It is frequently observed that medical treatments are evaluated in patient populations which have characteristics significantly different from those of patients upon whom the treatments will be used once established in clinical practice. The most striking illustration of this has been the almost complete exclusion, until recently, of elderly patients from trials of new medication. Whereas clinical trials include younger adults with a single pathology, the real world of patient care is dominated by older adults with multiple pathology.

There are two black boxes. One is Pandora's, stuff of myth and legend, and remembered for releasing into the world all its cares and troubles, leaving only hope behind in the bottom of the box. The other, more recent and less mythical, is the in-flight recorder, used to monitor the events in an aircraft's flight, for later analysis in case of difficulty. Both these boxes have their analogy when we consider the role and current state of rehabilitation research in physiotherapy.

Geriatric medicine started in long-term care, when the pioneers in the emerging specialty examined the inhabitants of the Victorian workhouses to discover elderly, largely ignored, yet eminently treatable patients. They focused attention on the then taboo subjects of incontinence, dementia and immobility. They developed a paradigm which entailed a proper assessment and, where appropriate, rehabilitation. This empirical process was central to their evident success, and achieved a reduction in unnecessary institutionalization by restricting long-stay care to those who could not, after full assessment and treatment, be discharged. The concept of progressive patient care developed, to make best use of somewhat meagre facilities. Day hospitals spread nationally, and outreach teams developed. Respite care schemes provided support to the huge numbers of informal carers, by sharing the load with the hospital service.

Distinguishing between health and social aspects of institutional care for frail elderly people remains confusing and contentious in the UK, even though health and community care reforms specifically sought to avoid such problems. Nursing home care in the UK has developed rapidly to 170 000 nursing home beds. Nursing home care now costs significantly more than the total committed to primary care. Some health authorities maintain a large commitment to long-term care provision in hospitals and contract nursing home beds; others have divested themselves of providing long-term care, becoming dependent on means-tested nursing home care provided by social services. Where 'free' health service contract nursing home beds are adjacent to social services means-tested placements the inconsistencies become even more perverse. Distinguishing between health and social patients/clients/supplicants on the basis of health or social care need is often impossible. Health Service responsibilities to support care home residents will become more onerous as cost pressures define the limits of social care for individuals and social services producers alike. There is, in addition, an unresolved tension between the professions associated with the care of elderly patients, who are seeking clear standards, and the hostile purchasing environment which fails to value the cost benefit, let alone the health gain of planned care management in deference to the Mammonism of treatment episodes.

Introduction

Aging is a detrimental, progressive process that affects all human beings fortunate to live long enough. This indistinct process renders an individual increasingly susceptible to disease, disability and death. For this reason, aging is expensive, both personally for an individual and financially for society as a whole. Aging is probably the result of damage to several different mechanisms. There are numerous potential contenders, one of which is the involvement of mitochondria. Harman in 1972 was one of the first to suggest that mitochondria may have a central role in aging. Linnane in 1989 proposed that the accumulation of mitochondrial DNA (mtDNA) mutations during life is a major cause of age-related disease. With the explosion of molecular biology in the last decade, our understanding of mitochondrial aging has advanced, raising many questions as to if and how mtDNA mutations may be involved in aging.

Reports on the death of the district general hospital (DGH) are premature. Despite frequent predictions of doom these hospitals are in good shape and over the years have shown a continuing readiness to adapt to changes in medical practice, technological advances and political fashion. The development of community services is not a threat to the DGH, but rather an opportunity to evaluate carefully what the DGH does best.

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.

Current knowledge suggests that parental age has many influences on offspring. This topic has been exhaustively reviewed in Finch's monograph. The major maternal age-related changes in humans are increases in fetal aneuploidy later in reproductive life; Down's syndrome (trisomy 21); Kleinfelter's syndrome (XXY); Edward's syndrome (trisomy 18); and Patau's syndrome (trisomy 13). Despite a recent dramatic decrease in fetal death rates, advanced maternal age remains an important independent risk factor for fetal death.

Diabetes mellitus is a common and expensive condition which is reported to be responsible for as much as 4-5% of national health care expenditure in developing countries. It is a disease of some antiquity, although the predominant clinical presentation is not that which was described by Aretaeus in the second century AD ('a melting down of the flesh and limbs into urine').

Like other organs in the body, the kidneys undergo age-associated anatomical, structural and physiological changes. Starting at 50 years of age, there is a 3-10% decline in kidney weight for each subsequent decade of life, with the loss of cortical mass greater than medullary mass. In fact, the number of glomeruli start to decrease progressively after age 40, and the number of sclerotic glomeruli increases, making the distinction between involutional and disease-related sclerosis unclear in some cases. The outer cortical glomeruli are, in general, more extensively involved than deeper glomeruli, but glomerular size does not change. In general, the loss of the glomerular mass is proportional to the loss of tubular mass, maintaining glomerulotubular balance. In addition to glomerular sclerosis, there is a gradual increase in interstitial fibrosis, and there is focal thickening of both glomerular and tubular basement membranes, probably due to the accumulation of type IV collagen.

