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.

Panagiota (Nota) Klentrou, PhD, Associate Professor, Department of Physical Education and Kinesiology, Faculty of Applied Health Sciences, Brock University, St. Catherines, ON.

Physical activity/exercise can provide an important tool for both the prevention and treatment of osteoporosis. Physical stress transmits load to the bone and can improve or maintain its structural competence and strength. Participation in weight-bearing activities during adolescence is an effective method to achieve an ample peak bone mass and to reduce the risk for the later development of osteoporosis. Postmenopause, the ideal exercise to stimulate bone mineral density would involve progressive, resistive-type training involving overloading of some nature.
Key words: functional loading, weight-bearing activities, resistance training, peak bone mass, bone mineral density.

Cathy R. Kessenich, DSN, ARNP, Professor, Department of Nursing, University of Tampa; Nurse Practitioner, Private Practice, Tampa, FL, USA.

Osteoporosis is a chronic, debilitating disease that is most distressing to patients and health care providers in the occurrence of fractures of the hip and spine. The lasting effects of vertebral and hip fractures can cause pain, deformity, and emotional distress. Various nonpharmacological modalities may be used adjunctively with prescribed agents to improve the quality of life of patients with fractures due to osteoporosis. Research evidence and clinical experience have determined that nutritional support, exercise and rehabilitation, pain management, orthopedic surgeries, fall prevention, alternative therapies, education, and social support may assist patients in coping with the pervasive effects of osteoporotic fractures. Clinicians need to be informed and encouraged about the use of nonpharmacological measures to assist patients at risk for experiencing the culminating event of this devastating disease.
Key words: osteoporosis, osteoporotic fracture, osteoporosis management.

Angela M. Cheung, MD, PhD, FRCP(C), CCD, Director, Osteoporosis Program, University Health Network and Mount Sinai Hospital; Associate Director, Women’s Health Program, University Health Network; Associate Professor, University of Toronto, Toronto,ON.

Osteoporosis is common in postmenopausal women and older men. There are various efficacious therapies for the treatment of osteoporosis and the prevention of osteoporotic fractures in Canada. First-line therapies include alendronate, risedronate and raloxifene; all of these are oral antiresorptive therapies. In this article, we review new drug therapies currently or soon to be available in Canada, such as bone formation therapies (parathyroid hormone and strontium ranelate) and intravenous infusions (such as zoledronic acid), and compare them to existing therapies.
Key words: osteoporosis, osteoporotic fractures, parathyroid hormone, strontium, zoledronic acid.

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

Susan J. Whiting, PhD, College of Pharmacy and Nutrition, University of Saskatchewan, Saskatoon, SK.
Hassanali Vatanparast, MD, College of Pharmacy and Nutrition, University of Saskatchewan, Saskatoon, SK.

This review describes the current state of knowledge in nutritional interventions in osteoporosis, using the Osteoporosis Society of Canada’s (OSC) 2002 clinical practice guidelines for the diagnosis and management of osteoporosis as a basis. Nutrients important for osteoporosis are calcium, vitamin D, protein, sodium, caffeine, and isoflavones. These recommendations are updated and other nutrients and food components, not covered in the OSC 2002 report, are described. As a single nutrient approach is no longer warranted, we discuss how the Dietary Approaches to Stop Hypertension (DASH) diet can be used to provide appropriate intakes of many key nutrients for persons with, or at risk of, osteoporosis.
Key words: DASH diet, calcium, vitamin D, protein, osteoporosis.

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

Lakshmi Ravindran, MD, Department of Psychiatry, University of Toronto and St. Michael’s Hospital, Toronto, ON.
David Conn, MB, FRCPC, Department of Psychiatry, University of Toronto and Baycrest Centre for Geriatric Care, Toronto, ON.
Arun Ravindran, MB, PhD, FRCPC, FRCPsych, Department of Psychiatry, University of Toronto and the Centre for Addiction and Mental Health, Toronto, ON.

Depression in the older population is a condition commonly encountered by the primary care physician. However, it is frequently underdiagnosed and undertreated. Selective serotonin reuptake inhibitors (SSRIs) and venlafaxine are the first-line choice of antidepressants for the treatment of depression. Mirtazapine and bupropion are second-line agents with tricylics and monoamine oxidase inhibitors (MAOIs) being considered for refractory patients. Although equally effective, these agents exhibit varying levels of tolerability and different adverse events profiles. After remission, patients need maintenance treatment, the duration varying with the number of episodes experienced. Treatment nonresponse is often associated with the presence of concurrent medical illnesses, poor compliance, and the presence of ongoing psychosocial stressors. Partial or nonresponse to optimum doses of antidepressants will necessitate either switch augmentation or combination strategies, but caution should be exercised to prevent drug interactions. Depression in the older adult is treatable, with key goals being recognition, diagnosis, aggressive acute treatment, and planned maintenance.
Key words: depressive disorders, older adult, antidepressants, nonresponse, augmentation.

Nages Nagaratnam, MD, FRCP, FRACP, FRCPA, FACC, Consultant Physician, Geriatric Medicine, formerly Blacktown-Mount Druitt Health, Blacktown, New South Wales, Australia.
Gowrie Pavan, MBBS, FRAGP, General Practitioner, The Surgery, Plympton Road, Beecroft, New South Wales, Australia.

Mutism in older adults is not uncommon. It is often confused with severe depression, locked-in syndrome, and persistent vegetative state, but it is important to distinguish among them as the management and prognosis are different. The family physician is the most consulted professional and so is the most helpful in making this distinction. Mutism is a neuropsychological disorder with marked heterogeneity among patients, raising the possibility of conditions such as advanced Alzheimer’s disease, Jacob-Creutzfeldt disease, frontotemporal dementias, and certain psychiatric and psychological conditions. It is both a symptom and a syndrome, and is often associated with akinesia when the term akinetic mutism is used. Akinetic mutism has a number of causes with varied pathology and is characterized by a marked reduction in motor function, including facial expression, gestures, and speech output, with awareness being preserved. All of the disease manifestations can be explained by damage to the frontal lobe or interruption of the complex frontal subcortical circuits and the frontal diencephalic brain stem system by focal lesions or diffuse brain damage.
Key words: mutism, akinetic mutism, frontal-subcortical circuitry, locked-in-syndrome, persistent vegetative state.