Anne Grand'Maison, MD, FRCPC, Hematologist, Research Fellow, Thromboembolism Department, Sunnybrook and Women's College Health Sciences Centre; University of Toronto, Toronto, ON.
William Geerts, MD, FRCPC, Consultant in Clinical Thromboembolism, Sunnybrook and Women's College Health Sciences Centre; University of Toronto, Toronto, ON.

The elderly population is at risk of arterial and venous thromboembolic diseases. Traditional anticoagulants have demonstrated their benefits for prevention and treatment of these conditions and are accepted as standard practice. Despite this evidence, anticoagulants are still underused in older people. Practitioners often hesitate to consider anticoagulation in the elderly because of comorbidities, potential drug interactions and increased risk of bleeding. Careful assessment of bleeding risk and close monitoring of anticoagulant level are essential strategies to optimize the use of anticoagulants in the elderly. Many recently developed antithrombotics that have completed late stage of testing are presented in this review, although further studies are needed to determine their exact role, particularly in the elderly.
Key words: factor Xa inhibitor, antithrombin, renal insufficiency, drug interactions, bleeding risk index.

Guillermo Paradiso, MD and Robert Chen, MBBChir, MSc, FRCPC, Division of Neurology and Krembil Neuroscience Centre, Toronto Western Research Institute, University Health Network; University of Toronto, Toronto, ON.

Restless legs syndrome (RLS) is a common disorder and its prevalence in the elderly is about 10%. It is characterised by unpleasant, difficult-to-describe sensations in the lower limbs and an irresistible desire to move the legs. The symptoms typically worsen in the evening and at night and often result in sleep disturbance. Idiopathic RLS is often familial. Secondary RLS may occur in several medical conditions, such as uremia and iron deficiency. Most patients with RLS also have periodic limb movements in sleep (PLMS), characterised by repetitive flexion of the lower extremities. RLS and PLMS may be the result of a dopaminergic dysfunction and PLMS may be due to release of spinal flexor reflex pathways. Dopaminergic agents, benzodiazepine and opioids are effective in treating RLS.
Key words: restless legs, periodic leg movement, sleep disorder, dopamine.

Chris MacKnight, MD, MSc, FRCPC, Division of Geriatric Medicine, Dalhousie University, Halifax. NS.

Creutzfeldt-Jakob disease (CJD) is rare, occurring in one per million people. It is difficult to eradicate from contaminated instruments, and so is important to recognise for infection control reasons. As well, there is much interest in possible changes in the epidemiology of this disease, and so familiarity is necessary among all physicians. Sporadic CJD presents in the young-old with a rapidly progressive dementia, while variant CJD presents in younger patients, initially with psychiatric symptoms. Electroencephalography, MRI and 14-3-3 protein testing are all helpful in the diagnostic process. There is no recognised therapy as yet.
Key words: Creutzfeldt-Jakob disease, variant Creutzfeldt-Jakob disease, prion, dementia.

G. Daniel Schachter, MD, FRCPC, DABD, Consultant Dermatologist, Sunnybrook & Women's College Health Sciences Centre and St. John's Rehabilitation Hospital; Lecturer, University of Toronto, Toronto, ON.

During the past century, the amount of time spent at leisure and exposed to the sun has increased, yet we have also become increasingly aware of the detrimental effects of the sun. The skin ages slowly (intrinsic, chronologic aging), but this process is enhanced or accelerated by sun exposure (extrinsic aging, photoaging). The features of photoaging will be presented, followed by the importance of the prevention of sun damage by sun avoidance and use of sunscreens. Methods of treating or reversing photodamage will be reviewed, including topical agents, chemical peels and use of lasers and other light sources.
Key words: photoaging, ultraviolet radiation, prevention, sunscreen, skin rejuvenation.

Anne G. McLeod, MD, FRCPC, Assistant Professor, Department of Medicine, University of Toronto; Staff Physician, Department of Medical Oncology and Hematology, University Health Network, Toronto, ON.

Bleeding in the elderly is a common problem. Careful assessment of a patient's bleeding history and physical examination is essential to try to establish if a clinically significant bleeding disorder is present. Initial laboratory testing should include a complete blood count, blood film review, PT/INR and PTT. Common etiologies of bleeding in the elderly include thrombocytopenia and medications such as Aspirin, non-steroidal anti-inflammatory agents and anti-coagulants. Unfortunately, no single approach to the treatment of coagulopathy exists; rather, a clear understanding of the cause of the bleeding disorder is needed to direct management.
Key words: coagulopathy, elderly, bleeding, hemostasis, clotting.

