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%.

In the last decade, great advances have been made in the understanding of the role of lipid management in the prevention of cardiovascular disease. Epidemiological data from the Framingham study and the Multiple Risk Factor Intervention Trial (MRFIT) have described a causal relationship between lipid and lipoprotein levels and the risk of coronary heart disease (CHD). Hitherto, the emphasis of therapeutic studies has focused on coronary heart disease specifically, especially in terms of treatment with 3-hydoxy-3-methylglutaryl-coenzyme A (HMG-CoA) reductase inhibitors or ‘statins’. The result has been a burgeoning evidence base demonstrating the effectiveness of statins in cholesterol reduction and, more importantly, in the reduction of coronary mortality and morbidity in subjects both with and without established CHD. Given that the vascular system is more commonly regarded as a single entity, with the pathophysiological basis of disease based on the development of atherosclerosis, it has been surprising to find that ischaemic stroke does not share the same robust relationship with cholesterol that CHD does. The lack of a consistent relationship between serum cholesterol and stroke has manifested itself in diverse attitudes towards cholesterol-lowering in cerebrovascular disease; this problem has been heightened by the relative lack of trial data and clinical guidelines on the subject. It is therefore important to review the current evidence regarding cholesterol and stroke and to derive conclusions that translate into the clinical management of cholesterol in patients with cerebrovascular disease.

Age-related changes affect all structures of the eye, and while age-related changes may influence the quality of vision, it is important to distinguish age-related physiological changes from pathological changes. This is important particularly when identifying pathological changes that may be treatable. The prevalence of visual loss increases substantially after 60 years of age and poor vision is the second most prevalent physical disability in older people. This review describes the normal ageing changes of the eye and outlines common ophthalmic diseases affecting older people. We refer to recent advances in diagnosis and treatment, and relevant current research.

A great deal of attention has been devoted to the ever-increasing incidence of fractures of the proximal femur in elderly patients and the impact which this has had upon their life expectancy and quality of life. The condition has also made heavy demands on the Health Service, and much effort has been devoted to increasing hospital throughput by effective programmes of rehabilitation. In these circumstances, it is not surprising that much less has been written about the issues involved in treating elderly patients with less serious forms of fracture. Nonetheless, closer attention to this group reveals that it also makes heavy demands on the Health Service. An example is that, in 1995, out of 1771 elderly patients admitted to the acute orthopaedic wards at Edinburgh Royal Infirmary, only 47% had fractures related to the proximal femur or displacement of a hip prosthesis (Figure 1) (CT Currie, unpublished data, 1996). Most of the remainder had fractures at other sites, while 8% had soft tissue injuries. The percentage of fractures involving more common sites in old people was 2.5% for the neck of humerus, 3% for the shaft of humerus, and 7% for the wrist. The low proportion of vertebral fractures emphasizes that this condition rarely leads to admission to an acute unit, so that the size of the problem is usually underemphasized.

Seasonal influenza remains a common cause of morbidity and mortality for older residents in aged care facilities. Whilst prevention is best managed by high vaccination rates for the general population, residents and aged care facility staff, new research suggests that a more active approach to surveillance and anti-viral treatment now plays an important role. The practicalities of managing an influenza outbreak are complex and best planned in advance with written protocols available. Good infection control remains a vital part of prevention and outbreak control.

Over the last two decades, the care home sector has been a significant provider of long-term care for older people, with 11 500 homes providing care for 236 700 people across England and Wales. New admissions to residential care homes are increasingly older, aged 80 and over and have high levels of physical dependency, cognitive impairment and behavioural problems.

Many changes occur in the aging immune system, which culminate in its functional decline, but the underlying mechanisms have proved difficult to define. Wick and Grubeck-Loebenstein have recently classified the changes in function as either primary ‘those that occur in perfectly healthy older individuals’ as the result of ‘an age dependent intrinsic decline of immune responsiveness’ or secondary ‘those that are due to underlying disease or various environmental factors including diet, drug intake, physical activity, etc’. Both types of alteration are important when considering immune dysfunction in older people which seems to be centred on the loss of cell-mediated immunity, in particular the activity of CD4 helper T lymphocytes.

Smoking has been closely implicated in many cardiovascular, lung and other diseases which are prevalent in the elderly, but most prevention programmes tend to be aimed at younger age groups.

The prevention of smoking in retired people is a subject which is not yet fully researched, but there is a little information which suggests that it may be a worthwhile pursuit. Certainly, work has shown that longevity can be improved even in older people by stopping smoking. Coronary heart disease death rates for 65-74 year olds who have recently given up are similar to non-smokers. For other causes of death, especially lung cancer and bronchitis, the benefits of stopping smoking take up to five years to appear. In terms of morbidity, there are suggestions that ex-smokers move reasonably quickly towards the state of non-smokers for bone density, pulmonary function and muscle strength.

Falls are common in late life. Evidence from New Zealand, the United States and Great Britain suggest that about a third of people aged over 65 will fall each year, a proportion that rises to about half for the community-dwelling population older than 85 years. Falls are the leading cause of death from injury in older people. Although many falls do not cause serious injury, nor precipitate referral to the health services for 30–50% of fallers, those that do have major consequences. From a purely financial perspective, acute care of those with falls is estimated to cost $10 billion per annum in the United States.

Introduction

Across the world, population structures are changing, with particularly rapid growth in the numbers of very old people. For example, in the USA, the number of people aged 85 or over is now around 4.6 million, having grown at nearly 4% per annum since 1980.1 It appears that human longevity has been increasing gradually over many years, with centenarians only appearing as a relatively recent phenomenon about 1800,2 the age of 110 being reached in the mid-20th century and 115 only by 1990. There is no sign of this extension of longevity slowing down towards a presumed biological maximum. In addition to the increase in the maximum age, there is a decrease in mortality rates in almost all age groups, and there has been a considerable rise in the chances of surviving from age 60 to 80 over the last century, which will further increase the numbers of very old people. Furthermore, the death rate in England and Wales for people aged 85 or over has decreased throughout the twentieth century.3

As the absolute numbers and proportion of older adults increases across most of the developed world, a greater understanding of the aetiopathogenic mechanisms of the increased vascular risk and their therapeutic implications becomes essential to all clinicians assessing and managing the geriatric patient. The role of endothelial function and the microcirculation is increasingly recognized in the maintenance of adequate perfusion, and their dysfunction is thought to be an early and potentially reversible mechanism by which age acts to increase cardiovascular risk.

Here we review evidence that altered microvascular function appears before other recognized predictors of vascular disease, and progresses from childhood to late adult life, preceding fulminant atherosclerotic or arteriosclerotic disease. Low birth-weight babies have reduced endothelial function in skin microvessels at 3 months, and by age ten brachial artery endothelial function is reduced in comparison with normal birth-weight babies. In overweight/obese adolescent children with clustering of traditional cardiovascular disease risk factors, endothelial function is lower compared with normal weight children and this appears to persist into early adulthood. Adult ageing is associated with impaired microvessel endothelial function and an increase in capillary blood pressure, independent of brachial artery blood pressure. Biological and lifestyle factors that influence microvessel function include body fat and visceral adiposity, sex hormone status, diet and physical activity.

Exploration of the therapeutic implications for management of endothelial dysfunction remains in embryonic state. The use of ACE-inhibitors, angiotensin receptor blockers and direct renin inhibitors in patients with evidence of microvascular damage such as retinopathy and microalbuminuria has been established; however, in the general older population the benefit has yet to be established. Therefore current recommendations are to screen for microvascular damage and if present target treatments after control of other vascular risk factors such as hypertension.