Heather H. Keller, RD, PhD, Associate Professor, Dept. Family Relations and Applied Nutrition, University of Guelph, Guelph, ON.

Although the prevalence of malnutrition and, specifically, undernutrition are unknown among Canadian seniors, nutritional risk has been identified as a common problem. As nutritional risk can lead to malnutrition and all of its sequelae, efforts are needed to identify nutrition problems early in their course to improve the quality of life of seniors. The following article provides a variety of approaches for identifying nutritional problems, from simple indicators to a simplified and standardized nutritional assessment. Suggestions also are provided on how the practitioner can seek assistance with intervening and helping the senior to overcome these problems.
Key words: nutrition, older adults, screening, intervention, risk, weight.

Gustavo A. Cardenas, MD, Carl J. Lavie, MD and Richard V. Milani, MD, Department of Cardiology, Ochsner Medical Institutions, New Orleans, LA, USA.

Substantial data from epidemologic, lipid intervention and serial coronary angiographic studies have established the importance of high-density lipoprotein cholesterol (HDL-C) on cardiovascular risk. Low levels of HDL-C should be treated with non-pharmacologic therapy, including weight reduction and aerobic exercise training. Persistently low levels of HDL-C can be treated with niacin therapy, fibrates (especially if the triglyceride levels are elevated) and the statin family of medications. For every 1% increase in HDL-C, one would expect a greater than 3% reduction in vascular risk.
Key words: high-density lipoprotein, niacin, fibrates, statins, exercise.

D. Little, MD, CCFP, Lecturer and Academic Fellow, Department of Family and Community Medicine, University of Toronto; Director of Medical Education, York Community Services; 2002 Royal Canadian Legion Scholar in Care of the Elderly, Toronto, ON.

Seniors are one of the fastest growing population groups in Canada.¹ Approximately 20% of our population is over the age of 65, and this phenomenon has been referred to as the “graying” of the population.^1,2 Families often play a central role in the lives of older people. “Life’s rhythms and seasons” are usually marked within the context of the family.³ Whether independent or dependent, older people view the family as integral to their daily life and wellbeing.⁴ When dependent, the family offers crucial support,³ especially in cases of dementia. Alzheimer’s disease (AD) is the most common cause of severe intellectual deterioration in the aging.5 Approximately 8% of people over 65 years and 35% of people over 85 years suffer from dementia.6 The majority of patients with dementia live in the community and are cared for by family and/or friends.⁷ However, research into and the clinical application of family therapy techniques and principles in older people and their families has been slow to develop.

G.A.E. Wong, MBChB, MRCP (UK); N.H. Shear, MD, FRCP(C), Divisions of Dermatology and Clinical Pharmacology, Sunnybrook & Women’s College Health Sciences Centre, University of Toronto, Toronto, ON.

Cutaneous adverse drug reactions (ADR) are a common problem affecting ambulatory and hospitalized patients. Older patients may be more predisposed to ADR due to inappropriate prescribing of medications, age-associated changes in pharmacokinetics and pharmacodynamics, altered homeostatic mechanisms, multiple medical pathology and use of drugs with a narrow therapeutic margin. In this first of two articles, a practical approach to the assessment and diagnosis of patients with suspected drug-induced rashes will be described. A subsequent article will discuss the management of patients with cutaneous ADR.
Key words: adverse drug reaction, skin, rash, cutaneous, diagnosis, assessment.

Jill Hightower, MA, Hightower and Associates, Halfmoon Bay, BC.

Violence against older women involves physical, emotional, sexual and financial abuse and denial of human rights, often in combination with one another. Abuse is gender- and age-based. The gender-neutral focus of the elder abuse field does not address the key issues of abuse of women in later life. Community-based women’s advocacy and services in the past have failed to recognize and address the needs of older women. By developing an appreciation of issues of gender- and age-based violence, health professionals have increased opportunities to help older women find support and assistance.
Key words: elder abuse, gender violence, women, aging, older women.

Leigh Turner, PhD, 2003-2004 Member, Institute for Advanced Study, School of Social Science, Princeton, NJ, USA; Assistant Professor, Biomedical Ethics Unit, Department of Social Studies of Medicine, McGill University, Montreal, QC.

