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.

Two previous publications by the author in Reviews in Clinical Gerontology have dealt firstly with the background physiology of exercise and secondly with the benefits to health of regular exercise across a wide spectrum of diseases and disabilities in older people. This article assumes that the reader is familiar with these reviews. A useful recent report focusing on coronary heart disease, diabetes mellitus and arthritis summarizes recommended physical activities for various age groups and conditions.

Meta-analyses of randomized controlled trials have reported the efficacy of dose-adjusted warfarin therapy (target International Normalised Ratio (INR) 2–3) in reducing stroke risk in atrial fibrillation by 68%, with aspirin reducing relative risk by 22%. Absolute benefit for an individual patient depends on the presence of the risk factors for stroke; these include previous stroke, transient ischaemic attack, hypertension, diabetes, valvular heart disease, heart failure and advanced age. In spite of reported benefit, many people with atrial fibrillation and a high risk of stroke are not receiving anticoagulation: disappointingly, risk stratification is not being sufficiently used to guide treatment.

Orthostatic hypotension (OH) is defined as a systolic blood pressure (SBP) drop of at least 20 mmHg, or a diastolic blood pressure drop of at least 10 mm Hg within three minutes of standing from a supine position. It can be symptomatic or asymptomatic and is a common condition that can affect up to one in three older people living in the community. The prevalence is higher amongst those with Parkinson's disease and, unsurprisingly, amongst those attending a syncope clinic. The aetiology and pathophysiology of OH have been comprehensively discussed in a previous article in this journal.

Bleeding in elderly patients is most commonly due to an underlying structural problem or an acquired coagulopathy. Occasionally, previously asymptomatic congenital bleeding disorders may present at an advanced age. When considering the possible causes of a clinical bleeding problem, the coagulation cascade is still a good starting-point. However, it is important to realize that the traditional model of the coagulation cascade has been superceded by the concept of a ‘coagulation network’. This updated model recognizes the importance of tissue factor in the initiation of coagulation. Despite the complexity of this model, the basic coagulation tests can still be interpreted in relation to the ‘intrinsic’, ‘extrinsic’ and ‘final common pathway’ components of the old-fashioned cascade (Figure 1).

Osteoporosis is defined in adults as having a bone mineral content at the lumbar spine or hip of more than 2.5 standard deviations below the expected mean for the healthy young sex-matched population (WHO criteria). Osteoporosis and consequent fragility fractures are common problems, increasing in frequency with age. Several classes of drug of proven value in reducing the risk of osteoporotic fractures are now available. This review will examine how the evidence that treatment of osteoporosis reduces fracture risk applies specifically to older people, particularly those over 70 years of age.

Old people are a growing minority. They comprise approximately 12% of the UK population, but consume an increasing proportion of health care resources. Gastrointestinal (GI) disorders are the third most common reason why patients over 65 years seek primary care advice, and 40% of these consultations relate to the upper GI tract.

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.

Airflow obstruction is common in older persons but frequently under-diagnosed. The term refers to a spectrum of chronic respiratory disorders characterized by cough, dyspnoea, mucus hypersecretion, wheeze and impaired pulmonary function tests. Patients may be diagnosed as having late-onset asthma, chronic obstructive pulmonary disease (COPD), chronic bronchitis, emphysema or fixed airflow obstruction of the elderly.

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.

Severe dementia is associated with frequent psychiatric and behavioural disturbances in addition to marked cognitive and functional deficits. Research to determine a neurochemical understanding of dementia over the last three decades has generated therapeutic strategies which improve patients' cognition and activities of daily living. Different key dementia syndromes have been shown to have distinct neurotransmitter biochemical patho-logy, with important implications for therapy. The current review focuses predominantly upon excitatory neurotransmitter systems.

Dizziness is one of the commonest symptoms described by older people and is associated with balance disorders, functional decline and falls.

Elder neglect and abuse is a widespread, largely undiagnosed and often ignored problem in our society. However, recently elder abuse has gained increasing recognition as a significant problem, meriting the attention of both clinicians caring for older people and society at large. Its occurrence in differing forms throughout the world has been highlighted as part of a recent WHO report about violence and health. In the United Kingdom, the House of Commons Health Committee has inquired into elder abuse and published its report and recommendations in April 2004. Concurrently with this rising public interest, there is a slowly developing body of scientific work on the subject. Although, much of the research has been criticized for significant scientific flaws, recent work has been more rigorously designed, tending to use standard case-definitions and scientifically acceptable research methods.

This review is the first in a three-part series on substance problems in older people. This section reviews terminology, epidemiology, outcome studies and policy directions. Subsequent articles will provide an overview of assessment, physical and psychological co-morbidity, as well as treatment options.

Over recent years, small-vessel cerebrovascular disease has become increasingly recognized as an important contributor to cognitive and functional decline in elderly people.

The care of older people to the end of this century and beyond presents a unique challenge to medicine and the rest of society. There is need for careful analysis and evaluation of our responses to this challenge.

In the UK, research continues to confirm that people with certain chronic illnesses, such as chronic lung disease and cardiac failure, represent the ‘disadvantaged dying’ compared to those with terminal cancer. But what is the situation for people dying with advanced dementia and what is the experience of their carers? Practical guidance for clinicians is scarce. In Standard 7 of the National Service Framework for Older People, which covers mental health, there is mention neither of how care should be provided nor of how patient choice should be ensured for people with dementia at the end of life. In the UK, 5% of the population aged 65 and over and 20% of those aged 80 and over have dementia similar prevalence figures are found in the USA. Current predictions suggest that the number of people with dementia will increase by 40% by 2026 and will double by 2050. The increased demand for end-of-life care for people with dementia will be associated with major social and economic costs, but what is the current standard of such care? How can the quality be improved? And how should future services be configured to cope with this increasing need? In this paper, we review current knowledge around end-of-life care in dementia, discuss the clinical challenges and ethical dilemmas presented to carers, consider the difficulties in delivering such care and suggest practical approaches to improve the quality of such care.

‘Syncope’ is derived from the Greek words ‘syn’ (meaning ‘together’) and ‘koptein’ (meaning ‘cut’). It is a syndrome characterized by transient loss of consciousness resulting from temporary and self-limited cerebral hypoperfusion, most often the result of systemic hypotension.

It is generally accepted that the study of human aging and the health-care needs of older people should form part of the undergraduate medical curriculum. This view was supported by policy documents from the World Health Organization, the Royal College of Physicians of London and the General Medical Council. Surveys in the 1980s showed that geriatric medicine was being taught in almost all medical schools, most commonly by a compulsory attachment to a hospital-based department of geriatric medicine.

The purpose of this review is to discuss how healthcare professionals, and particularly nursing practice, impact upon pain management with older people (65 years and over), following surgery. The review commences with an introduction presenting why this is an important area to consider. Current available literature and findings from an ethnographic study which was designed to examine peri-operative pain-management practices with older people will then be discussed to highlight the key issues of pain assessment and management. Three overarching themes; (1) pain assessment (2) knowledge/strategies to cope with pain and (3) organization of care (culture and context), will guide the discussion. It is suggested that comprehensive pain assessment, proficient communication and multidisciplinary working, are essential to improve pain-management practices. The paper demonstrates some of the multiple and complex factors that affect the older person's pain experience and identifies possible developmental work in this field.