As the proportion of elderly people in the general population increases, so does the number admitted to critical care. In caring for an older patient, the intensivist has to balance the complexities of an acute illness, pre-existing co-morbidities and patient preference for life-sustaining treatment with the chances of survival, quality of life after critical illness and rationing of expensive, limited resources. This remains one of the most challenging areas of critical care practice.

Epilepsy in older people is a common problem. It is estimated that in Europe there are 85 000 new cases of epilepsy annually in those over 65 years old, equivalent to an incidence of 100 per 100 000. Incidence increases with age and the rate in older people is higher than in all but the first year of life. The older population has a median prevalence of 4.7 per 1000 (range 3.0 to 7.3) from nine studies and may be underestimated by case-ascertainment bias common to many studies of older people.

This article will first set rehabilitation nursing and the older person into an appropriate context and then address the nature of rehabilitation nursing, how definitions have developed over time and lastly, what it is that we now provide, in conjunction with others, to meet the rehabilitative needs of our older population. The boundaries defining ‘old’, and between seeing a person as experienced, a bit wrinkly, forgetful and perhaps eccentric, versus a person who is old and demented are by no means clear-cut.

Cognitive impairment is one of the major health problems facing elderly people in the new millennium. This does not only refer to dementia, but also to lesser degrees of cognitive deficit that are associated with a decreased quality of life and, in many cases, progress to dementia. Some studies suggest that delaying the emergence of dementia for a few years would result in a considerable decrease in the human and economic burden related to the condition.

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.

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.

One of the greatest challenges of medicine in old age is for physicians to understand the process of aging and to be able to distinguish it from disease, lifestyle factors and environmental exposures whose cumulative effects account for many of the changes observed in older people. As a result, physicians have a duty to recognize and intervene appropriately against age-related diseases.

Hospitals are disappearing fast and have been doing so for many years almost without our noticing. Figure 1 shows the number of hospital beds and the number of discharges and deaths from hospital in the UK over the past 35 years.

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.

In their summary of changes in renal function with age, Porush and Faubert do not mention one of the most troublesome and least understood: the reversal of the circadian rhythm of water and electrolyte excretion. Young adults normally excrete the greater part of their 24-hour urine volume during the day and have a low night output. This rhythm has been shown to weaken by the age of 50 years and to be lost or apparently reversed by the eighth decade. Increased urine production is probably the principal cause of the need to get up at least once at night experienced by practically all elderly people. Together with bladder hyperreflexia, it is also an important cause of nocturnal incontinence.

This review discusses the role that the APOE gene plays in cognitive dysfunction both in demented and non-demented elderly people. The increasing problem of cognitive impairment in developed countries makes finding new and effective treatments a research priority. Understanding the biological basis of this impairment is therefore paramount. APOE has received much attention in the field of cognitive genetics due to it being a major susceptibility gene for Alzheimer's disease, which itself is characterized by a rapid and irreversible loss in memory function. Over the past 14 years this has generated a considerable number of publications that have produced conflicting findings, making it difficult for the reader to interpret whether the APOE gene regulates cognition or not. This review attempts to summarize the mass of information on this gene in relation to cognition, by weighting the pros and cons of the methodologies used, and offers suggestions for future study designs.

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.

Vitamin D has a wide range of biological effects beyond calcium and bone metabolism, and low 25-hydroxyvitamin D levels have been associated with many disease states in recent years, including cardiovascular disease, diabetes, infections and cancer. Association studies of vitamin D are notoriously prone to confounding and to reverse causality, however, and current intervention trial data for non-skeletal indications have been disappointing. Vitamin D is indicated for treatment of osteomalacia in older people, falls prevention in institutionalized older people, and as adjunctive therapy for osteoporosis. Large trials currently underway will ascertain whether potentially beneficial effects of vitamin D supplementation on all-cause mortality in older people are borne out.

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.

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.

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.

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.