Issue

CASE PRESENTATION
Mrs. R, a 64-year-old widowed woman, presented to the emergency department of an academic medical center with acute confusion, generalized weakness, and recurrent falls. She was awake and alert, but disoriented to time and place. Swelling of the face, neck, and upper limbs were noted. Multiple subcutaneous hard nodules approximately 2-3 cm in size were palpable in the chest and abdominal wall, as was a left breast mass approximately 7 cm in size. This was not Mrs. R’s first evaluation for these symptoms. Two weeks earlier, her family brought her to a local hospital with s

Behavioral and psychological symptoms of dementia (BPSD) is a term used to describe a heterogeneous group of noncognitive symptoms and behaviors that occurs in people with dementia.1 The term BPSD was defined by the International Psychogeriatric Association at the Update Consensus Conference, entitled “Behavioral and Psychological Symptoms of Dementia (BPSD): A Clinical and Research Update,” held in May 1999, as “Symptoms of disturbed perception, thought content, mood or behavior that frequently occur in patients with dementia.”2 The various behavioral symptoms described include physic

INTRODUCTION
Similar to most other health care providers, surgeons are seeing an ever-increasing proportion of elderly patients in their practices. Furthermore, this patient population is more likely to require operations. Patients age 65 and older currently account for approximately 60% of the average general surgeon’s work.1 The growth in general surgery over the next decade is expected to outpace the population growth due to a large increase in the number of older Americans. In specialties that care for a greater proportion of elderly patients, such as ophthalmology, urology, and cardio

INTRODUCTION
Owing largely to an increase in the incidence of diabetes mellitus and hypertension, chronic kidney disease (CKD) among the elderly is approaching epidemic levels. Among the more than 8 million Americans with an estimated glomerular filtration rate (GFR) of lower than 60 mL/min/1.73 m2, an estimated 6.6 million persons age 65 years or older are enrolled in the Medicare system.1,2 A GFR of lower than 60 mL/min/1.73 m2 would place these persons at CKD stage 3 or higher, according to classifications established by the National Kidney Foundation (Table).3 The prevalence of lower GFRs

ACCREDITATION
The Johns Hopkins University School of Medicine is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The Johns Hopkins University School of Medicine takes responsibility for the content, quality, and scientific integrity of this CME activity.

CREDIT DESIGNATION STATEMENT
The Johns Hopkins University School of Medicine designates this educational activity for a maximum of 1 AMA PRA Category 1 Credit™. Physicians should only claim credit commensurate with the extent of their participation in the

June 2006

This continuing medical education activity is presented by the Johns Hopkins University School of Medicine, Baltimore, Maryland. The Johns Hopkins University School of Medicine takes responsibility for the content, quality, and scientific integrity of this CME activity.

These examination questions are based on the article “Oral Infections in the Elderly—Part I: Bacterial Infections of the Mouth,” which appears on pages 36-45 in this issue of Clinical Geriatrics.

ACCREDITATION
The Johns Hopkins University School of Medicine is accredited by the Accreditation Counci

While Daylight Savings Time starts in April and spring brings flowers and warmer weather, in many parts of the country, June begins the season when we spend a greater time outdoors. Older persons should enjoy the summer season as much as anyone else, but for many, spending time outside remains a challenge. There are special concerns this time of year for our older patients, with a little prevention going a long way toward ensuring enjoyment while minimizing risk. Some thoughts follow that came quickly to mind. I’m sure you have your own list of items that we would all be well advised to thin

What are the real numbers regarding enrollment and why does it matter? The reason why knowing the real numbers is so important is that failing to do so will result in providers failing to be energized to persuade the 6 million Medicare beneficiaries who did not enroll in Medicare Part D to take advantage of this prescription insurance. In addition, not understanding the true numbers and how many persons have been affected or not affected will have a negative effect on how future health care policy is developed.

THE REAL NUMBERS
So what are the real numbers? There continues to be confus

43 million people are eligible for Medicare Part D. Roughly 20% of the population of the United States.

Lost in the confusion and the difficulties with the implementation of Medicare Part D is the realization that the U.S. government, in its endless bureaucracy and politics, just enrolled 37 million people into a prescription drug benefit that will on average save a typical Medicare beneficiary $1100 per year.1 This was no small feat. It’s easy for pundits and experts to bemoan the barriers and difficulties of such an endeavor—but the reality is that it worked.

There will be no dela

To the Editor:
Thank you for your Psychiatry Rounds column in Clinical Geriatrics—always thoughtful and thought-provoking. I was especially interested in “Decision-Making Capacity.”1 You made many of the same points as Ganzini et al,2 which are increasingly important to be understood by all practitioners caring for elderly and care-dependent patients.

I would like to ask the following:

1. While the law “presumes legal competence” unless adjudicated otherwise, should clinicians presume clinical capacity in settings with a known prevalence of incapacity exceeding 50%,3 such as