Barry D. Bultz, PhD, Director, Department of Psychosocial Resources, Tom Baker Cancer Centre, Alberta Cancer Board; Department of Oncology, University of Calgary, Calgary, AB.
Bejoy C. Thomas, PhD, Department of Psychosocial Resources, Tom Baker Cancer Centre, Alberta Cancer Board, Calgary, AB.
Douglas A. Stewart, MD, FRCPC, Divisions of Medical Oncology and Hematology, Departments of Oncology and Medicine, Tom Baker Cancer Centre and University of Calgary, Calgary, AB.
Linda E. Carlson, PhD, Department of Psychosocial Resources, Tom Baker Cancer Centre, Alberta Cancer Board; Department of Oncology, University of Calgary, Calgary, Alberta, Canada

Cancer is perceived as an illness that most frequently affects the older adult population, yet there is a dearth of research on the psychosocial aspects of cancer affecting this cohort. The effect of chemotherapy on the psychosocial sequelae in this group is moderately researched. This article discusses emotional distress across the trajectory of cancer care in the older adult population. It also identifies key milestones, times when distress is likely to peak, and the psychological, physiological, and social symptoms of distress. The benefits of psychosocial interventions are also discussed.
Key words: older adult, cancer, chemotherapy, emotional distress, 6th vital sign.

Andrew Liu, BSc Hon, BScPhm, RPh, Clinical Pharmacist, Thrombosis Service, Toronto East General Hospital, Toronto, ON.
Carmine Stumpo, BScPhm, PharmD, RPh, Director, Pharmacy and Emergency Services, Toronto East General Hospital, Toronto, ON.

Warfarin-drug interactions are often encountered in the care of older adults. Interactions may be classified as pharmacokinetic, resulting in changes in serum warfarin concentrations, or pharmacodynamic, resulting in changes in hemostasis or platelet function. Knowledge of these mechanisms of warfarin-drug interactions may help identify warfarin interactions, facilitate prescribing decisions, and assist with appropriate monitoring.
Key words: warfarin, drug interactions, anticoagulants, cytochrome P-450 enzyme system, older adults.

Simone Pomati, MD, PhD, Centre for Research and Treatment on Cognitive Dysfunctions, Institute of Clinical Neurology, Department of Clinical Sciences, Luigi Sacco Hospital, Milan, Italy.
Francesca Clerici, MD, PhD, Centre for Research and Treatment on Cognitive Dysfunctions, Institute of Clinical Neurology, Department of Clinical Sciences, Luigi Sacco Hospital, Milan, Italy.
Stefano Defendi, MD, Centre for Research and Treatment on Cognitive Dysfunctions, Institute of Clinical Neurology, Department of Clinical Sciences, Luigi Sacco Hospital, Milan, Italy.
Silvia Bovo, MD, Centre for Research and Treatment on Cognitive Dysfunctions, Institute of Clinical Neurology, Department of Clinical Sciences, Luigi Sacco Hospital, Milan, Italy.
Claudio Mariani, MD, Chair of Clinical Neurology, University of Milan; Centre for Research and Treatment on Cognitive Dysfunctions, Institute of Clinical Neurology, Department of Clinical Sciences, Luigi Sacco Hospital, Milan, Italy.

Frontotemporal dementia (FTD) is a progressive condition characterized by atrophy of the frontal and/or temporal lobes. Three main clinical syndromes have been described (behavioural variant, progressive nonfluent aphasia, and semantic dementia). The symptoms reflect the anatomical distribution of the pathological changes rather than the precise histological subtype. Frontotemporal dementia is a genetically complex disorder with a strong likelihood of inheritance, mainly transmitted as an autosomal dominant trait. Mutations in microtubule associated tau protein and progranulin have been reported in several families affected by FTD. The treatment is directed to the control of the behavioural disturbances through pharmacological and nonpharmacological approaches.
Key words: frontotemporal dementia, semantic dementia, progressive nonfluent aphasia, neuropsychology, progranulin.

George D. Oreopoulos MD, MSc, FRCS(C), Vascular Surgeon, University Health Network; Assistant Professor, Department of Surgery, University of Toronto, Toronto, ON.

Aortic dissection is the most common vascular emergency involving the aorta. Aortic dissection may present with a variety of clinical features and must be considered in order to avoid delay in diagnosis. Early CT scanning allows for the diagnosis to be confirmed and for the extent of the dissection to be determined. While proximal dissections require early surgery to prevent fatal complications, the initial treatment of distal dissections remains medical therapy with surgery or endovascular therapies being reserved for medical failures or for patients who develop specific complications. Newer endovascular treatments may ultimately alter the initial approach to distal dissections although this remains an area of controversy.
Key words: aortic dissection, clinical presentation, medical therapy, endovascular treatment, malperfusion syndromes.

Madhav V. Rao, MD1, Department of Medicine, Section of Nephrology, University of Chicago, Chicago, IL, USA.
Vijaykumar M. Rao, MD, FACP, FASN, President, Associates in Nephrology, Chicago, IL, USA.

