Tony Lo, MD, Resident, Department of Psychiatry, University of Calgary, Calgary, AB.
Nadeem H. Bhanji, BSc(Pharm), MD, FRCP(C), Assistant Professor, University of Calgary; Staff Psychiatrist, Carewest Glenmore Rehabilitation Hospital; Elderly Psychiatrist, Department of Psychiatry, Peter Lougheed Centre; Assistant Professor, University of Calgary, Calgary, AB.

Major depression and subsyndromal depression are common in older persons. Unrecognized depression results in increased morbidity and mortality. Recognition of depression is challenging due to patient- and clinician-related factors. Diagnosis in the older person is confounded by medical comorbidities as well as normal changes. Depression in older adults manifests differently: somatic complaints, nonspecific symptoms, and cognitive difficulties are common, as are behavioural changes, including apathy and irritability. Anhedonia better reflects depression, since depressed mood is often denied by the older person. Depression is likely to be missed if only typical symptoms are sought. Appropriate recognition can lead to improved treatment and outcomes.
Key words: depression, older adult, diagnosis, recognition, management.

S. Gogov, MD, Department of Medicine, University Health Network, Toronto, ON.
Shabbir M.H. Alibhai, MD, MSc, FRCPC, Department of Medicine, University Health Network; Departments of Medicine and Health Policy, Management, and Evaluation, University of Toronto, ON.

Prostate cancer remains the most common malignancy in men. Screening remains controversial due to a lack of evidence from randomized trials that it decreases mortality. Treatment decisions are based on assigning patients to one of three risk groups (low, intermediate, or high) based on stage, tumour grade, and prostate-specific antigen level, and considering remaining patient life expectancy (affected by age and comorbidity). Men with low-risk disease can consider expectant management, surgery, or radiotherapy (either external beam or brachytherapy). In intermediate-risk patients, all options except expectant management are associated with excellent long-term survival. In high-risk patients, combining either radiation or surgery with androgen deprivation has emerged as the best option. There is no role for primary androgen deprivation for most patients.
Key words: prostate cancer, screening, treatment, surgery, radiotherapy.

Goran Eryavec, MD, FRCP, Medical Director, Geriatric Psychiatry and Memory Clinic, North York General Hospital; Assistant Professor, Department of Psychiatry, University of Toronto, Toronto, ON.
Gabriel Chan, MD, FRCP, Medical Director, Geriatric Medicine, North York General Hospital; Assistant Professor, Department of Medicine, University of Toronto, Toronto, ON.
Brian Hoffman, MD, FRCP, Chief of Psychiatry, North York General Hospital; Associate Professor, Department of Psychiatry, University of Toronto, Toronto, ON.

Discussing a diagnosis of cancer and obtaining consent to treat older patients can be difficult and challenging. Older cancer patients are often frail, and may have depression or cognitive impairment that brings into question their ability to cope with the diagnosis and their capacity to consent to treatment. Family members may be distressed and fearful of how the patient will cope with the cancer diagnosis. Physicians can be pressured to withhold the diagnosis. The evolution of informed consent, informed decision making, and shared decision making is reviewed along with consent and capacity to consent or refuse treatment legislation in Ontario. We present a case study illustrating these issues and discuss how physicians can cope with the complex clinical, legal, and ethical issues involved.
Key words: informed consent, capacity, older adult, cancer.

Elizabeth Richard, Director of Environmental Services, Bess and Moe Greenberg Family Hillel Lodge, Ottawa, ON.

The Bess and Moe Greenberg Family Hillel Lodge is a 100-bed facility providing long-term care services and a traditional Jewish program to the community of Ottawa and its environs. Founded in 1965, Hillel Lodge relocated to a newer and larger building in 2000 to accommodate the needs of its 100 residents. Among the many improvements of the new facility was the addition of an electronic wander prevention system to protect residents prone to wandering.

Hillel Lodge typically cares for three to five residents prone to wandering at any one time. These residents may reside in the secured special care unit or in any of the three other units in the facility. Each exit from the Lodge is protected by a door monitor that is activated when a resident wearing a special bracelet approaches an open door.

While this system has been generally effective, there were areas for improvement identified by the staff. Hillel Lodge is a multifloor facility, with all 13 exits monitored by the wander prevention system. Previously, when an incident occurred, it was not always possible to know which exit the resident had used.
As a result of this concern, the Lodge undertook to upgrade the wander prevention system in early 2005 to provide full identification of residents in an alarm situation. The solution was a PC-based software package provided by Xmark (www.xmarksystems.com), the vendor of our wander prevention system. The WatchMate® software connects to the monitor devices installed at each exit. When a resident wearing a bracelet device approaches an open door, the software displays the location of the alarm and the name of the resident. The information is displayed in a clear, graphical format, including a floor layout of the facility.

Since its installation in January of this year, the software has improved response times when the alarm is sounded and provided staff with more complete information. A brief glance at the screen tells the staff responsible for monitoring the system exactly which resident has triggered the alarm and precisely which exit he or she has accessed. It removes guesswork and does this without delay, ensuring that the resident can be returned to safety in the minimum possible time.

This article was written with the cooperation of Xmark.

Jerome D. Schein, PhD, Professor Emeritus, New York University, New York, NY, USA; Adjunct Professor, University of Alberta, Edmonton, AB.
Maurice H. Miller, PhD, Department of Speech-Language Pathology & Audiology Steinhardt School of Education, New York University, New York, NY, USA.