Bioethicists typically pay little attention to how social and physical environments in health care facilities shape moral experience. Social scientists studying hospitals and long-term care facilities often characterize such facilities as bleak, alienating institutions. Too often, the ethics of place is overlooked as ethicists focus upon dramatic moral issues. Drawing upon my experience working as a clinical ethicist at Baycrest Centre for Geriatric Care, I suggest how long-term geriatric care facilities can be designed to promote respect for privacy, foster a warm social environment, and help preserve the dignity of residents, family members and staff members.
Key words: bioethics, hospital design, long-term care, geriatric care.

David J. Gladstone, BSc, MD, FRCPC; Lorne Zinman, MD, FRCPC; Jodie Burton, MD; Leanne Casaubon, MD; David Chan, MD; Neil Cashman, MD, FRCPC; Sandra E. Black, MD, FRCPC; Morris Freedman, MD, FRCPC.
From the Division of Neurology, University of Toronto, Toronto, ON.

At the Third Annual University of Toronto (U of T) Behavioural Neurology Clinic Day for residents, fellows and other trainees, presentations were given by faculty members from the U of T Department of Medicine (Divisions of Neurology and Geriatric Medicine) and the Department of Psychiatry. Highlights of this educational event are summarized herein by residents in the neurology training program.
Key words: dementia, diagnosis, fronto-temporal dementia, dementia with Lewy bodies, Creutzfeld-Jakob disease, vascular dementia.

Siobhan Ryan, MD, FRCPC, Dermatology Daycare & Wound Healing Centre, Women’s College Campus, Sunnybrook & Women’s College Health Sciences Centre, Toronto, ON.

Itch in the older patient is a common complaint, and one that must be approached in a systematic manner to determine the etiology. Deciding if the itchy older patient fits into one of two categories–itchy with a rash, versus itchy without a rash–will often help to establish the cause of the pruritus. Endogenous causes as well as exogenous causes of pruritus must be considered. Management depends on the etiology; however, regardless of the cause, control of xerosis and general skin care practices will help alleviate some of the distress of pruritus, especially in the aging population.
Key words: pruritus, itch, aging, skin assessment, scratching.

The itchy older adult represents a complex and somewhat convoluted path to diagnosis, and management may not always be that satisfying to the patient. However, there are a number of steps that can be followed in order to determine the etiology of pruritus in the older patient. A systematic approach to managing pruritus may lead to good symptomatic control, depending on the cause.

Pruritus, like pain, is a subjective and multifaceted symptom that can be affected by emotional, physiologic, environmental, cognitive and social factors, as well as comorbid illness and medications.¹ These features must be kept in mind throughout the assessment of the pruritic patient.

Gustavo A. Cardenas, MD, Carl J. Lavie, MD and Richard V. Milani, MD, Department of Cardiology, Ochsner Medical Institutions, New Orleans, LA, USA.

There is growing evidence that risk factors, which predict cardiovascular disease in younger people, are also predictive in older adults. Given the huge burden of cardiovascular disease in this latter population, older adults should not be excluded from primary or secondary prevention strategies, such as management of dyslipidemia. Low levels of high- density lipoprotein cholesterol (HDL-C) have a stronger association with cardiovascular disease than do high levels of low-density lipoprotein cholesterol (LDL-C). This article focuses on the importance of HDL-C as a risk factor for older patients, the evidence that exists supporting this association, the factors associated with low levels of HDL-C, and the mechanisms by which low HDL-C is related to an increased risk of cardiovascular diseases.
Key words: high-density lipoprotein cholesterol, aging, older adults, dyslipidemia, lipoprotein, atherosclerosis, cardiovascular disease.

Jacqueline Gardner-Nix, MBBS, PhD, MRCP(UK), Assistant Professor, Department of Anaesthesia, University of Toronto; Chronic Pain Consultant, Sunnybrook & Women’s College Health Sciences Centre; St. Michael’s Hospital Pain Clinic, Department of Anaesthesia, Toronto, ON.

Older adults pose additional challenges in pain management when noncancer pain has become chronic. Health care professionals are increasingly aware of the effect of past and current life stressors on the pain experience, and the roles of gender, genetics and culture. Reduced activity as individuals age often amplifies the disabling effects of pain. Pain medications are more problematic in this age group due to many factors, including polypharmacy, comorbidities and reduced renal function. However, judicious use of opioid analgesics in a subset of the population may allow increased function and access to activities, which become part of their pain management.
Key words: older adults, opioids, pain management, noncancer pain, holistic.