The issue of not taking medicines as prescribed by medical practitioners has a history as long as the medical profession itself. The World Health Organization recently described the problem of patients diagnosed with chronic illnesses not taking their medication as prescribed as ‘a worldwide problem of striking magnitude’. Not taking medicines as prescribed has consequences not only for the individual in terms of therapeutic failure, but also for the wider society. For the individual, failure to take medication as prescribed may result in ill health, poorer quality of life, and reduced life expectancy. For the wider society, consequences include avoidable health care expenditure and the development of drug resistance.

It is widely acknowledged that ‘rewarding personal and sexual relationships promote health and well-being’, an opinion exemplified by the identification of sexually-transmitted infections (STIs) as one of the key targets for disease reduction in the Health of the Nation White Paper. Indeed, since the advent of the AIDS pandemic in the early 1980s, a substantial body of research has been undertaken in the area of sexual health.

Suicide is a major health issue worldwide and is among the top ten causes of death in many countries. Much research, media attention and public health initiatives are focused on reducing the suicide rate among adolescents and young adults. In many countries, however, it is the elderly population with the greatest number of suicides, the majority of which die by drug overdose. This is commonly explained by an increased suicidal intent among older people due to co-morbidity and social isolation. The physical vulnerability of elderly people to potential toxins however is also likely to play an important role. This review examines the epidemiology of elderly suicide, considers commonly implicated drugs, and discusses associated risk factors in this complex and multifactorial problem.

Substance misuse in the elderly population has been referred to as a silent epidemic. One of the factors that contributes to the appropriateness of this description is the difficulty of diagnosis in this age group. There is abundant evidence that substance misuse is under-diagnosed in elderly people and that this applies to both alcohol and drug misuse, although the general principles of a diagnostic approach are not age-related. The increased incidence of anxiety, depression, dementing illness, and physical illness in this population, independent of substance misuse, means that diagnoses can often be missed. The impact of co-morbidity (Figure 1) in older age groups is such that it remains the most important confounding factor in diagnosis. In this second section of the review we explore the range of psychiatric and physical illnesses that can coexist with, or be caused by, substance misuse in the elderly population. The issue of assessment as part of a treatment framework is considered in the third section of the review. The risk of missed diagnosis in this age group was illustrated in a study of diagnosis of substance misuse problems in patients aged 65 and over who had been admitted to hospital. Only three out of a total of 88 patients using benzodiazepines, 29 out of 76 smokers, and 33 out of 99 problem drinkers were correctly identified. Of those who were identified only a small proportion were referred on for specialist treatment.

Although sarcopenia has been used to define muscle mass loss in older subjects, muscle mass is not directly linked to muscle function. Recent definitions consider sarcopenia as a syndrome characterized by progressive and generalized loss of skeletal muscle mass and strength with a risk of adverse outcomes, such as physical disability, poor quality of life, and death. It is closely linked with physical frailty, and also with other muscle wasting disorders, including cachexia and malnutrition. This review focuses on the incorporation of sarcopenia into clinical practice, reviews case finding and diagnosis of sarcopenia, proposes a syndromic approach for the diagnostic work-up of sarcopenic patients, and looks at intervention trials with physical exercise and nutrition, as drugs to treat this condition are not expected to be available in the near future.

Depression in old age is common, disabling and under-treated. This review will examine recent advances in our understanding of its clinical presentation, epidemiology, management and prognosis. The relationship of depression in old age with dementia and with physical illness is also discussed, as are the links between suicide, deliberate self-harm and depression in old age.

This article reviews the research into anxiety disorders in adults aged 65 years and older that has been published over the past ten years. The topics covered include: the construct of anxiety and its disorders in this age group; epidemiology, including prevalence, incidence, course, outlook, and risk factors; assessment scales; co-morbidity and differential diagnosis (depression, dementia, physical illness); and management, both pharmacological and non-pharmacological. There has been a significant improvement in our understanding of these disorders in older adults over this period, but evidence to support their treatment and prevention is still quite sparse.