Hospitals are disappearing fast and have been doing so for many years almost without our noticing. Figure 1 shows the number of hospital beds and the number of discharges and deaths from hospital in the UK over the past 35 years.

Only a tiny proportion of the huge epilepsy literature is devoted to elderly people. In recent years, however, this important and under-researched area in geriatric neurology has started to attract the attention it deserves. A small trickle of publications has started to swell and symposia or workshops devoted specifically to older people with seizures are becoming increasingly common.

Autonomic disorders in old age can be attributed to several main features associated with aging: the intrinsic neurobiological changes that occur with age, degenerative changes in effector organs innervated by autonomic nerves, and secondary involvement of the autonomic nervous system (ANS) in disease processes. As in most areas of clinical geriatrics, the distinction between disorders ascribed to ‘normal’ aging and those attributable to diseases of old age is difficult to make with any degree of certainty. Neurobiological changes with age have become the subject of intense investigation in recent years, with improvements in techniques for assessing autonomic nerve structure and function. This has included a better understanding of neurotransmitter and receptor transformations during development and aging. The versatility of the ANS, or ‘plasticity’, involves interactions with target organs, e.g. via nerve growth factor (NGF) and with other neurons, and it is as vital to the mature and aging autonomic neuron as it is during development. Some neurotrophic features of aging in the ANS and in disease processes in old age are considered in this paper.

Falls and funny turns are very common in old people, and many clinicians feel at a loss as to how to deal with them. Over the past few years, there have been important advances in our understanding of the causes of falls and how best to manage these in the vulnerable elderly population. Given the magnitude of the problem, it is important that such research finds its way into clinical practice.

Homeostasis is the ability of a living organism to control its internal environment despite fluctuations in the external environment. Claude Bernard proposed the concept of 'milieu interieur'. The hypothesis rests on the belief that cells need a precisely defined local environment in which to function optimally. The maintenance of the micro-environment is dependent on integration of the systems of the organism (body), including behaviour, to protect the cell(s) from external stressors. When the environment changes, the body needs to sense the alteration, then set in motion mechanisms which mitigate the change and restore the previous balance. If it fails to do this, the organism will ultimately die as systems fail.

Despite the increasing numbers of elderly subjects in society, the characteristic changes of old age such as the presence of wrinkles and grey hair still carry social stigma. This is taken advantage of by a cosmetics industry which produces enormous numbers of products to disguise aging. Contrary to popular belief, elderly people are often anxious to look attractive. Elderly patients present to dermatologists with a variety of skin problems. These may be directly related to aging (e.g. carcinogenesis) or may be common problems whose clinical expression, physical and emotional consequences and management may be altered by the age of the patient. A survey of elderly patients by Beauregard and Gilchrest revealed that two-thirds had symptoms relating to their skin and that this rose to 83% in subjects over 80 years.

Three diseases of bone are common in the elderly: osteoporosis, osteomalacia and Paget’s disease of bone. Osteoporosis is the result of bone loss, caused by a change in factors that regulate bone cell metabolism. The process of bone loss itself, resulting in osteoporosis, does not cause symptoms. It is the consequences of osteoporosis, fractures and bone deformity, that patients complain of. Osteomalacia is a defect in the process of mineralization of bone, nearly always due to vitamin D deficiency. In contrast to osteoporosis, patients with osteomalacia may have complaints of bone pain and muscle weakness. Page’s disease of bone is probably caused by a slow virus, which initially affects osteoclasts, followed by stimulation of osteoblasts. The process of increased bone cell turnover itself does not usually cause complaints. However, it results in deformation of bones and joints causing a painful secondary osteoarthritis. Pain resulting from high bone cell turnover responds remarkably quickly to treatment. In exceptional cases local pain in the long bones occurs. In an earlier review the problems of origin, diagnosis and treatment of osteoporosis were discussed. This paper focuses on diagnostic procedures and therapeutic regimens.

Urinary incontinence has been defined by the International Continence Society as 'the involuntary loss of urine which is a social and hygienic problem and can be objectively demonstrated'. This is a useful definition, although the subjective component leaves it open to variable interpretation, with consequent difficulty in establishing its prevalence. This is further contributed to by prevalence differences between populations and inconsistency of questions used. Thus, for example, studies have used such diverse questions as 'do you have difficulty in controlling your water?', 'do you have involuntary loss of urine on two or more occasions per month?', 'have you had involuntary loss of urine at any time in the previous year?' or 'have you ever suffered from bladder problems?'.

Because women die at an older age than men, and marry men older than themselves, widows outnumber widowers and the average woman can expect to survive her husband by five to six years. In fact, widows make up a substantial proportion of the elderly population. In this paper the current state of our knowledge of the reaction to bereavement in the elderly will be reviewed and its implications for the provision of services considered.

The problems of undernutrition, weight loss and feeding difficulty are more prevalent in elderly people than in their younger counterparts and are particularly prevalent in patients with dementia. These aspects of dementia challenge several members of the multidisciplinary team caring for elderly people with dementia, including geriatric and psychogeriatric physicians, dietitians and nurses.