Tuberculosis (TB) rates in the UK have increased by about 25% over the last 20 years. About 12% of cases occur in those over 65. Their diagnosis and treatment is similar to that of younger patients, but their presentation is often atypical, diagnosis is often delayed, there is a higher frequency of treatment side-effects and there is greater potential for drug interactions. Mortality increases markedly with age and more than half of those aged 80 years or more die before completing treatment. About 75% of TB in older patients is due to reactivation of latent disease acquired in childhood. The risk of reactivation is particularly increased by human immunodeficiency virus (HIV) infection and anti-tumour necrosis factor (anti-TNF) medication. Active disease spreads by the inhalation of airborne droplets, particularly in enclosed environments such as nursing homes. Interferon gamma release assays (IGRAs) are an important new development in recognizing latent infection. They should allow better targeting of treatment in those with recently acquired infection, or who are at risk of reactivation. With appropriate effort it should be possible to substantially reduce TB rates to fewer than 1 per million per year, the current US target.

Acute ischaemic stroke is common in older people and is associated with a higher morbidity and mortality compared with younger patients. Intravenous thrombolysis with recombinant tissue plasminogen activator (r-tPA) has become the mainstay of treatment and is the only evidence-based specific treatment for acute ischaemic stroke. However, little data are available on the safety of thrombolysis in the over-80 years age group due to under-representation of this group in trials and the upper age limit for licensing of the drug. In this review, we look at the pathophysiology of stroke and recent advances in neuroimaging techniques. We also look at the evidence base for use of thrombolysis in stroke and in particular analyse the trials that include the very elderly as subjects. Finally, issues around ongoing trials and future research are discussed.

Telomere length is a reflection of cumulative oxidative and inflammatory stress throughout the life course, as well as oestrogen exposure. There is evidence that telomere length is associated with lifespan; however, it does not appear to be a better indicator of biological age than chronological age, even though it can be considered a biomarker of ageing. There are studies showing association between leukocyte telomere length and many of the common diseases of ageing, lifestyle factors and socioeconomic status. However, the associations are less marked among older people. Research in the area of manipulation of genetic control of telomerase activity controlling telomere length may have clinical applications in future.

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.

Urinary incontinence is a common and under-reported symptom, affecting one in five people, with a higher prevalence in women and those who are elderly. It can have a major impact on physical health and social activity. Initial assessment to categorize symptom type is the key to guiding further therapy. Non-pharmacological (NP) options are preferred as first-line intervention, and if unsuccessful, are followed by anticholinergics, often in combination with NP options. Surgical intervention must be sought where appropriate. However, NP interventions are often not considered due to uncertainty about the evidence-base, perceived difficulty of application and perhaps a lack of awareness of or access to specialist continence services. This article addresses the first of the barriers, summarizing the evidence for various NP interventions, including lifestyle interventions, physical therapies, behavioural therapies and containment options, enabling the reader to formulate an evidence-based opinion and a pragmatic view on the feasibility, efficacy and applicability of the various NP interventions, without automatic recourse to anticholinergic medication in the first instance.

Orthostatic hypotension is a common condition seen in up to one-third of community-dwelling and two-thirds of hospitalized older people. It is part of a spectrum of abnormal cardiovascular responses to postural challenge and is associated with syncope, dizziness, falls, volume depletion, drug side-effects and an increased mortality. This article discusses the current classification of orthostatic hypotension and related conditions, and the clinical importance of the control of the cardiovascular response to orthostasis. These are considered with particular reference to the measurement of postural cardiovascular responses in the routine clinical setting. By improving understanding of the methods that are used for assessment of postural changes in blood pressure, clinicians should have greater confidence in the reliability of measurement and in their interpretation.

Benign and malignant prostate disease is common in older men and becomes more prevalent with age. Many seek medical help due to bother associated with lower urinary tract symptoms (LUTS). Some fear their LUTS are secondary to prostate cancer or seek advice regarding prostate cancer screening. Furthermore, prostate cancer is now the most common male cancer in the UK. However, not all prostate disease causes LUTS. Equally, not all LUTS are due to a disease of the prostate. Thorough clinical assessment is therefore required to identify urological from non-urological, and benign from malignant causes of LUTS. This review presents a description of the current terminology for diseases of the prostate, the essential clinical assessment and investigations, and a description of the many treatment options currently available for both benign and malignant prostate disease.

This review explores the recent advances in investigation and treatment of acute stroke, as well as its secondary prevention, with emphasis on the relevance of the evidence for the older population. Hyperacute reperfusion treatment is becoming increasingly embedded into the day-to-day management of stroke and trials are ongoing that will help determine its safety in the older patient. Managing all stroke patients in a stroke unit is known to improve outcome and recent work has helped to inform care decisions. Application of the robust data available on secondary prevention treatments may have to be weighed alongside the degree of frailty of the patient for whom treatment is being considered.

