Oral anticoagulant therapy has become more commonly prescribed for people of 65 years and over following the widening of its clinical indications to include thromboembolic prophylaxis in atrial fibrillation. It is estimated that approximately 470 000 people in the UK, almost 1% of the population, are currently receiving oral anticoagulant therapy and this is growing. Due to its narrow therapeutic index, and the intra-individual variation in dose requirement, there is a need to monitor the level of anticoagulation in each patient. In consequence, health systems have had to invest resources into monitoring services to cope with this development.

There seems reasonable, if depressing, agreement from studies of mixed aged subjects and elderly subjects in psychiatric settings that nonresponse or poor response to a course of an antidepressant occurs in at least one-third of depressed patients. The figure may be higher in elderly patients in general and those with poor physical health. The human cost of chronic depression is highlighted in the Medical Outcomes Study. The level of functional impairment and intereference with quality of life associated with depression was comparable with or worse than that of eight major chronic medical conditions, including diabetes, arthritis and severe coronary artery disease. The final tragedy for unremitting depression may of course be suicide.

With an aging population globally, and increasing numbers of older patients facing chronic illnesses, better palliative care in old age should be promoted.In this review we will

1. Highlight the pressing need for better palliative care for older people

2. Advocate the concept of palliative care as applied to geriatrics and gerontology

3. Review current end-of-life care for older people with chronic disease, both non-cancer and cancer

4. Discuss the palliative-care approaches to common physical symptoms and psychospiritual distress

5. Highlight advanced care planning and quality-of-life issues

Substance use and misuse are best viewed through the framework of a multifactorial biopsychosocial model, which acknowledges the interplay of genetic, familial, physiological, psychological and social factors. Age, role, gender, social group and peer pressure, the family, community and occupational environment, as well as overall cultural values and controls on substance use, will act upon substance-taking behaviour.

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.

In recent years, psychiatrists have improvedtheir accuracy and efficiency in diagnosingdelirium, particularly in hospitalized elderly patients. Early and accurate diagnosis is essential as unrecognized and untreated delirium isassociated with longer length of hospital stay and greater expense, accelerated functional decline, an increase in nursing home placements, persistent cognitive deficits, and elevated rates of mortality.

Delirium has been recognized since ancient times and was first called delirium by Celsus in the first century AD. Variously termed delirium, phrenitis and lethargy, severe disturbances of thought, mood and action were often seen to be associated with physical disease. In the nineteenth century delirium developed into a rather broader description of confusion, a state which emphasized chaotic thinking and cognitive failure but which included what we now call dementia as well as confusion arising in the context of other functional psychoses. During the twentieth century the concept of delirium has continued to evolve. Kurt Schneider emphasized clouding of consciousness as central to delirium and this assumption has largely persisted. Delirium has developed as an acute condition, often precipitated by major medical illness. Increased interest in elderly people as a special group has led to the recognition that delirium is a frequent feature of acute medical admissions of elderly patients.

Collecting outcome measures by patient or proxy-completed postal survey in stroke research offers a pragmatic and cost-effective alternative to interview-based assessments. The psychometric properties of outcome measures cannot be assumed to be equivalent across methods of questionnaire administration. Many stroke outcome measures have variable or unproven psychometric properties when administered by post. The validity of stroke research that uses postal surveys may be improved through the adoption of questionnaires with acceptable postal psychometric properties. This review identifies 60 reports of quantitative stroke studies using one or more of 36 instruments to collect stroke outcome data by postal survey. Three of these instruments have acceptable psychometric properties for postal administration in stroke populations (the Frenchay Activities Index (FAI), Subjective Index of Physical and Social Outcome (SIPSO) and the EuroQoL (EQ5D)). Two further instruments lack evidence to support proxy reliability (Nottingham Extended Activities of Daily Living and London Handicap Score), but have otherwise acceptable properties.

The upper limb (UL) is a common site for poststroke pain, which is often regarded as a direct consequence of proximal motor impairment. Although the subacromial region is the commonest site, pain can also occur lower down the UL and some causes are not directly related to hemiplegia. As distal clinical features unrelated to motor consequences of stroke can be useful for making a management plan for pain, this review will generally refer to poststroke upper limb pain (PULP) rather than use traditional terms such as hemiplegic shoulder pain (which may erroneously imply a proximal, purely motor related aetiology).

