There are estimated to be more than 18 million people world-wide suffering from dementia and, on entering the twenty-first century, demographic projections suggest that there will be a significant growth in elderly populations due to decreasing infant mortality, improved public health and safety, medical advances, better education and housing and increased service provision. These population shifts will predictably lead to a greater demand on medical and welfare services.

Despite the fact that a sizeable proportion of the elderly population will at some time develop cognitive problems, accurate diagnosis is difficult due to the multiple pathology involved in these impairments. With the introduction of pharmacological treatments for cognitive impairments, the emphasis on establishing if people are suffering from a dementing illness is crucial. Furthermore, patients who are categorized as ‘subclinical’ cases of cognitive impairment often have an underlying risk for further progression. Although all clinical definitions of dementia stress that there must be evidence of intellectual decline, the most common being memory failure, there is confusion surrounding the nature of cognitive deficits in the three most commonly applied criteria for dementia – The International Classification of Diseases (ICD-10), The Diagnostic and Statistical Manual for Mental Disorders (DSM–IV) and the National Institute of Neurological Disorders and Strokes (NINDS), Association Internationale pour le Recherche et l’Enseignement en Neurosciences (AIREN).

For each person the experience of aging highlights special concerns: Will it be possible to be happy in later life? How can this goal be attained? Is it worthwhile striving to remain youthful, without taking advantage of the experience offered by other stages of life?

The availability of high-quality, evidence-based, clearly communicated, user-focused information is central to the new NHS. Reliable information empowers patients and their families and enables them to become more knowledgeable about their care and condition following consultation and diagnosis or before a therapeutic intervention. It is an integral part of clinical governance and the clinical risk framework.

Housing tenure takes a variety of forms, the most common of which are rental and owner-occupation. Currently, in the United Kingdom (UK), approximately 70% of older people live in owner-occupier properties, with the majority of the remainder renting from a public or private landlord. Research has consistently shown higher levels of morbidity and mortality among renters compared with owner-occupiers. However, it is unclear whether this is due to tenure acting as a proxy for other indicators of socio-economic status, such as income, which directly influences health, or whether other characteristics associated with tenure, including housing quality and location, explain the association. Untangling these competing influences of tenure on health is important, as it may provide clues on tackling health inequalities at older ages. Tenure too, appears to be related to the risk of long-stay care admission, with owner-occupiers significantly less likely to leave their home than renters; more work is required to identify why this is the case, as it may provide some insights on facilitating ageing in place.

Hypoxaemia is a common complication of stroke, and an association between adverse outcomes and hypoxaemia has been reported. However, it remains unclear whether hypoxaemia is the cause or just a sign of poor prognosis. While clinical guidelines unanimously recommend treatment of hypoxaemia after stroke, the guidance does not specify at what level of hypoxaemia treatment should be started. Recent evidence from a Swedish study suggests that overtreatment can also have detrimental effects on outcome. The aim of this review is to explore issues relating to hypoxaemia after stroke.

Continence is a basic function that should be maintained in healthy elderly people, regardless of age. Loss of continence should be interpreted as a dysfunction of either the lower urinary tract or bowel, or of some other system that participates in the maintenance of continence, especially the nervous system.

It is not easy to establish with any confidence the prevalence of drug misuse in older people. The issue is confounded by variations in definition of what constitutes ‘elderly’ and ‘drug misuse’, and by the types of sample used (Tables 1 and 2). There are few large-scale studies in the UK, and much of the information has been extrapolated from the American findings. The available information can be organized into four main areas:

The autonomic nervous system comprises the sympathetic, parasympathetic and enteric nervous systems and plays an integral role in homeostasis. This includes cardiovascular and temperature control, glucose metabolism, gastrointestinal and reproductive function and increasing evidence to support its involvement in the inflammatory response to infection and cancer. Ageing is associated with autonomic dysfunction, and many clinical syndromes associated with older adults are due to inadequate autonomic responses to physiological stressors. The aim of this review is to explore the relationship between autonomic dysfunction and ageing illustrated with examples of maladaptive autonomic responses in a variety of different clinical syndromes including an exploration of autonomic cellular changes. Appropriate investigation and management strategies are outlined, recognizing the fine balance needed to improve symptoms without creating further medical complications.

A previous review described the literature outlining the characteristics and special needs of older people using accident and emergency (A&E) services, the service initiatives aimed at meeting these needs, and the implications of the findings for UK policy and practice. The review identified a lack of clear evidence to guide the development of specialist services for older people attending A&E. In particular it was noted that there was a deficit of work in the UK context. This seemed, in part at least, to be based on ambivalence about the legitimacy of developing specialist services in the emergency department for this group of patients, despite the large numbers of older people attending. However, the paper also noted encouraging trends and a move away from a preoccupation with whether or not older people were appropriate A&E attenders, to a consideration of how best to meet the particular needs of this group, that paralleled past developments of specialist services for children.

In the UK it is established that health and social care services for people with dementia from black and minority ethnic communities need to move towards providing evidence-based culturally appropriate care. At present, however, the evidence base available to guide professionals working with people with dementia from diverse ethnic and cultural groups is limited, and beliefs about dementia and the type of treatment and support needed have received little attention. Consequently this creates problems for service providers faced with appropriately supporting people with dementia and their families from black and minority ethnic communities.

Research carried out in the 1950s and early 1960s indicated that there was considerable unmet need amongst older people in Britain. This work prompted research into ways of meeting the health care needs of older people, a task made more important by the aging of the population at the end of this century. This focus resulted in the introduction in 1990 of a nationwide health assessment programme for older people, as a contractual obligation for general practitioners. The programme, the first in the world, remains in force but is widely ignored. This paper describes:

Hyponatraemia is frequent in older people and induces marked motor and cognitive dysfunction, even in patients deemed ‘asymptomatic’. Nutritional status is worse than in euvolaemic-matched controls, and the risk of fracture is increased following incidental falls. Yet hyponatraemia is undertreated, in spite of the fact that its correction is accompanied by a clear improvement in symptoms. Both evaluation of neurological symptoms and classification by volaemia are essential for a correct diagnosis and treatment of the hyponatraemic elderly patient. The syndrome of inappropriate anti-diuretic hormone secretion (SIADH) is the most common cause of hyponatraemia in older people. Nutritional status and chronicity of SIADH should be taken into account when deciding therapy. We propose an 8-step approach to the management of the elderly patient with hyponatraemia.