In the last decade, great advances have been made in the understanding of the role of lipid management in the prevention of cardiovascular disease. Epidemiological data from the Framingham study and the Multiple Risk Factor Intervention Trial (MRFIT) have described a causal relationship between lipid and lipoprotein levels and the risk of coronary heart disease (CHD). Hitherto, the emphasis of therapeutic studies has focused on coronary heart disease specifically, especially in terms of treatment with 3-hydoxy-3-methylglutaryl-coenzyme A (HMG-CoA) reductase inhibitors or ‘statins’. The result has been a burgeoning evidence base demonstrating the effectiveness of statins in cholesterol reduction and, more importantly, in the reduction of coronary mortality and morbidity in subjects both with and without established CHD. Given that the vascular system is more commonly regarded as a single entity, with the pathophysiological basis of disease based on the development of atherosclerosis, it has been surprising to find that ischaemic stroke does not share the same robust relationship with cholesterol that CHD does. The lack of a consistent relationship between serum cholesterol and stroke has manifested itself in diverse attitudes towards cholesterol-lowering in cerebrovascular disease; this problem has been heightened by the relative lack of trial data and clinical guidelines on the subject. It is therefore important to review the current evidence regarding cholesterol and stroke and to derive conclusions that translate into the clinical management of cholesterol in patients with cerebrovascular disease.

The term syncope has been used to describe collapse of any nature but this is not the appropriate use of the word. Syncope originates from the Greek and means ‘cessation’ or ‘interruption’. The specific application of the word syncope is a temporary loss of cerebral blood flow, resulting in loss of consciousness and postural tone, thus leading to collapse. Although other conditions resulting in collapse may be difficult to disentangle from a syncopal event, it is the broad spectrum of diagnoses resulting in syncope to which this article is dedicated.

It is frequently observed that medical treatments are evaluated in patient populations which have characteristics significantly different from those of patients upon whom the treatments will be used once established in clinical practice. The most striking illustration of this has been the almost complete exclusion, until recently, of elderly patients from trials of new medication. Whereas clinical trials include younger adults with a single pathology, the real world of patient care is dominated by older adults with multiple pathology.

The National Bed Inquiry indicated that up to 20% of older people might be inappropriately occupying acute hospital beds and could be discharged if alternative services were available. The report proposed the concept of ‘Intermediate Care’ as a scenario that might contribute to resolving issues around the use of acute hospital beds. The Department of Health (DoH) Circular to Health Authorities and Local Councils with regard to Intermediate Care and the publication of the National Service Framework for Older People have brought intermediate care into mainstream health policy.

Pulmonary rehabilitation is a multidisciplinary education and exercise programme of care for patients with chronic respiratory disease, particularly Chronic Obstructive Pulmonary Disease (COPD). It aims to reduce symptoms, decrease disability, increase participation in physical and social activities and improve overall quality of life in patients who may still be very disabled despite optimal pharmacological treatment. Pulmonary rehabilitation first began more than 30 years ago and is now established as an important part of the management of COPD.

Vascular cognitive impairment (V.C.I.) encompasses all forms of cognitive loss associated with cerebrovascular disease and ischaemic brain injury. It includes cognitive impairment related to stroke, cortical and subcortical infarcts, silent infarcts and strategic infarcts, white matter lesions associated with small vessel disease, and specific arteriopathies such as CADASIL (Cerebral Autosomal Dominant Arteriopathy with Subcortical Infarcts and Leucoencephalopathy). Recent studies have demonstrated that VCI is most commonly of a subcortical aetiology with small vessel disease being the major cause. VCI plays an important part in patients with other forms of dementia, such as Alzheimer's disease, who have coexisting vascular lesions and it has been proposed that VCI may be the most common form of cognitive impairment in older people, with a prevalence of 5% in people over the age of 65. In view of the aging population and the growing magnitude of vascular disease in western society, the prevalence of subcortical VCI is likely to increase, with a greater impact on patients and health care providers. In this article, we will review the cerebrovascular pathology underlying subcortical VCI and its role in mediating the characteristic cognitive deficits.

Diabetes mellitus is a common and expensive condition which is reported to be responsible for as much as 4-5% of national health care expenditure in developing countries. It is a disease of some antiquity, although the predominant clinical presentation is not that which was described by Aretaeus in the second century AD ('a melting down of the flesh and limbs into urine').

