The daily clinical practice of geriatric medicine is a grapple with complexity. The elderly patients who come to geriatricians typically have multiple, interacting, age-related physiological impairments, some of which manifest as medical problems. These interact with various social vulnerability factors to put them at risk, and to define them as being frail. This view of frailty, as a multiple-determined state of vulnerability has broad support, but how best to operationalize frailty is rather more controversial. Some of the proposed operational definitions receive more widespread support than others. In particular, the ‘phenotypic’ definition of frailty used in the Cardiovascular Health Study (CHS) has been endorsed at consensus conferences and employed by several groups. Indeed, it has even been claimed that ‘the terms “frail” and “frailty” should be avoided except when used in the context of a CHS assessment.’

Average world life expectancy has seen a dramatic rise over the last two centuries although active life expectancy remains relatively unchanged. One reason for this is that aging results in skeletal muscle becoming smaller, weaker and more susceptible to contraction-induced injury. By the age of 70, muscle strength is reduced by around 30–40% and this can have catastrophic effects on quality of life. Despite a vast amount of research into age-related changes in skeletal muscle, the exact mechanisms responsible for this is still unclear and thus treatments to preserve muscle function with aging remain elusive.

People of 65 years and older accounted for 21% of the population of England and Wales in 2001, and their proportion is increasing. It is forecast that the number of people over the age 75 years will double within the next 50 years, and that of those over the age of 90 will increase fivefold. The older patient with declining health poses significant challenges for health care professionals, in particular those of managing chronic morbidity and the effects of aging. Many older people require pharmacological treatment for multiple, co-existing pathologies. Those of 65 years and over receive 56% of all prescriptions in England, of which 78% are repeat prescriptions, and people in residential care, on average, receive five different medicines concurrently. The impact of repeat prescriptions means that, due to inadequate monitoring, many older people continue to administer medicines they no longer require, and thereby risk receiving an inappropriate drug, dose or duration of treatment. In addition to this, there is the propensity for older people to mismanage medicines, increasing their risk of unplanned drug-related admission to hospital and drug-related morbidity.

Interest in homocysteine's role in vascular disease was stimulated by the paper of McCully (1969) in which, based on autopsy evidence of extensive arterial thrombosis in two children with elevated plasma homocysteine concentrations and homocystinuria, he proposed that elevated plasma homocysteine (hyperhomocysteinaemia) can cause atherosclerotic vascular disease. A meta-analysis of subsequent prospective observational studies concluded that elevated homocysteine is indeed a modest independent predictor of ischaemic heart disease and stroke risk in healthy populations with a 25% reduction in serum homocysteine concentration, a reduction of approximately 3 micromol per litre (μmol/l) being associated with a 19% lower risk of stroke (odds ratio, 0.81; 95% confidence interval (CI), 0.69 – 0.95). In the nationally representative sample of US adults, elevated homocysteine concentration was independently associated with an increased likelihood of non-fatal stroke in both black and white adults. In this article, the current concepts relating homocysteine to ischaemic stroke are reviewed.

Vascular cognitive impairment (V.C.I.) encompasses all forms of cognitive loss associated with cerebrovascular disease and ischaemic brain injury. It includes cognitive impairment related to stroke, cortical and subcortical infarcts, silent infarcts and strategic infarcts, white matter lesions associated with small vessel disease, and specific arteriopathies such as CADASIL (Cerebral Autosomal Dominant Arteriopathy with Subcortical Infarcts and Leucoencephalopathy). Recent studies have demonstrated that VCI is most commonly of a subcortical aetiology with small vessel disease being the major cause. VCI plays an important part in patients with other forms of dementia, such as Alzheimer's disease, who have coexisting vascular lesions and it has been proposed that VCI may be the most common form of cognitive impairment in older people, with a prevalence of 5% in people over the age of 65. In view of the aging population and the growing magnitude of vascular disease in western society, the prevalence of subcortical VCI is likely to increase, with a greater impact on patients and health care providers. In this article, we will review the cerebrovascular pathology underlying subcortical VCI and its role in mediating the characteristic cognitive deficits.

Delirium is a disorder characterized by a fluctuating disturbance of consciousness and attention, with changes in cognition or perception, which develops over a short period of time and is attributable to an underlying physical cause. It is often accompanied by disturbance of the sleep-wake cycle and altered psychomotor behaviour.

Dementia is a syndrome describing progressive and largely irreversible brain dysfunction. Symptoms are varied but commonly include memory loss, mood changes and difficulties with language and judgement. Delusions and hallucinations can also occur. With disease progression there is a gradual loss of ability to perform tasks of daily living. A range of illnesses, most of which are currently incurable, can cause dementia. These include Alzheimer's disease (AD), vascular dementia (VaD), dementia with Lewy bodies (DLB) and frontotemporal dementia (FTD). Mixed patterns of dementia also exist, typically Alzheimer's disease overlapping with vascular dementia. This combination of pathologies is probably much commoner in the elderly than traditionally thought.