Evidence suggests that there is a greater prevalence of pain, particularly chronic pain, in the older than in the younger population. This review looks at how dementia affects older people's ability to report pain, and indicates that pain is poorly assessed and managed in people living with dementia, in particular in care and acute settings. The review also reports findings from two recent studies looking at ways of improving the assessment and management of pain in acute settings. Multi-dimensional, patient-centred approaches to assessing and managing pain in those living with dementia are required, and future research should focus on innovative and practical approaches that can be applied in care home and acute settings.

The increasing number of older people requiring interventions for improved health and social care has been identified as a crucial challenge for the twenty-first century. The reported high prevalence of pain in older people in long-term care facilities has been described as a public health issue not only in the USA but also globally. Rather than merely extending life, the reduction of morbidity, ways of coping with disability, preventing incapacity, extending the quality of life and enhancing the functional independence of older people are identified as important components of service provision. In Britain, the number of people aged over 65 years has doubled in the last 70 years and the number of people over 90 years is expected to double in the next 25 years, which will increase the need for health care in the future. Estimates for the UK indicate that approximately 445 800 older people are currently resident in care homes. The UK government has recently pledged to provide high-quality care and treatment for this population, to treat older people with respect and dignity and to allocate fair resources for conditions that affect them, while simultaneously easing the financial burden of long-term care.

Introduction

Physical therapy forms a large part of the multi-professional package of stroke care which has been shown to save lives and reduce disability, effects which may be maintained in the longer term. More specifically, physical therapy may improve performance of movement and functional ability poststroke, especially in the form of exercise-based interventions, and increased intensity of physical therapy may bring increased benefit. However, there is little evidence on which to base clinical decisions about what interventions to give to which patients, in what intensity and at what stage in the recovery process. In short, much of physical therapy practice remains based on clinical belief rather than objective evidence and robust research is needed.

The term myeloproliferative disorders (MPDs) describes a group of conditions in which an intrinsic stem cell defect is present in the bone marrow. This leads to hypercellularity in one or more of the myeloid cell lines (red blood cells, platelets, granulocytes and their precursors), or increased bone marrow fibrosis. MPDs are rare; combined annual incidence is 6 per 100,000.

MPDs may present in asymptomatic patients as an incidental finding, or may be associated with constitutional features such as weight loss, sweats or lethargy. Splenomegaly is common but lymphadenopathy is not a feature. The most significant complications are: arterial thrombosis, venous thrombosis, secondary marrow fibrosis and transformation to acute myeloblastic leukaemia (AML). Treatment aims to reduce the risk of such complications.

Recent advances in the understanding of the pathogenesis of these disorders have radically changed the approach to the diagnosis of MPD and are the focus of new treatment developments.

This paper reviews the handling of water and electrolytes by the ageing kidney and the clinical consequences in everyday clinical practice. Normal physiology in the adult kidney is discussed, followed by description of the main physiological changes (adaption) that occur as the kidney ages. Clearly, successful management of the elderly patient requires a knowledge of these changes, which result in: (i) increased tendency for volume depletion and dehydration; (ii) decreased ability to tolerate a volume load; (iii) increased propensity for potassium disturbances (hypo- and hyperkalaemia); (iv) diminished production of renin and blunted physiological response to the effects of aldosterone and antidiuretic hormone; (v) increased tendency to lower levels of phosphate; and (vi) tendency for the development of hypocalcaemia and hypomagnesaemia. A brief review of the role of extracellular fluid volume depletion and other factors contributing to acute renal failure in elderly patients is also presented.

Falls have a significant impact upon independent living ability in older people, with fall-related fractures one of the leading predictors of having to move into assisted living facilities. The loss of independence associated with a severe fall is often accompanied by a decline in physical, social, emotional and economic well-being. Rehabilitation programmes to restore functional ability following a fall have a greater chance of success if they adopt a multi-disciplinary approach and, if appropriate, are conducted in the patient's own home. Additional multi-component interventions that improve confidence and reduce the risk of subsequent falls may confer benefits by assisting individuals independently to perform activities of daily living.

Coronary artery disease is extremely common among elderly people and accounts for half of all deaths in those who are more than 65 years old. Although the condition is essentially the same as that encountered in younger patients, the management of coronary artery disease in elderly subjects can be difficult because the anticipated benefits and risks of the various treatment options are often altered by the presence of co-morbid conditions. Moreover, the results of the major outcome studies that underpin most treatment guidelines may not be relevant to the needs of many elderly patients for several reasons.

