Studies across the European Union have noted that chronic illness and chronic disabling conditions rather than acute infectious diseases are now the major causes of morbidity and mortality in member states. This transformation in the nature of health and illness has, and will continue to have, profound effects on the nature of both medicine and the policy and organization of health care. It is estimated that not only will the share of consultations with doctors about issues connected with problems of living with chronic conditions increase, but there will also be a corresponding shift in medical practice from cure to care.

Impaired hearing is prevalent amongst older people, adversely affecting physical and psychosocial function and, hence, quality of life. It may also cause depression. Yet evidence suggests that hearing problems are all too often regarded as a ‘normal’ part of ageing and more likely to be ignored than diagnosed and/or treated; many believe that little can be done to improve hearing. Furthermore, ‘many of the behaviours of a hearing-impaired individual (e.g. irritability, inattention or inappropriate responses) may be interpreted as evidence of dementia’ though they may simply reflect communication difficulties that can, in turn, damage personal relationships.

Darwin described how animal populations have two adaptation strategies: natural selection based on genetic variation acting over many generations, and developmental plasticity acting within the lifetime of an individual. The contribution of these processes can be difficult to distinguish at the individual level, and the relevance of human developmental plasticity to aging and health in later life is only now being recognized. The formal definition of developmental plasticity is ‘the ability of a single genotype to produce more than one alternative form of structure, physiological state or behaviour in response to environmental conditions’. As an alternative to adaptation to changing environments through genetic diversification, living things have evolved plastic responses. This enables the production of phenotypes that are better suited to their environment than would be possible if the same phenotype was produced regardless of environmental conditions

A decrease in habitual physical activity accompanies old age in mammalian species and in healthy man.74,142 This is not simply a consequence of a parallel decline in exercise capacity, and factors other than those which limit aerobic capacity and endurance performance must be involved.143 Moreover, most old people remain at least moderately active.144 Everyday activities may require cardiorespiratory and muscle performance which is much nearer the maximum in elderly individuals than in younger people and further reduction in reserves by, for example, illness, will more readily cause disability.

Regular moderate activity is sufficient to mitigate declining exercise capacity and muscle performance and conditioning programmes may well confer additional benefits even at advanced ages. Exercise remains good for you regardless of age. A suitable programme is one of moderate to high workrates, involving large muscle groups and performed for 15–30 minutes every other day.145 The intensity is best guided by heart rate, for which a variety of formulae have been proposed.146

The complex interaction of physiological factors influencing muscular performance has been illustrated. Only when these physiological processes are disentangled and better defined will we elucidate the molecular mechanisms which underlie age-associated changes. It is not yet possible to define the relative importance of intrinsic and extrinsic influences, but the proportion of the decline in VO2 max which is directly attributable to intrinsic aging is smaller than is usually assumed, probably less than 50%.147 While the most critical determinant of VO2 max in young subjects is probably cardiac output,148 we now recognize that in elderly people the balance shifts; muscle performance, changes in blood distribution and peripheral microvascular capacity become ever more important determinants of exercise performance and should command increasing research interest.

Whilst clinical psychologists and a few fellow professionals have long known the importance of psychology in rehabilitation, it has recently been formally acknowledged as an essential professional discipline in such settings. In relation to stroke care for example, the recently published National Service Framework for Older Adults, England (NSFOA) specifies (Standard Five) that multidisciplinary stroke rehabilitation teams should include clinical psychologists, a view that is echoed in the Royal College of Physicians’ ‘Guidelines for Stroke Care’. The NSF is not yet universal to all areas of the UK, however, this article will reflect the English NSF as appropriate standards for health care across the country.

The topic of hypoxaemia after stroke was last reviewed in this journal in 2001. Since then a lot of new information on the subject has been published, and while some questions have been resolved, new problems have emerged. This article discusses new research in the light of what is already known and outlines areas of persisting uncertainty.

What is spasticity?

Spasticity is a well-recognized and potentially important clinical syndrome comprising inappropriate and involuntary high muscle tone. It has been variably defined, with debate still ongoing. Currently, the most widely accepted definition is that of Lance, stating that spasticity is ‘a motor disorder characterized by a velocity-dependent increase in tonic stretch reflexes (muscle tone) with exaggerated tendon jerks, resulting from hyper-excitability of the stretch reflex.’ Unfortunately, even this description does not fully encompass the multifactorial nature of spasticity, since resistance to movement, even in the normal state, is subject to varied contributors. These include patient volition, inertia, visco-elastic muscle forces and range of joint movement, as well as true muscle activation secondary to reflex action. In the real clinical world, it is often not possible to distinguish which of these features is/are dominant. Furthermore, spastic muscle undergoes physiopathological, rheologic change with stiffness, atrophy, fibrosis and finally contracture.

