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.

Mary Beth Jennings, PhD, Reg. CASLPO, Aud(C), FAAA, Audiologist, Assistant Professor, National Centre for Audiology, Faculty of Health Sciences, University of Western Ontario, London, ON.
Frances Richert, MSc, Reg. CASLPO, Audiologist, H.A. Leeper Speech and Hearing Clinic, School of Communication Sciences and Disorders; National Centre for Audiology, Faculty of Health Sciences, University of Western Ontario, London, ON.

Older adults are the fastest-growing age group in Canada. Hearing loss is highly prevalent among this population. Of those persons who would benefit from the use of hearing aids, only a small number actually own and use them. Digital hearing aids now constitute the majority of hearing aids on the market. Technological advances in hearing aids and hearing assistive technologies have expanded the range of options available to improve the success of device use. Matching the needs and optimizing performance of older adults with the broad range of devices available requires appropriate assessment, selection, verification, and follow-up by the audiologist.
Key words: hearing aids, hearing assistive technologies (HATS), rehabilitation services, older adults.

Clodagh M. Ryan, MD MRCPI, Assistant Professor of Medicine, Division of Respirology, University Health Network / University of Toronto, Toronto, ON.

Chronic cough is defined as a cough that persists longer than eight weeks. It is one of the most frequent complaints of patients attending physicians’ outpatient clinics. Contrary to popular belief, the diagnosis and treatment of the majority of patients can be achieved by following an empiric, integrative approach. As chronic cough may be responsible for significant deterioration in quality of life, successful management and treatment is important for individual patients. Unfortunately, failure to adequately manage chronic cough is usually due to physician ignorance of the current diagnostic algorithms, which pertain as much to older as to younger adults.
Key words: chronic cough, older adults, upper airway cough syndrome, reflux disease, asthma.

Sudeep S. Gill, MD, MSc, FRCPC, Assistant Professor, Division of Geriatric Medicine, Queen’s University, Kingston, ON.

Delirium is common among hospitalized older adults and is associated with significant morbidity and excess mortality. Despite its prevalence and consequences, delirium is often underrecognized and undertreated. Antipsychotic drugs are commonly used to manage symptoms of delirium, but few controlled trials exist to support their efficacy and safety in this setting. Several recent studies have focussed on preventing delirium in high-risk populations. Clinical trials have demonstrated benefits with multifaceted nonpharmacological interventions, but widespread implementation of these interventions has not yet occurred. Two recent drug trials evaluated an antipsychotic and a cholinesterase inhibitor to prevent delirium, but neither trial demonstrated a reduction in incident delirium. At present, the most promising approach involves targeted, multifactorial interventions that focus on preventing delirium in high-risk patient groups. More work is needed to facilitate the implementation of these evidence-based strategies.
Key words: delirium, prevention, treatment, antipsychotic drugs, cholinesterase inhibitors.

Jagdish Butany, MBBS, MS, FRCPC, Department of Pathology, Toronto General Hospital/University Health Network, Toronto Canada Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON.
Gursharan S. Soor, BSc, Department of Pathology, Toronto General Hospital/University Health Network, Toronto, Toronto, ON.
Moyukh Chakrabarti, BSc, Department of Pathology, Toronto General Hospital/University Health Network, Toronto, ON.
Iva Vukin, BSc, Department of Pathology, Toronto General Hospital/University Health Network, Toronto, ON.
Shaun W. Leong, BSc, Department of Pathology, Toronto General Hospital/University Health Network, Toronto, ON.

Prosthetic heart valves (PHVs) are used to replace diseased native valves among patients with valvular stenosis, incompetence, or both. This paper reviews a number of contemporary prosthetic heart valves that are available for implantation in patients for whom valve repair is not possible. There are two major types of PHV: biological and mechanical. Each type of PHV has its own unique benefits and complications, which are outlined in this review. It is important that the practicing physician have some knowledge of contemporary prosthetic heart valves in order to treat patients safely and effectively.
Key words: prosthetic heart valve, mechanical heart valve, stented bioprosthesis, stentless bioprosthesis.

Krupa Shah, MD, MPH, Geriatric Fellow, Washington University at St. Louis, Division of Geriatric and Nutritional Science, St. Louis, MO, USA.
Dennis Villareal, MD, Associate Professor, Washington University at St. Louis, Division of Geriatric and Nutritional Science, St. Louis, MO, USA.

Obesity is associated with significant morbidity and mortality. In older adults, obesity can exacerbate declining physical function and quality of life that often accompanies aging, and can cause frailty. The value of treatment for obesity in older adults has been under debate because of the uncertain effectiveness of obesity therapies in this population as well as the potentially harmful effects of weight loss. However, current evidence shows that weight-loss treatment improves physical function and quality of life, and also eases the medical complications associated with obesity in older adults. Therefore, moderate weight loss that minimizes muscle and bone loss is recommended for obese older adults who have functional decline or medical complications.
Key words: obesity, body mass index, metabolic syndrome, weight loss, lifestyle modification.

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, Research Center on Aging, Health & Social Services Center - 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 a common problem among community-dwelling older adults. Although a slight decline in body weight is considered a normal part of the aging process, clinically significant weight loss (>5% of usual body weight) has harmful consequences on functional status and quality of life, and is associated with excess mortality over a three- to twelve-month period. A variety of physical and psychological conditions, along with age-related changes, can lead to weight loss. In up to one-quarter of patients, there is no identifiable cause. A rational approach to clinical investigation of these patients can facilitate arriving at a diagnosis and minimize unnecessary diagnostic procedures.
Key words: weight loss, older adults, mortality, epidemiology, diagnosis.