Parkinson's disease (PD) is a progressive neurodegenerative disease characterized typically by motor features of tremor, rigidity and bradykinesia due to depletion of dopaminergic nigrostriatal neurons. PD is increasingly recognized as a non-motor disorder since symptoms such as dementia, depression and falls emerge with disease progression to become dominant in the clinical picture. PD results in a significant decline in quality of life for both patients and family and contributes to significant economic and institutional costs on family and society. PD is uncommon before the age of 40 but affects approximately 1% of patients over the age of 60, with a rising incidence and prevalence thereafter to around 2% in the population over 80 years of age.

Improvements in health care together with superior standards of housing, nutrition and hygiene have led to an increase in average life expectancy, with a fifth of the UK population being over 60 years of age. Skin problems are common in elderly people: one study of 20 000 non-institutionalized US citizens found a significant dermatological problem in 40% of those aged 65 to 74 years. This review aims to discuss some common and important dermatological conditions seen in the elderly population and provide guidance on diagnosis and management.

Historical milestones in basic research on aging include (1) the demonstration that caloric res-triction (CR) increases average and maximum lifespan in rodents; (2) the proposal that oxidative stress is a major risk factor in the development of age-related pathology; and (3) the demonstration that human fibroblasts grown in culture have a finite lifespan. Thus, although research related to aging has been going on for well over 50 years, particularly on the age-related pathologies associated with aging, serious efforts to understand what factors modulate longevity are fairly new, and progress in this area is due primarily to the identification of genes that modulate longevity in short-lived animal models. Prior to 1980, the main focus was on describing aging phenomena in humans and rodents, and testing the various theories of aging resulting from these early observations. As the techniques of molecular biology were increasingly incorporated into aging-related research, it became possible to ask more mechanistic questions, and considerable progress was made during the period 1980–2000, largely because of the development of short-lived fruit fly and nematode models in which to study aging, followed by the sequencing of the genomes of these organisms. For example, this work quickly led to the discovery that the insulin-signalling pathway plays a major role in modulating longevity, not only in these organisms, but also in rodents and probably primates.

Aging is associated with impairments in maintaining homeostasis in response to physiologic and environmental disturbances. These age-associated impairments include alterations in metabolic and neuroendocrine function. Leptin is a hormone mainly produced in and secreted by adipose tissue, and mutations in the leptin gene are associated with extreme obesity and neuroendocrine impairments, including impaired reproduction and low sex hormones, low thyroid hormone, low growth hormone, and elevated glucocorticoids. Leptin replacement reversed many of the phenotypes of leptin-deficient mice. Fasting reduces leptin gene expression and fasting-induced neuroendocrine alterations are also reversed by leptin injection. However, it was quickly apparent that leptin is highly correlated with total fat mass, and obesity is associated with elevated, rather than reduced, leptin levels in both rodents and humans. Thus, increased adiposity is associated with leptin resistance. Since aging is associated with dramatic changes in adiposity and neuroendocrine impairments similar to those observed in leptin-deficient and leptin-resistant animals, leptin resistance and/or insufficiency might contribute to some of these age-related metabolic impairments.

A recent international definition of under-nutrition or malnutrition has been given by the WHO. Mal-nutrition means ‘badly nourished’ but it is more than a measure of what we eat, or fail to eat. Clinically, malnutrition is characterized by inadequate intake of protein, energy, and micronutri-ents and by susceptibility to infection or disease. Nutritional status is the result of the complex interaction between the food we eat, our overall state of health, and the environment in which we live – in short, food, health and caring are the three ‘pillars of well-being’.

Inflammation is an innate immunological response that fends off or repairs injuries caused by foreign agents as part of an essential defence mechanism. There are two main classifications of the inflammatory process, based on its intensity and time-dependent responses: an acute, rapid response with resolution or a low-grade, chronic process without resolution. In this review, the latter case of a long sustaining inflammatory process is discussed in relation to aging. Many epidemiological and experimental studies in recent years report on the age-related activation of inflammatory processes by showing age-related increases in the activities of many pro-inflammatory mediators such as, NFkß, TNFα, IL-1, IL-6, C-reactive protein (CRP), thromboxane A, adhesion molecules, and free fatty acids.

