With more elderly people in the population there are more people surviving with lung diseases that need assessing so that the best treatment options can be chosen and delivered. Lung function is known to deteriorate with age and this is largely due to a reduction in muscle strength, an increased alveolar size leading to reduced elastic recoil, and a reduction in chest wall compliance. The processes involved are outlined together with the effects this has on normal lung function. Tests of lung function are commonly used to determine whether an individual patient's lungs are working abnormally, and using a lower limit of normal is the best method to use. The problems and solutions for defining the lower limit of normal for older subjects are discussed. If a subject's lung function is deemed abnormal from comparing their tests against a predicted value, then assessing how severe this abnormality is can be determined by using the results as per cent of predicted, or better still by relating the value to a minimum survivable limit.

The N-terminal pro-brain natriuretic peptide (NT-pro-BNP) is released in response to volume expansion and/or increased tension on left ventricular myocytes. NT-pro-BNP is a useful diagnostic and prognostic biomarker both in patients with dyspnoea of unknown aetiology, and for risk assessment of patients with established heart failure. However, impaired kidney function – a common condition in older people as well as a strong risk factor for cardiovascular disease is associated with elevated circulating levels of NT-pro-BNP. Therefore, it is important to know the kidney function when interpreting an elevated NT-pro-BNP measurement obtained in older people in order to diagnose or stage congestive heart failure.

This paper reviews the handling of water and electrolytes by the ageing kidney and the clinical consequences in everyday clinical practice. Normal physiology in the adult kidney is discussed, followed by description of the main physiological changes (adaption) that occur as the kidney ages. Clearly, successful management of the elderly patient requires a knowledge of these changes, which result in: (i) increased tendency for volume depletion and dehydration; (ii) decreased ability to tolerate a volume load; (iii) increased propensity for potassium disturbances (hypo- and hyperkalaemia); (iv) diminished production of renin and blunted physiological response to the effects of aldosterone and antidiuretic hormone; (v) increased tendency to lower levels of phosphate; and (vi) tendency for the development of hypocalcaemia and hypomagnesaemia. A brief review of the role of extracellular fluid volume depletion and other factors contributing to acute renal failure in elderly patients is also presented.

The increasing prevalence of complementary and alternative medicine (CAM) use is a significant health care issue in contemporary societies and researchers have identified CAM as holding potential for treating and coping with chronic illness and other conditions experienced in later life. This paper focuses upon contemporary research literature to provide a critical review of the prevalence, correlates, conditions, perceptions and communication of CAM use in later life. Evidence from recent research illustrates the substantial prevalence and complexity of CAM use amongst older people and such ‘community’ use requires all providers, regardless of their experience or perception of the worth of CAM, to at least acknowledge and enquire with their older patients about the potential use of these other medicines.

Nursing homes and long-term care facilities are usually considered as reservoirs for methicillin-resistant Staphylococcus aureus (MRSA) carriers. Actually, there are major differences in MRSA carriage between institutions, with variations from 1% to more than 30%. Overall there is a low incidence of MRSA infection in these institutions, even though carriage is associated with a higher risk of subsequent MRSA infection, with high mortality rates. The main risk factors for carriage are well known: recent hospitalization in an acute-care ward, skin wounds and recent antimicrobial therapy. Age over 75 years is also a risk factor. Residents of nursing homes and long-term care facilities pose a risk of MRSA transfer to acute-care wards, with potential consequences in terms of infection control strategy or surgical antibiotic prophylaxis. No well-designed study has identified the best strategy for MRSA control in institutions for older people and strategies that have been proposed are controversial. Studies to elucidate this would be useful, as well as studies specifically designed to identify the relative importance of different ways of MRSA transmission in these institutions (cross-transmission via healthcare workers or the environment, or direct transmission from one resident to another). Finally, a first important step towards MRSA control is a strict application of standard precautions, particularly good compliance with hand hygiene.

Major traumatic injury is a leading cause of death in younger age groups, but increasingly older people are affected also. Adverse outcomes, both physical and psychological, are associated with injury in the older population. This review aims to locate and describe the evidence relating to older people and major trauma in order to inform policy, practice, research and education. The published research and systematic reviews fall into three main topics: mechanism of traumatic injury in older people, the effects of co-morbidities on older trauma patients and outcomes following serious traumatic injury in older people. The psychological impact of traumatic injury and the resulting functional alteration cannot be underestimated in this group of patients.

