The legacy of the workhouse origin of services for older people in the United Kingdom remains in the memory of patients and practitioners and is still a reality for some. In the area in which we work, geriatric medicine services are still provided in Victorian Poor Law buildings, although, we hope, not for much longer. The disadvantage that this causes to patients in terms of access to modern services and investigations is quite clear and the importance given to the ‘routing of age discrimination’ in the National Service Framework for Older People has in general been welcomed. In a parallel document, the Department of Health has stressed the importance of a robust policy for medicines management based on the twin principles of appropriate prescribing. Firstly, all older people should receive all the medication from which they would benefit. Secondly, steps should be taken to reduce the risk of adverse effects, the frequency of which rise with age. The prescribing principles outlined in these two documents, together with the other National Service Frameworks, form a powerful basis to improve the health of older people.

Epidemiology is the study of how often diseases occur in different groups of people and why. Cancer epidemiology is therefore the study of how often cancer occurs in different groups and why. Part of the work on examining why is to measure the effect of factors which may put a patient at high risk of getting the type of cancer in question.

It seems self-evident that the effectiveness of rehabilitation services requires well-organized, co-ordinated, multidisciplinary services, if only because no one discipline has the range of skills needed for rehabilitation. For one major service, at least, a problem-oriented approach has been shown to be effective.

Recent changes in medical education as well as in the organization and delivery of health care in the UK have emphasized the need for doctors, nurses and other health care professionals to learn to work together as teams in order to provide the best possible care for patients. The importance of interprofessional education (IPE) and teamwork is, therefore, being increasingly recognized and given priority in medical education.

Population aging, escalating costs in pensions, health care and long-term care have prompted the emergence of a new policy agenda for active aging and quality of life in old age across the European Union. In the UK, the government has made a commitment to improve services for older people through combating age discrimination, engaging with older people, better decision-making for services for older people, better meeting of older people's needs and promoting a strategic and ‘joined-up’ approach. A raft of policy initiatives not only sets the tone for service reconfiguration but also specifies objectives and time scales.

Two policy documents were published by the UK Department of Health in 2001 which established the service development agendas for their respective areas over the coming years. The National Service Framework (NSF) for Older People sets out national standards for ‘better, fairer and more integrated health and social care services for older people’ and ‘addresses conditions significant to older ages’ to promote ‘active and healthy aging’. The National Sexual Health Strategy identifies ways to ensure that that the sexual health of the UK population is maximized, predicated on the grounds that ‘our sexual health affects our physical and psychological well-being and is central to some of the most important and lasting relationships in our lives’. What is striking, if perhaps ultimately unsurprising, is that there is no overlap between the documents. The NSF for Older People makes no reference to sexuality or sexual health issues, and the National Sexual Health Strategy makes no reference to older people and, indeed, explicitly focuses on younger people, particularly through linking the prevention of sexually transmitted infections (STIs) with the reduction in teenage pregnancies.

The overall burden of stroke is well known. It is the third commonest cause of death in developed societies, and the commonest cause of severe acquired physical disability in old age. The incidence of stroke is approximately 1–2 per 1000 population per year in the United Kingdom, that approximates to a ‘stroke a day’ in most typical district general hospitals. As such, it is something all who take part in emergency medicine should know a great deal about, even more so for geriatricians as stroke becomes increasingly common with old age. Recent work from Oxford, England has demonstrated that although the age-specific incidence of stroke has fallen by 30% in the last 20 years, the overall incidence of stroke in the population has remained constant due to the increasing proportion of the population in the stroke-prone age. This suggests that the types of patient who have stroke will differ in time, as the population ages, and stroke will be seen more frequently in frailer older people. This could have profound influence for the organization and management of patients, as treatments that appear beneficial for a younger, more robust patient may have a different balance of risk and benefit in the frailer older person. Geriatricians must continue to contribute their patients to stroke research (or collaborate very closely with their neurological colleagues) if we are to keep an appropriate evidence base for the older patient with stroke.

