Zena Moore, RGN, MSc, FFNMRCSI, Health Research Board of Ireland, Clinical Nursing and Midwifery Research Fellow, Royal College of Surgeons in Ireland, Dublin, Ireland.
Seamus Cowman, PhD, MSc, FFNMRCSI, P.G Cert Ed (Adults), Dip N (London), RNT, RGN, RPN, Professor and Head of Department, Faculty of Nursing and Midwifery, Royal College of Surgeons in Ireland, Dublin, Ireland.

Pressure ulcers are common, costly, and adversely affect quality of life. Nutritional status is one risk factor that predisposes individuals to the development of a pressure ulcer. The impact of nutritional supplementation is reflected in the reduced incidence of pressure ulcers; however, the evidence is limited. The precise role of nutritional supplementation in pressure ulcer healing is less clear, yet a trend towards healing has been suggested. Patients should have their nutritional status monitored carefully. If difficulties arise, these should be detected early, and if it is not possible to increase the intake of normal food and fluids, then advice should be sought from the dietitian.
Key words: pressure ulcers, risk, prevention, treatment, nutrition.

Wey Leong, MSc, MD, Department of Surgical Oncology, Princess Margaret Hospital, University Health Network, University of Toronto, ON.
Alexandra M. Easson, MSc, MD, Department of Surgical Oncology, Princess Margaret Hospital and Mount Sinai Hospital, University of Toronto, ON.
Michael Reedijk, PhD, MD, Department of Surgical Oncology, Princess Margaret Hospital, University Health Network, University of Toronto, ON.

Melanoma must be considered in the differential diagnosis of any skin lesion in older adults. With the incidence of melanoma increasing in general and even more so among older people, more older adults are being diagnosed with melanoma than in the past. Among older adults, melanomas display more aggressive histological features with worse prognosis and treatment outcomes than among younger individuals. Furthermore, older individuals have fewer surgical and medical treatment options because of age-associated comorbidities. This article reviews the epidemiology and management of melanoma with emphasis on the older adult population.
Key words: older adults, melanoma, aged, cancer, skin neoplasm.

Jenny Rogers, MD, Psychiatry Department, Postgraduate Education, University of British Columbia, Vancouver, BC.
Bonnie S. Wiese, MD, Psychiatry Department, Postgraduate Education, University of British Columbia, Vancouver, BC.
Kiran Rabheru, MD, CCFP, FRCP, Clinical Associate professor, Psychiatry Department, University of British Columbia, Vancouver, BC.

Alcohol, recreational drugs, over-the-counter, and prescription medications may cause a range of cognitive impairments from confusion to delirium, and may even mimic dementia. Moderate to high alcohol consumption is one of the often overlooked risk factors for development of dementia and cognitive impairment among older adults. Substances such as opioids, benzodiazepines, and anticholinergics pose a particular risk of cognitive impaiment and the risk increases when these are combined with multiple medications, as polypharmacy is common in patients over 65. A substance-induced dementia may have a better prognosis compared to other types of dementia, as once the instigating factor is gone, the cognition often improves.
Key words: Alcohol related dementia, geriatric substance abuse and dependence, polypharmacy, anticholinergic adverse effects, cognitive impairment.

Robert J. Hinchliffe, MD, MRCS, Clinical Lecturer in Vascular Surgery, St George’s Regional Vascular Institute, St George’s Hospital and St George’s University of London, London, UK.
William Jeffcoate, FRCP, Professor, Foot Ulcer Trials Unit, Department of Diabetes and Endocrinology, Nottingham University Hospitals, City Hospital Campus, Nottingham, UK.

Individuals with ulceration of the foot should be identified and referred urgently to a specialist. Unfortunately there is little formal health care education in diabetic foot ulceration and often no specialist referral pathway. We discuss the common modes of presentation of patients with diabetes and foot ulcer. The clinical implications of a range of symptoms and signs will be explained, including the most common diagnostic pitfalls in everyday primary care practice.
Key words: diabetes, peripheral vascular disease, ulcer, vascular surgery, peripheral arterial disease, diabetic foot.

Jeffrey A. Fialkov, MD, MSc, FRCSC, Assistant Professor, Division of Plastic Surgery, Department of Surgery, University of Toronto; Staff Plastic Surgeon, Sunnybrook Health Sciences Centre, Toronto, ON.

