Delirium is a disorder characterized by a fluctuating disturbance of consciousness and attention, with changes in cognition or perception, which develops over a short period of time and is attributable to an underlying physical cause. It is often accompanied by disturbance of the sleep-wake cycle and altered psychomotor behaviour.

Pressure ulcers are the visible evidence of pathological changes in the blood supply to dermal tissues. Pressure ulcers are rare, affecting only about 0.5% of the total population. The distribution is clustered into two groups, peaking once in younger, mostly neurologically impaired persons and again in older persons. The cluster in the geriatric population accounts for about 70% of all pressure ulcers.

Insomnia is a prevalent sleep complaint amongst older people, affecting physical and mental health as well as many aspects of life quality and well-being. For the lack of explicit guidelines for the assessment and treatment of insomnia in older people, this summary of available information represents the best evidence to inform current practice. Clinicians need to be more aware of their patients’ sleep and conduct formal assessments as appropriate. Despite past practice trends, non-pharmacological treatments should be considered first for chronic insomnia as a means to reduce dependency, adverse effects, and polypharmacy. Behavioural treatment methods such as stimulus control and sleep restriction are especially beneficial for older insomniacs as they target maladaptive sleep habits. Pharmacological treatment should be employed only if insomnia persists, involving the careful patient-specific consideration of the lowest effective dose, best intermittence of dosing, shortest effective duration, best gradual discontinuation scheme, and most effective elimination half-life.

This review on Parkinson's disease (PD) considers pharmacological and surgical management and important non-motor symptoms (NMS) such as depression, dementia and sleep disorder. In the absence of a proven neuroprotective drug, therapy remains symptomatic and may be initiated with levodopa or a dopamine agonist or a monoamine oxidase inhibitor. Treatment should be tailored to the individual patient, with patient preference, extent of functional impairment and co-morbidity more important than age per se. As disease progresses, therapy usually becomes more complex and apomorphine, duodopa and surgical intervention may be useful.

NMS may be present at any stage of illness but become more common in severity and frequency with advanced disease, when neuropsychiatric features such as dementia and psychosis dominate the clinical picture. NMS are often unrecognized and undeclared by patients and carers in clinic. Novel agents for treating non-motor features, which are often poorly responsive to dopaminergic therapy, are urgently required.

Thyroid disorders become more common with advancing age. Clinical features of hypothyroidism overlap with signs and symptoms often present in euthyroid older people and there is high likelihood of misdiagnosis. Conversely, there may be a relative paucity of signs and symptoms in hyperthyroid older people. A large number of patients may have subclinical disease. High suspicion and confirmation by laboratory assay is the key to correct diagnosis, though thyroid function tests should be interpreted with caution during acute illnesses. There is a reduced requirement for levothyroxine replacement in elderly hypothyroid patients and dosage should be titrated up cautiously as it can unmask symptoms of ischaemic heart disease. Drug interactions should be taken into account because a number of drugs interfere with levothyroxine absorption and metabolism. Radioactive iodine ablation of overactive thyroid tissue is the preferred treatment of hyperthyroidism in older people.

Improvements in health care together with superior standards of housing, nutrition and hygiene have led to an increase in average life expectancy, with a fifth of the UK population being over 60 years of age. Skin problems are common in elderly people: one study of 20 000 non-institutionalized US citizens found a significant dermatological problem in 40% of those aged 65 to 74 years. This review aims to discuss some common and important dermatological conditions seen in the elderly population and provide guidance on diagnosis and management.

The care of older people to the end of this century and beyond presents a unique challenge to medicine and the rest of society. There is need for careful analysis and evaluation of our responses to this challenge.

Urinary incontinence is a condition in which involuntary loss of urine is objectively demonstrated and results in a social or hygienic problem. A poll conducted for the Association for Continence Advice estimated that up to three million people in the UK suffer from incontinence. The incontinence may be transient, e.g. as a result of a urinary tract infection, or permanent, e.g. as a result of damage to the pelvic floor. Many sufferers may not seek medical advice for their predicament and the figures given above may be a gross underestimation of the problem.

Although intermediate care takes a variety of different forms and has developed somewhat differently in different countries, we believe that intermediate-care schemes have enough in common to make it meaningful to examine the relationship between this method of care and the views of older patients receiving either it or its alternatives. This is particularly important as one of the underlying principles of intermediate care is to extend patient choice; furthermore, most intermediate-care services target older people. In this review we examine evidence about whether older people prefer intermediate or hospital care, and what they like and dislike about intermediate care.

Since the last review of hypertension in older patients in this journal in 1999, there has been an enormous expansion in the available evidence for management of hypertension. Blood pressure treatment is only one part in an overall strategy of cardiovascular risk reduction. The actual prevalence of hypertension depends on the level of blood pressure used to define when treatment should be started and thus varies between patients depending on their degree of risk. A publication from the University of York NHS Centre for Reviews and Dissemination quoted a figure of over 50% of older people as being hypertensive in 1999. Newer guidelines tend to be encouraging treatment at lower blood pressure levels than previously and some authors now suggest that around 70% of the elderly population could be considered as hypertensive.

Epilepsy is the third most common neurological disorder of older adults, with huge functional and psychological implications. It is often difficult to diagnose in the presence of cognitive impairment and lack of a witness account. The most common identifiable causes of epilepsy in old age are cerebrovascular disease and dementia. New guidelines recommend starting treatment after first unprovoked seizure. If there is any doubt about the diagnosis, electroencephalography (EEG) should be considered, or ‘wait and watch’. The aim of treatment should be to fully control seizure activity with the most effective monotherapy and fewest possible side-effects. Drug compliance is often difficult to achieve in older adults.

It is clearly established that older people suffer a high rate of disease related to medication. Probably the major reason for this is that older patients are prescribed more drugs than younger people and the rate of prescribing appears to be increasing all the time. In the UK, data are currently collected on all prescriptions dispensed and this shows that older patients (aged over 65 years) receive 35-40% of all drugs prescribed. Between 1977 and 1988, prescription items increased by 17% overall, but by 52% in people over 65 years. compared to only 1% in adults under 65. Prescription rates are rising for a number of reasons, including new advances in therapeutics, a rapidly enlarging older population, moves to treat older patients more effectively (i.e. a less agist policy), rising patient expectations and defensive medical practice.

Major traumatic injury is a leading cause of death in younger age groups, but increasingly older people are affected also. Adverse outcomes, both physical and psychological, are associated with injury in the older population. This review aims to locate and describe the evidence relating to older people and major trauma in order to inform policy, practice, research and education. The published research and systematic reviews fall into three main topics: mechanism of traumatic injury in older people, the effects of co-morbidities on older trauma patients and outcomes following serious traumatic injury in older people. The psychological impact of traumatic injury and the resulting functional alteration cannot be underestimated in this group of patients.