Increasingly, the term ‘dignity’ is becoming a part of contemporary discussions of health care. Phrases such as ‘respect for human dignity’, ‘treatment with dignity’, ‘death with dignity’ and the ‘right to dignity’ are so commonplace as to have almost become clichés. This is especially so in the context of older people. In the UK, the NHS Plan uses the term ‘dignity’ on a number of occasions (Chapter 15 is entitled ‘Dignity, security and independence in old age’) and the National Service Framework for Older People explicitly mentions dignity in relation to person-centred care. However, practice has often failed to measure up to this much-cited aspiration.

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.

Although a reduced liver size in elderly people has long been recognized from post-mortem studies, these studies do not allow the separation of true ‘age-related’ differences from the effects of premorbid illness, and death. An age-related effect was confirmed however by an in vivo study which measured liver size by ultrasound scanning of healthy individuals. This demonstrated a significant negative correlation between age and liver volume, with volumes being 28% lower in individuals above the age of 65 compared with those under 40 years of age.

Disequilibrium is typically described as a feeling of dizziness when standing or walking that is not present while sitting or lying down. Since dizziness is such a common symptom in older people, the symptom may be dismissed as a normal aging phenomenon. On the other hand, the patient may be inappropriately given nonspecific treatment for dizziness such as meclizine or diazepam, which may worsen the condition, due to sedation.

The incidence of deep vein thrombosis (DVT) and pulmonary embolism (PE) increases with age and it has been reported to be higher in males. The annual incidence rates per 1000 for DVT and PE are 1.3 and 1.8 respectively for people aged between 65 and 69 years, rising to 2.8 and 3.1 respectively in those aged between 85 and 89 years. Older people are about eight times more likely to develop venous thromboembolism (VTE) in hospitals, nursing homes or other chronic care facilities. About 1.7% develop PE and 8% develop recurrent PE within one year of treatment for DVT. About 3% of patients with DVT and 21% of those with PE die in hospital. One year mortality with DVT is 21% and that with PE is 39%. The diagnosis of PE is often missed in older people and it is often detected only at postmortem.

The difficulty in making an accurate diagnosis of idiopathic Parkinson’s disease (PD) should never be underestimated. Just as the introduction of CT scanning and, more recently, magnetic resonance imaging has revolutionized general neurological practice and exposed the diagnostic inadequacies of the most experienced clinician, current understanding of the pathophysiology of the extrapyramidal system has advanced considerably, even in the last decade or two.

Liaison psychiatry, a term that is sometimes used interchangeably with consultation-liaison psychiatry, refers to the interface between psychiatry and general hospital patients and specialists. It involves psychiatrists’ intervention in the care of medically ill patients who present with psychiatric symptoms whilst in a general hospital setting. It may also involve assessment of patients who have pre-existing psychiatric illness or those who develop psychiatric symptoms because of their medical or surgical illness (e.g. coping with bad news).

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.

Stroke is particularly prevalent in older people and the effects of stroke can be profound. Not only are the abilities to stand, balance and walk affected, but also the ability to use the upper limb and hand in its diversity of functions in everyday life. Loss of independence of upper limb function contributes enormously to functional disability, affecting quality of life and independence in ‘basic’ (washing, grooming, feeding, dressing, etc.) and ‘instrumental’ activities (shopping, home/financial management, etc.) of daily living. A larger proportion of stroke patients with initial severe upper limb paresis are discharged to institutionalized care (63%) than are discharged home (37%).

Comprehensive geriatric assessment (CGA) has been defined as ‘a multidimensional, often interdisciplinary, diagnostic process intended to determine a frail elderly person’s medical, psychosocial, and functional capabilities and problems, with the objective of developing an overall plan for treatment and long-term follow-up’. Evidence from recent meta-analyses of clinical trials of the effectiveness of CGA programmes suggest that older persons may experience a variety of health benefits from these comprehensive services.