Oral mucosal lesions occur frequently in older people and are important as they may reduce quality of life, represent pre-malignant change or indicate systemic disease. The commonest mucosal lesions in adults are denture-related lesions such as stomatitis, angular cheilitis, ulcers and hyperplasia, and occur in 8.4% of the adult population. In the hospital setting, oral mucosal lesions may lead to malnutrition, slow rehabilitation and recovery from illness, and adversely affect quality of life. The two major risk factors associated with oral lesions are denture use and smoking, and frequently older people have been exposed to both of these. Commonly used drugs such as antihypertensives, antidepressants and antibiotics may have oral mucosal side-effects, and polypharmacy may worsen these. Decreased awareness of changes in the oral mucosa, or inability to raise concerns due to dementia, delirium, social isolation, or difficulty accessing dental care may further compound the problem. Hospital admission could represent an opportunity to intervene, but oral mucosal lesions, and indeed oral hygiene, are areas which can be overlooked by doctors. This article is intended to highlight common or important oral mucosal diseases and increase awareness of these conditions for the practising hospital or community geriatrician.

Unfortunately, stroke is an extremely common disease. Around 100 000 people suffer a first-ever stroke each year. Stroke is the third commonest cause of death in the western world and is a major cause of long-term disability. Many patients admitted acutely to hospital after stroke will have a transient or persistent problem with their swallowing. Impaired swallowing results in a failure to maintain nutritional status and hydration, a break-down of vital organs, increasing susceptibility to infection and an increased likelihood of dying.

Age has been identified as the single most impor-tant demographic predictor of blindness and visual impairment. Visual impairment is the second most prevalent physical disability in the elderly population. The prevalence of blindness and visual impairment after 60 years of age increases significantly. Furthermore, the number of older people with functional vision impairment is expected to double in the next decade. Visual impairment in the elderly population is commonly due either to localized ocular pathology (cataracts, glaucoma and age-related macular degeneration) or systemic disease with associated ocular or visual pathway involvement (hypertension, diabetes and cerebrovascular disease). Physicians involved in the care of older people play a crucial role in the recognition, prevention and management of morbidity related to visual impairment in this population. Timely screening, referral, intervention and visual rehabilitation is thought to be capable of reducing new blindness and visual impairment by at least one-third.

A pressure ulcer is the visible evidence of pathological changes in blood supply to the dermal and underlying tissues, usually due to compression of the tissue over a bony prominence. Pressure ulcers are one of several types of chronic ulcers of the skin, including venous stasis, diabetic ulcers, and arterial insufficiency ulcers. The differential diagnosis of pressure ulcers is imperative, since the management of each wound type differs substantially.

Populations are ageing worldwide. The prevalence of dementia will rise exponentially with the oldest old the most rapidly growing segment of society. Caring for this ageing population with dementia, many of whom will have multiple chronic and disabling diseases, will be a challenge to healthcare systems, particularly general hospitals. At any one time, a quarter of acute hospital beds in the UK are in use by people with dementia. Delivery of high-quality care to this growing and vulnerable population must be high on any health service agenda.

Current medical training not only generates relatively low numbers of geriatricians and specialists with interest in dementia, but also there is a lack of appropriate training in assessment and management of dementia. There remains huge need for better staff training and support to provide safe, holistic and dignified dementia care. Here we explore various key features for non-specialist assessment and management of older people with dementia in the general hospital setting.

The number of emergency admissions to hospital in the United Kingdom continues to rise despite the shift in emphasis towards care in the community. Admissions are reported to have been increasing for four decades and, although these increases span all age groups, major contributions come from older persons. The most important and immediately apparent factors contributing to this change are that people are living longer, are more likely to suffer from multiple pathologies and are therefore frequent users of hospital acute services. OECD (1994) projections indicate that the proportion of people aged 65 and over in the population will have doubled from an average of below 10% in 1950 to over 20% by the year 2050.

As the number of people living to reach old age increases, so the proportion of cancers presenting in this age group increases to an even greater degree. Although 70% of all cancers in men and women occur over the age of 65 and in the over-75s, who are perhaps more appropriately classified as ‘elderly’, the figures are still very high (46% of all cancers occur in women over 75 and 35% in men over 75). As a consequence, cancer is rapidly becoming a problem of late life, and the management of patients in old age is an important part of general oncology. The magnitude of the overlap between old age and cancer is increasing because of improved life expectancy, more sensitive methods of diagnosing cancer and the biological fact that most cancers occur more commonly with increasing age. It is interesting, however, to put these figures into a more general context by examining the different causes of death in older patients by decade.

