The legacy of the workhouse origin of services for older people in the United Kingdom remains in the memory of patients and practitioners and is still a reality for some. In the area in which we work, geriatric medicine services are still provided in Victorian Poor Law buildings, although, we hope, not for much longer. The disadvantage that this causes to patients in terms of access to modern services and investigations is quite clear and the importance given to the ‘routing of age discrimination’ in the National Service Framework for Older People has in general been welcomed. In a parallel document, the Department of Health has stressed the importance of a robust policy for medicines management based on the twin principles of appropriate prescribing. Firstly, all older people should receive all the medication from which they would benefit. Secondly, steps should be taken to reduce the risk of adverse effects, the frequency of which rise with age. The prescribing principles outlined in these two documents, together with the other National Service Frameworks, form a powerful basis to improve the health of older people.

Two policy documents were published by the UK Department of Health in 2001 which established the service development agendas for their respective areas over the coming years. The National Service Framework (NSF) for Older People sets out national standards for ‘better, fairer and more integrated health and social care services for older people’ and ‘addresses conditions significant to older ages’ to promote ‘active and healthy aging’. The National Sexual Health Strategy identifies ways to ensure that that the sexual health of the UK population is maximized, predicated on the grounds that ‘our sexual health affects our physical and psychological well-being and is central to some of the most important and lasting relationships in our lives’. What is striking, if perhaps ultimately unsurprising, is that there is no overlap between the documents. The NSF for Older People makes no reference to sexuality or sexual health issues, and the National Sexual Health Strategy makes no reference to older people and, indeed, explicitly focuses on younger people, particularly through linking the prevention of sexually transmitted infections (STIs) with the reduction in teenage pregnancies.

A previous review described the literature outlining the characteristics and special needs of older people using accident and emergency (A&E) services, the service initiatives aimed at meeting these needs, and the implications of the findings for UK policy and practice. The review identified a lack of clear evidence to guide the development of specialist services for older people attending A&E. In particular it was noted that there was a deficit of work in the UK context. This seemed, in part at least, to be based on ambivalence about the legitimacy of developing specialist services in the emergency department for this group of patients, despite the large numbers of older people attending. However, the paper also noted encouraging trends and a move away from a preoccupation with whether or not older people were appropriate A&E attenders, to a consideration of how best to meet the particular needs of this group, that paralleled past developments of specialist services for children.

In the last decade, great advances have been made in the understanding of the role of lipid management in the prevention of cardiovascular disease. Epidemiological data from the Framingham study and the Multiple Risk Factor Intervention Trial (MRFIT) have described a causal relationship between lipid and lipoprotein levels and the risk of coronary heart disease (CHD). Hitherto, the emphasis of therapeutic studies has focused on coronary heart disease specifically, especially in terms of treatment with 3-hydoxy-3-methylglutaryl-coenzyme A (HMG-CoA) reductase inhibitors or ‘statins’. The result has been a burgeoning evidence base demonstrating the effectiveness of statins in cholesterol reduction and, more importantly, in the reduction of coronary mortality and morbidity in subjects both with and without established CHD. Given that the vascular system is more commonly regarded as a single entity, with the pathophysiological basis of disease based on the development of atherosclerosis, it has been surprising to find that ischaemic stroke does not share the same robust relationship with cholesterol that CHD does. The lack of a consistent relationship between serum cholesterol and stroke has manifested itself in diverse attitudes towards cholesterol-lowering in cerebrovascular disease; this problem has been heightened by the relative lack of trial data and clinical guidelines on the subject. It is therefore important to review the current evidence regarding cholesterol and stroke and to derive conclusions that translate into the clinical management of cholesterol in patients with cerebrovascular disease.

Stroke is a distressing event and in the western world it ranks in the top three leading causes of death in adults. The number of stroke survivors is increasing because of the improvement in the management of acute stroke. This has resulted in a larger group of patients with important residual physical and psychological impairment. The four major categories of cerebrovascular disease are atherosclerotic thrombosis, cerebral embolism, lacunae and intracranial hemorrhage. In this review, as in other published studies, all categories are defined as a stroke.

Vascular cognitive impairment (VCI) is a relatively new concept, encompassing all forms of cognitive loss associated with cerebrovascular disease and ischaemic brain injury. It covers a broad spectrum of pathologies within the brain, with different causes and clinical presentations. VCI includes vascular cognitive dementia, (VaD). VCI also encompasses mixed (AD and vascular dementia) as well as hereditary disorders. Table 1 shows the main subtypes of VCI.

Chronic Heart Failure (CHF) is a disease of older people. The prevalence of the disease increases with age, reaching over 10% in those aged 80 and above. Not only does heart failure carry a burden of mortality worse than many cancers, it also severely impairs function and quality of life and is a leading cause of hospitalization in older people. Heart failure cost the British National Health Service £360 million in 1990–91; the cost is estimated to have doubled in the last decade.

Provision of services for older people is now a priority for policy makers, not least because of population aging precipitating a ‘demographic revolution’. In England, one response by policy-makers has been a National Service Framework, designed to provide standards and models for the care of older people. Furthermore, recent moves to create strategic partnership agreements between the Department of Health, the NHS and the Voluntary and Community Sector point to increasing awareness of the interconnections between health and social care. However, even when services are in place, older people do not always use them. Understanding why this might be the case is key to further service planning and implementation.

Population aging is conventionally understood to refer to increases in the percentage of the population aged 65 and over. Developed economies have for some time shown evidence of this and it is projected that they will continue to experience aging over at least the next 20 years. As the population ages, so the level and pattern of demand for health care is likely to change, and difficulties in financing care to increase. Older persons, for example, tend to consume more health care than those in younger age cohorts, as well as different types of care (for example more long-term care). By the same token, older persons (who are often retired) tend to have less income than those in younger age cohorts. A consequence of this is that they are less able to meet the costs of health care directly (i.e. out of pocket) or contribute through direct taxation to meeting the costs of publicly funded health care. These two factors – growing demand and diminishing income among those for whom demand is expanding – will present challenges to the future finance and delivery of care.