Liaison psychiatry, a term that is sometimes used interchangeably with consultation-liaison psychiatry, refers to the interface between psychiatry and general hospital patients and specialists. It involves psychiatrists’ intervention in the care of medically ill patients who present with psychiatric symptoms whilst in a general hospital setting. It may also involve assessment of patients who have pre-existing psychiatric illness or those who develop psychiatric symptoms because of their medical or surgical illness (e.g. coping with bad news).

Falls and funny turns are very common in old people, and many clinicians feel at a loss as to how to deal with them. Over the past few years, there have been important advances in our understanding of the causes of falls and how best to manage these in the vulnerable elderly population. Given the magnitude of the problem, it is important that such research finds its way into clinical practice.

Old people are a growing minority. They comprise approximately 12% of the UK population, but consume an increasing proportion of health care resources. Gastrointestinal (GI) disorders are the third most common reason why patients over 65 years seek primary care advice, and 40% of these consultations relate to the upper GI tract.

Hospital readmission rates for COPD patients are high, with two-week readmission rates of 22% being recorded in one study of patients with acute exacerbation of chronic obstructive pulmonary disease (AECOPD). In a separate study, patients admitted with PaCO2> 50 mm Hg had a readmission rate of 40% at six months. There are no agreed clinical evidence factors that determine readmission. A few studies have reported that readmission is associated with an individual’s inability to cope with the disease, and that anxiety and socioeconomic status are important variables. Others argue that readmission relates to severity of lung function abnormality, changes in atmospheric pollution, and impaired quality of life (QoL).

Clinicians are increasingly faced with the problem of interpreting subtle, early cognitive symptoms. Enhanced awareness of Alzheimer's disease (AD) and available treatments has led to a growing demand for early assessment. Although it is known that a proportion of individuals with mild cognitive impairment will progress to dementia in following years, our ability to identify these individuals and predict individual cognitive trajectories is limited. The emergence of disease-modifying treatments would make these problems more acute. In this review, the potential role of magnetic resonance imaging (MRI) in aiding the clinician in early diagnosis of AD will be considered. The changes in grey matter structure that accompany ‘normal’ ageing will be described briefly, before moving on to studies that have attempted to distinguish the onset of disease from this background of structural change. Volumetric methods range from measurements of single key structures, such as the hippocampus, to methods based on computational neuroanatomy, which evaluate subtle structural alterations across the whole brain simultaneously. Computational methods are rapidly evolving and already perform as well as radiologists in distinguishing AD from normal ageing at an individual level. This article aims to provide a practical knowledge of how and why these methods work, point out the main advantages and disadvantages and sketch out outstanding issues and possible future directions.

Published literature shows that evidence-based medical care can improve hip fracture outcomes. The orthogeriatrician plays a key role in providing this care, in collaboration with surgical and multidisciplinary professionals, managing pre-operative conditions and post-operative complications that may affect functional recovery, and ensuring co-ordinated effective management of hip fractures right from admission to discharge. Several management guidelines are available for this vulnerable group of elderly patients. Recent UK guidelines recommend that, from time of admission, hip fracture patients should be offered a formal acute orthogeriatric or orthopaedic ward-based ‘Hip Fracture Programme’, which includes orthogeriatric assessment as an essential key component.

Hip fracture is a common and potentially devastating injury that occurs mainly in older people. The incidence is predicted to rise by 30% in the next 10 years alone. Many of those who recover suffer a loss of mobility and independence. There is growing emphasis to improve the care of patients sustaining hip fracture, especially in those with concurrent cognitive impairment. This review focuses on current best practice as well as several key areas of management, including analgesia, anaemia and nutrition. In doing so, we hope to identify interventions that may form the basis of a future Enhanced Recovery Pathway dedicated to hip fracture care.

Increasing numbers of older people are undergoing both emergency and elective surgery. However, they remain at increased risk of adverse outcome in comparison with younger patients. This may relate to the association of ageing with physiological deterioration, multi-morbidity and geriatric syndromes such as frailty, all of which are independent predictors of adverse post-operative outcome. Although there is an emerging evidence base for the identification and management of these predictors, this has not yet translated into routine clinical practice. Older patients undergoing surgery often receive sub-optimal care and surgical pathways are not well suited to complex older patients with multi-pathology. Evidence is emerging for alternative models of care that incorporate the evolving evidence base for optimal peri-operative management of the older surgical patient, including risk assessment and optimization. This article aims to provide a practical overview of the literature to all disciplines working in this field.

This review examines the demographic changes, the epidemiology of mental disorders and suicides, the potential risk and protective factors, access to secondary care old age psychiatry services (OAPSs) and the policy context pertaining to older people from ethnic minority groups in the United Kingdom. The number of older people from ethnic minority groups is increasing. The prevalence of mental disorders in older people from ethnic minority groups is either similar to or higher than that in the indigenous population. Therefore, the number of older people from ethnic minority groups with psychiatric morbidity is also increasing. Ethnic minority older people also have inequity of access to secondary care OAPSs. There is an urgent need to develop and implement practical strategies to improve access by older people from ethnic minority groups to OAPSs.