The classification of schizophrenia-like and paranoid disorders in elderly people has a long and somewhat confusing history which can largely be blamed for the currently uncertain nosological position of such patients. To Kraepelin, dementia praecox was fundamentally a disorder of emotion and volition, while paraphrenia was characterized by hallucinations and delusions without deterioration or disturbance of affective response, and paranoia involved the insidious development of a permanent delusional system which resulted from internal causes and was accompanied by perfect preservation of orderly thinking, acting and will. However, by the eighth edition of his textbook in 1913, Kraepelin was expressing serious doubts about the assumptions on which his conception of dementia praecox had been based. In some cases, a complete and lasting recovery was seen and the relationship between onset and early adult life was not absolute. Indeed, Bleuler had introduced the term ‘schizophrenia’ in order to get away from the concept of the disorder as an adolescent mental deterioration.

Cardiovascular disease (CVD) is a major cause of morbidity and mortality in the Western world in older people. Diet and lifestyle change can reduce CVD risk in older people, and this evidence base is reviewed. For example, diets low in trans fats can reduce CVD risk, while for saturated fats the CVD-lowering effect depends on what is substituted for the saturated fat. Diets rich in fish reduce CVD risk, although n-3 supplements have not been shown to have a consistent effect on CVD end-points. Antioxidant and B-group vitamin supplementation are unlikely to reduce CVD risk, but diets rich in these micronutrients (e.g. rich in fruits and vegetables and the Mediterranean diet) are associated with lower CVD risk, while, for the Mediterranean diet, this has been supported by randomized controlled trials. Maintaining a healthy weight and being physically active reduce CVD risk factors and CVD incidence and mortality.

Like other organs in the body, the kidneys undergo age-associated anatomical, structural and physiological changes. Starting at 50 years of age, there is a 3-10% decline in kidney weight for each subsequent decade of life, with the loss of cortical mass greater than medullary mass. In fact, the number of glomeruli start to decrease progressively after age 40, and the number of sclerotic glomeruli increases, making the distinction between involutional and disease-related sclerosis unclear in some cases. The outer cortical glomeruli are, in general, more extensively involved than deeper glomeruli, but glomerular size does not change. In general, the loss of the glomerular mass is proportional to the loss of tubular mass, maintaining glomerulotubular balance. In addition to glomerular sclerosis, there is a gradual increase in interstitial fibrosis, and there is focal thickening of both glomerular and tubular basement membranes, probably due to the accumulation of type IV collagen.

Much of Parkes’ thorough review of bereavement in the elderly in a previous issue of this journal is still highly relevant. Advances in our understanding of bereavement are surprisingly slow for a condition which is ubiquitous, and there are still disappointing gaps in our knowledge. A common difficulty for researchers in this field, and for clinicians reading their papers, is the problem of selection bias. Participants in studies on bereavement are often white and middle class. More often than not, grief research focuses on bereaved spouses rather than blood relatives or friends of the deceased. In addition, much research on bereavement originates from the USA, so the findings may not be as relevant in other countries. Lastly, of particular relevance to this paper, although many studies of grief purport to be of ‘older’ samples, closer inspection of the paper will often reveal a surprisingly young mean age; people over 75 are often excluded from bereavement research. These biases must be borne in mind when interpreting the findings from the studies discussed in this review.

Since pronounced aging of the population became evident in the 1976 Australian census, there have been repeated expressions of concern about the health care costs associated with this trend. The latest of these has come from the National Commission of Audit (NCA) which was established by the newly elected conservative Commonwealth Government in June 1996 to undertake a wide-ranging review of the financial position of the Commonwealth Government. The Terms of Reference on which the NCA was to report included 'the impact of demographic change on Commonwealth finances, with the intention of making recommendations as to how emerging pressures could be provisioned'. Many of the themes canvassed in its report are in common with those raised in analyses of the implications of aging for health care costs in other countries, but some reflect particular characteristics of the Australian aged care system and social policy context.

This review is the first in a three-part series on substance problems in older people. This section reviews terminology, epidemiology, outcome studies and policy directions. Subsequent articles will provide an overview of assessment, physical and psychological co-morbidity, as well as treatment options.

The dementias which affect the elderly are chronic diseases with protracted courses, substantial morbidity, complicated presentations and serious effects on families and caregivers. The care of a patient with dementia is therefore complex, requiring a rational model of treatment including careful multidisciplinary evaluation, a treatment plan, and ongoing reassessment. The aim of this article is to provide a framework for any clinician involved in the management of patients with dementia. Dementia has been thought of as untreatable by some health professionals: however, in many ways it can be managed effectively and its consequences reversed or stabilized, even though the disease process may be irreversible. With evolving knowledge in basic research and with the development of new intervention strategies, more effective treatments will be available over the next several years. Therefore we provide a guide to the management of patients with dementia which is responsive to the introduction of future treatments.

The growth of the elderly population in the UK and other Western societies, as well as in the USA, Australia and Japan, has led to widespread interest in the living arrangements of this group. Although co-residence patterns within the household alone are not sufficient indicators of the strength of conjugal and intergenerational ties, they do provide a measure of potential intra-household support for the elderly. Studies have shown that children who live at home provide greater assistance to their parents (both financially and with domestic tasks) than non-co-resident children. Thus, residential patterns appear to be important for exchange relationships between the elderly and their kin.

There is a rising prevalence of dementia in line with the continuing demographic transition. More timely diagnosis of dementia is recommended. Brief cognitive tests are useful as they provide a rapid assessment that can indicate the possibility of dementia and identify people for detailed cognitive assessment. Many brief cognitive tests have been developed and practitioners need information in order to select a test that performs well, is acceptable to patients, and is suitable for the relevant care setting. In a structured review, we identified twelve brief cognitive impairment tests, of which six have been sufficiently studied and can be recommended for use in routine care.

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.

There are inadequate data to formulate evidence-based guidelines on cardiovascular medication and falls. A critical systematic review of medication as a risk factor for falls concluded that there was a weak association between drugs that reduce blood pressure and falls. The population studies reviewed, looking for an association between cardiovascular drug usage and falls, consisted of subjects who were much younger and who had a much lower drug burden when compared with the older clinic population. The magnitude of the effect of cardiovascular medications on falls may therefore have been underestimated in these studies.

Two observational studies in falls clinics showed significant reductions in falls and syncope following withdrawal of cardiovascular medication, with improvements in symptoms, in tilt-table parameters predictive of syncope, and in measures of gait and balance.

There are no randomized controlled trials of the effect of cardiovascular drug withdrawal on falls. An expert audience of 200 members attending the 2009 British Geriatrics Society Falls Section Conference held the unanimous opinion that cardiovascular medications were a significant cause of falls in older people.

Dementia is not a disease. It is the neuropsychological deficit which results from chronic brain disease or encephalopathy. Dementias may be nonprogressive, for example resulting from brain trauma or cerebral hypoxia, or progressive, resulting from intrinsic, extrinsic or metabolic cerebral disorder. The progressive encephalopathies, in particular those resulting from intrinsic brain disease, form the subject of this review.

Depression is the most common mental health problem in old age, presenting a significant challenge to mental health services for older adults. The high chronicity, relapse and mortality rates associated with late-life depression suggest that existing treatments for late-life depression are insufficient. Therefore, current theoretical understandings may require further development. Given the growing population of older adults, the need to improve our understanding of late-life depression is increasingly urgent.