Use of the term frailty in the medical literature has increased significantly in the last 20 years. A MEDLINE search using the combined terms ‘frail’ and ‘elderly’ yielded 473 articles published between 1996 and 2001, compared with 85 between 1980 and 1985. This increasing interest in frailty has been fuelled by evidence that the ‘frail elderly’ are the group most likely to benefit from geriatric intervention programmes and by the close links between frailty and longer hospital stays, nursing home utilization and mortality.

Phosphate (PO4−) has a number of important functions in the human body and abnormalities of phosphate handling and phosphate levels are common in older people. We review the physiological functions of phosphate, the effects of phosphate deficiency and excess, and discuss the evidence underpinning management of these conditions in older people. Both hyper- and hypophosphataemia have been associated with a variety of adverse effects in different patient groups. There is currently little evidence to guide practice in treatment of abnormal phosphate levels specifically in older people. Studies looking into the effect of replacing phosphate on morbidity and mortality in milder cases of hypophosphataemia and into the dangers of, and treatment of, hyperphosphataemia in older people are required.

Small intestinal bacterial overgrowth (SIBO) is a condition in which non-native bacteria and/or native bacteria are present in increased numbers in the small bowel, resulting in excessive fermentation, inflammation or malabsorption. Patients with SIBO vary in presentation, from being only mildly symptomatic to suffering from chronic diarrhoea, weight loss and malabsorption. A number of diagnostic tests are currently available, with aspiration of the small intestinal fluid being the gold standard. Treatment encompasses a multimodal approach including treatment of the underlying disease, nutritional support and antibiotic therapy. In this review, we discuss the risk factors, clinical manifestations, diagnosis and treatment of SIBO in older people.

The number of people aged 65 years or more is increasing worldwide. Alcohol use disorders (AUD) are a common condition in the older population, and this combined with the changing age demographic in the population means that AUD in this population is a significant public health concern. AUD has a major impact upon the physical, psychological and social health of the older population. There is evidence that older people do benefit from interventions to reduce alcohol consumption as much as, if not more than, younger populations. There is evidence that AUD in the older population often goes undetected and the potential for beneficial behavioural health change is not realized.

There has been much discussion about the effect of aging on routinely analysed haematological parameters. The consensus view favours a slow decline in the median value of haemoglobin, including the lower limit of the reference range, especially in the very old. This could be explained in part by the recent finding that many elderly patients with a normocytic, but not a microcytic or a macrocytic, anaemia have an impaired response to erythropoietin. In addition, the number of bony sites exhibiting active haematopoiesis decreases with age, with the marrow being replaced by fatty tissue. This involution first takes place in the long bones, particularly the femur, while the flat bones are relatively spared. The sternal marrow, for example, is one of the last bony sites to show fatty change, usually occurring after 60 years of age. Magnetic resonance imaging confirms this age-related reduction in marrow cellularity.

Key strands in developing future services in geriatric medicine in Wales have been the 2000 ‘Review of Health and Social Care in Wales’ by Sir Derek Wanless, the Welsh Assembly Government document ‘Designed for Life’ of May 2005, and the National Service Framework (NSF) For Older People in Wales (published in March 2006). The common theme in these documents is for older people's health and social care issues to be managed nearer to their home, in the community. At present, the development of Intermediate Care Services has been ‘hit and miss’ – fragmented, unevenly developed and delivered with poor integration into mainstream services. The Academy of the Royal College's Medical Aspect of Intermediate Care identifies the lack of specialist medical input as being one of the reasons for the failure of development of Intermediate Care Services. It recommended that geriatricians should be encouraged to undertake well-defined roles in community work in planning and delivery of Intermediate Care Services.

The last five years have produced a large output on the epidemiology of dementia and cognitive impairment, specially on apolipoprotein E (apo E), vascular changes, and education as risk factors. Minor cognitive deficits have been studied prospectively to assess their value in predicting dementia. Reviews of work from particular centres and articles on special aspects give more detail. Preference is given to population-based over clinic-based studies and to those published in or after 1994.

