Spinal cord injury (SCI) is a catastrophe that affects the individual, the partner, the family and the community. Society is involved in the broader sense, in the funding of the treatment and long-term support of individuals with SCI. SCI causes complex medical, physical, psychological, social and financial interactions. Although the physiological impairment following a SCI typically affects the locomotor and sensory systems, there is nearly always a resulting dysfunction that affects most bodily systems. Both the multi-system physiological impairment/dysfunction and non-medical aspects of SCI remain in a dynamic state for the rest of the individual’s life. This means that lifelong treatment and monitoring is required by a dedicated multidisciplinary/interdisciplinary team of health and social care professionals.

Three diseases of bone are common in the elderly: osteoporosis, osteomalacia and Paget’s disease of bone. Osteoporosis is the result of bone loss, caused by a change in factors that regulate bone cell metabolism. The process of bone loss itself, resulting in osteoporosis, does not cause symptoms. It is the consequences of osteoporosis, fractures and bone deformity, that patients complain of. Osteomalacia is a defect in the process of mineralization of bone, nearly always due to vitamin D deficiency. In contrast to osteoporosis, patients with osteomalacia may have complaints of bone pain and muscle weakness. Page’s disease of bone is probably caused by a slow virus, which initially affects osteoclasts, followed by stimulation of osteoblasts. The process of increased bone cell turnover itself does not usually cause complaints. However, it results in deformation of bones and joints causing a painful secondary osteoarthritis. Pain resulting from high bone cell turnover responds remarkably quickly to treatment. In exceptional cases local pain in the long bones occurs. In an earlier review the problems of origin, diagnosis and treatment of osteoporosis were discussed. This paper focuses on diagnostic procedures and therapeutic regimens.

The psychosocial characteristics of older heroin-dependent patients (defined as 45 years and over) attending a specialist addiction clinic in Stoke on Trent, UK were studied using retrospective record analysis of the case notes of the 20 oldest heroin-dependent patients. This study draws attention to the multiple psychosocial problems facing ageing heroin addicts. On average, patients were 48 years old, had first been exposed to heroin at age 29, 85% were injectors and the majority were polydrug users. In 20% a major life event had preceded first use of heroin. Nineteen were male, 17 were single, only 10% were employed, while just 10% did not have a criminal history. Depression, self-harm and memory disturbance were frequently reported. Retention in treatment was a feature, with consequent improvements including reduction in criminality and injecting behaviour. However, there is little specific guidance on treatment, training or policy for this group in the UK.

A literature search was conducted to identify and evaluate non-pharmacological interventions available for people living with dementia, who present with sexual behaviours that challenge. A lack of research implementing and evaluating clinical interventions was identified, and the search was broadened to include discussion papers relating to sexuality and dementia. This included work both with couples affected by dementia at home, and with staff in institutional care settings. The papers identified come from a range of countries, with wide variation in care settings and practices. Literature suggests sexual behaviours that challenge in dementia are best understood within the broader context of behavioural and psychological symptoms of dementia (BPSD). There is a consensus highlighting the importance of training staff to recognize the sexual needs of people with dementia and to develop clear policy and guidelines to support staff in managing potential challenges. Few authors attempted to include the perspectives of either care partners or the person with dementia.

This paper addresses the ethical and legal issues which arise in the UK in the care of demented people, updating and revising the 1993 review in this journal. In 1993 the ‘end of medical ethics’ had recently been suggested, an American fear that the doctor‘s responsibility and authority would be fatally eroded by administrators and cost controllers, concerned only with budgets. These concerns persist.

A person's risk of developing cancer rises exponentially with age, an increase that is widely considered to result from cumulative exposure to mutagenic agents. However, cancer incidence rates decelerate and plateau beyond 85 years of age and numerous malignant pathologies peak in incidence during early or middle life, indicating an important role for additional factors in controlling the timing and nature of cancer development. Given that immune function is known to decrease with age, malignant neoplastic change may be induced by increased chronic infection and the onset of a pervasive low grade inflammatory environment. This article discusses in detail the ageing immune system's role in cancer pathogenesis and demonstrates that key polymorphisms coding for relatively low pro-inflammatory cytokine production act to protect some populations from age-induced neoplastic transformation.

Although a reduced liver size in elderly people has long been recognized from post-mortem studies, these studies do not allow the separation of true ‘age-related’ differences from the effects of premorbid illness, and death. An age-related effect was confirmed however by an in vivo study which measured liver size by ultrasound scanning of healthy individuals. This demonstrated a significant negative correlation between age and liver volume, with volumes being 28% lower in individuals above the age of 65 compared with those under 40 years of age.

Dysphagia is defined as difficulty in swallowing solids or liquids and is distinct from odynophagia, which is pain on swallowing. Dysphagia occurs in a range of conditions that affect the oral, pharyngeal and oesophageal phase of swallowing. The problem of dysphagia assumes greater importance in older persons. Some people may not be able to communicate that a problem exists. In others the lack of nutrition due to dysphagia compounds existing undernutrition, a common problem in institutionalized older persons. This paper discusses dysphagia in the context of the older person and outlines the normal mechanism of swallowing, the important clinical distinction between oropharyngeal dysphagia and oesophageal dysphagia, the aetiology of dysphagia and issues of management.

Parkinson's disease (PD) is a common and costly condition affecting a predominantly older population. Physical rehabilitation has been shown to enhance motor performance and functional mobility in the short-term. However, there is limited information available about how best to design and deliver an ambulatory rehabilitation (AR) programme for this patient group. This article reviews the current evidence, aiming to provide guidance about best-practice service provision. We highlight the benefits of group therapy and techniques aimed at reducing falls. Further research is required to determine the optimal dose and intensity of AR necessary to provide sustained benefits in people with different stages of PD.

