Parkinson's disease (PD) is a progressive neurodegenerative disease characterized typically by motor features of tremor, rigidity and bradykinesia due to depletion of dopaminergic nigrostriatal neurons. PD is increasingly recognized as a non-motor disorder since symptoms such as dementia, depression and falls emerge with disease progression to become dominant in the clinical picture. PD results in a significant decline in quality of life for both patients and family and contributes to significant economic and institutional costs on family and society. PD is uncommon before the age of 40 but affects approximately 1% of patients over the age of 60, with a rising incidence and prevalence thereafter to around 2% in the population over 80 years of age.

A recent international definition of under-nutrition or malnutrition has been given by the WHO. Mal-nutrition means ‘badly nourished’ but it is more than a measure of what we eat, or fail to eat. Clinically, malnutrition is characterized by inadequate intake of protein, energy, and micronutri-ents and by susceptibility to infection or disease. Nutritional status is the result of the complex interaction between the food we eat, our overall state of health, and the environment in which we live – in short, food, health and caring are the three ‘pillars of well-being’.

With an aging population globally, and increasing numbers of older patients facing chronic illnesses, better palliative care in old age should be promoted.In this review we will

1. Highlight the pressing need for better palliative care for older people

2. Advocate the concept of palliative care as applied to geriatrics and gerontology

3. Review current end-of-life care for older people with chronic disease, both non-cancer and cancer

4. Discuss the palliative-care approaches to common physical symptoms and psychospiritual distress

5. Highlight advanced care planning and quality-of-life issues

Substance use and misuse are best viewed through the framework of a multifactorial biopsychosocial model, which acknowledges the interplay of genetic, familial, physiological, psychological and social factors. Age, role, gender, social group and peer pressure, the family, community and occupational environment, as well as overall cultural values and controls on substance use, will act upon substance-taking behaviour.

Sleep disturbance is a clinically significant problem in nearly one half of patients with dementia and is a predictor of cognitive and functional decline. There are multiple causes of sleep disturbance in dementia and all represent diagnostic and management challenges. Impaired circadian rhythm is a disorder characterized by an increase in daytime sleep with reduced night-time sleep, a reversal of the sleep/wake cycle. Such disrupted circadian rhythm may occur early in Alzheimer's disease, worsen over time, and is associated with behavioural disturbance, including aggression. In addition to the timing of sleep, the structure of sleep may deteriorate, giving rise to poor sleep quality.

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 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.’