Delirium has been recognized since ancient times and was first called delirium by Celsus in the first century AD. Variously termed delirium, phrenitis and lethargy, severe disturbances of thought, mood and action were often seen to be associated with physical disease. In the nineteenth century delirium developed into a rather broader description of confusion, a state which emphasized chaotic thinking and cognitive failure but which included what we now call dementia as well as confusion arising in the context of other functional psychoses. During the twentieth century the concept of delirium has continued to evolve. Kurt Schneider emphasized clouding of consciousness as central to delirium and this assumption has largely persisted. Delirium has developed as an acute condition, often precipitated by major medical illness. Increased interest in elderly people as a special group has led to the recognition that delirium is a frequent feature of acute medical admissions of elderly patients.

A person who has a dropped foot is unable to lift the toes clear of the ground during the swing phase of walking. Such a problem is seen in people who have either a peripheral nerve lesion, as a result of trauma or disease, or an upper motor neuron les ion. It is the latter that responds to neuromuscular stimulation; lesions of the lower motor neurons result in destruction of the neural pathway so that muscle contraction can be achieved only through direct stimulation of the muscle fibres.

The cochleovestibular system is unique in that the peripheral labyrinth subserves two senses, hearing and balance, while the central auditory and vestibular connections diverge within the central nervous system and interact with a multiplicity of information from other sensory inputs. During the seventh decade of life, approximately 40% of people in Great Britain have a significant hearing impairment while in the eighth decade of life this figure rises to 60%. By the age of 65, 35% of people have experienced episodes of dizziness and by the age of 80, two-thirds of women and one-third of men have suffered episodes of vertigo. The elderly population is reported to be increasing by approximately 30% every 20 years and the prevalence of vertigo and hearing loss has been reported to rise in parallel with advancing age.

The three key words in the title deserve scrutiny. ‘Innovation’ can mean something that is completely new, but more often innovations are drawn from practice in other fields. Innovations can be imposed from above, developed from practitioners or even happen incrementally. They are very often creative responses to other pressures, necessity being the mother of invention in this field as much as any other. Innovations can be reflected in day-to-day practice or they can be embodied in whole new units. Stale, out-of-date practice can happen in new units, and vice versa. It is too easy to see new buildings alone as innovations.

Ramón y Cajal, the pioneer neuroanatomist, was one of the earliest Nobel laureates, sharing the 1906 physiology prize with Camillo Golgi at the height of his career. He went on to become something of an elder statesman in his field, overcoming the need, far more onerous then than now, to publish his results in foreign languages, while campaigning to bring Spain, if not to the forefront, than at least into communication with the rest of European science. In this he largely succeeded, though to date he remains the only Spaniard to have received a Nobel science award. One of that select generation whose research careers spanned the emergence of the most crucial modern technologies, he began work in total obscurity in the 1880s but lived to see his discoveries become commonplaces of the textbook, as he in person grew to be a hero of Spanish culture almost unequalled in his time and still remembered with justifiable pride.

Studies across the European Union have noted that chronic illness and chronic disabling conditions rather than acute infectious diseases are now the major causes of morbidity and mortality in member states. This transformation in the nature of health and illness has, and will continue to have, profound effects on the nature of both medicine and the policy and organization of health care. It is estimated that not only will the share of consultations with doctors about issues connected with problems of living with chronic conditions increase, but there will also be a corresponding shift in medical practice from cure to care.

Polymyalgia rheumatica and temporal arteritis are still held to represent opposite poles of a single disease spectrum. In the former, girdle stiffness predominates; in the latter, frank vasculitis is demonstrable. Earlier reviews that were slanted at geriatricians in 1983 and 1993 both bemoaned the lack of an adequate diagnostic test and the differential diagnosis still remains particularly difficult in elderly people. Reviewing the situation after a further five years, this diagnostic confusion still exists, though there has been an increased recent interest in research into this condition. Although such endeavours have yet to help us diagnostically, the last five years have seen further insights into aetiopathogenesis as well as new approaches to treatment.

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.

In this paper recent studies of the relationships between social networks and mortality among older people are reviewed. Although a large amount of research effort has been expended on identifying and explaining such relationships, many studies have focused predominantly on those in middle age groups and very few have included sufficient numbers of older old people to allow separate analyses. Moreover, although relationships between various indicators of social support, participation and mortality have been demonstrated, this finding is not universal and considerable uncertainties remain about the strength of any such association, how it may vary between age and social groups and how it operates. In part, these uncertainties reflect the wide range of conceptual definitions of social networks or social support, methodologies and data sets used to address the issue.