Alterations in potassium balance occur frequently in all patient populations, but in particular, among older adults. Physicians commonly encounter such disorders when taking care of patients in the clinic or in the hospital. Most often the etiology of such disturbances is due to prescribed medications, but a number of clinical conditions exist which predispose people to both hyperkalemia and hypokalemia. These conditions can have grave consequences if not addressed quickly. Furthermore, the approach to definitive treatment depends on the underlying physiology that often occurs at the tubular level within the kidney.
Key words: potassium balance, hyperkalemia, hypokalemia, older adults.

Gemini Tanna, MD, FRCPC, Division of Nephrology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
Sarbjit Vanita Jassal, MB, BCh, MD, Division of Nephrology, University Health Network, University of Toronto, Toronto, Ontario, Canada

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Chronic kidney disease (CKD) is increasingly common among older adults. In the older individual, the presence of CKD is predictive of cardiovascular death, increased all- cause mortality, and progression to end-stage renal disease and the need for dialysis. Early identification of these high-risk individuals may prevent or delay such adverse outcomes. The Canadian Society of Nephrology (CSN) released a position statement in September 2006 suggesting that screening be limited to those at high risk. We recommend that clinicians follow the CSN algorithm for screening for CKD among older adults.
Key words: chronic kidney disease, estimated glomerular filtration rate, older adults, renal function, screening.

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

Richard W. Norman, MD, FRCSC, Professor, Department of Urology, Dalhousie University, Halifax, NS.

Kidney stones occur frequently among the North American population and tend to be recurrent. It is usually possible to identify one or more abnormal urinary risk factors for the specific stone composition under consideration. The physician and dietician can counsel the patient on how to reduce the likelihood of further recurrences or stone growth by increasing fluid intake and dietary modification. If this is unsuccessful, a variety of medications are available depending upon which variable(s) is (are) abnormal. There are specific nuances that relate to the older adult age group.
Key words: kidney stones, nephrolithiasis, urinary risk factors, stone prevention.

MC Faes, MD, MSc, Department of Geriatric Medicine, University Medical Centre Nijmegen, The Netherlands.
MG Spigt, PhD, Department of General Practice/Research Institute CAPHRI, University of Maastricht, The Netherlands.
MGM Olde Rikkert MD, PhD, Department of Geriatric Medicine, University Medical Centre Nijmegen, The Netherlands.

Homeostasis of fluid balance is an important prerequisite for healthy aging. The high prevalence of disturbances of fluid balance among older adult patients has triggered clinical research on age- and disease-related changes in water homeostasis. Empirical findings on risk factors of dehydration and on diagnostic and therapeutic strategies are reviewed in this paper. No single measure has proved to be the gold standard in the diagnosis of dehydration. Diagnosing dehydration and monitoring fluid balance requires repeated measurements of weight, creatinine, and physical signs such as tongue hydration. Rehydration and prevention requires fluid on prescription (> 1.5 litre/day), and the route of fluid administration depends on the acuteness and severity of clinical signs.
Keywords: older adults, dehydration, fluid therapy, risk factors, diagnosis.

Tarek Rajji, MD, Geriatric Mental Health Program, Centre for Addiction and Mental Health; Department of Psychiatry, University of Toronto, Toronto, ON.
Benoit H. Mulsant, MD, MSc, FRCPC, Western Psychiatric Institute and Clinic and Department of Psychiatry, University of Pittsburgh, Pittsburgh, USA; Geriatric Mental Health Program, Centre for Addiction and Mental Health; Department of Psychiatry, University of Toronto, Toronto, ON.
Hiroyuki Uchida, MD, PhD, PET Centre, Centre for Addiction and Mental Health, Toronto, ON.
David Mamo, MD, MSc, FRCPC, PET Centre and Geriatric Mental Health Program, Centre for Addiction and Mental Health; Department of Psychiatry, University of Toronto; Centre for Addiction and Mental Health, Toronto, ON.

Antipsychotics are increasingly being prescribed to older patients for the management of a variety of neuropsychiatric conditions. Available evidence supports the use of second-generation antipsychotics (SGAs) when treating these conditions. However, given their modest clinical effect for certain conditions (e.g., behavioural and psychological symptoms of dementia), their adverse effects, and their safety profile, a careful analysis of their risks and benefits is needed before initiating treatment with an SGA for an older patient. Among SGAs, choice of medication should be guided by their respective clinical indications and adverse effect profile, with use of lower initial and target doses (compared to younger adults) and periodic reviews of whether or not their continued use is warranted.
Key words: antipsychotics, older adults, dementia, delirium, schizophrenia.

Kati Juva, MD, PhD, Department of Psychiatry, Helsinki University Central Hospital, Helsinki, Finland.
Sari Rastas, MD, PhD, Department of Neuroscience and Neurology, University of Kuopio, Kuopio, Finland; Kauniala Disabled War Veterans’ Hospital, Espoo, Finland.
Tuula Pirttilä, PhD, Professor, Department of Neuroscience and Neurology, University of Kuopio and Kuopio University Hospital, Kuopio, Finland.

The harmful effects of high blood pressure on cardiovascular morbidity and mortality are well established. However, hypertension in the very old is an extremely complex issue. Current epidemiological data suggest that high blood pressure may be a marker of survival in the very old, and lowering blood pressure may lead to an increase in total mortality. In this review we will summarize the evidence on the association between blood pressure and mortality and discuss the implications of the data.
Key words: older adults, hypertension, survival, very old, blood pressure.