Amit Morris, BSc, School of Medicine, Queen’s University, Kingston, ON; Department of Psychiatry, Sleep and Alertness Clinic, Toronto Western Hospital, University of Toronto, Toronto, ON.

Henry J. Moller, MD, FRCP(C), DABSM, Department of Psychiatry, Sleep and Alertness Clinic, Toronto Western Hospital, University of Toronto, Toronto, ON.

Colin M. Shapiro, MBBCh, PhD, FRCP(C), Department of Psychiatry, Sleep and Alertness Clinic, Toronto Western Hospital, University of Toronto, Toronto, ON.

Chronic insomnia is common among older adults and has significant negative consequences for health and well being. A comprehensive approach to treatment begins with identification and management of any underlying conditions. Treatment of insomnia includes both non-pharmacologic and pharmacologic options. Non-pharmacologic approaches form the foundation of treatment; hypnotic medications can also be effective but may be associated with adverse drug effects. Zopiclone and zaleplon appear to be associated with fewer side effects than benzodiazepines.

Key words: insomnia, older adults, drug therapy, behavioural therapy, hypnotics.

Kenneth I. Shulman, MD, SM, FRCPsych, FRCPC, Professor, Department of Psychiatry, Sunnybrook & Women’s College Health Sciences Centre, University of Toronto, Toronto, ON.

Mania in old age represents a neuropsychiatric syndrome reflecting its neurobiologic basis. This paper reviews the evidence for affective vulnerability (usually genetic) that is associated with the late manifestation of mania often precipitated by neurologic disease. Cerebrovascular pathology is a common comorbidity that is evident clinically or by neuroimaging. Localization of brain lesions to the right side and involving the orbito-frontal circuit appear to be specific to late-onset mania. The implications for management of mania in old age require further systematic evaluation.
Key words: mania, old age, neuropsychiatric syndrome, bipolar disorder, secondary mania.

Conan Kornetsky, PhD, Professor of Psychiatry and Pharmacology, Boston University School of Medicine, Boston, MA, USA.

There is a common belief, supported by considerable experimental reports, that the aged have higher pain thresholds than the young and are more responsive to the analgesic actions of opiate drugs. To a considerable degree this belief shapes pain treatment in aged adults. This article reviews the evidence for this belief and discusses why there is often a disparity between the reported alleviation of pain in older adults and the widely held belief that these individuals receive inadequate pain management. Among the issues discussed is the amount of control the patient really has in patient-controlled analgesia.

Key words: pain, aged, analgesia, pain measurement, morphine.

Lynn McNicoll, MD, FRCPC, Department of Internal Medicine, Brown University School of Medicine, Providence, RI.

Delirium in older hospitalized persons in non-critical care settings is associated with higher morbidity, mortality, and worse long-term outcomes. Delirium in critically ill persons is a growing field of research. This article presents recent research indicating a high frequency of delirium in critical care. Several studies have shown that delirium in critical care is associated with poor short-term as well as long-term outcomes, including increased length of stay, persistent cognitive deficits, and hospital and one-year mortality. Further research on strategies to prevent delirium in critical care may improve short- and long-term outcomes.

Key words: delirium, critical care, aging, outcomes, older adults.

Chanaka Wijeratne, MD, MB, BS, FRANZCP, Conjoint Senior Lecturer in Psychiatry, University of New South Wales, Sydney, AUS.

Somatic presentations such as fatigue, headache, and abdominal and joint pain are common in primary care, although investigation may not readily identify an underlying cause. Such “functional somatic syndromes” are best conceptualized within a multifactorial, inclusive illness model rather than as diagnoses of exclusion (that is, of medical pathology). For instance, the syndrome of fatigue occurs in up to 25% of older people and is predicted by factors as diverse as female gender, more severe medical illness, and concurrent anxiety and depression. Although the management of functional somatic syndromes is frustrating to the clinician, the importance of a multimodal management model is emphasized.

Key words: functional somatic syndromes, older adults, primary care.

