This review identifies and examines the clinical application of risk prediction tools, including the American Society of Anaesthesiology (ASA) Classification System and POSSUM-based scores, in the older general surgical patient. Predicting outcomes in this patient group remains difficult; it is challenging to design a risk prediction tool that will apply to both emergency and elective surgery and that remains valid across the wide age range that this patient group encompasses. Risk prediction tools can have benefit but should be used in conjunction with the clinical assessment of those experienced in the care of this challenging patient group.

Orthostatic hypotension is a common condition seen in up to one-third of community-dwelling and two-thirds of hospitalized older people. It is part of a spectrum of abnormal cardiovascular responses to postural challenge and is associated with syncope, dizziness, falls, volume depletion, drug side-effects and an increased mortality. This article discusses the current classification of orthostatic hypotension and related conditions, and the clinical importance of the control of the cardiovascular response to orthostasis. These are considered with particular reference to the measurement of postural cardiovascular responses in the routine clinical setting. By improving understanding of the methods that are used for assessment of postural changes in blood pressure, clinicians should have greater confidence in the reliability of measurement and in their interpretation.

The incidence of deep vein thrombosis (DVT) and pulmonary embolism (PE) increases with age and it has been reported to be higher in males. The annual incidence rates per 1000 for DVT and PE are 1.3 and 1.8 respectively for people aged between 65 and 69 years, rising to 2.8 and 3.1 respectively in those aged between 85 and 89 years. Older people are about eight times more likely to develop venous thromboembolism (VTE) in hospitals, nursing homes or other chronic care facilities. About 1.7% develop PE and 8% develop recurrent PE within one year of treatment for DVT. About 3% of patients with DVT and 21% of those with PE die in hospital. One year mortality with DVT is 21% and that with PE is 39%. The diagnosis of PE is often missed in older people and it is often detected only at postmortem.

The last three decades produced a striking increase in investigations of the neurobiological basis of brain aging and aging-related changes in neural and cognitive function. Experimental and clinical studies of aging have become more valuable as the population, at least in industrialized countries, has become ‘greyer’. The increase in adult life expectancy that occurred in the twentieth century produced the motivation and necessity to invest resources in increasing ‘health span’ as well as lifespan, in order to maximize quality of life and minimize the financial and social burdens associated with disability in the later years of life. Specific interest in the aging nervous system is driven by recognition that increased longevity has little appeal for most people unless it is accompanied by maintenance of cognitive abilities. Indeed, surveys of older individuals routinely show that loss of mental capacity is among their greatest fear. In recent years, neuroscientists and gerontologists, with a variety of training and experimental approaches, have applied increasingly powerful quantitative methods to investigate why neural function declines with age. New animal model systems have been developed and old ones have become better characterized and standardized. The necessary and important descriptive studies that dominated the field in earlier years are increasingly supplemented by more hypothesis-driven research, resulting in sophisticated investigations and models of the mechanisms of brain aging. This review provides a selective overview of recent and current research on brain aging. The focus throughout will be on normal brain aging and the moderate cognitive changes that often accompany it, not on aging-related neurodegenerative diseases that result in dementia. To provide a context for studies of neurobiological changes in the aging brain, a brief overview of the types of cognitive changes that are commonly seen in aging humans is first provided. The remainder of the review focuses on animal studies that are progressively overcoming the unique challenges of aging research to reveal the neurobiological mechanisms of aging-related cognitive dysfunction, and suggest new targets for therapies to prevent or ameliorate cognitive decline.

This is the second in a series of three papers reviewing 69 patient-based outcome measures that have been developed specifically for use with older people, or that have been administered to populations that include older people. The first paper described how the measures were identified, and provided a brief description of 17 measures of general health status and quality of life. This paper reviews nine measures of mental status and cognitive function, 10 measures of depression and anxiety, and seven psychological wellbeing measures (see Tables 1-3).

Editorial

Even a decade ago, there was compelling evidence that, as older individuals age, a decline in caloric intake is observed, with as many as one in five subjects aged 60 years and over consuming less than 1000 calories per day. Those from ethnic minority backgrounds or nursing homes were particularly at risk of malnutrition. In many cases, this decline can be confidently attributed to the presence of disease and co-morbidities such as chronic illness (for example, chronic pulmonary lung disease) with results in weight loss. Other factors such as decreased resting metabolic rate, reduced physical activity, threshold alterations in taste-bud activity or lowering of smell acuity, provide background inhibitory influences on nutritional intake.

