Hershl Berman, MD, FRCPC, Department of Internal Medicine, Department of Psychosocial Oncology and Palliative Care, University Health Network, Toronto, ON.
Shawna Silver, BASc, PEng, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON.

Pain in the older adult can present unique challenges. Cognitive impairment and polypharmacy can make assessment and treatment difficult. An interdisciplinary team that includes family caregivers is essential. A rational approach to the ambulatory older patient with nociceptive pain would be to begin with regularly dosed acetaminophen, then add an NSAID if appropriate. The next step would be to add a low-dose opioid. If the patient uses a sufficient quantity of the opiate, dosing should be spread out throughout the day. Once a stable dose is reached, one can use a sustained-release formulation. Nonopioids should be continued throughout the titration process.
Key words: pain, analgesia, opioids, older adult, pain assessment.

Abdul Razakjr Omar, MBBS, MMed (Int Med), MRCP (UK), FAMS (Cardiology) Consultant Cardiologist, National University Hospital, Singapore.
Kumaraswamy Nanthakumar, MD, FRCPC, Staff Cardiologist, Cardiac Electrophysiologist, University Health Network, Toronto General Hospital; Assistant Professor of Medicine, University of Toronto, Toronto, ON.

In older patients the aging process is complicated by underlying comorbid diseases. An implantable cardioverter-defibrillator (ICD) has been shown to reduce mortality due to sudden cardiac death and improve survival in patients at risk of lethal arrhythmia. However, its role in older adults with coronary artery disease (CAD) is less well understood. A literature review of ICD trials was conducted, assessing efficacy and feasibility of the device in older adults.
The use of an ICD should be individualized in older patients. ICD therapy is feasible and safe in preventing sudden cardiac death. Age is insufficient to exclude an older adult with CAD from ICD therapy.
Key words: coronary artery disease, implantable cardioverter-defibrillator, sudden cardiac death, ventricular tachycardia, cardiac resynchronization therapy.

Patricia Hall, MD, Department of Psychiatry, University of Western Ontario, London, ON.
Verinder Sharma, MB, BS, FRCPC, Professor, Faculty of Medicine and Dentistry, University of Western Ontario, London, ON.

Bipolar disorder is less common in the older adult population. However, the quality of life for older adults with bipolar disorder is significantly impacted. Older patients with bipolar disorder have more cognitive and functional impairment than younger patients. Studies show that older adults with bipolar disorder also have an increased risk of suicide, dementia, and medical illness, as well as a higher mortality rate. This article provides a review of the epidemiology, clinical features, suicide risk, comorbidities (including dementia), and management of bipolar disorder in older adults.
Key words: bipolar disorder, mania, bipolar depression, treatment.

James L. Silvius, MD, FRCPC, Calgary Health Region, Clinical Associate Professor, Department of Medicine; Head and Chief, Division of Geriatric Medicine, University of Calgary, Calgary, AB.

Depression is common in older adults. This condition is often under-recognized and undertreated in this patient segment as it may present differently than in younger individuals. A number of risk factors for depression have been identified and may help increase recognition. Altered presentations include generalized anxiety/worry, somatisation, presence of a disability gap, subjective but not objective memory complaints, pseudodementia, hopelessness, change in adherence to medical regimens or change in function not otherwise explained. For individuals with dementia syndromes, excess disability may indicate depression. A high index of suspicion, recognition of risk factors, and asking about specific aspects of depression may increase diagnosis.
Key words: depression presentation, risk factors, function, dementia.

Jie Jin Wang, MMed, PhD, Centre for Vision Research, Department of Ophthalmology, Westmead Millennium Institute, University of Sydney, Australia.
Jennifer L. Smith, BA, PhD, Australian Health Policy Institute, University of Sydney, Australia.
Stephen R. Leeder, BSc (Med), MB, PhD, Australian Health Policy Institute, University of Sydney, and The Menzies Centre for Public Health Policy, Australia.

Vision and hearing impairments are common in older people. They not only impact on the quality of life and independent living of affected individuals, but also contribute to the overall burden of aged care. Although current evidence supports screening for age-related vision and/or hearing impairments, good- quality evidence on the effectiveness of sensory interventions (e.g., treatment for eye conditions or rehabilitation for hearing loss) is lacking. Evidence from community-based randomized controlled trials is needed before implementing community-wide screening. Case-finding during primary health care can be considered. Strategies to reduce the overall burden from common disabilities, including sensory impairments, among older people are keys to achieving the goal of “aging well, aging productively.”
Key words: aging, screening, vision, hearing, sensory impairment.

Terence Kavanagh, MD, FRCPC, DSc(Hon), Associate Professor, Faculty of Medicine; Professor, Graduate School of Exercise Science, Faculty of Physical Education and Health, University of Toronto, Toronto, ON.

Coronary heart disease is a major cause of morbidity and mortality in older patients. For this population cardiac rehabilitation offers an improvement in functional capacity, alleviation of symptoms, enhanced mood state and quality of life, and a modification of coronary risk factors. The components of a comprehensive programme specific to older adults are the same as for younger patients, with exercise training the mainstay. However, the changes that accompany the aging process require some modification in both the aerobic and resistance exercise programmes. Unfortunately, the referral rate of older patients, particularly women, is poor. Hopefully, this could be rectified if physicians come to realize that this segment of the population is the most likely to benefit from cardiac rehabilitation.
Key words: cardiac rehabilitation, aging, exercise training, coronary heart disease, referral patterns.

