Bhaskar Ghosh, MD, DNB, DM, MNAMS, Movement Disorders Program, Department of Clinical Neurosciences, University of Calgary, Calgary, AB.
Oksana Suchowersky, MD, FRCPC, FCCMG, Movement Disorders Program, Department of Clinical Neurosciences; Department of Medical Genetics, Faculty of Medicine, University of Calgary, Calgary, AB.

Chorea is a hyperkinetic movement disorder characterized by nonsustained, rapid, and random contractions that may affect all body parts. Chorea is hypothesized to be due to an imbalance between the direct and indirect pathways in the basal ganglia circuitry. Important causes of chorea among older adults include medications, stroke, and toxic-metabolic, infective, immune-mediated, and genetic causes. The history and clinical examination guide appropriate investigations and help determine an accurate diagnosis. In secondary causes, removal of the precipitating cause is the mainstay of treatment. If the chorea is persistent or progressive, drug therapy may be instituted. Genetic counselling is important in hereditary chorea.
Key words: movement disorders, chorea, older adults, diagnosis, treatment.

Emily Saks, MD, Fellow, Division of Urogynecology and Female Reproductive Surgery, Department of Obstetrics and Gynecology, University of Pennsylvania, Philadelphia, PA, USA.
Lily Arya, MD, Assistant Professor and Program Director, Division of Urogynecology and
Female Reproductive Surgery, Department of Obstetrics and Gynecology, University of Pennsylvania, Philadelphia, PA, USA.

Pelvic organ prolapse is a common condition among women, and its prevalence increases with age. Pelvic organ prolapse is multifactorial in etiology but ultimately results from a disruption in the pelvic floor muscles and their attachments. Patients may be asymptomatic or may report a variety of pelvic floor symptoms. Prolapse can be easily diagnosed through clinical examination. Treatment involves simple observation, pessary, or surgery.
Key words: pelvic organ prolapse, older women, pessary, vaginal surgery.

Ali Ahmed, MD, MPH, FACC, FAHA, FESC, associate professor, Division of Gerontology, Geriatric Medicine, and Palliative Care, Department of Medicine, School of Medicine and Department of Epidemiology, School of Public Health, University of Alabama at Birmingham; director, Geriatric Heart Failure Clinics, Veterans Affairs Medical Center, Birmingham, AB, USA.

Heart failure (HF) is the leading cause of hospitalization among older adults. Digoxin has been shown to reduce hospitalization due to worsening HF. However, at the commonly prescribed dose of 0.25 mg/day, digoxin does not reduce mortality. New data suggest that at low doses (0.125 mg/day or lower) digoxin not only reduces hospitalization due to HF, but may also reduce mortality. Further, at lower doses, it also reduces the risk of digoxin toxicity and obviates the need for routine serum digoxin level testing. Digoxin in low doses should be prescribed to older adults with symptomatic HF.
Key words: chronic heart failure, older adults, treatment, digoxin, update.

Eran Metzger, MD, Associate Director of Geropsychiatry, Hebrew SeniorLife, Boston; Assistant Professor of Psychiatry, Harvard Medical School, Boston, MA, USA.

The management of depression among individuals with dementia can be one of the more challenging problems in geriatric practice. Depression in dementia is common regardless of the type of dementia and compounds the impairment of the underlying dementing illness. Some symptoms of dementia, including apathy, impaired concentration, and decreased food intake, may be difficult to distinguish from similar symptoms of depression. This article presents background information on the epidemiology and pathophysiology of depression in dementia followed by recommendations for a systematic approach to diagnosis. Treatment modalities including psychotherapy, pharmacotherapy, and electroconvulsive therapy are reviewed.
Key words: dementia, depression, Alzheimer’s disease, psychotherapy, psychopharmacology.

Vikas Kuriachan, MD, FRCP(C), Fellow, Cardiac Arrhythmia, Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, AB.
Robert Sheldon, MD, PhD, FRCP(C), Professor, Cardiac Sciences, and Associate Dean of
Clinical Research, Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, AB.

The implantable cardioverter defibrillator (ICD) plays an important role in primary and secondary preventions of sudden cardiac death. Several trials conducted in the past few years have shown the superiority of ICDs over drug therapy. Cardiac resynchronization therapy (CRT) is also emerging as an adjunctive treatment for heart failure, with some survival benefits as well. This article reviews the major recent clinical trials of ICD and CRT devices and summarizes their importance in contemporary cardiology.
Key words: cardioverter defibrillator, cardiac resynchronization, older adults, sudden cardiac death, cardiology.

Jagdish Butany, MBBS, MS, FRCPC, Department of Pathology, Toronto General Hospital, University Health Network; Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON.
Gursharan S. Soor, BSc, Department of Pathology, Toronto General Hospital, University Health Network, Toronto, ON.
Adriana Luk, BSc, Department of Pathology, Toronto General Hospital, University Health Network, Toronto, ON.
Anna Woo, MD, FRCPC, FACC, Hypertrophic Cardiomyopathy Program, Division of Cardiology, Toronto General Hospital; Department of Medicine, University of Toronto,Toronto, ON.
Anthony Ralph-Edwards, MD, FRCSC, Division of Surgery, Toronto General Hospital, University of Toronto, Toronto, ON.
Heather Ross, MD, FRCPC, Department of Medicine, Division of Cardiology, University of Toronto, Toronto General Hospital, Toronto, ON.

