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.

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.