The proportion of older people in our society is increasing more rapidly than any other section of the population. This group uses health and social services more than the young do and this is reflected in the NHS and social service budgets from recent years. For example, 40% of the NHS budget was spent on patients over 65 years in 1998. The much-heralded National Service Framework (NSF) for Older People, recently published by the Department of Health in England, was therefore awaited with much anticipation by all sections of the community concerned with older people’s health. This document is described as the ‘key vehicle for ensuring that the needs of older people are at the heart of the government’s reform programme for health and social services’. It has as its first and fundamental standard ‘rooting out age discrimination’. The sections on prevention and treatment of stroke, general hospital care, the management of falls and mental health have been generally well received and when implemented fully are likely to be beneficial to older people. Some areas such as the treatment of care home residents have not been addressed in nearly enough detail. In contrast, one particular section, that on ‘Intermediate Care’, has been heavily criticized, including a fierce attack by two of the United Kingdom’s leading geriatricians.

Editorial

In the UK, one of the strategic aims for the health services is to reduce death by suicide. Older people are over-represented in national suicide figures in most developed countries so they are de facto a high risk group. For example, in the UK, people aged over 65 comprise about 15% of the population but this age group accounts for between 20 and 25% of all completed suicides.

In the developed, as well as developing countries, there is an immediate challenge to ensure an adequate supply of health professionals trained in providing care for older people to meet the needs of increasing numbers. Currently 20% of the population of the United Kingdom (UK) is over 60 – 12 million people. By 2031 this proportion will be nearly a third – 18.6 million people. The largest increases are anticipated among the over-85 age group, from 0.8 million in 1987 to 1.4 million in 2025. In Europe the number of people aged over 80 years will double within the next 25 to 30 years. It is estimated that there will be more than 1.2 billion elderly people in the world by the year 2025 – three-quarters of them living in the developing countries.

The term euthyroid sick syndrome (ESS) is used to describe abnormalities in thyroid function tests that are observed in patients with systemic non-thyroid illness. Despite these abnormalities, there is usually little clinical evidence of hypothyroidism. Patients with ESS are generally considered to have altered thyroid hormone metabolism and to be euthyroid.

Older people with cognitive impairment and dementia are at increased risk of falls and their adverse consequences when compared with cognitively intact older adults. Using prospectively gathered data, approximately three-quarters of older people with cognitive impairment and dementia can expect to fall each year, double the fall-risk of cognitively normal older people. In addition, compared with their cognitively normal counterparts, people with cognitive impairment and dementia have an increased annual incidence of fractures, and are less likely to make a good functional recovery after a fall. The prevalence of dementia in the United Kingdom is about 5% of the population aged over 65, and 15% of those aged over 80. Falls in patients with cognitive impairment and dementia represent a significant health problem in the UK.

Research shows that approximately one in three people over the age of 65 years falls in any one year, with approximately one in three falling again in the following year. Prevalence of falls also increases with age, and women are more likely to fall than men. However, in advanced old age the ratio of men and women fallers reaches equal proportions.

Incontinence is a common and distressing condition of later life. Prevalence studies have reported rates of urinary incontinence from about 3% to 60%, depending on how incontinence is defined and the type of population studied. There is much less information about the prevalence of faecal incontinence. However, some studies have found approximately 2% of the general population and about 60% of the nursing home population to be incontinent of faeces. Although some studies have examined the impact of urinary incontinence on health status, the impact of faecal incontinence has not been investigated previously. Quantification of the prevalence and specific impact on health of common disorders such as incontinence will help commissioners and providers in the prioritization of diagnostic and therapeutic services for this distressing condition. With this in mind, we report the relevant results of the Tipping the Balance Survey, which quantified the prevalence and impact on self-perceived health, anxiety and depression of both faecal and urinary incontinence.

Anaemia is the most common haematological problem of older patients. Given the heterogenous nature of this group, with an age span of over 30 years, the reported prevalence of anaemia is, not surprisingly, quite variable. However, a large survey from the UK has reported an overall prevalence of anaemia of 20.1% in elderly men and 13.7% in elderly women.

