Editorial

It was Benjamin Franklin who wrote that the only two things that one can be certain of in life are death and taxes. Those of us working in the health service in the United Kingdom would probably want to add change as the third certainty. No one was surprised, therefore, when New Labour, in their first White Paper on health, introduced us to a vocabulary of reforms with their now widely-used initials and acronym. These included HIPs (health improvement programmes), NSFs (national service frameworks), NICE (National Institute for Clinical Excellence), CHI (Commission for Health Improvement) and, to replace fund-holding, a new organization for general practice, the PCG or Primary Care Group.

Many changes occur in the aging immune system, which culminate in its functional decline, but the underlying mechanisms have proved difficult to define. Wick and Grubeck-Loebenstein have recently classified the changes in function as either primary ‘those that occur in perfectly healthy older individuals’ as the result of ‘an age dependent intrinsic decline of immune responsiveness’ or secondary ‘those that are due to underlying disease or various environmental factors including diet, drug intake, physical activity, etc’. Both types of alteration are important when considering immune dysfunction in older people which seems to be centred on the loss of cell-mediated immunity, in particular the activity of CD4 helper T lymphocytes.

Active lifestyles are associated with better health and lower rates of mortality from all causes. Increasing activity levels also have positive effects on many of the risk factors for developing chronic disease and on mortality rates (see Figure 1).

Evidence to support these claims, at least for middle-aged men, has accumulated steadily over the last 20 years. This review presents evidence that physical activity can contribute to health and wellbeing in old age.

Introduction

The methodology of quality of life measurement has developed markedly in the last few years. Clinicians and researchers have increasingly acknowledged that the burden of illness can not be described only in terms of disease status. Measurement of psychosocial factors such as pain, restricted mobility, difficulties fulfilling family or work responsibilities, and psychological wellbeing provides a far more comprehensive and meaningful assessment of the impact of disease on the patient’s life. Similarly, such patient-based measures are increasingly replacing traditional clinical or disease indicators as the primary measures of outcome in clinical trials.

Introduction

Longevity has lengthened in recent times. This has resulted in an increase in the elderly population, with life expectancy at birth in men in the UK being approximately 72.5 years and women, 78.5 years. Despite the risk of death from cardiovascular diseases decreasing in the past 40 years, these still continue to be the largest cause of mortality in the elderly. Cardiovascular mortality and morbidity are lower in women. However, this is not true in the later years of life. After the age of 80, the risk of cardiovascular problems increases to that of men. The cardiovascular changes occurring with aging consists of changes in the heart and arterial system.

Introduction

This is a review of recent and clinically relevant work on neuroimaging and its contribution to the diagnosis of neurodegenerative or other neurological and psychiatric diseases in older patients. Earlier research has been summarized in our previous review. We include publications on cranial computed tomography (CT) and magnetic resonance imaging (MRI), on single photon emission computed tomography (SPECT) and positron emission tomography (PET), electroencephalo-graphy (EEG), and on other methods.

What is spasticity?

Spasticity is a well-recognized and potentially important clinical syndrome comprising inappropriate and involuntary high muscle tone. It has been variably defined, with debate still ongoing. Currently, the most widely accepted definition is that of Lance, stating that spasticity is ‘a motor disorder characterized by a velocity-dependent increase in tonic stretch reflexes (muscle tone) with exaggerated tendon jerks, resulting from hyper-excitability of the stretch reflex.’ Unfortunately, even this description does not fully encompass the multifactorial nature of spasticity, since resistance to movement, even in the normal state, is subject to varied contributors. These include patient volition, inertia, visco-elastic muscle forces and range of joint movement, as well as true muscle activation secondary to reflex action. In the real clinical world, it is often not possible to distinguish which of these features is/are dominant. Furthermore, spastic muscle undergoes physiopathological, rheologic change with stiffness, atrophy, fibrosis and finally contracture.

Geriatric medicine emerged from long-term care championed by Marjory Warren and contemporaries, who focused attention on the opportunities and rewards of assessing, treating and, in particular, rehabilitating older people resident in institutional care. Then as now, people in long-term care were generally beyond the remit of hospital medicine. From this rehabilitative initiative in long-term care, geriatric medicine has continually developed and in the process has become increasingly divorced from its roots. The present evolutionary state of the specialty could be summarized by the goals of concentrating on the early detection, treatment and rehabilitation of acute and chronic ill health, in an attempt to improve quality of life and reduce dependency.

The debate surrounding what has been termed in the literature as relocation stress, transplantation shock, transfer trauma, and pure relocation effect has fuelled academic interest and research over the last half century. Coffman’s review of both published and unpublished data on 26 groups of relocated individuals highlights the breadth of equivocal evidence of mortality post-relocation. Although his review found no general relocation effect, research on the effects of relocation are still found to be ambiguous and contradictory, and its causative or other link to physical and mental health and mortality measures are unclear. In the United States there have even been legal moves (i.e. O’Bannon v. Town Court Nursing Center, Inc.) to persuade courts that relocation ‘should be a legally recognized phenomenon invoking judicial protection against transfer.’