There comes a time in the lives of a minority of older people when the extent of their disabilities makes it impossible for them to continue living in their own homes. When this happens, long-term institutional care may be the only option. Given that most residents in long-term care are over 75 years old and that the numbers in this age group will increase into the next century, we can expect an increase in the number of people requiring long-term care.

The number of emergency admissions to hospital in the United Kingdom continues to rise despite the shift in emphasis towards care in the community. Admissions are reported to have been increasing for four decades and, although these increases span all age groups, major contributions come from older persons. The most important and immediately apparent factors contributing to this change are that people are living longer, are more likely to suffer from multiple pathologies and are therefore frequent users of hospital acute services. OECD (1994) projections indicate that the proportion of people aged 65 and over in the population will have doubled from an average of below 10% in 1950 to over 20% by the year 2050.

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.

Symptoms of thyroid disease in older people are often subtle, and in most cases the diagnosis of hypothyroidism is made on the biochemical findings of high thyroid-stimulating hormone (TSH) combined with a low thyroxine (T4) level. However, with the routine use of sensitive assays, a significant number of patients have been identified with elevated TSH but normal T4 level and few or no symptoms. These patients have subclinical hypothyroidism (SCH).

The problem of patients not following drug therapy has long been recognized. Having reviewed studies which attempted to quantify the problem, determine its causes and advise about its management, Sacket concluded that the magnitude of compliance as a problem in clinical and health care is matched by the extent of our ignorance of its determinants and remedies. He defined compliance as the extent to which a person‘s behaviour coincides with medical or health advice. This definition has been used widely since.

The concept of formal or standardized tests for assessing function came to the fore in the 1960s. Katz et al. acknowledged the hierarchical nature of activities of daily living (ADL) such as eating, continence, transferring, going to the toilet, dressing and bathing in his ’Index of ADL’ and by 1968 ‘ADL’ was an accepted Index Medicus category. The definition of instrumental activities of daily living (IADL) began in 1969 with the work of Lawton and Brody who presented two scales to assess function which recognized the different degrees of complexity required for performing functional tasks. The first scale, taking life maintenance and activities essential for self-care as the primary level, was called the Physical Self-Maintenance Scale.

The need for integration of health and social services for institutionalized elderly people is urgent. A possible approach, based on information-management, using established technologies, is described.

The well-being of older adults in general, and their loneliness in particular, are important themes in recent discussions in the Western world. The social integration and participation of older adults in society are seen as indicators of productive aging, and the alleviation of loneliness forms part of policies aimed at achieving the goal of ‘successful’ aging. Discussions about loneliness date back to ancient times, when they were led by philosophers. They wrote primarily about ‘positive’ loneliness. This positive type of loneliness - as indicated in the concept of ‘Einsamkeit’ used in German literature until 1945 - is perceived to be related to the voluntary withdrawal from the daily hassles of life and oriented towards higher goals, such as reflection, meditation and communication with God.

In July 1997 Harriet Harman, the new Secretary of State for Social Security in the UK, announced a fundamental and wide-ranging review of all aspects of pension provision. The review comes at a time when trust in the pensions industry is at an all-time low. The reputation of occupational pensions was dealt a severe blow by the Maxwell scandal, and personal pensions have now been revealed as a very bad buy for many of the almost six million people who have signed up for them since 1988. That such pensions were mis-sold has now been formally acknowledged and steps taken to prevent a repetition, but many people are still waiting for their compensation. State provision is also not immune from this crisis of confidence. Since 1980 the basic pension has been indexed to prices rather than to earnings as previously. As a result its value has shrunk to 14% of average male earnings, compared with 21% in 1980, and it is predicted to fall further to a ‘nugatory’ 9% by 2020.

The clinical syndrome of heart failure affects more than 1% of the population, and its prevalence increases steeply with advancing age, especially after 75, where it reaches approximately 10%. It is one of the commonest reasons for the admission of elderly people to hospital.

Despite recent advances in treatment of heart failure with angiotensin-converting enzyme (ACE) inhibitors, which were proven to provide survival benefit, the rates of morbidity and mortality from heart failure remain high, and new therapeutic strategie s are needed.