The increasing prevalence of complementary and alternative medicine (CAM) use is a significant health care issue in contemporary societies and researchers have identified CAM as holding potential for treating and coping with chronic illness and other conditions experienced in later life. This paper focuses upon contemporary research literature to provide a critical review of the prevalence, correlates, conditions, perceptions and communication of CAM use in later life. Evidence from recent research illustrates the substantial prevalence and complexity of CAM use amongst older people and such ‘community’ use requires all providers, regardless of their experience or perception of the worth of CAM, to at least acknowledge and enquire with their older patients about the potential use of these other medicines.

The problems of undernutrition, weight loss and feeding difficulty are more prevalent in elderly people than in their youngercounterparts and are particularly prevalent in patients with dementia. These aspects of dementia challenge several members of the multidisciplinary team caring for elderly people with dementia, including geriatric and psychogeriatric physicians, dietitians and nurses.

Driving: a new geriatric giant?

Over the last fifty years geriatric medicine has promoted the concept that functional loss in older people is primarily a health issue. For a major loss of function, such as incontinence or immobility, we recognize the need for detection, investigation and treatment. The diagnostic / therapeutic / rehabilitation paradigm takes precedence over the prosthetic approach. Not only do we appreciate the benefits of an interdisciplinary assessment, but we are also accustomed to estimating risk and competence when making decisions about discharging frail older people back to their home environment.

Falls are predominantly a problem of older people. In the UK, people over 65 currently account for around 60% of admissions and 70% of bed days in hospitals. There are approximately half a million older people in long-term care settings – many with frailty and multiple long-term conditions. The proportion of the population over 65 years is predicted to rise 25% by 2025, and that over 80 by 50%, with a similar increase in those with dependence for two or more activities of daily living. Despite policies to drive care to the community, it is likely that the proportion of older people in hospitals and care homes will therefore increase. Accidental falls are the commonest reported patient/resident safety incidents. Similar demographic trends can be seen in all developed nations, so that the growing problem of fall prevention in institutions is a global challenge. There has been far more focus in falls-prevention research on older people in ‘community’ settings, but falls are a pressing issue for hospitals and care homes, and a threat to the safety of patients and residents, even if a relatively small percentage of the population is in those settings at any one time.

Older people in residential or nursing care may have needs comparable with those of a healthy person living in the community, compounded by additional health-care needs. Sexual needs can be ignored or pushed into the background, with barriers created to their expression and satisfaction.

Delirium is a distressing but preventable condition associated with increased morbidity and mortality, and significant financial costs. Most research on delirium has focused on high-risk patients in hospitals. Another group also at high risk are residents in care homes for older people. This report reviews the literature on the occurrence, aetiology, outcomes, prevention and treatment of delirium in long-term care. Delirium appears to be common in this setting, with a median point prevalence estimate of 14.2% in studies comparable to the UK. However, there is a paucity of high-quality studies, likely to reflect the difficulty in conducting research in this population and the particular challenges of investigating delirium. Addressing delirium successfully in care homes presents an opportunity to improve care standards and to reduce inequalities in health and social care. Well-designed prospective cohort studies and robust evaluations of interventions to prevent and treat delirium are needed.

Over the last three decades there has been a change in attitude to the care of patients after stroke from a somewhat nihilistic stance to a predominantly acute focus with potential for rehabilitation. More recently there has been a widening of perspective, with recognition that stroke is a long-term condition. Aligned with this has been a gradual shift in focus from a primarily biomedical approach to stroke care, to one that considers the psychological and social elements of the poststroke experience. However, the evidence base for stroke is still dominated by prevention and early-care treatments: only eight of the 238 recommendations reported in the UK national clinical guidelines for stroke specifically address longer-term management. The Australian clinical guidelines for stroke offer a similar pattern: 22 (14%) of 162 recommendations relate to community participation and organization of longer-term support. However, ongoing research efforts to develop and evaluate interventions for longer-term stroke care are beginning to address the imbalance in the evidence base. In our previous review, surveys reporting the types and prevalence of longer-term problems experienced after stroke were summarized and synthesized within a structured framework. The review demonstrated the complexity and diversity of the longer-term stroke experience, and highlighted the challenges that support services face in meeting the needs of patients and carers living with the aftermath of stroke. Keeping abreast with this challenging subject area is key to promoting the continued development of stroke services. This review is an update of our previous work, presenting the most recently published data on the prevalence of longer-term stroke-related problems.

Research shows that approximately one in three people over the age of 65 years falls in any one year, with approximately one in three falling again in the following year. Prevalence of falls also increases with age, and women are more likely to fall than men. However, in advanced old age the ratio of men and women fallers reaches equal proportions.

