Polymyalgia rheumatica and temporal arteritis represent opposite poles of a single disease spectrum. In the former, girdle stiffness predominates; in the latter, frank vasculitis is demonstrable. There is no diagnostic laboratory test for polymyalgia rheumatica, and earlier reviews in 1993 and 1998 in this journal both drew attention to the difficulty in diagnosing polymyalgia rheumatica, particularly in the elderly.

Good communication between health and social care professionals and patients, their families and carers is recognized increasingly as integral to best management. Thus a central principle of the NHS Plan is that all patients should have open access to information about services, treatments and performance and should be treated as partners in their own care. Lack of information and poor communication is a common basis for complaints, and there is little evidence that older patients want any less information than those who are younger Certainly, if elderly people living with long-term illness, frailty or disability are fully informed, they will be better able to make appropriate decisions and actively participate in managing their own condition and their lives. In general, it is for professionals to provide the required information and support, or to direct people to other quality sources of evidence-based information, and not for them to decide whether or what should be disclosed.

As a correlate of psychological well-being, insomnia continues to be regarded as a critical indicator of both mental health and quality of life, appearing as a prominent diagnostic feature in both DSM-IV1 and ICD-102 (particularly in relation to depression and anxiety states), and included in many of the most commonly used health outcome measures, including the Nottingham Health Profile and the SF-364. The symptom of disturbed sleep is also included in most of the available schedules for assessing the mental health of elderly people, including the GMS, CAMDEX, and the CARE. Whether specified as a diagnostic criterion or included in a diagnostic algorithm, the assumption is made that certain patterns of sleep disturbance are associated with, and consequently predict, certain types of mental illness. The evidence would suggest, however, that the strength of the association, and hence the validity of this assumption, may diminish across the human lifespan.

Syncope is a common cause of presentation to the emergency department in the older population, who are at increased risk of syncope resulting in serious injury in the form of fractures, adverse cardiac outcomes and death, lack of confidence and mental health issues. Older patients can present diagnostic challenges due to multiple co-morbidities, polypharmacy and the problem of amnesia associated with transient loss of consciousness. The underlying cause of their syncope can be established through a structured approach, and targeted patient selection can limit inappropriate investigations in syncope assessment units and ensure appropriate treatments are instituted. A previous review article in this journal, by Nath and Kenny in 2005, examined the evidence surrounding various aspects of syncope, including prevalence, cause, risks, investigations and treatment. This review updates the evidence and guidelines on the aetiology, investigation and treatments of syncope in the older person, with emphasis on recent advances.

The purpose of this review is to discuss how healthcare professionals, and particularly nursing practice, impact upon pain management with older people (65 years and over), following surgery. The review commences with an introduction presenting why this is an important area to consider. Current available literature and findings from an ethnographic study which was designed to examine peri-operative pain-management practices with older people will then be discussed to highlight the key issues of pain assessment and management. Three overarching themes; (1) pain assessment (2) knowledge/strategies to cope with pain and (3) organization of care (culture and context), will guide the discussion. It is suggested that comprehensive pain assessment, proficient communication and multidisciplinary working, are essential to improve pain-management practices. The paper demonstrates some of the multiple and complex factors that affect the older person's pain experience and identifies possible developmental work in this field.

Stroke is a disease with which we are all too familiar; it is the leading cause of severe disability and the third most common cause of death in the developed world. Over the last few years there has been a tidal wave of literature on the subject. Not before time, the impact of stroke worldwide has been recognized and this, it is to be hoped, signals an end to the nihilism that used to be so common.

The N-terminal pro-brain natriuretic peptide (NT-pro-BNP) is released in response to volume expansion and/or increased tension on left ventricular myocytes. NT-pro-BNP is a useful diagnostic and prognostic biomarker both in patients with dyspnoea of unknown aetiology, and for risk assessment of patients with established heart failure. However, impaired kidney function – a common condition in older people as well as a strong risk factor for cardiovascular disease is associated with elevated circulating levels of NT-pro-BNP. Therefore, it is important to know the kidney function when interpreting an elevated NT-pro-BNP measurement obtained in older people in order to diagnose or stage congestive heart failure.

The recent Royal Commission report on funding long-term care was produced following more than 100 visits and evidence from 400 organizations. It was set up following concern at the costs of long-term care for elderly people and what was seen to be the anomalous position of elderly people cared for by the NHS in long-term beds, where all costs were found by the state, albeit that elderly persons themselves lost most of their benefits. This contrasted with those in the social or independent sector, where payment has to be made unless the elderly person is poor.

Alzheimer's disease (AD) is the commonest form of dementia, estimated to affect 37 million people worldwide. Currently there is nothing to halt the progression of AD – treatment focuses largely on slowing the development of symptoms. More recently disease-modifying interventions, such as immunotherapy, have been investigated as their aim is to halt or even reverse symptoms by removing β-amyloid (Aβ) pathology. This paper assesses the developments made in this particular field, offers critical appraisal of important papers and assesses the viability of this potential form of treatment.