Subcutaneous hydration, or hypodermoclysis (HDC), is a very simple technique that should be practised more often by doctors and nurses who care for older patients. It involves less discomfort, generates less cost and has fewer adverse effects than the intravenous route and may reduce the need for admission to the emergency department. The main indication is the management of mild to moderate dehydration, and prevention of dehydration in patients who are intolerant of oral intake. It should not be administered in situations of severe dehydration, in emergency situations, or in patients with fluid overload. Isotonic or hypotonic solutions must be used with appropriate electrolytes. Certain medicines can be given simultaneously by HDC and this may be especially valuable in palliative care settings. In most cases there is no need to add hyaluronidase.

In this review, we analyse original research articles in English and Spanish in which fear of falling (FoF) as a long-term syndrome defines the participants, or is the main outcome, or in cases where FoF is a secondary outcome, falls or activity are the main outcomes.

FoF is difficult to measure. Attempts are made to do so by use of single questions or scales. Restriction in activity due to FoF is a secondary outcome and can be an important influence on a person's quality of life. There are also various methods of measuring it by use of single questions or scales, and general questions in basic or instrumental activities of daily living (ADL) indices are frequently used. Other scales or questionnaires about quality of life (such as the SF-36) or activity (such as the Survey of Activity and Fear of Falling Scales (SAFE), or the Groningen Activity Restriction Scale (GARS)) are also used. The varying objectives of the analysed articles explain some of the variations in measures used. Further work is required to reach a consensus on definition and standardized measurement of FoF and its effect on quality of life and activity.

At times providing pain relief in elderly patients can prove troublesome. Their tolerance and perception of pain can differ from that of younger patients, while the incidence of pain is above that found in those of less advanced years.

Conventional approaches to providing pain relief can be successful, but the tolerance to the side-effects of those drugs used to provide pain relief can be less. Furthermore, polypharmacy can have implications for the range of analgesic drugs that can be considered. Fortunately there are an increasing range of medicinal products with reduced potential for side-effects that can be considered when treating older patients with pain.

Survival to discharge after in-hospital cardiopulmonary resuscitation (CPR) is about 20% in those aged 65–69 years, declining with advancing age to about 10% in those aged 90 years or more. There are conflicting reports on whether or not advanced age, independent of the severity of acute and chronic illness, is a determinant of outcome. Recognition that the outcome of CPR in hospital patients is often poor has prompted extensive debate regarding the appropriate use of this procedure. In particular, there has been concern about unnecessary CPR in extended-care and hospice settings. Conversely, there has also been evidence that doctors and families may be prone to underestimate the quality of life and likelihood of benefit from CPR in older people and to make resuscitation decisions without considering the preferences of older people themselves. Recent guidelines have attempted to strike a balance between ensuring patient participation whenever possible but without offering illusory choices where CPR is very unlikely to succeed.

Urinary incontinence is a common symptom in women, more so in older people, with a significant impact on physical health and wellbeing. About 1 in 5 people have impaired continence. Symptom categorization at initial assessment is the key to guiding further therapy. Non-pharmacological options (bladder training for 6 weeks with guidance from a trained physiotherapist) are preferred and can be supported with biofeedback. If unsuccessful, anticholinergics are added and, rarely, surgical options need consideration.

Anticholinergics are the mainstay of pharmacological management of urge incontinence. The National Institute of Health and Clinical Excellence (NICE) recommends immediate release oxybutynin as the first-line agent, with recourse to others if there are adverse effects. The pharmacology, efficacy and adverse effect profile of the various anticholinergic drugs is reviewed, allowing the reader to make an informed choice of appropriate anticholinergics for urge incontinence.

An important protective function of the brain's innate immune system is to detect the presence of proteins such as amyloid and to remove them before they become neurotoxic, as is thought to occur in Alzheimer's disease (AD). Ageing affects the immune system response to infection and can influence the systemic response to vaccination and other potential immunotherapeutic agents. The generation of systemic antibodies is a vital component of the immune response, facilitating the identification and clearance of pathogens from the central nervous system (CNS). Experimental evidence using transgenic animal models of AD has shown successful clearance of amyloid from the CNS following vaccination with an amyloid peptide, and consequently a trial of amyloid beta peptide (Aβ) vaccination was undertaken in older people with AD. This produced some unexpected results, as not only was there evidence for amyloid plaque removal, but also a small number of cases developed encephalitis. A detailed review of the response to vaccination and the neuropathology findings are discussed, showing that the findings are understandable given the effects of ageing upon the innate immune system in the brain. Finally, the therapeutic potential of manipulating the regulatory components of the ageing innate immune system in order to inhibit brain inflammation and reduce cognitive decline is outlined.

