This article provides an overview of spine surgery in older people and reviews outcome and novel techniques. Improvements in pain, disability, and quality of life can be expected following surgery and demand for surgery of this type is likely to increase as the mean age of the population increases. Novel techniques and improved intsrumentation offer surgical treatments for conditions that were previously untreatable and show encouraging early results.

The increase in the ageing population has generated much interest and research into what constitutes normal ageing. By identifying normal ageing processes it is hoped it will be possible to distinguish risk factors for the development of abnormal or premature ageing.

This review discusses biological, structural and mechanical changes in the cardiovascular system with ageing that are thought to increase the risk of cardiovascular disease with ageing. Contributory factors are thought to be genetic and lifestyle related. Measurements of biological as opposed to chronological ageing such as vascular stiffness are explored as a possible useful predictor of cardiovascular morbidity and mortality, indicating its possible utilization as a non-invasive screening tool in older people.

The identification of those at risk of cardiovascular disease and modification of risk factors may minimize interactions of the ageing process and therefore reduce the incidence of cardiovascular disease within the UK population.

Humans have an intrinsic lifespan of approximately 120 years. Classic evolutionary theories of ageing explain the limit as a response to inevitable cellular damage. The theories share the notion that natural selection acts less strongly to purge deleterious genes that are expressed after reproduction. Reproduction schedules are influenced by a species' ecology and so it is ecological factors which explain interspecies variation in lifespan. Human ecology has favoured the selection of an unusually large brain that both confers advantages that promote longevity and requires longevity to make it a worthwhile investment. The relatively long human lifespan therefore co-evolved with the large human brain.

Chronic liver disease is increasingly prevalent and, as the population ages, geriatricians will see an increasing burden. We present an overview of the investigation and management of older adults with chronic parenchymal liver disease and highlight the potential roles of transjugular intrahepatic portosytemic shunts and orthotopic liver transplantation.

Ageing is associated with multiple changes in many different components of the immune system. A healthy immune system exists in a state of balance between efficient effector responses against pathogens and tolerance to self antigens. This balance is changed with age; functions such as antigen recognition, phagocytosis, antigen presentation, chemotaxis, cytokine secretion and killing ability are all compromised. Aberrant cellular responses lead to an altered cytokine network with increases in inflammatory cytokines and decreases in anti-inflammatory cytokines leading to a pro-inflammatory state. Consequently older patients require extra care in diagnosis of infections as symptoms may be perturbed, resulting in unusual presentations of common conditions. The defects in immunity due to immunosenescence also mean that older patients require more care and screening than other patients in the same disease cohort. Though it is generally understood by clinicians that older patients are more at risk from multiple infections, the wider clinical effects of immunosenescence are less understood. The immune system is involved in several neurodegenerative conditions and the inflammatory conditions of immunosenescence may be a key factor in pathogenesis. Similarly, there is reason to believe that immunosenescence might be a key factor explaining the increased incidence of cancer in older age. With increasing understanding of the immune system's involvement in many of these pathological processes, and the contribution that immunosenescence makes to these, more efficient vaccines and novel therapies may be developed to prevent/treat these conditions.

Longer lifespans have been accompanied by an increasing number of older people suffering from impaired cognitive function (dementia) including Alzheimer's disease (AD) and vascular dementia (VaD). Some studies have suggested that hypertension in old age correlates with the pathogenesis of dementia. Since hypertension is potentially reversible, a number of randomized trials have examined whether antihypertensive treatment may help to prevent dementia. We review five studies, all using subjects aged 60 years or older, which investigated different antihypertensive pharmacological treatments and found conflicting results regarding impact on dementia. At the same time, other studies have suggested that hypotension in older people, especially those with low diastolic blood pressure, are also at higher risk for developing dementia. Four studies are reviewed here, but none is able to determine unequivocally if hypotension is a cause or a consequence of dementia in old age.

The incidence of pneumonia is higher in older than younger people, due to both an increase in factors facilitating entry of infectious agents into the lungs, and attenuated functioning of the immune system. Classic features of presentation of pneumonia may be absent. The most common signs of pneumonia in old age are tachypnoea and tachycardia. Aetiology is established in only 50% of older patients. The empirical treatment of community-aquired pneumonia (CAP) should be aimed at its most common cause, Streptococcus pneumoniae. The empirical treatment of health care-associated pneumonia (HCAP) should be targeted at Gram-negative agents. Choice of antibiotic must include consideration of potential drug interactions.

The prevalence of undernutrition in older individuals, living independently in a community setting, or living in a supported setting, is considerable. The negative health effects of undernutrition are wide ranging, with implications for quality of life (QOL), well-being and general health, through to the individual's ability to recovery from acute disease. There are a number of key measures that indicate both nutritional status and the effectiveness of any intervention. These include conventional anthropometric and biochemical measures of nutrient status, as well as measures of QOL, well-being and depression. The latter have huge importance to the life of the individual, and to date appear to have undergone only preliminary investigation. This review suggests that the efficacy of interventions to address undernutrition and improve health in older people living in a variety of settings is highly variable, and that considerable opportunities for research in this area exist.