The human lung is a resilient and complex organ, capable of uninterrupted functioning without defect over a lifetime. While there is a body of knowledge regarding macroscopic and physiological changes that occur in the lung with age, there is still much to be understood. In itself this is not surprising given the complex interaction of intrinsic and extrinsic factors that might play a role in these changes. Lung tissue is highly susceptible to environmental factors, which can have an impact over the course of a lifetime, including smoking, pollutants, occupation and nutrition.

There is growing support for characterizing human aging from a life-course perspective, in terms of recognizing important influences operating from conception to death, and this approach provides a framework for understanding aging processes operating at the individual level. Kirkwood's disposable soma theory proposes that aging is a manifestation of imperfect somatic maintenance and repair processes. We can therefore predict that differing exposure to the determinants of somatic damage across the life-course, and variable capacity to respond in terms of repair are likely to underlie the wide variation in rates of aging between individuals.

Older people in residential or nursing care may have needs comparable with those of a healthy person living in the community, compounded by additional health-care needs. Sexual needs can be ignored or pushed into the background, with barriers created to their expression and satisfaction.

Peripheral neuropathy encompasses disorders of the peripheral nervous system, affecting the axon and/or the myelin sheath. The prevalence of peripheral neuropathy increases with age. Thought to be of about 3000 per 100 000 in adults generally, this figure could be as high as 8000 above the age of 60 years. However more than half of these cases would be due to impaired glucose metabolism in its various forms. In the remainder, an aetiology may be found in about 70% of cases. The elderly population is at higher risk of peripheral neuropathy, as there is a correlation between age and impairment of the peripheral nervous system. The natural aging process affects adversely the function of peripheral nerves and of their target organs, resulting in the development of motor, sensory and autonomic symptoms in the absence of additional damage of other causes. In addition, the increased prevalence of chronic systemic disorders causing neuropathy, as well as the use of neurotoxic drugs in older patients, contribute to the onset of neuropathy.

The suggestion from post-mortem studies that there is an age-related fall in liver weight has been confirmed by in vivo studies, employing ultrasound or CT scanning. These demonstrate an estimated 28% lower volume in individuals above the age of 65 compared with those under 40 years of age. The functional significance of the fall in liver size with age is confirmed by the highly significant correlation between age, liver volume estimated by ultrasound and galactose elimination, the clearance of which is determined by functional hepatic mass this fall in mass of functional hepatocytes is also illustrated by an age-related reduction in binding of radiolabelled galactosyl-albumin. Liver blood flow, estimated by pulsed echo-doppler, or functional hepatic flow measured by the hepatic clearance of D-sorbitol or indocyanine green, falls significantly with aging, with around a 33% fall between youth and old age., The thickening of the sinusoidal endothelial lining with collagen, and fall in endothelial cell fenestrations, noted with increasing age in human liver, is likely to impair blood flow through liver sinusoids and hepatic perfusion, and reduce oxygen-dependent hepatocyte function, such as uptake of macromolecules. This may contribute to the link between the aging process and disease susceptibility.

With an aging population globally, and increasing numbers of older patients facing chronic illnesses, better palliative care in old age should be promoted.In this review we will

1. Highlight the pressing need for better palliative care for older people

2. Advocate the concept of palliative care as applied to geriatrics and gerontology

3. Review current end-of-life care for older people with chronic disease, both non-cancer and cancer

4. Discuss the palliative-care approaches to common physical symptoms and psychospiritual distress

5. Highlight advanced care planning and quality-of-life issues

Heart failure is predominantly a disease of older patients, and varies in its severity and presentation. Advances in the understanding of both the pathophysiology and approaches to treatment for patients with heart failure have resulted in marked improvements in prognosis over the past 20 years. In younger patients, heart failure is often a consequence of myocardial infarction, with resultant left ventricular remodelling and dilatation, while it is more likely to be due to hypertension, valvular heart disease and atrial fibrillation in older patients. Other heart-failure aetiologies include the cardiomyopathies and reno-vascular disease, and additional non-cardiac disease such as anaemia can result in a symptomatic deterioration.

