Neurocardiovascular instability (NCVI) is defined as ‘age-related changes in blood pressure and heart-rate behaviour, predominantly resulting in hypotension and bradyarrhythmia’ The four most common presentations of NCVI are orthostatic hypotension (OH), carotid sinus hypersensitivity/syndrome (CSH/CSS), vasovagal syncope (VVS) and post-prandial hypotension (PPH), although there is considerable overlap between these conditions. The criteria for diagnosis of these syndromes are given in Table 1. Clinically, these conditions manifest as dizziness, falls, pre-syncope and syncope. Older people are more susceptible to NCVI because of age-related physiological changes in the cardiovascular system, the autonomic nervous system, and humoral control of blood pressure. These neurocardiovascular changes are further complicated by co-morbidity and polypharmacy in older people.

Falls are predominantly a problem of older people. In the UK, people over 65 currently account for around 60% of admissions and 70% of bed days in hospitals. There are approximately half a million older people in long-term care settings – many with frailty and multiple long-term conditions. The proportion of the population over 65 years is predicted to rise 25% by 2025, and that over 80 by 50%, with a similar increase in those with dependence for two or more activities of daily living. Despite policies to drive care to the community, it is likely that the proportion of older people in hospitals and care homes will therefore increase. Accidental falls are the commonest reported patient/resident safety incidents. Similar demographic trends can be seen in all developed nations, so that the growing problem of fall prevention in institutions is a global challenge. There has been far more focus in falls-prevention research on older people in ‘community’ settings, but falls are a pressing issue for hospitals and care homes, and a threat to the safety of patients and residents, even if a relatively small percentage of the population is in those settings at any one time.

The last three decades produced a striking increase in investigations of the neurobiological basis of brain aging and aging-related changes in neural and cognitive function. Experimental and clinical studies of aging have become more valuable as the population, at least in industrialized countries, has become ‘greyer’. The increase in adult life expectancy that occurred in the twentieth century produced the motivation and necessity to invest resources in increasing ‘health span’ as well as lifespan, in order to maximize quality of life and minimize the financial and social burdens associated with disability in the later years of life. Specific interest in the aging nervous system is driven by recognition that increased longevity has little appeal for most people unless it is accompanied by maintenance of cognitive abilities. Indeed, surveys of older individuals routinely show that loss of mental capacity is among their greatest fear. In recent years, neuroscientists and gerontologists, with a variety of training and experimental approaches, have applied increasingly powerful quantitative methods to investigate why neural function declines with age. New animal model systems have been developed and old ones have become better characterized and standardized. The necessary and important descriptive studies that dominated the field in earlier years are increasingly supplemented by more hypothesis-driven research, resulting in sophisticated investigations and models of the mechanisms of brain aging. This review provides a selective overview of recent and current research on brain aging. The focus throughout will be on normal brain aging and the moderate cognitive changes that often accompany it, not on aging-related neurodegenerative diseases that result in dementia. To provide a context for studies of neurobiological changes in the aging brain, a brief overview of the types of cognitive changes that are commonly seen in aging humans is first provided. The remainder of the review focuses on animal studies that are progressively overcoming the unique challenges of aging research to reveal the neurobiological mechanisms of aging-related cognitive dysfunction, and suggest new targets for therapies to prevent or ameliorate cognitive decline.

The daily clinical practice of geriatric medicine is a grapple with complexity. The elderly patients who come to geriatricians typically have multiple, interacting, age-related physiological impairments, some of which manifest as medical problems. These interact with various social vulnerability factors to put them at risk, and to define them as being frail. This view of frailty, as a multiple-determined state of vulnerability has broad support, but how best to operationalize frailty is rather more controversial. Some of the proposed operational definitions receive more widespread support than others. In particular, the ‘phenotypic’ definition of frailty used in the Cardiovascular Health Study (CHS) has been endorsed at consensus conferences and employed by several groups. Indeed, it has even been claimed that ‘the terms “frail” and “frailty” should be avoided except when used in the context of a CHS assessment.’

Pressure ulcers are the visible evidence of pathological changes in the blood supply to dermal tissues. Pressure ulcers are rare, affecting only about 0.5% of the total population. The distribution is clustered into two groups, peaking once in younger, mostly neurologically impaired persons and again in older persons. The cluster in the geriatric population accounts for about 70% of all pressure ulcers.

Average world life expectancy has seen a dramatic rise over the last two centuries although active life expectancy remains relatively unchanged. One reason for this is that aging results in skeletal muscle becoming smaller, weaker and more susceptible to contraction-induced injury. By the age of 70, muscle strength is reduced by around 30–40% and this can have catastrophic effects on quality of life. Despite a vast amount of research into age-related changes in skeletal muscle, the exact mechanisms responsible for this is still unclear and thus treatments to preserve muscle function with aging remain elusive.

