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.

Robert W. Teasell, MD, FRCPC, Physical Medicine and Rehabilitation, Lawson Health Research Institute, University of Western Ontario, London, ON.
Jeffrey W. Jutai, PhD, Cpsych, Physical Medicine and Rehabilitation, Lawson Health Research Institute, University of Western Ontario, London, ON.

Stroke rehabilitation is best provided by a specialized interdisciplinary team, and the benefits of such a program in improving functional outcomes and reducing disability have been well established in multiple randomized controlled trials (RCTs). There is also evidence that the intensity of therapy is important. The risk of not providing stroke rehabilitation, established in one RCT, is a marked increase in death and dependency for moderate to severe stroke patients. Rehabilitation is best provided early to take advantage of post-stroke brain plasticity. Increasing age has an impact on stroke recovery, and very old patients respond better to a slower, less intensive approach to rehabilitation. Insufficient attention is often given to the importance of assistive devices.

Key words: stroke rehabilitation, interdisciplinary stroke rehabilitation unit, older adult, assistive devices.

Christopher B. Johnson, MD, FRCPC, University of Ottawa Heart Institute, Ottawa, ON.

Older patients have a high prevalence of heart valve disease and prosthetic heart valves, and are therefore at particularly high risk for endocarditis. Streptococcus viridans and Staphylococcus aureus are the most common pathogens in older patients with endocarditis. While antibiotics may cure endocarditis, surgery is required on occasion to treat complications of endocarditis such as heart failure due to valvular regurgitation, systemic and cerebral emboli, and persistent bacteremia. Endocarditis can be accurately diagnosed in aging patients using clinical, microbiological, and echocardiographic criteria. Early diagnosis and prompt institution of antibiotic therapy can result in excellent outcome among older patients with endocarditis.

Key words: endocarditis, older adults, echo, heart valve, bacteria.

David B. Hogan, MD, FACP, FRCPC, Professor and Brenda Strafford Foundation Chair in Geriatric Medicine, University of Calgary, Calgary, AB.

Dementia is a common condition that places its victims at risk for injury. This article provides an overview of home safety for those with dementia. A conceptual approach to this management challenge is the Home Safety / Injury Model described by Hurley and colleagues. I focus on two common safety concerns: wandering and falls. Unfortunately, most recommendations are based on “common sense” (i.e., what seems reasonable). Whether these approaches actually decrease the likelihood of harm is largely unknown. It is anticipated that future research will lead to evidence-based recommendations.

Key words: dementia, home safety, wandering, falls.

Isabelle J. Dionne, PhD, Faculty of Physical Activity and Sports, University of Sherbrooke; Research Centre on Aging, Geriatric Institute of Sherbrooke University, Sherbrooke, QC.
Martin Brochu, PhD, Faculty of Physical Activity and Sports, University of Sherbrooke; Research Centre on Aging, Geriatric Institute of Sherbrooke University, Sherbrooke, QC.

There is a high prevalence of obesity in older adults up to the age of 80. While women generally gain body weight during the menopausal transition, men tend to accumulate an excess of fat mass earlier in life for as yet unknown reasons. Consequently, an increasing proportion of older adults are now obese. Obesity’s association with metabolic diseases such as metabolic syndrome, type II diabetes, and cardiovascular disease is widely recognized. However, recent evidence shows that, in older adults, obesity is also related to functional impairment and decreased quality of life. This review addresses the actual prevalence and definition of obesity in older adults, the energy-balance equation, and the known consequences of obesity. Finally, the heterogeneity of obesity in older adults regarding its association with metabolic diseases and functional capacity will be discussed, as well as how obesity treatment should be conducted in this population.

Key words: obesity, metabolic syndrome, diabetes, weight loss, impaired functional capacity.

George P. Chandy, MD, MSc, Department of Medicine, University of Ottawa, Ottawa, ON.
Shawn D. Aaron, MD, MSc, Department of Medicine and the Ottawa Health ResearchInstitute, University of Ottawa, Ottawa, ON.

Chronic Obstructive Pulmonary Disease (COPD) has been increasing in prevalence over the past several decades. The impact of COPD on the health status of Canadians will continue to be a major issue, despite declining rates of smoking, as physiologic manifestations of COPD may only be evident decades after the initiation of smoking. Given the delay between the initiation of smoking and the development of significant disease, COPD is primarily a disease of the older population. While a cure for COPD is not available, a number of medications have been noted to have a significant impact on symptoms, exercise tolerance, and quality of life.

Key words: COPD, treatment, management, older adults.

David Fitchett, MD FRCP(C), St Michael’s Hospital, University of Toronto, Toronto, ON.

As a response to recent clinical trials of low-density lipoprotein (LDL) lowering, the Adult Treatment Panel III (ATP III) has proposed new thresholds and targets for treatment. In addition, the population that is considered to benefit from LDL lowering has been extended to include the diabetic and the older patient. This article reviews the clinical trial evidence, and the new recommendations, and provides commentary with special reference to management of the older person.

Key words: cardiovascular disease, LDL cholesterol, statin therapy, older patients, diabetes.