Sudeep S. Gill, MD, MSc, FRCPC, Assistant Professor, Division of Geriatric Medicine, Queen’s University, Kingston, ON.

Delirium is common among hospitalized older adults and is associated with significant morbidity and excess mortality. Despite its prevalence and consequences, delirium is often underrecognized and undertreated. Antipsychotic drugs are commonly used to manage symptoms of delirium, but few controlled trials exist to support their efficacy and safety in this setting. Several recent studies have focussed on preventing delirium in high-risk populations. Clinical trials have demonstrated benefits with multifaceted nonpharmacological interventions, but widespread implementation of these interventions has not yet occurred. Two recent drug trials evaluated an antipsychotic and a cholinesterase inhibitor to prevent delirium, but neither trial demonstrated a reduction in incident delirium. At present, the most promising approach involves targeted, multifactorial interventions that focus on preventing delirium in high-risk patient groups. More work is needed to facilitate the implementation of these evidence-based strategies.
Key words: delirium, prevention, treatment, antipsychotic drugs, cholinesterase inhibitors.

Jagdish Butany, MBBS, MS, FRCPC, Department of Pathology, Toronto General Hospital/University Health Network, Toronto Canada 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, Toronto, ON.
Moyukh Chakrabarti, BSc, Department of Pathology, Toronto General Hospital/University Health Network, Toronto, ON.
Iva Vukin, BSc, Department of Pathology, Toronto General Hospital/University Health Network, Toronto, ON.
Shaun W. Leong, BSc, Department of Pathology, Toronto General Hospital/University Health Network, Toronto, ON.

Prosthetic heart valves (PHVs) are used to replace diseased native valves among patients with valvular stenosis, incompetence, or both. This paper reviews a number of contemporary prosthetic heart valves that are available for implantation in patients for whom valve repair is not possible. There are two major types of PHV: biological and mechanical. Each type of PHV has its own unique benefits and complications, which are outlined in this review. It is important that the practicing physician have some knowledge of contemporary prosthetic heart valves in order to treat patients safely and effectively.
Key words: prosthetic heart valve, mechanical heart valve, stented bioprosthesis, stentless bioprosthesis.

Krupa Shah, MD, MPH, Geriatric Fellow, Washington University at St. Louis, Division of Geriatric and Nutritional Science, St. Louis, MO, USA.
Dennis Villareal, MD, Associate Professor, Washington University at St. Louis, Division of Geriatric and Nutritional Science, St. Louis, MO, USA.

Obesity is associated with significant morbidity and mortality. In older adults, obesity can exacerbate declining physical function and quality of life that often accompanies aging, and can cause frailty. The value of treatment for obesity in older adults has been under debate because of the uncertain effectiveness of obesity therapies in this population as well as the potentially harmful effects of weight loss. However, current evidence shows that weight-loss treatment improves physical function and quality of life, and also eases the medical complications associated with obesity in older adults. Therefore, moderate weight loss that minimizes muscle and bone loss is recommended for obese older adults who have functional decline or medical complications.
Key words: obesity, body mass index, metabolic syndrome, weight loss, lifestyle modification.

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, Research Center on Aging, Health & Social Services Center - 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 a common problem among community-dwelling older adults. Although a slight decline in body weight is considered a normal part of the aging process, clinically significant weight loss (>5% of usual body weight) has harmful consequences on functional status and quality of life, and is associated with excess mortality over a three- to twelve-month period. A variety of physical and psychological conditions, along with age-related changes, can lead to weight loss. In up to one-quarter of patients, there is no identifiable cause. A rational approach to clinical investigation of these patients can facilitate arriving at a diagnosis and minimize unnecessary diagnostic procedures.
Key words: weight loss, older adults, mortality, epidemiology, diagnosis.

Roger E.Thomas,MD, Ph.D., CCFP, MRCGP, Professor, Department of Family Medicine, University of Calgary, and Cochrane Coordinator, University of Calgary, Calgary, AB.

Recent evidence has shown that vaccination against influenza is effective in reducing the complications of influenza (pneumonia, hospitalization for influenza or pneumonia, and deaths due to influenza or pneumonia) for those 60 years and over living in long-term care facilities (LTCs) during periods of high viral circulation if the vaccine has a good match to the circulating strain. Vaccination was found to be similarly effective for those 60 and over living in the community. There is further evidence that health care workers should be vaccinated for their own benefit, as vaccination is demonstrably effective for healthy adults under 60, and most health professionals are under 60.There is some evidence that vaccination of these workers may provide additional protection for residents of LTCs from the complications of influenza. Influenza can be detected by rapid office-based tests and should be used when the pretest probability of influenza is less than 30%. The evidence suggests that oseltamivir and zanamivir are effective in reducing the symptoms of cases and reducing infections in households and contacts of cases.
Keywords: influenza, older adults, vaccination, prevention of influenza, antivirals.

