Gabriel Gregoratos, MD, FACC, Clinical Professor, Emeritus, Division of Cardiology, University of California, San Francisco, CA, USA.

Syncope accounts for six percent of all hospital patient admissions and is a common and frequently debilitating symptom in older patients. The common causes of syncope in older populations are orthostasis, cardiac arrhythmias, neurocardiogenic syncope, and carotid sinus hypersensitivity. The cause of syncope can usually be deduced or suspected by simple initial clinical evaluation. Arrhythmic syncope will usually require ambulatory ECG monitoring or possibly an implantable loop recorder for precise diagnosis. Neurocardiogenic syncope can be frequently confirmed with a tilt-table test and carotid sinus hypersensitivity by careful carotid sinus stimulation during ECG rhythm monitoring. A permanent pacemaker is indicated for all types of symptomatic bradycardia whether complete AV block, severe sinus bradycardia, or the bradycardia-tachycardia syndrome in patients with sinus node dysfunction. Pacemaker therapy is also indicated to prevent certain pause-dependent tachyarrhythmias, although its role in atrial fibrillation remains controversial unless there is clear evidence of bradycardia-tachycardia sequence. Pacing therapy can also effectively treat syncope due to carotid sinus hypersensitivity when the cardioinhibitory component (heart rate slowing) predominates. The role of pacing therapy for neurocardiogenic (vasovagal) syncope remains controversial.
Key words: syncope, pacemakers, neurocardiogenic, carotid sinus, bradycardia-tachycardia.

Martin Pinquart, PhD, Associate Professor, Department of Developmental Psychology and Center for Applied Developmental Science, Friedrich Schiller University, Jena, Germany.
Silvia Sörensen, PhD, Assistant Professor, Department of Psychiatry, University of Rochester, Rochester, NY, USA.

Due to the aging of society and the increase in ethnic diversity, there is a growing interest in the needs of ethnically diverse caregivers for older adults. Based on a recent meta-analysis, this article outlines ethnic differences in caregiving stressors, available social resources, and caregiver health. We offer suggestions on how to consider ethnic differences in the planning and implementation of caregiver interventions.
Key words: family caregivers, ethnicity, stress, burden, depression.

Roger Y. Wong, MD, FACP, FRCPC, Division of Geriatric Medicine, Department of Medicine, University of British Columbia, Vancouver, BC.

Mobility impairment is a common cause of disability in older persons. The etiology is often multiple, with medical illnesses that affect the musculoskeletal, neurologic, cardiac, and/or respiratory systems superimposed on aging-related changes in gait and balance. A detailed history on the onset, duration, nature, and course of the mobility impairment is helpful. Physical examination should focus on direct observation of gait and balance, while performance- based tests can quantify the abnormalities. Simple tests for assessing walking speed, endurance, and balance are available for both outpatient and inpatient settings. The management of mobility impairment requires a multifaceted interdisciplinary approach.
Key words: mobility, gait and balance, impairment, assessment, walk tests.

Elliott M. Kanner, MD, PhD, Department of Ophthalmology, Edward S. Harkness Eye Institute, Columbia University College of Physicians and Surgeons, New York, NY, USA.
James C. Tsai, MD, Associate Professor and Director, Glaucoma Division, Department of Ophthalmology, Edward S. Harkness Eye Institute, Columbia University College of Physicians and Surgeons, New York, NY, USA.

Glaucoma is a sight-threatening, progressive optic neuropathy whose incidence increases with age. Currently, the only proven treatment for glaucoma is the reduction of intraocular pressure (IOP). As medical treatment has become safer and diagnostic modalities have become more sensitive, it has become possible to detect and treat glaucoma earlier. This means that with more aggressive screening and treatment, a common cause of irreversible blindness can be prevented. As more patients are treated earlier, it is important not only for ophthalmologists but also for primary care physicians to be aware of the barriers to adherence and possible interactions and side effects of glaucoma medications. Parallels between glaucoma and other neurodegenerative disease are stimulating new approaches to therapy beyond IOP control, targeted directly at the prevention of axonal loss.
Key words: glaucoma, intraocular pressure, medications, neuroprotection, retinal ganglion cell.

Paul J. Christo, MD, Assistant Professor; Director, Pain Treatment Center & Multidisciplinary Pain Fellowship, Division of Pain Medicine, Department of Anesthesiology and Critical Care, The Johns Hopkins University School of Medicine, Baltimore, MD, USA.
Greg Hobelmann, MD, Postdoctoral Fellow, Division of Pain Medicine, Department of Anesthesiology and Critical Care, The Johns Hopkins University School of Medicine, Baltimore, MD, USA.
Amit Sharma, MD, Postdoctoral Fellow, Division of Pain Medicine, Department of Anesthesiology and Critical Care, The Johns Hopkins University School of Medicine, Baltimore, MD, USA. *Current Address: Assistant Professor, College of Physicians & Surgeons of Columbia University, New York, NY.