Sleep problems in older adults are common and disturbance in sleep is associated with increased mortality. These problems are more pronounced in the care home population because of institutional factors and a high prevalence of frailty and co-morbidity. This article reviews the randomized controlled trials undertaken to address sleep problems in care homes. These suggest that stand-alone therapies – oral melatonin and light therapy – have no effect on sleep but that combination treatments – physical exercise plus sleep hygiene, physical exercise plus sleep hygiene plus light and melatonin plus light – may have positive effects. These effects are more marked for daytime arousal than nocturnal sleep. Practical considerations for care homes are how to maximize light exposure, incorporate exercise into daily routines and minimize night-time disruption for residents. Trials undertaken so far are compromised by small sample size and inappropriate randomization strategies and further research is therefore required.

Our ability to heal wounds deteriorates with age, leading in many cases to a complete lack of repair and development of a chronic wound. Moreover, as the elderly population continues to grow the prevalence of non-healing chronic wounds is escalating. Cutaneous wound repair occurs through a combination of overlapping phases, including an initial inflammatory response, a proliferative phase and a final remodelling phase. In elderly subjects the inflammatory response is delayed, macrophage and fibroblast function compromised, angiogenesis reduced and re-epithelialization inhibited. Whilst a large body of historic research describes the defective processes that lead to delayed healing, only recently have the molecular mechanisms by which these defects arise begun to be elucidated. Current therapies available for treatment of chronic wounds in elderly people are surprisingly limited and generally ineffective. Thus there is an urgent need to develop new therapeutic strategies based on these recent molecular and cellular insights.

Electroconvulsive therapy (ECT) is a powerful acute treatment for severe and resistant depression. We review literature related to the efficacy, safety and tolerability of ECT in older people, with an emphasis on research studies and reviews published in the last 25 years. In general ECT has been considered a very effective and safe treatment for depression and other psychiatric and non-psychiatric disorders in older people. Amnesia is commonly attributed to ECT treatment, but studies suggest that the negative effects of ECT on cognition are probably small in older patients. Currently the balance of risks and benefits of ECT justify its use for severe depression in older patients, both with and without dementia.

In the last review on this topic for this journal the focus was mainly upon service principles and an overview of variation in provision around the world. While there have been important developments and challenges within old age psychiatry in the last five years, these fundamental principles remain valid. This paper will therefore not simply present an updated version of the last but will instead concentrate on specific issues which seem to be of particular salience in the consideration of the organization and delivery of old age psychiatry services.

Rehabilitation has received considerable attention recently, having been the subject of a number of consultations, reviews and policy documents. Despite such activity it is recognized that ‘there is widespread confusion about the meaning of rehabilitation’, with a general failure to clarify aims and objectives. Nevertheless, there is an emerging consensus that the elements of effective rehabilitation include:

- responsiveness to users' needs and wishes

- multidisciplinary and interagency working

- availability when required

- clear rehabilitative purpose and goals

Older people are high consumers of prescription drugs and are at increasing risk of polypharmacy and adverse reactions. Pharmacokinetic and pharmacodynamic modifications due to age and co-morbidities are an important consideration, but pharmacological background evidence to guide safe and effective therapeutic approaches are often inadequate since the older population is under-represented in clinical trials. We review the pharmacokinetic and pharmacodynamic changes that are characteristic in old age and consider evidence regarding potentially safer prescription and monitoring of drugs commonly used in older patients. We also introduce the possible role of pharmacogenomics and therapeutic drug monitoring as tools to guide the individualization of drug therapy.

Alcohol misuse among older people has now been investigated for over 30 years. Schonfeld and Dupree previously described studies of alcohol use and abuse in the USA and UK, categories of older problem drinkers, age-inappropriate assessments, and examples of age-specific treatment. This review addresses more recent studies on drinking behaviour across several countries, screening assessment for older adults, alcohol problems in primary care medical settings, current age-specific treatment programmes, and treatment recommendations by expert panels, as well as in-home detoxification and use of the medication naltrexone as adjuncts to treatment.