In the UK, research continues to confirm that people with certain chronic illnesses, such as chronic lung disease and cardiac failure, represent the ‘disadvantaged dying’ compared to those with terminal cancer. But what is the situation for people dying with advanced dementia and what is the experience of their carers? Practical guidance for clinicians is scarce. In Standard 7 of the National Service Framework for Older People, which covers mental health, there is mention neither of how care should be provided nor of how patient choice should be ensured for people with dementia at the end of life. In the UK, 5% of the population aged 65 and over and 20% of those aged 80 and over have dementia similar prevalence figures are found in the USA. Current predictions suggest that the number of people with dementia will increase by 40% by 2026 and will double by 2050. The increased demand for end-of-life care for people with dementia will be associated with major social and economic costs, but what is the current standard of such care? How can the quality be improved? And how should future services be configured to cope with this increasing need? In this paper, we review current knowledge around end-of-life care in dementia, discuss the clinical challenges and ethical dilemmas presented to carers, consider the difficulties in delivering such care and suggest practical approaches to improve the quality of such care.

In this paper recent studies of the relationships between social networks and mortality among older people are reviewed. Although a large amount of research effort has been expended on identifying and explaining such relationships, many studies have focused predominantly on those in middle age groups and very few have included sufficient numbers of older old people to allow separate analyses. Moreover, although relationships between various indicators of social support, participation and mortality have been demonstrated, this finding is not universal and considerable uncertainties remain about the strength of any such association, how it may vary between age and social groups and how it operates. In part, these uncertainties reflect the wide range of conceptual definitions of social networks or social support, methodologies and data sets used to address the issue.

The purpose of this review is to explore the evidence currently available and to identify the framework within which to consider bladder and bowel emptying problems following a stroke. The author was a member of the Intercollegiate Working Party for Stroke Continence Subgroup that reviewed the evidence for the National Guidelines. The review is based on the author’s personal knowledge of published and unpublished work. References in large textbooks and in the landmark papers were checked and a Medline search was performed using the terms stroke, cerebrovascular disease, incontinence and constipation.

Scientific progress in human immunosenescence research is pointing increasingly towards the clinical importance of age-associated changes in immunity, although many areas remain controversial. For infectious disease, there is accumulating good empirical evidence, discussed in this review, that immunosenescence compromises protection in elderly people. This implies that an age-associated decreasing immunity results in increased incidence of those diseases that the immune system is designed to protect against, i.e. infectious diseases. This unsurprising conclusion suggests that preventing these infections using interventions designed to prevent or reverse immunosenescence could extend the period of life enjoyed in good health.

Current knowledge suggests that parental age has many influences on offspring. This topic has been exhaustively reviewed in Finch's monograph. The major maternal age-related changes in humans are increases in fetal aneuploidy later in reproductive life; Down's syndrome (trisomy 21); Kleinfelter's syndrome (XXY); Edward's syndrome (trisomy 18); and Patau's syndrome (trisomy 13). Despite a recent dramatic decrease in fetal death rates, advanced maternal age remains an important independent risk factor for fetal death.

This paper reviews the limited evidence on the causes of homelessness in old age and on the circumstances and problems of older homeless people, and it describes the few services dedicated to the group. Health care and social care professionals rarely encounter homelessness among the many problems of older people that present to them, but in many developed countries there is evidence that the number of older homeless people has recently been growing. Some among them have been homeless intermittently or continuously for years, but many became homeless for the first time in later life. The reasons for becoming homeless and the problems and needs of the group are exceptionally diverse. Many have been estranged from their family or have no living relatives, and they have a high prevalence of health problems and functional limitations. Although services for homeless people in general have improved since the early 1990s, few have targeted the needs of older people.

