Linda Boise, PhD, MPH, Director, Education/Information Transfer Core, Layton Aging & Alzheimer Disease Research Center, Oregon Health & Science University, Portland, OR, USA.
Cathleen M Connell, PhD, Professor, Department of Health Behavior and Health Education, School of Public Health; Director, Education/Information Transfer Core, Michigan Alzheimer’s Disease Research Center, University of Michigan, Ann Arbor, MI, USA.

The high prevalence of dementia and the increased availability of treatments for Alzheimer’s disease and related dementias have increased the need to find optimal approaches to disclosing the diagnosis of dementia. In this article, relevant research is reviewed on physician practices and perspectives, and on older patients’ and family members’ preferences. Research suggests that, in general, patients and families want an accurate and clearly explained diagnosis, and that they desire guidance from the physician in understanding the course of the illness over time as well as resources that will help them to cope. Considerations in disclosing a dementia diagnosis and recommendations on how to disclose a dementia diagnosis are offered.

Key words: dementia, Alzheimer’s disease, disclosure, physicians, diagnosis.

Lan Xiong, MD, PhD, CHUM Research Centre, Notre-Dame Hospital, Montréal Hospital, Montréal, QC.
Claudia Gaspar, PhD, CHUM Research Centre, Notre-Dame Hospital, Montréal Hospital, Montréal, QC.
Guy A. Rouleau, MD, PhD, FRCPC, CHUM Research Centre, Notre-Dame Hospital, Montréal Hospital, Montréal, QC.

Both Alzheimer’s disease (AD) and frontotemporal dementia (FTD) are genetically complex and heterogeneous disorders. Although fully penetrant (causal) mutations leading to predominantly familial early onset AD have been identified in three genes (APP, PSEN1, and PSEN2), they only account for a small fraction of AD patients. PSEN1 is considered the most frequently mutated gene in early onset AD. Mutations in the microtubule-associated protein tau (MAPT) gene have been reported in up to 50% of hereditary cases of FTD. One partially penetrant genetic risk factor (APOE4) has been established for the more common late-onset form of AD. Despite advances in elucidating the genetic epidemiology of AD and FTD, the etiology for most patients with dementia remains unclear.

Key words: Alzheimer’s disease, frontotemporal dementia, genetics, linkage, mutation.

Dorothy A Forbes, RN, PhD, CIHR New Investigator, Associate Professor, College of Nursing, University of Saskatchewan, Saskatoon, SK.
Shelley Peacock, RN, MN, Faculty Member, Saskatchewan Institute of Applied Science and Technology, Saskatoon, SK.
Debra Morgan, RN, PhD, Associate Professor, Institute of Agricultural, Rural, and Environmental Health, University of Saskatchewan, Saskatoon, SK.

Strategies such as simulated presence therapy, pet therapy, light therapy, validation therapy, music, massage, therapeutic touch, aromatherapy, and multisensory stimulation have shown promising results in decreasing physical aggression, physical nonaggression, verbal aggression, and verbal nonaggression in older adults with dementia. Further research is needed to identify which strategies are most effective in managing symptoms of agitation associated with the different types of dementia and at different levels of cognitive impairment.

Key words: Alzheimer’s disease, dementia, nonpharmacological strategies, agitation, aggression, behaviour.

The accredited CME learning activity based on this article is offered under the auspices of the CE department of the University of Toronto. Participating physicians are entitled to one (1) MAINPRO-M1 credit by completing this program, found online at www.geriatricsandaging.ca/cme.htm

Ann Schmidt Luggen, PhD, GNP, Professor, Department of Nursing and Health Professions, Northern Kentucky University, Highland Heights, KY; Gerontological Nurse Practitioner, Evercare, Cincinnati, OH, USA.

Medical management of Alzheimer’s disease patients involves drugs that temporarily relieve or stabilize symptoms, or lessen the expected decline in cognition, function, and behaviour, but ultimately fail to halt progression of the disease. Commonly used agents in the management of early- to mid-stage dementias--albeit with modest outcomes--are the cholinesterase inhibitors (ChEIs). Antipsychotics have been used with mixed success to treat psychiatric symptoms that occur in 30-60% of patients with moderate-to-severe AD. In the terminal stages of dementia, palliation of symptoms and a focus on comfort care is important. Management of pain and relief from depression and anxiety are useful.

Key words: dementia, Alzheimer’s disease, cholinesterase inhibitors, behaviour, antipsychotics.