Pressure ulcers (PU) may cause intolerable suffering to the patient. Not only do they affect patients but they also increase nursing workload. In Finnish studies, PU prevalence was 5.4–22% depending on the type of institution caring for the patient. The same level of prevalence is reported from other European countries. In 2000, it was reported that PUs, as the main diagnosis, were responsible for over 20000 bed days in Finnish long-term care hospitals, at a cost of approximately 3 million EUROs a year. In England, it was estimated that a 600-bed general hospital spends 600000 to 3 million GB£/year to care for PUs. Some US statistics estimate that nearly 2 million American patients acquire a PU during the course of their care, and the cost to treat one wound is from 2000 US$ to 70000 US$. Prevention is therefore not only beneficial for the patient but obviously cost-effective for the health care system.

Important and common syndromes of old age, such as dementia, parkinsonism, falls, depression, and urinary incontinence, may be associated with vascular pathology affecting subcortical brain structures. The advent of neuroimaging has brought this more to the attention of clinicians and researchers, with increasing evidence that the common findings of white matter change, and small lacunar infarcts are not entirely benign, as previously assumed. Such lesions are common in elderly populations: only 5% of 1077 subjects aged between 60 and 90 from the Rotterdam study were found to be completely free of white matter lesions. Even in otherwise healthy elderly people, such lesions may impact on cognitive and physical abilities.

Coronary atherosclerosis is a nearly universal finding in people over 75 years old living in developed countries, but is often sub-clinical. Broadly speaking, symptomatic patients manifest coronary artery disease in two distinct ways: chronic stable angina or an acute coronary syndrome. Stable angina produces symptoms of exertional chest pain due to fixed atherosclerotic narrowing of the coronary artery, and requires chronic therapy. In contrast, the acute coronary syndromes, namely acute myocardial infarction (MI) and unstable angina, occur as a result of plaque rupture or erosion leading to acute coronary arterial thrombosis and occlusion that requires emergency hospitalization and treatment.

Since the last review of hypertension in older patients in this journal in 1999, there has been an enormous expansion in the available evidence for management of hypertension. Blood pressure treatment is only one part in an overall strategy of cardiovascular risk reduction. The actual prevalence of hypertension depends on the level of blood pressure used to define when treatment should be started and thus varies between patients depending on their degree of risk. A publication from the University of York NHS Centre for Reviews and Dissemination quoted a figure of over 50% of older people as being hypertensive in 1999. Newer guidelines tend to be encouraging treatment at lower blood pressure levels than previously and some authors now suggest that around 70% of the elderly population could be considered as hypertensive.

A previous review described the literature outlining the characteristics and special needs of older people using accident and emergency (A&E) services, the service initiatives aimed at meeting these needs, and the implications of the findings for UK policy and practice. The review identified a lack of clear evidence to guide the development of specialist services for older people attending A&E. In particular it was noted that there was a deficit of work in the UK context. This seemed, in part at least, to be based on ambivalence about the legitimacy of developing specialist services in the emergency department for this group of patients, despite the large numbers of older people attending. However, the paper also noted encouraging trends and a move away from a preoccupation with whether or not older people were appropriate A&E attenders, to a consideration of how best to meet the particular needs of this group, that paralleled past developments of specialist services for children.

Benign enlargement of the prostate gland does not always cause symptoms or obstruction to the flow of urine. Old terminology, for example, ‘prostatism’ can therefore be misleading, and the British Association of Urological Surgeons (BAUS), the International consultation on BPH and the International Continence Society accept the definitions given below:

Benign prostatic hyperplasia (BPH) is a histological diagnosis. The first pathological signs appear under the age of 40 years, followed by a rapid increase in prevalence with age; 80% of 80-year-olds have evidence of BPH. The onset of BPH is dependent on the presence of functioning testes and increasing age. It is characterized by a combination of atrophy and proliferation in both glandular and stromal tissue. Although BPH is detectable in most elderly men, it does not always cause enlargement of the prostate, symptoms, or obstruction to the flow of urine.

