Chronic kidney disease (CKD) refers to long-term impairment of renal function. It is predominantly a disease of older people and the true extent of this has only recently been recognized. CKD has a number of implications including increased cardiovascular risk, secondary complications such as renal anaemia and bone disease and a small but significant risk of progression to established renal failure (ERF). It is associated with significant morbidity, mortality and healthcare costs and, against the background of an ageing population and the rising prevalence of type 2 diabetes, represents a growing public health problem. Evidence that specific interventions can reduce the cardiovascular risk associated with CKD and the risk of progressive CKD, as well as improving quality of life, has highlighted the importance of early detection of this disease.

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.

Polymyalgia rheumatica and giant cell arteritis are closely related conditions, considered by many to represent opposite poles of a single disease spectrum. They can occur together or separately.

Polymyalgia rheumatica is characterized by pain and morning stiffness in the shoulder girdle and sometimes the pelvic girdle. The symptoms are felt to be related to synovitis of proximal joints and extra-articular synovial structures. Giant cell arteritis displays a frank vasculitis affecting the regions supplied by the temporal artery to give visual loss and scalp tenderness but is increasingly recognized to also affect the aorta and its extra-cranial branches. For this reason the term ‘giant cell arteritis’, which is descriptive of the pathology, is used instead of the alternative term ‘temporal arteritis’, which gives a misleading impression of localization but which was the term used in previous reviews for this journal, the most recent in 2003.

This paper will review some fundamentals of normal renal physiology necessary to understand the changes occurring with age and enable the reader to distinguish between chronic renal insufficiency and the consequences of normal ageing on kidney function.

In 2004 the Stroke Association stated ‘Each year over 130,000 people in England and Wales have a stroke. Of all people who suffer from a stroke, about a third are likely to die within the first 10 days, about a third are likely to make a recovery within one month and about a third are likely to be left disabled and needing rehabilitation. Stroke has a greater disability impact than any other medical condition. A quarter of a million people are living with long-term disability as a result of stroke in the UK.’

Urinary tract infection is the most common bacterial infection in older populations. It is an important clinical problem across the full spectrum – from elderly persons who are well and living in the community to highly functionally impaired residents of long-term care facilities. Symptomatic urinary infection is a frequent cause of morbidity, and urinary infection is responsible for substantial antimicrobial use. This review summarizes current knowledge relevant to both asymptomatic and symptomatic urinary infection in older populations, and identifies unresolved issues for further study. The discussion is relevant to older individuals without indwelling urethral catheters, unless it is specifically stated that the older person with an indwelling catheter is being addressed.

This article provides information about the projected need for specialist dementia care environments in the United Kingdom. It summarizes the adverse effects of poorly designed environments and acknowledges that, despite a range of residential models, none has been shown or agreed to be the best. It considers current efforts in the UK that might influence future care environments positively.

Accurate assessment of renal function is vital, especially in older individuals, as this is the population in which the greatest burden of chronic kidney disease (CKD) occurs. With ageing, the kidneys undergo a multitude of structural and functional changes. The age-related changes in the kidneys may be further complicated by concurrent pre-renal, renal and post-renal factors common in old age, such as hypertensive glomerulosclerosis, diabetic nephropathy, congestive cardiac failure, renovascular atheroma, urinary outflow obstruction, urinary tract infections, renal stones and drug-induced nephrotoxicity. Structurally, there is a progressive loss of predominantly cortical renal mass, a decrease in the number of glomeruli, an increase in the proportion of sclerotic glomeruli, tubulo-interstitial changes resulting in fibrosis and atrophy, arteriosclerotic vascular changes and a reduction in renal blood flow. Excretory and reabsorptive capacities of the renal tubules may also decline with ageing. Functionally, although there may be a decline in the glomerular filtration rate (GFR) resulting primarily from a reduction in the number of functioning nephrons, this decline may not be universal. Up to a third of elderly people may not demonstrate a decline in GFR with ageing, whilst in some individuals GFR may actually increase with age.

Cognitive impairment has been recognized as a risk factor for falls and for increasing the severity of injury following a fall, but the mechanisms by which cognitive impairment influences gait and postural control have been unclear. A recent report that galantamine improves gait parameters in older adults may help to untangle this.

Primary total hip replacement (THR) is one of the most common and cost-effective major operations performed in the developed world: annually approximately 50,000 are undertaken in England and Wales and over half a million are performed worldwide. The majority of these operations are performed for primary or secondary osteoarthritis (over 75% from Swedish data), traumatic fracture (11.3%) or rheumatoid arthritis (6%), but indications are varied and include avascular necrosis, congenital dislocation, Paget's disease, and ankylosing spondylitis. The primary goal of the procedure is the relief of pain that can no longer be controlled by analgesia or non-operative procedures, but severely impaired mobility affecting independence is a secondary indication.

Impaired hearing is prevalent amongst older people, adversely affecting physical and psychosocial function and, hence, quality of life. It may also cause depression. Yet evidence suggests that hearing problems are all too often regarded as a ‘normal’ part of ageing and more likely to be ignored than diagnosed and/or treated; many believe that little can be done to improve hearing. Furthermore, ‘many of the behaviours of a hearing-impaired individual (e.g. irritability, inattention or inappropriate responses) may be interpreted as evidence of dementia’ though they may simply reflect communication difficulties that can, in turn, damage personal relationships.

