The human lung is a resilient and complex organ, capable of uninterrupted functioning without defect over a lifetime. While there is a body of knowledge regarding macroscopic and physiological changes that occur in the lung with age, there is still much to be understood. In itself this is not surprising given the complex interaction of intrinsic and extrinsic factors that might play a role in these changes. Lung tissue is highly susceptible to environmental factors, which can have an impact over the course of a lifetime, including smoking, pollutants, occupation and nutrition.

The three key words in the title deserve scrutiny. ‘Innovation’ can mean something that is completely new, but more often innovations are drawn from practice in other fields. Innovations can be imposed from above, developed from practitioners or even happen incrementally. They are very often creative responses to other pressures, necessity being the mother of invention in this field as much as any other. Innovations can be reflected in day-to-day practice or they can be embodied in whole new units. Stale, out-of-date practice can happen in new units, and vice versa. It is too easy to see new buildings alone as innovations.

Dementia has traditionally been viewed as a global, undifferentiated impairment of intellect and memory. The implication is that patients with dementia share a common clinical syndrome. It is, however, now recognized that different dementing diseases give rise to distinct patterns of mental change, reflecting differences in the topographical distribution of pathological change within the brain. Contrary to the traditional view, analysis of the characteristics of dementia can contribute substantially to differential diagnosis. Indeed, since many patients with a dementing illness exhibit few physical signs, evaluation of the mental changes may be critical to diagnostic accuracy. With the advent of new therapies for dementia, precise diagnosis has become increasingly important. Moreover, understanding of patients’ symptom pattern provides a rational basis for patient management and for advice to carers.

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.

Recent changes in medical education as well as in the organization and delivery of health care in the UK have emphasized the need for doctors, nurses and other health care professionals to learn to work together as teams in order to provide the best possible care for patients. The importance of interprofessional education (IPE) and teamwork is, therefore, being increasingly recognized and given priority in medical education.

As people age they almost invariably develop diseases which lead to the prescription of drugs – both to prevent disease progression and for symptomatic relief. Unfortunately, drug treatment in later life is also problematic. There is a dearth of evidence on the efficacy of drugs in people over the age of 80, and members of this age group are at highest risk of adverse drug reactions (ADR).

Benign and malignant prostate disease is common in older men and becomes more prevalent with age. Many seek medical help due to bother associated with lower urinary tract symptoms (LUTS). Some fear their LUTS are secondary to prostate cancer or seek advice regarding prostate cancer screening. Furthermore, prostate cancer is now the most common male cancer in the UK. However, not all prostate disease causes LUTS. Equally, not all LUTS are due to a disease of the prostate. Thorough clinical assessment is therefore required to identify urological from non-urological, and benign from malignant causes of LUTS. This review presents a description of the current terminology for diseases of the prostate, the essential clinical assessment and investigations, and a description of the many treatment options currently available for both benign and malignant prostate disease.

Two previous publications by the author in Reviews in Clinical Gerontology have dealt firstly with the background physiology of exercise and secondly with the benefits to health of regular exercise across a wide spectrum of diseases and disabilities in older people. This article assumes that the reader is familiar with these reviews. A useful recent report focusing on coronary heart disease, diabetes mellitus and arthritis summarizes recommended physical activities for various age groups and conditions.

Homeostasis is the ability of a living organism to control its internal environment despite fluctuations in the external environment. Claude Bernard proposed the concept of 'milieu interieur'. The hypothesis rests on the belief that cells need a precisely defined local environment in which to function optimally. The maintenance of the micro-environment is dependent on integration of the systems of the organism (body), including behaviour, to protect the cell(s) from external stressors. When the environment changes, the body needs to sense the alteration, then set in motion mechanisms which mitigate the change and restore the previous balance. If it fails to do this, the organism will ultimately die as systems fail.

Agism was the term chosen by Butler to name the process of discrimination based on chronological age, which usually results in an image of the elderly as unproductive, sick, depressed and with cognitive impairment. This form of bias, like others that devaluate and stereotype groups of people, has a marked effect on social interaction, influencing social attitudes and perceptions in a covert manner. The use of negative images relating to old age and the aging process promotes negative attitudes relating to elderly people, affects the way they live and the way people of other ages prepare to face their old age.

