Jonathan M. Flacker, MD, Division of Geriatric Medicine and Gerontology, Emory University School of Medicine, Atlanta, GA, USA.

The term "Geriatric Syndrome" is commonly used but ill defined. In publications, authors claim that all sorts of conditions are a "Geriatric Syndrome", including, but not limited to, delirium,¹ dementia,¹ depression,² dizziness,³ emesis,⁴ falls,¹ gait disorders,¹ hearing loss,¹ insomnia,¹ urinary incontinence,¹ language disorders,¹ functional dependence,⁵ lower extremity problems,⁶ oral and dental problems,⁶ malnutrition,¹ osteoporosis,¹ pain,¹ pressure ulcers,¹ silent angina pectoris,⁷ sexual dysfunction,⁶ syncope⁶ and vision loss.¹ Can this be possible? Can any condition commonly encountered in older adults be a "Geriatric Syndrome"?

The Origins of "Syndrome"
The word syndrome seems to have appeared in an English translation of Galen in about 1541.⁸ Derived from the Greek roots "syn" (meaning "together") and "dromos" (meaning "a running"), this term generally refers to "a concurrence or running together of constant patterns of abnormal signs or symptoms".

John Wherrett, MD, FRCPC, PhD, Division of Neurology, Toronto Western Hospital and the University of Toronto, Toronto, ON.

This commentary addresses current views about the interaction of vascular disorders and Alzheimer disease, including vascular pathologies that may be intrinsic to the Alzheimer process as identified through demonstration of amyloid plaques and neurofibrillary tangles. The common cerebrovascular pathologies accompanying aging, mainly atherosclerosis and arteriosclerosis, will coincide in varying proportions with the Alzheimer pathology, also a concomitant to aging. Because interventions are available to modify both risks and complications of these vasculopathies, an important goal of dementia research is to develop means to characterize the contribution of cerebrovascular disease in Alzheimer and other dementias. Realization of this goal is confounded by the recognition that Alzheimer pathology, usually considered a parenchymal process, involves important vascular changes.
Key words: Alzheimer disease, dementia, cerebrovascular, pathology, imaging.

Jagdish Butany, MBBS, MS, FRCPC, Departments of Pathology, Toronto General Hospital, University Health Network and University of Toronto, Toronto, ON.
Manmeet S. Ahluwalia, MBBS and Vidhya Nair, MBBS, MD, Departments of Pathology, Toronto General Hospital, Toronto, ON.
Christopher Feindel, MD, FRCPC, Cardiovascular Surgery, Toronto General Hospital, University Health Network and University of Toronto, Toronto, ON.

Valvular heart disease is a common cardiac problem. There are many age-associated changes that can occur in otherwise healthy heart valves. These commonly develop in the aortic valve and, to a lesser extent, in the mitral valve. In both cases there is fibrosis and thickening of the tissues with the deposition of calcium salts in the aortic valve cusps and in the annulus of the mitral valve. These changes can contribute to progressive secondary changes in the heart (left ventricle and left atrium), which can be associated with significant morbidity related to complications of valvular disease, such as congestive heart failure, infective endocarditis and sudden death.
Key words: heart valves, age-related changes, calcified aortic valve, mitral annular calcification.

K.H.O. Deane, BSc, PhD and C.E. Clarke, BSc, MD, FRCP, Department of Neurosciences, The University of Birmingham and City Hospital, Birmingham, UK.

Many clinicians, therapists and patients support the use of rehabilitation in the treatment of Parkinson's disease. However, systematic reviews reveal a lack of conclusive evidence to support the use of common forms of rehabilitation therapy in this movement disorder. Lack of evidence of efficacy is not proof of lack of effect. Large pragmatic randomized controlled trials are required to determine the effectiveness and safety of rehabilitation therapies for people with Parkinson's disease.
Key words: Parkinson's disease, occupational therapy, physiotherapy, speech therapy, rehabilitation.

Lona Mody, MD, University of Michigan Medical School, Division of Geriatric Medicine; Geriatric Research Education and Clinical Center, Ann Arbor VA Healthcare System, Ann Arbor, MI, USA.

Skin and soft tissue infections are frequent in older adults residing in both community and nursing homes. Common skin and soft tissue infections include bacterial infections such as cellulitis, erysipelas and necrotizing fasciitis, chronic wound infections, fungal infections such as intertrigo and viral infections like herpes zoster. Early diagnosis is the key to optimal management. Most of these infections can be treated on an outpatient basis and in nursing homes; however, serious infections may require hospitalization especially in frail older adults with a high comorbidity load. This review focuses on clinical manifestations and treatment options for common skin and soft tissue infections in older adults.
Key words: skin infections, cellulitis, necrotizing fasciitis, pressure ulcer, viral infection.

