Chamandeep Thind, MRCP, Department of Dermatology, Aberdeen Royal Infirmary, Aberdeen, Scotland, UK.
Simone Laube, MD MRCP, Department of Dermatology, Aberdeen Royal Infirmary, Aberdeen, Scotland, UK.

Skin and soft tissue infections are an important cause of morbidity and mortality in older adults. Decreased immunity, changes in skin anatomy, and comorbidities contribute to an increased susceptibility to infections. Methicillin-resistant Staphylococcus aureus is an increasingly common problem in both the community as well as hospitals. Clinical features and management of some common skin infections encountered in this population are reviewed here. Local microbiological guidelines and drug susceptibilities should be taken into account in the treatment.
Key words: bacterial skin infections, cellulitis, MRSA, fungal infection, scabies.

Rory Fisher, MB, FRCP(Ed)(C), Professor Emeritus, Department of Medicine, University of Toronto and The Regional Geriatric Program of Toronto, Toronto, ON.

Euthanasia and assisted suicide are attracting increasing public interest. The experiences in the Netherlands and Oregon are explored as well as the topics of terminal sedation and voluntary dehydration. The reasons for requests for euthanasia are broadening beyond medical issues. Reasons for and against are presented. Recommendations are made to improve care of the dying and the frail elderly to decrease the perceived need for euthanasia. If changes are made to legalize euthanasia and/or assisted suicide in Canada, there will be a need to protect conscientious objectors.
Key words: euthanasia, physician-assisted suicide, terminal sedation, end-of-life care, conscientious objectors.

Richard J. Payne, MD, MSc, FRCSC, BComm Fellow, Head & Neck Oncology, Department of Otolaryngology--Head & Neck Surgery, University of Toronto, ON.
Jamil Asaria, MD, BSc, Resident, Department of Otolaryngology--Head & Neck Surgery, University of Toronto, Toronto, ON.
Jeremy L. Freeman, MD, FRCSC, FACS, Professor of Otolaryngology--Head & Neck Surgery; Temmy Latner/Dynacare Chair in Head & Neck Oncology, Otolaryngologist-in-Chief, Mount Sinai Hospital, Toronto, ON.

The oral cavity is a frequent site of head and neck cancer. The population most commonly afflicted with cancer of the oral cavity is older adults. Tobacco and alcohol are often implicated as associated preventable factors for oral cavity cancer--when used in combination their effects are synergistic. Malignant lesions may present as a persistent ulceration, mass, or red or white irritations in the oral cavity. They tend to be painful and cause difficulty with chewing. It is not uncommon for patients to complain of a neck mass. Investigation of suspicious lesions mandates a biopsy. Diagnostic imaging involving CT and MRI are important components of staging the primary tumour, and determining the extent of loco-regional and distant metastases. The treatment of early cancers is primarily surgical, while the treatment of advanced disease involves a multimodal approach incorporating a combination of surgery, radiation, and chemotherapy. However, the situation of each patient is unique, especially in the older adult, and other factors such as comorbidities often dictate the specific treatment approach.
Key Words: oral cancer, head and neck cancer, cancer in the older adult, oral malignancies.

Michael J. Sigal DDS, MSc, Dip Ped, FRCD(C), Professor and Head, Pediatric Dentistry, Faculty of Dentistry, University of Toronto; Director of Dental Services, Toronto Rehabilitation Institute; Dentist-in-Chief and Director, Dental Program for Persons with Disabilities; Mount Sinai Hospital, Toronto, ON.

Due to the increase in the older population, the management of individuals with dementia in long-term care settings will continue to present a challenge to the health care team. Many individuals with dementia will have some or all of their teeth upon admission due to improved dental care throughout their lives. Oral hygiene and oral care for individuals with dementia is generally poor in long-term care; however, the continuance of good oral health is essential both to maintain the demented individual’s quality of life and to prevent infections that may affect his/her general health. The maintenance of good oral health has the potential to reduce the incidence of long-term care-acquired pneumonia. This article presents an overview of the relationship between oral and general health in the demented patient and then provides an overview regarding oral assessment, treatment, and prevention of dental disease.
Key words: dementia, dental caries, dental plaque, aspiration pneumonia, oral hygiene.

Rachel L. McIntosh, B.Orth, Grad Dip Journ, Research Orthoptist, Retinal Vascular Imaging Centre, Eye Research Australia, University of Melbourne, Melbourne, Australia.
Tien Y. Wong, FRANZCO, FRCSE, PhD, Associate Professor of Ophthalmology, Retinal Vascular Imaging Centre, Eye Research Australia, University of Melbourne, Melbourne, Australia.

