A basic notion relating to development during adulthood and old age, according to a lifespan perspective, refers to the progressive increase in individual differences in psychological wellbeing. It is possible to find diverse ‘health trajectories’, shaping patterns of evolution regarding the general health of adult and elderly individuals, such as (1) permanent good health (2) good health most of the time and decline by the end of life (3) health decline and recovery (4) permanent poor health, (5) progressive decline and (6) irregular health.

Prescribing for older people is often complex and challenging. With age, people almost invariably develop diseases leading to the prescription of drugs and the risk of multiple prescribing increases, especially if there is strict adherence to single disease guidelines. There remains a paucity of evidence from clinical trials as to the efficacy of many drugs in patients aged over 80 years due to the gross under-representation of older people in clinical trials. Older people are also at increased risk of adverse drug events, which are an important cause of morbidity and mortality. A significant percentage of these are both predictable and potentially avoidable.

In this updated review the concept of appropriate prescribing in older people is explored, including the importance of individualized care and shared decision-making. The available tools to enhance prescribing practice are examined, including those aimed at reducing inappropriate prescriptions and under prescribing. The limitations of existing tools are discussed and areas with particular promise and scope for advancement are highlighted, including the development of integrated IT systems and software engines to aid clinicians in appropriate prescribing.

Pruritus in older people is caused by a wide range of dermatological, systemic, neurological and psychogenic diseases. It can also be attributed to various cutaneous drug reactions. The dermatological, neurological and immunological changes associated with ageing predispose older people to pruritus of a wide range of aetiologies. The most common cause of pruritus in older people is xerosis, or dry skin. Regular use of emollients is the mainstay of treatment for pruritus of any cause, with general measures aiming to ensure optimal skin hydration and to prevent the itch–scratch cycle. Topical treatments are generally better tolerated for localized pruritus. Anti-histamines are the predominant agents to treat pruritus, but can be inadequate in many cases. Numerous other systemic agents have been demonstrated to alleviate pruritus depending on the cause, but may be limited by their adverse effects. This article reviews the current published literature on pruritus in older people, with a practical approach to its evaluation and management in non-specialist settings.

Parkinson's disease (PD) is a progressive neurodegenerative disease characterized typically by motor features of tremor, rigidity and bradykinesia due to depletion of dopaminergic nigrostriatal neurons. PD is increasingly recognized as a non-motor disorder since symptoms such as dementia, depression and falls emerge with disease progression to become dominant in the clinical picture. PD results in a significant decline in quality of life for both patients and family and contributes to significant economic and institutional costs on family and society. PD is uncommon before the age of 40 but affects approximately 1% of patients over the age of 60, with a rising incidence and prevalence thereafter to around 2% in the population over 80 years of age.

The incidence of pneumonia is higher in older than younger people, due to both an increase in factors facilitating entry of infectious agents into the lungs, and attenuated functioning of the immune system. Classic features of presentation of pneumonia may be absent. The most common signs of pneumonia in old age are tachypnoea and tachycardia. Aetiology is established in only 50% of older patients. The empirical treatment of community-aquired pneumonia (CAP) should be aimed at its most common cause, Streptococcus pneumoniae. The empirical treatment of health care-associated pneumonia (HCAP) should be targeted at Gram-negative agents. Choice of antibiotic must include consideration of potential drug interactions.

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.

The involvement of service users as active participants is a stated aim of many current developments within health and social care, and self-assessment has been identified as a key mechanism. For over 15 years, the UK Department of Health has referred to the importance of the service user's views in assessment, and this has been re-emphasized recently in guidance issued to both local authorities social services and the NHS. The concept of the expert patient and the promotion of self-care amongst people with long-term conditions are also highlighted as central to current NHS development. Although not specified as such, self-assessment is an important component of these person-centred initiatives which encourage self-diagnosis, self-monitoring and self-management.

Agism was the term chosen by Butler to name the process of discrimination based on chronological age, which usually results in an image of the elderly as unproductive, sick, depressed and with cognitive impairment. This form of bias, like others that devaluate and stereotype groups of people, has a marked effect on social interaction, influencing social attitudes and perceptions in a covert manner. The use of negative images relating to old age and the aging process promotes negative attitudes relating to elderly people, affects the way they live and the way people of other ages prepare to face their old age.

This review describes the concept of disablement, with particular reference to the World Health Organization’s International Classification of Impairments, Disabilities and Handicaps (ICIDH), and its forthcoming revision. Applications for a disablement classification are discussed, and the various approaches which have been applied to the measurement of disablement are reviewed. The relevance of disablement to psychiatric research and clinical practice is also addressed. In the second section of the review, data are presented from the last two phases of the Gospel Oak Survey, illustrating the value of simple measures of disablement in a community epidemiological study of the aetiology of late-life depression.

Dying is the one common and certain event in life but it is a difficult process to study. Official statistics give information about the point of death; studies covering random samples of deaths are inevitably retrospective and based on the accounts of those who knew the person who died; other studies are selective and generally focused on people dying from cancer, so they include a relatively small proportion of old people. Yet, in developed countries, deaths are concentrated among older people. In England and Wales in 1994 83.6% of all deaths were of people aged 65 or over; 59.0% were 75 or more.

Why measure?

Before we consider what to measure and how to measure outcomes in the rehabilitation of frail older adults, an antecedent question is, why measure these things? Without an answer satisfactory for both measurers and measured, much effort and ingenuity will be expended with resultant perspiration and exasperation and little else.

Traditionally, medical care, i.e. that identified by physicians, has assumed that its principal objective was patient care, i.e. that appreciated by patients. Outcomes of care from the viewpoint of the patient, of his or her informal supporters, of the involved health care professionals, and of the health care delivery system have to be clarified and made operationally explicit. This recognition requires definition and measurement. Thus a powerful reason for measuring outcomes for recipients and providers of health care, as well as the health care delivery system, is to know what is happening (the descriptive question) and with what effect (the analytical question).

A decrease in habitual physical activity accompanies old age in mammalian species and in healthy man.74,142 This is not simply a consequence of a parallel decline in exercise capacity, and factors other than those which limit aerobic capacity and endurance performance must be involved.143 Moreover, most old people remain at least moderately active.144 Everyday activities may require cardiorespiratory and muscle performance which is much nearer the maximum in elderly individuals than in younger people and further reduction in reserves by, for example, illness, will more readily cause disability.

Regular moderate activity is sufficient to mitigate declining exercise capacity and muscle performance and conditioning programmes may well confer additional benefits even at advanced ages. Exercise remains good for you regardless of age. A suitable programme is one of moderate to high workrates, involving large muscle groups and performed for 15–30 minutes every other day.145 The intensity is best guided by heart rate, for which a variety of formulae have been proposed.146

The complex interaction of physiological factors influencing muscular performance has been illustrated. Only when these physiological processes are disentangled and better defined will we elucidate the molecular mechanisms which underlie age-associated changes. It is not yet possible to define the relative importance of intrinsic and extrinsic influences, but the proportion of the decline in VO2 max which is directly attributable to intrinsic aging is smaller than is usually assumed, probably less than 50%.147 While the most critical determinant of VO2 max in young subjects is probably cardiac output,148 we now recognize that in elderly people the balance shifts; muscle performance, changes in blood distribution and peripheral microvascular capacity become ever more important determinants of exercise performance and should command increasing research interest.