Oral mucosal lesions occur frequently in older people and are important as they may reduce quality of life, represent pre-malignant change or indicate systemic disease. The commonest mucosal lesions in adults are denture-related lesions such as stomatitis, angular cheilitis, ulcers and hyperplasia, and occur in 8.4% of the adult population. In the hospital setting, oral mucosal lesions may lead to malnutrition, slow rehabilitation and recovery from illness, and adversely affect quality of life. The two major risk factors associated with oral lesions are denture use and smoking, and frequently older people have been exposed to both of these. Commonly used drugs such as antihypertensives, antidepressants and antibiotics may have oral mucosal side-effects, and polypharmacy may worsen these. Decreased awareness of changes in the oral mucosa, or inability to raise concerns due to dementia, delirium, social isolation, or difficulty accessing dental care may further compound the problem. Hospital admission could represent an opportunity to intervene, but oral mucosal lesions, and indeed oral hygiene, are areas which can be overlooked by doctors. This article is intended to highlight common or important oral mucosal diseases and increase awareness of these conditions for the practising hospital or community geriatrician.

Vitamin D has been known to play a key role in calcium homeostasis and bone health for almost a century. Its main current clinical use is as an agent to prevent osteomalacia and reduce fragility fractures in older people. Vitamin D may however play a wider physiological role, with effects on cancer prevention, cardiovascular health and immune function. This review article will outline the physiological role of vitamin D, the disease processes that have been associated with insufficiency and examine whether vitamin D supplementation can ameliorate these disease processes in older people.

Rehabilitation in broad terms is a process aimed at restoring a person's functional capacity particularly in relation to activities of daily living. Studies have shown that hospitalization of older patients is a major risk factor for an often irreversible decline in function, and that functional decline from baseline occurs as early as day two of admission. Rehabilitation is therefore often required for older patients following an admission to an acute hospital. Older patients admitted for rehabilitation are more likely to be functionally impaired and are more medically complex than younger patients.

The incidence of deep vein thrombosis (DVT) and pulmonary embolism (PE), collectively called venous thromboembolism (VTE), increases with age and has been reported to be higher in males. The annual incidence rates per 1000 for DVT and PE are 1.3 and 1.8, respectively, for people aged between 65 and 69 years, rising to 2.8 and 3.1, respectively, in those aged between 85 and 89 years. Older people are about eight times more likely to develop VTE in hospitals, nursing homes or other chronic care facilities than younger adults. About 1.7% develop PE within one year of treatment for DVT, whilst the one year recurrence rate for PE was 8.0%. About 3% of patients with DVT and 21% of those with PE die in hospital. One year mortality with DVT is 21% and that with PE is 39%.

Providing symptomatic palliation in terminal malignant disease is integral to high-quality elderly-care medicine. Effective pharmacological treatment, especially pain relief, is the mainstay of palliative care, but physical intervention is sometimes required to relieve mechanical problems. Interventional radiology is rapidly evolving and there are many clinical situations in which it is indicated. It is as effective as open surgery, but without the risk of general anaesthesia and surgical morbidity. Most interventional radiology procedures can be performed with a much shorter hospital stay than the alternative surgical procedure, and often as a day case admission. Reducing hospital stay and recovery time is of great importance to the older patient who may have a short life expectancy because of the cancer and co-morbidities.

The topic of hypoxaemia after stroke was last reviewed in this journal in 2001. Since then a lot of new information on the subject has been published, and while some questions have been resolved, new problems have emerged. This article discusses new research in the light of what is already known and outlines areas of persisting uncertainty.

Optimal prescribing is critical to the goals of geriatric medicine of curing disease, eliminating or reducing symptoms, and improving functioning. However, prescribing decisions in older people are often complex. There is marked heterogeneity in health status and functional capacity amongst older people, who range from fit, active, independent individuals to those who are physically and mentally frail, with limited physiological reserve. Age-related changes in physiology affect drug pharmacokinetics and pharmacodynamics, and together with various pathological processes, increase the risk of adverse drug events (ADEs). This risk is heightened by prescription of multiple medications to treat multiple co-morbidities. Consequently, balancing safety and quality of prescribing for older people with appropriate treatment of all co-morbidities can be challenging.

Salt and electrolyte disturbances are commonly encountered in older patients. A sound understanding of the underlying physiological and pathological mechanisms underpinning the predisposition of older people to the common electrolyte imbalances can help clinicians minimize their considerable associated morbidity and mortality. This review focuses on the more common and clinically relevant salt and electrolyte disorders of older people. The epidemiology, causes, symptoms, diagnosis and treatment of hyponatraemia, hypernatraemia, hyperkalaemia, hypokalaemia and calcium and phosphate imbalance in old age are covered from a clinician's perspective.

The clinical diagnosis of Alzheimer's disease (AD) involves neuropsychological testing to assess the integrity of higher order cerebral functions such as memory, cognition, visual perception, language and executive function. However, the onset of AD is insidious and diagnosing the very early stages may be precluded as such tests may lack the necessary sensitivity and specificity. This, together with the potential for similar shortcomings in relation to assessing disease progression and response to treatment, has prompted the search for disease markers based on abnormalities in additional aspects of brain processing. One area receiving increasing investigation is the integrity of visual and visual-attention-related processing.