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.

Mary Anne Cooper, MSc, MD, FRCPC, Assistant Professor, Department of Medicine, University of Toronto; Lecturer, Sunnybrook and Women's Health Sciences Centre, Toronto, ON.

Gastroesophageal reflux disease is a common condition responsible for significant morbidity in older adults. It causes disease in the esophagus, and it is increasingly recognized as a cause of extra-esophageal symptoms such as chronic cough, adult-onset asthma, and hoarseness. Despite significant symptoms, endoscopy may be negative. Endoscopy-negative reflux disease may be a unique disease entity within the acid reflux group of disorders that includes erosive esophagitis and Barrett’s esophagus. Regardless of the symptoms or endoscopic findings, treatment remains geared to reducing the contact time between acid and sensitive tissue through lifestyle modification measures, acid suppression, and improved upper gastrointestinal motility.

Key words: GERD, extra-esophageal reflux, endoscopy-negative reflux disease, acid suppression, older adults.

MV Apte, MBBS, MMedSci, PhD, Pancreatic Research Group, The University of New South Wales, Sydney, AUS.

RC Pirola, MD, FRACP, Pancreatic Research Group, The University of New South Wales, Sydney, AUS.

JS Wilson, MD, FRACP, FRCP, Pancreatic Research Group, The University of New South Wales, Sydney,

AUS.Pancreatitis (inflammation of the pancreas) has both acute and chronic manifestations. Gallstones are the predominant cause of acute pancreatitis in older adults, while chronic pancreatitis is usually due to alcohol abuse (although an idiopathic, late-onset form of chronic pancreatitis is also recognized). The majority of cases of acute pancreatitis are mild and self-limiting, and supportive therapy is usually sufficient. Increasing age is a known risk factor for the development of severe acute pancreatitis. In contrast to the reversible nature of acute pancreatitis, chronic pancreatitis is characterized by progressive loss of pancreatic structure and function. Management of chronic pancreatitis involves treatment of pain, maldigestion, and diabetes. The most serious complication of chronic pancreatitis is pancreatic cancer; the risk of developing pancreatic cancer increases with increasing age.

Key words: acute pancreatitis, chronic pancreatitis, pancreatic pain, maldigestion.

Jill M. Watanabe, MD, MPH, Department of Medicine, University of Washington School of Medicine, Seattle, WA, USA.
Christina M. Surawicz, MD, FACG, Department of Medicine and Division of Gastroenterology, University of Washington School of Medicine, Seattle, WA, USA.

The principal causes of diarrhea are infectious and inflammatory in origin, but the diagnosis and management of diarrhea in older patients may be complicated by age-related vulnerabilities and comorbidities. Several studies have indicated that the bacterial composition of feces may change with increasing age¹ and that immune response at the mucosal surface may also diminish.² Outbreaks of infectious diarrhea, including Escherichia coli 0157:H7 and viral origins, have occurred in the long-term care setting.^3,4 It is also known that a wide spectrum of medications can cause diarrhea through various mechanisms. Older patients are at greater risk of developing mesenteric or colonic ischemia due to underlying atherosclerotic disease and risk of embolic events from atrial fibrillation, valvular heart disease, or cardiomyopathies.^7,8 This article highlights the age-related considerations for the diagnosis and management of diarrhea in the older adult.

Key words: mesenteric ischemia, ischemic colitis, Escherichia coli 0157:H7, Clostridium difficile, microscopic colitis, radiation colitis

Hannah I. Lipman, MD, Hertzberg Palliative Care Institute, Brookdale Department of Geriatrics and Adult Development, Mount Sinai School of Medicine, New York, NY, USA.

Diane E. Meier, MD, Hertzberg Palliative Care Institute, Brookdale Department of Geriatrics and Adult Development, Mount Sinai School of Medicine, New York, NY, USA.

Nausea and vomiting are common problems in the care of the older palliative care patient. Depending on the population studied, incidence is as high as 60%. Distress associated with nausea and vomiting may be relieved in the majority of cases by careful determination of the underlying cause and selection of one or more antiemetic agents. Pathophysiology of nausea and vomiting involves complex interactions among multiple neurotransmitter systems. Antiemetic agents work via modulation of neurotransmitter signalling. Pharmacologic agents are reviewed and geriatric dosing recommendations are made.

Key words: palliative, end of life, geriatric, nausea, vomiting