Ischaemia of the deep subcortical white matter in the brain may be a common contributor to disability and cognitive impairment in old age. There is tremendous potential for preventing, or at least slowing, some of this damage. However, progress both in research and in clinical practice has been hampered by the confused nosology, with various diagnostic and descriptive labels applied to appearances on neuroimaging, to the underlying pathology and to clinical states (Table 1).

The connective tissue diseases and vasculitides are primarily conditions of the early and middle years. However, a significant proportion of patients do present in later life, and some conditions, such as giant cell arteritis, are almost exclusively confined to older patients. In later years, their presentation may differ from the classical descriptions and require a broader diagnostic sieve. Thirty per cent of elderly patients with pyrexia of unknown origin have a multi-system disorder. Autoantibody tests throw up more false positives with the risk of over-diagnosis and treatment is further complicated by the burden of co-existent disease and morbidity from therapeutic side-effects.

Over the past several years health care policies ‘have created a lack of NHS recuperative care beds. As a result, elderly patients have been discharged too early, or kept in acute care - blocking these beds.’ A King’s Fund discussion paper stated: ‘There is a group of people who have health care needs which, while not requiring the facilities of the acute hospital sector, do demand considerable support to regain a maximum level of health’.

Alzheimer’s disease (AD) is a treatable disorder. Two classes of anti-dementia agents have emerged in the recent past: anti-oxidants and cholinesterase inhibitors. A recent study showed that the anti-oxidants alpha tocopherol (vitamin E) and selegiline slowed the progress of AD. Patients treated with either agent alone or with both agents in combination progressed to end-point more slowly than patients on placebo. Patients on placebo reached one of the end-points - death, nursing home placement, progression to severe AD, or significant loss of activities of daily living - in approximately 400 days, whereas patients on active agent required approximately 600 days to reach the same end-points. Both these agents have anti-oxidant properties; selegiline is a monoamine oxidase-B inhibitor that reduces free radical generation and alpha tocopherol has free radical capture capabilities. These agents are applied to patients in mild or moderate phases of AD, where slowing the progression of the illness and maintenance of patients at higher levels of function are the principal goals. Slowing the progression of the disease in more advanced phases of the illness may be less desirable.

Foot disorders are common in elderly people and lead to significant difficulties in the form of immobility, pain and gait imbalance. Neuropathic changes associated with systemic disease, such as diabetes, carries the potential for ulcer development leading to possible foot or lower limb amputation. The role of the podiatric surgeon and the podiatrist/chiropodist in the prevention of foot problems in elderly patients is an important and often neglected element of health care for this group. Foot care is at present provided by podiatrists/chiropodists, nurses, orthotists, general practitioners, rheumatologists, geriatricians, casualty specialists, orthopaedic surgeons and podiatric surgeons. Sadly, foot care provision by these professionals is poorly co-ordinated. In most cases this is the result of the general lack of knowledge most professions have about the role of others; however, in at least one instance (orthopaedics), the issue is one of professional rivalry.

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.

We read with interest the review article by Paul V Knight and Alan McKenzie on diabetes in the elderly. They highlight the fact that close examination of the feet or fundoscopy is often not performed. We have audited the care of elderly diabetic patients on our acute wards using the BGS guidline for diabetic care.

In Europe, vertebral fracture incidence has increased 300–400% for women and more than 400% for men during the last 30 years. These data are age-adjusted and therefore highlight that there is a decrease in bone mass or bone quality from generation to generation. To arrest or reverse the increases in osteoporotic fractures, effective general preventive regimens must be established. However, in order to do so, basic understanding of age-related changes in the material quality, 3D cancellous bone architecture, macrostructure (shape and size), and strength of human bone is crucial.

There is considerable debate as to the effects of aging on the susceptibility of old people to infection, and the extent to which this modifies the signs and symptoms of infection. Factors that may be of even greater importance are the effects of poor nutrition, multiple pathology and polypharmacy on their response to infection, and the effectiveness of their immune systems.

The majority of patients seen in ophthalmic clinics are over the age of 60. In addition, ophthalmology is a major care provider for elderly people. In the author’s unit a recent review of patients undergoing surgery showed that 75% of them were over the age of 60 and 38% over 75. Ten years ago these proportions were 50% and 25% respectively. Much of this reflects the increasing demand for and success of cataract surgery. Age-related macular degeneration is the major cause of visual loss in the United Kingdom and elsewhere and is responsible for 48.5% of all patients registered blind or partially sighted in England and Wales.