The elderly population has greatly increased in the last few decades as life expectancy has risen. In 2005 life expectancy at birth for females born in the UK is 80.2 years, compared with 75.2 years for males. This is in contrast to 49 and 45 years respectively in 1901. Cardiovascular disease is still the most important cause of death in the population over the age of 65, causing 40% of deaths in women and 42% in men of this age.

This article will first set rehabilitation nursing and the older person into an appropriate context and then address the nature of rehabilitation nursing, how definitions have developed over time and lastly, what it is that we now provide, in conjunction with others, to meet the rehabilitative needs of our older population. The boundaries defining ‘old’, and between seeing a person as experienced, a bit wrinkly, forgetful and perhaps eccentric, versus a person who is old and demented are by no means clear-cut.

Urinary incontinence is a common symptom in women, more so in older people, with a significant impact on physical health and wellbeing. About 1 in 5 people have impaired continence. Symptom categorization at initial assessment is the key to guiding further therapy. Non-pharmacological options (bladder training for 6 weeks with guidance from a trained physiotherapist) are preferred and can be supported with biofeedback. If unsuccessful, anticholinergics are added and, rarely, surgical options need consideration.

Anticholinergics are the mainstay of pharmacological management of urge incontinence. The National Institute of Health and Clinical Excellence (NICE) recommends immediate release oxybutynin as the first-line agent, with recourse to others if there are adverse effects. The pharmacology, efficacy and adverse effect profile of the various anticholinergic drugs is reviewed, allowing the reader to make an informed choice of appropriate anticholinergics for urge incontinence.

Orthostatic hypotension (OH) is a clinical condition which frequently results in troublesome symptoms such as dizziness, giddiness, blurred vision and light-headedness. It is a common disorder associated with an increased risk of falling, especially in older individuals. OH is the presenting haemodynamic manifestation of several different and diverse underlying pathological conditions, including disorders of blood pressure (BP) regulation and disorders leading to reduced intravascular volume.

The importance of a specialist viewpoint on blood tests in elderly people and their interpretation was established by Hodkinson. He described the need for full investigation, the choice of suitable reference populations in old age, the difference in reference ranges between older and younger people and the effect of the special features of medicine in old age on appropriate testing strategies. In this journal, Rochman has discussed problems in chemical pathology interpretations in the elderly. This review builds on previous work by looking at recent papers relevant to biochemical and haematological investigations of practical relevance to the clinical medicine of old age. It is based on a Medline search combining sets of papers relating to specific investigations and clinical situations with those using the key word ‘elderly’. Added to these papers are others known to the author and colleagues.

Good communication between health and social care professionals and patients, their families and carers is recognized increasingly as integral to best management. Thus a central principle of the NHS Plan is that all patients should have open access to information about services, treatments and performance and should be treated as partners in their own care. Lack of information and poor communication is a common basis for complaints, and there is little evidence that older patients want any less information than those who are younger Certainly, if elderly people living with long-term illness, frailty or disability are fully informed, they will be better able to make appropriate decisions and actively participate in managing their own condition and their lives. In general, it is for professionals to provide the required information and support, or to direct people to other quality sources of evidence-based information, and not for them to decide whether or what should be disclosed.

Type 2 diabetes is a chronic progressive condition with a prevalence which rises with age. Its origins are believed to be multifactorial, and include genetic effects and environmental interactions, which may start in the uterus (with an association with low birth weight) and early developmental plasticity, resulting in compensatory growth through childhood and a tendency to abnormal glucose tolerance in adult life. The consequences are multi-systemic, with a combination of microvascular and macrovascular disease affecting multiple organs of the body. There is a high level of morbidity and mortality, typically accruing through adult life and into older age.

The current focus on dementia risks eclipsing other mental health problems of later life. While the National Service Framework for Older People (NSF) has highlighted depression as an important disorder meriting special consideration,1 anxiety and psychoses in older people remain difficult problems for practitioners to manage. This paper reviews the prevalence and impact, recognition, complexity and prognosis and treatment for these three clinical problems, and proposes a framework for ‘good enough practice’

Polymyalgia rheumatica and temporal arteritis represent opposite poles of a single disease spectrum. In the former, girdle stiffness predominates; in the latter, frank vasculitis is demonstrable. There is no diagnostic laboratory test for polymyalgia rheumatica, and earlier reviews in 1993 and 1998 in this journal both drew attention to the difficulty in diagnosing polymyalgia rheumatica, particularly in the elderly.