This article reviews surgical and nonsurgical rejuvenation techniques as they relate to the anatomic changes that occur with facial aging. An understanding of the changes that occur to the facial soft tissues and their support structures over time and with exposure to the elements facilitates individualized treatment optimization for older adults seeking facial rejuvenation. In addition, treatment optimization must take into account the patient’s underlying medical status and personal psychosocial concerns.
Key words: facial rejuvenation, cosmetic surgery, facial aging, noninvasive rejuvenation, photoaging.

Kristen Davidge, MD, Plastic Surgery Resident; Candidate, Master of Surgical Science, Department of Surgery, University of Toronto, ON.
Joel Fish, MD, MSc, FRCS(C), Burn Surgeon, Ross Tilley Burn Unit, Sunnybrook Health Sciences Centre; Chief Medical Officer, St. Johns Rehab Hospital; Associate Professor, Department of Surgery, University of Toronto; Director of Research, Division of Plastic Surgery, University of Toronto, Toronto, ON.

Burn injury among older adults will result in significant morbidity and mortality despite the many advances in burn treatment. Many adult burn units in North America admit and treat a significant number of older adults so understanding the issues and problems specific to this age group is important. Older adults experience specific problems with wound care, and if the injury is large, they will require critical care interventions during the course of treatment. Despite the advances in wound care and critical care that have occurred, the mortality rates of older adults with burn injuries remain quite high. This article reviews the literature on specific issues for older adults that need to be considered when treating older adults with burn injury.
Key words: burn injury, burn depth, older adults, geriatric, mortality.

Foy White-Chu, MD, Geriatric Fellow, Division of Gerontology, Beth Israel Deaconess Medical Center, Boston, MA, USA.
Madhuri Reddy, MD, MSc, Department of Medicine, Director of the Chronic Wound Healing Program, Hebrew Rehabilitation Center; Division of Gerontology, Beth Israel Deaconess Medical Center, Boston, MA; Director, Wound Healing Clinic, Lahey Clinic, Burlington, MA, USA.

The skin of older adults undergoes intrinsic aging and is susceptible to multiple ailments. Both comorbidities and environmental issues increase the risk for particular skin diseases among older adults who live in long-term care facilities. This article looks at four common skin conditions frequently found among older adults living in long-term care facilities, and reviews methods of treatment and prevention.
Key words: skin, wound, skin tear, scabies, incontinence dermatitis.

Shen-Yang Lim, MBBS, FRACP, Movement Disorder Centre, University of Toronto, Toronto Western Hospital, Toronto, ON.
Susan H. Fox, MRCP (UK), PhD, Movement Disorder Centre, University of Toronto, Toronto Western Hospital, Toronto, ON.

Parkinson’s disease (PD) is characterized by the presence of bradykinesia, rigidity, and rest tremor. Nonmotor symptoms are also very common in PD and may result in significant disability. Many approaches are available to reduce symptoms. In this article we provide an update on the management of PD. We also discuss the limitations of current treatments.
Key words: Parkinson’s disease, treatment, motor response complications, nonmotor, nondopaminergic.

Andrea Németh, MA, Managing Editor, Geriatrics & Aging.

Introduction
Australian researchers who conducted a randomized controlled trial of a targeted multifactorial intervention to prevent falls among hospitalized older adults have found that the approach was not effective for those with relatively short hospital stays.¹ Researchers gathered falls data from 24 acute and older adult rehabilitation wards in 12 Sydney, Australia, hospitals between October 2003 and October 2006. Investigators paired wards on the basis of type (acute care or rehabilitation), fall rates, length of stay, and patient age before randomization: each ward was studied for 3 months. All patients in the ward at the time of the study were included, and data were collected on the health, medication, and physical function of each patient from their medical records. A total of 3999 patients, mean age 79 years and with a median hospital stay of 7 days, were included in the study.

Method
A part-time nurse and a part-time physiotherapist delivered select interventions during the 3-month study. The interventions used were selected from published recommendations^2-4 that could be implemented with the available resources (additional staff time and alarms) of the study. The study nurse assessed patients; provided education to patients and their families; arranged for appropriate walking aids (together with the physiotherapist), eyewear, modifications at bedside, and increased patient supervision; and worked with other staff regarding the necessity of changing medications, managing confusion, and the possibility of foot problems. The study nurse also provided education to groups of staff and individual staff members.

