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.

Jayna M. Holroyd-Leduc, MD, FRCPC, Assistant Professor, Department of Medicine, University of Toronto; Clinician-Investigator, University Health Network, Toronto, ON.
Cara Tannenbaum, MD, FRCPC, MSc, Assistant Professor, Department of Medicine, University of Montreal; Director, Geriatric Incontinence Clinic, McGill University Health Centre; Director, Institut Universitaire de Geriatrie de Montreal, Montreal, QC.

Urinary incontinence is a prevalent condition among long-term care residents, particularly those with dementia. The costs and morbidity associated with urinary incontinence are significant. Urinary incontinence can be easily assessed within the long-term care setting. Several modifiable risk factors should be identified and addressed. Effective behavioural treatment options for incontinence exist and several treatment strategies can be used successfully for patients with dementia.

Key words: urinary incontinence, dementia, long-term care, diagnosis, management.

Joseph M. Blondeau, Department of Clinical Microbiology, Royal University Hospital; Department of Microbiology, Department of Immunology and Pathology, University of Saskatchewan, Saskatoon, SK.
Glenn S. Tillotson, Oscient Pharmaceuticals, Waltham, MA; Public Health Research Laboratory, Newark, NJ, USA.

Antimicrobial agents are essential for the treatment of patients with bacterial infectious diseases. Unfortunately, the global escalation of antibiotic resistant pathogens in both the community and hospital settings have compromised the use of some compounds for treating both common and uncommon infections. Over the past three to four years, several new or modified compounds have been approved and may have applicability in treating a wide range of infections in older patients. Some brief characteristics of these compounds and their appropriate indications are summarized.

Key words: older adult, antimicrobial agents, antibiotics, fluoroquino-lones, ketolides.

Wilbert S. Aronow, MD, CMD, Clinical Professor of Medicine, Divisions of Cardiology, Geriatrics, and Pulmonary/Critical Care Medicine; Chief, Cardiology Clinic; Senior Associate Program Director and Research Mentor, Fellowship Programs, Department of Medicine, New York Medical College, Valhalla, NY; Adjunct Professor of Geriatrics and Adult Development, Mount Sinai School of Medicine, New York City, NY, USA.

Older patients are more likely to have hypertension and isolated systolic hypertension, to have target organ damage and clinical cardiovascular disease, and to develop myocardial infarction, angina pectoris, stroke, congestive heart failure, and peripheral arterial disease. Yet, considering the increased risk of cardiovascular death, older patients are less likely to have hypertension controlled. Antihypertensive drug therapy reduces coronary events, stroke, heart failure, and cardiovascular death in older patients. The goal of treatment of hypertension in older patients is to reduce the blood pressure to less than 140/90mmHg and to ≤130/80mmHg in older patients with diabetes mellitus or chronic renal insufficiency. Diuretics should be used as initial drug therapy in older patients with hypertension and no associated medical conditions. The selection of antihypertensive drug therapy in older patients depends on the associated medical conditions.

Key words: hypertension, diuretics, beta-blockers, angiotensin-converting enzyme inhibitors, calcium channel blockers.

Christine A. Fruhauf, PhD, Director and Assistant Professor, Center on Aging, Colorado State University, Fort Collins, CO, USA.

During the past 30 years, health care professionals and caregivers have not only been concerned with neurological aspects of dementia but also with behaviour management of individuals who have dementia. The purpose of this article is to highlight theoretical perspectives and techniques using a case study example for formal caregivers (i.e., nurses, nursing aids, and staff) in formal care settings (i.e., hospitals, long-term care facilities, and adult day centres). The use of these techniques will likely improve dementia care and the lives of both individuals with dementia and their formal caregivers.

Key words: dementia care, person-centred care, dementia care mapping, reframing behaviours.