Sarah E. Wilson, MSc, MD, PGY1, Internal Medicine, University of Toronto, Toronto, ON.
Mark A. Crowther, MD, MSc, Associate Professor of Medicine, Department of Medicine, McMaster University, Hamilton, ON.

Warfarin reduces the risk of thrombotic complications in a wide range of patients and appears to be particularly effective in older adults. Warfarin initiation should be undertaken with care in the older adults because they are likely to require smaller maintenance doses to achieve the same target international normalized ratio (INR). Inappropriate prescribing of medications among older adults increases the risk of drug interactions that may alter warfarin anticoagulation. Such interactions should be anticipated and monitored to ensure that over- or under-anticoagulation do not persist. A range of strategies are available to follow warfarin therapy in the outpatient setting to ensure safe and effective anticoagulation.
Key words: warfarin, anticoagulation, vitamin K, atrial fibrillation.

Michael A. Borger, MD, PhD, Division of Cardiovascular Surgery, Toronto General Hospital and Department of Surgery, University of Toronto, Toronto, ON.
Tirone E. David, MD, Division of Cardiovascular Surgery, Toronto General Hospital and Department of Surgery, University of Toronto, Toronto, ON.

Systolic murmurs in older adults require investigation with echocardiography. The most common cause is aortic sclerosis, which does not require therapy, followed by aortic stenosis. Surgery is indicated for aortic stenosis in patients with symptoms (fatigue, shortness of breath, angina and/or syncope) and in asymptomatic patients with left ventricular dysfunction or marked hypertrophy. Older aortic stenosis patients can undergo surgery with minimal increased risk, excellent long-term outcomes, and marked improvements in quality of life. Such patients may be referred directly to cardiac surgeons in order to limit age discrimination that may be present within the medical community.
Key words: aortic stenosis, congestive heart failure, aortic valve replacement, quality of life, outcomes.

Molly Thangaroopan, MD, FRCPC, Senior Fellow, Cardiology (Echocardiography), University Health Network, Toronto, ON.
Anusha Jegatheeswaran, MD, Resident, Cardiac Surgery, University of Toronto, University Health Network, Toronto, ON.
Vivek Rao, MD, FRCPC, Staff Surgeon and Associate Professor, University of Toronto, University Health Network, Toronto, ON.
Jagdish Butany, MBBS, MS, FRCPC, Staff Pathologist, University Health Network, Professor, University of Toronto, Toronto, ON.

Deaths from cardiovascular diseases have been declining in many countries; however, the incidence and prevalence of heart failure continues to increase in most countries. This is related, at least in part, to the increasing proportion of older people, a fact that is emphasized by the nearly three-fold increase in the incidence of heart failure in women. Good medical treatments are now available, and for refractory cases there are increasing numbers of surgical interventions available and new ones being devised. The morbidity and mortality associated with heart failure are higher than those associated with any other chronic condition. This article addresses the basis of heart failure, its appropriate management, and some of the newer treatments available.
Key words: heart failure, therapy, surgical treatment, ventricular assist devices.

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

Kenneth M. Madden, MSc, MD, FRCP(C), Assistant Professor, Division of Geriatric Medicine, Department of Medicine, University of British Columbia, Vancouver, BC.

Syncope is a common presenting complaint in the older adult population. Unfortunately, cognitive issues and the fact that most falls are not witnessed in older adults can make the separation of falling and syncope quite difficult. In fact, about one third of older adults will have amnesia for faints, even if they are cognitively normal. A systemic approach can help separate cardiac from neurocardiovascular causes and avoid future mortality and morbidity.
Key words: syncope, aging, neurocardiovascular instability, Holter monitoring, tilt table testing.

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

Lonn Myronuk, MD, FRCPC, Member of the Canadian Academy of Geriatric Psychiatry; President, GeriPsych Medical Services, Inc., Parksville, BC.

Progress in basic neuroscience has brought disparate clinical phenotypes of dementia together in categories based on common pathophysiological processes. Degenerative dementias are all proteinopathies featuring abnormal processing and CNS accumulation of different proteins in different neuroanatomic distributions dictating patterns of presentation of clinical symptoms and potential responsiveness to treatment. Alzheimer’s disease (AD) is an amyloidopathy. Dementia with Lewy bodies (DLB), Parkinson’s disease (PD) and multiple system atrophy (MSA) are synucleinopathies. Frontotemporal lobar degeneration (FTLD), progressive supranuclear palsy, and corticobasal degeneration are tauopathies. Vascular dementia (VaD) has been considered a distinct pathophysiologic process yet may exist on a continuum with AD. Currently available dementia treatments are not specific for a single disorder, yet not all dementias are treatment responsive. Exclusion of otherwise treatable depressive disorders and metabolic derangements as well as surveillance for deleterious cognitive effects of medication remain central to the assessment and treatment of the older adult with cognitive complaints. Identification of those syndromes for which certain medications may be contraindicated, as well as those that may be selectively responsive to particular compounds, will continue to increase in importance as our range of therapeutic options widens over the coming years.
Key Words: Alzheimer’s disease, Lewy body, frontotemporal lobar degeneration, vascular dementia, differential diagnosis.

