Sir William Osler referred to pneumonia as “the old man’s friend,” correctly realizing that infection is a common cause of death in old age. Some hundred years later, even in this age of potent antimicrobial agents, Osler’s assessment still holds true. Disease frequently presents in an atypical manner in old age, and often fever in bacterial infections is a late manifestation, following delirium, falls, or “taking to bed.” Delay in treatment may result in poor outcomes but, on the other hand, overtreatment may be likely to harm an older person. One of the most difficult environments in which to accurately diagnose infection is the long-term care (LTC) facility. The residents tend to be more frail and more likely to be cognitively impaired than community-dwelling patients coming to their family doctor’s office; therefore, the utility of the history is much decreased. As well, the vast array of diagnostic tools available in the acute hospital is relatively inaccessible in LTC, and the transfer to acute care from LTC often results in deleterious consequences to the patient.

Our focus in this issue is infectious disease in the older adult, and our CME article addresses a major public health concern: “Long-term Care for Older Adults: Reservoirs of Methicillin-Resistant Staphylococcus Aureus and Vancomyin-Resistant Enterococci” by Drs. D.F. Gilpin, M.M. Tunney, N. Baldwin, and C.M. Hughes. We all know that we should not treat asymptomatic bacteriuria, but most of us are unsure whether our patients are truly asymptomatic or not. The article “Asymptomatic Bacteriuria: To Treat or Not to Treat” by Dr. Dimitri M. Drekonja will address this clinical conundrum. I still remember treating my first case of severe antibiotic-induced colitis as an intern. It was in the wife of my physician-in-chief and occurred two months before clindamycin-associated pseudomembranous colitis was first described in a classic article in the Annals of Internal Medicine. Since then, C. difficile infection has become a major problem in older patients, particularly for those in acute hospital or LTC. This important topic is addressed in the article “Treatment and Prevention of Clostridium difficile Infection in the Long-Term Care Setting” by Dr. Natasha Bagdasarian and Dr. Preeti N. Malani.

Further, we offer our usual collection of important and informative articles on medical care of older people. In geriatric medicine, it has been frequently noted that the risk factors for each of the “geriatric giants” overlap to a great degree. In our Cardiovascular column, our frequent and much valued contributor, Dr. Wilbert S. Aronow, asks the question “Bone Mineral Density: What Is Its Relationship to Heart Disease?” Our Dementia column reviews the difficult area of screening in the article “Screening for Dementia: First Signs and Symptoms Reported by Family Caregivers” by Dr. Mary Corcoran. There is more evidence arriving on a regular basis to show how important our teeth are for both quality of life and for good health, so it is very appropriate that our Biology of Aging column by Dr. Gregory An discusses “Normal Aging of Teeth.” Our Falls and Fitness column, “Psychoactive Medications and Falls” is written by Dr. James Cooper and Dr. Allison Burfield. Our featured geriatrician this month is Dr. Angela Juby, the president of the Canadian Geriatrics Society.

Enjoy this issue,
Barry Goldlist

As I rapidly advance towards the geriatric age group, fears of cancer, in my case colon cancer because of a positive family history, start to increase. As a result, the unpleasantness of a recent colonoscopy was greatly alleviated later on by learning that I had no polyps or tumours. I am not alone in my concern about cancer, and the increasing prevalence of cancer as our population ages (and as age-corrected cardiovascular mortality declines) make these concerns quite legitimate. This high prevalence of cancer means that nearly all physicians--specialists as well as family physicians--who cares for adult patients will be caring for individuals with cancer in their practice. This issue’s focus on cancer in older adults allows us to address some of the learning needs of physicians caring for older adults with cancer.

Before her untimely death from breast cancer, a colleague of mine at the University Health Network wrote poignantly about the fatigue she experienced with her cancer. This taught me that as important as relieving pain is in cancer, many other symptoms are equally distressing for the patient. Our continuing education article this month is on some of these symptoms, and is titled “Fatigue, Pain, and Depression among Older Adults with Cancer: Still Underrecognized and Undertreated” by Dr. Manmeet Aluwhalia. An overview for supportive care of patients with cancer is addressed in the article ”Psychosocial Oncology for Older Adults in the Primary Care Physician’s Office” by Dr. Bejoy Thomas and Dr. Barry Bultz. Finally, in the same vein, is the article “Palliative Care in the Primary Care Setting” by Dr. Sandy Buchman, Dr. Anthony Hung, and Dr. Hershl Berman.

Our Cardiovascular Disease column this month is on “Diabetes and Cardiovascular Disease among Older Adults: An Update on the Evidence” by Dr. Pamela Katz and Dr. Jeremy Gilbert. Our Dementia column is on “Managing Non-Alzheimer’s Dementia with Drugs” by Dr. Kannayiram Alagiakrishnan and Dr. Cheryl Sadowski. One of the most important problems facing older adults, “Age-Related Hearing Loss,” is addressed by Dr. Christopher Hilton and Dr. Tina Huang. Urinary incontinence is usually considered a concern for older women; however, men are not exempt. Our Men’s Health column this month is on “Urinary Incontinence among Aging Men,” and is written by Dr. Ehab A. Elzayat, Dr. Ali Alzahran, and Dr. Jerzy Gajewski, who is a member of our partner association, the Canadian Society for the Study of the Aging Male. Dr. Gayatri Gupta and one of our international advisers, Dr. Wilbert S. Aronow, contribute an important article on "Prevalence of the Use of Advance Directives among Residents of a Long-term Care Facility" this month. Finally, it is imperative that physicians acknowledge the increasing prevalence of herbal medication use, which can lead to adverse drug interactions among their older patients. Dr. Edzard Ernst reviews this this topic in "What Physicians Should Know about Herbal Medicines.

Enjoy this issue.
Barry Goldlist

Christina S. McCrae, PhD, Assistant Professor, Center for Gerontological Studies, Institute on Aging, and Department of Psychology, University of Florida, Gainesville, FL, USA.

Candece Glauser, MA, Department of Psychology and Institute on Aging, University of Florida, Gainesville, FL, USA.

A variety of patient and environmental factors make nursing home residents particularly vulnerable to insomnia or poor sleep. Although precise estimates are not available, research suggests that up to 75% of institutionalized older adults suffer from disturbed sleep.^1-3 Identifying the contributory factors and intervening to resolve or limit their impact on sleep is the key to effective management. Frequently, these factors can be difficult to control, and as a result, standard sleep evaluation and treatment practices may need to be modified for use in long-term care settings.

Evaluation
Insomnia may be present if an individual has more than 30 minutes of unwanted awake time on six or more days during a two-week period. Evaluation involves having patients record various aspects of their sleep habits, such as bed and wake times, in a sleep diary, daily for two weeks. Polysomnographic (PSG) evaluation is not necessary to diagnose insomnia; however, it may be necessary in some cases in order to rule out other sleep disorders such as sleep apnea.