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.

Fatim Ajwani, BSc RD, ARAMARK Canada Ltd at the Toronto Rehabilitation Institute, Toronto, ON.
Maria Ricupero, BA, RD, CDE, ARAMARK Canada Ltd at the Toronto Rehabilitation Institute, Toronto, ON.

Dietary trans fatty acids (TFA) have been implicated in contributing to cardiovascular disease (CVD). Higher intakes of industrial TFA negatively impact cholesterol and inflammation levels, endothelial function, and LDL particle size. Dietary TFA are also associated with myocardial infarction and death. Due to the negative impact of TFA on cardiovascular health, the current recommendation is to keep total TFA intake to less than 2 grams/day. New labeling legislation has made it easier to achieve this goal. However, nutrition claims can be misleading. Despite positive new changes, patient counseling will still be required for accurate and careful interpretation of nutrition information.
Key words: trans fatty acids, diet, cholesterol, cardiovascular disease, conjugated linoleic acid.

P. N. Sylaja, MD, Calgary Stroke Program, Department of Clinical Neurosciences, University of Calgary, Calgary, AB.
Philip A. Barber, MD, MRCP (UK), FRCPC, Calgary Stroke Program, Department of Clinical Neurosciences, University of Calgary, Calgary, AB.

The very old represent the fastest-growing segment of the population in developed and developing countries and, in view of the increased incidence of stroke with advancing age, stroke-related disability is expected to increase in the population. Although patients more than 80 years of age account for 30% of the patients with strokes, the role of intravenous thrombolysis in this age group is insufficiently defined. There are no randomized trials that focus specifically on older patients with acute ischemic stroke. Recently, several case series on the use of intravenous tissue plasminogen activator (tPA) in older adults in clinical practice have shown that the outcome of older patients after stroke is poor, but the risk of symptomatic intracerebral hemorrhage (SICH) after tPA has been variable, ranging from 4.4-13%. Current evidence suggests that, by careful selection, tPA may be safely given to older adults without increased risk of SICH within the three-hour time window. Further randomized data from trials will allow more definitive conclusions on the use of tPA in the older population.
Key words: thrombolytic therapy, acute stroke, cerebral ischemia, tissue plasminogen activator, symptomatic intracerebral hemorrhage.

Miguel N. Burnier Jr., MD, PhD, FRCSC, Chairman, Ophthalmology, McGill University, Montreal, QC.
Vinicius S. Saraiva, MD, PhD, Fellow, Ocular Oncology & Pathology, McGill University, Montreal, QC.

Second malignant neoplasms (SMN) are nonmetastatic malignancies occurring in patients previously diagnosed with another malignant neoplasm. This clinical entity is becoming increasingly more frequent with the aging of the overall population and better diagnosis and treatment of cancers. Although a reasonable percentage of cases may be explained by genetic, iatrogenic, and/or shared environmental exposure, it is estimated that the majority of cases are sporadic. Recognizing the possibility of SMNs is essential for appropriate and timely diagnosis and treatment, but even more important for the development of preventive strategies.
Key words: oncology, second malignant neoplasms, ophthalmology, eye tumours.

Patricia K. Long, FNP-C, Division of Surgical Oncology and Endocrine Surgery, Department of Surgery, University of North Carolina, Chapel Hill, NC.
David W. Ollila, MD, Division of Surgical Oncology and Endocrine Surgery, Department of Surgery, University of North Carolina, Chapel Hill, NC.

The incidence of melanoma continues to rise. The clinician needs to be familiar with characteristics of lesions more likely to be melanoma and be able to apply the “ABCDE” criteria. Additional imaging techniques such as digital photography and dermoscopy aid the clinician in deciding which nevi require biopsy. The techniques for biopsying cutaneous lesions vary, and clinicians need to be familiar with the various techniques. Once a cutaneous melanoma is diagnosed, the most important histologic feature of the primary is Breslow thickness.
Key words: melanoma, pigmented nevi, digital imaging, dermoscopy.

Barbara Brillhart, RN, PhD, CRRN, FNP-C, Arizona State University, College of Nursing, Tempe, Arizona, USA.

Prevention of and assessment for pressure ulcers and skin tears are the responsibilities of the client, family, caregivers, and the health care team. Prevention will avoid discomfort, disfigurement and decreased quality of life, and decrease health care expenses. Assessment includes use of the Braden, Gosnell, Norton, or Waterlow Scales for pressure ulcers and the Payne-Martin classification for skin tears. Factors to prevent pressure ulcers are pressure relief, prevention of shearing and friction, skin cleansing, plus adequate nutrition and hydration. Variables to prevent skin tears include nonbinding clothing, careful transfers, environmental protection, adequate nutrition and hydration, and individualized skin care.
Key words: pressure ulcers, skin tears, assessment, prevention.

Maeve A. Mc Aleer, MRCP(UK), Regional Centre of Dermatology, Mater Misericordiae University Hospital, Dublin, Ireland.
Frank C. Powell, MD, FRCPI, Regional Centre of Dermatology, Mater Misericordiae University Hospital, Dublin, Ireland.

Rosacea is a common, but frequently misunderstood, skin condition. As it affects the face and is unsightly, rosacea can cause considerable social distress, especially because of the historical belief that alcohol is involved in its causation. This article outlines the clinical features of rosacea and the standard subtype classification of the condition. The theories of pathogenesis are outlined and the management approaches are discussed.
Key words: rosacea, classification, rhinophyma, ocular disease, management.