There comes a time in the lives of a minority of older people when the extent of their disabilities makes it impossible for them to continue living in their own homes. When this happens, long-term institutional care may be the only option. Given that most residents in long-term care are over 75 years old and that the numbers in this age group will increase into the next century, we can expect an increase in the number of people requiring long-term care.

The alarming statistics of dementia are now widely acknowledged. The most recent estimates indicate 24.3 million suffer from this condition worldwide, with a new case being diagnosed every seven seconds. For the person afflicted, it robs him of his identity and, in the opinion of many, even his personhood. For family members, bereavement can begin from the early stages of the disease where a once-treasured relationship is gradually eroded. Family carers remain the main persons providing care, having to face much emotional, practical and economic strain in the process. Although there is no standard definition of family caregiving, it is understood to involve providing extraordinary care, often outside the bounds of what is usual in family relationships. Caregiving typically stretches over a prolonged period and entails significant expenditure of time, energy, finances, and tasks that may be unpleasant, emotionally stressful and physically exhausting.

Being able to perform physically at a level which ensures a satisfying and independent life is taken for granted in youth, but it comes under threat as physical capabilities deteriorate with advancing age. An independent lifestyle requires muscle strength, muscle power, cardiorespiratory endurance, as well as balance and motivation. It used to be assumed that deterioration in these capabilities with the passage of time in later life was inevitable. Now it is clear that much of the deterioration is due to reduced levels of physical activity. This means that it can be reversed. If physical activity increases so do physical capabilities, even in extreme old age.

In this review, we analyse original research articles in English and Spanish in which fear of falling (FoF) as a long-term syndrome defines the participants, or is the main outcome, or in cases where FoF is a secondary outcome, falls or activity are the main outcomes.

FoF is difficult to measure. Attempts are made to do so by use of single questions or scales. Restriction in activity due to FoF is a secondary outcome and can be an important influence on a person's quality of life. There are also various methods of measuring it by use of single questions or scales, and general questions in basic or instrumental activities of daily living (ADL) indices are frequently used. Other scales or questionnaires about quality of life (such as the SF-36) or activity (such as the Survey of Activity and Fear of Falling Scales (SAFE), or the Groningen Activity Restriction Scale (GARS)) are also used. The varying objectives of the analysed articles explain some of the variations in measures used. Further work is required to reach a consensus on definition and standardized measurement of FoF and its effect on quality of life and activity.

What is palliative medicine?

In 1987, the Royal College of Physicians recognized palliative medicine as a specialty, defining it as ‘the study and management of patients with far-advanced disease for whom the prognosis is limited and the focus of care is quality of life’. In 1990, the World Health Organization added its definition, ‘the active and total care of a person whose condition is not responsive to curative therapy’. The aim of palliative medicine is to control pain and other physical symptoms, together with integration of psychological, social, spiritual care and support. The ultimate goal is to help patients to achieve their best quality of life. Palliative medicine places emphasis on a holistic approach, offering care and support not just for patients but also for their families. Palliative medicine hence requires an interdisciplinary team approach. With the co-ordinated efforts of all disciplines (such as doctors, nurses, therapists, social workers, clinical psychologists, dieticians, pastoral care workers and volunteers), patients can be supported in living their remaining lives as actively as possible, and families can be assisted in coping with illness, death and bereavement. Palliative care neither intends to postpone death nor does so, but affirms life and regards dying as a normal process. When a patient faces an incurable illness, it is incumbent on the palliative care team to provide the best treatment and care, adding life to days when days cannot be added to life.

Communication is integral to human life. During the communication process, an idea or concept is received by an individual either from another individual or from the physical environment. Person-to-person transmission of ideas could be through the medium of spoken/written language or through non-verbal media such as body language, gesture or facial expression. Ideas or concepts communicated from the physical environment allow the individual to function within that environment. For example, the concept of traffic must be understood, so as to allow safe and effective day-to-day functioning, whilst comprehension of the concept of a CD player could allow the individual to acquire appropriate auditory stimulation for relaxation and enjoyment.

Despite the growing recognition of the importance of housing for the health and well-being of elderly people there has been less research on the topic than on health or personal social services. Moreover, until recently, what research there was tended to concentrate on specialized, rather than mainstream, forms of housing. This review looks at research on the meaning of home; the kind of housing elderly people live in; tenure; specialized and nonspecialized housing; some issues to do with an assessment of needs; and at links between services. The very important related topic of moving in old age is not covered because this was the focus of a recent review in this journal. However, it is relevant to note that research shows that many people move into specialized housing against their will and wish that they could have remained at home. This review also excludes consideration of other related topics such as household composition, affordability, the contribution of technology such as alarms and ‘smart’ houses, and problems of specific groups, such as those who are homeless.