Nursing homes and long-term care facilities are usually considered as reservoirs for methicillin-resistant Staphylococcus aureus (MRSA) carriers. Actually, there are major differences in MRSA carriage between institutions, with variations from 1% to more than 30%. Overall there is a low incidence of MRSA infection in these institutions, even though carriage is associated with a higher risk of subsequent MRSA infection, with high mortality rates. The main risk factors for carriage are well known: recent hospitalization in an acute-care ward, skin wounds and recent antimicrobial therapy. Age over 75 years is also a risk factor. Residents of nursing homes and long-term care facilities pose a risk of MRSA transfer to acute-care wards, with potential consequences in terms of infection control strategy or surgical antibiotic prophylaxis. No well-designed study has identified the best strategy for MRSA control in institutions for older people and strategies that have been proposed are controversial. Studies to elucidate this would be useful, as well as studies specifically designed to identify the relative importance of different ways of MRSA transmission in these institutions (cross-transmission via healthcare workers or the environment, or direct transmission from one resident to another). Finally, a first important step towards MRSA control is a strict application of standard precautions, particularly good compliance with hand hygiene.

Introduction

With their ease of administration, relatively benign side-effect profile and safety in overdose, in the United States the selective serotonin reuptake inhibitors (SSRIs) have become de facto first choice in the treatment of geriatric depression, displacing tricyclic antidepressants (TCAs). In this paper, the relevant literature regarding neurochemistry, kinetics, dosing, efficacy and differential side-effect profiles of citalopram, fluvoxamine, fluoxetine, sertraline, and paroxetine, the five currently available SSRIs in the USA, will be reviewed with special emphasis on geriatric data. Of late, considerable controversy has been generated regarding whether SSRIs are as effective as TCAs in severe and melancholic depressive subtypes. This important issue will be explored and the relative utility of all the SSRIs in the elderly patient compared and contrasted. Finally, reasons for difficulties in comparing results across studies will be elucidated.

Introduction

This is the last in a series of three papers reviewing 69 patient-based outcome measures that have been developed specifically for use in older people, or that have been administered to populations that include older people. The previous papers described how the measures were identified, and provided brief descriptions of measures of general health status and quality of life, instruments assessing mental status, measures of depression, and measures of psychological wellbeing. In this paper we describe six pain measures, 12 measures of physical disability and handicap, and eight measures of social health (see Tables 1–3). References in the text which include a copy of the questionnaire are marked with a # sign. Otherwise, a copy can be obtained from the address provided. It is recommended, however, before using any of the questionnaires to contact the authors to obtain permission to use them.

People of 65 years and older accounted for 21% of the population of England and Wales in 2001, and their proportion is increasing. It is forecast that the number of people over the age 75 years will double within the next 50 years, and that of those over the age of 90 will increase fivefold. The older patient with declining health poses significant challenges for health care professionals, in particular those of managing chronic morbidity and the effects of aging. Many older people require pharmacological treatment for multiple, co-existing pathologies. Those of 65 years and over receive 56% of all prescriptions in England, of which 78% are repeat prescriptions, and people in residential care, on average, receive five different medicines concurrently. The impact of repeat prescriptions means that, due to inadequate monitoring, many older people continue to administer medicines they no longer require, and thereby risk receiving an inappropriate drug, dose or duration of treatment. In addition to this, there is the propensity for older people to mismanage medicines, increasing their risk of unplanned drug-related admission to hospital and drug-related morbidity.

Longer lifespans have been accompanied by an increasing number of older people suffering from impaired cognitive function (dementia) including Alzheimer's disease (AD) and vascular dementia (VaD). Some studies have suggested that hypertension in old age correlates with the pathogenesis of dementia. Since hypertension is potentially reversible, a number of randomized trials have examined whether antihypertensive treatment may help to prevent dementia. We review five studies, all using subjects aged 60 years or older, which investigated different antihypertensive pharmacological treatments and found conflicting results regarding impact on dementia. At the same time, other studies have suggested that hypotension in older people, especially those with low diastolic blood pressure, are also at higher risk for developing dementia. Four studies are reviewed here, but none is able to determine unequivocally if hypotension is a cause or a consequence of dementia in old age.

Tuberculosis (TB) rates in the UK have increased by about 25% over the last 20 years. About 12% of cases occur in those over 65. Their diagnosis and treatment is similar to that of younger patients, but their presentation is often atypical, diagnosis is often delayed, there is a higher frequency of treatment side-effects and there is greater potential for drug interactions. Mortality increases markedly with age and more than half of those aged 80 years or more die before completing treatment. About 75% of TB in older patients is due to reactivation of latent disease acquired in childhood. The risk of reactivation is particularly increased by human immunodeficiency virus (HIV) infection and anti-tumour necrosis factor (anti-TNF) medication. Active disease spreads by the inhalation of airborne droplets, particularly in enclosed environments such as nursing homes. Interferon gamma release assays (IGRAs) are an important new development in recognizing latent infection. They should allow better targeting of treatment in those with recently acquired infection, or who are at risk of reactivation. With appropriate effort it should be possible to substantially reduce TB rates to fewer than 1 per million per year, the current US target.