The lymphatic system must have variation in tissue pressure to load it and to help flow. Being a low pressure system, external pressure must not be constantly high on any segment and there must be a pressure gradient along it. When the flow rate of lymph fails there can be compromised immunity, a tendency to deposit fat, fibrotic induration, and a vicious cycle of worsening of cellular and organ health often associated with recurrent infection.

As we age we become less active, lose muscle tone, and increase our weight, develop a higher percentage of body fat, and may have poor skin care and be prescribed medications which impact on lymphatic load. Combined with this, the tendency to immobility, limb dependency and periods of time when high external pressures exist in small superficial areas increase the risk of or contribute to lymphoedema through reducing lymphatic flow. Older people are more likely to have had more radical surgery and radiotherapy for cancer with more significant damage to their lymphatic systems, again adding to lymphoedema risk. Immobility, hypertension, venous disease, kidney and liver failure can lead to oedema, while thyroid dysfunction can cause myxedema, and genetic or metabolic issues can cause lipoedema, compounding the clinical problems.

A key point in good management is early identification and accurate diagnosis. Ideally, other issues that especially impact on lymphatic load should be managed prior to targeted and sequenced treatment for the swelling, with the aim being to improve patient comfort. Management can involve the patient, partner, family or carer as well as a range of health professionals to help reduce or maintain limb size, appearance and function as well as reduce symptoms of heaviness, tension and discomfort and a range of other issues that impact on quality of life and activities of living.

Agism in the form of age-based health care allocation fosters the separation of the physiological part of a patient from the person who is the patient. It does so by ignoring the holistic best interests of the patient and instead focuses on providing certain procedures or therapies only when the patient’s age is less than or equal to a specified value (the allocation limit). Certainly not all forms of clinically relevant care and treatment are age-restricted in the scheme of aged-based health care allocation, but it is clear that this scheme functions on the arbitrary, and patients may miss out on optimal therapy presumably because it will be ranked as too expensive or too rare to provide to older people. Arbitrarily chosen age limits or those chosen based upon an estimation of humans’ natural lifespan have the effects of minimizing the patient’s clinical choices, devaluing the experiential skills and knowledge of the medical team, weakening the doctor-patient relationship, and commodifying medicine. Policies of this nature do not solve our current health care dilemma, rather they are an economic bandage over the still present (and unattended to) root cause.

The epidemiology of hearing loss in the elderly has been well documented in the UK by Davis and in the USA by Gates. Both studies confirm that presbyacusis is common. Hearing loss results in significant disability in social communication. Davis based his conclusions on a cohort of 2910 subjects while Gates looked at 1475 subjects six years apart. Both studies carried out detailed audiological examinations.

Rehabilitation stands between acute care and long-term care. As such, it is difficult to define and harder still to measure. Put simply, it is a process, an attitude of mind, a philosophy; something that patients need but acute hospitals would rather do without. This paper discusses the problems of measuring and forecasting rehabilitative activity before explaining how behavioural models of flow demonstrate the interaction between acute, rehabilitative and long-stay care. Managers, directors of social service departments, and clinicians need scientifically valid methods that enable them to measure performance and to optimize decision-making. Inherent flaws in the current methods used to measure hospital activity must be overcome if rehabilitation is to occupy its rightful place in health care management.

Introduction

Illnesses such as acute and especially chronic diarrhoea are personally incapacitating to older people, more so in those with physical and mental impairment or other acute or chronic illnesses. Diarrhoea is also socially restrictive: diarrhoea adversely impacts on the individual’s and carer’s quality of life.

The population of the UK is aging, with a fifth of the population of England now over 60years old. Between 1995 and 2025, the number of people over the age of 80 is set to increase by almost half, and the number of those over 90 will double. While there is some decline in cognitive function as a result of normal aging, most older people do not develop dementia. Only about 2% of people aged between 65 and 75 have some form of dementia, and this is thought to rise to 20% in those over 80. Thus there are some 670000 people with dementia in the UK, and this figure is expected to rise to nearly 1000000 by 2021. The cost of dementia care, at 5.6% of total healthcare costs, is almost equal to that of the combined costs of cancer (3.2%) and coronary heart disease (2.5%). Twenty-five per cent of the costs of caring for this group may be attributable to the time carers spend helping with eating and drinking. Eating and drinking involve the co-ordination of complex physical and mental activity. These activities are often affected by aging as well as the progressive impairment of memory, thinking, perception, planning, organization, communication and skilled movement that characterize dementia. Consequently eating and drinking may be affected by tooth and mouth problems, poor hand-to-mouth co ordination, poor concentration, apparent food refusal, wandering away during mealtimes and the side-effects of individual drugs, polypharmacy and dysphagia.

Cerebral multi-infarct states (MIS) have a very variable clinical presentation (Table 1). Dementia is often stressed as the primary feature, however, many patients have relative preservation of cognitive abilities and personality, although their mobility may be severely affected, with a small-stepped shuffling gait, poor balance and frequent falls associated with bilateral (often asymmetrical) pyramidal tract signs. Urinary incontinence is common, dysphagia and dysarthria may occur, and some patients develop emotionalism and/or depression. In the later stages, patients may become immobile, requiring 24-hour nursing care.

