Lan Xiong, MD, PhD, CHUM Research Centre, Notre-Dame Hospital, Montréal Hospital, Montréal, QC.
Claudia Gaspar, PhD, CHUM Research Centre, Notre-Dame Hospital, Montréal Hospital, Montréal, QC.
Guy A. Rouleau, MD, PhD, FRCPC, CHUM Research Centre, Notre-Dame Hospital, Montréal Hospital, Montréal, QC.

Both Alzheimer’s disease (AD) and frontotemporal dementia (FTD) are genetically complex and heterogeneous disorders. Although fully penetrant (causal) mutations leading to predominantly familial early onset AD have been identified in three genes (APP, PSEN1, and PSEN2), they only account for a small fraction of AD patients. PSEN1 is considered the most frequently mutated gene in early onset AD. Mutations in the microtubule-associated protein tau (MAPT) gene have been reported in up to 50% of hereditary cases of FTD. One partially penetrant genetic risk factor (APOE4) has been established for the more common late-onset form of AD. Despite advances in elucidating the genetic epidemiology of AD and FTD, the etiology for most patients with dementia remains unclear.

Key words: Alzheimer’s disease, frontotemporal dementia, genetics, linkage, mutation.

Dorothy A Forbes, RN, PhD, CIHR New Investigator, Associate Professor, College of Nursing, University of Saskatchewan, Saskatoon, SK.
Shelley Peacock, RN, MN, Faculty Member, Saskatchewan Institute of Applied Science and Technology, Saskatoon, SK.
Debra Morgan, RN, PhD, Associate Professor, Institute of Agricultural, Rural, and Environmental Health, University of Saskatchewan, Saskatoon, SK.

Strategies such as simulated presence therapy, pet therapy, light therapy, validation therapy, music, massage, therapeutic touch, aromatherapy, and multisensory stimulation have shown promising results in decreasing physical aggression, physical nonaggression, verbal aggression, and verbal nonaggression in older adults with dementia. Further research is needed to identify which strategies are most effective in managing symptoms of agitation associated with the different types of dementia and at different levels of cognitive impairment.

Key words: Alzheimer’s disease, dementia, nonpharmacological strategies, agitation, aggression, behaviour.

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

Ann Schmidt Luggen, PhD, GNP, Professor, Department of Nursing and Health Professions, Northern Kentucky University, Highland Heights, KY; Gerontological Nurse Practitioner, Evercare, Cincinnati, OH, USA.

Medical management of Alzheimer’s disease patients involves drugs that temporarily relieve or stabilize symptoms, or lessen the expected decline in cognition, function, and behaviour, but ultimately fail to halt progression of the disease. Commonly used agents in the management of early- to mid-stage dementias--albeit with modest outcomes--are the cholinesterase inhibitors (ChEIs). Antipsychotics have been used with mixed success to treat psychiatric symptoms that occur in 30-60% of patients with moderate-to-severe AD. In the terminal stages of dementia, palliation of symptoms and a focus on comfort care is important. Management of pain and relief from depression and anxiety are useful.

Key words: dementia, Alzheimer’s disease, cholinesterase inhibitors, behaviour, antipsychotics.

Andrew Kertesz, MD, FRCP(C), Director of Cognitive Neurology, St. Joseph’s Health Center, University of Western Ontario, London, ON.
David Munoz, MD, FRCP(C), Department of Pathology, St. Michael’s Hospital, University of Toronto, Toronto, ON.

Frontotemporal dementia (FTD or Pick’s disease) is a relatively common but underdiagnosed form of presenile dementia. Estimated prevalence is 20% of dementias and 50% of dementia in patients under age 65. Common presentations are disinhibition with indifference; progressive aphasia; semantic dementia; unexplained falls, vertical gaze palsy, and dysarthria; and dementia with motor neuron disease. Neuroimaging is essential to exclude a slow tumour. Tau mutations are found in some families. Atypical neuroleptics and antidepressants can effectively treat some of the characteristics of FTD.

Key words: frontotemporal dementia, Pick’s disease, primary progressive aphasia, corticobasal degeneration, progressive supranuclear palsy.

Peter N. McCracken, MD, FRCPC, Professor of Medicine, Division of Geriatric Medicine, University of Alberta, Edmonton, AB.
Darryl Rolfson, MD, FRCPC, Assistant Professor of Medicine, Division of Geriatric
Medicine, University of Alberta, Edmonton, AB.

Even within the Canadian health care system, one which strives to be comprehensive, universal, and accessible, disparities exist for Canadians who are unable to access timely clinical and educational support due to distance. Telemedicine, which bridges distances to allow clinical, educational, and administrative interactions, fits this need like a glove. In 2005, the acceptability of the technology now leaves clinicians, health educators, and health care administrators in a position to assist almost without excuse. To be successful, telehealth requires willing participants, sensible application technology, and a dense network of broadband linkages. Although qualitative research is plentiful, high quality quantitative research into telehealth is still only emerging, as evidenced by the example of telehealth applications in educational and clinical geriatrics.