The term ‘older people with learning disability’ refers to a highly heterogeneous group of people. By definition, they all have delayed or abnormal early development, together with significant intellectual and functional impairments, but they differ considerably in terms of cause, developmental profile, nature and degree of impairments and their social and personal backgrounds. Overall, people with learning disabilities make up only a small minority of the population, however it is well recognized that they have increased overall health care needs, including mental health needs. It has been estimated there are 210 000 people living in England and Wales who have a severe or profound learning disability: only 25 000 (12%) of these are older people aged over 60 years. Of the 1.2 million people with mild or moderate learning disability, 265 000 (21%) of these are older people over the age of 60. Life expectancy seems to be influenced by severity of learning disability, the age profile of the mild to moderate learning-disabled population being much more closely matched to that of the general population. As a result of this differential mortality, across the spectrum of disability there is a reduced level of learning disability with advancing age, and older people with learning disabilities, when considered as a group, have higher levels of functional ability (and reduced levels of challenging behaviour) than the younger group.

Clostridium difficile is a spore-forming gram positive anaerobic bacillus that is part of the normal faecal flora of about 3% of healthy adults. Colonization rates may be much higher than that in hospitalized patients and in newborns. It can occur at any age, but elderly adults and debilitated patients are most susceptible to disease. In such patients, even a short course of antibiotic therapy for prophylaxis or treatment of minor infections can lead to colonization and Clostridium difficile infection. The list of causative antimicrobials is extensive but, in general, any antimicrobial agent that can get into the intestinal lumen can, even in small amounts, induce disease.

Autonomic disorders in old age can be attributed to several main features associated with aging: the intrinsic neurobiological changes that occur with age, degenerative changes in effector organs innervated by autonomic nerves, and secondary involvement of the autonomic nervous system (ANS) in disease processes. As in most areas of clinical geriatrics, the distinction between disorders ascribed to ‘normal’ aging and those attributable to diseases of old age is difficult to make with any degree of certainty. Neurobiological changes with age have become the subject of intense investigation in recent years, with improvements in techniques for assessing autonomic nerve structure and function. This has included a better understanding of neurotransmitter and receptor transformations during development and aging. The versatility of the ANS, or ‘plasticity’, involves interactions with target organs, e.g. via nerve growth factor (NGF) and with other neurons, and it is as vital to the mature and aging autonomic neuron as it is during development. Some neurotrophic features of aging in the ANS and in disease processes in old age are considered in this paper.

Physical training, if including specific different training modalities, reduces the fall risk in healthy community-dwelling older people, as does a home hazards modification programme. Vitamin D supplementation in older individuals with low levels of vitamin D, adjustment of psychotropic medication, and structured modification of multi-pharmacy are all drug-focused programmes that reduce the number of falls. Anti-slip shoe devices during icy conditions for older people who walk outdoors and multifaceted podiatry in patients with specific foot disability reduce the fall risk. First eye cataract surgery and pacemakers in patients with cardio-inhibitory carotid sinus hypersensitivity are surgical interventions that reduce the fall risk. Multi-factorial preventive programmes that include training, both individually designed and generally prescribed, also reduce the fall frequency. With this in mind, we ought to initiate fall preventive programmes in older people, especially in high- risk groups, to reduce the number of falls and fallers in society.

Factors increasing the risk of urinary tract infections in old age include reduced T lymphocyte regulation, decreased B lymphocyte antibody synthesis, impaired killer T cell function and slowed neutrophil chemotaxis. More practical causes for a high incidence of urinary infections are multiple pathology and poor nutrition. In women, a low oestrogen level increases the intravaginal pH, resulting in the lactobacillus being replaced by a pathogenic agent. Faecal stasis may also increase the risk of a urinary infection. The presentation and severity of a urinary infection are affected by intercurrent disorders such as diabetes mellitus, poor bladder control, concurrent medication and cognitive impairment. Other relevant but less common disorders are bladder calculi and tumours. Common signs of pyouria in old age are urinary incontinence, anorexia, lethargy and confusion. The infection may even be asymptomatic and this is discussed later.

This article updates a previous review of this topic published in this series in 1996. The number of studies and review articles that have been published since then is encouraging, and suggests that there is a growing awareness of and interest in these disorders in old age.

The kidneys undergo a multitude of structural and functional changes with advancing age. Structurally, there is a progressive loss of predominantly cortical renal mass, a decrease in the number of glomeruli, an increase in the proportion of sclerotic glomeruli, atherosclerotic vascular changes and interstitial changes resulting in atrophy and fibrosis. Functionally, there is a decline in the glomerular filtration rate (GFR), resulting primarily from a decrease in the number of functioning nephrons.

Nutrient inadequacies, especially in older persons, impact adversely on health, increasing the risk of acute and chronic disease and prolonging recovery from illness. Malnutrition is a condition due to an inadequate calorie and micronutrient intake that fails to meet the basic requirements for body maintenance, growth and development. Malnutrition often occurs in older people in acute hospital settings, among residents in nursing homes and in long-term care. Malnutrition in institutionalized older people is as high as 40–50%.

Musculoskeletal symptoms are extremely common, with almost one-third of people aged 75 years and over having a significant musculoskeletal problem. Joint pain due to inflammatory arthritis is important to identify, as it is potentially treatable. In elderly patients, inflammatory arthritis may not present in the ‘classical’ way, may present with non-specific symptoms and may co-exist with other musculoskeletal problems, all of which can result in diagnostic difficulty. In addition, co-morbid conditions and polypharmacy may present treatment challenges. In this paper, we discuss the general considerations in the clinical evaluation and management of a patient with inflammatory joint symptoms and discuss in more detail the diagnosis and management of the common causes of inflammatory arthritis.