Diuretics are commonly prescribed in older people and are often used for prolonged periods. Indications for their use include heart failure and hypertension. They are also used to empirically treat complaints such as swollen ankles and shortness of breath. The aging body is particularly susceptible to the adverse effects of diuretic therapy. Many of the problems are a result of intravascular and extravascular fluid imbalance. It is therefore important that diuretics are prescribed rationally and with good reason. Most major clinical trials do not include older people with multiple co-morbidities. This review will consider whether trials involving diuretics are any different, through an evaluation of what evidence there is to support diuretic use in older people. We will also evaluate the evidence which implicates diuretics as a cause of common clinical problems such as falls, postural hypotension and incontinence. Finally, a rational approach to the use of diuretics in older people will be suggested so that the benefits of diuretic therapy can be maximized and potential adverse effects minimized.

Age has been identified as the single most impor-tant demographic predictor of blindness and visual impairment. Visual impairment is the second most prevalent physical disability in the elderly population. The prevalence of blindness and visual impairment after 60 years of age increases significantly. Furthermore, the number of older people with functional vision impairment is expected to double in the next decade. Visual impairment in the elderly population is commonly due either to localized ocular pathology (cataracts, glaucoma and age-related macular degeneration) or systemic disease with associated ocular or visual pathway involvement (hypertension, diabetes and cerebrovascular disease). Physicians involved in the care of older people play a crucial role in the recognition, prevention and management of morbidity related to visual impairment in this population. Timely screening, referral, intervention and visual rehabilitation is thought to be capable of reducing new blindness and visual impairment by at least one-third.

Substance use and misuse are best viewed through the framework of a multifactorial biopsychosocial model, which acknowledges the interplay of genetic, familial, physiological, psychological and social factors. Age, role, gender, social group and peer pressure, the family, community and occupational environment, as well as overall cultural values and controls on substance use, will act upon substance-taking behaviour.

The World Health Organization's definition of anaemia is a haemoglobin level of less than 13g/dL for men and less than 12g/dL for women. Haemoglobin levels have been shown to decline with age, making anaemia a relatively common problem among older people. Because of this fall in haemoglobin with age, there has been some debate about whether an age-related reference range should be used. However, most clinicians believe that, because of the association between anaemia and increased risk of morbidity, mortality and hospitalization, the normal haemoglobin range should not be lowered for older people.

Myopathy is a convenient shorthand term meaning muscle disease or dysfunction. In other words, the myopathies are those conditions in which the patient's symptoms and signs can be attributed to a pathological process affecting either the structure of muscle fibres or their associated interstitial tissues, or to disturbance of the biochemical or electrophysiological function of those fibres. Myopathies are rare in all age ranges. They may be inherited or acquired. Onset of inherited myopathies in elderly people, not surprisingly, is uncommon, but some of these diseases are asymptomatic, or cause such minor symptoms that their significance is not appreciated by the patient, and thus they may not be recognized until late on in life. Their recognition may have implications for other, younger, family members. Many of the acquired myopathies afflicting older people are treatable, but the commonest, inclusion body myositis, is not, and incorrect diagnosis and inappropriate use of steroids may compound morbidity.

Coeliac disease (CD) is a chronic enteropathy caused by intolerance to gluten in genetically susceptible people. The first description of the coeliac lesion was provided in 1954 by Paulley et al, who examined full-thickness biopsy specimens taken at laparotomy from a patient with CD. They referred to broad flat villi and a dense chronic inflammatory cell infiltrate in the small intestinal mucosa. Following this, the use of unguided suction biopsy devices, such as the Crosby capsule, allowed the study of patients with malabsorption. The advent of fibreoptic endoscopy as a diagnostic tool has led to extensive study of the duodenal mucosa in less florid forms of CD.

Sleep disturbance is a clinically significant problem in nearly one half of patients with dementia and is a predictor of cognitive and functional decline. There are multiple causes of sleep disturbance in dementia and all represent diagnostic and management challenges. Impaired circadian rhythm is a disorder characterized by an increase in daytime sleep with reduced night-time sleep, a reversal of the sleep/wake cycle. Such disrupted circadian rhythm may occur early in Alzheimer's disease, worsen over time, and is associated with behavioural disturbance, including aggression. In addition to the timing of sleep, the structure of sleep may deteriorate, giving rise to poor sleep quality.