The proportion of older people in the UK is increasing in relation to the population as a whole. This trend is reflected in the age profile of patients in hospital and those requiring continuing care in the community – domicilary, residential and nursing home sector. The HAS Report identified that more than 40% of patients over 65 with disability will require admission to an acute hospital over a two-year period. Ensuring appropriate, equitable and quality care for this age group is therefore a priority.

The legacy of the workhouse origin of services for older people in the United Kingdom remains in the memory of patients and practitioners and is still a reality for some. In the area in which we work, geriatric medicine services are still provided in Victorian Poor Law buildings, although, we hope, not for much longer. The disadvantage that this causes to patients in terms of access to modern services and investigations is quite clear and the importance given to the ‘routing of age discrimination’ in the National Service Framework for Older People has in general been welcomed. In a parallel document, the Department of Health has stressed the importance of a robust policy for medicines management based on the twin principles of appropriate prescribing. Firstly, all older people should receive all the medication from which they would benefit. Secondly, steps should be taken to reduce the risk of adverse effects, the frequency of which rise with age. The prescribing principles outlined in these two documents, together with the other National Service Frameworks, form a powerful basis to improve the health of older people.

In 2004 the Stroke Association stated ‘Each year over 130,000 people in England and Wales have a stroke. Of all people who suffer from a stroke, about a third are likely to die within the first 10 days, about a third are likely to make a recovery within one month and about a third are likely to be left disabled and needing rehabilitation. Stroke has a greater disability impact than any other medical condition. A quarter of a million people are living with long-term disability as a result of stroke in the UK.’

Cerebral infarction, as the result of atheroma in large blood vessels, was one of the first explanations for dementia in older people. However, this was a relatively uncommon finding in those presenting with dementia and it was soon realized that subcortical infarctions due to non-atheromatous changes in small blood vessel walls were more important factors in cognitive decline. Furthermore, small vessel disease (SVD) producing lacunar infarcts (LI) and white matter changes increased dementia severity in individuals with only moderate Alzheimer's disease (AD) pathology. Magnetic resonance imaging (MRI) found subcortical (lacunar) ‘silent infarcts’ and white matter changes were surrogate markers for SVD and increased significantly the likelihood of developing dementia. Detailed histopathological studies of SVD showed it was in fact a range of pathologies, but the aetiology of the most common type (arteriosclerosis/lipohyalinosis) is difficult to explain. Theories to explain SVD include effects of hypertension, a leaky blood–brain barrier (BBB), amyloid accumulation, microbleeds, venous changes and endothelial inflammation. Endothelial expressed inflammatory molecules could represent potential biomarkers of SVD. Many of the risk factors associated with SVD are also present in AD, such as diabetes, systemic hypertension and ageing; all of these can target the endothelium with the potential to initiate SVD, resulting in ischaemic changes and neurodegeneration, including AD pathology.

Bleeding in elderly patients is most commonly due to an underlying structural problem or an acquired coagulopathy. Occasionally, previously asymptomatic congenital bleeding disorders may present at an advanced age. When considering the possible causes of a clinical bleeding problem, the coagulation cascade is still a good starting-point. However, it is important to realize that the traditional model of the coagulation cascade has been superceded by the concept of a ‘coagulation network’. This updated model recognizes the importance of tissue factor in the initiation of coagulation. Despite the complexity of this model, the basic coagulation tests can still be interpreted in relation to the ‘intrinsic’, ‘extrinsic’ and ‘final common pathway’ components of the old-fashioned cascade (Figure 1).

In the developed, as well as developing countries, there is an immediate challenge to ensure an adequate supply of health professionals trained in providing care for older people to meet the needs of increasing numbers. Currently 20% of the population of the United Kingdom (UK) is over 60 – 12 million people. By 2031 this proportion will be nearly a third – 18.6 million people. The largest increases are anticipated among the over-85 age group, from 0.8 million in 1987 to 1.4 million in 2025. In Europe the number of people aged over 80 years will double within the next 25 to 30 years. It is estimated that there will be more than 1.2 billion elderly people in the world by the year 2025 – three-quarters of them living in the developing countries.

This paper addresses some ethical and legal issues which arise in the UK in the care of people with dementia, focusing on the law in England and Wales – updating and revising the 1997 and earlier version. The ‘end of medical ethics’ continues to be debated, with an attendant fear of doctors’ responsibility and authority being fatally eroded by administrators and cost controllers, concerned only with budgets and ‘bureaucratic parsimony’.

Hip fracture is very common among older patients, who are characterized by increased co-morbidities, including cognitive impairment. These patients have an increased risk of falls and fractures, poorer functional recovery and lower survival both in hospital and 12 months after discharge. We review the survival and functional outcomes of older patients with cognitive impairment and hip fracture managed in orthogeriatric units, and highlight the gaps in our knowledge of the efficacy and efficiency of specific orthogeriatric programmes for such patients and the future research perspectives in this field.

The term 'graduate' (hereafter without quotation marks) has been used to describe the following groups of patients:

1) All those patients with enduring psychiatric illness who have graduated to old age (usually defined as age over 65 years);

2) 'Patients who entered hospitals for the mentally ill before modern methods of treatment were available and have grown old in them after many years there.'

3) Specifically, long-stay patients with schizophrenia over the age of 65 years who came into continuous psychiatric contact well before that age.

It is often said that the demand for health care is growing inexorably in the UK, so that the NHS is constantly struggling to keep up. The dilemma was most famously put by Enoch Powell, who said that any health service faces the problem of infinite demand meeting finite resources. This was an economist's view, which suggests that anything that is free will be demanded infinitely.

Urinary tract infection is the most common bacterial infection in older populations. It is an important clinical problem across the full spectrum – from elderly persons who are well and living in the community to highly functionally impaired residents of long-term care facilities. Symptomatic urinary infection is a frequent cause of morbidity, and urinary infection is responsible for substantial antimicrobial use. This review summarizes current knowledge relevant to both asymptomatic and symptomatic urinary infection in older populations, and identifies unresolved issues for further study. The discussion is relevant to older individuals without indwelling urethral catheters, unless it is specifically stated that the older person with an indwelling catheter is being addressed.

Joint problems in older people are common–both as ongoing chronic problems but also individuals presenting for the first time with joint symptoms. The assessment of an elderly person presenting with joint symptoms poses special challenges. There is a large potential differential diagnosis and more than one form of arthritis may co-exist, most commonly osteoarthritis. The clinical presentation in older patients may differ from typical findings in a younger individual and co-morbid conditions may complicate management strategies. In this article we discuss the differential diagnosis and management of conditions presenting as inflammatory arthritis in older people.

Average world life expectancy has seen a dramatic rise over the last two centuries although active life expectancy remains relatively unchanged. One reason for this is that aging results in skeletal muscle becoming smaller, weaker and more susceptible to contraction-induced injury. By the age of 70, muscle strength is reduced by around 30–40% and this can have catastrophic effects on quality of life. Despite a vast amount of research into age-related changes in skeletal muscle, the exact mechanisms responsible for this is still unclear and thus treatments to preserve muscle function with aging remain elusive.