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.

Francis S. W. Zih, BSc, Research Associate and Mary-Ann Fitzcharles, MB, ChB, FRCP(C), Associate Professor, Division of Rheumatology and McGill-MGH Pain Centre, McGill University and McGill University Health Centre, Montreal, QC.

The inflammatory polyarthritides take a huge toll on the well-being of an individual. The ability to specifically target inflammatory molecules with the new "biologic" treatments has been an outstanding laboratory development that has rapidly entered the clinical domain. Early experience in the use of these costly agents has shown an excellent clinical response with both alleviation of symptoms and slowing of disease progression. There is, however, concern regarding the emergence of adverse effects. The side effect of both chronic and bacterial infections, likely more prevalent in the elderly, requires caution and meticulous patient care. Until more is known about the long-term use regarding both continued efficacy and side effects, these treatments currently should be offered to patients with the most severe and poorly responsive disease.
Key words: inflammatory arthritis, disease modifiers, biologics, infectious complications.

Christina M. Canil, MD, FRCPC, Clinical Research Fellow and Jennifer J. Knox, MD, MSc, FRCPC, Staff Medical Oncologist; Department of Medical Oncology and Hematology, Princess Margaret Hospital, University Health Network, Toronto, ON.

Renal cell carcinoma is more prevalent in older people. The incidence of this cancer is rising secondary to incidental detection on routine imaging. In localized disease, radical nephrectomy is standard therapy; however, options of laparoscopic procedures or surveillance may be appropriate for small tumours. Treatment of advanced or metastatic renal cell carcinoma is limited and the main goal of therapy is palliation of symptoms. Nephrectomy and surgical removal of metastases have been shown to improve survival in patients with good performance status. Results with chemotherapy have been disappointing, but clinical trials of novel systemic agents are underway.
Key words: renal cell carcinoma, kidney cancer, older person, nephrectomy, interferon.

Milita Crisby, MD, PhD, Neurotec Department, Division of Geriatric Medicine, Stockholm, Sweden.

The interaction of genetic and multiple environmental factors contributes to the development of Alzheimer disease (AD). Hypertension and hypercholesterolemia have been identified as risk factors for ischemic heart disease (IHD). Recent epidemiological data also have revealed an association between hypercholesterolemia and AD. Experimental models of AD and in vitro studies have shown that cholesterol modulates the amyloidogenic pathway in favour of production and deposition of amyloid in the brain. Dysregulation of the lipid metabolism in the brain due to apolipoprotein E4 or 24-hydroxylase polymorphisms has been observed in patients with AD and related dementias. Furthermore, observational studies have revealed that statin use could have a potential role in the prevention of AD.
Key words: cholesterol, statins, lipid-lowering, Alzheimer disease, neurodegeneration.

A Review of the Literature

Alan K. Berger, MD, Sections of Cardiology and Epidemiology, University of Minnesota, Minneapolis, MN, USA.

While elderly patients (aged = 75 years) represent a small segment of the general population, they account for disproportionate morbidity and mortality associated with acute myocardial infarction. Consequently, the efficacy and utilization of reperfusion therapy--thrombolysis and primary coronary angioplasty/stenting--remain highly relevant. A randomized clinical trial of thrombolysis in the elderly has never been performed, although subgroup analyses have suggested a benefit. The effectiveness of thrombolysis in the elderly has been challenged by observational studies documenting unexpectedly high mortality. The efficacy of primary coronary angioplasty/stenting is now well established and growing evidence suggests this approach is superior to thrombolysis in the elderly.
Key words: geriatrics, thrombolysis, primary coronary angioplasty, acute myocardial infarction, guidelines.

Charles D. Ray, MD, FACS, FRSH (Lond.), President, American College of Spine Surgery; President, International Spine Arthroplasty Society; Past President, North American Spine Society, Yorktown, VA, USA.

Stenoses, or nerve entrapment, can occur at several sites. The focus here is on lumbar spine segments. Compression by stenosis can exist wherever nerve tissue is protectively covered by bone or where thick ligaments are located adjacent to nerve. Overgrowth of bone by spurs is the most common cause of compression producing disability and pain. Neurologic changes are rare. Diagnostic radiological imaging is needed, sometimes aided by selective injections of medications. Due to the limitations of non-surgical treatment, surgical decompression is common with generally good results.
Key words: spinal stenosis, vertebral bone spurs, claudication, surgical decompression, nerve injections.

Benjamin R. Davis, BSc, DDS, FRCD(C), Department of Oral and Maxillofacial Surgery, Queen Elizabeth II Health Sciences Centre, Halifax, NS.

Temporomandibular disorders (TMDs) are common and can be divided into either muscular or intra-joint conditions. With advancing age, the craniomandibular complex undergoes changes that are similar to other musculoskeletal structures. Many of these changes may explain the decrease in incidence of TMDs seen in the older population. Conservative treatment is usually effective at decreasing TMD pain and improving function. A small percentage of patients will benefit from surgery when appropriate conservative measures have failed, and an intra-joint etiology has been definitively established.
Key words: temporomandibular disorders, aging, facial pain, temporomandibular joint surgery.