‘Cerebral small vessel disease’ is common in older adults and is an important cause of morbidity, functional impairment and cognitive decline. Small vessel disease is a collective term used to describe a number of underlying pathological processes and neuroimaging findings, such as lacunar infarcts, white matter lesions and microhaemorrhages.

With readily available neuroimaging, diagnostic accuracy has improved; however, the management of small vessel disease and prevention of cognitive decline remains uncertain. Treatment of conventional vascular risk factors may be appropriate, but future research is required to provide definitive answers. We have conducted a comprehensive literature review of cerebral small vessel disease in older adults. This highlights the clinical sequelae and underlying pathological processes, whilst discussing novel diagnostic neuroimaging and therapeutic strategies.

The prevalence of undernutrition in older individuals, living independently in a community setting, or living in a supported setting, is considerable. The negative health effects of undernutrition are wide ranging, with implications for quality of life (QOL), well-being and general health, through to the individual's ability to recovery from acute disease. There are a number of key measures that indicate both nutritional status and the effectiveness of any intervention. These include conventional anthropometric and biochemical measures of nutrient status, as well as measures of QOL, well-being and depression. The latter have huge importance to the life of the individual, and to date appear to have undergone only preliminary investigation. This review suggests that the efficacy of interventions to address undernutrition and improve health in older people living in a variety of settings is highly variable, and that considerable opportunities for research in this area exist.

Myopathy is a convenient shorthand term meaning muscle disease or dysfunction. In other words, the myopathies are those conditions in which the patient’s symptoms and signs can be attributed to a pathological process affecting either the structure of muscle fibres or their associated interstitial tissues, or to disturbance of the biochemical or electrophysiological function of those fibres. Myopathies are rare in all age ranges. They may be inherited or acquired. Onset of inherited myopathies in the elderly, not surprisingly, is uncommon, but some of these diseases are asymptomatic or cause such minor symptoms that their significance is not appreciated by the patient, and thus they may not be recognized until late on in life. Their recognition may have implications for other, younger, family members. Many of the acquired myopathies afflicting the elderly are treatable, but the commonest, inclusion body myositis, is not, and incorrect diagnosis and inappropriate use of steroids may compound morbidity.

Population aging is conventionally understood to refer to increases in the percentage of the population aged 65 and over. Developed economies have for some time shown evidence of this and it is projected that they will continue to experience aging over at least the next 20 years. As the population ages, so the level and pattern of demand for health care is likely to change, and difficulties in financing care to increase. Older persons, for example, tend to consume more health care than those in younger age cohorts, as well as different types of care (for example more long-term care). By the same token, older persons (who are often retired) tend to have less income than those in younger age cohorts. A consequence of this is that they are less able to meet the costs of health care directly (i.e. out of pocket) or contribute through direct taxation to meeting the costs of publicly funded health care. These two factors – growing demand and diminishing income among those for whom demand is expanding – will present challenges to the future finance and delivery of care.

Degenerative-calcific aortic stenosis is mainly a disease of old age. Patients with mild to moderate stenosis without symptoms and those with aortic valve sclerosis do not require mechanical intervention. There is no firm evidence that the rate of progression can be modified by medical therapies, though statins might have some effect. Patients who develop severe stenosis with symptoms have a very poor prognosis if managed medically. Surgical aortic valve replacement greatly improves symptoms and mortality rates and remains the treatment of choice for those fit for major surgery, even above the age of 80 years. For those not suitable for surgery, or who are unwilling to have an operation, outcomes can be significantly improved by trans-catheter aortic valve replacement, which has become an important option for frail elderly patients. Balloon aortic valvuloplasty improves symptoms and short-term survival, but has a less clear impact on mortality beyond 1 year. It is useful as a palliative treatment and as a bridging procedure for patients who are not ready for valve replacement. There is less agreement on the best approach to patients with asymptomatic severe aortic stenosis. Trials indicate that early valve replacement results in outcomes that are comparable to those seen in symptomatic patients, though guidelines advocate delaying surgery until symptoms occur or left ventricular function begins to decline rapidly. All elderly patients with severe aortic stenosis should be considered for a mechanical intervention unless there is a properly considered reason for not doing so, or they are not willing to receive such treatment.

Severe dementia is associated with frequent psychiatric and behavioural disturbances in addition to marked cognitive and functional deficits. Research to determine a neurochemical understanding of dementia over the last three decades has generated therapeutic strategies which improve patients' cognition and activities of daily living. Different key dementia syndromes have been shown to have distinct neurotransmitter biochemical patho-logy, with important implications for therapy. The current review focuses predominantly upon excitatory neurotransmitter systems.