‘When I use a word, it means just what I choose it to mean’. So it is with rehabilitation, except that several definitions and explanations have been proposed. Although the similarities between the definitions are considerable and far eclipse any differences, the perceived diversity of view has contributed to confusion over the purpose and process of rehabilitation. Is it ‘elderly care’? Is it ‘therapy’? Is it ‘post-acute’ care? The apparent ambiguity and the intangible qualities of rehabilitation contrast with the concrete ‘ologies’ of contemporary organ-based medicine and contribute to its vulnerability in our modern general hospitals. Pressures caused by rising emergency admissions and cost-driven bed closures have necessitated steadily reducing lengths of stay and rehabilitation, as a less visible component of care, has tended to be squeezed out. Paradoxically, the consequences of the ‘sicker and quicker’ discharge approach, with fresh burdens placed on community health and social services, have drawn attention to rehabilitation as a missing ingredient. We have now entered a phase of rediscovering at a strategic policy level the rehabilitation needs of older people but redefined in new terminology as ‘recuperation’ or ‘recovery’ This article will describe the core concepts of rehabilitation for older people and set the scene for forthcoming articles addressing specific rehabilitation topics.

Inflammation is an innate immunological response that fends off or repairs injuries caused by foreign agents as part of an essential defence mechanism. There are two main classifications of the inflammatory process, based on its intensity and time-dependent responses: an acute, rapid response with resolution or a low-grade, chronic process without resolution. In this review, the latter case of a long sustaining inflammatory process is discussed in relation to aging. Many epidemiological and experimental studies in recent years report on the age-related activation of inflammatory processes by showing age-related increases in the activities of many pro-inflammatory mediators such as, NFkß, TNFα, IL-1, IL-6, C-reactive protein (CRP), thromboxane A, adhesion molecules, and free fatty acids.

The daily clinical practice of geriatric medicine is a grapple with complexity. The elderly patients who come to geriatricians typically have multiple, interacting, age-related physiological impairments, some of which manifest as medical problems. These interact with various social vulnerability factors to put them at risk, and to define them as being frail. This view of frailty, as a multiple-determined state of vulnerability has broad support, but how best to operationalize frailty is rather more controversial. Some of the proposed operational definitions receive more widespread support than others. In particular, the ‘phenotypic’ definition of frailty used in the Cardiovascular Health Study (CHS) has been endorsed at consensus conferences and employed by several groups. Indeed, it has even been claimed that ‘the terms “frail” and “frailty” should be avoided except when used in the context of a CHS assessment.’

Optimal prescribing is critical to the goals of geriatric medicine of curing disease, eliminating or reducing symptoms, and improving functioning. However, prescribing decisions in older people are often complex. There is marked heterogeneity in health status and functional capacity amongst older people, who range from fit, active, independent individuals to those who are physically and mentally frail, with limited physiological reserve. Age-related changes in physiology affect drug pharmacokinetics and pharmacodynamics, and together with various pathological processes, increase the risk of adverse drug events (ADEs). This risk is heightened by prescription of multiple medications to treat multiple co-morbidities. Consequently, balancing safety and quality of prescribing for older people with appropriate treatment of all co-morbidities can be challenging.

The debate surrounding what has been termed in the literature as relocation stress, transplantation shock, transfer trauma, and pure relocation effect has fuelled academic interest and research over the last half century. Coffman’s review of both published and unpublished data on 26 groups of relocated individuals highlights the breadth of equivocal evidence of mortality post-relocation. Although his review found no general relocation effect, research on the effects of relocation are still found to be ambiguous and contradictory, and its causative or other link to physical and mental health and mortality measures are unclear. In the United States there have even been legal moves (i.e. O’Bannon v. Town Court Nursing Center, Inc.) to persuade courts that relocation ‘should be a legally recognized phenomenon invoking judicial protection against transfer.’

Transport is the invisible glue that holds our lives together, an under-recognized contributor to economic, social and personal well-being. In public health terms, the medical profession had previously allowed itself to focus almost exclusively on the downsides of transport. However, the research basis for transport, driving and ageing is steadily evolving and has important academic and practical considerations for gerontologists and geriatricians. For gerontologists, teasing out the critical role of transport in the health and well-being of older people is an imperative, as well as the key challenges inherent in transitioning from driving to not driving. The safe crash record of a group with significant multi-morbidity allows us to focus on the remarkable strategic and adaptive skills of older people. From a policy perspective, strictures on older drivers are an exemplar of institutionalized ageism. For geriatricians, a key challenge is to develop strategies for including transportation in our clinical assessments, formulating effective strategies for assessment of medical fitness to drive, incorporating enabling techniques, giving due consideration to ethical and legal aspects, and developing and promoting multi-modality and alternative transportation options.

Current guidelines in stroke management are divided on the issue of providing further rehabilitation to stroke patients who have had stroke six months ago and longer. Whilst consensus considers that long-term rehabilitation is neither practical nor beneficial, rehabilitation remains vital in the complex management of longer-term stroke care, as it provides continuity from the formal rehabilitation intervention in the hospital setting. Longer-term rehabilitation is principally a community-based intervention, as it aims to assist the survivors to become more independent through social and leisure-based interventions. Available evidence is limited, with available studies heterogeneous and small in sample size. This review aims to look into the existing evidence, and discusses the feasibility and challenges in providing longer-term rehabilitation to stroke survivors.

This review summarizes research into the phenomenon of patronizing speech addressed to older people by doctors, nurses, health professionals and other carers. Patronizing speech is defined and illustrated and its negative impact on the dignity and well-being of older people described. Key empirical and theoretical perspectives of patronizing speech are reviewed. Different aspects of the practice are examined and practical recommendations made for how it can be recognized and avoided. The beneficial effects of training and education of health professionals are discussed.