Introduction

Single organ therapy for medical specialties, general medicine and its subspecialties, has increasingly failed a number of groups of people over the last 200 years or so. The largest group were elderly people who were summarily dismissed from the Infirmaries from the days of their building as ‘vagabond beggars, incurables and elderly’.The vagabonds at least were welcomed after 1948, when the NHS diverted attention from people's cheque books and on to their illnesses. However, other groups have continued to suffer from the tyranny of single organ care, notably the ‘incurables’, young chronically sick people and those who were not capable of ‘getting better’ immediately. The lack of good, consistent mycocardial infection advice, despite excellent research findings, and a lack of rapid admission and full rehabilitation services for stroke victims remain a matter for concern in general medicine. How will new changes in the NHS, especially the development of Primary Care Groups (PCGs) and Trusts affect geriatrics?

In this review, the principal morphological and functional changes which occur in relationship to aging in both the genital tract and lower urinary tract are discussed. Aging of the upper urinary tract is not considered.

Much of the evidence for age-related changes comes from cross-sectional studies with their inherent methodological limitations. Furthermore, it is difficult to accept ‘normal aging’ criteria that do not take into consideration the role of the acute and chronic disease so prevalent in elderly people. Thus, more longitudinal studies are needed in order to provide a more exact analysis of the influence of aging on the urogenital system, as for all other systems of the body.

Introduction

Illnesses such as acute and especially chronic diarrhoea are personally incapacitating to older people, more so in those with physical and mental impairment or other acute or chronic illnesses. Diarrhoea is also socially restrictive: diarrhoea adversely impacts on the individual’s and carer’s quality of life.

A previous review dealt with the management of chronic pain in old age and attempted to provide an up-to-date account of management at that time. The present review will try to avoid going over the same ground but will discuss more recent developments in pain medicine, with an emphasis on those aspects relevant to the management of older patients.

Introduction

With their ease of administration, relatively benign side-effect profile and safety in overdose, in the United States the selective serotonin reuptake inhibitors (SSRIs) have become de facto first choice in the treatment of geriatric depression, displacing tricyclic antidepressants (TCAs). In this paper, the relevant literature regarding neurochemistry, kinetics, dosing, efficacy and differential side-effect profiles of citalopram, fluvoxamine, fluoxetine, sertraline, and paroxetine, the five currently available SSRIs in the USA, will be reviewed with special emphasis on geriatric data. Of late, considerable controversy has been generated regarding whether SSRIs are as effective as TCAs in severe and melancholic depressive subtypes. This important issue will be explored and the relative utility of all the SSRIs in the elderly patient compared and contrasted. Finally, reasons for difficulties in comparing results across studies will be elucidated.

Introduction

This paper considers the approach to decision-making on behalf of mentally incapacitated adults. It updates and revises the 1996 article Ethical Aspects of the Law Commission Report on Mental Incapacity in this journal. The Law Commission Report No. 231, Mental Incapacity, issued in February 1995, was the final outcome of a lengthy and wide-ranging process of consultation. This process resulted in four consultation papers over a period of four years. The Government did not support the Law Commission’s draft bill on mental incapacity and a further consultation period was initiated (Who Decides? Making Decisions on Behalf of Mentally Incapacitated Adults, Cm. 3803). This process culminated in October 1999 when the Lord Chancellor’s Office issued its report, Making Decisions (Cm. 4465). This policy statement sets out the Government’s proposals to improve the decision-making process for those who are incapable of making decisions for themselves or who cannot communicate their decisions.

Introduction

Physical therapy forms a large part of the multi-professional package of stroke care which has been shown to save lives and reduce disability, effects which may be maintained in the longer term. More specifically, physical therapy may improve performance of movement and functional ability poststroke, especially in the form of exercise-based interventions, and increased intensity of physical therapy may bring increased benefit. However, there is little evidence on which to base clinical decisions about what interventions to give to which patients, in what intensity and at what stage in the recovery process. In short, much of physical therapy practice remains based on clinical belief rather than objective evidence and robust research is needed.

Introduction

Day hospitals for older people typically provide a multidisciplinary service for a heterogeneous group of patients based largely upon a health care model. The broad objectives of day hospital attendance are now widely accepted (Figure 1). There is wide variation, nationally and locally, in the types of service provision. Little information is available to support evidence-based day hospital practice, partly due to the lack of an established methodology to evaluate current practice and allow comparison of different types of community-based rehabilitation and support. This review will confine itself to day hospitals for older people; day care and day hospitals for psychiatry of old age will not be discussed in any detail.

Falls are common in late life. Evidence from New Zealand, the United States and Great Britain suggest that about a third of people aged over 65 will fall each year, a proportion that rises to about half for the community-dwelling population older than 85 years. Falls are the leading cause of death from injury in older people. Although many falls do not cause serious injury, nor precipitate referral to the health services for 30–50% of fallers, those that do have major consequences. From a purely financial perspective, acute care of those with falls is estimated to cost $10 billion per annum in the United States.

Introduction

The context for the review of loneliness and social isolation in later life is that of ‘successful aging’ and ‘quality of life’. The term ‘quality of life‘ includes a broad range of areas of life and there is little agreement about the definition of the term. Models of quality of life range from identification of ‘life satisfaction’ or ‘social wellbeing’ to models based upon concepts of independence, control, and social and cognitive competence. However, regardless of how the concept of quality of life is defined, research has consistently demonstrated the importance of social and family relationships in the definition of a ‘good quality of life’.