The incidence of deep vein thrombosis (DVT) and pulmonary embolism (PE), collectively called venous thromboembolism (VTE), increases with age and has been reported to be higher in males. The annual incidence rates per 1000 for DVT and PE are 1.3 and 1.8, respectively, for people aged between 65 and 69 years, rising to 2.8 and 3.1, respectively, in those aged between 85 and 89 years. Older people are about eight times more likely to develop VTE in hospitals, nursing homes or other chronic care facilities than younger adults. About 1.7% develop PE within one year of treatment for DVT, whilst the one year recurrence rate for PE was 8.0%. About 3% of patients with DVT and 21% of those with PE die in hospital. One year mortality with DVT is 21% and that with PE is 39%.

Malnutrition is common in older people and is associated with a number of adverse outcomes. We review the evidence for the effectiveness of nutritional supplementation for older people in the community, in institutional care and following discharge from hospital. Studies in these settings are scarce, often include only small numbers of participants and are of variable quality. The interventions used are heterogeneous and difficult to directly compare. Oral nutritional supplements (sip feeds), dietary fortification, educational programmes, exercise, flavour enhancement and meal setting have all been studied. Evidence for use of oral nutritional supplements as sip feeds in undernourished community-dwelling and institutionalized older people and in those discharged from hospital is currently insufficient to recommend routine use. Flavour enhancement and more sociable meal environments may be beneficial. Further, more methodologically robust research is needed to clarify the effect of these interventions.

The publication of the Black Report in 1980 is rightly seen as a landmark in the acknowledgement of an association between poverty and increased incidence of and premature mortality from a wide range of diseases. However, an increased incidence of disease with certain lifestyles or habits has been recognized since the time of Hippocrates, who identified ‘the mode in which inhabitants live, and what are their pursuits, whether they are fond of drinking and eating in excess’ as determinants of illness.

There is overwhelming evidence to suggest that the neuropathology of Alzheimer's disease (AD) extends beyond amyloid plaques and neurofibrillary tangles. There is a clear overlap between the pathology of AD and vascular dementia (VaD), but the relationship is different for different types of vascular lesion. Cerebral amyloid angiopathy (CAA) and degeneration of the microvasculature are probably intrinsic to the AD process, whilst ischaemic white matter disease and areas of infarction are largely independent of AD pathology, but result in additional cognitive deficits and reduce the threshold of AD pathology necessary for the emergence of a clinical dementia syndrome.

Chronic obstructive pulmonary disease (COPD) is the fifth leading cause of mortality in the USA. For 1984 to 1993, among Canadian seniors aged over 65, COPD was the fourth cause of mortality in men and the seventh in women. Though the underlying pathology is initially confined to the lungs, the associated physical deconditioning and the emotional responses to chronic respiratory disease contribute greatly to the resulting morbidity. Increased shortness of breath leads to inactivity and consequent cardiorespiratory and muscular deconditioning, which in turn leads to further inactivity, social isolation, fear of dyspnoea and depression. Respiratory rehabilitation may offer a way to break this vicious circle.

Providing symptomatic palliation in terminal malignant disease is integral to high-quality elderly-care medicine. Effective pharmacological treatment, especially pain relief, is the mainstay of palliative care, but physical intervention is sometimes required to relieve mechanical problems. Interventional radiology is rapidly evolving and there are many clinical situations in which it is indicated. It is as effective as open surgery, but without the risk of general anaesthesia and surgical morbidity. Most interventional radiology procedures can be performed with a much shorter hospital stay than the alternative surgical procedure, and often as a day case admission. Reducing hospital stay and recovery time is of great importance to the older patient who may have a short life expectancy because of the cancer and co-morbidities.

Over the last few decades, the prevalence of chronic renal impairment has increased throughout the population, especially in the older age group. This is not just a consequence of the general increase in longevity, but is also caused by a higher incidence related to improved survival of patients with chronic diseases affecting renal function, such as diabetes, hypertension and ischaemic heart disease, and improved survival of patients with established renal failure.