Jennifer L. Gold, LLB, MPH, Kunin-Lunenfeld Applied Research Unit, Baycrest Centre for Geriatric Care, Toronto, ON.
Tamara J. Shulman, BA, MSc, Kunin-Lunenfeld Applied Research Unit, Baycrest Centre for Geriatric Care, Toronto, ON
Paula A. Rochon, MD, MPH, FRCPC, Kunin-Lunenfeld Applied Research Unit, Baycrest Centre For Geriatric Care; Institute for Clinical Evaluative Sciences, Sunnybrook & Women’s College Health Sciences Centre; Department of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON.

Quality of care provided in long-term care facilities (LTC) is an important social issue. To improve quality of care, Canada is moving in the direction of public reporting. In this paper, we discuss current efforts to assess and report LTC home quality, and provide an overview of quality assessment initiatives in Canada as compared to the United States. We include a thorough description of the new Ontario Ministry of Health and Long-Term Care web-based public reporting feature, and discuss some possible future attempts at improving this tool to incorporate quality indicators.
Key words: public reporting, quality, long-term care homes.

John R. Wherrett, MD, PhD, FRCPC, Department of Medicine (Neurology), Toronto Western Hospital and University of Toronto, Toronto, ON.

Contemporary technologies, including digital imaging of the brain during life and quantative microscopy (unbiased stereology) for estimating histological features postmortem, have resulted in important new knowledge about changes in the brain that accompany healthy aging, including evidence that grey matter atrophies with an anterior-posterior gradient. Neurons shrink but numbers are preserved; however, there is moderate reduction in dendritic spines and in synapses that have altered function. This is to be interpreted in the light of evidence for neurogenesis continuing into late life. White matter volume increases into maturity, but in aging there is a marked reduction due mostly to a loss of small myelinated fibres. Cell inclusions characteristic of neurodegenerative disease are commonly found postmortem in the healthy aged.
Key words: brain, aging, morphometry, imaging.

AM Johnson, PhD, Assistant Professor, School of Communication Sciences and Disorders, the University of Western Ontario, London, ON.
SG Adams, PhD, Associate Professor, School of Communication Sciences and Disorders, the University of Western Ontario, London, ON.

In addition to its widely recognized effects on gait, posture, balance, and upper limb coordination, Parkinson’s disease (PD) can have a profound effect on speech and voice, within a cluster of speech characteristics termed hypokinetic dysarthria. Although dopaminergic therapy produces significant benefits in the early stages of PD, speech symptoms may show selective resistance to pharmaceutical therapy in patients with a disease history of more than 10 years. This article discusses the pathophysiology of PD as it relates to speech disorders and considers nonpharmaceutical therapeutic options for hypokinetic dysarthria.
Key words: Parkinson’s disease, speech pathology, dysarthria, treatment.

Rajneesh Calton, MD, FACC, Division of Cardiac Electrophysiology, University Health Network, Toronto General Hospital, Toronto, ON.
Vijay Chauhan, MD, FRCPC, Division of Cardiac Electrophysiology, University Health Network, Toronto General Hospital, Toronto, ON.
Kumaraswamy Nanthakumar, MD, FRCPC, Division of Cardiac Electrophysiology, University Health Network, Toronto General Hospital, Toronto, ON.

Atrial fibrillation (AF) is the most common clinically significant cardiac arrhythmia worldwide, with an estimated prevalence of 0.4% in the general population. Despite recent advances in our understanding of the mechanism and consequences of AF, effective therapy for patients with AF remains difficult in many patients. Antiarrhythmic drug therapy includes control of ventricular rate as well as restoration and maintenance of sinus rhythm. The risks and benefits of each treatment modality must be assessed according to each individual patient’s circumstances. Anticoagulation for stroke prevention is a critical component of AF management that is currently underprescribed. Anticoagulation with vitamin K antagonists, such as warfarin, remains the treatment of choice for preventing stroke and cardio embolism. The oral direct thrombin inhibitor ximelagatran has the potential to favourably influence the management of patients with AF by maximizing the potential of anticoagulation for stroke prevention.
Key words: atrial fibrillation, anticoagulation, rate control, warfarin, ximelagatran, antiarrhythmic.

Ging-Yuek Robin Hsiung, MD, MHSc, FRCPC, Assistant Professor, Division of Neurology, Department of Medicine, UBC Clinic for Alzheimer Disease & Related Dementias, University of British Columbia, Vancouver, BC.

Dementia care represents a significant burden to our society. Although we are still far from any cure for dementia, there are several medications available for symptomatic management of Alzheimer’s disease and vascular dementia. These agents not only improve the cognitive and behavioural symptoms of dementia but may also help maintain patients’ functional independence and lessen caregiver stress. There are also a number of clinical trials currently in place to investigate new agents for treatment of Alzheimer’s disease. This article reviews the current medications available for Alzheimer’s disease and vascular dementia, as well as a number of promising agents that are under investigation.
Key words: Alzheimer’s disease, vascular dementia, cholinesterase inhibitors, donepezil, galantamine, rivastigmine, memantine.