Diagnosis and Management of Mild Cognitive Impairment

Raj C. Shah, MD, Rush Alzheimer’s Disease Center; Department of Family Medicine, Rush University Medical Center, Chicago, IL, USA.
David A. Bennett, MD, Rush Alzheimer’s Disease Center; Department of Neurological Sciences, Rush University Medical Center, Chicago, IL, USA.

Mild cognitive impairment (MCI), the presence of cognitive difficulties without having dementia, is viewed as a preclinical state for Alzheimer’s disease (AD) or another dementing illness. With the burden of AD expected to increase, research efforts have focused on interventions to delay the progression of MCI to AD. In this review, we first discuss the current conceptual understanding of MCI. Then, we outline a simplified approach to help clinicians diagnose MCI. Finally, we provide an overview of how to address the clinical needs of individuals with MCI.
Key words: mild cognitive impairment, Alzheimer’s disease, diagnosis, prognosis, treatment.

Erectile Dysfunction as an Early Marker for Cardiovascular Disease

Kevin L. Billups, MD, Urologist & Medical Director, The EpiCenter for Sexual Health & Medicine, Edina; Adjunct Assistant Professor, Laboratory Medicine & Pathology, University of Minnesota, Minneapolis, MN, USA.

Erectile dysfunction (ED) is a prevalent vascular disorder that, like cardiovascular disease, is now believed to cause endothelial dysfunction. In fact, a growing body of literature now suggests that ED may be an early marker for atherosclerosis, increased cardiovascular risk, and subclinical vascular disease. The emerging awareness of ED as a barometer of overall cardiovascular health represents a unique opportunity for primary prevention of vascular disease in all men. Although the implications of this relationship for primary and secondary prevention of cardiovascular disease are not yet fully appreciated, the available literature makes a strong argument for the role of erectile dysfunction as an early marker for the development of significant cardiovascular risk factors and cardiovascular disease. Early detection of erectile dysfunction could play a major role in improving male cardiovascular health.
Key words: erectile dysfunction, cardiovascular disease, atherosclerosis, endothelium, prevention.

The Clinical Approach to Dysthymic Disorder in Older Adults

Elizabeth J. Santos, MD, Geriatric Psychiatry and Interdisciplinary Geriatric Fellow, Program in Geriatrics and Neuropsychiatry, Department of Psychiatry, University of Rochester Medical Center, Rochester, NY, USA.
Lisa L. Boyle, MD, Geriatric Psychiatry and Interdisciplinary Geriatric Fellow, Program in Geriatrics and Neuropsychiatry, Department of Psychiatry, University of Rochester Medical Center, Rochester, NY, USA.
Jeffrey M. Lyness, MD, Associate Professor and Director, Program in Geriatrics and Neuropsychiatry, Department of Psychiatry, University of Rochester Medical Center, Rochester, NY, USA.

Dysthymic disorder is a chronic depressive illness that affects approximately one to five percent of seniors. Often undetected and untreated, dysthymia is associated with significant psychological distress, medical burden, and functional impairment. Dysthymic disorder in the older population can be challenging to diagnose because of comorbid medical conditions and life losses. Dysthymic seniors often present differently than younger patients. The general practitioner plays a crucial role in identifying and providing interventions for older dysthymic patients. Careful evaluation, psychoeducation, and therapeutic interventions are essential to alleviate further suffering and to improve quality of life and function for these patients.
Key words: dysthymic disorder, depression, psychological symptoms, medical comorbidities.

Primary Care Prevention of Suicide among Older Adults

Marnin J. Heisel, PhD, C.Psych, Center for the Study and Prevention of Suicide, Department of Psychiatry, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA.
Paul S. Links, MD, FRCP(C), Arthur Sommer Rotenberg Chair in Suicide Studies, Suicide Studies Unit, Department of Psychiatry, University of Toronto/St. Michael’s Hospital, Toronto, ON.

Older adults have high rates of suicide worldwide. Suicide rates increase with advancing age, and older adults typically use highly lethal means of self-destruction. In addition, suicidal older adults tend to pursue treatment in primary care rather than mental health settings, but current limitations in the primary care system potentially restrict suicide prevention in older patients. We briefly review the epidemiology of late-life suicide and suggest modifications in primary care to better address the psychosocial needs of at-risk older adults, supported by research on suicide risk and resiliency, clinical assessment and treatment options, and collaborative models of primary medicine and mental healthcare.
Key words: suicide, suicide ideation, suicidal behaviour, older adults, primary care.

Nonpharmacological Treatments for Older Adults with Depression

Pharmacotherapy of Depression in Older Adults

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

Beyond Sad Mood: Alternate Presentations of Major Depression in Late Life

Cancer Diagnosis and Consent to Treatment in the Older Adult

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.

Software Tracks Wandering Patients

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.

Sudden Deafness, Part 2: Rehabilitation

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.