Ageing is associated with multiple changes in many different components of the immune system. A healthy immune system exists in a state of balance between efficient effector responses against pathogens and tolerance to self antigens. This balance is changed with age; functions such as antigen recognition, phagocytosis, antigen presentation, chemotaxis, cytokine secretion and killing ability are all compromised. Aberrant cellular responses lead to an altered cytokine network with increases in inflammatory cytokines and decreases in anti-inflammatory cytokines leading to a pro-inflammatory state. Consequently older patients require extra care in diagnosis of infections as symptoms may be perturbed, resulting in unusual presentations of common conditions. The defects in immunity due to immunosenescence also mean that older patients require more care and screening than other patients in the same disease cohort. Though it is generally understood by clinicians that older patients are more at risk from multiple infections, the wider clinical effects of immunosenescence are less understood. The immune system is involved in several neurodegenerative conditions and the inflammatory conditions of immunosenescence may be a key factor in pathogenesis. Similarly, there is reason to believe that immunosenescence might be a key factor explaining the increased incidence of cancer in older age. With increasing understanding of the immune system's involvement in many of these pathological processes, and the contribution that immunosenescence makes to these, more efficient vaccines and novel therapies may be developed to prevent/treat these conditions.

Pruritus in older people is caused by a wide range of dermatological, systemic, neurological and psychogenic diseases. It can also be attributed to various cutaneous drug reactions. The dermatological, neurological and immunological changes associated with ageing predispose older people to pruritus of a wide range of aetiologies. The most common cause of pruritus in older people is xerosis, or dry skin. Regular use of emollients is the mainstay of treatment for pruritus of any cause, with general measures aiming to ensure optimal skin hydration and to prevent the itch–scratch cycle. Topical treatments are generally better tolerated for localized pruritus. Anti-histamines are the predominant agents to treat pruritus, but can be inadequate in many cases. Numerous other systemic agents have been demonstrated to alleviate pruritus depending on the cause, but may be limited by their adverse effects. This article reviews the current published literature on pruritus in older people, with a practical approach to its evaluation and management in non-specialist settings.

Parkinson's disease (PD) is a progressive neurodegenerative disease characterized typically by motor features of tremor, rigidity and bradykinesia due to depletion of dopaminergic nigrostriatal neurons. PD is increasingly recognized as a non-motor disorder since symptoms such as dementia, depression and falls emerge with disease progression to become dominant in the clinical picture. PD results in a significant decline in quality of life for both patients and family and contributes to significant economic and institutional costs on family and society. PD is uncommon before the age of 40 but affects approximately 1% of patients over the age of 60, with a rising incidence and prevalence thereafter to around 2% in the population over 80 years of age.

The incidence of pneumonia is higher in older than younger people, due to both an increase in factors facilitating entry of infectious agents into the lungs, and attenuated functioning of the immune system. Classic features of presentation of pneumonia may be absent. The most common signs of pneumonia in old age are tachypnoea and tachycardia. Aetiology is established in only 50% of older patients. The empirical treatment of community-aquired pneumonia (CAP) should be aimed at its most common cause, Streptococcus pneumoniae. The empirical treatment of health care-associated pneumonia (HCAP) should be targeted at Gram-negative agents. Choice of antibiotic must include consideration of potential drug interactions.

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.

The involvement of service users as active participants is a stated aim of many current developments within health and social care, and self-assessment has been identified as a key mechanism. For over 15 years, the UK Department of Health has referred to the importance of the service user's views in assessment, and this has been re-emphasized recently in guidance issued to both local authorities social services and the NHS. The concept of the expert patient and the promotion of self-care amongst people with long-term conditions are also highlighted as central to current NHS development. Although not specified as such, self-assessment is an important component of these person-centred initiatives which encourage self-diagnosis, self-monitoring and self-management.

Dying is the one common and certain event in life but it is a difficult process to study. Official statistics give information about the point of death; studies covering random samples of deaths are inevitably retrospective and based on the accounts of those who knew the person who died; other studies are selective and generally focused on people dying from cancer, so they include a relatively small proportion of old people. Yet, in developed countries, deaths are concentrated among older people. In England and Wales in 1994 83.6% of all deaths were of people aged 65 or over; 59.0% were 75 or more.

This review describes the concept of disablement, with particular reference to the World Health Organization’s International Classification of Impairments, Disabilities and Handicaps (ICIDH), and its forthcoming revision. Applications for a disablement classification are discussed, and the various approaches which have been applied to the measurement of disablement are reviewed. The relevance of disablement to psychiatric research and clinical practice is also addressed. In the second section of the review, data are presented from the last two phases of the Gospel Oak Survey, illustrating the value of simple measures of disablement in a community epidemiological study of the aetiology of late-life depression.

Parkinson's disease is a progressive neurodegenerative condition. There is an increasing incidence and prevalence with advancing age and more cases are predicted as the population ages. Because of likely differing aetiology, genetics and pathology in individual patients, as well as confounding co-morbidities, diagnosis can be difficult even for specialists. We present an overview of the pathology, aetiology and differential diagnosis of Parkinson's disease in older people. The importance of specialist medical input in diagnosis is emphasized.

Why measure?

Before we consider what to measure and how to measure outcomes in the rehabilitation of frail older adults, an antecedent question is, why measure these things? Without an answer satisfactory for both measurers and measured, much effort and ingenuity will be expended with resultant perspiration and exasperation and little else.

Traditionally, medical care, i.e. that identified by physicians, has assumed that its principal objective was patient care, i.e. that appreciated by patients. Outcomes of care from the viewpoint of the patient, of his or her informal supporters, of the involved health care professionals, and of the health care delivery system have to be clarified and made operationally explicit. This recognition requires definition and measurement. Thus a powerful reason for measuring outcomes for recipients and providers of health care, as well as the health care delivery system, is to know what is happening (the descriptive question) and with what effect (the analytical question).

Elder neglect and abuse is a widespread, largely undiagnosed and often ignored problem in our society. However, recently elder abuse has gained increasing recognition as a significant problem, meriting the attention of both clinicians caring for older people and society at large. Its occurrence in differing forms throughout the world has been highlighted as part of a recent WHO report about violence and health. In the United Kingdom, the House of Commons Health Committee has inquired into elder abuse and published its report and recommendations in April 2004. Concurrently with this rising public interest, there is a slowly developing body of scientific work on the subject. Although, much of the research has been criticized for significant scientific flaws, recent work has been more rigorously designed, tending to use standard case-definitions and scientifically acceptable research methods.

Vertigo and dizziness are common problems in older patients visiting primary health care centres. Dizziness is often used as a non-specific term to describe many sensations, including vertigo, presyncope, disequilibrium and lightheadedness. In another sense, dizziness can be described more specifically as a feeling of unsteadiness or a mild intoxication, or as if the ground is rocking, or the affected person has to take side-steps to keep balance. Vertigo, by comparison, is often described as a feeling of rotation; the room or surroundings are spinning around like a carousel. Presyncope is often described as sensation of impending fainting or sense of falling. Lightheadedness is a much more vague description of dizziness, difficult to define. Disequilibrium, on the other hand, can be described almost in the same terms as dizziness: a feeling of unsteadiness or loss of balance.