Editorial

Even a decade ago, there was compelling evidence that, as older individuals age, a decline in caloric intake is observed, with as many as one in five subjects aged 60 years and over consuming less than 1000 calories per day. Those from ethnic minority backgrounds or nursing homes were particularly at risk of malnutrition. In many cases, this decline can be confidently attributed to the presence of disease and co-morbidities such as chronic illness (for example, chronic pulmonary lung disease) with results in weight loss. Other factors such as decreased resting metabolic rate, reduced physical activity, threshold alterations in taste-bud activity or lowering of smell acuity, provide background inhibitory influences on nutritional intake.

ob/ob mice with mutations in the obese gene are extremely obese and hyperphagic and have characteristic neuroendocrine impairments, including impaired reproduction and low sex hormones, low thyroid hormone, low growth hormone, and elevated glucocorticoids, a pattern also observed in fasting mice. The product of the obese gene, called leptin, was originally characterized on the basis of positional cloning. Injections of leptin not only reversed many of the phenotypes of ob/ob mice, many of the neuroendocrine effects of fasting are also reversed by leptin injection.

Cerebral multi-infarct states (MIS) have a very variable clinical presentation (Table 1). Dementia is often stressed as the primary feature, however, many patients have relative preservation of cognitive abilities and personality, although their mobility may be severely affected, with a small-stepped shuffling gait, poor balance and frequent falls associated with bilateral (often asymmetrical) pyramidal tract signs. Urinary incontinence is common, dysphagia and dysarthria may occur, and some patients develop emotionalism and/or depression. In the later stages, patients may become immobile, requiring 24-hour nursing care.

This is the second in a series of three papers reviewing 69 patient-based outcome measures that have been developed specifically for use with older people, or that have been administered to populations that include older people. The first paper described how the measures were identified, and provided a brief description of 17 measures of general health status and quality of life. This paper reviews nine measures of mental status and cognitive function, 10 measures of depression and anxiety, and seven psychological wellbeing measures (see Tables 1-3).

Constipation is a common complaint in geriatric patients, especially when older people are asked specifically about their bowel habits. It can cause serious complications, such as recurrent urinary tract infections, urinary incontinence, faecal incontinence and even bowel obstruction and perforation. As a result of the tremendous advances in understanding of the epidemiology and pathophysiology of constipation in the older patient, the definition of constipation has changed considerably, leading to the development of new treatment options.

Depression is the most common mental health problem in old age, presenting a significant challenge to mental health services for older adults. The high chronicity, relapse and mortality rates associated with late-life depression suggest that existing treatments for late-life depression are insufficient. Therefore, current theoretical understandings may require further development. Given the growing population of older adults, the need to improve our understanding of late-life depression is increasingly urgent.

Communication is integral to human life. During the communication process, an idea or concept is received by an individual either from another individual or from the physical environment. Person-to-person transmission of ideas could be through the medium of spoken/written language or through non-verbal media such as body language, gesture or facial expression. Ideas or concepts communicated from the physical environment allow the individual to function within that environment. For example, the concept of traffic must be understood, so as to allow safe and effective day-to-day functioning, whilst comprehension of the concept of a CD player could allow the individual to acquire appropriate auditory stimulation for relaxation and enjoyment.

The clinical indications and potential uses of botulinum toxin A (BtA) have steadily increased since it first became available for clinical use in the late 1980s. A pattern has emerged of anecdotal reports of possible benefit in a new indication, followed by multiple small uncontrolled or open studies, with the eventual publication of controlled and blinded trials. This process has been fastest in easily defined clinical situations such as focal dystonias - blepharospasm is a good example - and slowest in the more complex world of rehabilitation. For some indications, uncritical initial enthusiasm has created an atmosphere inhibiting adequate controlled trials.

Driving: a new geriatric giant?

Over the last fifty years geriatric medicine has promoted the concept that functional loss in older people is primarily a health issue. For a major loss of function, such as incontinence or immobility, we recognize the need for detection, investigation and treatment. The diagnostic / therapeutic / rehabilitation paradigm takes precedence over the prosthetic approach. Not only do we appreciate the benefits of an interdisciplinary assessment, but we are also accustomed to estimating risk and competence when making decisions about discharging frail older people back to their home environment.

Chronic obstructive pulmonary disease is a major cause of morbidity, disability and mortality in old age. The disease is characterized by shortness of breath, impaired ventilatory function and easy fatiguability. These are the most distressing and disabling symptoms of COPD, limiting exercise tolerance, interfering with basic activities of daily living and often, in turn, impairing quality of life.