Depression in old age is common, disabling and under-treated. This review will examine recent advances in our understanding of its clinical presentation, epidemiology, management and prognosis. The relationship of depression in old age with dementia and with physical illness is also discussed, as are the links between suicide, deliberate self-harm and depression in old age.

This narrative review of hearing, cognitive impairment and aging considers studies reported in English that have used objective assessment or manipulation of hearing and cognitive performance in participants aged 50 years and above. Its purpose is to provide a general overview of an increasingly technical literature. The lower age limit is arbitrary. For the present purpose, hearing is defined as the detection and interpretation of auditory stimuli, and cognitive impairment is defined as implicit or explicit decline in cognitive function. Existing general overviews of the area are not current, whilst more recent reviews tend to be fairly specialist in scope.

In the last decade, great advances have been made in the understanding of the role of lipid management in the prevention of cardiovascular disease. Epidemiological data from the Framingham study and the Multiple Risk Factor Intervention Trial (MRFIT) have described a causal relationship between lipid and lipoprotein levels and the risk of coronary heart disease (CHD). Hitherto, the emphasis of therapeutic studies has focused on coronary heart disease specifically, especially in terms of treatment with 3-hydoxy-3-methylglutaryl-coenzyme A (HMG-CoA) reductase inhibitors or ‘statins’. The result has been a burgeoning evidence base demonstrating the effectiveness of statins in cholesterol reduction and, more importantly, in the reduction of coronary mortality and morbidity in subjects both with and without established CHD. Given that the vascular system is more commonly regarded as a single entity, with the pathophysiological basis of disease based on the development of atherosclerosis, it has been surprising to find that ischaemic stroke does not share the same robust relationship with cholesterol that CHD does. The lack of a consistent relationship between serum cholesterol and stroke has manifested itself in diverse attitudes towards cholesterol-lowering in cerebrovascular disease; this problem has been heightened by the relative lack of trial data and clinical guidelines on the subject. It is therefore important to review the current evidence regarding cholesterol and stroke and to derive conclusions that translate into the clinical management of cholesterol in patients with cerebrovascular disease.

‘In this world nothing can be said to be certain, except death and taxes.’ To these two could be added rheumatic disease. Only one in 19 of us will escape one or more significant episode of rheumatic disease. Osteoarthritis is the single commonest cause of disability and handicap in Britain. Although arthritis is seen in childhood and early adult life, the burden of joint disease increases with age. The majority of arthritic conditions have a low incidence but a high prevalence. In other words, once you get arthritis, it stays with you. Nodal osteoarthritis is seen in about 70% of women by the end of their lives in Britain, and in 55 to 60% of men. Any inflammatory disorder that damages joints will lead to secondary osteoarthritis (OA). Injury, such as that seen with the menisci of the knees, will also be complicated in later life by secondary OA. Ankylosing spondylitis never burns itself out. This is all very gloomy and perhaps we should all be ordering our bath chairs now.

Stroke is a distressing event and in the western world it ranks in the top three leading causes of death in adults. The number of stroke survivors is increasing because of the improvement in the management of acute stroke. This has resulted in a larger group of patients with important residual physical and psychological impairment. The four major categories of cerebrovascular disease are atherosclerotic thrombosis, cerebral embolism, lacunae and intracranial hemorrhage. In this review, as in other published studies, all categories are defined as a stroke.

Continence is a basic function that should be maintained in healthy elderly people, regardless of age. Loss of continence should be interpreted as a dysfunction of either the lower urinary tract or bowel, or of some other system that participates in the maintenance of continence, especially the nervous system.

Parkinson's disease (PD) is one of the most common neurodegenerative diseases and occurs in all ethnic groups, affects both sexes, and becomes increasingly common with advanced age. With population aging, the impact of PD in human, social and economic terms is growing.