The concept of formal or standardized tests for assessing function came to the fore in the 1960s. Katz et al. acknowledged the hierarchical nature of activities of daily living (ADL) such as eating, continence, transferring, going to the toilet, dressing and bathing in his ’Index of ADL’ and by 1968 ‘ADL’ was an accepted Index Medicus category. The definition of instrumental activities of daily living (IADL) began in 1969 with the work of Lawton and Brody who presented two scales to assess function which recognized the different degrees of complexity required for performing functional tasks. The first scale, taking life maintenance and activities essential for self-care as the primary level, was called the Physical Self-Maintenance Scale.

Evidence from England, Australia, Canada, Japan and the USA indicates that the single homeless population is ageing, and that increasing numbers of older people are homeless. This paper reviews evidence of changes in the age structure of the single homeless population, and the factors that are likely to have had an influence on the growth of the older homeless population. In many Western cities, the housing situation of older people is changing and there is a growing reliance on the private rented sector. Unemployment is also having an impact on older people who are under the official retirement age. An increasing number of older people are experiencing problems linked to alcohol, drugs, gambling and criminality, and these are all behaviours that can contribute to homelessness. Despite high levels of morbidity and disability among older homeless people, they are a relatively neglected group and receive little attention from policy makers and mainstream aged care services.

China has an increasing ageing population. Depression, as one of the most common problems in older people, is a concern that merits attention. This paper reviewed published studies of the prevalence of depression and its related factors in older people in China. Seventeen papers were identified by searching the following electronic databases: Web of Science, PsycINFO, MEDLINE, PubMed, CINAHL, China Academic Journal and VIP Database for Chinese Technical Periodicals. Whilst prevalence varied across studies, health status, social support, financial status, living arrangements and some demographic factors were consistently related to older people's depression. Further well-designed studies are needed to explore depression in older people in China to identify more culture-specific contributors to maximize well-being.

Aging processes are time-dependent, deteriorative functional changes. These functional changes lead to a progressive loss of the organism’s ability to withstand both internal and environmental stresses, causing the failure of cellular homeostasis. Among the modern hypotheses, the ‘Oxidative Stress Hypothesis’ offers the best mechanistic elucidation of aging phenomena. Based on the ‘Free Radical Theory of Aging’, this hypothesis has gained popularity among researchers in the field of gerontology as well as other biomedical fields. Its primary premise proposes that aging and its related disease processes are the net result of free radical-induced damage, asserting further that an organism’s inability to produce counterbalancing antioxidative defences, i.e. defences that offset disturbances in the redox state, underlies its cause.

Provision of services for older people is now a priority for policy makers, not least because of population aging precipitating a ‘demographic revolution’. In England, one response by policy-makers has been a National Service Framework, designed to provide standards and models for the care of older people. Furthermore, recent moves to create strategic partnership agreements between the Department of Health, the NHS and the Voluntary and Community Sector point to increasing awareness of the interconnections between health and social care. However, even when services are in place, older people do not always use them. Understanding why this might be the case is key to further service planning and implementation.

Suicide is accepted as a major health problem worldwide, especially in the young and middle aged. It is, however, a significant health problem in older people as well, and those aged 65 years and over generally have the highest suicide rates compared with all other age groups. In research literature from the last decade, there has been an increased interest in disentangling the phenomenon of suicide in later life. This paper aims to critically review the literature on suicide and suicidality in later life published from 2000 to 2009. Prevalence rates as well as risk and protective factors are mapped and correlates reviewed. The association between suicidality and help-seeking behaviour is considered. Finally, potential prevention strategies are reviewed.

This systematic review, with meta-analyses conducted where data were available, aimed to investigate the prevalence of symptoms of depression and anxiety in mild cognitive impairment (MCI), and to establish how symptoms of depression and anxiety relate to the progression from no cognitive impairment to MCI, and from MCI to dementia. Sixty studies were included in the review. Meta-analyses indicated that symptoms of depression and anxiety were more prevalent in people with MCI than in people with normal cognitive function, and increased the risk of progression from no cognitive impairment to MCI. There were mixed results regarding the effect of such symptoms on progression from MCI to dementia. The findings highlight the need for more research in this area, which can inform attempts to slow or halt the progression of cognitive impairment in later life, with resulting benefits for quality of life.