The continued imbalance of fatty acids in western diets has led to concerns about the effect this may be having on physical and mental wellbeing. Diets rich in omega-3 fatty acids, mainly docosahexaenoic acid (DHA) and eicosahexanoic acid (EPA), are argued to help with cardiovascular health as well as cognition. The mechanisms by which this happens are complex and not well understood. However, results from research in this area speculate that individuals with cognitive difficulties may benefit from increasing their omega-3 fatty acid intake, especially if they already show depleted levels of omega-3 fatty acids. This review examines mechanistic reasons behind why low intake of omega-3 fatty acids may affect physical and cognitive health, as well as evidence suggesting diets high in omega-3 fatty acids fend off cognitive disorders. It will also discuss the small body of evidence indicating that omega-3 fatty acids are depleted in those with already manifest cognitive disorders and the possibility that elevating omega-3 fatty acid status in such individuals may benefit their cognition.

Over recent years, small-vessel cerebrovascular disease has become increasingly recognized as an important contributor to cognitive and functional decline in elderly people.

Disequilibrium is typically described as a feeling of dizziness when standing or walking that is not present while sitting or lying down. Since dizziness is such a common symptom in older people, the symptom may be dismissed as a normal aging phenomenon. On the other hand, the patient may be inappropriately given nonspecific treatment for dizziness such as meclizine or diazepam, which may worsen the condition, due to sedation.

Urinary incontinence is a common problem, more so in older people and those in residential or nursing homes. Guidelines promote a structure to the management of incontinence, recommending non-pharmacological measures (including continence aids) as first-line options. Anticholinergic medications are used widely for urge incontinence, and surgical measures employed in selective cases.

Whilst other treatments are being tried, or where incontinence is refractory to treatment (about 30% of cases), it is important to promote continence or contain incontinence with continence aids in order to minimize psychological complications. What can be a bewildering array of aids is available and choosing the right type of aid requires knowledge of these. Here, we suggest a classification of continence aids, describing individual characteristics and appropriate situations for use.

Frailty as a clinical syndrome is becoming more widely recognized and current evidence shows the importance of early detection of pre-frail states with a potential for reversibility of poor outcomes. The purpose of this review is to present the latest literature on frailty since the last review in this journal in 2007, with a particular focus on interventions aimed at reversing the processes of frailty.

Frailty as a concept has been around in medical practice for many years but has only relatively recently been established as a medical syndrome. Although frailty is not synonymous with chronological age, it is recognized to be more common as people get older. Frailty is independently associated with increasing dependency, hospital admissions and morbidity and mortality. As populations age, frailty will become more of a challenge to health care systems. It is important that health care professionals, especially geriatricians, are aware of this emerging syndrome and its potential adverse outcomes, as well as measures to reverse and slow its progress. The aim of this review is to discuss the definition, identification and potential treatment options for frailty, most relevant to the practising clinician.

The status of the geriatric day hospital within the National Health Service (NHS) in the UK has changed significantly over the past fifty years. We conducted a literature review starting from the inception of the geriatric day hospital, when it was viewed as the ‘shop front for geriatric services’ and was subsequently replicated in many western health systems, to the present uncertainty surrounding the model in terms of outcomes and cost effectiveness. The article also highlights the input of the Royal College of Physicians and the British Geriatric Society to the management and development of day hospitals. The geriatric day hospital has become one of the many service models under the umbrella of intermediate care services, offering comprehensive geriatric assessment and care to older people in the community. However, with the current practices of commissioning of services and ‘payment by results’, the future of this precious health resource remains uncertain.

Sleep disturbance is a clinically significant problem in nearly one half of patients with dementia and is a predictor of cognitive and functional decline. There are multiple causes of sleep disturbance in dementia and all represent diagnostic and management challenges. Impaired circadian rhythm is a disorder characterized by an increase in daytime sleep with reduced night-time sleep, a reversal of the sleep/wake cycle. Such disrupted circadian rhythm may occur early in Alzheimer's disease, worsen over time, and is associated with behavioural disturbance, including aggression. In addition to the timing of sleep, the structure of sleep may deteriorate, giving rise to poor sleep quality.

The world's older population is projected to rise to some two billion people in the next 50 years. The health of older adults deteriorates with increasing age and creates greater demand for healthcare resources. Prevalence of the metabolic syndrome in older adults is causing concern due to its interplay between type 2 diabetes, obesity and associated morbidity and mortality. This call to action discusses comorbidities associated with type 2 diabetes and obesity in the older population and its impact on patients. We cover several topics to consider when designing prevention and treatment strategies for older adults and areas for improvement in our care of this special population are discussed. We know that dietary, exercise and weight-loss interventions are effective. However, these strategies require effort by both patient and physician. If all parties responsible in patient care take action, a change in lifestyle can lead to longer, healthier lives in older adults.