Richard A. Wells, MD, DPhil, FRCP(C), Assistant Professor of Medicine, University of Toronto; Staff Physician, Leukaemia Group, Princess Margaret Hospital; Scientist, Ontario Cancer Institute, Toronto, ON.

In myelodysplastic syndrome (MDS), genetic mutations in bone marrow stem cells result in production of defective blood cells. These defective cells fail to meet the intrinsic "quality control" standards of the bone marrow and are not released into the circulation, leading to anemia, leukopenia or thrombocytopenia. In some, but not all, patients with MDS, there also is a greatly increased risk of development of acute myelogenous leukemia. Until very recently, therapeutic options in MDS were extremely limited. This article reviews recent advances in risk-based classification of MDS, and describes new therapies that promise to revolutionize our approach to patients with this disorder.
Key words: myelodysplastic syndrome, bone marrow, anemia, acute myelogenous leukemia.

Sudeep S. Gill, MD, FRCP(C), Research Fellow, Division of Geriatric Medicine, University of Toronto and Kunin-Lunenfeld Applied Research Unit, Baycrest Centre for Geriatric Care, Toronto, ON.
Shabbir M.H. Alibhai, MD, MSc, FRCP(C), Staff Physician, Department of Medicine, University Health Network, Toronto, ON.

Folate deficiency is relatively common in older adults. There is now growing interest in the roles played by folate and B vitamins in the metabolism of homocysteine. Recent studies have suggested a link between elevated levels of homocysteine and the risk of Alzheimer disease. In this article, we will focus on the physiology and pathophysiology related to folate and homocysteine metabolism. We have also included a discussion of the laboratory evaluation of these compounds. Finally, we review the evidence supporting the relationships between folate deficiency, hyperhomocysteinemia and the development of dementia.
Key words: folic acid, vitamin B12, deficiency diseases, homocysteine, dementia.

12 Deficiency in the Elderly

Sudeep S. Gill, MD, FRCP(C), Research Fellow, Division of Geriatric Medicine, University of Toronto and Kunin-Lunenfeld Applied Research Unit, Baycrest Centre for Geriatric Care, Toronto, ON.
Shabbir M.H. Alibhai, MD, MSc, FRCP(C), Staff Physician, Department of Medicine, University Health Network, Toronto, ON.

Vitamin B12 deficiency is a common disorder in older adults, but its diagnostic work-up and management can be complex. In this article, we review the metabolic pathways involving vitamin B12 and the various pathologies that can interfere with these pathways. This discussion provides a framework to understand the following section, which outlines an approach to the clinical examination, laboratory evaluation and treatment of subjects with suspected vitamin B12 deficiency.
Key words: vitamin B12, folic acid, deficiency diseases, dementia, aging.

Vikas Gupta MD, MRCP(UK), MRCPath, Department of Medical Oncology and Hematology, Princess Margaret Hospital/University Health Network; University of Toronto, Toronto, ON.

Old age is usually considered a significant risk factor for venous thromboembolism (VTE), and the incidence of VTE increases exponentially with age. Associated comorbid conditions such as heart failure, postoperative states, malignancy and long-term immobility contribute considerably towards the higher incidence of these hypercoagulable disorders in this subgroup of patients. The optimal, cost-effective laboratory work-up for underlying thrombophilic or hypercoagulable states is not clear in older patients. The main aim of this article is to review the inherited thrombophilic disorders and discuss their clinical relevance in older patients.
Key words: hypercoagulable disorders, thrombophilia, venous thromboembolism, risk factors.

With the popularity of herbs, botanicals and other natural remedies continuing to explode, a unique web-based resource recently launched by Memorial Sloan-Kettering Cancer Center will help fill the information gap for both medical practitioners and the general public.

The web resource includes monographs on 135 agents, providing clinical summaries of each, as well as the purported uses, mechanisms of action, adverse reactions, drug interactions and links to scientific research and critiques. The website provides invaluable information for physicians that is comprehensive and current, and will be continually updated by the Chief of Integrative Medicine at MSKCC and a pharmacist and botanicals expert. Discover what you don't know at: http://www.mskcc.org/aboutherbs.