The social environment is one of the key factors determining the quality of life of older people. Research has consistently demonstrated a strong and positive relationship between social engagement in all forms but especially participation within kin and wider social networks, and a high quality of life. However, this recognition of the importance of this relationship is not new. In the early 1960s, the ‘activity theorists’ of aging posited that the key to a good old age was the maintenance of high levels of activity, including social participation and the maintenance of kin- and friendship-based relationships. This resonates with the ideas of Rowe and Kahn who suggest that a high level of social engagement is a key factor in achieving the individually and socially desired goal of ‘successful aging’. Furthermore, they argue that, with advanced age, the social context, in combination with the physical environment, exerts a more potent influence upon the experience of later life than either intrinsic genetic or biological factors. Whilst the prescriptive strictures of activity theory and successful aging remain the subject of debate, there seems little doubt that the social environment continues to exert both a powerful influence upon, and provides a context within which people experience old age, both individually and collectively.

The term ‘older people with learning disability’ refers to a highly heterogeneous group of people. By definition, they all have delayed or abnormal early development, together with significant intellectual and functional impairments, but they differ considerably in terms of cause, developmental profile, nature and degree of impairments and their social and personal backgrounds. Overall, people with learning disabilities make up only a small minority of the population, however it is well recognized that they have increased overall health care needs, including mental health needs. It has been estimated there are 210 000 people living in England and Wales who have a severe or profound learning disability: only 25 000 (12%) of these are older people aged over 60 years. Of the 1.2 million people with mild or moderate learning disability, 265 000 (21%) of these are older people over the age of 60. Life expectancy seems to be influenced by severity of learning disability, the age profile of the mild to moderate learning-disabled population being much more closely matched to that of the general population. As a result of this differential mortality, across the spectrum of disability there is a reduced level of learning disability with advancing age, and older people with learning disabilities, when considered as a group, have higher levels of functional ability (and reduced levels of challenging behaviour) than the younger group.

Substance misuse in the elderly population has been referred to as a silent epidemic. One of the factors that contributes to the appropriateness of this description is the difficulty of diagnosis in this age group. There is abundant evidence that substance misuse is under-diagnosed in elderly people and that this applies to both alcohol and drug misuse, although the general principles of a diagnostic approach are not age-related. The increased incidence of anxiety, depression, dementing illness, and physical illness in this population, independent of substance misuse, means that diagnoses can often be missed. The impact of co-morbidity (Figure 1) in older age groups is such that it remains the most important confounding factor in diagnosis. In this second section of the review we explore the range of psychiatric and physical illnesses that can coexist with, or be caused by, substance misuse in the elderly population. The issue of assessment as part of a treatment framework is considered in the third section of the review. The risk of missed diagnosis in this age group was illustrated in a study of diagnosis of substance misuse problems in patients aged 65 and over who had been admitted to hospital. Only three out of a total of 88 patients using benzodiazepines, 29 out of 76 smokers, and 33 out of 99 problem drinkers were correctly identified. Of those who were identified only a small proportion were referred on for specialist treatment.

The alarming statistics of dementia are now widely acknowledged. The most recent estimates indicate 24.3 million suffer from this condition worldwide, with a new case being diagnosed every seven seconds. For the person afflicted, it robs him of his identity and, in the opinion of many, even his personhood. For family members, bereavement can begin from the early stages of the disease where a once-treasured relationship is gradually eroded. Family carers remain the main persons providing care, having to face much emotional, practical and economic strain in the process. Although there is no standard definition of family caregiving, it is understood to involve providing extraordinary care, often outside the bounds of what is usual in family relationships. Caregiving typically stretches over a prolonged period and entails significant expenditure of time, energy, finances, and tasks that may be unpleasant, emotionally stressful and physically exhausting.

This review summarizes research into the phenomenon of patronizing speech addressed to older people by doctors, nurses, health professionals and other carers. Patronizing speech is defined and illustrated and its negative impact on the dignity and well-being of older people described. Key empirical and theoretical perspectives of patronizing speech are reviewed. Different aspects of the practice are examined and practical recommendations made for how it can be recognized and avoided. The beneficial effects of training and education of health professionals are discussed.

Good quality research on grief and bereavement has flourished in the last decade. Until now, relatively few studies have studied grief specifically in an older population. However, a series of papers arising from the Changing Lives of Older Couples (CLOC) study carried out at the University of Michigan have clarified the mechanisms of psychological and social adjustment to spousal bereavement in a population of older people. The last five years have witnessed the replication and refinement of the University of Pittsburgh group's research on the important concept of complicated or ‘traumatic’ grief, which was highlighted in the last review of this topic in this journal. Major reviews on social support after bereavement and on treatments for grief symptoms have been published, and guidelines written on the management of the bereaved in a general hospital setting. This review will attempt to summarize the main themes from these and other important recently published papers in this area.