Scientific progress in human immunosenescence research is pointing increasingly towards the clinical importance of age-associated changes in immunity, although many areas remain controversial. For infectious disease, there is accumulating good empirical evidence, discussed in this review, that immunosenescence compromises protection in elderly people. This implies that an age-associated decreasing immunity results in increased incidence of those diseases that the immune system is designed to protect against, i.e. infectious diseases. This unsurprising conclusion suggests that preventing these infections using interventions designed to prevent or reverse immunosenescence could extend the period of life enjoyed in good health.

Cancer in older patients is an international health problem of mounting importance, resulting from the slow rise in the proportion of the population over 65. Age is the major risk factor for malignancy, with two-thirds of cancer deaths in the USA in those over 65. By 2000 this will be the same in Europe. Most treatment trials have included only patients under 65 and results cannot necessarily be applied to older patients. Many trials now include older patients, but these may overestimate population benefits by excluding the particularly frail.

The importance of a specialist viewpoint on blood tests in elderly people and their interpretation was established by Hodkinson. He described the need for full investigation, the choice of suitable reference populations in old age, the difference in reference ranges between older and younger people and the effect of the special features of medicine in old age on appropriate testing strategies. In this journal, Rochman has discussed problems in chemical pathology interpretations in the elderly. This review builds on previous work by looking at recent papers relevant to biochemical and haematological investigations of practical relevance to the clinical medicine of old age. It is based on a Medline search combining sets of papers relating to specific investigations and clinical situations with those using the key word ‘elderly’. Added to these papers are others known to the author and colleagues.

In the last review on this topic for this journal the focus was mainly upon service principles and an overview of variation in provision around the world. While there have been important developments and challenges within old age psychiatry in the last five years, these fundamental principles remain valid. This paper will therefore not simply present an updated version of the last but will instead concentrate on specific issues which seem to be of particular salience in the consideration of the organization and delivery of old age psychiatry services.

Age is deformed, youth unkind,

We scorn their bodies, they our mind.

Thomas Bastard, 1566-1618

There is a universal acceptance in the Western world that age and arthritis are inextricably associated and that both will steam on, leaving our youthful minds wallowing in their wake. However, the danger in accepting this as a fact of life is that relatively less importance is attached to arthritis in older people, despite the often enormous impact this group of conditions may have on them. In addition, the changing demography of the Western world ensures that ever greater numbers will be afflicted by arthritis, not only due to disease arising de novo but also to the carry-through effect.

Benign prostatic enlargement (BPE) is an increase in the volume of the prostate gland which can be detected by digital rectal examination (DRE) or more accurately by transrectal ultrasound (TRUS). BPE may be due to benign prostatic hyperplasia (BPH) which is a histological diagnosis characterized by a combination of atrophy and proliferation in both glandular and stromal tissue. The onset of BPH is dependent on the presence of testes and increasing age. The first pathological signs appear under the age of 40 years followed by a rapid increase in prevalence with age: 80% of 80-year-olds have evidence of BPH. Bladder outlet obstruction (BOO) is defined by pressure-flow studies (PQS) and may be due to benign prostatic obstruction (BPO).

This review examines the relationship between dysequilibrium, falling and anxiety, and their combined impact on the lives of elderly people. More than one in four people aged over 69 fall each year, and a higher proportion of those over 74. Although only one in ten incurs serious injury as a direct result of the fall, fear of falling can often lead not only to psychological distress but also to restriction of activity and an unnecessary and undesirable loss of independence. Naturally, symptoms of imbalance constitute a key risk factor for falling.

Rehabilitation has received considerable attention recently, having been the subject of a number of consultations, reviews and policy documents. Despite such activity it is recognized that ‘there is widespread confusion about the meaning of rehabilitation’, with a general failure to clarify aims and objectives. Nevertheless, there is an emerging consensus that the elements of effective rehabilitation include:

- responsiveness to users' needs and wishes

- multidisciplinary and interagency working

- availability when required

- clear rehabilitative purpose and goals

This review describes the concept of disablement, with particular reference to the World Health Organization’s International Classification of Impairments, Disabilities and Handicaps (ICIDH), and its forthcoming revision. Applications for a disablement classification are discussed, and the various approaches which have been applied to the measurement of disablement are reviewed. The relevance of disablement to psychiatric research and clinical practice is also addressed. In the second section of the review, data are presented from the last two phases of the Gospel Oak Survey, illustrating the value of simple measures of disablement in a community epidemiological study of the aetiology of late-life depression.

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.