This review discusses the role that the APOE gene plays in cognitive dysfunction both in demented and non-demented elderly people. The increasing problem of cognitive impairment in developed countries makes finding new and effective treatments a research priority. Understanding the biological basis of this impairment is therefore paramount. APOE has received much attention in the field of cognitive genetics due to it being a major susceptibility gene for Alzheimer's disease, which itself is characterized by a rapid and irreversible loss in memory function. Over the past 14 years this has generated a considerable number of publications that have produced conflicting findings, making it difficult for the reader to interpret whether the APOE gene regulates cognition or not. This review attempts to summarize the mass of information on this gene in relation to cognition, by weighting the pros and cons of the methodologies used, and offers suggestions for future study designs.

Age is strongly associated with risk of sexual dysfunction in both men and women. For many years it was assumed that such a loss of sexuality was natural and inevitable, and therefore little attention was given to sexual behaviour and treatment in this population. However, more recent data have suggested that sexuality remains important into later life for many individuals. Although appreciation of sexuality persists, a decline in sexual activity is typical with advancing age, which is in part attributable to both general health problems and specific sexual dysfunctions, both becoming more prevalent with ageing. The principle sexual health issues in older men include erectile dysfunction and late onset hypogonadism. Although premature ejaculation is prevalent in older men, the bother from this disorder is generally lower in older men. This manuscript consists of a review of the contemporary peer-reviewed literature and attempts to provide insights for the physician treating the geriatric population. We discuss sexual behaviour at older age, and address erectile and androgen biology in older men and the prevalence and aetiology of sexual dysfunction in this population. Furthermore, an overview of contemporary pharmacological treatments for older men's sexual problems is provided.

Our ability to heal wounds deteriorates with age, leading in many cases to a complete lack of repair and development of a chronic wound. Moreover, as the elderly population continues to grow the prevalence of non-healing chronic wounds is escalating. Cutaneous wound repair occurs through a combination of overlapping phases, including an initial inflammatory response, a proliferative phase and a final remodelling phase. In elderly subjects the inflammatory response is delayed, macrophage and fibroblast function compromised, angiogenesis reduced and re-epithelialization inhibited. Whilst a large body of historic research describes the defective processes that lead to delayed healing, only recently have the molecular mechanisms by which these defects arise begun to be elucidated. Current therapies available for treatment of chronic wounds in elderly people are surprisingly limited and generally ineffective. Thus there is an urgent need to develop new therapeutic strategies based on these recent molecular and cellular insights.

Faecal incontinence in older people is a distressing and socially isolating symptom and increases the risk of morbidity, mortality and dependency. Many older individuals with faecal incontinence will not volunteer the problem to their general practitioner or nurse and, regrettably, health care providers do not routinely enquire about the symptom. Even when older people are noted by health care professionals to have faecal incontinence, the condition is often managed passively, especially in the long-term care setting where it is most prevalent. The importance of identifying treatable causes of faecal incontinence in older people, rather than just managing passively, is strongly emphasized in national and international guidance, but audit shows that adherence to such guidance is generally poor. This article describes epidemiology, causes, assessment, diagnosis and treatment of faecal incontinence in older people.

The prevalence of type 2 diabetes is set to increase, and with it the complications associated with diabetes. Since 2007 there have been a number of significant trials that may change the way we think about treating people with diabetes, especially our older patients. These trials include the Steno-2 trial, UKPDS legacy trial, ADVANCE, ACCORD and VADT. These trials are reviewed in detail in this article, including the implications for the patients we treat. Recent work assessing the effect of HbA1c on cognitive function and the effects of hypoglycaemia are also discussed. We conclude with suggestions for targets for glycated haemoglobin level based on NICE guidance.

Testosterone production declines with age in men. The decline is associated with several risk factors and diseases, including obesity and cardiovascular and metabolic diseases, diminished muscular, cognitive and sexual function and changes in body composition. Androgen treatment in elderly men has mostly been addressed in small short-term studies, and larger long-term investigations with sufficient statistical power are still needed for a proper evaluation of the benefit-risk-ratio of testosterone treatment. Current data do not support testosterone supplementation in healthy, asymptomatic older men with normal or low-normal testosterone levels. Treatment may be beneficial in older men with clear hypoandrogenic symptoms, especially reduced libido, erectile dysfunction and decreased muscle strength, if testosterone concentration is consistently low, and the patient selection, counselling and follow-up are adequate.

There is a high prevalence of pain in older people. Optimal assessment and management of pain in this population is challenging. The pharmacokinetics and pharmacodynamics of analgesic medications are affected by ageing and frailty, as well as by intercurrent medical conditions and their treatments. This review describes what is currently understood about the impacts of old age and frailty on the clinical pharmacology of commonly used analgesics, to provide a rational basis for the use of these medicines. In view of the wide age-related inter-individual variability in pharmacokinetics and pharmacodynamics of analgesic medications, monitoring of clinical response and adverse effects is essential to optimize pain control in older people.