Janet E. McElhaney, MD, FRCPC, FACP, Geriatrician, Center for Immunotherapy of Cancer and Infectious Diseases and UConn Center on Aging, University of Connecticut School of Medicine, Farmington, CT, USA.

Influenza is a serious illness and is probably the single cause of excess mortality during the winter months in the portion of the population that is aged 65 and over. In spite of its limited efficacy in older adults, influenza vaccination is a cost-saving medical intervention that can help to prevent pneumonias, exacerbations of heart failure, and, surprisingly, heart attacks and strokes. As hospitalization rates for acute respiratory illnesses continue to rise in spite of widespread vaccination programs, antiviral drugs need to be incorporated into prophylaxis and early treatment strategies for influenza. Particularly in the institutional setting, seasonal prophylaxis or influenza outbreak control that involves the staff is essential.

Key words: influenza, antiviral drugs, vaccination, prophylaxis, drug resistance.

James Shepherd, MD, PhD, Institute of Biochemistry, Royal Infirmary, Glasgow, Scotland, UK.

In the last two decades the prevalence of stroke, diabetes mellitus, and heart disease has increased significantly as a tangible index of aging in the population. All these diseases are increasing the strain on community health care and social services. Policy-makers need to understand and monitor these trends in order to make informed and cogent decisions about the management of this growing problem. This review highlights some of the key health issues facing older adults in regard to vascular disease and statin therapy in the hope that enlightened debate will inform decision makers in resource allocation for this important and growing segment of society.

Key words: statins, PROSPER, vascular risk reduction, economic evaluations, 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

Lonn Myronuk, MD, FRCPC, Member of the Canadian Academy of Geriatric Psychiatry, President, GeriPsych
Medical Services, Inc., Parksville, BC.

Depressive symptoms in older adults are common and are associated with subjective distress, increased rates of functional impairment, and death. The natural history of depression in the aged appears to differ from that of the younger population, such that conventional criteria for diagnosis of a major depressive episode may not be met by the older patient. Yet, these subsyndromally depressed patients have equivalent levels of disability and risk of morbidity and mortality. Current thinking advises the inclusion of subsyndromal patients in treatment for depression, in contrast to earlier recommendations.

Key words: aged, depressive disorders, morbidity, mortality.

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

L. Creed Pettigrew, MD, MPH, Professor of Neurology, Director, Stroke Program, Sanders-Brown Center on Aging, University of Kentucky College of Medicine, Lexington, KY, USA.

Stroke is the most common life-threatening neurological disease and is the fourth leading cause of death among adult Canadians. Aspirin is the most frequently prescribed antithrombotic drug to prevent stroke but may not be a suitable choice in older patients who have already had stroke symptoms despite its use, or cannot tolerate its side effects. For these patients, clopidogrel or the combination of low-dose aspirin with extended release (ER) dipyridamole should be considered for prevention of stroke. This review will compare the relative benefits of aspirin, clopidogrel, and low-dose aspirin/ER-dipyridamole in geriatric patients at risk for stroke.

Key words: stroke, myocardial infarction, aspirin, clopidogrel, dipyridamole.

Irving E. Salit, MD, Director of Immunodeficiency Clinic, Division of Infectious Diseases, Toronto General Hospital; Associate Professor, University of Toronto, Toronto, ON.

Kaposi’s sarcoma (KS) is a malignancy closely associated with human herpesvirus-8 (HHV-8). KS occurs in immunocompromised subjects—those with HIV infection or after immunosuppressive therapy—but it also occurs without obvious immune deficiency (older men of Mediterranean origin or in central Africans). The incidence of KS in Acquired Immunodeficiency Syndrome (AIDS) has markedly decreased in recent years. Treatment depends on the predisposing condition and the extent of disease. Common management options include no therapy, reversal of immunosuppression, local radiation, and systemic chemotherapy.

Key words: Kaposi’s sarcoma, malignancy, HIV, AIDS, transplant.