will discuss the classification, risk factors, and diagnosis of AD and VaD, and present distinguishing characteristics between them.
Key words: dementia, Alzheimer’s disease, vascular dementia, stroke, memory.

Jagdish Butany, MBBS, MSc, FRCPC, Department of Pathology, Toronto General Hospital, University Health Network; Departments of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON.
Nasir A. Khan, BSc, Department of Pathology, Toronto General Hospital, University Health Network, Toronto, ON.
Sarah A. Erlich, BSc, Department of Pathology, Toronto General Hospital, University Health Network, Toronto, ON.
Anusha Jegatheeswaran, MD, Department of Cardiac Surgery, Toronto General Hospital, University Health Network, Toronto, ON.
Frances Budden, MD, FRCPC, Department of Geriatric Medicine, St. Joseph’s Health Centre, Toronto, ON.
Vivek Rao, MD, PhD, Department of Cardiac Surgery, Toronto General Hospital, University Health Network, Toronto; Department of Surgery, University of Toronto, Toronto, ON.

The incidence of valvular heart disease continues to increase, and the majority of individuals undergoing heart valve replacement today are older adults. Good postoperative management of these patients is critical and should include a complete history and thorough physical examination along with regular testing (typically including chest x-ray, echocardiogram, and blood tests) to carefully monitor heart function. Older adults are particularly at risk of bleeding and thromboembolic complications and, as such, compliance with anticoagulation and other medication should be closely monitored. Judicious attention to these issues will help minimize potential complications and improve survival in this patient population. This review discusses the postoperative management of older adults with a mechanical or a biological prosthetic heart valve.
Key words: heart valve replacement, prosthetic heart valves, older adults, anticoagulation, prosthetic valve endocarditis.

Adrienne H. Kovacs, PhD, CPsych, Behaviour Cardiology, Division of Cardiology, University Health Network, Toronto, ON.

Approximately 20% of older adults with cardiovascular disease (CVD) experience significant depression. Further, in a pattern consistent with the general adult population, women with CVD have double the rates of depression compared to men. Among older men and women with CVD, depression is associated with poorer cardiac outcomes, although patterns of depressive symptoms appear to differ between men and women. Treatment approaches include traditional modalities, namely psychotherapy and pharmacotherapy. Additional recommendations involve emphasizing adherence to prescribed medical and behavioural health regimens, fostering social support, and increasing referrals to cardiac rehabilitation programs as medically appropriate.
Key words: depression, gender differences, cardiovascular disease, myocardial infarction, mortality.

Sherryn Rambihar, MD, Internal Medicine Resident, Schulich School of Medicine, University of Western Ontario, London, ON.
Beth Abramson, MD, MSc, FRCP(C), FACC, Assistant Professor of Medicine, University of Toronto; Director, Cardiac Prevention Centre and Women’s Cardiovascular Health, Department of Cardiology, St. Michael’s Hospital, Toronto, ON.

Coronary heart disease (CHD) is the leading cause of death among men and women at all ages, and older adults are at increased risk. In assessing an older adult at risk for CHD, Bayes’ theorem guides rational clinical decision-making. Physicians should consider a diagnosis of CHD for older adults, who have a high prevalence of disease but may present with atypical symptoms and multiple risk factors. In clinical presentation, older women may be more similar than dissimilar to men. Exercise treadmill testing is the recommended first-line noninvasive strategy in most symptomatic older adults. Risk factor optimization is imperative in all patients.
Key words: imaging, diagnostic, women, geriatrics, clinical practice patterns, delivery of health care.

Shakaib U. Rehman, MD, Primary Care Service Line, Ralph H. Johnson V.A. Medical Center; Department of Medicine, Medical University of South Carolina, Charleston, SC, USA.
Jan N. Basile, MD, Director, Primary Care Service Line, Ralph H. Johnson VA Medical Center; Professor of Medicine, Medical University of South Carolina, Charleston, SC, USA.
Florence N. Hutchison, MD, Chief of Staff, Ralph H. Johnson V.A. Medical Center; Department of Medicine, Medical University of South Carolina, Charleston, SC, USA.

Older patients with hyperthyroidism present with atypical symptoms such as difficulty concentrating. This is in contrast to younger patients, who present with classic symptoms such as heat intolerance, tremor, and tachycardia. Hyperthyroidism in older adults is most often caused by toxic multinodular goiter and Graves’ disease. Thyroid hormones and thyroid-stimulating hormone assays can establish the diagnosis quickly. Antithyroid medication can be used in medically unstable older hyperthyroid patients to quickly suppress the hormones. When the patient is stable, definitive therapies such as radioactive iodine or surgery should be considered. Radioactive iodine therapy is well tolerated and effective. Surgery is indicated in patients who fail to respond to radioactive iodine therapy and patients with multinodular goiter.
Key words: thyrotoxicosis, older adults, hyperthyroidism, Graves’ disease, T3 toxicosis.