Phosphate (PO4−) has a number of important functions in the human body and abnormalities of phosphate handling and phosphate levels are common in older people. We review the physiological functions of phosphate, the effects of phosphate deficiency and excess, and discuss the evidence underpinning management of these conditions in older people. Both hyper- and hypophosphataemia have been associated with a variety of adverse effects in different patient groups. There is currently little evidence to guide practice in treatment of abnormal phosphate levels specifically in older people. Studies looking into the effect of replacing phosphate on morbidity and mortality in milder cases of hypophosphataemia and into the dangers of, and treatment of, hyperphosphataemia in older people are required.

Smoking remains prevalent in elderly people in the UK and similar countries. The adverse health effects of current smoking continue to accumulate in old age and stopping smoking in old age confers benefits on function, morbidity and mortality. Many elderly people wish to stop smoking and many are successful. Structured support from health and social care workers improves quit rates and nicotine replacement therapy can be an effective aid to smoking cessation in old age. Doctors and other healthcare staff should use the opportunities of patient contact to encourage older smokers to quit. Cognitive impairment is a barrier to successful smoking cessation.

People with dementia are particularly vulnerable to abuse. It is inherently difficult to study as it is a hidden offence, perpetrated against vulnerable people with memory impairment, by those on whom they depend. In the general population, 6% of older people have experienced abuse in the last month and this rises to approximately 25% in vulnerable populations such as people with dementia. We know that various factors in the carer and the care recipient can predispose to a higher rate of abuse and this knowledge can be harnessed to try and improve prevention. There are also valid and reliable scales available to help detect abuse in vulnerable older adults. All health and social care professionals have a responsibility to act on any suspicion or evidence of significant abuse or neglect in order to ensure that appropriate management is taken.

Suicide is accepted as a major health problem worldwide, especially in the young and middle aged. It is, however, a significant health problem in older people as well, and those aged 65 years and over generally have the highest suicide rates compared with all other age groups. In research literature from the last decade, there has been an increased interest in disentangling the phenomenon of suicide in later life. This paper aims to critically review the literature on suicide and suicidality in later life published from 2000 to 2009. Prevalence rates as well as risk and protective factors are mapped and correlates reviewed. The association between suicidality and help-seeking behaviour is considered. Finally, potential prevention strategies are reviewed.

Thyroid disorders become more common with advancing age. Clinical features of hypothyroidism overlap with signs and symptoms often present in euthyroid older people and there is high likelihood of misdiagnosis. Conversely, there may be a relative paucity of signs and symptoms in hyperthyroid older people. A large number of patients may have subclinical disease. High suspicion and confirmation by laboratory assay is the key to correct diagnosis, though thyroid function tests should be interpreted with caution during acute illnesses. There is a reduced requirement for levothyroxine replacement in elderly hypothyroid patients and dosage should be titrated up cautiously as it can unmask symptoms of ischaemic heart disease. Drug interactions should be taken into account because a number of drugs interfere with levothyroxine absorption and metabolism. Radioactive iodine ablation of overactive thyroid tissue is the preferred treatment of hyperthyroidism in older people.

This review examines the demographic changes, the epidemiology of mental disorders and suicides, the potential risk and protective factors, access to secondary care old age psychiatry services (OAPSs) and the policy context pertaining to older people from ethnic minority groups in the United Kingdom. The number of older people from ethnic minority groups is increasing. The prevalence of mental disorders in older people from ethnic minority groups is either similar to or higher than that in the indigenous population. Therefore, the number of older people from ethnic minority groups with psychiatric morbidity is also increasing. Ethnic minority older people also have inequity of access to secondary care OAPSs. There is an urgent need to develop and implement practical strategies to improve access by older people from ethnic minority groups to OAPSs.

The status of the geriatric day hospital within the National Health Service (NHS) in the UK has changed significantly over the past fifty years. We conducted a literature review starting from the inception of the geriatric day hospital, when it was viewed as the ‘shop front for geriatric services’ and was subsequently replicated in many western health systems, to the present uncertainty surrounding the model in terms of outcomes and cost effectiveness. The article also highlights the input of the Royal College of Physicians and the British Geriatric Society to the management and development of day hospitals. The geriatric day hospital has become one of the many service models under the umbrella of intermediate care services, offering comprehensive geriatric assessment and care to older people in the community. However, with the current practices of commissioning of services and ‘payment by results’, the future of this precious health resource remains uncertain.