The growing number of old and very old people in the United Kingdom is attracting increasing attention, particularly with respect to the cost of providing institutional, residential and nursing home care. It is estimated that about 6% of people will require this type of care and the current annual cost is over 3.5 billion pounds. In the United Kingdom, provision of institutional care for elderly people has undergone significant change in the past two decades, with a shift from National Health Service provision of long-term hospital care to the current dominant role of private home care by independent commercial sector providers.

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.

Stroke is a leading cause of disability worldwide and patients with stroke frequently require prolonged periods of in-patient rehabilitation prior to discharge. This poses a large economic strain on health services, and the cost-effectiveness of this system has been questioned. However, in implementing changes in the delivery of post-acute stroke care it is important that patient outcome is not compromised. Early supported discharge (ESD) was introduced approximately 15 years ago and allows suitable patients to be discharged home early with increased support from a well co-ordinated, multi-disciplinary rehabilitation team in the patient's own home. This paper focuses upon the evidence available from multiple international studies of ESD over the last decade, including both clinical benefit and cost-effectiveness. Findings from these trials are largely positive resulting from a reduction in bed days, therefore overall cost, and an improvement in function and independence reported in many studies. Suitable patient selection, careful discharge planning and continuity of care by the ESD linked to a stroke unit are essential components of the success of this service.

Parkinson’s disease (PD) is a progressive neurological disorder affecting at least 120 000 persons in the UK today. Age is the most potent risk factor. With the rising numbers of elderly, PD will become an increasingly important cause of disability and mortality. This has significant implications for health planning.

In recent years, there has been growing emphasis on the key role of the specialist clinic, interdisciplinary team and the PD specialist nurse in the management of the condition, as well as recognition that quality of life for people with PD and their carers relates to more than motor disability and disease severity. Appropriate care planning requires skilled assessment, and a new paradigm, incorporating four progressive clinical management stages (diagnosis, stable maintenance stage, complex stage and palliative stage) may be useful. The importance of all these aspects to successful holistic management of PD should be emphasized but is beyond the scope of this review, as is diagnosis, which is the subject of a separate contribution.

The essential polyunsaturated fatty acids (PUFAs) are divided into two classes, n-3 (ω-3) and n-6 (ω-6) and their dietary precursors are α-linolenic (ALA) and linoleic acid (LA), respectively. PUFAs are precursors of a wide range of metabolites, for example eicosanoids like prostaglandins and leukotrienes, which play critical roles in the regulation of a variety of biological processes, including bone metabolism.

A large body of evidence supports an effect of PUFA on bone metabolism which may be mediated by regulation of osteoblastogenesis and osteoclast activity, change of membrane function, decrease in inflammatory cytokines, such as interleukin-1 (IL-1), interleukin-6 (IL-6), and tumour necrosis factor alpha (TNF-α), modulation of peroxisome proliferators-activated receptor γ (PPARγ) and influence in NO secretion and NO synthase.

Animal studies have shown that a higher dietary omega-3/omega-6 fatty acids ratio is associated with beneficial effects on bone health. Human studies conducted in elderly subjects suggest that omega-3 instead of omega-6 has a positive effect on bone metabolism. In spite of increasing evidence, studies conducted in humans do not allow us to draw a definitive conclusion on the usefulness of PUFAs in clinical practice.

Prescribing for older people is often complex and challenging. With age, people almost invariably develop diseases leading to the prescription of drugs and the risk of multiple prescribing increases, especially if there is strict adherence to single disease guidelines. There remains a paucity of evidence from clinical trials as to the efficacy of many drugs in patients aged over 80 years due to the gross under-representation of older people in clinical trials. Older people are also at increased risk of adverse drug events, which are an important cause of morbidity and mortality. A significant percentage of these are both predictable and potentially avoidable.

In this updated review the concept of appropriate prescribing in older people is explored, including the importance of individualized care and shared decision-making. The available tools to enhance prescribing practice are examined, including those aimed at reducing inappropriate prescriptions and under prescribing. The limitations of existing tools are discussed and areas with particular promise and scope for advancement are highlighted, including the development of integrated IT systems and software engines to aid clinicians in appropriate prescribing.

A basic notion relating to development during adulthood and old age, according to a lifespan perspective, refers to the progressive increase in individual differences in psychological wellbeing. It is possible to find diverse ‘health trajectories’, shaping patterns of evolution regarding the general health of adult and elderly individuals, such as (1) permanent good health (2) good health most of the time and decline by the end of life (3) health decline and recovery (4) permanent poor health, (5) progressive decline and (6) irregular health.

‘The current care systems cannot do the job. Trying harder will not work. If we want safer, higher-quality care, we will need to have redesigned systems of care, including the use of information technology to support clinical and administrative processes.’