Although the prevalence of acute pain does not increase as a result of aging, chronic pain problems tend to increase in late life. There is also limited evidence that there is a plateau or even a slight reduction in the frequency of chronic pain following the eighth decade of life. Many health conditions that affect older adults are associated with pain, and overall prevalence estimates for this population range from 25% to 65% for community-dwelling older persons, and up to 80% for seniors living in long-term care facilities. The wide variation in prevalence estimates is likely to be due to differences in survey methodologies and operational definitions of pain (e.g. ‘pain during the last week’ vs. ‘pain during the last month’). Nonetheless, a consensus view appears to converge on the conclusion that at least 50% of older persons suffer from at least one persistent or bothersome pain problem at any one point in time. Although many seniors with dementia have difficulty reporting pain due to cognitive impairment, in a large-scale investigation of nursing-home residents, it was shown that conditions that are likely to cause pain occur with equal frequency in residents with and without dementia.

The development of intermediate care services, aimed predominantly at older people, formed a significant part of the UK Department of Health's National Service Framework (NSF) designed to guide the development of services for older people at the beginning of the 21st Century. The stated intention was to provide a more appropriate environment of care for some of the large number of elderly patients who occupied acute beds ‘inappropriately’. The goal was to prevent unnecessarily extended stay in acute care, to improve the outcome of the transition between acute and community care and prevent ‘excess’ dependence, including unnecessary hospitalization and iatrogenic dependence. Despite such positive statements of intent, the plan to create 5000 intermediate care beds in the UK by 2004 led some to voice concern that this heralded a return to ‘workhouse’ wards. Fears were expressed that patients would experience inadequate rehabilitation and diagnostic failure due to lack of proper assessment.

The involvement of service users as active participants is a stated aim of many current developments within health and social care, and self-assessment has been identified as a key mechanism. For over 15 years, the UK Department of Health has referred to the importance of the service user's views in assessment, and this has been re-emphasized recently in guidance issued to both local authorities social services and the NHS. The concept of the expert patient and the promotion of self-care amongst people with long-term conditions are also highlighted as central to current NHS development. Although not specified as such, self-assessment is an important component of these person-centred initiatives which encourage self-diagnosis, self-monitoring and self-management.

In the past, most amputees have been veterans of war or other younger people who have sustained traumatic injury. There are now an increasing number of older people undergoing lower-limb amputation, most commonly because of vascular problems. Anecdotal evidence suggests that there is a lack of support for patients facing limb amputation, and a lack of recognition from staff that these patients may be at risk of ongoing psychological problems following the procedure.

‘The current care systems cannot do the job. Trying harder will not work. If we want safer, higher-quality care, we will need to have redesigned systems of care, including the use of information technology to support clinical and administrative processes.’

Disequilibrium, or imbalance, is a type of dizziness typically described as a feeling of unsteadiness when standing or walking that is not present while sitting or lying down. Patients with disequilibrium often complain of vertigo, lightheadedness, or a similar ‘head’ sensation as the main symptom, but disequilibrium also occurs in isolation. The first step in determining the cause is to define exactly what the patient is experiencing, and any associated symptoms. The complaint of imbalance is very common among older people. Since the population is quickly aging, we can only expect the number of patients presenting with it to increase. As a result of this frequent presentation and the many potential causes of the symptom, some authors even argue that disequilibrium should be considered part of a geriatric syndrome. Further complicating the evaluation is the fact that most elderly people have at least one chronic disease and are taking several medications, factors that could contribute to, or even cause, disequilibrium. Signs on examination that could indicate early features of neurodegenerative disorders are also common in older people. Because dizziness and imbalance have a strong association with falls, searching for a reversible disorder and directing attention to fall-prevention strategies are paramount. Falls themselves are a major source of morbidity and mortality in the elderly population.