A person's risk of developing cancer rises exponentially with age, an increase that is widely considered to result from cumulative exposure to mutagenic agents. However, cancer incidence rates decelerate and plateau beyond 85 years of age and numerous malignant pathologies peak in incidence during early or middle life, indicating an important role for additional factors in controlling the timing and nature of cancer development. Given that immune function is known to decrease with age, malignant neoplastic change may be induced by increased chronic infection and the onset of a pervasive low grade inflammatory environment. This article discusses in detail the ageing immune system's role in cancer pathogenesis and demonstrates that key polymorphisms coding for relatively low pro-inflammatory cytokine production act to protect some populations from age-induced neoplastic transformation.

Stem cells are a potential means of tissue regeneration in the brain that hold promise for treatment of the large number of stroke survivors who have permanent disability. Animal studies with stem cells derived from many different sources indicate that cells can migrate to the site of ischaemic injury in the brain, and that some survive and differentiate into neurones and glia with evidence of electrical function. Cells additionally promote endogenous repair mechanisms, including mobilization of neural stem cells resident within the adult brain. Whether the behavioural benefits seen with stem cell administration in rodent models reflect enhanced endogenous recovery or tissue regeneration is unclear. Production of stem cells to clinical standards and in quantities required for clinical studies is technically challenging. To date only a handful of patients have been involved in preliminary clinical studies of cell therapies for stroke, and there are therefore insufficient data to draw conclusions about either safety or efficacy. Further trials with several cell types are ongoing or planned, including neural stem cells, and bone marrow-derived stem cells and endothelial progenitor cells.

The incidence of most haematological malignancies increases with age. Given that those aged >65 years represent the fastest growing segment of Western populations, these cancers may commonly present to medical teams with an interest in older patients. Over the last 20 years there have been dramatic improvements in the outlook for patients diagnosed with haematological cancers, but there is evidence that many of these improvements have been restricted to younger patients. It is therefore important that older patients with haematological malignancies are rapidly diagnosed and promptly treated with the best available therapies. Clinical trials that specifically encompass older patients are clearly important. In this review, the presentation and management of common haematological malignancies will be discussed, including myelodysplasia, acute leukaemia, lymphoproliferative disorders and myeloma.

The autonomic nervous system comprises the sympathetic, parasympathetic and enteric nervous systems and plays an integral role in homeostasis. This includes cardiovascular and temperature control, glucose metabolism, gastrointestinal and reproductive function and increasing evidence to support its involvement in the inflammatory response to infection and cancer. Ageing is associated with autonomic dysfunction, and many clinical syndromes associated with older adults are due to inadequate autonomic responses to physiological stressors. The aim of this review is to explore the relationship between autonomic dysfunction and ageing illustrated with examples of maladaptive autonomic responses in a variety of different clinical syndromes including an exploration of autonomic cellular changes. Appropriate investigation and management strategies are outlined, recognizing the fine balance needed to improve symptoms without creating further medical complications.

The vast majority of cardiac pacemakers are implanted in older people. Pacing is a safe and effective treatment for patients with symptomatic bradyarrhythmias. This review provides a clinician's guide to the essential aspects of modern pacemaker therapy in older patients, including aetiology and epidemiology of bradycardia. We discuss some barriers to access to pacing. We review indications for pacemakers, and describe pacing system function, including the different types of pacemakers used. We also review clinical outcomes following pacing, follow-up requirements and problems encountered in clinical practice. Finally, we discuss ethical and end of life considerations with these devices.

In the last 20 years a realization has developed that acute stroke is a condition that benefits from early intensive investigation and treatment. Older people are historically less likely to receive such active management through a combination of limited evidence due to their exclusion from clinical trials and a level of ‘therapeutic nihilism’ regarding older subjects with severe, acute illness.

There is increasing evidence that many acute therapies, including thrombolysis, benefit older stroke patients. Older subjects may not achieve as good results as younger groups but differential benefits are often comparable when expected outcomes are considered. Risk of haemorrhagic complications with thrombolysis is not substantially increased and older subjects are now receiving this therapy despite a dearth of relevant trial data.

Intensive physiological monitoring and stroke unit care has been found to be of benefit to patients of all ages. Surgical options for intracerebral haemorrhage are limited, but there is little difference in the management of intracranial haemorrhage in older people. There is unlikely to be a benefit to surgical hemicraniectomy for cerebral infarction in those >60 years. In conclusion, active management for acute stroke in older people is frequently beneficial and age should not be a barrier to such care.