The types and causes of anaemia differ between elderly and younger patients. Anaemia of chronic disease becomes the commonest cause of anaemia in the older age group and reflects the increased incidence of chronic inflammation and malignancy in later years. Iron deficiency anaemia is commonly seen and due to gastrointestinal blood loss. Furthermore dietary deficiencies not only of iron, but also of folate, protein and ascorbic acid can all precipitate anaemia in the many elderly subjects who live in poor socio-economic conditions. Pernicious anaemia, as with other autoimmune conditions, is also encountered more commonly in the elderly than in the younger population. Malignant blood disorders with associated anaemia, such as myelodysplasia and leukaemia, become more frequent with advancing age.

Visual impairment in the aging population may be brought about by localized pathological change or it may be associated with systemic disease. Localized ocular disorders include three of the commonest causes of visual loss in the elderly, namely cataract, glaucoma and age-related macular degeneration. Systemic diseases, with associated ocular involvement which may progress to blindness, include diabetes, hypertension and hyperlipidaemia, which predispose to retinal vascular occlusion. Visual function may also be affected by various autoimmune disorders (e.g. rheumatoid arthritis), cerebrovascular disease, intraocular or intracranial tumours (primary or metastatic), as well as by infectious agents (herpes zoster ophthalmicus) and drugs (steroids).

A pressure ulcer is the visible evidence of pathological changes in blood supply to the dermal and underlying tissues, usually due to compression of the tissue over a bony prominence. Pressure ulcers are one of several types of chronic ulcers of the skin, including venous stasis, diabetic ulcers, and arterial insufficiency ulcers. The differential diagnosis of pressure ulcers is imperative, since the management of each wound type differs substantially.

Heart failure has been defined in many ways and definitions change over time. The multiplicity of definitions reflect the paucity of our understanding of the primary underlying physiology of heart failure and the many diseases for which heart failure is the common end-point. Fundamentally, heart failure represents a failure of the heart to meet the body’s requirement for blood supply for whatever reason. It is thus a clinical syndrome with characteristic features – not a single disease in its own right. The syndrome includes symptoms and signs of organ underperfusion, fluid retention and neuroendocrine activation. The syndrome arises from a range of possible causes of which ischaemic heart disease is the commonest. From the point of view of a clinician, the underlying pathology will determine treatment options and prognosis. The extensive range of possible aetiologies present a diagnostic challenge both to correctly identify the syndrome amongst all other causes of dyspnoea and to identify the aetiology, allowing optimization of treatment.

The diagnosis of neurosyphilis is important but remains difficult because of variable clinical features and an unpredictable course. Laboratory confirmation involves a combination of serological tests, none of which alone provides a reliable indication of current disease activity. Although in the UK the incidence of neurosyphilis has fallen steadily, its many manifestations require clinicians to remain alert to the diagnosis, particularly because incidental antibiotic therapy may modify the presenting features. As a sexually-transmitted disease, the diagnosis of syphilis carries great social stigma. The need for informed consent before routine testing, and the provision of psychological support for the patient and carers in the event of a positive diagnosis, must be considered.

Dietary, biochemical and anthropometric data indicate good nutritional status, in general, in community-dwelling, healthy elderly people, at least in the USA. In a sample of 209 men over 65 years of age without acute disease-related nutritional risk factors, mean intake of nutrients generally met or exceeded the recommended dietary values, with the exception of calories, although 7% of subjects consumed inadequate amounts of thiamine, vitamin A, vitamin C and calcium. Few subjects were extremely underweight or obese, although body fat, as assessed by skinfold thickness, fell over the two years of evaluation. The prevalence of malnutrition in patients with chronic disease living in the community in the UK is estimated to be around 8%, however. In this study of more than 11 000 men and women aged 18 years or over, consultation rates in general practice and prescription rates were lowest amongst patients with a body-mass index between 20 and 25. Hospital outpatient referral rates were not related to nutritional status, but both hospital admission rates and mortality were greatest in people with a body-mass index(BMI) (kg/m2) below 20, and declined as BMI increased.