In the context of an aging population, the importance of falls and their prevention has arguably never been greater. Both injurious and non-injurious falls are a frequent occurrence resulting in potentially devastating physical and social consequences. In recent years, there has been a marked expansion in falls research, meta-analysis, and local and national management guidelines, reflecting increased multidisciplinary professional and public awareness of falls.

The improvements of socio-environmental conditions, medical care and quality of life have caused a general improvement in the health status of the population and a consequent reduction of morbidity and mortality, resulting in an overall increased life-expectancy. The role of immunosenescence was negligible in the past, when the human lifespan was 40–50 years, and its impact on morbidity and mortality has emerged in combination with the extension of lifespan. Immunosenescence results from multifactorial processes that act on all components of the immune system. The changes associated with immunosenescence are playing an increasingly important role in the emergence of a series of age-related pathologies, conditioning the present epidemiology of old people.

People of 65 years and older accounted for 21% of the population of England and Wales in 2001, and their proportion is increasing. It is forecast that the number of people over the age 75 years will double within the next 50 years, and that of those over the age of 90 will increase fivefold. The older patient with declining health poses significant challenges for health care professionals, in particular those of managing chronic morbidity and the effects of aging. Many older people require pharmacological treatment for multiple, co-existing pathologies. Those of 65 years and over receive 56% of all prescriptions in England, of which 78% are repeat prescriptions, and people in residential care, on average, receive five different medicines concurrently. The impact of repeat prescriptions means that, due to inadequate monitoring, many older people continue to administer medicines they no longer require, and thereby risk receiving an inappropriate drug, dose or duration of treatment. In addition to this, there is the propensity for older people to mismanage medicines, increasing their risk of unplanned drug-related admission to hospital and drug-related morbidity.

The world population is aging rapidly. The post World War II ‘baby boomers’ have benefited from improved medical science, sanitation, political freedom, and social and economic development, resulting in the knock-on demographic trend of an aging population. From a health-economic perspective, this places increasing demands on society and on health services to meet evolving medical and social needs. By 2025, over 30% of the populations of developed countries will be aged over 60 years (US Bureau of Census 2004).

Frailty as a concept has been around in medical practice for many years but has only relatively recently been established as a medical syndrome. Although frailty is not synonymous with chronological age, it is recognized to be more common as people get older. Frailty is independently associated with increasing dependency, hospital admissions and morbidity and mortality. As populations age, frailty will become more of a challenge to health care systems. It is important that health care professionals, especially geriatricians, are aware of this emerging syndrome and its potential adverse outcomes, as well as measures to reverse and slow its progress. The aim of this review is to discuss the definition, identification and potential treatment options for frailty, most relevant to the practising clinician.

Orthostatic hypotension (OH) is a clinical condition which frequently results in troublesome symptoms such as dizziness, giddiness, blurred vision and light-headedness. It is a common disorder associated with an increased risk of falling, especially in older individuals. OH is the presenting haemodynamic manifestation of several different and diverse underlying pathological conditions, including disorders of blood pressure (BP) regulation and disorders leading to reduced intravascular volume. In younger and middle-aged adults, the presence of OH should not be considered a primary diagnosis in itself but rather a starting point in the diagnostic pathway before the primary underlying abnormality has been identified. In older patients however, asymptomatic blood pressure drops are very frequently encountered so that, in certain cases, an exhaustive diagnostic search for an underlying cause is not warranted. However, reversible causes of OH do frequently exist in older patients. Prominent among these are the use of several commonly prescribed cardiovascular drugs and vitamin B12 deficiency.

Over the last three decades there has been a change in attitude to the care of patients after stroke from a somewhat nihilistic stance to a predominantly acute focus with potential for rehabilitation. More recently there has been a widening of perspective, with recognition that stroke is a long-term condition. Aligned with this has been a gradual shift in focus from a primarily biomedical approach to stroke care, to one that considers the psychological and social elements of the poststroke experience. However, the evidence base for stroke is still dominated by prevention and early-care treatments: only eight of the 238 recommendations reported in the UK national clinical guidelines for stroke specifically address longer-term management. The Australian clinical guidelines for stroke offer a similar pattern: 22 (14%) of 162 recommendations relate to community participation and organization of longer-term support. However, ongoing research efforts to develop and evaluate interventions for longer-term stroke care are beginning to address the imbalance in the evidence base. In our previous review, surveys reporting the types and prevalence of longer-term problems experienced after stroke were summarized and synthesized within a structured framework. The review demonstrated the complexity and diversity of the longer-term stroke experience, and highlighted the challenges that support services face in meeting the needs of patients and carers living with the aftermath of stroke. Keeping abreast with this challenging subject area is key to promoting the continued development of stroke services. This review is an update of our previous work, presenting the most recently published data on the prevalence of longer-term stroke-related problems.

