Linda Boise, PhD, MPH, Director, Education/Information Transfer Core, Layton Aging & Alzheimer Disease Research Center, Oregon Health & Science University, Portland, OR, USA.
Cathleen M Connell, PhD, Professor, Department of Health Behavior and Health Education, School of Public Health; Director, Education/Information Transfer Core, Michigan Alzheimer’s Disease Research Center, University of Michigan, Ann Arbor, MI, USA.

The high prevalence of dementia and the increased availability of treatments for Alzheimer’s disease and related dementias have increased the need to find optimal approaches to disclosing the diagnosis of dementia. In this article, relevant research is reviewed on physician practices and perspectives, and on older patients’ and family members’ preferences. Research suggests that, in general, patients and families want an accurate and clearly explained diagnosis, and that they desire guidance from the physician in understanding the course of the illness over time as well as resources that will help them to cope. Considerations in disclosing a dementia diagnosis and recommendations on how to disclose a dementia diagnosis are offered.

Key words: dementia, Alzheimer’s disease, disclosure, physicians, diagnosis.

Sohel Somani, MD, FRCSC, Clinical Instructor, Department of Ophthalmology and Vision Sciences, University of Toronto; Associate Staff, Princess Margaret Hospital, Toronto, ON.

Age-related macular degeneration (ARMD) is a progressive disease affecting the central vision of patients older than 55 years. ARMD is classified as atrophic (dry) or exudative (wet) forms based on clinical characteristics. Management of atrophic ARMD includes vitamin supplementation with high-dose antioxidants in appropriate patients. Patients who develop exudative ARMD may be eligible for treatment depending on flourescein angiogram characteristics. Options available to close a choroidal neovascular membrane include thermal laser photocoagulation or photodynamic therapy. Other treatment modalities are currently under investigation that may lead to more therapeutic options in the future.

Key words: macular degeneration, vitamins, laser, photodynamic therapy, angiogenesis.

Eric M. Morrow, MD, PhD, Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA.
William E. Falk, MD, Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA.

Anxiety in older patients, when excessive in degree and duration, can cause significant impairment and, if left untreated, may result in profound comorbidity--in particular, depression. Anxiety symptoms emerging in the older patient necessitate an extensive medical and psychosocial workup. There is a paucity of data for pharmacological treatment of anxiety disorders in older adults. In this review, we will discuss some of the research in the area of diagnosis and treatment of anxiety in older adults. We will also summarize some practice parameters common in our clinic when data are absent or lacking. The use of psychotherapies (such as cognitive behavioural therapy) and of medications such as the SSRIs, as well as benzodiazepines and other agents including the atypical antipsychotics, are discussed. The differential diagnosis of anxiety symptoms in the older patient, including careful attention to underlying medical and neurologic causes of anxiety, are emphasized.

Key words: SSRIs, benzodiazepines, psychotherapy, anxiety, depression, dementia.

JE Simon, MB, ChB, MRCP (UK), Calgary Stroke Program, Seaman Family MR Research Centre, Department of Clinical Neurosciences, University of Calgary, Calgary, AB.
MD Hill, MD, MSc, FRCPC, Director, Stroke Unit, Associate Professor, Calgary Stroke Program, Departments of Clinical Neurosciences / Medicine / Community Health Sciences, University of Calgary, Calgary, AB.

Despite the fact that stroke is both common and devastating in older patients, very little randomized controlled data is available on the efficacy or safety of thrombolysis in older age groups. We review literature from both randomized control studies and case series data treating older patients, and look at the hemorrhage rate and mortality associated with thrombolysis. In addition, we examine risk markers, other than age, for a poor outcome. We suggest that older age alone is not a contraindication to thrombolytic therapy.

Key words: ischemic stroke, tPA, thrombolysis, hemorrhage risk.

Andreas Kastrup, MD, Department of Neurology, Friedrich-Schiller-University of Jena, Jena, Germany.
Klaus Gröschel, MD, Department of Neurology, Friedrich-Schiller-University of Jena, Jena, Germany.

Atherosclerotic carotid artery stenosis is relatively frequent in older patients and is a major cause of disabling stroke or death. Carotid endarterectomy is currently considered the standard of care for all patients with severe symptomatic and asymptomatic carotid stenosis. However, data regarding the efficacy of this treatment in the older patient are limited. In the past few years, carotid angioplasty and stenting have increasingly been used as an alternative to surgery. Although these endovascular techniques have the advantage of avoiding general anesthesia and surgical incisions, preliminary trial data do not support their widespread use in older patients.

Key words: carotid stenosis, carotid endarterectomy, angioplasty, stent, old age.

Vadim Beletsky, MD, PhD, Senior Stroke Fellow, Department of Clinical Neurological Sciences, London Health Sciences Centre, London, ON.

