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.

Joseph F. Coffey, BSc, MD, Currently PGY4 Dermatology, University of Alberta, Edmonton, AB.
Gordon E. Searles, OD, MD, MSc, FRCPC, Assistant Clinical Professor; Program Director, University of Alberta, Edmonton, AB.

Accumulation of sun exposure is an important factor resulting in aging of the skin and development of cutaneous malignancy. Unfortunately, most people think of suntanning as a healthy, natural process, and damaging effects of the sun are not experienced until 15-20 years after the initial damage has been done. By the time we see patients in our clinic, the majority of our older clientele has extensive, irreversible photo damage and precursors of skin cancer. It is difficult to treat many of these patients as multiple lesions are frequently present, and patients are sometimes unwilling to initiate sun-protective measures, are not ideal surgical candidates, and may not comply with treatments suggested by the dermatologist due to financial burden. We emphasize the critical role of sun exposure as a cause of skin aging, benign stigmata of aging, and development of skin cancers. Treatment options including topical therapies, oral medications, surgery, and new-age technologies are discussed.
Key words: photo-aging, therapy, skin cancer, dermatoheliosis, melanoma.

Jerilynn C. Prior, BA, MD, FRCPC, Endocrinology and Metabolism, University of British Columbia; Centre for Menstrual Cycle and Ovulation Research; Vancouver Coastal Health Research Institute, Vancouver, BC.

Most menopausal women require no treatment. Despite controlled trial data showing risks from menopausal hormone treatment, three conditions benefit from ovarian hormone therapy: early menopause, severe vasomotor symptoms with osteoporosis, and sleep-disturbing night sweats. For early menopause, transdermal estradiol with full-dose oral micronized progesterone is needed until age 50. Severe hot flushes plus osteoporosis is treated for five years with estradiol and continuous progesterone. Severe night sweats disturbing sleep are effectively treated with daily full dose progesterone. Vaginal dryness despite lubricants and regular, gentle sex is treated with vaginal low, controlled-dose estradiol preparations or estriol cream.
Key words: early menopause, hot flushes, night sweats, vaginal dryness, ovarian hormone therapy, progesterone.

Julian W.E. Jarman, MBBS, MRCP, St. Mary’s Hospital and Imperial College, London, UK.
Tom Wong, MBChB, MRCP, St. Mary’s Hospital and Imperial College, London, UK.

The prevalence of cardiac arrhythmia increases within a continuously aging population. This is illustrated by the projection of a 2.5-fold increase in the number of cases of atrial fibrillation (AF) in the United States by 2050. Approaches to arrhythmia management have changed considerably in recent years; this is, in part, related to the better understanding of effects of the existing drug therapy in patients with arrhythmia, and the advances of catheter ablation and complex device therapies for selected older patients.
In this review, we have broadly classified arrhythmias into brady- and tachyarrhythmias (AF, paroxysmal supraventricular tachycardias, and ventricular arrhythmias) and followed by highlighting the contemporary therapies for these arrhythmias in older adults.
Key words: aging, arrhythmia, drug, ablation, devices.

Rowena Ridout, MD, FRCPC, Toronto Western Hospital, Toronto, ON.

Osteoporosis is a significant cause of morbidity and mortality in the older population. Bone density testing is recommended for all men and women 65 or older. In postmenopausal women, and in men over the age of 50, testing is recommended for those at high risk for osteoporosis. Effective therapy is available for those at risk for fracture. Bone density testing combined with clinical risk factors, including age and fracture history, can be used to assess fracture risk and identify those individuals most likely to benefit from drug therapy.
Key words: osteoporosis, bone density, fracture, diagnosis.