Loren K. Mell, MD, Department of Radiation and Cellular Oncology, University of Chicago and the University of Illinois at Chicago, Chicago, IL, USA.

Arno J. Mundt, MD, Department of Radiation and Cellular Oncology, University of Chicago and the University of Illinois at Chicago, Chicago, IL, USA.

Radiation therapy (RT) is commonly used in the treatment of older cancer patients. RT may be used as definitive therapy for benign or malignant tumours, as adjuvant therapy with surgery and/or chemotherapy, as palliative therapy when cure is no longer possible, and as alternative to surgery in patients with multiple comorbidities. However, RT is often not given to older patients who might benefit from it, due to biases, misapprehensions about potential toxicity, and social factors particular to this patient population. The preponderance of data suggest that RT is well tolerated in older adults and treatment decisions should be based on prognostic factors irrespective of age. Emerging RT technologies may particularly benefit aged patients by reducing potential toxicities, shortening treatment times, and improving tumour control.

Key words: age, radiation therapy, toxicity, cancer, procedures.

Rory Fisher, MB, FRCP(Ed)(C), Professor Emeritus, Department of Medicine, University of Toronto, Toronto, ON.

Eoin Connolly, MA, Clinical Ethics Fellow, Joint Centre for Bioethics, University of Toronto, Toronto, ON.

Canada's aging population makes appropriate end-of-life care a priority. Alzheimer's disease and related dementias become increasingly common with aging. The terminal stages are characterized by severe cognitive and physical incapacity with a poor prognosis. Artificial nutrition and hydration may be provided by feeding tubes; however, there is no
evidence of benefit, and there are significant side effects to be considered. Barriers to appropriate end-of-life decision making are identified, and current evidence indicates that this patient population should be treated with appropriate palliative care.

Key words: Alzheimer’s disease, artificial nutrition and hydration, dementia, end-of-life care, ethics.

D’Arcy 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.

Part II of this series briefly reviews the literature on the success of family therapy in families with dementia. A case from the author’s practice (with significant details modified to conserve privacy) is then presented with a view toward applying family therapy. Finally, as the author has an interest in medical education, a proposal on how to integrate family therapy for families with dementia into an educational program is briefly described. The author welcomes comments and suggestions at darcy.little@geriatricsandaging.ca.
Key words: dementia, Alzheimer’s disease, family therapy, family, Systems Theory.

Serge Gauthier, MD, FRCPC, McGill Centre for Studies in Aging, Montréal, QC.

Functional disability is an important component of Alzheimer’s disease. A number of scales are available to measure activities of daily living (ADL) throughout the course of disease, including instrumental as well as self-care activities. A randomized clinical study comparing donepezil to a placebo in moderate-to-severe stages of AD showed a stabilization of ADL decline over six months for patients on donepezil. Less time for ADL care was required by caregivers of patients on donepezil compared to those on placebos.

Key words: Alzheimer, therapy, activities of daily living, donepezil, caregiving time

Introduction
The importance of decline in activities of daily living (ADL) in older adults with dementia has been recognized in the condition’s diagnostic criteria, described as “significant impairment in social or occupational functioning” in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV).

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.

Ekaterina Rogaeva, PhD, Assistant Professor, Department of Medicine, University of Toronto, Centre for Research in Neurodegenerative Diseases, University of Toronto, Toronto, ON.

To date, four genes responsible for Alzheimer disease (AD) have been identified. However, in about 50% of the familial AD cases, there is no known cause of the disease. The majority of AD cases are sporadic with onset after 65 years of age. The apolipoprotein E gene is the only well-replicated risk factor for late-onset AD. Up to 5% of AD cases are early-onset AD, for which genetic analyses have found three causal genes: b-amyloid precursor protein, presenilin-1 and presenilin-2. Treatment and diagnostic strategies based on genetic knowledge are now about to reach the clinic.
Key words: Alzheimer disease, presenilin, gene, bAPP, apolipoprotein E.

Introduction
Alzheimer disease (AD) is a progressive dementia and is the fourth leading cause of death in industrialized countries. AD brain pathology is characterized by neuronal loss, intra-neuronal tau-accumulation and extracellular amyloid plaques. The plaques consist mainly of Ab40/42 peptides generated by cleavage of the b-amyloid precursor protein (bAPP) (Figure 1). The longer and more neurotoxic isoforms, Ab42, appear to be elevated in the brains of individuals affected with either sporadic or familial AD, implying that they have a shared pathogenetic mechanism.