Chronic liver disease is increasingly prevalent and, as the population ages, geriatricians will see an increasing burden. We present an overview of the investigation and management of older adults with chronic parenchymal liver disease and highlight the potential roles of transjugular intrahepatic portosytemic shunts and orthotopic liver transplantation.

The incidence of pneumonia is higher in older than younger people, due to both an increase in factors facilitating entry of infectious agents into the lungs, and attenuated functioning of the immune system. Classic features of presentation of pneumonia may be absent. The most common signs of pneumonia in old age are tachypnoea and tachycardia. Aetiology is established in only 50% of older patients. The empirical treatment of community-aquired pneumonia (CAP) should be aimed at its most common cause, Streptococcus pneumoniae. The empirical treatment of health care-associated pneumonia (HCAP) should be targeted at Gram-negative agents. Choice of antibiotic must include consideration of potential drug interactions.

The autonomic nervous system comprises the sympathetic, parasympathetic and enteric nervous systems and plays an integral role in homeostasis. This includes cardiovascular and temperature control, glucose metabolism, gastrointestinal and reproductive function and increasing evidence to support its involvement in the inflammatory response to infection and cancer. Ageing is associated with autonomic dysfunction, and many clinical syndromes associated with older adults are due to inadequate autonomic responses to physiological stressors. The aim of this review is to explore the relationship between autonomic dysfunction and ageing illustrated with examples of maladaptive autonomic responses in a variety of different clinical syndromes including an exploration of autonomic cellular changes. Appropriate investigation and management strategies are outlined, recognizing the fine balance needed to improve symptoms without creating further medical complications.

In the last 20 years a realization has developed that acute stroke is a condition that benefits from early intensive investigation and treatment. Older people are historically less likely to receive such active management through a combination of limited evidence due to their exclusion from clinical trials and a level of ‘therapeutic nihilism’ regarding older subjects with severe, acute illness.

There is increasing evidence that many acute therapies, including thrombolysis, benefit older stroke patients. Older subjects may not achieve as good results as younger groups but differential benefits are often comparable when expected outcomes are considered. Risk of haemorrhagic complications with thrombolysis is not substantially increased and older subjects are now receiving this therapy despite a dearth of relevant trial data.

Intensive physiological monitoring and stroke unit care has been found to be of benefit to patients of all ages. Surgical options for intracerebral haemorrhage are limited, but there is little difference in the management of intracranial haemorrhage in older people. There is unlikely to be a benefit to surgical hemicraniectomy for cerebral infarction in those >60 years. In conclusion, active management for acute stroke in older people is frequently beneficial and age should not be a barrier to such care.

Providing information to older adults is essential for informed decision-making and good health. Because there are significant deficits in providing information verbally, health professionals must use written information as well. Most studies have focused on the content and literacy of documents. However, the legibility and formatting are critically important for older adults, who are more likely to suffer with visual impairment. Providing written information that is tested for appropriate reading level and for presentation is necessary to ensure that older adults can use the information given. There are a number of tools available that test these aspects of written information, but not one tool that is universally accepted. Further research regarding the design and presentation of written information for older adults is necessary.

Frailty is a central concept in geriatric medicine, but without a clear definition. Many regard it as a syndrome with its own clinical manifestations and pathophysiology, whilst others consider it to be the result of the accumulation of age-related deficits that predict adverse changes in health. We analysed, through a systematic review, the definitions and markers of the frailty syndrome. Twenty-five articles were included and divided, according to design, into observational, intervention, review and qualitative studies. There was a predominance of operational definitions that used only physical markers to identify frailty. The only qualitative study found that health professionals chose a multidimensional definition that took into account factors other than just the physical. We conclude that there is still no standard definition or agreement about markers of the frailty syndrome.

This review provides an update on current evidence surrounding the epidemiology, treatment and prevention of non-respiratory infections in care homes. It covers urinary tract infection (UTI), methicillin-resistant Staphylococcus aureus (MRSA), decubitus ulcers, scabies, tinea infections and viral and bacterial gastroenteritis. The care home sector provides a unique ecological niche for infections, housing frail older people with multiple co-morbidities and frequent contact with healthcare services in a semi-closed environment. This leads to differences in the diagnosis and management of infections – particularly of outbreaks – when compared with community-dwelling counterparts. It is essential that care home staff play a role in the early recognition, isolation and treatment of infections, but they are often not trained as healthcare professionals – this presents a challenge to systematized response. Effective interface between care homes, public health and infection control services are essential to the delivery of care, yet it is not clear how to structure such links most effectively.

Seasonal influenza remains a common cause of morbidity and mortality for older residents in aged care facilities. Whilst prevention is best managed by high vaccination rates for the general population, residents and aged care facility staff, new research suggests that a more active approach to surveillance and anti-viral treatment now plays an important role. The practicalities of managing an influenza outbreak are complex and best planned in advance with written protocols available. Good infection control remains a vital part of prevention and outbreak control.