D. Larry Sparks, PhD, Senior Scientist and Head, Roberts Laboratory for Neurodegenerative Disease Research, Sun Health Research Institute, Sun City, AZ, USA.

The primary care physician is often pressed with first-line treatment of Alzheimer’s disease (AD). A number of FDA-approved therapies are available. Emerging data indicate that circulating cholesterol levels may influence progression of the dementing disorder. A recent pilot, proof-of-concept, placebo-controlled clinical trial suggests that the cholesterol-lowering medication atorva-statin provides benefit in treating mild-to-moderate AD. Although not approved for the treatment of AD, statin therapy might be considered in the setting of elevated cholesterol levels--even when LDL/HDL ratios are acceptable.
Key words: Alzheimer’s disease, cholesterol, statins, dementia, atorvastatin.

Anna J.M. van de Sande, BSc, Medical Student, Thoraxcenter, Erasmus Medical Center, Rotterdam, The Netherlands. Visiting Medical Student, Canadian VIGOUR Center, University of Alberta, Edmonton, AB.
Paul W. Armstrong, MD, Professor, Division of Cardiology, Department of Medicine, University of Alberta, Edmonton, AB.
Padma Kaul, PhD, Assistant Professor, Division of Cardiology, Department of Medicine, University of Alberta, Edmonton, AB.

The burden of cardiovascular disease increases significantly with age. One of the most complex decisions facing clinicians is whether or not to perform coronary revascularization in an older patient. Our review of recent evidence on revascularization therapies for aging patients with non-ST-elevation acute coronary syndromes found an inverse relationship between age and the use of evidence-based medications as well as revascularization procedures. Older patients undergoing revascularization had a higher likelihood of adverse outcomes compared with younger patients undergoing revascularization. However, older patients who underwent revascularization had significantly better outcomes than their counterparts who did not undergo revascularization, suggesting that they deserve the same consideration as younger patients in the use of coronary interventions.
Key words: acute coronary syndromes, percutaneous coronary intervention, coronary artery bypass graft surgery, evidence-based medications, outcomes.

Patrice Bourée, MD, Head of the Department of Tropical Medicine, Bicetre Hospital (AP-HP); Paris-XI University, Paris, France.

The older population continues to increase; these individuals generally have substantial leisure time and are in good mental and physical health. As a result, they take the opportunity to travel. To avoid unnecessary risks, trips should be carefully planned with regard to updating immunizations according to the destination. Some older individuals suffer from chronic diseases which, though not a contraindication to travel, should be considered. Their medication should be reviewed with regard to the climate; there may be a need for specific travel medication such as chemoprophylaxis of malaria. It may be necessary to seek the advice of different specialists related to the patient’s medical problem. With careful planning, older adults shall remember only the pleasant moments of the trip.
Key words: immunization, travel, older adults, infectious disease, advice.

Michael A. Drebot, PhD, Chief, Viral Zoonoses, Zoonotic Diseases and Special Pathogens, National Microbiology Laboratory, Public Health Agency of Canada, Winnipeg, Manitoba, Canada.
Harvey Artsob, PhD, Director, Zoonotic Diseases and Special Pathogens, National Microbiology Laboratory, Public Health Agency of Canada, Winnipeg, Manitoba, Canada.

Since its introduction into North America in 1999, West Nile virus (WNV) has rapidly expanded its range across the continent. There is evidence that it has moved into the Caribbean and South and Central America. The virus has significantly affected public health, causing more than 20,000 cases of associated illness and resulting in the largest WNV epidemic ever recorded. Although neuroinvasive disease occurs in less than 1% of infections, the risk for encephalitis and other neurological illnesses increases with age. Currently there is no specific therapy for the treatment of WNV-associated disease and a vaccine is not yet available. Decreasing the risk of virus exposure requires seasonal preventative and control measures.
Key Words: West Nile virus, epidemiology, diagnosis, neurological illness, disease prevention.

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.