The study physiotherapist saw those patients who were referred by the study nurse and other ward staff. She led patients, individually or in groups, through exercises designed to enhance balance and ability with functional tasks, and practiced safe mobility with patients around the ward.

Ambulant patients assessed to be at high risk of a fall due to delirium or cognitive impairment were fitted with a custom-designed alarm in the form of a neoprene rubber sock with a pressure switch under the heel and a small loudspeaker in a pocket in the sock. The alarm emitted a loud, high-pitched tone when weight was put on the pressure switch, indicating that the patient was standing and required support.

Results
Among the 24 hospital wards (12 acute and 12 rehabilitation), 3,999 patients were studied; the average total number per ward during the 3-month study period was 167 overall, 233 (range 113-332) for the acute wards and 100 (range 56-170) for rehabilitation wards.

During the study period, 381 falls occurred, with an overall rate of falls of 9.2 per 1,000 bed days. The authors saw no difference between the rate of falls in acute care wards (9.4 per 1,000 bed days) and rehabilitation wards (9.0 falls per 1,000 bed days), nor did they find a differing rate of falls in the intervention versus control wards during the period studied. The mean fall rate in the intervention wards was 9.26 per 1,000 bed days, while the control wards saw 9.20 falls per 1000 bed days.

The intervention was also found to have no effect on the rate of injurious falls, for which the unadjusted incidence rate ratio was 1.12 (95% confidence interval 0.71 to 1.77).

The study authors posit that previous falls prevention studies^5,6 may have demonstrated a positive effect of intervention due to the relatively long length of stay in those studies (30 days and 20 days). In this study, the median length of hospital stay for patients was just 7 days. The investigators suggest that prevention interventions such as exercise require longer than a few days to take effect. They conclude that preventing falls among older adults in the hospital may require innovative approaches, including better ways to assess cognitive impairment, the use of low beds and hip protectors for preventing injury, a redesign of wards so that high-risk patients are easily seen at all times by staff, continual supervision of those patients at highest risk of falling, and a system-wide approach to falls prevention led by ward staff themselves.

References

1. Cumming RG, Sherrington C, Lord SR, et al. Cluster randomized trial of a targeted multifactorial intervention to prevent falls among older people in hospital. BMJ 2008;336:758-60.
2. Shanely C. Putting your best foot forward: preventing and managing falls in aged care facilities. Sydney: Centre for Education and Research on Ageing, 1998.
3. Lord SR, Sherrington C, Menz H. Falls in older people: risk factors and strategies for prevention. Cambridge: Cambridge University Press, 2001.
4. Australian Council for Safety and Quality in Health Care. Preventing falls and harm from falls in older people. Best practice guidelines for Australian hospitals and residential aged care facilities. Canberra: Australian Council for Safety and Quality in Health Care, 2005.
5. Haines TP, Bennell KL, Osbourne RH, et al. Effectiveness of targeted falls prevention programme in subculture hospital setting: randomized controlled trial. BMJ 2007;334:82-7.
6. Healey F, Monro A, Cockram A, et al. Using a targeted risk factor reduction to prevent falls in older in-patients: a randomized controlled trial. Age Aging 2004;33:390-5.

Christian Werner, MD, Klinik für Innere Medizin III, Kardiologie, Angiologie und Internistische Intensivmedizin, Universitätsklinikum des Saarlandes, Homburg/Saar, Germany.
Michael Böhm, MD, Klinik für Innere Medizin III, Kardiologie, Angiologie und Internistische Intensivmedizin, Universitätsklinikum des Saarlandes, Homburg/Saar, Germany.

Cardiovascular disease represents a continuum that starts with risk factors such as hypertension and progresses to atherosclerosis, target organ damage, and ultimately to heart failure or stroke. Renin-angiotensin system (RAS) blockade with angiotensin converting enzyme (ACE) inhibitors or angiotensin II type 1 receptor blockers (ARBs) has turned out to be beneficial at all stages of this continuum. Several mechanisms govern the progression of myocardial damage to end-stage chronic heart failure (CHF). Chronic neuroendocrine activation, comprising the RAS, sympathetic nervous system and the release of cytokines, leads to remodelling processes and via forward / backward failure to clinical symptoms of CHF. Therefore, combined RAS inhibition is especially effective to improve neuroendocrine blockade in CHF patients with repetitive cardiac decompensations.
Key words: angiotensin converting enzyme inhibitors, angiotensin receptor blockers, renin-angiotensin system, chronic heart failure, clinical trials.