As the mean life expectancy of the population continues to increase, the challenge for individuals is to remain healthy and fit throughout their life span. This review examines the relationships between moderate-vigorous physical activity and sedentary behaviour in relation to the fitness-frailty continuum. The association between increased physical activity and decreased adverse health outcomes is firmly established. A direct association between frailty and moderate-vigorous physical activity has been established to a lesser degree. What has some potential to undermine even these gains is the increasingly recognized relationship between sedentary behaviour and poor health. It now seems likely that sedentary behaviour can have a negative impact on an individual's health, over and above that of meeting the recommendations of moderate-vigorous physical activity. Individuals must consider both increasing their level of moderate-vigorous physical activity and minimizing their level of sedentary behaviour during all aspects of daily life.

In the past, most amputees have been veterans of war or other younger people who have sustained traumatic injury. There are now an increasing number of older people undergoing lower-limb amputation, most commonly because of vascular problems. Anecdotal evidence suggests that there is a lack of support for patients facing limb amputation, and a lack of recognition from staff that these patients may be at risk of ongoing psychological problems following the procedure.

Faecal incontinence in older people is a distressing and socially isolating symptom and increases the risk of morbidity, mortality and dependency. Many older individuals with faecal incontinence will not volunteer the problem to their general practitioner or nurse and, regrettably, health care providers do not routinely enquire about the symptom. Even when older people are noted by health care professionals to have faecal incontinence, the condition is often managed passively, especially in the long-term care setting where it is most prevalent. The importance of identifying treatable causes of faecal incontinence in older people, rather than just managing passively, is strongly emphasized in national and international guidance, but audit shows that adherence to such guidance is generally poor. This article describes epidemiology, causes, assessment, diagnosis and treatment of faecal incontinence in older people.

The clinical diagnosis of Alzheimer's disease (AD) involves neuropsychological testing to assess the integrity of higher order cerebral functions such as memory, cognition, visual perception, language and executive function. However, the onset of AD is insidious and diagnosing the very early stages may be precluded as such tests may lack the necessary sensitivity and specificity. This, together with the potential for similar shortcomings in relation to assessing disease progression and response to treatment, has prompted the search for disease markers based on abnormalities in additional aspects of brain processing. One area receiving increasing investigation is the integrity of visual and visual-attention-related processing.

People with dementia are particularly vulnerable to abuse. It is inherently difficult to study as it is a hidden offence, perpetrated against vulnerable people with memory impairment, by those on whom they depend. In the general population, 6% of older people have experienced abuse in the last month and this rises to approximately 25% in vulnerable populations such as people with dementia. We know that various factors in the carer and the care recipient can predispose to a higher rate of abuse and this knowledge can be harnessed to try and improve prevention. There are also valid and reliable scales available to help detect abuse in vulnerable older adults. All health and social care professionals have a responsibility to act on any suspicion or evidence of significant abuse or neglect in order to ensure that appropriate management is taken.

The National Service Frameworks for Older People and for Mental Health are setting standards for services in areas where problems are complex and solutions limited. Primary Care Trusts seeking to raise the quality of primary care for older people and commission specialist services rationally face many challenges. Specialists in old age medicine and old age psychiatry will find themselves working closely with primary care practitioners to develop services and extend professional skills, for it is uncertain that specialist services will be able to deal with the scale of the clinical and social problems unaided.

Alcohol use is common in older adults and is associated with numerous health and social problems. Recent evidence suggests that in addition to level of alcohol consumption, drinking pattern may also be important. Moderate alcohol intake may confer some cardiac benefits, while heavy episodic drinking seems particularly problematic. Detecting alcohol misuse in older adults is difficult since clinical acumen is often poor, screening questionnaires have serious limitations and laboratory tests are not diagnostic. Brief alcohol interventions to reduce alcohol consumption appear useful in younger populations, but are less studied in older adults. While there is increasing research into the issue of alcohol use among older adults, clinicians and policy-makers must rely on limited evidence when making clinical decisions.

Human sexuality is a complex interaction of biological, social and emotional factors. When any or all of these factors are disrupted by a progressive dementia it is unsurprising that sexual ‘problems’ are identified. Most sexual behaviour ‘problems’ relate to expressions of normal sexuality complicated by changes in relationships, care needs and cognitive function, and complex ethical and legal considerations emerge. Rarely, new and severe hypersexual or paraphilic behaviours arise de novo, usually due to damage to certain brain areas, and sometimes due to medication side-effects, psychiatric disorder or delirium. Evidence and approaches to assess and to manage sexual behaviour problems in dementia are discussed.

Cognitive impairment has been recognized as a risk factor for falls and for increasing the severity of injury following a fall, but the mechanisms by which cognitive impairment influences gait and postural control have been unclear. A recent report that galantamine improves gait parameters in older adults may help to untangle this.