The ‘take home’ messages for managing elderly patients with symptomatic carotid disease are that they need to be investigated as soon as possible after onset of the index event and that someone has to take active responsibility for ensuring that risk factor control and best medical therapy is started as soon as possible. In this modern era, patients suffering a transient ischaemic attack/minor stroke should be seen in dedicated, rapidly accessible single visit clinics, and those found to have significant carotid disease should generally be admitted and undergo expedited carotid endarterectomy (CEA) unless contra-indicated. Every centre should now aim to be performing carotid surgery within 14 days of onset of symptoms, with this threshold likely to become even shorter in the future. The current culture of allowing delays to treatment should be considered unacceptable. Evidence suggests that the risk of procedural stroke is lower in higher volume centres and this should be considered when planning referrals. Recently symptomatic elderly patients deemed unfit for CEA should be considered for carotid artery stenting (CAS), but with the caveat that this may be associated with an increased risk of procedural stroke. In this situation, every patient should be considered on an individual basis and no symptomatic patient should be denied access to surgery simply on the grounds of age. Meta-analyses of data from the international trials have clearly shown that patients aged >75 years gain considerably more benefit from CEA than any other age group. In contrast, there is no compelling evidence that patients aged >75 years with asymptomatic carotid artery disease benefit from CEA or CAS. For this category of patients, risk factor control and best medical therapy should remain the first line of management.

The essential polyunsaturated fatty acids (PUFAs) are divided into two classes, n-3 (ω-3) and n-6 (ω-6) and their dietary precursors are α-linolenic (ALA) and linoleic acid (LA), respectively. PUFAs are precursors of a wide range of metabolites, for example eicosanoids like prostaglandins and leukotrienes, which play critical roles in the regulation of a variety of biological processes, including bone metabolism.

A large body of evidence supports an effect of PUFA on bone metabolism which may be mediated by regulation of osteoblastogenesis and osteoclast activity, change of membrane function, decrease in inflammatory cytokines, such as interleukin-1 (IL-1), interleukin-6 (IL-6), and tumour necrosis factor alpha (TNF-α), modulation of peroxisome proliferators-activated receptor γ (PPARγ) and influence in NO secretion and NO synthase.

Animal studies have shown that a higher dietary omega-3/omega-6 fatty acids ratio is associated with beneficial effects on bone health. Human studies conducted in elderly subjects suggest that omega-3 instead of omega-6 has a positive effect on bone metabolism. In spite of increasing evidence, studies conducted in humans do not allow us to draw a definitive conclusion on the usefulness of PUFAs in clinical practice.

Osteoporosis is a common, chronic condition. Fracture risk assessment tools are increasingly being used to identify those patients who may benefit from treatment, but in older patients clinical judgement is still essential in deciding whom to treat. The treatment of osteoporosis in older people has seen several important developments in recent years. Whilst bisphosphonates are the mainstay of treatment, several newer medications have proven benefit in terms of increases in bone mineral density and fracture prevention. Additionally, some of the newer therapies have characteristics that particularly lend themselves to use in an older population group. This article focuses upon treatment of osteoporosis in older people with an emphasis on newer drug and therapeutic options.

The scale of foot problems in the population is high, and highest in older people. Whilst podiatry is solely concerned with the foot, other professions with a broader remit are also involved in foot care, as not only the foot may be at risk but also there may be serious systemic sequelae. Foot problems can be usefully viewed from a functional, hierarchical perspective. The interventions required are suggested by considering problems according to this hierarchy. Many approaches exist for the management of foot conditions from educated self-care to surgery. In managing such conditions, multi-disciplinary approaches are required. Podiatry has developed considerably over the years, has a growing research base, an extensive scope of practice and anticipated developments. The profession can develop further, particularly in its preventative role, in terms of professional autonomy and in further increasing its evidence base.

The complexities of defining what appears to be the relatively simple concept of resilience are widely recognized. This paper analyses the concept of resilience from a range of disciplinary perspectives and clarifies a definition in order to inform research, policy and practice. The work takes a life course approach to resilience, examining evidence derived from research across the lifespan. It incorporates the methods of systematic review, concept analysis and consultation through face-to-face meetings. The synthesis of methodological approaches enables a clear identification of the antecedents, defining attributes and consequences of resilience, validated with stakeholder partners. Through this process, resilience is defined as the process of effectively negotiating, adapting to, or managing significant sources of stress or trauma. Assets and resources within the individual, their life and environment facilitate this capacity for adaptation and ‘bouncing back’ in the face of adversity. Across the life course, the experience of resilience will vary. A large proportion of resilience research is routed within the discipline of developmental psychology, and has mainly been developed with children and adolescents. A major contribution to resilience research could be made through more multi-disciplinary studies that examine the dynamics of resilience across the lifespan, its role in healthy ageing and in managing loss, such as changes in cognitive functioning.

Providing information to older adults is essential for informed decision-making and good health. Because there are significant deficits in providing information verbally, health professionals must use written information as well. Most studies have focused on the content and literacy of documents. However, the legibility and formatting are critically important for older adults, who are more likely to suffer with visual impairment. Providing written information that is tested for appropriate reading level and for presentation is necessary to ensure that older adults can use the information given. There are a number of tools available that test these aspects of written information, but not one tool that is universally accepted. Further research regarding the design and presentation of written information for older adults is necessary.