Dementia is a syndrome characterized by a progressive impairment in cognition, function and behaviour, with a considerable burden in terms of health and social care, and economic costs. As Alzheimer's disease and other dementias advance, the patient's capacity, competence and possibility of participation in decision-making decrease. Key points in managing people with dementia include screening of cognitive impairment, neuropsychological assessment, laboratory tests and neuroimaging, genetic tests, informed consent, inclusion in clinical trials and discussion of advance directives, driving, managing finances and testamentary capacity, pharmolocogical and non-pharmacological treatment and also palliative and end-of-life care. In this article we review these crucial points in decision-making for people with dementia and their families and caregivers.

There is a high prevalence of pain in older people. Optimal assessment and management of pain in this population is challenging. The pharmacokinetics and pharmacodynamics of analgesic medications are affected by ageing and frailty, as well as by intercurrent medical conditions and their treatments. This review describes what is currently understood about the impacts of old age and frailty on the clinical pharmacology of commonly used analgesics, to provide a rational basis for the use of these medicines. In view of the wide age-related inter-individual variability in pharmacokinetics and pharmacodynamics of analgesic medications, monitoring of clinical response and adverse effects is essential to optimize pain control in older people.

The search for the most appropriate, effective and efficient ways to care for vulnerable older people is an enduring one. Hence, the importance of research which seeks to explore how best to meet the needs of frail older people at the margins of care, whose care needs can therefore be appropriately met in more than one setting. The theme of balance of care has been a recurrent theme in the literature of long-term care and relates to ideas of optimality and efficiency in resource use and has been primarily, but not exclusively, applied to the care of older people. Interestingly, it is not a new concept but rather one which is implicit in policy relating to the care of vulnerable older people since the 1970s, although periodically it has risen to become more explicit. In this context it almost always relates to the relative priority accorded to services provided in the community compared to those provided in long-term care settings, such as care homes or hospital.

The heart failure epidemic predominantly affects older people, particularly those with concurrent co-morbid conditions and geriatric syndromes. Mortality and heath service utilization associated with heart failure are significant, and extend beyond the costs associated with acute care utilization. Over time, older people with heart failure experience a journey characterized by gradual functional decline, accelerated by unpredictable disease exacerbations, requiring greater support to remain in the community, and often ultimately leading to institutionalization. In this narrative review, we posit that the rate of functional decline and associated health care resource utilization can be attenuated by optimizing the management of heart failure and associated co-morbidities. However, to realize this objective, the manner in which care is delivered to frail older people with heart failure must be restructured, from the bedside to the level of the health care system, in order to optimally anticipate, diagnose and manage co-morbidities.

Because women die at an older age than men, and marry men older than themselves, widows outnumber widowers and the average woman can expect to survive her husband by five to six years. In fact, widows make up a substantial proportion of the elderly population. In this paper the current state of our knowledge of the reaction to bereavement in the elderly will be reviewed and its implications for the provision of services considered.

Two policy documents were published by the UK Department of Health in 2001 which established the service development agendas for their respective areas over the coming years. The National Service Framework (NSF) for Older People sets out national standards for ‘better, fairer and more integrated health and social care services for older people’ and ‘addresses conditions significant to older ages’ to promote ‘active and healthy aging’. The National Sexual Health Strategy identifies ways to ensure that that the sexual health of the UK population is maximized, predicated on the grounds that ‘our sexual health affects our physical and psychological well-being and is central to some of the most important and lasting relationships in our lives’. What is striking, if perhaps ultimately unsurprising, is that there is no overlap between the documents. The NSF for Older People makes no reference to sexuality or sexual health issues, and the National Sexual Health Strategy makes no reference to older people and, indeed, explicitly focuses on younger people, particularly through linking the prevention of sexually transmitted infections (STIs) with the reduction in teenage pregnancies.

The evidence regarding the association between mood and cognitive function is conflicting, suggesting the involvement of moderating factors. This systematic review aimed to assess whether cognitive reserve moderates the association between mood and cognition in older people. Cognitive reserve was considered in terms of the three key proxy measures – educational level, occupation, and engagement in cognitively stimulating leisure activities – individually and in combination. Sixteen studies representing 37,101 participants were included in the review. Of these, 13 used a measure of education, one used a measure of occupation, two used a measure of participation in cognitively stimulating activities, and one used a combination of these. In general, cognitive reserve moderated the association between mood and cognition, with a larger negative association between mood and cognition in those with low cognitive reserve than in those with high cognitive reserve. Further research utilizing multiple proxy measures of cognitive reserve is required to elucidate the associations.