I. W. Fong, MB, BS, FRCPC, Department of Medicine, Division of Infectious Diseases, University of Toronto, St. Michael's Hospital, Toronto, ON.

Atherosclerosis and its vascular complications are the leading causes of death in older people in developed countries. There are accumulating, albeit conflicting, data suggesting that infections, particularly Chlamydia pneumoniae, may play a role in atherogenesis and vascular events. Although prospective epidemiological and clinical studies have provided conflicting results, pathological studies have confirmed the association of C. pneumoniae with atherosclerotic disease. Moreover, many in vitro studies on biological mechanisms and studies in animal models have largely supported a plausible role of infections in atherogenesis. These data suggest that infections, especially C. pneumoniae, may be involved in the initiation and acceleration of atherosclerosis and potentially could lead to acute ischemic events by influencing plaque stability and coagulation.
Key words: atherosclerosis, Chlamydia pneumoniae, infections, older people.

Dr. Lindsay E. Nicolle, MD, FRCPC, Department of Internal Medicine and Medical Microbiology, University of Manitoba, Winnipeg, MB.

The prevalence of asymptomatic bacteriuria increases with advancing age in community populations, and approaches 50% in the functionally impaired, institutionalized elderly. Asymptomatic bacteriuria is usually associated with pyuria, but has not been shown to contribute to any short- or long-term negative clinical outcomes in the older population. Treatment of asymptomatic bacteriuria is not recommended. Clinical trials evaluating antimicrobial therapy have found no improved outcomes, and therapy is usually followed by recurrence of bacteriuria. Antimicrobial treatment also is associated with increasing antimicrobial resistance and adverse drug effects. Due to the high prevalence of positive urine cultures, bacteriuria is not a useful diagnostic test for symptomatic urinary tract infection. However, a negative urine culture may exclude the urinary tract as a potential source of infection.
Key words: urinary tract infection, bacteriuria, older adults, long-term care.

Focus on Long-term Care Facilities

Shelly A. McNeil, MD, FRCPC, Division of Infectious Diseases, Queen Elizabeth II Health Sciences Centre and Dalhousie University, Halifax, NS.
Lona Mody, MD, Divisions of Geriatric Medicine, Veterans Affairs Medical Center and The University of Michigan Medical School, Ann Arbor, MI, USA.
Suzanne Bradley, MD, Divisions of Geriatric Medicine and Infectious Diseases, Veterans Affairs Medical Center and The University of Michigan Medical School, Ann Arbor, MI, USA.

Methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant enterococci (VRE) are important causes of morbidity and mortality in hospitals, and rates of MRSA and VRE in long-term care facilities (LTCF) have increased. However, the majority of residents in LTCF are asymptomatically colonized and the risk of infection with MRSA or VRE in this setting is low. Extension of stringent infection control practices required to control the spread of MRSA and VRE in acute care hospitals is not warranted in the LTCF setting. Patients known to be colonized with MRSA or VRE should not be refused admission to a LTCF and, in the absence of symptomatic infection, measures beyond routine standard precautions are not necessary.

Caroline Penn, MD, CCFP, Travel Medicine & Vaccination Centre, Vancouver, BC.
Rusung Tan, MD, PhD, FRCPC, Travel Medicine & Vaccination Centre; Department of Pathology & Laboratory Medicine, University of British Columbia, Vancouver, BC.

Cruise ships are a popular way for seniors to travel to all parts of the world. Although cruises are generally safe, day and overnight excursions to tropical countries can expose travellers to diseases such as malaria, yellow fever and dengue fever and to pathogens that cause diarrhea. Family physicians should ensure that those patients considering a cruise are medically stable and receive up-to-date travel medicine advice. With proper preparation and precautions against infectious and vector-borne illness, risks can be minimized and older people can benefit from the stimulation of travel.
Key words: cruise ships, older traveller, travel medicine, vaccinations, yellow fever, dengue, malaria.

Jonathan A. Ship, DMD, Department of Oral Medicine and the Bluestone Center for Clinical Research; New York University College of Dentistry, New York, NY.

Saliva is critically important for oral and pharyngeal health. Xerostomic complaints and salivary hypofunction are common in older adults, producing impaired nutritional intake, host defence and communication. Salivary function remains remarkably intact in healthy older persons. Systemic diseases, medications and head and neck radiotherapy for cancer account for the majority of salivary disorders in the elderly. Diagnosis of the underlying phenomenon is critical before implementing therapy. Management strategies include replacement therapies and gustatory, masticatory and pharmacological stimulants. Prevention of the oral and pharyngeal sequelae of salivary hypofunction requires a multidisciplinary approach to stomatological care.
Key words: xerostomia, saliva, Sjögren's syndrome, salivary glands, radiotherapy.