For persons whose hearing does not return in 60–90 days following idiopathic sudden sensorineural hearing loss (ISSNHL), audiologic rehabilitation should be provided. This article describes aspects of audiologic rehabilitation, including counselling, information about lifestyle changes, and techniques (such as amplification) for overcoming the communication handicap ISSNHL imposes. Advantages and limitations of various hearing aids are presented.
Key words: audiology, counselling, hearing aids, otology, rehabilitation, sensorineural, hearing loss.

L. Giangregorio, PhD, Lyndhurst Centre, Toronto Rehabilitation Institute, Toronto, ON.
A. Papaioannou, MD, Department of Medicine, McMaster University, Hamilton, ON.
J.D. Adachi, MD, Department of Medicine, McMaster University, Hamilton, ON.

Osteoporosis is characterized by compromised bone strength, predisposing a person to an increased risk of fracture. The wrist, hip, and spine are the most common sites for fractures associated with osteoporosis. The economic and human costs of osteoporosis-related fractures are considerable. Although it is often considered a woman’s disease, osteoporosis is a significant source of morbidity and mortality in men. Available pharmacological treatments for osteoporosis include bisphosphonates, selective estrogen receptor modulators, calcitonin, parathyroid hormone, and hormone replacement therapy. Non-pharmacological interventions, such as nutritional counselling, exercise, and fall prevention, should also be considered in a fracture prevention plan.
Key words: osteoporosis, fragility fracture, bone, skeleton, bone density.

Donna L. Algase, PhD, RN, FAAN, FGSA, School of Nursing, University of Michigan, Ann Arbor, MI, USA.

Wandering is among the most challenging behaviours associated with dementia. While research is progressing toward a fuller understanding of this phenomenon, the basis for deriving effective and tested interventions has not been fully developed. In this paper, wandering is defined from multiple perspectives, and its various outcomes and risks are discussed. Putative causes of wandering are summarized. Finally, an approach to aid clinicians in discovering effective strategies for managing an individual’s wandering is presented.
Key words: wandering, dementia, assessment, intervention, primary care.

Manmeet S. Ahluwalia, MD, Department of Internal Medicine, Fairview Hospital, Cleveland Clinic Health System, Cleveland, OH, USA.
Hamed A. Daw, MD, The Cleveland Clinic Cancer Center, Cleveland, OH, USA.

Multiple myeloma (MM) is a neoplasm of plasma cells that is characterized by tumour cell tropism of the bone marrow and production of monoclonal immunoglobulins (Ig) detectable in serum and/or urine. It often manifests as one or more of lytic bone lesions, monoclonal protein in the blood or urine, disease in the bone marrow, renal failure, anemia, and hypercalcemia. Better understanding of the biology of myeloma has led to the development of agents, such as bortezomib, CC-5013, and thalidomide, that target the myeloma cell and the bone-marrow microenvironment. Ongoing trials promise to define the roles of new agents, mini-allogeneic transplantation, and maintenance therapy.
Key words: bone marrow, biology, transplant, chemotherapy, multiple myeloma.

Christine B. Brezden-Masley, MD, PhD, Staff Physician, Department of Medicine, Division of Hematology and Oncology, St. Michael’s Hospital; Assistant Professor, Department of Medicine, University of Toronto, Toronto, ON.
Monika K. Krzyzanowska, MD, MPH, Staff Physician, Department of Medical Oncology & Hematology, Princess Margaret Hospital; Assistant Professor, Department of Medicine, University of Toronto, Toronto, ON.

Pancreatic cancer is the fourth and fifth leading cause of cancer-related death for men and women, respectively (following lung, colon, and prostate cancers in men; lung, breast, colon, and ovarian cancers in women). Patients usually present with advanced disease, making curative attempts difficult. Surgery is the only curative therapy; however, local disease recurrence with or without spread to distant organs occurs in over 80% of patients. Attempts at better therapeutic modalities are necessary in order to improve outcome in this disease. This review will focus on staging, risk factors, and therapies for resectable, locally advanced, and advanced (metastatic) pancreatic cancer. Novel molecular targeted therapies will also be briefly highlighted.
Key words: pancreatic cancer, chemotherapy, radiation therapy, Whipple procedure, staging.

Natasha B. Leighl, MD, FRCPC, Assistant Professor of Medicine, Division of Medical Oncology, Princess Margaret Hospital/University Health Network; Department of Medicine, University of Toronto, Toronto, ON.

Lung cancer is the leading cause of cancer-related mortality in North America and most commonly affects older patients. Patterns of investigation and treatment in older individuals differ, which may compromise outcome. Older patients should be carefully evaluated, using comprehensive geriatric assessment, to assess for function, functional reserve, comorbidities, polypharmacy, and other issues. Fit patients with few or no comorbidities should be offered standard treatments such as surgical resection for early-stage lung cancer with adjuvant chemotherapy, combined modality treatment (chemotherapy and radiation) for locally advanced disease, and systemic chemotherapy with supportive care for metastatic disease. Frail patients should be reviewed to optimize function and comorbid illnesses, and then considered for other treatment alternatives aimed at minimizing toxicity while still trying to maximize the curative or palliative potential of lung cancer therapy depending upon disease stage.
Key words: lung cancer, aging, chemotherapy, surgery, radiation, treatment.