Edward Etchells,MD, MSc, FRCP, Division of General Internal Medicine and Patient Safety Service, Sunnybrook & Women’s College Health Sciences Centre; Associate Professor, Department of Medicine, University of Toronto,Toronto, ON.
Tasnim Vira, BScPhm, Medical Student, Faculty of Medicine,University of Toronto, Toronto, ON.
Vincent C.Tam,MD, BSc(Hon), Internal Medicine Resident, Department of Medicine, McMaster University, Hamilton, ON; Thunder Bay, ON.

Medication errors at the time of acute care transition (admission, transfer, and discharge) are common. Health care providers can reduce these errors by obtaining an insightful medication history, documenting medication changes in medication orders and on discharge prescriptions, and promoting close teamwork among physicians, nurses, and pharmacists. The patient and family can also play an active role in reducing these errors. Medication reconciliation is a method for identifying and rectifying medication errors at transition. Reconciliation is a safe medication practice promoted by the Safer Healthcare Now campaign and is an accreditation requirement by the Canadian Council on Health Services Accreditation (CCHSA). Debates about the need for better studies examining the impact of reconciliation are ongoing.
Keywords: medication error, patient safety, hospital admission, discharge, transfer.

Meera George, JD, Postgraduate Fellow, Houston Center for Quality of Care and Utilization Studies, Michael E. DeBakey VA Medical Center, Houston,TX, USA.
Aanand D. Naik,MD, Assistant Professor, Health Services Research and Geriatrics, Baylor College of Medicine; Houston Center for Quality of Care and Utilization Studies, Michael E. DeBakey VA Medical Center, Houston,TX, USA.

Many older adults have difficulty bathing.Those unable to bathe are more likely to need formal home care and to be admitted to long-term care than those who can bathe without help. Disability with bathing function is complex, involving multiple subtasks; inability to perform those subtasks has many attributable causes. Bathing disability can be remediated through timely diagnosis and prescription of appropriate assistive devices and adaptations to the home bathing environment. Clinicians have an important role in the diagnosis of bathing disability, and collaborative planning of bathing remediation with patients, caregivers, and allied health providers is key.
Keywords: activities of daily living, assessment, disability, assistive devices.

Kristine E. Pringle, Ph.D., Health Care Consultant, First Health Services Corporation/PAPACE, Harrisburg, PA, USA.
Frank M. Ahern, Ph.D., Senior Research Associate, Department of Biobehavioral Health, Pennsylvania State University, University Park, PA, USA.
Debra A. Heller, Ph.D., Senior Health Care Consultant, First Health Services Corporation/PA-PACE, Harrisburg, PA, USA.

Many medications have the potential to interact with alcohol, and older patients may be at greater risk of experiencing adverse effects due to issues of comorbidity and polypharmacy. Even small amounts of alcohol consumed by an older person who is taking multiple medications can have serious consequences. A retrospective analysis linked prescription claim records with self-reported alcohol use. Results showed that 77% of older adults used at least one alcohol-interactive medication, and 19% of alcohol-interactive drug users reported concomitant alcohol use. Because many individuals are unaware of the risks posed by alcohol and medications, it is important for clinicians to warn patients about potential interactions.
Keywords: older adults, alcohol, prescription drug use, alcohol-drug interactions, concomitant use of alcohol and prescription drugs.

Marie D.Westby, BSc(PT), PhD Candidate, Mary Pack Arthritis Program,Vancouver Coastal Health, School of Rehabilitation Sciences, University of British Columbia,Vancouver, BC.
Linda Li, BSc(PT), PhD, Harold Robinson/Arthritis Society Chair, Assistant Professor, School of Rehabilitation Sciences, University of British Columbia,Vancouver, BC.

Physiotherapy aims to prevent physical impairment and restore functional ability through the use of exercise, education, and physical modalities. While there is solid evidence supporting physical activities in the management of arthritis, inactivity continues to be a problem among both younger and older patients with arthritis as compared to the general population. Current evidence supports the effectiveness and safety of moderate- to highintensity aerobic and strengthening exercises for osteoarthritis and stable rheumatoid arthritis. Participation in recreational activities does not replace the need for therapeutic exercises. Physicians and health professionals should be equipped with strategies to overcome barriers and facilitate treatment adherence when prescribing exercise.
Keywords: osteoarthritis, rheumatoid arthritis, physical therapy, exercise, physical activity.

Patrick Couture,MD, FRCP(C), PhD, Lipid Research Center, Laval University Medical Center, Laval,QC.
Nancy Gilbert, RN, Lipid Research Center, Laval University Medical Center, Laval,QC.

Several lines of evidence suggest that triglyceride-rich lipoproteins contribute significantly to the development of atherosclerosis. However, the relationship between cardiovascular disease and plasma levels of triglyceride remains complex due to the presence of two major confounders: (1) the inverse relationship between plasma triglyceride levels and highdensity lipoprotein-cholesterol and (2) the heterogeneity in triglyceriderich lipoprotein size, number, and composition between individuals. Plasma apo-B measurement is recommended for patients with high triglyceride levels to identify their risk category.The goals of lipidmodifying therapy for these patients are to reduce the atherogenic lipoprotein number and to increase HDL particle number.
Keywords: triglyceride, lipoprotein, atherosclerosis, coronary heart disease, cholesterol.