Prostate cancer is the most common malignancy and the second leading cause of cancer death, in men, in western countries. Prostate cancer is diagnosed in very few people aged younger than 50 years (<0.1% of all patients). The mean age of patients with this disorder is 72–74 years. Most men aged older than 85 years have histological prostate cancer. Androgen deprivation reduces tumour activity in approximately 80% of patients with advanced disease, but most tumours relapse within 2 years to an incurable castrate-resistant state. Treatment options for patients with castrate-resistant prostate cancer are very limited and, even with toxic therapy, such as docetaxel, the life expectancy is only improved by a median of 2 months. Hence earlier diagnosis and improved treatments for prostate cancer are urgently required. Novel drugs, such as Abiratorone acetate and MDV-3100 have shown promise in pre-clinical and early clinical trials, and a number are now in phase III clinical trials, alone or in combination with docetaxel.

Research into end of life and dying with dementia in care homes from the family carer's perspective is limited. From the available evidence, it appears that family carers find themselves in an unfamiliar situation about which they lack knowledge and experience. Whilst dementia tends not to be acknowledged as a terminal illness by many family carers, they are expected to make end of life decisions on behalf of their relatives. Family carer decision-making is underpinned by values of quality of life, previously expressed wishes, comfort provision and dignity preservation. This is often approached when family carers are grieving for the anticipated loss of their relative and have their own personal needs that require to be addressed. Within a care home setting, a curative care–palliative care split is unhelpful in resolving these tensions and a model of comprehensive care appears a more appropriate approach. This requires ongoing communication between the person with dementia, family members and professionals from the early stages of the condition.

Sleep problems in older adults are common and disturbance in sleep is associated with increased mortality. These problems are more pronounced in the care home population because of institutional factors and a high prevalence of frailty and co-morbidity. This article reviews the randomized controlled trials undertaken to address sleep problems in care homes. These suggest that stand-alone therapies – oral melatonin and light therapy – have no effect on sleep but that combination treatments – physical exercise plus sleep hygiene, physical exercise plus sleep hygiene plus light and melatonin plus light – may have positive effects. These effects are more marked for daytime arousal than nocturnal sleep. Practical considerations for care homes are how to maximize light exposure, incorporate exercise into daily routines and minimize night-time disruption for residents. Trials undertaken so far are compromised by small sample size and inappropriate randomization strategies and further research is therefore required.

Musculoskeletal symptoms are extremely common, with almost one-third of people aged 75 years and over having a significant musculoskeletal problem. Joint pain due to inflammatory arthritis is important to identify, as it is potentially treatable. In elderly patients, inflammatory arthritis may not present in the ‘classical’ way, may present with non-specific symptoms and may co-exist with other musculoskeletal problems, all of which can result in diagnostic difficulty. In addition, co-morbid conditions and polypharmacy may present treatment challenges. In this paper, we discuss the general considerations in the clinical evaluation and management of a patient with inflammatory joint symptoms and discuss in more detail the diagnosis and management of the common causes of inflammatory arthritis.

Appropriate social and medical interventions may help maintain independence in older people. Determinants of functional decline, disability and reduced independence are recognized and specific interventions target the treatment of clinical conditions, multiple health problems and geriatric conditions, prevention of falls and fractures, and maintenance of physical and cognitive function and social engagement.

Preventive strategies to identify and treat diverse unmet needs of older people have been researched extensively. We reviewed systematically recent randomized controlled trials evaluating these ‘complex’ interventions and incorporated the findings of 21 studies into an established meta-analysis that included 108,838 people in 110 trials. There was an overall benefit of complex interventions in helping older people to live at home, explained by reduced nursing home admissions rather than death rates. Hospital admissions and falls were also reduced in intervention groups. Benefits were largely restricted to earlier studies, perhaps reflecting general improvements in health and social care for older people. The wealth of high-quality trial evidence endorses the value of preventive strategies to help maintain independence in older people.

Insomnia is a prevalent sleep complaint amongst older people, affecting physical and mental health as well as many aspects of life quality and well-being. For the lack of explicit guidelines for the assessment and treatment of insomnia in older people, this summary of available information represents the best evidence to inform current practice. Clinicians need to be more aware of their patients’ sleep and conduct formal assessments as appropriate. Despite past practice trends, non-pharmacological treatments should be considered first for chronic insomnia as a means to reduce dependency, adverse effects, and polypharmacy. Behavioural treatment methods such as stimulus control and sleep restriction are especially beneficial for older insomniacs as they target maladaptive sleep habits. Pharmacological treatment should be employed only if insomnia persists, involving the careful patient-specific consideration of the lowest effective dose, best intermittence of dosing, shortest effective duration, best gradual discontinuation scheme, and most effective elimination half-life.