Key words: telemedicine, telehealth, geriatrics, medical education, research.

D’Arcy Little, MD, CCFP, Lecturer, Department of Family and Community Medicine, University of Toronto, Toronto, ON.

The skin can be a window to certain internal diseases. Notable internal diseases with a prominent skin component include systemic lupus erythematosus, dermatomyositis, scleroderma, psoriasis, and sarcoidosis. This article will review some of the common skin manifestations of these diseases.

Key words: skin disease, internal disease, systemic lupus erythematosus, dermatomyositis, scleroderma, psoriasis, sarcoidosis.

Nages Nagaratnam, MD, FRCP, FRACP, FRCPA, FACC, Consultant Physician in
Geriatric Medicine, Formerly of Department of Geriatric Medicine, Blacktown-Mt-Druitt Health, Blacktown, NSW, AUS.
Kujan Nagaratnam, MB, FRACP, Consultant Physician in Geriatric Medicine, Department of Geriatric Medicine, Blacktown-Mt Health, Blacktown, NSW, AUS.

Screaming is widely viewed as a common behavioural disturbance in dementia. It influences the performance in daily life of the patient, adds to the burden and embarrassment experienced by the caregiver and the frustrations encountered by the treating physician, and is a decisive factor for institutionalization. This article outlines an approach to screaming and its possible neuroanatomical substrates and neurotransmitter systems. The ultimate basis for discussion will be the strategies available for management of this challenging behaviour.

Key words: screaming, disruptive vocalization, dementia, limbic system, frontal-subcortical circuitry.

Max Huang, MD, FRCPC, Respirology Fellow, Division of Respirology, Department of Medicine, University of Toronto, Toronto, ON.
Lianne G. Singer, MD, FRCPC, Medical Director, Toronto Lung Transplant Program, University Health Network; Assistant Professor, Department of Medicine, University of Toronto, Toronto, ON.

Chronic obstructive pulmonary disease (COPD) often has a profound effect upon the quality of life and mortality of the older adult. Despite numerous medical treatments, surgery may be considered for the symptomatic patient with medically-optimized, end-stage COPD. Bullectomy, lung volume reduction surgery (LVRS), and lung transplantation have all proven to be important surgical therapies. This article reviews the current state of these interventions, and the criteria when deciding on the best surgical option for a given patient.

Key words: emphysema, COPD, lung transplant, lung volume reduction surgery, bullectomy.

Kristopher S. Cunningham, MD, PhD, University Health Network, University of Toronto, Department of Pathology, Toronto, ON.
Sharmi Shafi, BSc, University of Toronto, Toronto, ON.
Mellitta Mezony, MD, FRCPC, Mount Sinai Hospital, Department of Cardiology, Toronto, ON.
Molly Thangaroopan, MD, FRCPC, University Health Network, University of Toronto, Department of Cardiology, Toronto, ON.
Jagdish Butany, MBBS, MS, FRCPC, University Health Network, University of Toronto, Department of Pathology, Toronto, ON.

Pericardial inflammation is a familiar but uncommon cause of chest pain. The classic triad of retrosternal chest pain, pericardial friction rub, and serial ECG changes facilitates diagnosis of pericarditis, the etiology most often being idiopathic in nature. Because older adults more frequently contend with multiple conditions that may require cardiovascular surgical intervention, receive numerous medications, or result in an immunocompromised state, other important causes of pericarditis need to b e considered. This article considers pericarditis in the older population and emphasizes diagnosis and management of this condition. Situations common to this age group that require special attention to the appropriate treatment are also discussed.

Key words: pericarditis, pericardium, heart, inflammation, tamponade.

David L. Snyder, PhD, Senior Research Analyst, Evidence-Based Practice Center, ECRI, Plymouth Meeting, PA, USA.
David Doggett, PhD, Senior Research Analyst, Evidence-Based Practice Center, ECRI, Plymouth Meeting, PA, USA.
Charles Turkelson, PhD, Chief Research Analyst and Director, Evidence-Based Practice Center, ECRI, Plymouth Meeting, PA, USA.

Degenerative lumbar spinal stenosis is a common problem among older adults. Stenotic compression of spinal nerves can result in low back pain, disabling leg pain, and greatly restricted walking capacity. Conservative therapies are usually prescribed for mild symptoms and surgery is prescribed for severe symptoms, while patients with moderate symptoms may not have an obvious treatment choice. The clinical evidence supporting these treatment options has been criticized because of problems with study design and quality that complicate their assessment. Despite the poor quality of most of the literature, recent studies provide better information and a means of starting to judge the effectiveness of treatment.

Key words: lumbar spinal stenosis, neurogenic claudication, conservative therapy, surgical intervention.