Raymond Fung, MD, BSc, Fellow, Division of Endocrinology, University of Toronto, Toronto, ON.

Lorraine L. Lipscombe, MD, FRCPC, Clinical Associate, Research Fellow, Division of Endocrinology, Sunnybrook and Women’s College Health Sciences Centre, University of Toronto, Toronto, ON.

The prevalence of diabetes has been increasing significantly in the last several years, especially in the older population. Cardiovascular disease (CVD) represents the most important complication of diabetes in this age group, as up to 80% of persons with diabetes die from CVD. The treatment of dyslipidemia and hypertension are both key in ameliorating CVD risk. Recent randomized controlled trials have included older persons with diabetes and have demonstrated that both statin therapy for dyslipidemia and antihypertensive agents are highly effective and safe in preventing CVD in this population. This review will examine the evidence for treatment in both areas, outlining the special considerations in the aged.

Key words: diabetes mellitus, cardiovascular disease, statins, hypertension, cholesterol.

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

Jean Bourbeau MD, MSc, FRCPC, Montreal Chest Institute of the Royal Victoria Hospital, McGill University Health Centre; Respiratory Epidemiology and Clinical Research Unit, Department of Epidemiology and Biostatistics, McGill University, Montreal, QC.

With the population progressively aging, the geriatric aspects of COPD deserve special consideration. Older adults with respiratory symptoms and a current or previous history of smoking should be considered for a diagnosis of COPD. Objective demonstration of airflow obstruction is mandatory for the diagnosis of COPD. The majority of older people can adequately perform spirometry for an objective demonstration of airflow obstruction. Nonpharmacological treatment includes smoking cessation, vaccination, self-management education and communication with a case manager, and pulmonary rehabilitation. Bronchodilators are the most important agents in the pharmacotherapy of COPD. Inhaled corticosteroids are indicated for patients with recurrent exacerbations who are already on optimal bronchodilator therapy.

Key words: chronic obstructive pulmonary disease, older adults, diagnosis, spirometry, management.

Diego H. Delgado, MD, Division of Cardiology and Transplant, Toronto General Hospital, Toronto, ON.

The incidence of heart failure is rising rapidly, and it is currently the most common cardiovascular disease. Approximately 20–40% of patients with heart failure have preserved left ventricular systolic function, and an impairment of ventricular relaxation is considered the primary cause. There is controversy surrounding the definition of diastolic dysfunction and the diagnostic criteria for diastolic heart failure. Moreover, there are few studies on therapy for diastolic heart failure, which makes the management of these patients a real challenge.

Key words: heart failure, treatment, diagnosis, diastolic dysfunction.

Nasreen Khalil, MD, FRCPC, FCCP, Associate Professor of Medicine, The University of British Columbia, Jack Bell Research Centre, Vancouver, BC.

Bronchiectasis is an anatomic abnormality of the airway characterized by irreversible dilatation and thickening of the airway wall. The most common etiology in older patients appears to be a previous pulmonary infection. Prior to the antibiotic era the age group most frequently affected by bronchiectasis was young children. Currently, bronchiectasis is seen primarily in individuals between the ages of 60 and 80. Pseudomonas aeruginosa and Hemophilus influenza are the most commonly isolated pathogens in the sputum of bronchiectatic patients. Treatment consists of ruling out reversible or correctible causes, commencing antibiotic therapy, and improving bronchial hygiene.

Key words: bronchiectasis, chronic cough, chronic sputum, mucociliary, immunodeficiency.

Samir Gupta, MD, FRCPC, Division of Respirology, Department of Medicine, St. Michael’s Hospital, University of Toronto, Toronto, ON.

Robert Hyland, MD, FRCPC, Division of Respirology, Department of Medicine, St. Michael’s Hospital, University of Toronto, Toronto, ON.

Hemoptysis is an important clinical problem that is especially ominous when seen in older patients. The main causes of hemoptysis in first world nations are bronchogenic carcinoma, bronchitis, and bronchiectasis. In older patients cancer remains the main concern, especially if there is a smoking history. The diagnostic approach to nonmassive hemoptysis starts with a chest x-ray, followed by a CT scan and then fibre optic bronchoscopy, which is well tolerated by older adults. In massive hemoptysis, chest x-ray is usually followed immediately by fibre optic or rigid bronchoscopy. Older patients require closer monitoring due to poor cardiopulmonary reserve; management options include endoscopic interventions, bronchial artery embolization,
surgery, and radiation.

