Shailaja Shah, MD, Clinical Assistant Professor, Assistant Director Geriatric Psychiatry Fellowship, Robert Wood Johnson Medical School, University of Medicine and Dentistry of New Jersey, Piscataway, NJ, USA.
Gautam Rohatgi, DO, Geriatric Psychiatry Fellow, Robert Wood Johnson Medical School, University of Medicine and Dentistry of New Jersey, Piscataway, NJ, USA.
Daniela Ganescu, MD, Geriatric Psychiatry Fellow, Robert Wood Johnson Medical School, University of Medicine and Dentistry of New Jersey, Piscataway, NJ, USA.

Alzheimer’s disease (AD) is the most common cause of dementia, affecting nearly 18 million people around the world. Alzheimer’s disease is characterized by cognitive, functional, and behavioural decline. As the condition progresses the affected individual becomes increasingly dependent on others for assistance in performing all activities of daily living. Neuropsychiatric symptoms (NPS) such as agitation, psychosis, and apathy are very common in dementia and especially in AD. Agitation and apathy contribute to a tremendous amount of caregiver distress. Treatment guidelines recommend utilizing nonpharmacologic behavioural approaches in all instances. When behavioural interventions fail or when the behaviour is severe, medications are recommended. At present, no psychotropic agent presently available within the United States is FDA-approved for use in dementia complicated with behaviour disturbance.
Key words: agitation, apathy, behaviour interventions, atypical antipsychotics, dementia.

Chris MacKnight, MD, MSc, FRCPC, Associate Professor, Department of Medicine, Dalhousie University, Halifax, NS.

Three cholinesterase inhibitors are available in Canada for the treatment of mild and moderate Alzheimer’s disease. As the three agents differ in their pharmacology, switching among them does sometimes make sense. Switching may be necessary because of intolerance, lack of response, and occasionally loss of response. This article will describe how and when to switch cholinesterase inhibitor.
Key words: Alzheimer’s disease, treatment response, cholinesterase inhibitors, switching, dementia.

David F. Tang-Wai, MDCM, FRCPC, Assistant Professor, University of Toronto; Division of Neurology, University Health Network Memory Clinic, Toronto Western Hospital, Toronto, ON.

Alzheimer’s disease is the most common cause of dementia among older adults. After a century of research, there have been significant scientific advances in the understanding of this disorder. Over the past 15 years, treatment for Alzheimer’s disease exists but it is symptomatic and its effects are modest at best. Currently, newer disease-modifying treatments are being investigated that have the potential of slowing the progression of the disease.
Key words: Alzheimer’s disease, disease-modifying agents, amyloid, tau, neuroprotection.

Esmé Finlay, MD, Fellow, Division of Hematology/Oncology, Hospital of the University of Pennsylvania, Philadelphia, PA, USA.
Joseph B. Straton, MD, MSCE, Chief Medical Director, Wissahickon Hospice; Assistant Professor, Family Medicine and Community Health; Assistant Professor, Anesthesiology and Critical Care, Hospital of the University of Pennsylvania, Philadelphia, PA, USA.
Jonathan R. Gavrin, MD, Director, Symptom Management and Palliative Care; Clinical Associate Professor, Anesthesiology and Critical Care; Clinical Associate Professor, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA, USA.

Nausea and emesis are distressing symptoms that can contribute to malnutrition, dehydration, and decreased quality of life in older patients. Dopaminergic, cholinergic, histaminergic, serotonergic, and neurokinin receptor mechanisms play roles in the causation of nausea. Pharmacologic therapy targeted at these and other mechanisms is necessary to effectively treat the symptoms of nausea and vomiting. Multidrug regimens that target multiple mechanisms are often needed to control persistent symptoms. However, caution is advised when prescribing these medications in older patients, as many of the effective medications can cause sedation, confusion, or delirium. This article describes the mechanisms of nausea and vomiting and reviews effective treatment regimens.
Key words: nausea, vomiting, emesis, antiemetics, older adults.

Karen E. Hall, MD, PhD, Department of Internal Medicine, Division of Geriatric Medicine, University of Michigan Healthcare System; Geriatric Research, Education, and Care Center, Veterans Affairs Medical Center, Ann Arbor, MI, USA.

An understanding of the changes in gastrointestinal function that occur with aging can assist physicians in making patient care decisions. Aging affects many aspects of gastrointestinal function; however, swallowing and colonic function are particularly vulnerable to age-related changes. This explains the high prevalence of swallowing disorders and lower GI tract problems such as constipation and fecal incontinence seen by gastroenterologists and primary care physicians among the older adults they treat. Common comorbid conditions in the geriatric population, such as impairment in cognition and mobility, can affect the treatment of older adults with GI disease. This article highlights important changes in gastrointestinal function that occur with aging.
Key words: dysphagia, constipation, diarrhea, gastrointestinal immunity, gastric function.