Hypertensive retinopathy has long been regarded as a risk indicator of mortality in persons with severe hypertension, but its value in contemporary clinical practice is uncertain. New population-based studies now show that hypertensive retinopathy signs are common in the general population of adults age 40 and older, including persons without a clinical diagnosis of hypertension. Some hypertensive retinopathy signs are associated not only with concurrent blood pressure levels, but with past blood pressure levels as well, suggesting that they reflect chronic hypertensive damage. Mild hypertensive retinopathy, such as generalized and focal retinal arteriolar narrowing and arteriovenous nicking, are only weakly associated with cardiovascular diseases. In contrast, moderate hypertensive retinopathy, such as retinal hemorrhages, cotton wool spots, and microaneurysms, are strongly associated with both subclinical and clinical cardiovascular diseases, including stroke and congestive heart failure. Thus, a clinical assessment of hypertensive retinopathy signs in older persons may provide useful information for cardiovascular risk stratification.
Key words: hypertensive retinopathy, retinal microvascular disease, hypertension, cardiovascular disease.

Lucia Gagliese, PhD, CIHR New Investigator, School of Kinesiology and Health Science, York University; Department of Anesthesia, Behavioural Sciences & Health Research Division, University Health Network; Departments of Anesthesia and Psychiatry, University of Toronto, Toronto, ON.

Depression is highly prevalent among older adults with chronic pain living both in community and institutional settings. It is associated with decreased quality of life, including impairments in physical and social well-being. This article reviews the relationship between pain and depression. The potential mediating role of disability, life interference, and perceived control are described. Routine assessment of both pain and mood, using scales validated for this age group, is advocated. Finally, the importance of integrating pharmacological and psychological interventions for the management of pain and depression in the older adult is highlighted.
Key words: chronic pain, depression, mood disturbance, assessment, management.

Sophie Pautex, MD, Pain and Palliative Care Consultation, Department of Rehabilitation and Geriatrics, University Hospital Geneva, Collonge-Bellerive, Switzerland.
Gabriel Gold, MD, Department of Rehabilitation and Geriatrics, University Hospital Geneva, Switzerland.

Persistent pain is common in older adults, and its consequences are often severe. Self-assessment scales have been validated in older populations and remain the gold standard for the evaluation of pain intensity in this age group. Most patients with dementia demonstrate appropriate use of self-assessment scales. Observational scales correlate moderately with self-assessment and tend to underestimate pain intensity; thus, their use should be reserved for patients who have demonstrated their inability to use self-assessment tools reliably.
Key words: pain, dementia, self-assessment, pain scale, cognitive impairment.

Deborah Dillon McDonald, RN, PhD, Associate Professor, University of Connecticut School of Nursing, Storrs, CT.

Older adults experience moderate to severe postoperative pain during and after their hospital stay. Preoperative education about pain management decreases postoperative pain. Postoperative pain management should generally include concurrent treatment of pre-existing chronic pain problems and a multimodal approach that incorporates postoperative opioids, nonopioids, and nonpharmacologic pain treatments. Opioids should be started at 25-50% of the adult dose and titrated until pain is reduced to a mild level. Older adults should be monitored closely to prevent side effects from opioid accumulation. A consistent pain scale that the older adult understands should be used to evaluate the pain response.
Key words: postoperative pain, pain assessment, opioids, nonopioids, nonpharmacologic treatments.

Marek Gawel, MB BCh FRCPC, Department of Medicine (Neurology), Sunnybrook and Women’s Health Sciences Centre, Toronto, ON.

Headache has been classified in an exhaustive classification by the International Headache Society Classification Committee. As people age the presentation of headaches may change, making them more difficult to classify and diagnose. In addition, secondary causes of headache become more common and need to be rigorously sought out. This article describes some of the types of headaches found in older adults.
Key words: headache, older adult, tumour, arteritis, primary headache, secondary headache.

John Kraft, HBSc, Medical Student, University of Toronto, ON.
Carrie Lynde, HBSc, Medical Student, University of Toronto, ON.
Charles Lynde, MD, FRCPC, Assistant Professor, Dermatology, University of Toronto, Toronto; Dermatology Consultant for Metropolitan Homes for the Aged in Toronto, Markham-Stouffville Hospital, and Scarborough Grace Hospital; Dermatologist, Dermatology Practice, Markham; Former President, Canadian Dermatology Association.

Skin neoplasias are more commonly seen in older patients. These skin diseases can frequently be more severe, particularly in long-term care residents. Common nonmelanoma skin cancers seen in these individuals include actinic keratoses, squamous cell carcinomas, and basal cell carcinomas. Benign neoplasias that are seen in older patients include seborrheic keratoses, skin tags, and classical Kaposi’s sarcoma. Treatment for neoplasias in the older adult are often not as aggressive as in younger patients.
Key words: actinic keratosis, squamous cell carcinoma, basal cell carcinoma, seborrheic keratosis, skin tag, classical Kaposi’s sarcoma.