Editorial

Whilst preparing this editorial, I was struck by the ambivalent attitudes displayed towards older people in Western society. In London, for example, the crowds thronging the Mall and cheering the Queen Mother for reaching her centenary belied the fact that society generally treats its older members with disdain. That is, until they reach 100 years and then everyone wants to know the secret of their success.

Editorial

Even a decade ago, there was compelling evidence that, as older individuals age, a decline in caloric intake is observed, with as many as one in five subjects aged 60 years and over consuming less than 1000 calories per day. Those from ethnic minority backgrounds or nursing homes were particularly at risk of malnutrition. In many cases, this decline can be confidently attributed to the presence of disease and co-morbidities such as chronic illness (for example, chronic pulmonary lung disease) with results in weight loss. Other factors such as decreased resting metabolic rate, reduced physical activity, threshold alterations in taste-bud activity or lowering of smell acuity, provide background inhibitory influences on nutritional intake.

Introduction

Single organ therapy for medical specialties, general medicine and its subspecialties, has increasingly failed a number of groups of people over the last 200 years or so. The largest group were elderly people who were summarily dismissed from the Infirmaries from the days of their building as ‘vagabond beggars, incurables and elderly’.The vagabonds at least were welcomed after 1948, when the NHS diverted attention from people's cheque books and on to their illnesses. However, other groups have continued to suffer from the tyranny of single organ care, notably the ‘incurables’, young chronically sick people and those who were not capable of ‘getting better’ immediately. The lack of good, consistent mycocardial infection advice, despite excellent research findings, and a lack of rapid admission and full rehabilitation services for stroke victims remain a matter for concern in general medicine. How will new changes in the NHS, especially the development of Primary Care Groups (PCGs) and Trusts affect geriatrics?

Editorial

It was Benjamin Franklin who wrote that the only two things that one can be certain of in life are death and taxes. Those of us working in the health service in the United Kingdom would probably want to add change as the third certainty. No one was surprised, therefore, when New Labour, in their first White Paper on health, introduced us to a vocabulary of reforms with their now widely-used initials and acronym. These included HIPs (health improvement programmes), NSFs (national service frameworks), NICE (National Institute for Clinical Excellence), CHI (Commission for Health Improvement) and, to replace fund-holding, a new organization for general practice, the PCG or Primary Care Group.

ob/ob mice with mutations in the obese gene are extremely obese and hyperphagic and have characteristic neuroendocrine impairments, including impaired reproduction and low sex hormones, low thyroid hormone, low growth hormone, and elevated glucocorticoids, a pattern also observed in fasting mice. The product of the obese gene, called leptin, was originally characterized on the basis of positional cloning. Injections of leptin not only reversed many of the phenotypes of ob/ob mice, many of the neuroendocrine effects of fasting are also reversed by leptin injection.

In this review, the principal morphological and functional changes which occur in relationship to aging in both the genital tract and lower urinary tract are discussed. Aging of the upper urinary tract is not considered.

Much of the evidence for age-related changes comes from cross-sectional studies with their inherent methodological limitations. Furthermore, it is difficult to accept ‘normal aging’ criteria that do not take into consideration the role of the acute and chronic disease so prevalent in elderly people. Thus, more longitudinal studies are needed in order to provide a more exact analysis of the influence of aging on the urogenital system, as for all other systems of the body.

Aging processes are time-dependent, deteriorative functional changes. These functional changes lead to a progressive loss of the organism’s ability to withstand both internal and environmental stresses, causing the failure of cellular homeostasis. Among the modern hypotheses, the ‘Oxidative Stress Hypothesis’ offers the best mechanistic elucidation of aging phenomena. Based on the ‘Free Radical Theory of Aging’, this hypothesis has gained popularity among researchers in the field of gerontology as well as other biomedical fields. Its primary premise proposes that aging and its related disease processes are the net result of free radical-induced damage, asserting further that an organism’s inability to produce counterbalancing antioxidative defences, i.e. defences that offset disturbances in the redox state, underlies its cause.

Many changes occur in the aging immune system, which culminate in its functional decline, but the underlying mechanisms have proved difficult to define. Wick and Grubeck-Loebenstein have recently classified the changes in function as either primary ‘those that occur in perfectly healthy older individuals’ as the result of ‘an age dependent intrinsic decline of immune responsiveness’ or secondary ‘those that are due to underlying disease or various environmental factors including diet, drug intake, physical activity, etc’. Both types of alteration are important when considering immune dysfunction in older people which seems to be centred on the loss of cell-mediated immunity, in particular the activity of CD4 helper T lymphocytes.