Clinical presentation of cervical arterial dissection is highly variable, but headache or neck pain is frequently observed. Both invasive and noninvasive imaging are used to confirm the diagnosis but noninvasive techniques overshadow traditional digital subtraction angiography (DSA), which should be reserved for cases where invasive procedures are planned. In spite of the accumulated clinical, diagnostic, and etiological data on cervical arterial dissections in recent years, there is no evidence to support the use of a particular class of antithrombotic agents in these patients. Different pathophysiology of brain ischemia in acute and chronic states of dissection may advocate different treatment strategies, including surgical. There are also no imaging follow-up guidelines, both in terms of frequency and modality, further affecting secondary stroke prevention uncertainties.

Key words: arterial dissection, cervical, stroke, carotid, vertebral.

Ashfaq Shuaib, MD, FRCPC, FAHA, Professor of Neurology and Medicine, Director, Division of Neurology, University of Alberta, Edmonton, AB.

Stroke is a common neurological problem in older adults. Most patients have identifiable risk factors. Identification and treatment of such conditions can result in a significant reduction in recurrence. In addition, patients with an acute ischemic stroke require lifelong treatment with antithrombotic agents. For the vast majority of patients, acetylsalicylic acid (ASA) in a dose of 50-325mg per day is sufficient. In patients who are unable to tolerate ASA (75mg per day) clopidogrel may be an alternative. Both clopidogrel and ASA/ extended-release dipyridamole are useful alternative medications, especially in patients with recurrent symptoms. In 20% of patients the ischemic stroke may be secondary to cardioembolic causes (atrial fibrillation is the most frequent cardiac cause). In such subjects, treatment with warfarin with INRs in the range of two to three may provide better reduction in recurrence than ASA.

Key words: stroke, stroke prevention, antithrombotic agents, cardioembolic.

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.htm

Yves Lacourcière, MD, FRCP, Hypertension Research Unit, CHUL du CHUQ, Laval University, QC.

There are many reasons why gaining control over high blood pressure (BP) in older patients is desirable. When choosing an antihypertensive agent for older patients, physicians should seek a drug that sustains BP control, especially in the last six hours of the dosing interval or if a dose is missed. Agents with a long duration of action that inhibit the renin-angiotensin system (RAS) are likely to be more useful in controlling the early-morning surges in norepinephrine that have been linked to target organ damage and stroke, particularly in older patients.

Key words: hypertension, renin-angiotensin, angiotensin-receptor blockers, norepinephrine, peroxisome proliferator-activated receptor (PPAR).

K. C. Giede, MD, FRCP, Clinical Fellow in Gynecologic Oncology, Princess Margaret Hospital, University Health Network, University of Toronto, Toronto, ON; Associate Professor of Gynecology and Obstetrics, University of Saskatchewan, Saskatoon, SK.
A. M. Oza, MD, FRCP, Co-Director, Drug Development Program; Co-Chair, NCIC Clinical Trials Group, Princess Margaret Hospital, University Health Network, University of Toronto, Toronto, ON.

The purpose of this article is to review the incidence, prognosis, and management of metastatic cervical cancer in older patients. A literature review was conducted using the key words cervical cancer, elderly, and metastatic disease. There were no studies found specific to metastatic cervical cancer in older patients. The incidence of cervical cancer over the age of 65 remained significant with a greater proportion of older patients presenting with metastatic disease. We found good phase III data on the use of chemotherapy for metastatic cervical cancer. We reviewed data supporting the safe use of chemotherapy and radiotherapy in older patients.
We conclude that older patients are more likely to present with metastatic cervical cancer then their younger counterparts. Standard therapies should not be withheld on the basis of age, though management should focus on palliation.

Key words: cervical cancer, older patients, metastatic.

Dale A. Lund, PhD, Professor of Gerontology & Sociology, University of Utah Center on Aging, Salt Lake City, UT, USA.
Scott D. Wright, PhD, Associate Professor of Gerontology, University of Utah Center on Aging, Salt Lake City, UT, USA.
Michael S. Caserta, PhD, Associate Professor of Gerontology, University of Utah Center on Aging, Salt Lake City, UT, USA.

Obtaining respite, defined as having time away from performing caregiving tasks and meeting various responsibilities, has been found to be the single most desired and needed service by family caregivers to older adults. Although respite has the potential to enhance the quality of life for most caregivers, far too many caregivers wait too long to use the services, do not use them often or regularly enough, or spend their respite time unwisely (thus not deriving the maximum benefit). Also, many caregivers feel guilty and reluctant to use the services even when they are available. This article helps document the value of using respite services, describes the various forms in which they are available, and offers suggestions on how to make the most out of these promising services.

Key words: respite, caregiving, older adults, quality of life.