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

David F. Tang-Wai, MDCM, Department of Medicine (Neurology), University of
Toronto, University Health Network, Toronto, ON.

Keith A. Josephs, MST MD, Department of Neurology, Mayo Clinic, Rochester, MN, USA

Neurodegenerative diseases commonly affect cortical and subcortical structures, resulting in clinical features of mixed dementia and parkinsonism. Dementia, albeit an uncommon presenting feature of Parkinson’s disease, may become a complication with disease progression. In this review we discuss the relationship of dementia and parkinsonism. We outline a clinical approach to the diagnosis and management of dementia with Lewy bodies and emphasize the importance of understanding the complexity of the disease, for which in-depth knowledge of medication side-effect profiles is a must if treatment is to be undertaken. We also briefly discuss progressive supranuclear palsy, corticobasal syndrome, and vascular dementia with parkinsonism.

Key words: Parkinson’s disease, dementia with Lewy bodies, visual hallucinations, fluctuations, acetylcholinesterase inhibitors.

Robert E. Hobbs, MD, The Kaufman Center for Heart Failure, Department of
Cardiology, Cleveland Clinic Foundation, Cleveland, OH, USA.

Guidelines for managing heart failure recommend angiotension-converting enzyme (ACE) inhibitors, beta-blockers, diuretics, digoxin, and aldosterone antagonists as standard therapy in order to improve morbidity and mortality. Angiotensin receptor blockers (ARBs) are considered second-line agents for patients who are intolerant of ACE inhibitors due to cough or angioedema. Because ACE inhibitors do not completely block the formation of angiotensin II and aldosterone, add-on therapy with an ARB has been evaluated in several clinical trials. In general, the results were mixed. Combination therapy with an ACE inhibitor and an ARB may improve morbidity and probably mortality, but with an increased incidence of hypotension, hyperkalemia, and azotemia. This approach could be considered in patients who remain symptomatic despite optimal doses of standard agents.

Key words: angiotensin receptor blockers, ACE inhibitors, heart failure, vasodilators, hyperkalemia.

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

Anil Minocha, MD, FACP, FACG, Division of Digestive Diseases, Department of Medicine, University of Mississippi Medical Center, Jackson, MS, USA.
Thomas Abell, MD, FACG, Division of Digestive Diseases, Department of Medicine, University of Mississippi Medical Center, Jackson, MS, USA.

Irritable bowel syndrome (IBS) in the older adult offers challenges for diagnosis and treatment; however, very little research has been done in this regard. IBS has significant impact on the quality of life, especially in frail individuals. The diagnostic criteria have not been validated in older subjects. Diagnostic strategy needs to be modified to account for the expanded list of differential diagnosis, including high prevalence of colorectal cancer. There is a lack of evidence related to the efficacy of the treatment regimens used. Therapy should focus on specific symptoms and be matched for the potential for side effects and drug interactions. The prognosis for IBS is excellent and in a majority of cases symptoms disappear within five years.

Key words: Irritable bowel syndrome, Functional bowel disorder, Rome II criteria, older adults, spastic colon

Scott RA Walsh, MD, PhD, Division of Dermatology, Sunnybrook and Women’s College Health Sciences Centre, University of Toronto Medical School, Toronto, ON.

Madhuri Reddy, MD, MSc, FRCPC, Divisions of Dermatology and Geriatric Medicine, Department of Medicine, Sunnybrook and Women’s College Health Sciences Centre, University of Toronto Medical School, Toronto, ON.

Psoriasis is a chronic, recurring T-cell- mediated skin disease that causes significant morbidity. The disease is often life-long and thus prevalence is highest in older adults. Severe clinical variants are also more frequent. Complicating psoriasis presentation and treatment in older adults are issues related to polypharmacy, including a higher frequency of drug-induced or drug-exacerbated disease and potential drug interactions. Treatment should be tailored to the individual with his/her respective limitations and reflect disease severity. This review examines suitable treatment protocols, including patient education and topical and systemic medications in older populations coping with psoriasis.

Key words: psoriasis, older adults, complications, treatment, immunologic disease

Nimesh P. Nagarsheth, MD, Division of Gynecologic Oncology, Department of Obstetrics, Gynecology and Reproductive Science, Mount Sinai Medical Center, New York, NY, USA.

Jamal Rahaman, MD, Division of Gynecologic Oncology, Department of Obstetrics,
Gynecology and Reproductive Science, Mount Sinai Medical Center, New York, NY, USA.

The diagnosis and management of cervical cancer in the older patient presents important challenges to the geriatrician and oncologist. Cervical cancer almost never occurs in older patients who have followed screening guidelines and have had a history of normal Pap smears prior to age 70. Early stage disease is best managed by radical surgery. While radical pelvic surgery has been proven safe in selected older patients, the current management of early cervical cancer depends upon the resources available to the geographical location. For locally advanced cervical cancer and early stage patients who are not surgical candidates, radiation therapy with concurrent platinum-based chemotherapy is the standard of care. Radiation therapy and chemotherapy can be safely administered to older patients once allowances are made for age-related physiologic changes. Advanced age should not be used as justification to alter the standard of care for the management of cervical cancer.

Key words: cervical cancer, older adults, chemotherapy, radiation therapy, radical pelvic surgery.

Randy Harris, MSW, RSW, Mental Health Therapist, Community Geriatric Mental Health Services, Calgary Health Region, Calgary, AB.

Substance abuse experienced by older clients is frequently seen in medical practices. This article reviews approaches to assessing and treating older adults, including practical ideas for conducting interviews with older clients. A philosophical stance that recognizes a client’s readiness to change is also discussed.

Key words: older adults, substance use, stages of change, assessment, intervention.