Steven E. Lo, MD, The Neurological Institute, Columbia University Medical Center, New York, NY, USA.
Steven J. Frucht, MD, The Neurological Institute, Columbia University Medical Center, New York, NY, USA.

Parkinson’s disease (PD) is a neurodegenerative disorder that can significantly impact older patients’ quality of life. Although there are many pharmacologic options to treat PD, the clinician needs to know the indications and potential adverse effects of new medications in the older patient population. Carbidopa/levodopa remains the gold standard for treatment, and new formulations and levodopa-extenders fill specific niches. This article reviews the pros and cons of these medications in older PD patients, and demonstrates therapeutic strategies through case presentations.
Key words: Parkinson’s disease, treatment, levodopa, COMT inhibitor, aging.

Norm R.C. Campbell, MD, FRCPC, Division of General Internal Medicine, University of Calgary, Calgary, AB.
J. George Fodor, MD, FRCPS, PhD, Ottawa Heart Institute, Ottawa, ON.
Robert Herman, MD, FRCPC, Division of General Internal Medicine, University of Calgary, Calgary, AB.
Pavel Hamet, MD, FRCPC, PhD, Research Center, CHUM, Montréal, QC (for the Canadian Hypertension Education Program).

Hypertension is a leading risk for morbidity and mortality in Canada. The older population is at greater risk from hypertension and has a greater reduction in cardiovascular risk with treatment than young patients. Frequent screening for hypertension is prudent as the estimated risk of developing hypertension is about 90%, even in normotensive 65-year-olds. Systolic blood pressure is a more relevant risk factor than diastolic blood pressure in older patients and is more difficult to treat to target. Most hypertensive patients will have multiple cardiovascular risks that require screening and management to reduce cardiovascular risk optimally. Lifestyle therapy is efficacious. Effective first-line drug therapies that reduce hypertension complications include thiazide-type diuretics, ACE inhibitors, long-acting calcium-channel blockers, and angiotensin-receptor blockers. Most patients require two or more drugs to achieve current blood pressure targets.
Key words: high blood pressure, hypertension, guidelines, recommendations, evidence-based medicine.

C. Tissa Kappagoda, MBBS, PhD, Professor of Medicine, Department of Internal Medicine, University of California, CA, USA.
Dianne A. Hyson, RD, PhD, Assistant Professor, Department of Consumer Sciences, California State University of Sacramento, CA, USA.

This paper examines the potential impact of some popular diets on cardiovascular risk factors in aging populations. The compositions of these diets are compared against the broader recommendations of the Food and Nutrition Board and the American Heart Association. The Atkins and South Beach diets have been advanced as components of weight loss programs, while the Mediterranean type of diet has been promoted as being especially beneficial to those who are at risk of developing cardiovascular disease. When viewed against the recommendations of the Food and Nutrition Board, it is apparent that these diets are unlikely to meet the special nutritional needs of the older population.
Key words: Atkins, South Beach, Mediterranean diet, nutrition, coronary artery disease.

David Fitchett, MD, FRCP(C), Cardiologist, St. Michael’s Hospital; Associate Professor of Medicine, University of Toronto, Toronto, ON.

Coronary and cerebrovascular disease is the leading cause of death and disability in the older population. Control of vascular risk factors such as blood pressure, lipids, and glucose is important in higher risk patients to reduce the impact of stroke and myocardial infarction, whatever their age. Although total and LDL cholesterol levels are less predictive of coronary heart disease in the older patient, clinical trials demonstrate an important benefit from statin therapy in high-risk individuals over a wide age range with either established cardiovascular disease or diabetes. Older patients with multiple risk factors for vascular disease, yet without coronary, cerebrovascular, or peripheral vascular disease, should also be considered for statin treatment.
Key words: cholesterol, lipid management, statin, cardiovascular disease.

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

Secondary prevention has been shown to decrease coronary artery disease morbidity and mortality by 20-25%. Exercise, smoking cessation, and management of dyslipidemia, hypertension, diabetes, and obesity, along with psychological therapies, are typical elements of secondary prevention programs offered by a multidisciplinary clinical team often including physicians, nurses, pharmacists, exercise physiologists, registered dieticians, and psychologists. Special considerations for older adults in a secondary prevention setting in reference to medications, exercise, diet, smoking cessation, and hypertension are addressed. Current practice guidelines and clinical trials are presented, along with practical tools for the primary care physician treating the older coronary artery disease patient.
Key words: multidisciplinary, cardiac rehabilitation, coronary artery disease, secondary prevention.