Richard Holland, BA, BM BCh, DA, DPH, MFPH, PhD, Senior Lecturer in Public Health Medicine, School of Medicine Health Policy & Practice, University of East Anglia, Norwich, UK.
David Wright, BPharm, PhD, Senior Lecturer in Pharmacy Practice, School of Chemistry and Pharmacy, University of East Anglia, Norwich, UK.

Older people consume a disproportionate quantity of drugs compared to younger people. Furthermore, the volume and cost of these drugs is increasing markedly. In theory, drugs are prescribed to reduce both morbidity and mortality but can also cause harm, particularly amongst older people. Medication review has been advocated as a technique to reduce such problems, whilst at the same time ensuring patients gain maximum benefit from their drugs. Whilst medication review seems a logical solution to inappropriate prescribing in general and adverse reactions in particular, evidence that specific interventions are effective at reducing morbidity or mortality is lacking.
Key words: medication review, adverse drug reactions, medication appropriateness, pharmacists, background.

Marian Garfinkel, EdD, Medical Researcher and Adjunct Professor, Temple University, College of Health Professions, Department of Kinesiology; Medical Researcher, University of Pennsylvania, School of Medicine, Department of Rheumatology; Veterans Administration Hospital, Department of Rheumatology; Director, BKS Iyengar Yoga Studio of Philadelphia, Philadelphia, PA, USA.

By broadening yoga’s application beyond stress-related ailments to include preventative and curative therapies, physicians today have an advantage in treating patients’ illnesses and disorders. Specifically, yoga therapy complements patients’ traditional medical treatment of osteoarthritis and other bone and joint disorders. Following anatomical guidelines, yoga teachers can adapt postures (asanas) to ensure patients’ organs, joints, and bones are aligned to achieve physiologic changes. Recent studies performed by this author assessing the effect of yoga therapy on rheumatic diseases, such as osteoarthritis, and repetitive strain injuries, such as carpal tunnel syndrome, showed that yoga therapy caused physiologic changes, relieved pain, and improved motion.
Key words: osteoarthritis, yoga, Iyengar, exercise, repetitive strain injuries.

Barbara Resnick, PhD, CRNP, FAAN, FAANP, Professor, University of Maryland School of Nursing, Baltimore, MD, USA.
Marcia G. Ory, PhD, MPH, Professor, Social and Behavioral Health; Director, Active for Life National Program Office, School of Rural Public Health, The Texas A & M University System, College Station, TX, USA.
Michael E. Rogers, PhD, CSCS, FACSM, Associate Professor, Department of Kinesiology and Sport Studies, Center for Physical Activity and Aging, Wichita State University, Wichita, Kansas, USA.
Phillip Page, MS, PT, ATC, CSCS, Manager, Clinical Education & Research, The Hygenic Corporation, Akron, OH, USA.
Roseann M. Lyle, PhD, Purdue University, Department of Health and Kinesiology, West Lafayette, IN, USA.
Cody Sipe, MS, Program Director, A.H. Ismail Center, Purdue University, West Lafayette, IN, USA.
Wojtek Chodzko-Zajko, PhD, Professor, Department Head of Kinesiology, University of Illinois at Urbana-Champaign, Urbana, IL, USA.
Terry L. Bazzarre, PhD, Senior Program Officer, Robert Wood Johnson Foundation, Princeton, NJ, USA.

Physical activity helps to maintain function, health, and overall quality of life for older adults. It is challenging, however, for health care providers and others who work with older adults to know what type of activity to encourage older adults to engage in, and how to motivate them to initiate and adhere to physical activity and exercise over time. The purpose of this piece is to provide an overview of physical activity for older adults and provide the resources needed to evaluate older adults and help them establish safe and appropriate physical activity programs, as well as providing motivational interventions that will eliminate the barriers to exercise and optimize the benefits.
Key words: exercise, screening, motivation, self-efficacy, outcome expectations.

The accredited CME learning activity based on this article is offered under the auspices of the CE department of the University of Toronto. Participating physicians are entitled to one (1) MAINPRO-M1 credit by completing this program, found online at www.geriatricsandaging.ca/cme

Shabbir M.H. Alibhai, MD, MSc, FRCPC, Department of Medicine, University Health Network; Department of Medicine and Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON.

More than one-half of new cancers and over 70% of cancer deaths in industrialized nations occur in adults age 65 or older. Systematic screening has been associated with reductions in cancer-related mortality for a variety of cancers, including breast, cervical, and colorectal cancer. While increasing numbers of older adults are living beyond 70, few guidelines address cancer screening in this group of older adults. In this article, evidence-based guidelines are reviewed for cancer screening in adults and limitations of screening studies with respect to older adults are discussed. A framework for deciding when to stop cancer screening in older adults is presented based on estimating remaining life expectancy, which incorporates age, comorbidity, and functional status.
Key words: cancer screening, aged, mass screening, overdiagnosis, cancer mortality.