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.

David A. Goukassian, MD, PhD, Department of Dermatology, Boston University School of Medicine, Boston, MA, USA.

One important goal in the field of DNA repair is to use current knowledge of DNA damage and repair mechanisms in normal young and adult cells and animal models in the chemoprevention and chemotherapeutics of DNA damage-related diseases. However, such a translation into a true in vivo setting can prove difficult. No doubt, the scope of human in vivo studies is currently restricted by the complexity of this setting and by the relatively limited availability of safe and effective in vivo chemopreventive and chemotherapeutic substances, as well as tremendous ethical responsibility. This article’s focus is on human and human skin organ-culture studies and outlines possible future directions for the field of photobiology in “translational” applications.
Key words: aging, DNA repair, UV, skin tumour, T-oligos.

Raj C. Shah, MD, Rush Alzheimer’s Disease Center; Department of Family Medicine, Rush University Medical Center, Chicago, IL, USA.
David A. Bennett, MD, Rush Alzheimer’s Disease Center; Department of Neurological Sciences, Rush University Medical Center, Chicago, IL, USA.

Mild cognitive impairment (MCI), the presence of cognitive difficulties without having dementia, is viewed as a preclinical state for Alzheimer’s disease (AD) or another dementing illness. With the burden of AD expected to increase, research efforts have focused on interventions to delay the progression of MCI to AD. In this review, we first discuss the current conceptual understanding of MCI. Then, we outline a simplified approach to help clinicians diagnose MCI. Finally, we provide an overview of how to address the clinical needs of individuals with MCI.
Key words: mild cognitive impairment, Alzheimer’s disease, diagnosis, prognosis, treatment.

Kevin L. Billups, MD, Urologist & Medical Director, The EpiCenter for Sexual Health & Medicine, Edina; Adjunct Assistant Professor, Laboratory Medicine & Pathology, University of Minnesota, Minneapolis, MN, USA.

Erectile dysfunction (ED) is a prevalent vascular disorder that, like cardiovascular disease, is now believed to cause endothelial dysfunction. In fact, a growing body of literature now suggests that ED may be an early marker for atherosclerosis, increased cardiovascular risk, and subclinical vascular disease. The emerging awareness of ED as a barometer of overall cardiovascular health represents a unique opportunity for primary prevention of vascular disease in all men. Although the implications of this relationship for primary and secondary prevention of cardiovascular disease are not yet fully appreciated, the available literature makes a strong argument for the role of erectile dysfunction as an early marker for the development of significant cardiovascular risk factors and cardiovascular disease. Early detection of erectile dysfunction could play a major role in improving male cardiovascular health.
Key words: erectile dysfunction, cardiovascular disease, atherosclerosis, endothelium, prevention.

Elizabeth J. Santos, MD, Geriatric Psychiatry and Interdisciplinary Geriatric Fellow, Program in Geriatrics and Neuropsychiatry, Department of Psychiatry, University of Rochester Medical Center, Rochester, NY, USA.
Lisa L. Boyle, MD, Geriatric Psychiatry and Interdisciplinary Geriatric Fellow, Program in Geriatrics and Neuropsychiatry, Department of Psychiatry, University of Rochester Medical Center, Rochester, NY, USA.
Jeffrey M. Lyness, MD, Associate Professor and Director, Program in Geriatrics and Neuropsychiatry, Department of Psychiatry, University of Rochester Medical Center, Rochester, NY, USA.

Dysthymic disorder is a chronic depressive illness that affects approximately one to five percent of seniors. Often undetected and untreated, dysthymia is associated with significant psychological distress, medical burden, and functional impairment. Dysthymic disorder in the older population can be challenging to diagnose because of comorbid medical conditions and life losses. Dysthymic seniors often present differently than younger patients. The general practitioner plays a crucial role in identifying and providing interventions for older dysthymic patients. Careful evaluation, psychoeducation, and therapeutic interventions are essential to alleviate further suffering and to improve quality of life and function for these patients.
Key words: dysthymic disorder, depression, psychological symptoms, medical comorbidities.

Marnin J. Heisel, PhD, C.Psych, Center for the Study and Prevention of Suicide, Department of Psychiatry, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA.
Paul S. Links, MD, FRCP(C), Arthur Sommer Rotenberg Chair in Suicide Studies, Suicide Studies Unit, Department of Psychiatry, University of Toronto/St. Michael’s Hospital, Toronto, ON.

Older adults have high rates of suicide worldwide. Suicide rates increase with advancing age, and older adults typically use highly lethal means of self-destruction. In addition, suicidal older adults tend to pursue treatment in primary care rather than mental health settings, but current limitations in the primary care system potentially restrict suicide prevention in older patients. We briefly review the epidemiology of late-life suicide and suggest modifications in primary care to better address the psychosocial needs of at-risk older adults, supported by research on suicide risk and resiliency, clinical assessment and treatment options, and collaborative models of primary medicine and mental healthcare.
Key words: suicide, suicide ideation, suicidal behaviour, older adults, primary care.

Marie Crowe, RPN, PhD, Associate Professor, Department of Psychological Medicine, Christchurch School of Medicine and Health Sciences, Christchurch, New Zealand.
Sue Luty, FRANZCP, PhD, Associate Professor, Department of Psychological Medicine, Christchurch School of Medicine and Health Sciences, Christchurch, New Zealand.

Because there are particular corollaries to the treatment of depression in older adults, which include contraindications to the use of antidepressant drugs in combination with many medications, there is a need to examine nonpharmacological forms of treatment. This paper is based on a review of the literature on nonpharmacological treatments for depression in older adults. Electroconvulsive therapy has a role in severely depressed older adults because of its rapid effectiveness in life-threatening situations while psychotherapy, either on its own or in combination with antidepressants, is effective in the treatment of mild to moderate depression.
Key words: older adults, psychotherapy, depression, electroconvulsive therapy.

Tony Lo, MD, Resident, Department of Psychiatry, University of Calgary, Calgary, AB.
Nadeem H. Bhanji, BSc(Pharm), MD, FRCP(C), Assistant Professor, University of Calgary; Staff Psychiatrist, Carewest Glenmore Rehabilitation Hospital; Elderly Psychiatrist, Department of Psychiatry, Peter Lougheed Centre; Assistant Professor, University of Calgary, Calgary, AB.

Major depression and subsyndromal depression are common in older persons. Unrecognized depression results in increased morbidity and mortality. Recognition of depression is challenging due to patient- and clinician-related factors. Diagnosis in the older person is confounded by medical comorbidities as well as normal changes. Depression in older adults manifests differently: somatic complaints, nonspecific symptoms, and cognitive difficulties are common, as are behavioural changes, including apathy and irritability. Anhedonia better reflects depression, since depressed mood is often denied by the older person. Depression is likely to be missed if only typical symptoms are sought. Appropriate recognition can lead to improved treatment and outcomes.
Key words: depression, older adult, diagnosis, recognition, management.

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

Prostate cancer remains the most common malignancy in men. Screening remains controversial due to a lack of evidence from randomized trials that it decreases mortality. Treatment decisions are based on assigning patients to one of three risk groups (low, intermediate, or high) based on stage, tumour grade, and prostate-specific antigen level, and considering remaining patient life expectancy (affected by age and comorbidity). Men with low-risk disease can consider expectant management, surgery, or radiotherapy (either external beam or brachytherapy). In intermediate-risk patients, all options except expectant management are associated with excellent long-term survival. In high-risk patients, combining either radiation or surgery with androgen deprivation has emerged as the best option. There is no role for primary androgen deprivation for most patients.
Key words: prostate cancer, screening, treatment, surgery, radiotherapy.