Hypertrophic cardiomyopathy (HCM) is an uncommon disease with significant consequences. Since the 1950s, major strides in understanding its etiology and pathogenesis have led to improved management and patient survival. Hypertrophic cardiomyopathy is associated with various mutations in several cardiac sarcomeric genes. Due to the complications of HCM, such as left ventricular outflow tract obstruction, diastolic dysfunction, arrhythmias, increased risk of stroke, infective endocarditis, and, most importantly, sudden cardiac death, appropriate and timely diagnosis is critical. This review summarizes current knowledge about HCM and the most appropriate investigations for persons suspected of having HCM. Treatment strategies for the disease and its complications are presented briefly.
Key words: hypertrophic cardiomyopathy, cardiomyopathy, sudden cardiac death, older adults.

The burden of heart failure is rapidly rising. Heart failure is associated with substantial mortality, morbidity, and economic cost, which disproportionately affect older adults. Heart failure among older individuals is frequently complicated by geriatric syndromes, including frailty, functional decline, cognitive impairment, and atypical clinical presentations. Understanding the nature of these geriatric syndromes and their impact on the assessment and management of heart failure is a critical component to diagnosing and delivering appropriate care to these patients. In this article we review the geriatric aspects of heart failure.
Key words: geriatric syndrome, heart failure, older adults, diagnosis, frailty.

Fatemeh Akbarian, MD, Dermatologist, Clinical Research Fellow, University of Toronto, Toronto, ON.
Vahid Ghafarian, MD, MPH, BSc.PT, Physiotherapist, Northpark Physiotherapy and Annex Retirement Residence, Toronto, ON.
Mohammad Ali Shafiee, MD, FRCPC, General Internist, Nephrologist, Department of Medicine, Toronto General Hospital, University Health Network; Clinician Teacher, University of Toronto, Toronto, ON.

Treatment-resistant hypertension (TRHTN) is a common challenge in geriatric practice and a significant cause of mortality and morbidity among older adults. In this overview, we will use a case-based approach to define the magnitude of the problem, identify characteristics of individuals with TRHTN, and explore the causes of uncontrolled hypertension including technical issues, patient-related and physician-related factors, and secondary causes of hypertension. We will then provide a simple approach to the problem, illustrating straightforward diagnostic workup and therapeutic options. In our approach most of the emphasis has been given to detailed history-taking and a targeted physical examination.
Key words: resistant hypertension, hyperaldosteronism, obstructive sleep apnea, older adults.

Lina Medeiros, MSW, Social Worker, University Health Network - Toronto Western Hospital, Toronto, ON.
Debbie Kwan, MSc, Assistant Professor, University of Toronto; Pharmacist, University Health Network - Toronto Western Hospital, Toronto, ON.
Carol Banez, MAN, Clinical Nurse Specialist, University Health Network - Toronto Western Hospital, Toronto, ON.
Beatrise Poroger-Edelstein, MHSc, Manager of Elder Care, North York General Hospital, Toronto, ON.
Kitty Mak, BHthSc, Nurse, University Health Network - Toronto Western Hospital, Toronto, ON.
Keegan K. Barker, MEd, PhD(c), University of Toronto, Toronto, ON.
Rory Agellon, BSc, Dietitian (Retired), University Health Network - Toronto Western Hospital, Toronto, ON.

In light of the aging population trend and the complex needs of the aging population, there is an increasing impetus to develop innovative service delivery models that focus on health promotion and disease prevention and management, are easily accessible for older adults of diverse ethnic backgrounds, are community-oriented, and incorporate an interprofessional team approach.
This article describes the development, implementation, and evaluation of the Seniors Wellness Clinic, an innovative health promotion model of care for older adults focusing on primary and secondary disease prevention and disease management.
Key words: health services for the aged, multidisciplinary care team, program development, health promotion.

Hershl Berman, MD, FRCPC, Assistant Professor, University of Toronto Faculty of Medicine, Department of Medicine, University Health Network, Toronto, ON.
Laura Brooks, RegN, MscN, APN, Advanced Practice Nurse in Palliative Care, Department of Psychosocial Oncology and Palliative Care, University Health Network, Toronto, ON.
Shawna Silver, MD, PEng, Hospital for Sick Children; University of Toronto, Toronto, ON.

Constipation is a common complaint, especially in older adults. It results in millions of physician visits per year, with hundreds of millions of dollars spent on laxatives. Untreated it can lead to serious morbidity and can be a contributing factor in mortality. A rational approach to the patient presenting with constipation includes a detailed history, general and focused physical examination, specific investigations, and appropriate therapy. Treatment should aim to address the underlying cause, as should the choice of laxative. In general, it is best to clear out hard stool in the distal bowel before using an aggressive oral regimen.
Key words: constipation, laxatives, older adults, opioids.