Sylvia Davidson, MSc, BSc, Dip Ger, OT Reg.(Ont.), Psychogeriatric Resource Consultant, Toronto Rehabilitation Institute, Toronto, ON.

Caregivers frequently struggle to manage challenging behaviours associated with dementia, often without a good understanding of why these behaviours occur. This article presents a simple framework to help build understanding as well as a systematic approach to dealing with resistance to care.
Key words: dementia, caregiver, systematic approach, understanding behaviour, resisting care.

Anita W. Asgar, MD, FRCPC, Interventional Cardiology Fellow, Montreal Heart Institute, Montreal, QC.
Renee L. Schiff, MD, FRCPC, Echocardiography Fellow, Montreal Heart Institute, Montreal, QC.
Reda Ibrahim, MD, CSPQ, FRCPC, Interventional Cardiologist, Montreal Heart Institute, Associate Professor of Medicine, Universite de Montreal, Montreal, QC.

Hypertension is a common health concern among older adults and constitutes an important risk factor for cardiovascular disease. Despite its prevalence, it is a constant management challenge. We review four aspects of hypertension management that have been of interest over the past year.
Key words: hypertension, diabetes, drug therapy, gender differences, resistant hypertension.

Karen L. Smith, MSc, Kunin Lunenfeld Applied Research Unit, Baycrest and Department of Nutritional Sciences, University of Toronto, Toronto, ON.
Carol Greenwood, PhD, Kunin Lunenfeld Applied Research Unit, Baycrest and Department of Nutritional Sciences, University of Toronto, Toronto, ON.
Helene Payette, PhD, Director, Research Center on Aging, Health & Social Services Centre - University Institute of Geriatrics of Sherbrooke, Faculty of Medicine and Health Sciences, University of Sherbrooke, Sherbrooke, QC.
Shabbir M.H. Alibhai, MD, MSc, Division of General Internal Medicine & Clinical Epidemiology, University Health Network; Geriatric Program, Toronto Rehabilitation Institute; Departments of Medicine and Health Policy, Management and Evaluation, University of Toronto, Toronto, ON.

Unintentional weight loss is common among older adults and is associated with significant adverse health outcomes, increased mortality, and progressive disability. The diagnosis is often associated with an underlying illness; however, in as many as one in four older adults with unintentional weight loss, no obvious medical cause can be identified. A variety of nonpharmacologic interventions may improve energy intake and lead to weight gain. The most common approach to the treatment of weight loss among older adults is consumption of high-energy/protein oral supplements between meals as a means of increasing daily energy intake. Involving other health professionals, including a dietitian, may be helpful in the assessment and management plan. In addition, a number of pharmacologic treatments have been investigated, but the potential benefit of these treatments remains unclear.
Key words: weight loss, older adults, malnutrition, oral nutritional supplementation, megestrol.

Richard Saad, MD, Lecturer, Division of Gastroenterology, Department of Medicine, University of Michigan Medical Center, Ann Arbor, MI, USA.
William D. Chey, MD, AGAF, FACG, FACP, Associate Professor of Internal Medicine; Director, GI Physiology Laboratory, University of Michigan Medical Center, Ann Arbor, MI, USA.

Irritable bowel syndrome (IBS) is traditionally considered a disorder of young adulthood; however, it affects adults of all ages, including older adults. As the older population increases so will the impact of IBS in this age group. Irritable bowel syndrome with constipation (IBS-C) is believed to be particularly significant given the prevalence of constipation among the aged. At present, the evaluation and management of this disorder has been largely driven by data obtained from younger adults. However, there are numerous aspects of the underlying pathophysiology, evaluation, and treatment of IBS-C that remain unique to older adults, of which the clinician should be cognizant.
Key words: irritable bowel syndrome, constipation, older adults, functional bowel disorder.

Constantine A. Soulellis, MD, FRCP(C), GI Fellow, McGill University; Division of Gastroenterology, McGill University Health Centre, Montreal, QC.
Carlo A. Fallone, MD, FRCP(C), AGA(F), Associate Professor, McGill University; Director, GI Services, Royal Victoria Site of the McGill University Health Centre, Montreal, QC.

Peptic ulcer disease (PUD) is a prevalent medical problem among older adults. Several issues unique to older adults impart variability and complexity to PUD, making this entity difficult to diagnose and treat. Age-related gastrointestinal physiological changes, increasing prevalence of Helicobacter pylori, comorbidities, and polypharmacy (especially nonsteroidal anti-inflammatory drug [NSAID] use) are factors that potentiate ulcer formation. Older adults may present with few or none of the usual features of PUD, often delaying diagnosis and therapy. The cornerstones of therapy include cessation of NSAIDs, proton pump inhibition, and eradication of H. pylori if present.
Key words: peptic ulcer, older adults, NSAIDs, Helicobacter pylori.