Rehabilitation is a necessary step in the process of recovery from most serious illness and from many clinical interventions. The nature of rehabilitation, and the form of any programme of rehabilitation provided to help patients with this process, depends greatly on patient, illness, treatment or intervention, co-morbidity and on the availability of appropriate services. Heart disease is the leading cause of death in most developed countries and acute myocardial infarction (MI) is a major cause of acute medical admissions to hospitals, and revascularization by coronary artery bypass graft surgery (CABG) is a leading surgical intervention. Both MI and CABG involve a day or more in intensive care followed by several days recuperation in hospital. There is a fairly obvious case for rehabilitation for patients surviving the truly life-threatening experience of MI (20% sudden deaths and a further 10% die within 24 hours of onset of pain), and for patients following the major ‘trauma’ of open heart surgery (operative mortality about 1%). The specific needs of these two groups may differ because their experiences differ; one medical the other surgical, and, possibly more significantly, one unexpected, the other planned.

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.

Until recently, there has been relatively little scientific research investigating the influence of food or nutrient intake on longevity. This is partly due to the fact that most investigators have been interested in the relationship of food or nutrient intake to specific diseases i.e. communicable diseases, coronary heart disease and cancer of specific sites, rather than to overall mortality or longevity. Another significant factor is the difficulty of comparing the nutritional intake of populations, owing to the wide variability in individual intake and poor individual recall of specific food items in epidemiological studies.

Elderly people and their carers are not homogeneous groups, but are highly diverse in terms of their age, ethnicity, income, housing, education, geographical location and access to providers of health. In planning provision, particularly respite care, we need to focus attention on the needs and preferences of those who are not currently receiving help, as well as on the satisfaction with existing services of those who are. There been evidence for some years, for instance, that those in rural areas have different needs from those in urban areas.

Vascular cognitive impairment (VCI) is a relatively new concept, encompassing all forms of cognitive loss associated with cerebrovascular disease and ischaemic brain injury. It covers a broad spectrum of pathologies within the brain, with different causes and clinical presentations. VCI includes vascular cognitive dementia, (VaD). VCI also encompasses mixed (AD and vascular dementia) as well as hereditary disorders. Table 1 shows the main subtypes of VCI.

Growth hormone and related growth factors are essential for normal childhood development, secretion rate then declining from early adulthood. Adults with growth hormone deficiency, e.g. after pituitary ablation, have many clinical features such as reduced muscle and bone mass which are also seen in healthy older people. In both cases, growth hormone treatment at least partly reverses these changes. This has led to the rather elegant notion that growth hormone decline may be responsible for age-related involution and death and raises the prospect of hormonal replacement therapy for aging and frailty.

Vitamin D has been known to play a key role in calcium homeostasis and bone health for almost a century. Its main current clinical use is as an agent to prevent osteomalacia and reduce fragility fractures in older people. Vitamin D may however play a wider physiological role, with effects on cancer prevention, cardiovascular health and immune function. This review article will outline the physiological role of vitamin D, the disease processes that have been associated with insufficiency and examine whether vitamin D supplementation can ameliorate these disease processes in older people.

Older people with cognitive impairment and dementia are at increased risk of falls and their adverse consequences when compared with cognitively intact older adults. Using prospectively gathered data, approximately three-quarters of older people with cognitive impairment and dementia can expect to fall each year, double the fall-risk of cognitively normal older people. In addition, compared with their cognitively normal counterparts, people with cognitive impairment and dementia have an increased annual incidence of fractures, and are less likely to make a good functional recovery after a fall. The prevalence of dementia in the United Kingdom is about 5% of the population aged over 65, and 15% of those aged over 80. Falls in patients with cognitive impairment and dementia represent a significant health problem in the UK.