Introduction

In 1995, Safe reviewed the major advances in the investigation and management of upper gastrointestinal tract (UGT) disorders over the previous 25 years. Further research over the past five years, particularly in the field of the ethics of nutrition in the elderly, has stimulated this review of the literature. Rather than attempt a comprehensive review, however, we focus on areas where the approach to the management of UGT disease has been significantly influenced. The following topics are covered: gastrooesophageal reflux disease (GORD); peptic ulcer disease (PUD); the management of non-steroidal drug-induced mucosal injury; UGT bleeding; UGT cancer and the ethics of artificial nutrition support.

Polymyalgia rheumatica and giant cell arteritis are closely related conditions, considered by many to represent opposite poles of a single disease spectrum. They can occur together or separately.

Polymyalgia rheumatica is characterized by pain and morning stiffness in the shoulder girdle and sometimes the pelvic girdle. The symptoms are felt to be related to synovitis of proximal joints and extra-articular synovial structures. Giant cell arteritis displays a frank vasculitis affecting the regions supplied by the temporal artery to give visual loss and scalp tenderness but is increasingly recognized to also affect the aorta and its extra-cranial branches. For this reason the term ‘giant cell arteritis’, which is descriptive of the pathology, is used instead of the alternative term ‘temporal arteritis’, which gives a misleading impression of localization but which was the term used in previous reviews for this journal, the most recent in 2003.

Testosterone production declines with age in men. The decline is associated with several risk factors and diseases, including obesity and cardiovascular and metabolic diseases, diminished muscular, cognitive and sexual function and changes in body composition. Androgen treatment in elderly men has mostly been addressed in small short-term studies, and larger long-term investigations with sufficient statistical power are still needed for a proper evaluation of the benefit-risk-ratio of testosterone treatment. Current data do not support testosterone supplementation in healthy, asymptomatic older men with normal or low-normal testosterone levels. Treatment may be beneficial in older men with clear hypoandrogenic symptoms, especially reduced libido, erectile dysfunction and decreased muscle strength, if testosterone concentration is consistently low, and the patient selection, counselling and follow-up are adequate.

Faecal incontinence is a disabling condition, with a high personal, social and economic cost. Whilst it may occur at any age, prevalence and severity of symptoms is higher among older people. There are many therapeutic options, ranging from non-invasive treatments to complex surgical techniques, with results that can be considered satisfactory in about 70% of individuals. A comprehensive study of the type of incontinence and its presentation and severity, together with consideration of the general condition of the patient and their environment, are the keys that will decide the best treatment option.

Osteoporosis is defined in adults as having a bone mineral content at the lumbar spine or hip of more than 2.5 standard deviations below the expected mean for the healthy young sex-matched population (WHO criteria). Osteoporosis and consequent fragility fractures are common problems, increasing in frequency with age. Several classes of drug of proven value in reducing the risk of osteoporotic fractures are now available. This review will examine how the evidence that treatment of osteoporosis reduces fracture risk applies specifically to older people, particularly those over 70 years of age.

Consent is a conceptual issue, and it can be argued that some of the most complex cases in assessing competence to consent arise when dealing with patients with dementia. This paper is concerned with the practical difficulties nurses face, an area for which there is little guidance.

Much of the literature relates to the ethics and legalities of informed consent for treatment or research, frequently in relation to medicine, philosophy and the law. Some frameworks are offered within these areas by which to assess a person‘s competence to consent, but they are of limited use in nursing.

Prion diseases are rare degenerative disorders of the nervous system caused by abnormal accumulation and/or metabolism of prion proteins. They are invariably fatal. Creutzfeldt-Jakob disease (CJD) is the most common human prion disease and the sporadic form accounts for 85% of cases, whilst about 15% are genetic and 1% is iatrogenic. Variant CJD (vCJD) was mostly seen in the UK and France and mainly affected young people. Sporadic CJD (sCJD) occurs throughout the world with mean age of onset in the seventh decade. It typically presents with rapidly declining cognition that may get confused with other forms of dementia. Thus identification of sCJD in older people depends on a judicious awareness of the clinical features. Here we present a clinical, pathological, therapeutic and diagnostic review of sCJD.

In England there are over 100 000 elderly people registered blind and a further 80 000 registered partially sighted. Visual impairment is common in the elderly population, with approximately 10% of people of 65 years of age and over having poor vision. The prevalence of visual problems appears to be much greater among older people in institutionalized care. A study of 100 elderly people living in residential homes in London revealed that 51% had cataract and 34% had significant refractive errors. A further study of patients attending a geriatric day centre found that about one-third had unrecognized visual loss.

The improvements of socio-environmental conditions, medical care and quality of life have caused a general improvement in the health status of the population and a consequent reduction of morbidity and mortality, resulting in an overall increased life-expectancy. The role of immunosenescence was negligible in the past, when the human lifespan was 40–50 years, and its impact on morbidity and mortality has emerged in combination with the extension of lifespan. Immunosenescence results from multifactorial processes that act on all components of the immune system. The changes associated with immunosenescence are playing an increasingly important role in the emergence of a series of age-related pathologies, conditioning the present epidemiology of old people.

The diagnosis of neurosyphilis is important but remains difficult because of variable clinical features and an unpredictable course. Laboratory confirmation involves a combination of serological tests, none of which alone provides a reliable indication of current disease activity. Although in the UK the incidence of neurosyphilis has fallen steadily, its many manifestations require clinicians to remain alert to the diagnosis, particularly because incidental antibiotic therapy may modify the presenting features. As a sexually-transmitted disease, the diagnosis of syphilis carries great social stigma. The need for informed consent before routine testing, and the provision of psychological support for the patient and carers in the event of a positive diagnosis, must be considered.