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.

Parkinson’s disease (PD) is a progressive neurological disorder affecting at least 120 000 persons in the UK today. Age is the most potent risk factor. With the rising numbers of elderly, PD will become an increasingly important cause of disability and mortality. This has significant implications for health planning.

In recent years, there has been growing emphasis on the key role of the specialist clinic, interdisciplinary team and the PD specialist nurse in the management of the condition, as well as recognition that quality of life for people with PD and their carers relates to more than motor disability and disease severity. Appropriate care planning requires skilled assessment, and a new paradigm, incorporating four progressive clinical management stages (diagnosis, stable maintenance stage, complex stage and palliative stage) may be useful. The importance of all these aspects to successful holistic management of PD should be emphasized but is beyond the scope of this review, as is diagnosis, which is the subject of a separate contribution.

Hypoxaemia is a common complication of stroke, and an association between adverse outcomes and hypoxaemia has been reported. However, it remains unclear whether hypoxaemia is the cause or just a sign of poor prognosis. While clinical guidelines unanimously recommend treatment of hypoxaemia after stroke, the guidance does not specify at what level of hypoxaemia treatment should be started. Recent evidence from a Swedish study suggests that overtreatment can also have detrimental effects on outcome. The aim of this review is to explore issues relating to hypoxaemia after stroke.

Control of hypertension is generally acknowledged to be important in reducing the risk of vascular events. Although hypertension affects over 50% of people aged 60 years or over, a study in 1995 showed that general practitioners were much less likely to treat an older person with a blood pressure outside the normal range than a younger person.

What is palliative medicine?

In 1987, the Royal College of Physicians recognized palliative medicine as a specialty, defining it as ‘the study and management of patients with far-advanced disease for whom the prognosis is limited and the focus of care is quality of life’. In 1990, the World Health Organization added its definition, ‘the active and total care of a person whose condition is not responsive to curative therapy’. The aim of palliative medicine is to control pain and other physical symptoms, together with integration of psychological, social, spiritual care and support. The ultimate goal is to help patients to achieve their best quality of life. Palliative medicine places emphasis on a holistic approach, offering care and support not just for patients but also for their families. Palliative medicine hence requires an interdisciplinary team approach. With the co-ordinated efforts of all disciplines (such as doctors, nurses, therapists, social workers, clinical psychologists, dieticians, pastoral care workers and volunteers), patients can be supported in living their remaining lives as actively as possible, and families can be assisted in coping with illness, death and bereavement. Palliative care neither intends to postpone death nor does so, but affirms life and regards dying as a normal process. When a patient faces an incurable illness, it is incumbent on the palliative care team to provide the best treatment and care, adding life to days when days cannot be added to life.

The classification of schizophrenia-like and paranoid disorders in elderly people has a long and somewhat confusing history which can largely be blamed for the currently uncertain nosological position of such patients. To Kraepelin, dementia praecox was fundamentally a disorder of emotion and volition, while paraphrenia was characterized by hallucinations and delusions without deterioration or disturbance of affective response, and paranoia involved the insidious development of a permanent delusional system which resulted from internal causes and was accompanied by perfect preservation of orderly thinking, acting and will. However, by the eighth edition of his textbook in 1913, Kraepelin was expressing serious doubts about the assumptions on which his conception of dementia praecox had been based. In some cases, a complete and lasting recovery was seen and the relationship between onset and early adult life was not absolute. Indeed, Bleuler had introduced the term ‘schizophrenia’ in order to get away from the concept of the disorder as an adolescent mental deterioration.

This article updates a previous review of this topic published in this series in 1996. The number of studies and review articles that have been published since then is encouraging, and suggests that there is a growing awareness of and interest in these disorders in old age.