Introduction

The methodology of quality of life measurement has developed markedly in the last few years. Clinicians and researchers have increasingly acknowledged that the burden of illness can not be described only in terms of disease status. Measurement of psychosocial factors such as pain, restricted mobility, difficulties fulfilling family or work responsibilities, and psychological wellbeing provides a far more comprehensive and meaningful assessment of the impact of disease on the patient’s life. Similarly, such patient-based measures are increasingly replacing traditional clinical or disease indicators as the primary measures of outcome in clinical trials.

There is growing support for characterizing human aging from a life-course perspective, in terms of recognizing important influences operating from conception to death, and this approach provides a framework for understanding aging processes operating at the individual level. Kirkwood's disposable soma theory proposes that aging is a manifestation of imperfect somatic maintenance and repair processes. We can therefore predict that differing exposure to the determinants of somatic damage across the life-course, and variable capacity to respond in terms of repair are likely to underlie the wide variation in rates of aging between individuals.

Fear of falling (FoF) is a common condition in older age. However, there is a paucity of research on its prevalence, impact and treatment in older people with dementia. People with dementia have an increased risk of falls which present a significant threat to their independence, as well as having a significant economic impact on health and social services. This review outlines the key issues in relation to FoF, current guidelines and assessment tools and their use for people with dementia. Further research needs to be completed in both addressing the specific assessment barriers that people with dementia may face regarding the use of current FoF tools, with further exploration surrounding the individual's experience of FoF and how this may be impacting upon their quality of life and functionality. Until a well-validated method has been developed, clinicians need to utilize available tools as guidelines, seek the assistance of proxies at all stages of the care journey, and use clinical judgement to assess FoF in patients with dementia.

Smoking remains prevalent in elderly people in the UK and similar countries. The adverse health effects of current smoking continue to accumulate in old age and stopping smoking in old age confers benefits on function, morbidity and mortality. Many elderly people wish to stop smoking and many are successful. Structured support from health and social care workers improves quit rates and nicotine replacement therapy can be an effective aid to smoking cessation in old age. Doctors and other healthcare staff should use the opportunities of patient contact to encourage older smokers to quit. Cognitive impairment is a barrier to successful smoking cessation.

Introduction

A stroke patient puts on his shoes and then tries to put on his socks over his shoes. Entering the kitchen, this patient puts milk in the teapot, places the sugar bowl in the oven, and tries to drink from the milk jug. This patient is most probably apractic. Apraxia is one of the four classical neuropsychological deficits – such as agnosia, amnesia and aphasia – causing restrictions in the ability to carry out purposeful and learned activities. One of the first definitions of apraxia was given by Geschwind: ‘Disorders of the execution of learned movements which cannot be accounted for by either weakness, inco-ordination, or sensory loss, nor by incomprehension of, or inattention to commands.’

Dizziness is one of the commonest symptoms described by older people and is associated with balance disorders, functional decline and falls.

Parkinson's disease (PD) is one of the most common neurodegenerative diseases and occurs in all ethnic groups, affects both sexes, and becomes increasingly common with advanced age. With population aging, the impact of PD in human, social and economic terms is growing.

Rising unplanned hospital admissions are a problem in ageing populations worldwide. These admissions are associated with poor outcomes for older people, contribute to rising health care costs and impede the provision of planned care. Policy and practice in recent years has focused on identification of those at risk of unplanned admission and early intervention via a range of admission avoidance services. Despite this, unplanned admissions in older people continue to rise, and managing demand for unplanned care remains a priority. Questions remain about the risk factors for unplanned admission and the best approaches to identifying and intervening with those at risk. This review explores recent evidence on admission rates, risk factors for unplanned admission in older people, identification of those at highest risk and interventions to avert unplanned admission.

This study systematically reviews the published literature regarding inappropriate prescribing in frail individuals aged at least 65 years. Twenty-five of 466 identified studies met the inclusion criteria. All papers measured some surrogate indicators of frailty, such as performance-based tests, cognitive function and functional dependency. Beers criteria were used in 20 studies (74%) to evaluate inappropriate medication use and 36% (9/25) studies used more than one criterion. The prevalence of inappropriate medications ranged widely from 11 to 92%. Only a few studies reported the relationship between potentially inappropriate medication use and surrogate measures of frailty. These diverse findings indicate the need for a standardized measure for assessing appropriateness of medication in frail older individuals. Prescribing tools should address both medication and patient-related factors such as life expectancy and functional status to minimize inappropriate prescribing in frail individuals.