Key words: hemoptysis, etiology, management, older adults, bronchiectasis.

Loren K. Mell, MD, Department of Radiation and Cellular Oncology, University of Chicago and the University of Illinois at Chicago, Chicago, IL, USA.

Arno J. Mundt, MD, Department of Radiation and Cellular Oncology, University of Chicago and the University of Illinois at Chicago, Chicago, IL, USA.

Radiation therapy (RT) is commonly used in the treatment of older cancer patients. RT may be used as definitive therapy for benign or malignant tumours, as adjuvant therapy with surgery and/or chemotherapy, as palliative therapy when cure is no longer possible, and as alternative to surgery in patients with multiple comorbidities. However, RT is often not given to older patients who might benefit from it, due to biases, misapprehensions about potential toxicity, and social factors particular to this patient population. The preponderance of data suggest that RT is well tolerated in older adults and treatment decisions should be based on prognostic factors irrespective of age. Emerging RT technologies may particularly benefit aged patients by reducing potential toxicities, shortening treatment times, and improving tumour control.

Key words: age, radiation therapy, toxicity, cancer, procedures.

Rory Fisher, MB, FRCP(Ed)(C), Professor Emeritus, Department of Medicine, University of Toronto, Toronto, ON.

Eoin Connolly, MA, Clinical Ethics Fellow, Joint Centre for Bioethics, University of Toronto, Toronto, ON.

Canada's aging population makes appropriate end-of-life care a priority. Alzheimer's disease and related dementias become increasingly common with aging. The terminal stages are characterized by severe cognitive and physical incapacity with a poor prognosis. Artificial nutrition and hydration may be provided by feeding tubes; however, there is no
evidence of benefit, and there are significant side effects to be considered. Barriers to appropriate end-of-life decision making are identified, and current evidence indicates that this patient population should be treated with appropriate palliative care.

Key words: Alzheimer’s disease, artificial nutrition and hydration, dementia, end-of-life care, ethics.

Dror Marchaim, MD, Department of Internal Medicine A, Asaf-Harofeh Medical Center, Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv, IL.

Victor Dishy, MD, Department of Internal Medicine A, Asaf-Harofeh Medical Center, Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv, IL.

Ahuva Golik, MD, Department of Internal Medicine A, Asaf-Harofeh Medical Center, Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv, IL.

Geriatric clinical pharmacology is considered an established subdiscipline in the field of clinical pharmacology. This review will address some of the effects of aging on drug treatment in general, and will focus on specific classes of drugs commonly consumed by older adults: cardiovascular medications, non steroidal anti-inflammatory drugs, and psychoactive agents.

Key words: clinical pharmacology, older adults, drug metabolism, pharmacokinetics.

Ashraf Alzaabi, MD, FRCPC, Respirology Fellow, University of Toronto, Toronto, ON.

Theodore K. Marras, MD, FRCPC, Respirologist, Toronto Western Hospital, University Health Network; Assistant Professor of Medicine, University of Toronto, Toronto, ON.

Community-acquired pneumonia (CAP) in the older adult is a common disease with significant mortality. This review focuses on the management of CAP, with specific reference to the older adult. Common etiologic organisms and organism-specific risk factors that tend to be associated with increasing age are presented. A systematic approach is described to help physicians decide on the best treatment site (ambulatory, long-term care facility, or acute care hospital). The rationale behind initial empiric antibiotic therapy and drug resistance are discussed. Recent guidelines for the selection of empiric antibiotic therapy are compared and a synthesis of guidelines for antibiotic selection and recommendations regarding parenteral to oral switch-therapy are presented. Guidelines are suggested to help the physician safely discharge the patient home.

Key words: pneumonia, management, older adults, guidelines, resistance.

Fred Saibil, MD, FRCPC, Staff Physician, Division of Gastroenterology, Sunnybrook and Women’s College Health Science Centre, Associate Professor of Medicine,
University of Toronto, Toronto, ON.

Dysphagia is frequently under-rated as a symptom by both patients and their physicians. This article highlights the common causes of dysphagia in older patients and discusses the potential contributing factors in this age group. Newer therapies are also mentioned.

Key words: dysphagia, presbyesophagus, swallowing, motility.