Geriatric medicine started in long-term care, when the pioneers in the emerging specialty examined the inhabitants of the Victorian workhouses to discover elderly, largely ignored, yet eminently treatable patients. They focused attention on the then taboo subjects of incontinence, dementia and immobility. They developed a paradigm which entailed a proper assessment and, where appropriate, rehabilitation. This empirical process was central to their evident success, and achieved a reduction in unnecessary institutionalization by restricting long-stay care to those who could not, after full assessment and treatment, be discharged. The concept of progressive patient care developed, to make best use of somewhat meagre facilities. Day hospitals spread nationally, and outreach teams developed. Respite care schemes provided support to the huge numbers of informal carers, by sharing the load with the hospital service.

Introduction

Aging is a detrimental, progressive process that affects all human beings fortunate to live long enough. This indistinct process renders an individual increasingly susceptible to disease, disability and death. For this reason, aging is expensive, both personally for an individual and financially for society as a whole. Aging is probably the result of damage to several different mechanisms. There are numerous potential contenders, one of which is the involvement of mitochondria. Harman in 1972 was one of the first to suggest that mitochondria may have a central role in aging. Linnane in 1989 proposed that the accumulation of mitochondrial DNA (mtDNA) mutations during life is a major cause of age-related disease. With the explosion of molecular biology in the last decade, our understanding of mitochondrial aging has advanced, raising many questions as to if and how mtDNA mutations may be involved in aging.

Only a tiny proportion of the huge epilepsy literature is devoted to elderly people. In recent years, however, this important and under-researched area in geriatric neurology has started to attract the attention it deserves. A small trickle of publications has started to swell and symposia or workshops devoted specifically to older people with seizures are becoming increasingly common.

Autonomic disorders in old age can be attributed to several main features associated with aging: the intrinsic neurobiological changes that occur with age, degenerative changes in effector organs innervated by autonomic nerves, and secondary involvement of the autonomic nervous system (ANS) in disease processes. As in most areas of clinical geriatrics, the distinction between disorders ascribed to ‘normal’ aging and those attributable to diseases of old age is difficult to make with any degree of certainty. Neurobiological changes with age have become the subject of intense investigation in recent years, with improvements in techniques for assessing autonomic nerve structure and function. This has included a better understanding of neurotransmitter and receptor transformations during development and aging. The versatility of the ANS, or ‘plasticity’, involves interactions with target organs, e.g. via nerve growth factor (NGF) and with other neurons, and it is as vital to the mature and aging autonomic neuron as it is during development. Some neurotrophic features of aging in the ANS and in disease processes in old age are considered in this paper.

Three diseases of bone are common in the elderly: osteoporosis, osteomalacia and Paget’s disease of bone. Osteoporosis is the result of bone loss, caused by a change in factors that regulate bone cell metabolism. The process of bone loss itself, resulting in osteoporosis, does not cause symptoms. It is the consequences of osteoporosis, fractures and bone deformity, that patients complain of. Osteomalacia is a defect in the process of mineralization of bone, nearly always due to vitamin D deficiency. In contrast to osteoporosis, patients with osteomalacia may have complaints of bone pain and muscle weakness. Page’s disease of bone is probably caused by a slow virus, which initially affects osteoclasts, followed by stimulation of osteoblasts. The process of increased bone cell turnover itself does not usually cause complaints. However, it results in deformation of bones and joints causing a painful secondary osteoarthritis. Pain resulting from high bone cell turnover responds remarkably quickly to treatment. In exceptional cases local pain in the long bones occurs. In an earlier review the problems of origin, diagnosis and treatment of osteoporosis were discussed. This paper focuses on diagnostic procedures and therapeutic regimens.

The maintenance of independence by older people is seen as a priority by health and social services, and by people themselves. This review explores the constructs of independence and dependence in relation to aging, and considers the ways that discourses surrounding these topics affect our thinking about growing older.

This paper addresses the ethical and legal issues which arise in the UK in the care of demented people, updating and revising the 1993 review in this journal. In 1993 the ‘end of medical ethics’ had recently been suggested, an American fear that the doctor‘s responsibility and authority would be fatally eroded by administrators and cost controllers, concerned only with budgets. These concerns persist.

Dementia with Lewy bodies (DLB) is being increasingly recognized as a common cause of progressive cognitive decline in the elderly, with hospital-based autopsy series demonstrating rates of between 7% and 25% of all cases of dementia, second only in frequency to Alzheimer's disease (AD). Although DLB has only recently been described, it is unlikely to be a newly occurring disease but one which has become identifiable as a result of advances in neuropathological techniques which make cortical Lewy bodies (LBs) easier to detect.

Despite the growing recognition of the importance of housing for the health and well-being of elderly people there has been less research on the topic than on health or personal social services. Moreover, until recently, what research there was tended to concentrate on specialized, rather than mainstream, forms of housing. This review looks at research on the meaning of home; the kind of housing elderly people live in; tenure; specialized and nonspecialized housing; some issues to do with an assessment of needs; and at links between services. The very important related topic of moving in old age is not covered because this was the focus of a recent review in this journal. However, it is relevant to note that research shows that many people move into specialized housing against their will and wish that they could have remained at home. This review also excludes consideration of other related topics such as household composition, affordability, the contribution of technology such as alarms and ‘smart’ houses, and problems of specific groups, such as those who are homeless.

For those of us who have been working in the elder abuse movement for a decade or more, progress towards understanding and prevention of elder abuse has been exceptionally slow. This situation may be attributed as much to the complexities of elder abuse as to the importance given to the problem by national governments. However, one trend in the past five years is particularly noteworthy. The increased awareness of elder abuse among the nations of the world, underscored by an ‘“explosion” of interest’ in the UK, has been the most salutary accomplishment. The purpose of this paper is to review the status of the field with specific reference to the past five years. Of necessity, this review is selective and thus may omit worthy research and policy achievements. As with an earlier paper (see Rev Clin Gerontol 1992; 2: 269-76), this review is limited to elder abuse in domestic settings.

Over 2000 randomized trials are reported in the literature for the treatment of dementia and cognitive decline. Yet the responses to the question, ‘Which treatments are effective in dementia?’ are likely to be various and conflicting. Wide variation in practice exists, and for drug therapy, where information is more readily available, different treatments are used in different countries. For example, only one drug (Hydergine) is licensed in the UK for dementia, though rarely used, while there are over 30 drugs in use in Japan for dementia and cognitive decline,five in Spain, and two in the USA. This inconsistency is likely to be even greater for interventions of psychological and behavioural therapies, environmental therapy and the organization of care.