Interest in homocysteine's role in vascular disease was stimulated by the paper of McCully (1969) in which, based on autopsy evidence of extensive arterial thrombosis in two children with elevated plasma homocysteine concentrations and homocystinuria, he proposed that elevated plasma homocysteine (hyperhomocysteinaemia) can cause atherosclerotic vascular disease. A meta-analysis of subsequent prospective observational studies concluded that elevated homocysteine is indeed a modest independent predictor of ischaemic heart disease and stroke risk in healthy populations with a 25% reduction in serum homocysteine concentration, a reduction of approximately 3 micromol per litre (μmol/l) being associated with a 19% lower risk of stroke (odds ratio, 0.81; 95% confidence interval (CI), 0.69 – 0.95). In the nationally representative sample of US adults, elevated homocysteine concentration was independently associated with an increased likelihood of non-fatal stroke in both black and white adults. In this article, the current concepts relating homocysteine to ischaemic stroke are reviewed.

In the past two decades, the rate of surgery in older people has increased more rapidly than the rate of aging of the population, so both a larger proportion and a greater number of older people are now undergoing surgery. This may partly reflect a cultural change in surgery and anaesthesia with respect to a greater willingness to undertake elective procedures in older people, although there remain areas where they have less access to surgery than do younger patients. For instance, older people are less likely to undergo operative procedures after a cancer diagnosis. Furthermore, in those who do have surgery, resection rate (i.e. curative therapy) is lower than in younger people with equivalent tumour stages, and even more so in older patients with COPD, cardiovascular disease or diabetes. This article explores the complex relationship between age and surgical outcome, provides an evidence-based overview of risk assessment and common postoperative problems in older people, and summarizes good practice points (at times necessarily pragmatic) for clinical management of the older surgical patient. There has been a substantial expansion in the literature examining risks, outcomes and interventions in older surgical patients since the previous review article of this subject published in this journal. Although we do not cover anaesthesia in older people, the review of that topic remains relevant. The American Society of Anaesthesiologists' Classification of Risk which illustrates that risk is disease- rather than age- based, is shown in Table 1. Most publications examine elective rather than emergency surgery in older people (with the exception of hip fracture), and this is reflected in the content of the paper.

This review opens with an outline definition of dysphagia, its causes, and why it is vital that people involved in the health care of older people should be aware of it. A brief consideration of prevalence is followed by an overview of assessment options. We conclude with a section on management.

Vascular cognitive impairment (V.C.I.) encompasses all forms of cognitive loss associated with cerebrovascular disease and ischaemic brain injury. It includes cognitive impairment related to stroke, cortical and subcortical infarcts, silent infarcts and strategic infarcts, white matter lesions associated with small vessel disease, and specific arteriopathies such as CADASIL (Cerebral Autosomal Dominant Arteriopathy with Subcortical Infarcts and Leucoencephalopathy). Recent studies have demonstrated that VCI is most commonly of a subcortical aetiology with small vessel disease being the major cause. VCI plays an important part in patients with other forms of dementia, such as Alzheimer's disease, who have coexisting vascular lesions and it has been proposed that VCI may be the most common form of cognitive impairment in older people, with a prevalence of 5% in people over the age of 65. In view of the aging population and the growing magnitude of vascular disease in western society, the prevalence of subcortical VCI is likely to increase, with a greater impact on patients and health care providers. In this article, we will review the cerebrovascular pathology underlying subcortical VCI and its role in mediating the characteristic cognitive deficits.

Suicide is a major health issue worldwide and is among the top ten causes of death in many countries. Much research, media attention and public health initiatives are focused on reducing the suicide rate among adolescents and young adults. In many countries, however, it is the elderly population with the greatest number of suicides, the majority of which die by drug overdose. This is commonly explained by an increased suicidal intent among older people due to co-morbidity and social isolation. The physical vulnerability of elderly people to potential toxins however is also likely to play an important role. This review examines the epidemiology of elderly suicide, considers commonly implicated drugs, and discusses associated risk factors in this complex and multifactorial problem.

As people age they almost invariably develop diseases which lead to the prescription of drugs – both to prevent disease progression and for symptomatic relief. Unfortunately, drug treatment in later life is also problematic. There is a dearth of evidence on the efficacy of drugs in people over the age of 80, and members of this age group are at highest risk of adverse drug reactions (ADR).

Nutritional assessment in older people to detect malnutrition or risk of malnutrition is essential to avoid adverse nutrition-related outcomes. Poor nutritional status appears to be a major contributing factor for poor prognosis in malnourished individuals. Nowadays, nutritional assessment is considered to be one of the domains which should be evaluated in comprehensive geriatric assessment (CGA). CGA is a comprehensive assessment tool with the capacity of detecting impairments in older people and, at the same time, suggest interventions. Although many assessment tools are proposed, those used in CGA are not widely agreed. After 20 years of clinical practice and research, the Mini Nutritional Assessment (MNA) seems to be the tool most widely accepted by health carers and patients for the assessment of nutritional impairment in CGA.