In the past two decades, the rate of surgery in older people has increased more rapidly than the rate of aging of the population, so both a larger proportion and a greater number of older people are now undergoing surgery. This may partly reflect a cultural change in surgery and anaesthesia with respect to a greater willingness to undertake elective procedures in older people, although there remain areas where they have less access to surgery than do younger patients. For instance, older people are less likely to undergo operative procedures after a cancer diagnosis. Furthermore, in those who do have surgery, resection rate (i.e. curative therapy) is lower than in younger people with equivalent tumour stages, and even more so in older patients with COPD, cardiovascular disease or diabetes. This article explores the complex relationship between age and surgical outcome, provides an evidence-based overview of risk assessment and common postoperative problems in older people, and summarizes good practice points (at times necessarily pragmatic) for clinical management of the older surgical patient. There has been a substantial expansion in the literature examining risks, outcomes and interventions in older surgical patients since the previous review article of this subject published in this journal. Although we do not cover anaesthesia in older people, the review of that topic remains relevant. The American Society of Anaesthesiologists' Classification of Risk which illustrates that risk is disease- rather than age- based, is shown in Table 1. Most publications examine elective rather than emergency surgery in older people (with the exception of hip fracture), and this is reflected in the content of the paper.

Orthostatic hypotension (OH) is a clinical condition which frequently results in troublesome symptoms such as dizziness, giddiness, blurred vision and light-headedness. It is a common disorder associated with an increased risk of falling, especially in older individuals. OH is the presenting haemodynamic manifestation of several different and diverse underlying pathological conditions, including disorders of blood pressure (BP) regulation and disorders leading to reduced intravascular volume. In younger and middle-aged adults, the presence of OH should not be considered a primary diagnosis in itself but rather a starting point in the diagnostic pathway before the primary underlying abnormality has been identified. In older patients however, asymptomatic blood pressure drops are very frequently encountered so that, in certain cases, an exhaustive diagnostic search for an underlying cause is not warranted. However, reversible causes of OH do frequently exist in older patients. Prominent among these are the use of several commonly prescribed cardiovascular drugs and vitamin B12 deficiency.

The last twenty years have seen a rapid expansion in the provision of post-acute rehabilitation services for patients with traumatic brain injuries (TBI) in North America, although such provision remains limited in Britain. These developments have been precipitated by a growing appreciation by health purchasers and providers of the neuropsychological and social sequelae of TBI and demands by patients and their families for effective treatment. Most investigations have found that the majority of TBI survivors are young males under the age of thirty and that by far the most common cause of TBI is road traffic accidents. Typically the frontal and temporal lobes of the brain suffer the greatest impact and survivors subsequently present with deficits affecting memory and new learning, attentional dysfunction and impaired planning and organizational skills.

The challenges of treating malignant disease in the elderly population have gained greater prominence over the last 5–10 years. Developed nations all have ageing populations, and cancer in older people is an increasing physical and financial burden on both healthcare systems and populations.

When assessing oncology patients, oncologists have traditionally used the Eastern Cooperative Oncology Group or Karnofsky performance status. However, it has been shown that sometimes this does not detect potential problems in older patients, and that a comprehensive geriatric assessment may be a better tool. However good surgeons and oncologists are at adapting their services for older patients, there is little value if they are inappropriately referred or filtered out by either primary or secondary care.

Surgery forms the basis of most curative treatment options. The elderly have more peri-operative risk factors including multiple co-morbidities, poly-pharmacy, malnutrition, frailty, cognitive dysfunction and an increased anaesthetic risk, which can create obstacles.

Treating older patients with systemic cytotoxic therapy often relies on extrapolating evidence from younger patients. In previous decades, the majority of trials had upper age limits of 65 or 70 years. More recent trials normally include patients of all ages, and entry is based on performance status. Radiotherapy may be chosen as a potentially curative option in patients with an operable tumour, who are unfit. However, oncologists should not underestimate the burden that multiple frequent visits to hospital for treatment may have on an elderly patient population.

This article looks at the assessment of elderly oncology patients, referral patterns, surgery, systemic therapies, radiotherapy, supportive therapies and long-term side-effects from treatment.