The use of the term ‘technology’ in relation to dementia care provokes conflicting reactions. For some, ‘technology is a saviour, the way to paradise; others are deeply suspicious of technology and scrutinize its proponents carefully for any tell-tale marks of the Beast’. These conflicting reactions may be attributed to the confusion surrounding the term ‘technology’, the lack of awareness at all levels of the potential of technology to assist people with dementia, and the ethical issues surrounding the use of technology.

This article will first set rehabilitation nursing and the older person into an appropriate context and then address the nature of rehabilitation nursing, how definitions have developed over time and lastly, what it is that we now provide, in conjunction with others, to meet the rehabilitative needs of our older population. The boundaries defining ‘old’, and between seeing a person as experienced, a bit wrinkly, forgetful and perhaps eccentric, versus a person who is old and demented are by no means clear-cut.

There is overwhelming evidence to suggest that the neuropathology of Alzheimer's disease (AD) extends beyond amyloid plaques and neurofibrillary tangles. There is a clear overlap between the pathology of AD and vascular dementia (VaD), but the relationship is different for different types of vascular lesion. Cerebral amyloid angiopathy (CAA) and degeneration of the microvasculature are probably intrinsic to the AD process, whilst ischaemic white matter disease and areas of infarction are largely independent of AD pathology, but result in additional cognitive deficits and reduce the threshold of AD pathology necessary for the emergence of a clinical dementia syndrome.

Rehabilitation can be described either as a set of technologies, akin to drug treatment, or as a person-centered process. We will use both frames of reference in this review. Our orientation in Part 1 will be technological, with initial consideration of the pathophysiology of parkinsonian impairments, before examining the rationale for non-drug interventions in Parkinson's disease (PD). In Part 2 we describe how the process of rehabilitation can be applied in a progressive disease such as PD.

The upper limb (UL) is a common site for poststroke pain, which is often regarded as a direct consequence of proximal motor impairment. Although the subacromial region is the commonest site, pain can also occur lower down the UL and some causes are not directly related to hemiplegia. As distal clinical features unrelated to motor consequences of stroke can be useful for making a management plan for pain, this review will generally refer to poststroke upper limb pain (PULP) rather than use traditional terms such as hemiplegic shoulder pain (which may erroneously imply a proximal, purely motor related aetiology).

Rehabilitation is a necessary step in the process of recovery from most serious illness and from many clinical interventions. The nature of rehabilitation, and the form of any programme of rehabilitation provided to help patients with this process, depends greatly on patient, illness, treatment or intervention, co-morbidity and on the availability of appropriate services. Heart disease is the leading cause of death in most developed countries and acute myocardial infarction (MI) is a major cause of acute medical admissions to hospitals, and revascularization by coronary artery bypass graft surgery (CABG) is a leading surgical intervention. Both MI and CABG involve a day or more in intensive care followed by several days recuperation in hospital. There is a fairly obvious case for rehabilitation for patients surviving the truly life-threatening experience of MI (20% sudden deaths and a further 10% die within 24 hours of onset of pain), and for patients following the major ‘trauma’ of open heart surgery (operative mortality about 1%). The specific needs of these two groups may differ because their experiences differ; one medical the other surgical, and, possibly more significantly, one unexpected, the other planned.

The aims of psychosocial intervention for people with early-stage dementia are essentially those of rehabilitation. That is to say, the focus should be an attempt to optimize functioning and wellbeing, and to support the person’s social system, thus facilitating continued engagement and participation. It can be argued that a focus on rehabilitation is consistent with the person-centred approach advocated by Kitwood, emphasizing the potential disabling effects of negative social environments and the importance of attempting to counter the resulting excess disability and thus support the selfhood of the person with dementia.

Falls, once thought to be an inevitable consequence of aging are now known to be the result of multiple pathological, psychological and social factors. Moreover, well-conducted research has shown that they can be prevented. Initially it appeared that multiple interventions by a multi-disciplinary team would be the most sensible and indeed the only effective approach. However, single interventions may sometimes be appropriate and on cost grounds would be preferable, provided that they are effective. This is clearly the case in the use of pacemakers for patients who are falling because of cardioinhibitory syncope. However, home modification, a seemingly obvious and intuitively correct intervention, has not been shown to prevent falls, although advice from an experienced occupational therapist can reduce falls, especially in those who have fallen previously. Whether balance training on its own is effective in reducing falls, or needs to be combined with muscle-strengthening exercises and other interventions, will be examined.

A basic notion relating to development during adulthood and old age, according to a lifespan perspective, refers to the progressive increase in individual differences in psychological wellbeing. It is possible to find diverse ‘health trajectories’, shaping patterns of evolution regarding the general health of adult and elderly individuals, such as (1) permanent good health (2) good health most of the time and decline by the end of life (3) health decline and recovery (4) permanent poor health, (5) progressive decline and (6) irregular health.

The increasing number of older people requiring interventions for improved health and social care has been identified as a crucial challenge for the twenty-first century. The reported high prevalence of pain in older people in long-term care facilities has been described as a public health issue not only in the USA but also globally. Rather than merely extending life, the reduction of morbidity, ways of coping with disability, preventing incapacity, extending the quality of life and enhancing the functional independence of older people are identified as important components of service provision. In Britain, the number of people aged over 65 years has doubled in the last 70 years and the number of people over 90 years is expected to double in the next 25 years, which will increase the need for health care in the future. Estimates for the UK indicate that approximately 445 800 older people are currently resident in care homes. The UK government has recently pledged to provide high-quality care and treatment for this population, to treat older people with respect and dignity and to allocate fair resources for conditions that affect them, while simultaneously easing the financial burden of long-term care.

The Government’s National Health Service Plan followed by the English National Service Framework for Older People (NSF) has sparked widespread discussions, debates, research agendas, service developments and resource allocations surrounding ‘intermediate care’. In the UK there has been no universally accepted definition for the term. Different authorities have defined intermediate care in different ways.

Over the last two decades, the care home sector has been a significant provider of long-term care for older people, with 11 500 homes providing care for 236 700 people across England and Wales. New admissions to residential care homes are increasingly older, aged 80 and over and have high levels of physical dependency, cognitive impairment and behavioural problems.

The growing number of old and very old people in the United Kingdom is attracting increasing attention, particularly with respect to the cost of providing institutional, residential and nursing home care. It is estimated that about 6% of people will require this type of care and the current annual cost is over 3.5 billion pounds. In the United Kingdom, provision of institutional care for elderly people has undergone significant change in the past two decades, with a shift from National Health Service provision of long-term hospital care to the current dominant role of private home care by independent commercial sector providers.

The publication of the Black Report in 1980 is rightly seen as a landmark in the acknowledgement of an association between poverty and increased incidence of and premature mortality from a wide range of diseases. However, an increased incidence of disease with certain lifestyles or habits has been recognized since the time of Hippocrates, who identified ‘the mode in which inhabitants live, and what are their pursuits, whether they are fond of drinking and eating in excess’ as determinants of illness.