The proportion of older people in our society is increasing more rapidly than any other section of the population. This group uses health and social services more than the young do and this is reflected in the NHS and social service budgets from recent years. For example, 40% of the NHS budget was spent on patients over 65 years in 1998. The much-heralded National Service Framework (NSF) for Older People, recently published by the Department of Health in England, was therefore awaited with much anticipation by all sections of the community concerned with older people’s health. This document is described as the ‘key vehicle for ensuring that the needs of older people are at the heart of the government’s reform programme for health and social services’. It has as its first and fundamental standard ‘rooting out age discrimination’. The sections on prevention and treatment of stroke, general hospital care, the management of falls and mental health have been generally well received and when implemented fully are likely to be beneficial to older people. Some areas such as the treatment of care home residents have not been addressed in nearly enough detail. In contrast, one particular section, that on ‘Intermediate Care’, has been heavily criticized, including a fierce attack by two of the United Kingdom’s leading geriatricians.

The present review, building on a previous review published in 1993, gives a general overview of a large subject. As on the previous occasion, it is primarily concerned with the assessment of risk and the improvement of outcome in the older surgical patient. However, some of the previously-discussed technical difficulties of assessing risk, which apply to a wide range of medical and surgical specialties, have not been repeated this time. Updates have been given on cardiac, respiratory and nutritional risk assessment in older surgical patients, and a section on post-operative changes in mental function has been added. The use of new outcome measures, including the measurement of quality of life, is also discussed more fully in the present review.

This review provides an update on current evidence surrounding epidemiology, treatment and prevention of lower respiratory tract infection, with special reference to pneumonia and influenza, in care home residents. The care home sector is growing and provides a unique ecological niche for infections, housing frail older people with multiple co-morbidities and frequent contact with healthcare services. There are therefore considerations in the epidemiology and management of these conditions that are specific to care homes. Opportunities for prevention, in the form of vaccination strategies and improving oral hygiene, may reduce the burden of these diseases in the future. Work is needed to research these infections specifically in the care home setting, and this article highlights current gaps in our knowledge.

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.

Insomnia is a prevalent sleep complaint amongst older people, affecting physical and mental health as well as many aspects of life quality and well-being. For the lack of explicit guidelines for the assessment and treatment of insomnia in older people, this summary of available information represents the best evidence to inform current practice. Clinicians need to be more aware of their patients’ sleep and conduct formal assessments as appropriate. Despite past practice trends, non-pharmacological treatments should be considered first for chronic insomnia as a means to reduce dependency, adverse effects, and polypharmacy. Behavioural treatment methods such as stimulus control and sleep restriction are especially beneficial for older insomniacs as they target maladaptive sleep habits. Pharmacological treatment should be employed only if insomnia persists, involving the careful patient-specific consideration of the lowest effective dose, best intermittence of dosing, shortest effective duration, best gradual discontinuation scheme, and most effective elimination half-life.

Pressure ulcers are the visible evidence of pathological changes in the blood supply to dermal tissues. Pressure ulcers are rare, affecting only about 0.5% of the total population. The distribution is clustered into two groups, peaking once in younger, mostly neurologically impaired persons and again in older persons. The cluster in the geriatric population accounts for about 70% of all pressure ulcers.

Geriatric medicine emerged from long-term care championed by Marjory Warren and contemporaries, who focused attention on the opportunities and rewards of assessing, treating and, in particular, rehabilitating older people resident in institutional care. Then as now, people in long-term care were generally beyond the remit of hospital medicine. From this rehabilitative initiative in long-term care, geriatric medicine has continually developed and in the process has become increasingly divorced from its roots. The present evolutionary state of the specialty could be summarized by the goals of concentrating on the early detection, treatment and rehabilitation of acute and chronic ill health, in an attempt to improve quality of life and reduce dependency.

The accurate measurement of renal function in elderly subjects is often required, due to structural and functional changes resulting from age and diseases affecting the kidney. Structurally, with age there is progressive loss of renal mass, particularly in the cortex, leading to a decreased number of glomeruli and an increase in the proportion of sclerotic glomeruli. A decline in the glomerular filtration rate (GFR) has been observed in both cross-sectional and longitudinal studies. However, it has also been noted that about one third of subjects have stable renal function, implying that this decline is not universal, and may reflect the effects of age-associated diseases.