Active lifestyles are associated with better health and lower rates of mortality from all causes. Increasing activity levels also have positive effects on many of the risk factors for developing chronic disease and on mortality rates (see Figure 1).

Evidence to support these claims, at least for middle-aged men, has accumulated steadily over the last 20 years. This review presents evidence that physical activity can contribute to health and wellbeing in old age.

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

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.

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.

Introduction

This is the last in a series of three papers reviewing 69 patient-based outcome measures that have been developed specifically for use in older people, or that have been administered to populations that include older people. The previous papers described how the measures were identified, and provided brief descriptions of measures of general health status and quality of life, instruments assessing mental status, measures of depression, and measures of psychological wellbeing. In this paper we describe six pain measures, 12 measures of physical disability and handicap, and eight measures of social health (see Tables 1–3). References in the text which include a copy of the questionnaire are marked with a # sign. Otherwise, a copy can be obtained from the address provided. It is recommended, however, before using any of the questionnaires to contact the authors to obtain permission to use them.

A previous review dealt with the management of chronic pain in old age and attempted to provide an up-to-date account of management at that time. The present review will try to avoid going over the same ground but will discuss more recent developments in pain medicine, with an emphasis on those aspects relevant to the management of older patients.

This is the second in a series of three papers reviewing 69 patient-based outcome measures that have been developed specifically for use with older people, or that have been administered to populations that include older people. The first paper described how the measures were identified, and provided a brief description of 17 measures of general health status and quality of life. This paper reviews nine measures of mental status and cognitive function, 10 measures of depression and anxiety, and seven psychological wellbeing measures (see Tables 1-3).

Introduction

The methodology of quality of life measurement has developed markedly in the last few years. Clinicians and researchers have increasingly acknowledged that the burden of illness can not be described only in terms of disease status. Measurement of psychosocial factors such as pain, restricted mobility, difficulties fulfilling family or work responsibilities, and psychological wellbeing provides a far more comprehensive and meaningful assessment of the impact of disease on the patient’s life. Similarly, such patient-based measures are increasingly replacing traditional clinical or disease indicators as the primary measures of outcome in clinical trials.

Introduction

With their ease of administration, relatively benign side-effect profile and safety in overdose, in the United States the selective serotonin reuptake inhibitors (SSRIs) have become de facto first choice in the treatment of geriatric depression, displacing tricyclic antidepressants (TCAs). In this paper, the relevant literature regarding neurochemistry, kinetics, dosing, efficacy and differential side-effect profiles of citalopram, fluvoxamine, fluoxetine, sertraline, and paroxetine, the five currently available SSRIs in the USA, will be reviewed with special emphasis on geriatric data. Of late, considerable controversy has been generated regarding whether SSRIs are as effective as TCAs in severe and melancholic depressive subtypes. This important issue will be explored and the relative utility of all the SSRIs in the elderly patient compared and contrasted. Finally, reasons for difficulties in comparing results across studies will be elucidated.

Introduction

Dementia is a syndrome which involves progressive disturbance of multiple cognitive functions, emotional control and social behaviour in clear consciousness (International Classification of Diseases, ICD-10).1 Alzheimer’s disease (AD) accounts for more than 50% of all dementias and hence is the most widely studied. Although Alzheimer’s first description of the condition included noncognitive features like hallucinations, delusions and screaming,2 most research has focused on the cognitive features, i.e. memory loss, perceptuo-motor skills and language disturbance.

Constipation is a common complaint in geriatric patients, especially when older people are asked specifically about their bowel habits. It can cause serious complications, such as recurrent urinary tract infections, urinary incontinence, faecal incontinence and even bowel obstruction and perforation. As a result of the tremendous advances in understanding of the epidemiology and pathophysiology of constipation in the older patient, the definition of constipation has changed considerably, leading to the development of new treatment options.

Introduction

Longevity has lengthened in recent times. This has resulted in an increase in the elderly population, with life expectancy at birth in men in the UK being approximately 72.5 years and women, 78.5 years. Despite the risk of death from cardiovascular diseases decreasing in the past 40 years, these still continue to be the largest cause of mortality in the elderly. Cardiovascular mortality and morbidity are lower in women. However, this is not true in the later years of life. After the age of 80, the risk of cardiovascular problems increases to that of men. The cardiovascular changes occurring with aging consists of changes in the heart and arterial system.