Delirium is a common disorder in ill older patients, characterized by a fluctuating disturbance of consciousness and changes in cognition that develop over a short period of time. Studies have shown that delirium is an independent predictor of increased length of hospital stay, and is associated with increased dependency and mortality, as well as being distressing for patients and families. Much is known about the epidemiology of delirium, including predisposing factors such as pre-existing dementia and advanced age, and common precipitants such as infection, drugs and major surgery. In comparison, very little is known about the neuropathological mechanisms that lead to the development of delirium.

Introduction

Dementia is a syndrome which involves progressive disturbance of multiple cognitive functions, emotional control and social behaviour in clear consciousness (International Classification of Diseases, ICD-10).1 Alzheimer’s disease (AD) accounts for more than 50% of all dementias and hence is the most widely studied. Although Alzheimer’s first description of the condition included noncognitive features like hallucinations, delusions and screaming,2 most research has focused on the cognitive features, i.e. memory loss, perceptuo-motor skills and language disturbance.

Incontinence is a common and distressing condition of later life. Prevalence studies have reported rates of urinary incontinence from about 3% to 60%, depending on how incontinence is defined and the type of population studied. There is much less information about the prevalence of faecal incontinence. However, some studies have found approximately 2% of the general population and about 60% of the nursing home population to be incontinent of faeces. Although some studies have examined the impact of urinary incontinence on health status, the impact of faecal incontinence has not been investigated previously. Quantification of the prevalence and specific impact on health of common disorders such as incontinence will help commissioners and providers in the prioritization of diagnostic and therapeutic services for this distressing condition. With this in mind, we report the relevant results of the Tipping the Balance Survey, which quantified the prevalence and impact on self-perceived health, anxiety and depression of both faecal and urinary incontinence.

Adverse drug reactions (ADR) pose significant health-related problems for the older person. Many studies from around the world report a significant incidence of ADR in general and in elderly people in particular, resulting in an increase in drug-related morbidity and mortality. Older people appear to be particularly at risk of experiencing an ADR due to a range of factors, which include polypharmacy, altered drug pharmacokinetic profiles and pharmacodynamic responses, drug interactions and cognitive problems that increase the risk in this patient group. Certain drug classes, such as hypoglycaemic agents and cardiovascular active medicines, have been identified as common causes of ADR. Many studies suggest that the majority of ADR are preventable, so that several different approaches have been tried in an attempt to limit this problem, such as the use of computerized systems to communicate routine issues of patient care, interventions made by pharmacists, spontaneous reporting and continuous education of health care professionals. Whilst all have been shown to reduce drug-related events, identifying individuals at high risk of developing ADR at the point of prescribing by using a risk stratification model could improve the identification and prevention of ADR. This article discusses the clinical impact of ADR in older people and the relative merits of the various approaches tested to date before suggesting areas that require further research.

A recent international definition of under-nutrition or malnutrition has been given by the WHO. Mal-nutrition means ‘badly nourished’ but it is more than a measure of what we eat, or fail to eat. Clinically, malnutrition is characterized by inadequate intake of protein, energy, and micronutri-ents and by susceptibility to infection or disease. Nutritional status is the result of the complex interaction between the food we eat, our overall state of health, and the environment in which we live – in short, food, health and caring are the three ‘pillars of well-being’.

Although the prevalence of acute pain does not increase as a result of aging, chronic pain problems tend to increase in late life. There is also limited evidence that there is a plateau or even a slight reduction in the frequency of chronic pain following the eighth decade of life. Many health conditions that affect older adults are associated with pain, and overall prevalence estimates for this population range from 25% to 65% for community-dwelling older persons, and up to 80% for seniors living in long-term care facilities. The wide variation in prevalence estimates is likely to be due to differences in survey methodologies and operational definitions of pain (e.g. ‘pain during the last week’ vs. ‘pain during the last month’). Nonetheless, a consensus view appears to converge on the conclusion that at least 50% of older persons suffer from at least one persistent or bothersome pain problem at any one point in time. Although many seniors with dementia have difficulty reporting pain due to cognitive impairment, in a large-scale investigation of nursing-home residents, it was shown that conditions that are likely to cause pain occur with equal frequency in residents with and without dementia.

The population is ageing and the rights, welfare and wellbeing of this age cohort are becoming more globally prominent and the focus of much policy development. Whilst research is leading the way and informing this in many spheres of an older person's life, this is not the case for sexual health. Campaigns of sexual health literacy and intervention are targeted at ‘at-risk’ cohorts, largely ignoring those over 60 years of age. With increases in sexually transmitted infections (STIs) in this age group and the potentially serious nature of untreated conditions, this review highlights the need for increased research, health literacy and targeted interventions. Social, societal and physical barriers preventing older adults engaging with safer sex have been identified, highlighting the extent of the attitudinal and policy shifts required to provide age parity.