The connective tissue diseases and vasculitides are primarily conditions of the early and middle years. However, a significant proportion of patients do present in later life, and some conditions, such as giant cell arteritis, are almost exclusively confined to older patients. In later years, their presentation may differ from the classical descriptions and require a broader diagnostic sieve. Thirty per cent of elderly patients with pyrexia of unknown origin have a multi-system disorder. Autoantibody tests throw up more false positives with the risk of over-diagnosis and treatment is further complicated by the burden of co-existent disease and morbidity from therapeutic side-effects.

Foot disorders are common in elderly people and lead to significant difficulties in the form of immobility, pain and gait imbalance. Neuropathic changes associated with systemic disease, such as diabetes, carries the potential for ulcer development leading to possible foot or lower limb amputation. The role of the podiatric surgeon and the podiatrist/chiropodist in the prevention of foot problems in elderly patients is an important and often neglected element of health care for this group. Foot care is at present provided by podiatrists/chiropodists, nurses, orthotists, general practitioners, rheumatologists, geriatricians, casualty specialists, orthopaedic surgeons and podiatric surgeons. Sadly, foot care provision by these professionals is poorly co-ordinated. In most cases this is the result of the general lack of knowledge most professions have about the role of others; however, in at least one instance (orthopaedics), the issue is one of professional rivalry.

There is considerable debate as to the effects of aging on the susceptibility of old people to infection, and the extent to which this modifies the signs and symptoms of infection. Factors that may be of even greater importance are the effects of poor nutrition, multiple pathology and polypharmacy on their response to infection, and the effectiveness of their immune systems.

In the last review on this topic for this journal the focus was mainly upon service principles and an overview of variation in provision around the world. While there have been important developments and challenges within old age psychiatry in the last five years, these fundamental principles remain valid. This paper will therefore not simply present an updated version of the last but will instead concentrate on specific issues which seem to be of particular salience in the consideration of the organization and delivery of old age psychiatry services.

This review describes the concept of disablement, with particular reference to the World Health Organization’s International Classification of Impairments, Disabilities and Handicaps (ICIDH), and its forthcoming revision. Applications for a disablement classification are discussed, and the various approaches which have been applied to the measurement of disablement are reviewed. The relevance of disablement to psychiatric research and clinical practice is also addressed. In the second section of the review, data are presented from the last two phases of the Gospel Oak Survey, illustrating the value of simple measures of disablement in a community epidemiological study of the aetiology of late-life depression.

Delirium has been recognized since ancient times and was first called delirium by Celsus in the first century AD. Variously termed delirium, phrenitis and lethargy, severe disturbances of thought, mood and action were often seen to be associated with physical disease. In the nineteenth century delirium developed into a rather broader description of confusion, a state which emphasized chaotic thinking and cognitive failure but which included what we now call dementia as well as confusion arising in the context of other functional psychoses. During the twentieth century the concept of delirium has continued to evolve. Kurt Schneider emphasized clouding of consciousness as central to delirium and this assumption has largely persisted. Delirium has developed as an acute condition, often precipitated by major medical illness. Increased interest in elderly people as a special group has led to the recognition that delirium is a frequent feature of acute medical admissions of elderly patients.

Studies across the European Union have noted that chronic illness and chronic disabling conditions rather than acute infectious diseases are now the major causes of morbidity and mortality in member states. This transformation in the nature of health and illness has, and will continue to have, profound effects on the nature of both medicine and the policy and organization of health care. It is estimated that not only will the share of consultations with doctors about issues connected with problems of living with chronic conditions increase, but there will also be a corresponding shift in medical practice from cure to care.

There comes a time in the lives of a minority of older people when the extent of their disabilities makes it impossible for them to continue living in their own homes. When this happens, long-term institutional care may be the only option. Given that most residents in long-term care are over 75 years old and that the numbers in this age group will increase into the next century, we can expect an increase in the number of people requiring long-term care.

Symptoms of thyroid disease in older people are often subtle, and in most cases the diagnosis of hypothyroidism is made on the biochemical findings of high thyroid-stimulating hormone (TSH) combined with a low thyroxine (T4) level. However, with the routine use of sensitive assays, a significant number of patients have been identified with elevated TSH but normal T4 level and few or no symptoms. These patients have subclinical hypothyroidism (SCH).

The need for integration of health and social services for institutionalized elderly people is urgent. A possible approach, based on information-management, using established technologies, is described.