The increase in the ageing population has generated much interest and research into what constitutes normal ageing. By identifying normal ageing processes it is hoped it will be possible to distinguish risk factors for the development of abnormal or premature ageing.

This review discusses biological, structural and mechanical changes in the cardiovascular system with ageing that are thought to increase the risk of cardiovascular disease with ageing. Contributory factors are thought to be genetic and lifestyle related. Measurements of biological as opposed to chronological ageing such as vascular stiffness are explored as a possible useful predictor of cardiovascular morbidity and mortality, indicating its possible utilization as a non-invasive screening tool in older people.

The identification of those at risk of cardiovascular disease and modification of risk factors may minimize interactions of the ageing process and therefore reduce the incidence of cardiovascular disease within the UK population.

Ageing is associated with multiple changes in many different components of the immune system. A healthy immune system exists in a state of balance between efficient effector responses against pathogens and tolerance to self antigens. This balance is changed with age; functions such as antigen recognition, phagocytosis, antigen presentation, chemotaxis, cytokine secretion and killing ability are all compromised. Aberrant cellular responses lead to an altered cytokine network with increases in inflammatory cytokines and decreases in anti-inflammatory cytokines leading to a pro-inflammatory state. Consequently older patients require extra care in diagnosis of infections as symptoms may be perturbed, resulting in unusual presentations of common conditions. The defects in immunity due to immunosenescence also mean that older patients require more care and screening than other patients in the same disease cohort. Though it is generally understood by clinicians that older patients are more at risk from multiple infections, the wider clinical effects of immunosenescence are less understood. The immune system is involved in several neurodegenerative conditions and the inflammatory conditions of immunosenescence may be a key factor in pathogenesis. Similarly, there is reason to believe that immunosenescence might be a key factor explaining the increased incidence of cancer in older age. With increasing understanding of the immune system's involvement in many of these pathological processes, and the contribution that immunosenescence makes to these, more efficient vaccines and novel therapies may be developed to prevent/treat these conditions.

Stem cells are a potential means of tissue regeneration in the brain that hold promise for treatment of the large number of stroke survivors who have permanent disability. Animal studies with stem cells derived from many different sources indicate that cells can migrate to the site of ischaemic injury in the brain, and that some survive and differentiate into neurones and glia with evidence of electrical function. Cells additionally promote endogenous repair mechanisms, including mobilization of neural stem cells resident within the adult brain. Whether the behavioural benefits seen with stem cell administration in rodent models reflect enhanced endogenous recovery or tissue regeneration is unclear. Production of stem cells to clinical standards and in quantities required for clinical studies is technically challenging. To date only a handful of patients have been involved in preliminary clinical studies of cell therapies for stroke, and there are therefore insufficient data to draw conclusions about either safety or efficacy. Further trials with several cell types are ongoing or planned, including neural stem cells, and bone marrow-derived stem cells and endothelial progenitor cells.

The ‘take home’ messages for managing elderly patients with symptomatic carotid disease are that they need to be investigated as soon as possible after onset of the index event and that someone has to take active responsibility for ensuring that risk factor control and best medical therapy is started as soon as possible. In this modern era, patients suffering a transient ischaemic attack/minor stroke should be seen in dedicated, rapidly accessible single visit clinics, and those found to have significant carotid disease should generally be admitted and undergo expedited carotid endarterectomy (CEA) unless contra-indicated. Every centre should now aim to be performing carotid surgery within 14 days of onset of symptoms, with this threshold likely to become even shorter in the future. The current culture of allowing delays to treatment should be considered unacceptable. Evidence suggests that the risk of procedural stroke is lower in higher volume centres and this should be considered when planning referrals. Recently symptomatic elderly patients deemed unfit for CEA should be considered for carotid artery stenting (CAS), but with the caveat that this may be associated with an increased risk of procedural stroke. In this situation, every patient should be considered on an individual basis and no symptomatic patient should be denied access to surgery simply on the grounds of age. Meta-analyses of data from the international trials have clearly shown that patients aged >75 years gain considerably more benefit from CEA than any other age group. In contrast, there is no compelling evidence that patients aged >75 years with asymptomatic carotid artery disease benefit from CEA or CAS. For this category of patients, risk factor control and best medical therapy should remain the first line of management.

The complexities of defining what appears to be the relatively simple concept of resilience are widely recognized. This paper analyses the concept of resilience from a range of disciplinary perspectives and clarifies a definition in order to inform research, policy and practice. The work takes a life course approach to resilience, examining evidence derived from research across the lifespan. It incorporates the methods of systematic review, concept analysis and consultation through face-to-face meetings. The synthesis of methodological approaches enables a clear identification of the antecedents, defining attributes and consequences of resilience, validated with stakeholder partners. Through this process, resilience is defined as the process of effectively negotiating, adapting to, or managing significant sources of stress or trauma. Assets and resources within the individual, their life and environment facilitate this capacity for adaptation and ‘bouncing back’ in the face of adversity. Across the life course, the experience of resilience will vary. A large proportion of resilience research is routed within the discipline of developmental psychology, and has mainly been developed with children and adolescents. A major contribution to resilience research could be made through more multi-disciplinary studies that examine the dynamics of resilience across the lifespan, its role in healthy ageing and in managing loss, such as changes in cognitive functioning.

There are inadequate data to formulate evidence-based guidelines on cardiovascular medication and falls. A critical systematic review of medication as a risk factor for falls concluded that there was a weak association between drugs that reduce blood pressure and falls. The population studies reviewed, looking for an association between cardiovascular drug usage and falls, consisted of subjects who were much younger and who had a much lower drug burden when compared with the older clinic population. The magnitude of the effect of cardiovascular medications on falls may therefore have been underestimated in these studies.

Two observational studies in falls clinics showed significant reductions in falls and syncope following withdrawal of cardiovascular medication, with improvements in symptoms, in tilt-table parameters predictive of syncope, and in measures of gait and balance.

There are no randomized controlled trials of the effect of cardiovascular drug withdrawal on falls. An expert audience of 200 members attending the 2009 British Geriatrics Society Falls Section Conference held the unanimous opinion that cardiovascular medications were a significant cause of falls in older people.

Populations throughout the world are ageing, with the oldest old the most rapidly growing segment of society. Caring for this ageing population, some of whom have multiple chronic and disabling diseases, will be challenging to healthcare systems. Current training programmes are generating relatively low numbers of geriatricians, largely because students and residents lack interest in a career in geriatric medicine. Therefore, specialists in geriatric medicine cannot directly provide care for all older people. There is a responsibility to ensure that successful practices and essential skills are shared.

Here we explore negative attitudes towards geriatric medicine and contrast these with factors motivating change. Educational theories are discussed to investigate how processes of learning and the personal development of students can be optimized. An understanding of geriatric medicine is important for undergraduates, postgraduate trainees in geriatric medicine, general practitioners and allied health professionals. The different challenges presented by each group are reviewed, accompanied by recommendations to enhance learning and examples of effective teaching practices.