Nutritional assessment in older people to detect malnutrition or risk of malnutrition is essential to avoid adverse nutrition-related outcomes. Poor nutritional status appears to be a major contributing factor for poor prognosis in malnourished individuals. Nowadays, nutritional assessment is considered to be one of the domains which should be evaluated in comprehensive geriatric assessment (CGA). CGA is a comprehensive assessment tool with the capacity of detecting impairments in older people and, at the same time, suggest interventions. Although many assessment tools are proposed, those used in CGA are not widely agreed. After 20 years of clinical practice and research, the Mini Nutritional Assessment (MNA) seems to be the tool most widely accepted by health carers and patients for the assessment of nutritional impairment in CGA.

Introduction

Physical therapy has been found to improve sensorimotor function following stroke.–5 Early intervention might be better than late6 but even late poststroke physical therapy may be beneficial.3,7–9 Increased intensity of physical therapy may bring increased benefit,10–12 but this might not always be the case,13 as the severity of motor impairment may influence response to additional treatment.14 Not surprisingly, the content of physical therapy might also influence sensorimotor response,15 but at present, choice of treatment by physiotherapists appears to be mostly determined by the treatment approach which was prevalent during their training.16,17 As there are several different physical therapy approaches (Partridge18 describes nine), the potential for variation is extensive. Variation also arises from location of groups of therapists, e.g. the emphasis on the Movement Science Approach in Australia and the emphasis on the Bobath approach in the UK. There is a strong impression that physiotherapy practice has often been shaped by fashion, underpinned by clinical intuitions, based on uncontrolled observations and rationalized by quasi-scientific theories. An example of this is the Bobath approach, which we shall use as an illustration of the current inadequate scientific basis for commonly-used physical therapies.

The VIPS framework is a four-part definition of person-centred care for people with dementia (PCC), which arose out of an earlier review article for this journal. The definition has assisted in the practical application of person-centred care. It has been operationalized into the VIPS practice model (VPM), which has been subject to a recent randomized controlled trial within Norwegian nursing homes. The VPM provided a vehicle for the VIPS framework to be utilized during reflective practice meetings focusing on understanding care situations from the perspective of residents with moderate to severe dementia. VPM incorporated an education and coaching approach, clearly defined staff roles, and resident-focused outcomes in a cycle to support improvements in quality of care. The use of VPM in practice is discussed. VPM was built utilizing the literature from organizational change. The role of literature reviews in bringing about change in practice is highlighted.

That transfer of older people from one institution to another is detrimental to well-being, health and survival has been reported for 50 years. This has led to fear, anger and legal challenges when closures occur. Previous reviews identified accounts of relocation followed by adverse outcomes and others where problems were avoided or benefits claimed. This paper reviews the last twelve years of literature on health outcomes following involuntary relocation between nursing homes. Reports of post-move mortality, physical or psychological health suggest and confirm that relocation without preparation carries higher risk of poor outcomes than moves that are orderly and include preparation. The literature on the care home closure process, admissions and individual transfers offers insights into practices that might help minimize adverse outcomes. A number of agencies have produced helpful guidelines. How these are implemented needs to be monitored and linked to in-depth studies of sample closures.

Loneliness and social isolation are two core concepts regarding social relationships in human life that are particularly relevant in old age. This article focuses on the prevalence of loneliness in a community sample of 1266 autonomous people aged 50 or more and on the structural circumstances (demographic social network and general health condition) that could better contribute to its experience. The prevalence of loneliness was 16.3% (n = 206) and a small number of people presented low social network (7%). Predictors of loneliness (explaining 29% of variance) were being widowed, perceiving own health as poor or very poor, and having psychological distress and cognitive impairment. The authors emphasize the importance of psychological distress as a predictor of loneliness and the need for social and psychological interventions to prevent its consequences in morbidity and mortality.