The term euthyroid sick syndrome (ESS) is used to describe abnormalities in thyroid function tests that are observed in patients with systemic non-thyroid illness. Despite these abnormalities, there is usually little clinical evidence of hypothyroidism. Patients with ESS are generally considered to have altered thyroid hormone metabolism and to be euthyroid.

Anaemia is the most common haematological problem of older patients. Given the heterogenous nature of this group, with an age span of over 30 years, the reported prevalence of anaemia is, not surprisingly, quite variable. However, a large survey from the UK has reported an overall prevalence of anaemia of 20.1% in elderly men and 13.7% in elderly women.

The types and causes of anaemia differ between elderly and younger patients. Anaemia of chronic disease becomes the commonest cause of anaemia in the older age group and reflects the increased incidence of chronic inflammation and malignancy in later years. Iron deficiency anaemia is commonly seen and due to gastrointestinal blood loss. Furthermore dietary deficiencies not only of iron, but also of folate, protein and ascorbic acid can all precipitate anaemia in the many elderly subjects who live in poor socio-economic conditions. Pernicious anaemia, as with other autoimmune conditions, is also encountered more commonly in the elderly than in the younger population. Malignant blood disorders with associated anaemia, such as myelodysplasia and leukaemia, become more frequent with advancing age.

Visual impairment in the aging population may be brought about by localized pathological change or it may be associated with systemic disease. Localized ocular disorders include three of the commonest causes of visual loss in the elderly, namely cataract, glaucoma and age-related macular degeneration. Systemic diseases, with associated ocular involvement which may progress to blindness, include diabetes, hypertension and hyperlipidaemia, which predispose to retinal vascular occlusion. Visual function may also be affected by various autoimmune disorders (e.g. rheumatoid arthritis), cerebrovascular disease, intraocular or intracranial tumours (primary or metastatic), as well as by infectious agents (herpes zoster ophthalmicus) and drugs (steroids).

Parkinson’s disease (PD) is a progressive neurological disorder affecting at least 120 000 persons in the UK today. Age is the most potent risk factor. With the rising numbers of elderly, PD will become an increasingly important cause of disability and mortality. This has significant implications for health planning.

In recent years, there has been growing emphasis on the key role of the specialist clinic, interdisciplinary team and the PD specialist nurse in the management of the condition, as well as recognition that quality of life for people with PD and their carers relates to more than motor disability and disease severity. Appropriate care planning requires skilled assessment, and a new paradigm, incorporating four progressive clinical management stages (diagnosis, stable maintenance stage, complex stage and palliative stage) may be useful. The importance of all these aspects to successful holistic management of PD should be emphasized but is beyond the scope of this review, as is diagnosis, which is the subject of a separate contribution.

This article updates a previous review of this topic published in this series in 1996. The number of studies and review articles that have been published since then is encouraging, and suggests that there is a growing awareness of and interest in these disorders in old age.

As a correlate of psychological well-being, insomnia continues to be regarded as a critical indicator of both mental health and quality of life, appearing as a prominent diagnostic feature in both DSM-IV1 and ICD-102 (particularly in relation to depression and anxiety states), and included in many of the most commonly used health outcome measures, including the Nottingham Health Profile and the SF-364. The symptom of disturbed sleep is also included in most of the available schedules for assessing the mental health of elderly people, including the GMS, CAMDEX, and the CARE. Whether specified as a diagnostic criterion or included in a diagnostic algorithm, the assumption is made that certain patterns of sleep disturbance are associated with, and consequently predict, certain types of mental illness. The evidence would suggest, however, that the strength of the association, and hence the validity of this assumption, may diminish across the human lifespan.

Why measure?

Before we consider what to measure and how to measure outcomes in the rehabilitation of frail older adults, an antecedent question is, why measure these things? Without an answer satisfactory for both measurers and measured, much effort and ingenuity will be expended with resultant perspiration and exasperation and little else.

Traditionally, medical care, i.e. that identified by physicians, has assumed that its principal objective was patient care, i.e. that appreciated by patients. Outcomes of care from the viewpoint of the patient, of his or her informal supporters, of the involved health care professionals, and of the health care delivery system have to be clarified and made operationally explicit. This recognition requires definition and measurement. Thus a powerful reason for measuring outcomes for recipients and providers of health care, as well as the health care delivery system, is to know what is happening (the descriptive question) and with what effect (the analytical question).

The use of the term ‘family (informal) carer’, as it is currently conceptualized, is recent and is largely the product of increased attention in the academic and policy literature over the last two decades. Despite their fairly late arrival on the scene, family carers now occupy centre stage in UK government policy, having being described by the Prime Minister, Tony Blair, as the ‘unsung heroes’ of British life, who are essential to the fabric and character of Britain. Such recognition stems from the growing realization that family carers are the lynchpin of community care, providing 80% of all the care needed at an estimated saving to the UK government of some £40 billion annually.

Hospital readmission rates for COPD patients are high, with two-week readmission rates of 22% being recorded in one study of patients with acute exacerbation of chronic obstructive pulmonary disease (AECOPD). In a separate study, patients admitted with PaCO2> 50 mm Hg had a readmission rate of 40% at six months. There are no agreed clinical evidence factors that determine readmission. A few studies have reported that readmission is associated with an individual’s inability to cope with the disease, and that anxiety and socioeconomic status are important variables. Others argue that readmission relates to severity of lung function abnormality, changes in atmospheric pollution, and impaired quality of life (QoL).